Hip ortho

1. Dreamz Learning Innovations_____________________________________________ Page 1
• Anatomy of Hip joint
o hip joint is a ball and socket joint with inherent
stability (MCQ)
o Stability is largely as a result of the adaptation
of the articulating surfaces of the acetabulum
and femoral head to each other.
o The capsule and ligaments of the joint provide
additional stability.
o Acetabulum faces an angle of 30° outwards
and anteriorly(MCQ)
o The normal neck-shaft angle of the femur is
125° in adults, with 15° of anteversion.
(MCQ)

2. Dreamz Learning Innovations_____________________________________________ Page 2

3. Dreamz Learning Innovations_____________________________________________ Page 3
o Neck is made up of spongy bone with
aggregation of bony trabeculae along the
lines of stress.
o Blood supply of the femoral head:
n Three main sources
• medullary vessels from the neck
• retinacular vessels entering from the lateral
side of the head
• foveal vessel from the ligamentum teres.

4. Dreamz Learning Innovations_____________________________________________ Page 4

5. Dreamz Learning Innovations_____________________________________________ Page 5
n Most important are medullary vessels,
retinacular vessels
• generally cut off following a fracture of the
neck of the femur
• result in avascular necrosis of the head.

6. Dreamz Learning Innovations_____________________________________________ Page 6
o The abductor mechanism of the hip
n When a person stands on one leg, the body
weight tends to tilt the pelvis down on the
other side. (MCQ)
• The ipsilateral hip acts as a fulcrum in this.
• The abductors of the hip on the side on
which one is standing, contract to counter
this
• This helps in keeping the pelvis horizontal.
n This abductor mechanism is disrupted in
conditions like dislocation of the hip, fracture
of the neck of the femur

7. Dreamz Learning Innovations_____________________________________________ Page 7

8. Dreamz Learning Innovations_____________________________________________ Page 8
• Dislocations of the hip
• Classification
o posterior dislocation (the commonest) (MCQ)
o anterior dislocation
o central fracture-dislocation.
• All of these may be associated with fracture
of the lip of the acetabulum.

9. Dreamz Learning Innovations_____________________________________________ Page 9

10. Dreamz Learning Innovations_____________________________________________ Page 10
• Posterior dislocation of the hip
• The head of the femur is pushed out of the
acetabulum posteriorly
• In about 50 per cent of cases, this is associated
with a chip fracture of the posterior lip of the
acetabulum, in which case it is called a
fracture-dislocation.
• The injury is sustained by violence directed
along the shaft of the femur, with the hip flexed.
- also known as dashboard injury. (MCQ)
• Deformity - flexion, adduction and internal
rotation(MCQ)

11. Dreamz Learning Innovations_____________________________________________ Page 11
dashboard injury.

12. Dreamz Learning Innovations_____________________________________________ Page 12

13. Dreamz Learning Innovations_____________________________________________ Page 13

14. Dreamz Learning Innovations_____________________________________________ Page 14
• This is associated with a shortening of the
leg(MCQ)
• One may be able to feel the head of the
femur in the gluteal region.
• Why is it "wise to X-ray the pelvis in all
patients with fracture of the femur (MCQ)
n Dislocation is sometimes missed, especially
when associated with other more obvious
injuries such as fracture of the shaft of the
femur
n Dislocation may go unnoticed in an
unconscious patient

15. Dreamz Learning Innovations_____________________________________________ Page 15
o Radiological features:
n femoral head is out of the acetabulum (MCQ)
n thigh is internally rotated so that the lesser
trochanter is not seen(MCQ)
n Shenton's line is broken. (MCQ)

16. Dreamz Learning Innovations_____________________________________________ Page 16

17. Dreamz Learning Innovations_____________________________________________ Page 17

18. Dreamz Learning Innovations_____________________________________________ Page 18

19. Dreamz Learning Innovations_____________________________________________ Page 19

20. Dreamz Learning Innovations_____________________________________________ Page 20
Acetabular
fracture
orientation
with a
computed
tomography
(CT) scan

21. Dreamz Learning Innovations_____________________________________________ Page 21
Posterior wall fracture with a posterior
dislocation of the hip.

22. Dreamz Learning Innovations_____________________________________________ Page 22
Anterior wall acetabular fracture. A
computed tomography (CT) scan

23. Dreamz Learning Innovations_____________________________________________ Page 23
o Treatment
n Reduction of a dislocated hip is an
emergency, since longer the head remains
out, more the chances of it becoming
avascular.
n In most cases it is possible to reduce the hip
by manipulation under general anaesthesia.
n The chip fracture of the acetabulum, if
present, usually falls in place as the head is
reduced. (MCQ)

24. Dreamz Learning Innovations_____________________________________________ Page 24
n Open reduction -Indications
• closed reduction fails, usually in those
presenting late
• if there is intra-articular loose fragment not
allowing accurate reduction
• if the acetabular fragment is large and is
from the weight bearing part of the
acetabulum. Such a fragment makes the hip
unstable.

25. Dreamz Learning Innovations_____________________________________________ Page 25
o Complications
n Injury to the sciatic nerve: (MCQ)
• The sciatic nerve lies behind the posterior
wall of the acetabulum.
• Treatment:
o Injury is a neurapraxia in most cases and
recovers spontaneously(MCQ)
o In cases where the fragment of the posterior
lip is not reduced by closed method, open
reduction of the fracture, and nerve
exploration may be required.

26. Dreamz Learning Innovations_____________________________________________ Page 26
o If the sciatic nerve
is severely
damaged at this
level, prognosis is
poor.
n Avascular necrosis
of the femoral
head
n Osteoarthritis:
• Commonly, a total
hip replacement is
required
n Myositis ossificans

27. Dreamz Learning Innovations_____________________________________________ Page 27
• Anterior dislocation
o usually sustained when the legs are forcibly
abducted and. externally rotated. (MCQ)
o This may occur in a
n fall from a tree when the foot gets stuck and
the hip abducts excessively(MCQ)
n in a road accident.
o Clinically, the limb is in an attitude of external
rotation (MCQ)
o There may be true lengthening, with the
head palpable in the groin(MCQ)

28. Dreamz Learning Innovations_____________________________________________ Page 28
Anterior dislocation. Hip is in
abduction.

29. Dreamz Learning Innovations_____________________________________________ Page 29

30. Dreamz Learning Innovations_____________________________________________ Page 30
Anterior dislocation Hip

31. Dreamz Learning Innovations_____________________________________________ Page 31
• Central fracture-dislocation of the hip
o In this common injury
o femoral head is driven through the medial
wall of the acetabulum towards the pelvic
cavity
o Joint stiffness and osteoarthritis are
inevitable.
o skeletal traction is applied distally and
laterally

32. Dreamz Learning Innovations_____________________________________________ Page 32

33. Dreamz Learning Innovations_____________________________________________ Page 33

34. Dreamz Learning Innovations_____________________________________________ Page 34
o If the fragments fall in place and reasonably
reconstitute the articular margins, the traction
is continued for 8-12 weeks(MCQ)
o In some young individuals, in whom the
fragments do not fall back in place by
traction, surgical reconstruction of the
acetabular floor may be necessary. (MCQ)
o Complications - Hip stiffness, myositis and
osteoarthritis