This document provides information on hip dislocations and femoral head fractures. It begins with an introduction noting that hip dislocations caused by significant force are associated with other fractures and damage to the vascular supply of the femoral head, resulting in a high chance of complications. It then discusses anatomy, mechanisms of injury, evaluation, classification, clinical management including emergent treatment and reduction, and indications for operative versus nonoperative treatment. The key points are that hip dislocations
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
This video explains Lumbar Disc Replacement in Detail. When degenerative disc disease begins to affect the spine this is called degenerative disc disease. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Lumbar Disc Replacement feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
Can read freely here
https://sethiortho.blogspot.com/
Challenges and Solutions in
Management of Distal Humerus Fractures
Epidemiology
Anatomy
Classification
Controversies and Recent studies
Approach
Implants selection
Plate configuration
Ulnar nerve transposition
Role of total elbow arthroplasty in DHF
Role of hemiarthroplasty in DHF
Metaphyseal comminution –
Anatomic complexity of the distal humerus
Positioning of the plates
TBW –
Skin closure
Osteoporotic nature of the bone –
Less BMD/Thin metaphysis
Screw Pullout strength is low
DHF account for 2% of all adult fractures
The common pattern of fracture
Intraarticular and involves both columns
Bimodal distribution
Peak incidence in young male and in older female patients
Young male – High-velocity injury
Older female - Osteoporosis
The distal humerus is flattened and expanded bony structure
It is composed of lateral and medial columns with the trochlea situated between these columns.
The location of the trochlea is central rather than medial
Formed by Medial SCR + M/Epicondyle
The distal end has 450 angulation with humeral shaft
M/ Epicondyle gives attachment for MCL & Common Flexor Origin
The MCL originates from the undersurface of the medial epicondyle where it is vulnerable to excessive dissection
Ulnar nerve
Formed by Lateral SCR and L/Epicondyle and Capitulum
Distal end has 200 with humeral shaft
L/ epicondyle gives attachment for LCL & common extensor origin
Its posterior surface is non articular and can be used as a site for a plate fixation
The lateral column curves anteriorly
Placement of a straight plate on the posterolateral surface of the humerus risks straightening of distal humerus.
The medial column including the medial epicondyle is in line with the humeral shaft.
It forms the center of the triangle
It has 30 - 80 – external rotation & 250 anterior divergent with the shaft
It forms a 40 - 80 degree valgus direction
X-ray -
Anterior-posterior view
lateral View
Traction View – This can help to define articular fragments and aid in pre-operative classification of the fracture.
NCCT – Elbow
Articular surfaces
Position of the fracture fragments
useful for identifying impacted fracture fragments that make reduction challenging
Olecranon Osteotomy Approach – 52-57%
Triceps sparing VS Olecranon osteotomy approach
The lateral column was often the first to fail as a result of excessive varus forces acting on the elbow during normal activities of daily living. Small anterior-posterior diameter
Smaller diameter of the humerus, permitting only one or two short screws for fixation.
Interruption of blood supply to the lateral column
blood supply to the lateral column is also derived from posterior segmental vessels. Sagittal plane plating has less risk of injuring these structures, which may improve the chances of union
Imaging anatomy dislocation of the hip jointAkram Jaffar
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to the etiology of a fracture or dislocation.
The anatomy of displacement or deformity.
Imaging anatomy features and how to differentiate from epiphyseal lines.
Anatomy related to correct relocation and alignment.
Anatomical complications of a fracture or dislocation.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
L01 hip dislocation, pipkin
1. Hip Dislocations and Femoral
Head Fractures
John T. Gorczyca, MD
University of Rochester Medical Center
2. Introduction
Hip dislocations caused by significant force:
– Associated with other fractures
– Damage to vascular supply to femoral head
Thus, high chance of complications
3. Anatomy
Hip is a ball and socket joint.
Femoral head is slightly asymmetric, forms 2/3
sphere.
Acetabulum has inverted “U” shaped cartilaginous
surface.
Ligamentum teres, with artery to femoral head,
passes through middle of inverted “U”.
4. Joint Contact Area
Throughout ROM:
• 40% of femoral head is in contact
with acetabular articular cartilage.
• 10% of femoral head is in contact
with labrum.
6. Hip Joint Capsule
• Extends from intertrochanteric ridge of
proximal femur to bony perimeter of
acetabulum
• Has several thick bands of fibrous tissue
Iliofemoral ligament
• Upside-down “Y”
• Blocks hip extension
• Allows muscle relaxation with standing
7. Femoral Neck Anteversion
• Averages 70
in Caucasian males
• Slightly higher in females
• Oriental males and females have been noted
to have anteversion of 140
and 160
respectively
8. Blood Supply to Femoral Head
1. Artery of Ligamentum Teres
• Most important in children.
• Its contribution decreases with age, and is
probably insignificant in elderly patients.
9. Blood Supply to Femoral Head
2. Ascending Cervical Branches
• Arise from ring at base of neck.
• Ring is formed by branches of medial and lateral
circumflex femoral arteries.
• Penetrate capsule near its femoral attachment and
ascend along neck.
• Perforate bone just distal to articular cartilage.
• Highly susceptible to injury with hip dislocation.
10. Sciatic Nerve
Composed from roots of L4 to S3.
Peroneal and tibial components differentiate early,
sometimes as proximal as in pelvis.
Passes posterior to posterior wall of acetabulum.
Generally passes inferior to piriformis muscle, but
occasionally the piriformis will split the peroneal
and tibial components
11. Hip Dislocation:
Mechanism of Injury
Almost always due to high-energy trauma.
Most commonly involve unrestrained
occupants in MVAs.
Can also occur in pedestrian-MVAs, falls
from heights, industrial accidents and
sporting injuries.
12. Posterior Dislocation
• Generally results from axial load applied to
femur, while hip is flexed.
• Most commonly caused by impact of
dashboard on knee.
13. Type of Posterior Dislocation
depends on:
Direction of applied force
Position of hip at time of injury
Strength of patient’s bone
14. Position vs. Type of Dislocation
In General,
Abduction: fracture-dislocation
Adduction: pure dislocation
Extension: femoral head fracture-dislocation
Flexion: pure dislocation
15. Anterior Dislocation
Caused by extreme abduction with external
rotation of hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.
16. Effect of Dislocation on Femoral
Head Circulation
When capsule tears, ascending cervical branches
are torn or stretched.
Artery of ligamentum teres is torn.
Some ascending cervical branches may remain
kinked or compressed until the hip is reduced.
Thus, early reduction of the dislocated hip can
improve blood flow to femoral head.
17. Associated Injuries
Mechanism: high-energy, unrestrained occupants
Thus, associated injuries are common:
•
• Head and facial injuries
• Chest injuries
• Intra-abdominal injuries
• Extremity fractures and dislocations
19. Associated Injuries
Sciatic nerve injuries occur in 10% of hip
dislocations.
Most commonly, these resolve with reduction
of hip and passage of time.
Stretching or contusion most common.
Piercing or transection of nerve by bone can
occur.
21. Thomas and Epstein Classification
Most well-known
• Type I Pure dislocation with at most a small posterior
wall fragment.
• Type II Dislocation with large posterior wall fragment.
• Type III Dislocation with comminuted posterior wall.
• Type IV Dislocation with “acetabular floor” fracture
(probably transverse + post. wall acetabulum
fracture-dislocation).
• Type V Dislocation with femoral head fracture.
22. AO/OTA Classification
• Most thorough.
• Best for reporting data, to allow comparison of
patients from different studies.
• 30-D10 Anterior Hip Dislocation
• 30-D11 Posterior Hip Dislocation
• 30-D30 Obturator (Anterior-Inferior)
Hip Dislocation
26. Physical Examination
• Pain to palpation of hip.
• Pain with attempted motion of hip.
• Possible neurological impairment:
Thorough exam essential!
27. Radiographs: AP Pelvis X-Ray
• In primary survey of ATLS Protocol.
• Should allow diagnosis and show direction of
dislocation.
– Femoral head not centered in acetabulum.
– Femoral head appears larger (anterior) or
smaller (posterior).
• Usually provides enough information to
proceed with closed reduction.
28. Reasons to Obtain More
X-Rays before Reduction
• View of femoral neck inadequate to rule out
fracture.
• Patient requires CT scan of abdomen/pelvis for
hemodynamic instability
– and additional time to obtain 2-3 mm cuts through
acetabulum would be minimal.
29. X-rays after Hip Reduction:
• AP pelvis, Judet views pelvis.
• CT scan with 2-3 mm cuts.
30. CT Scan
Most helpful after hip reduction.
Reveals: non-displaced fractures
congruity of reduction
intra-articular fragments
size of fragments
31. MRI Scan
• Will reveal labral tear and soft-tissue
anatomy
• Has not been shown to be of benefit in
acute evaluation and treatment of hip
dislocations
33. Emergent Reduction
• Allows restoration of flow through occluded or
compressed vessels.
• Literature supports decreased AVN with earlier
reduction.
• Requires proper anesthesia.
• Requires “team” (i.e. more than one person).
34. Anesthesia
• General anesthesia with muscle relaxation
facilitates reduction, but is not necessary.
• Conscious sedation is acceptable.
• Attempts at reduction with inadequate analgesia/
sedation will cause unnecessary pain, cause
muscle spasm, and make subsequent attempts at
reduction more difficult.
35. General Anesthesia if:
• Patient is to be intubated emergently in
Emergency Room.
• Patient is being transported to Operating
Room for emergent head, abdominal or
chest surgery.
• Take advantage of opportunity.
36. Reduction Maneuvers
Allis: Patient supine
Requires at least two persons
Stimson: Patient prone, hip flexed and
leg off stretcher
Requires one person
Impractical in trauma (i.e. most
patients)
37. Allis Maneuver
• Assistant: Stabilizes pelvis
• Posterior-directed force on both ASIS’s
• Surgeon: Stands on stretcher
• Gently flexes hip to 900
• Applies progressively increasing traction to
the extremity
• Applies adduction with internal rotation
• Reduction can often be seen and felt
38. Reduced Hip
• Moves more freely
• Patient more comfortable
• Requires testing of stability
• Simply flexing hip to 900
does not
sufficiently test stability
39. Stability Test
1. Hip flexed to 90
o
2. If hip remains stable, apply internal rotation,
adduction and posterior force.
3. The amount of flexion, adduction and internal
rotation that is necessary to cause hip dislocation
should be documented.
4. Large posterior wall fractures may make
appreciation of dislocation difficult.
40. Irreducible Hip
Requires emergent reduction in O.R.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in O.R. with
anesthesia.
Repeated efforts not likely to be successful and may create
harm to the neurovascular structures or the articular
cartilage.
Surgical approach from side of dislocation.
41. Nonoperative Treatment
• If hip stable after reduction, and reduction congruent.
• Maintain patient comfort.
• ROM precautions (No adduction, Internal Rotation).
• No flexion > 60
o
.
• Early mobilization.
• Touch down weight-bearing for 4-6 weeks.
• Repeat x-rays before allowing weight-bearing.
42. Operative Treatment: Indications
1. 1. Irreducible Hip Dislocations
2. 2. Hip dislocation with femoral neck
fracture
3. 3. Incarcerated fragment in joint
4. 4. Incongruent reduction
5. 5. Unstable hip after reduction
43. 1. Irreducible Anterior Dislocation
Smith-Peterson approach
• Watson-Jones is an alternate approach
1. Allows visualization and retraction of interposed
tissue.
2. Placement of Schanz pin in intertrochanteric
region of femur will assist in manipulation of the
proximal femur.
3. Repair capsule, if this can be accomplished
without further dissection.
44. Irreducible Posterior Dislocation
1. Kocher-Langenbeck approach.
1.Remove interposed tissue, or
release buttonhole.
1.Repair posterior wall of acetabulum if
fractured and amenable to fixation.
45. Irreducible Posterior Dislocation
with Large Femoral Head Fracture
Fortunately, these are rare.
Difficult to fix femoral head fracture from
posterior approach without transecting
ligamentum teres.
46. Two Options
1.Detach femoral head from ligamentum teres,
repair femoral head fracture with hip dislocated,
reduce hip.
2.Close posterior wound, fix femoral head fracture
from anterior approach (either now or later)
Best option not known: Damage to blood supply
from anterior capsule vs. damage to blood supply
from ligamentum teres.
47. 2. Hip Dislocation with Femoral
Neck Fracture
Attempts at closed reduction potentiate chance of fracture
displacement with consequent increased risk of AVN.
If femoral neck fracture is already displaced, the the
ability to reduce the head by closed means is markedly
compromised.
Thus, closed reduction should not be attempted.
48. 2. Hip Dislocation with Femoral
Neck Fracture
Usually the dislocation is posterior.
Thus, Kocher-Langenbeck approach.
If fracture is non-displaced, stabilize fracture
with parallel lag screws first.
If fracture is displaced, reduce femoral head
into acetabulum, reduce femoral neck
fracture, and stabilize femoral neck fracture.
49. 3. Incarcerated Fragment
Can be detected on x-ray or CT scan.
Surgical removal necessary to prevent abrasive wear
of the articular cartilage.
Posterior approach allows best visualization of
acetabulum after intra-op dislocation.
Anterior approach only if:
dislocation was anterior
and, fragment is readily accessible anteriorly.
50. 4. Incongruent Reduction
From:
• Acetabulum Fracture (weight-bearing
portion).
• Femoral Head Fracture (any portion).
• Interposed tissue.
Goal is to achieve congruence by removing
interposed tissue and/or reducing and
stabilizing fracture.
51. 5. Unstable Hip after Reduction
• Due to posterior wall and/or femoral head fracture.
• Reduce and stabilize fracture.
• Labral detachment or tear
– Highly uncommon cause of instability.
– Its presence in the unstable hip would justify surgical repair.
– MRI may be helpful in establishing diagnosis.
52. Results of Treatment
• Large range: from normal to severe pain
and degeneration.
• In general, dislocations with associated femoral head
or acetabulum fractures fare worse.
• Dislocations with fractures of both the femoral head
and the acetabulum have a strong association with
poor results.
• Irreducible hip dislocations have a strong association
with poor results.
53. Complications of Treatment
• Avascular Necrosis (AVN): 1-20%
– Several authors have shown a positive
correlation between duration of dislocation and
rate of AVN.
– Results are best if hip reduced within six hours.
54. Post-traumatic Osteoarthritis
• Can occur with or without AVN.
• May be unavoidable in cases with severe
cartilaginous injury.
• Incidence increases with associated femoral head
or acetabulum fractures.
• Efforts to minimize osteoarthritis are best directed
at achieving anatomic reduction of injury and
preventing abrasive wear between articular
carrtilage and sharp bone edges.
55. Recurrent Dislocation
Rare, unless an underlying bony instability problem
has not been surgically corrected (e.g. excision of
large posterior wall fragment instead of ORIF).
Some cases involve pure dislocation with inadequate
soft-tissue healing – may benefit from surgical
imbrication.
Can occur from detached labrum, which would
benefit from repair.
56. Recurrent Dislocation caused by
Decreased size of Posterior Wall or
Incomplete Femoral Head
Can occur after excision of fractured fragment.
Bony block can provide stability.
Pelvic or intertrochanteric osteotomy could also
improve the alignment of the hip and improve
stability.
57. Delayed Diagnosis of Hip Dislocation
Increased in multiple trauma patients.
Higher if patient has altered sensorium.
Results in: more difficult closed reduction
higher incidence of AVN
In NO Case should a hip dislocation be treated
without reduction.
58. Sciatic Nerve Injury
Occurs in up to 20% of patients with hip
dislocation.
Nerve stretched, compressed or transected.
With reduction: 40% complete resolution
25-35% partial resolution
59. If No Improvement after 3–4 Weeks:
EMG and Nerve Conduction Studies for
baseline information and for prognosis.
Allows localization of injury in the event that
surgery is required.
63. Iatrogenic Sciatic Nerve Injury
Most common with posterior approach to hip.
Results from prolonged retraction on nerve.
64. Iatrogenic Sciatic Nerve Injury
Prevention:
Maintain hip in full extension
Maintain knee in flexion
Avoid retractors in lesser sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)
65. Thromboembolism
Hip dislocation = high risk patient.
Prophylactic treatment with:
• low molecular weight heparin, or
• coumadin
Early postoperative mobilization.
Discontinue when mobilizing independently.
67. Femoral Head Fractures –
Mechanism
• Fracture occurs by shear as femoral head
dislocates.
• With less hip flexion, femoral head
fracture tends to be larger.
70. Pipkin Classification
I Fracture inferior to fovea
II Fracture superior to fovea
III Fracture of femoral head with
acetabulum fracture
IV Fracture of femoral head with
fracture of femoral neck
78. Displaced Infra-foveal Fractures
Can be reduced and stabilized, or excised.
ORIF preferred if possible.
Anterior approach allows best visualization.
80. Pipkin III Fractures
Require appropriate treatment of femoral head
and acetabulum fractures.
Have high incidence of post-traumatic
osteoarthritis.
81. Pipkin IV Fractures
High incidence of AVN with displaced
fractures.
Relative indication for hemiarthroplasty in
older patient.
If femoral head fracture is non-displaced, do
not attempt manipulative reduction of hip
until femoral neck is stabilized.
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Lower Extremity
Index