6. • The head of femur slips out
through the capsule and displaces
according to the direction of force.
• Dislocation of hip is serious injury
INTRODUCTION
9. MECHANISM
• Commonest
• 50% of cases, it is associated
with a chip fracture of posterior
lip of acetabulum, in which case
it is known as a fracture
dislocation.
• It occurs when adducted and
flexed femur Is pushed
backwards by violent thrust to
the knee.
10. CLINICAL SIGN
• Localized pain and tenderness
• • Attitude of limb- flex, add, IR
• • Shortening of limb
• Stiff and painful attempted movements
• Localized haematoma
• • Palpable posteriorly in gluteal region
• Diminished / absent femoral artery Pulsation
(Vascular sign of Narath)
POSTERIOR DISLOCATION
POSTERIOR : FLEXED ,INERNALLY
ROATATED ,AND ADDUCTED
11. INVESTIGATION
• Head out of acetabulum
• Thigh internally rotated
• Lesser trochanter less prominent
• Shenton's line is broken.
• Look for any bony chip.
12. TREATMENT
• Reduction is an emergency- more chance of being
avascular
• • Reduced under general anesthesia by classical
Watson jones axial traction technique.
• • old dislocation, failure of closed reduction, intra
articular loose fragment, large acetabular fragment---
cause of open reduction.
• immobilization for both - 6-8 weeks.
• • Mobilization started after 6-8 weeks
16. MECHANISM
• Rare
• Violent abduction force, with thigh flexed
• Occurs in RTAS
• Dislocated head of femur lies in obturator foramen of
symphysis pubis.
17. CLINICAL PRESENTATION
• • Attitude of limb- externally rotated
• • Head palpable in groin
• • Localized pain, stiffness, tenderness
• • Inability to bear weight
• • True lengthening of limb
21. CLINICAL FEATURES
• • Severe localized pain and stiffness
• • Hip abduction and rotation markedly restricted with
severe pain
• • Bony mass is palpable in per rectal examination
• • Limb remains in neutral rotation and short.
23. TREATMENT
• Aim of treatment in these cases is to achieve as congruous an
articular surface as possible.
• For that skeletal traction is applied distally and laterally.
• If fragments fall in place- cont. for 8-12 weeks; if not- surgical
reconstruction of the acetabular floor may be necessary.
• Full weight bearing started after 3 months (after radiographic
evidence of consolidation
25. • EPIDEMIOLOGY
• In elderly typically NOF # results from low energy falls and associated with
osteoporosis.
• in young typically NOF # result of a high energy mechanism and other associated
injuries are common.
• Mostly intra capsular and compromise blood supply of head of femur.
26. • History
• History of a traumatic event with the exception of patients who have stress
fractures of the femoral neck.
• young patients with high-energy femoral neck fractures have associated injuries
including head injuries.
• missed femoral neck fracture can be disastrous.
27. • Risk factors
• Female sex
• Increasing age
• Poor health
• Tobacco and alcohol use
• previous fracture
• Fall history
• Low estrogen level
28. • ANATOMY
• The upper femoral epiphysis closes by age16 years.
• Neck-shaft angle: 125-130 degrees
• Angle of Anteversion is 10-15 degrees
29. • Blood Supply
• major contributor is medial femoral
circumflex Artery
• some contribution to anterior and
inferior head from lateral femoral
circumflex
• some contribution from inferior
gluteal artery small and insignificant
supply from
• artery of ligamentum teres
32. • GARDEN'S CLASSIFICATION
• Based on the degree of displacement of fracture and trabeculae.
• Garden classification is based on AP pelvis radiograph
• Stage I: incomplete fracture line (VALGUS IMPACTED)
• Stage II: complete fracture line; nondisplaced
• Stage III: complete fracture line; partially displaced
• Stage IV: complete fracture line; completely displaced
33.
34. Pauwels classification
• The classification is based on the angle, the fracture line makes in reference to
the horizontal.
• Type I--fracture is between 0 and 30 degrees in Reference to the horizontal
• Type II--between 30 and 50 degrees
• Type III--more than 50 degrees
38. • RADIOGRAPH
• X Ray of Pelvis with both hip is more useful rather than xray of affected hip alone.
• X Ray Features:
• Break in medial cortex of neck.
• External rotation of femur is evident, the lesser trochanter appears more prominent.
• Overriding of greater trochanter, so that it lies at the level of Head of femur.
• Break in trabecular strem.
• Break in Shenton's Line.
49. • Nonunion
• incidence of 5 to 30% increased incidence in displaced fractures
• TREATMENT:
• 1. Neck Reconstruction: The fracture is exposed from behind, the ends freshened
and the fracture stabilized with multiple screws and muscle-pedicle graft (Baksi's
procedure). Some surgeons use free fibular graft for reconstructing the neck.
• 2. Pauwel's osteotomy: This is a valgus ostestomy at the level of the lesser
trochanter such that he shearing forces are converted into compression forces.
50.
51. • 3. Meyer's Procedure : In this
procedure, the fracture is reduced by
exposing it from behind. It is fixed
with multiple screws and
supplemented with a vascularized
muscle-pedicle bone graft taken
from the femoral attachment of the
quadratus femoris muscle.
52. • After a fracture through the neck, all the medullary blood supply and most of the capsular
blood supply to the head are cut off.
• The viability of the femoral head may therefore depend almost entirely on the blood
supply through the ligamentum teres.
• If this blood supply is insufficient, avascular necrosis of a segment or whole of the head
occurs
• TREATMENT:
• 1. In young patients treatment options are between bipolar arthroplasty (a special type of
prosthesis), Meyer's procedure or rarely total hip replacement (THR).
• 2. In elderly patients, a hemi-replacement arthroplasty is performed or .Total Hip
Replacement(THR)
Avascular necrosis
53. • Osteoarthritis
• It may be because of:
• avascular deformation of the head
• union in faulty alignment. The patient presents with pain and stiffness.
• TREATMENT:
• 1. Younger patients are treated by either an inter-trochanteric osteotomy.
• 2. For an elderly patient, total hip replacement is the best option.
55. • INTER-TROCHANTERIC FRACTURES
• Fractures in the inter trochanteric region of the proximal femur, involving either
the greater or the lesser trochanter or both
56. • PATHOANATOMY
• The distal fragment rides up so that the
femoral neck-shaft angle is reduced
(coxa vara).
57.
58.
59.
60. • Clinical features
• The patient is brought in with a history of a fall or road accident.
• Pain in the region of the groin
• Swelling in the region of the hip
• Inability to move the leg
• Leg will be short and externally rotated
• Tenderness over the greater trochanter
61.
62. • TREATMENT
• The main objective of treatment is to maintain a normal femoral neck-shaft angle
during the process of union. This can be done by conservative means (traction) or
by internal fixation.
63. • Conservative
methods
• Russell's traction and skeletal
traction in a Thomas splint.
• With the success of operative
methods, whereby, early mobilisation
is possible, conservative methods are
used less often.
