Clinical Serise Hip Widad

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Jan 19th 2010
Clinical Series Hip by Widad

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Clinical Serise Hip Widad

  1. 1. Dr. Widad Nasser
  2. 2. Introduction Hip and femur fracture Hip / femur dislocation Other common condition of hip and femur Special pead. consideration
  3. 3. Regarding anatomy of hip and femur ,, what's FALSE : The predominant bone in proximal part is cancellous and distal to intertrochantric is cortical The arterial supply to femoral head arise from 3 source , the major source is the intraoasseous cervical arteries The common femoral vein is posterior and medial to the common femoral artery,,, at the inguinal ligament Sciatica nerve arise from L 4 to S 3
  4. 4. compartments muscles nerves vesssels Quadriceps,femoris ,sartorius,iliacus, Lat.femoral Femoral a/v anterior psous,pectineus cutanous Gracilis,add. Longus medial obturator Profounds & magnus,obt. femoris a.& externus obt. a/v Biceps femoris posterior Sciatica,pos. Profundus ,semitendinous,smi femoral femoris membranosus,add. cutaneous branches magnus
  5. 5. Age and gender are prediposing factors for specifi injury (stress#/patho. #/oesteop.) Mechanism of trauma may aid in predicting injury pattern Ch. medical condition predipose pt to certain complication e.g. AVN in ch. Steroid used Femoral /hip # may lead to hypotention --- diagnosis of exclusion After stabilizing pt --- examine limb for asymerical , neurovascular
  6. 6. When femoral # supected ,, the pt will be transported from the area to A/E with traction ,,,,, whats FALSE regarding traction : Traction should be discontinued once the pt arrives in the A/E Traction should not be used in open fracture with exposed bone Traction should not be used in pt suggested to have neurological involvement Injured exterimities should be immobilized with traction when moving the pt
  7. 7. Which of the following statements about femoral neck fractures is FALSE? The injury is most common in older women after a minor fall, but it occurs at all ages with significant trauma. Stress fracture may not show on initial films; treat conservatively and repeat x-rays in 10-14 days. Rest pain and inability to walk are always present With complete displaced fracture, the leg will be held in slight external rotation and abduction and shortening will be noted
  8. 8. displaced # rtFemoral Neck Subtle rt femoral neck #
  9. 9. Fig 53-16
  10. 10. Fig. 53-24
  11. 11. Which of the following statements describing the treatment for femoral neck fractures is FALSE? Nondisplaced: a prosthesis is always required Displaced: open reduction and internal fixation or a joint prosthesis Stress fracture: either internal fixation or expectant treatment may be used. Non-displaced : early ambulation and internal fixation
  12. 12. Hip arthroplasty Indication : Joint damage 2ndry to arthritis Hip # AVN Tumor Complication : Aspetic losning of prosthesis Infection DVT Post op. femoral dislocation
  13. 13. Undisplaced # of neck femur treated with screw and plate
  14. 14. Intertrochentric fracture exetended between greater and lesser trochenter of femur ,,, whats FALSE : Associated mortality rate is > 80 % due to risk of hemodynamic instability The leg apperas internaly rotated and shorter on examination In patient with other medical condition mortality rate increased if patient taken to OT on the day of injury Internal fixation is preferable on urgent but not emergent basis 10-30 % only
  15. 15. In trochentric fracture , whats FALSE : Fracture of lesser and greater trochenter is rare Is more common on female than in male Result of direct fall over trochenter or avulsed by iliopsoas muscle If avulsed, the fragment will be displaced superiorly and anteriorly Sup.& pos.
  16. 16. The treatment for trochanteric hip fracture (avulsion of the trochanter) is __. 1. internal fixation 2. bed rest with progressive rehabilitation or internal fixation depending on the degree of displacement 3. hip replacement 1 and 2 but not 3 since primary closure is best 1, 2, and 3 are correct
  17. 17. Subtrochentric fracture occur between the lesser trochenter and proximal 5 cm of femoral shaft ,,, whats FALSE : The proximal fragment produce flexion,abduction and external rotation Often accompaine femoral nerve and artery injury Its mostly comminuated fracture and increase the risk of non-union Fracture fastly heal because highly vascular region Delay union and non-union are rare It is poor vascular region
  18. 18. Classsification of subtrochentric fracture
  19. 19. Subtrochanteric hip fracture may occur with high-speed trauma or due to a fall in elderly patients. Which of the following statements regarding the treatment of subtrochanteric hip fractures is correct? Treatment of the fracture should take priority regardless of the other injuries sustained. Traction immobilization; it is usually followed by internal fixation Internal fixation is seldom required Long-leg cast. Surgical intervention is preferable in children < 10 years old
  20. 20. Rt Femur shaft # AP view
  21. 21. Femoral shaft fracture are common injury in young adult after high energy trauma ,,, what is FALSE : Open fracture are less frequent and often the result of gunshot wound Almost half are a/w ligmantous damage in knee , so knee examination is unremarkable Severly comminuted fracture are more likely to be treated by open reduction and internal fixation Refracture commonly occur during early healing and period immediately after hardware removed Severly comm. Rx mostly close reduction
  22. 22. Fracture of the femoral shaft requires significant trauma, and is most often caused by a motor vehicle accident, fall or child abuse. The victim is most often a younger male. Several units of blood may be lost into the thigh, resulting in hemorrhagic shock. Which of the following statements regarding treatment is true? An intramedullary rod or nail allows early mobilization (within a few days) in uncomplicated fractures. A traction splint should never be applied in the field Prolonged bed rest with traction is the treatment of choice Treat with 6-8 weeks of skeletal traction progressing to a cast brace Plate fixation is never required for comminution
  23. 23. The capsule of the hip joint is weakest __, where it inserts on the femoral neck rather than the intertrochanteric crest. This partly explains why most hip joint dislocations are __. Anteriorly; anterior Posteriorly; anterior Posteriorly; posterior Anteriorly ; posterior
  24. 24. Which of the following statements about the classifications of hip dislocation is FALSE? Anterior: less common than posterior dislocation Posterior: the most common type (about 90%) Central (impaction through the acetabulum): the second most common type Inferior : occur exculusively in children younger than 7 years Post./ant./cent.
  25. 25. About 90% of hip dislocations are posterior. Which of the following statements about posterior hip dislocations is FALSE? Use traction in line with the femoral axis with flexion of the hip and gentle manipulation while an assistant fixates the pelvis. The leg is shortened and internally rotated It usually results from a posteriorly-directed force applied to the flexed knee. Posterior acetabular fracture is common and can be seen on oblique views. adducted The thigh is abducted Treat with closed reduction as soon as possible to avoid avascular necrosis of the femoral head or neurovascular injury to the extremity
  26. 26. About 5-10% of hip dislocations are anterior. Which of the following statements about anterior hip dislocations is FALSE? Apply persistent traction in line with the femur with gentle manipulation while an assistant fixates the pelvis. Flexion, adduction, and/or internal rotation manipulation while maintaining in-line traction may be required Closed reduction should be performed as soon as possible to minimize the chance of avascular necrosis of the hip or neurovascular injury to the extremity. Rule out associated fracture prior to manipulation The leg is abducted and externally rotated The hip is extended Hip is flexed
  27. 27. Fig. 53-21,,,,53-22
  28. 28. Post. Dislocation of hip with adduct thigh and internally roated ansd shorten
  29. 29. Posterior Dislocation of the Left Hip - AP View
  30. 30. Posterior Dislocation of the Left Hip - Oblique View
  31. 31. Fig. 53-26 ,,,53-27
  32. 32. Femoral Shaft Fracture & Fracture/Dislocation of the Hip - Hip X- Ray
  33. 33. Myositis ossification is pathological bone formation at a site where a bone is not normally found ,,, what is FALSE : Traumatic myositis result from # or direct severe trauma and repaited minor trauma The incidince is 2 % after treatment of close hip dislocation and 40 % in when open reduction required In X-ray it appears as irregularly shaped masses of hetarogeneous bone in the soft tissuearound the joint Surgical intervention is contraindicated if the lession is near joint Its indicated not C.I.
  34. 34. Motion of the muscles, tendons and skin about the hip joint is facilitated by more than a dozen bursae, any of which can become inflamed. Which of the following statements about hip bursitis is FALSE? Usually due to overuse or trauma Infection or gout: should also be considered as possible causes Seen on exam: hip or lateral thigh pain, increased with abduction and external rotation, as well as with straight-leg raising or impaction of the heel with the leg extended Seen on exam: tenderness and possibly heat and swelling over the greater trochanter May be helpful: ice, rest, and anti-inflammatory medications; intrabursal local anesthetic and steroid injections Pain not with straight leg or impaction
  35. 35. Treatment of an open wound of the hip joint includes: 1. irrigation and debridement in the operating room 2. tetanus prophylaxis and antibiotics 3. secondary closure 1 and 2 but not 3 since primary closure is best 1, 2, and 3 are correct
  36. 36. Singh intreduce a grading system involving the trabecular pattern of proximal end of femur that’s useful in evaluating the degree of osteoprosis ,,,What is FALSE regarding singh score : X-ray of the head of femur can quantify the degree of osteoporosis even n non-fractured bones The singh score contains six score depend on five trabecular groups,, the worses is grade VI As osteoprosis progress,,the trabecular groups dissapear one at a time in predictable pattern All five grup of trabeculae are seen normally in AP view of non-diseased head,neck ,proximal end of femur Worser grade I
  37. 37. Fig. 53-6
  38. 38. Which statement is FALSE : Hamstring muscle starin : toe-touch weight bearing i.e. walking with crutches with toes of inj. Limb rest on ground w/o wt bearing Quadriceps tear : surgical repair and extensive rehabilitation Iliopsoas strain : partial flexion at knee and hip for 7-10 D Hip adductor strain : complete bed rest for 3 mnths
  39. 39. AVN result of ischemic bone death of femoral head after compromise of its blood supply ,,,, whats FALSE : On normal person ,,,,,, non-traumatic painful hip doesn’t R/O AVN Hip dislocation should reduced within 48-72 hrs to significantly reduced incidence of AVN AVN rarly complicated intertrochanteric fracture With optimal treatment, femoral neck fracture are complicated by AVN in 11% to 19% of cases Within 24 hrs
  40. 40. Box 53-1
  41. 41. 86 male pt present with h/o hip pain since 3 months , no h/o recent trauma ,the pain is more in the morning and progressivly increased with time , o/e no deformities or shorthining , only minor active and passive tenderness on motion ,,, whats best answer : If plain film is negative ,, discharge pt with analgesia If plain film is negative ,, discharge pt with analgesia and to repait xray after 10-14 days Addmit the pt for pain mangment Order CT/MRI hip
  42. 42. Development of femoral head and neck with its growth palates and two primary ossification center New 4mnth 4 yr 6 yr 1 yr born
  43. 43. Physis # transcervical cervicotrochentric intertrochentric Delbet classification of femoral head fracture in peads
  44. 44. 2 years old child present with h/o fever,limp and pain in lt hip , gram +ve bacteria are recovered from the hip joint , which of the following is most correct : Causative organism include Neisseria and group B streptoccocus Culture will be positive in approximatl 50 % Girls are afftected more than boys The hip is most commonly affected joint Sed rate is superior to CRP in making diagnosis
  45. 45. 8 years boy with no h/o fever or trauma , present with pain in his groin ,Legg-Calve- perthes disease is suspected ,,, which of following is correct : Disease is bilateral in 50 % of cases Finding in initial LCP inclde widning of medial joint space and irregularity of physis Peak year of incidence is 10 – 12 yrs Radionnuclear scan give more information than plain film regarding femoral head necrosis There is limited adduction and internl rotaion on examination
  46. 46. ☺ Perthes disease is AVN to femoral head of peads resulted in softining and break down of femoral head ☺ B/w 2 -10 yrs of age. ,,,, male > female ☺ 20 % b/l ,, limitation abd. & ext. rotation ☺Rx immobilization or limitations on usual activities or surgical ☺ After 18 months to 2 years of treatment, most children return to normal activities without major limitations.
  47. 47. 14 yrs old obese boy present with acute onset of pain in his lt hip after a football injury ,, xray of affected hip demonistrate a Slipped Cappital Femoral Head ,,, which of following is most correct : Xray of controlateral hip is indicated AVN would not be a complication on this pateient Boy present at younger age than girl This injury can be classify as stable
  48. 48. ☺ SCFEis a Salter-Harris type 1 fracture through the proximal femoral physis. ☺ Stress around the hip causes a shear force to be applied at the growth plate and epiphysis to move posteriorly and medially. ☺ The almost exclusive incidence of SCFE during the adolescent growth spurt indicates a hormonal role. ☺ Obesity is another key predisposing factor in the development of SCFE. ☺ Because the physis has yet to close, the blood supply to the epiphysis still should be derived from the femoral neck; however, this late in childhood, the supply is tenuous and frequently lost after the fracture occurs. ☺ Clinical presentation often is misleading, with only 50% of patients presenting with hip pain and 25% presenting with knee pain☺

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