Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
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
A fractured neck of femur (NOF) is a serious injury, especially in older people. It is likely to be life changing and for some people life threatening.
Neck of femur fractures (NOF) are common injuries sustained by older patients who are both more likely to have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. Elderly osteoporotic women are at greatest risk.
Avascular necrosis (AVN) of the femoral head is a pathologic process that results from interruption of blood supply to the bone. AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head. Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment
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
A fractured neck of femur (NOF) is a serious injury, especially in older people. It is likely to be life changing and for some people life threatening.
Neck of femur fractures (NOF) are common injuries sustained by older patients who are both more likely to have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. Elderly osteoporotic women are at greatest risk.
Cervical Hybrid Arthroplasty by Pablo Pazmino MDPablo Pazmino
This video explains Cervical Arthroplasty in combination with a fusion. When people have more than one cervical disc which has degenerated or which has sustained a traumatic rupture they may need a procedure to address both levels. These herniations may begin to affect the surrounding nerves and/or spinal cord. 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 Cervical Herniations/ Radiculopathy at multiple levels feel free to look us up online www.beverlyspine.com or call toll free 1-8SPINECAL-1
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
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
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
2. Learning Objectives
Provide an intuitive understanding of the
morphologic types, injury mechanisms, and
classification systems of adult proximal femur
fractures, using multimodality imaging
examples, 3-D models, and animations.
Review the potential complications and
management.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
3. Proximal Femur Fractures:
Organization Tree
* Basicervical fractures, although intracapsular, are managed like intertrochanteric fractures.
Proximal Femur Fractures
Femoral Head
Osteochondral
Subchondral
Extracapsular
Intertrochanteric
Greater Trochanter
Lesser Trochanter
Subtrochanteric
Intracapsular
Basicervical*
Transcervical
Subcapital
Proximal femur fractures may be divided into femoral head, intracapsular femoral neck, and
extracapsular fractures. Accurately categorizing the anatomic location and subtype of the
fracture has significant implications for surgical management.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
5. Anatomy
MOVIE: Computer generated tour of the relevant muscular, ligamentous, labral, and bony
anatomy of the hip.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
6. Anatomy
The hip is a synovial joint with wide range of rotational motion and stability
Stability is conferred by its ball and deep socket configuration, acetabular labrum, a strong joint capsule,
articular cartilage, and surrounding muscle
One of the few inherently stable joints because of its bony anatomy
Iliofemoral and pubofemoral ligaments cover hip joint anteriorly. Ischiofemoral ligament covers hip joint
posteriorly
Byrne DP et al. The Open Sports Medicine Journal 2010
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
7. Anatomy: Arterial Supply
Medial femoral circumflex artery
• Largest, most important contributor
• Posterior portion of vascular ring
• Supplies superolateral femoral head
Lateral femoral circumflex artery
• Anterior portion of vascular ring
• Supplies inferoanterior femoral head
Obdurator artery
• Via ligamentum teres
• Little supply to femoral head, inadequate in
setting of displaced head/heck fractures
Ascending cervical arteries
• Feeder vessels arising from extracapsular ring
• Penetrate capsule
• Run parallel to femoral neck towards the head
• Lateral vessels provide greatest supply
A major concern of femoral head and
neck fractures is disruption of the
arterial supply, which results in
avascular necrosis. In fractures, the
intraosseous cervical vessels are
disrupted.
Trueta J et al. J Bone Joint Surg BR 1953; Ly TV et al. J Boint Joint Surg Am 2008.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Lat. fem
circumflex
Med. fem
circumflex
Deep femoral
art.
Obdurator art.
8. Hip experiences combined
mechanical loads
• Axial load along shaft, compressive stress
• Bending load along neck, tensile stress applied
at upper neck and compressive stress at lower
neck
Cancellous bone arranged along
principal lines of stress
• Primary medial trabeculae resist compression
• Primary lateral trabeculae resist tension
Stress lines explain patterns of injury
Ward’s Triangle: Weakest point of
femoral neck
Tensile groupCompressive group
Ward’s Triangle
Anatomy: Stress Lines
Byrne DP et al. The Open Sports Medicine Journal 2010; Bowman KF Arthroscopy 2010.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
9. Imaging Modalities
Dominguez S et al. Acad Emerg Med 2005; Frihagen F et al. Acta Orthop 2005; Kirby MW et al. AJR Am J Roentgenol 2010; Khurana B et al. AJR 2012
Plain Film Radiography
• First line study
• 90% sensitive, however 2-11% of ED patients
have radiologically occult fractures
• AP and lateral radiographs of the hip
• AP radiograph of the pelvis, to assess for
pelvic injury and compare with contralateral
hip
CT
• More readily accessible than MRI in acute ED
settings
• Useful in trauma for detecting intra-articular
extension, acetabular fracture, pelvic ring, and
sacral fractures
• However, second-line compared to MRI
because of concerns for missing fracture lines
• May be useful for preoperative evaluation
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Coronal CT demonstrates a valgus impacted
femoral neck fracture
10. Imaging Modalities
Dominguez S et al. Acad Emerg Med 2005; Frihagen F et al. Acta Orthop 2005; Kirby MW et al. AJR Am J Roentgenol 2010 Khurana B et al. AJR 2012
MRI
• Obtain if radiographs are negative/equivocal and clinical suspicion is high
• More sensitive than CT for evaluating occult fractures
• Best for evaluating bone marrow, joint space, osteochondral injuries, early diagnosis
and staging of AVN
• May be limited in access in an acute ED setting
• Technique: Useful MR sequences include the following: coronal STIR, coronal T1, axial
dual-echo, axial T2 fat-saturated FSE, axial fat-saturated FSE proton density, sagittal
T1, axial T1.
• Most useful sequences are coronal STIR (for edema) and coronal T1 (for fracture line)
Bone Scan
• Indicated for suspected fracture or AVN not demonstrated on plain film, and where MRI
unavailable
• High sensitivity, but poor specificity
• Minimum of 4 hours to perform, and may take up to 24-48 hours
• Relatively less useful in osteoporotic patients
• Poor spatial localization of fracture lines
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
11. Occult Femoral Neck Fracture
Seen Only on MRI
Dominguez S et al. Acad Emerg Med 2005
AP radiograph of the hip demonstrates no
evidence of fracture.
On coronal T1 MRI, a hypointense fracture
line is present.
Up to 11% of ED patients have radiologically occult hip fractures
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
12. Traumatic Femoral Head
(Osteochondral) Fractures
Traumatic femoral head fractures typically result from high energy impact, and are often
associated with hip dislocations
Posterior dislocations 9x more common than anterior
Partial flexion, internal rotation typically leads to a posterior fracture-dislocation pattern
Ross JR et al. Curr Rev Musculosk Med. 2012
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
13. Femoral Head Fractures:
Pipkin Classification
Posterior dislocation
Fracture below fovea, non-weight-bearing
Posterior dislocation
Fracture above fovea, weight-bearing
Associated femoral neck fracture Type I, II, or III, associated acetabular fracture
Rockwood and Green’s Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med 2012
Most commonly used classification for femoral head fractures, and used to guide
operative versus nonoperative managementDisclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
15. Traumatic Femoral Head Fractures:
Surgical Considerations
Intra-capsular fracture, concern for avascular necrosis
• Emergent closed reduction as soon as feasible, preferably within 6 hours
• If irreducible, or with femoral neck fracture, then ORIF
Above or below fovea?
• Above fovea, weight bearing
• Below fovea, non-weight bearing, could potentially be treated conservatively
Is traction indicated?
• If fracture flipped, then traction indicated
Congruent?
• If incongruent, then operative management
Management Strategies
• Conservative management: Pipkin I
• ORIF: Pipkin II, Pipkin III, IV, irreducible fracture-dislocation
• Core decompression for osteonecrosis is controversial
Rockwood and Green’s Fractures in Adults 2010; Ross JR et al. Curr Rev Musculosk Med. 2012
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
16. Subchondral Insufficiency
Versus Osteonecrosis
Osteonecrosis
• Typically 30s-40s in age
• Associated with steroid/alcohol use
• 50-70 percent bilateral
MRI
• T1: Smooth band that is concave to the articular surface,
and circumscribes necrotic segments
Treatment
• No femoral head collapse: conservative treatment
• Femoral head collapse: THA or hemiarthroplasty
Yamamoto T Clin Orthop Surg 2012; Ikemura S et al. AJR 2010
Subchondral insufficiency fractures are a recently recognized entity that may mimic osteonecrosis of the
femoral head. However, certain clinical and imaging features will favor one diagnosis over the other.
Osteonecrosis: coronal T1: bilateral decreased T1 signal in the femoral
heads, and serpiginous bands concave to articular surface
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
A B
Subchondral Insufficiency
• Biphasic pattern: elderly females and young active individuals
• Typically unilateral
MRI
• Irregular, hypointense disconnected band that runs almost
parallel to femoral head
• High signal proximal segment on C+ images
Treatment
• No femoral head collapse
• Young: Trochanteric rotational osteotomy
• Elderly: THA or hemiarthroplasty
Subchondral Insufficiency: coronal STIR (A) demonstrates
irregular band parallel to the femoral head. Post-contrast T1
image (B) in a different patient demonstrates femoral head
enhancement
17. Femoral Neck Fracture:
Mechanism
Caused by fall with applied force to the greater trochanter
High energy impact in younger patients, and low energy impact in elderly patients
Weakest site just below articular surface
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
18. Subcapital, Transcervical,
Basicervical Fractures
Transcervical
Treated as intracapsular fx
Basicervical
Treated as extracapsular fx
e.g. like intertrochanteric fx
Subcapital
Treated as intracapsular fx
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
19. Incomplete
Valgus impaction + retroversion
Complete, non-displaced
Marked angulation
Minimal/no proximal translation
Complete displacement
Proximal translation
Commonly used classification for
surgical management of femoral
neck fractures
Valgus impacted fractures are
often missed
Good interobserver agreement
between I-II and III-IV, but poor
between all groups
Better to distinguish I-II and III-IV,
as types III and IV typically treated
with arthroplasty
IVIII
I II
Garden Classification
Frandsen PA et al. Acta Orthop Scand 1984; Kreder HJ J Bone Joint Surg AM 2002
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
20. Pauwel Classification
Type I
More stable
Type III
More unstable, higher energy injury
Determined by angle of fracture from horizontal plane
Increased shear forces with increased angles worsens prognosis
Better categorizes stability than the Garden Classification
Better predicts difficulty of obtaining stable fixation
More vertically oriented fractures may also require plate fixation
Type III fractures complicated by nonunion may require intertrochanteric osteotomy to reorient the fracture
line to a more Type 1 (stable) angle
Ly TV et al. J Bone Joint Surg Am 2008
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Type II
Most common
21. Types of Stress Fractures
Tensile
Unstable, fracture can
propagate
Compressive
More stable
Displaced
Unstable
Worse prognosis and risk for
avascular necrosis
Emergent operation and reduction
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Femoral neck stress fractures are often related to increased activity. The
pattern of the stress fracture relates to the lines of stress within the
proximal femur and has significant management implications
22. Tensile Stress Fracture
Superior, lateral aspect of the femoral neck
Bimodal distribution: Elderly individuals and young runners
Potentially unstable, obtain MRI to assess fracture extent
Warrants internal fixation (nail fixation in young athletes)
Femoral Neck:
Tensile Stress Fracture
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
23. Femoral Neck:
Tensile Stress Fracture
Tensile stress fracture in the superolateral
femoral neck in an elderly patient. Note
osteoarthritis of the hip.
Tensile stress fracture (Garden III) in the
superolateral femoral neck in a young, active,
patient. Note the normal bone mineral density.
Bimodal distribution: elderly individuals and young runners
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
24. Femoral Neck:
Fatigue Compression Fracture
Fatigue Compression Fracture
Inferior aspect of femoral neck
Active individuals
May potentially be treated non-operatively
Coronal STIR image demonstrates edema at the
inferomedial femoral neck.
Coronal T1 image demonstrates a hypointense
region and a subtle fracture line.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
25. Femoral Neck Fractures: Surgical
Considerations
AVN, nonunion may result from delayed diagnosis
• Risk for AVN is greater for femoral neck fractures than for pertrochanteric fractures
Young ( < 65) and/or active
• Goal: preserve femoral head, avoid osteonecrosis, achieve union
Old ( > 75) and/or immobile
• Goal: restore mobility and minimize complications
Fracture pattern determines treatment
• Basicervical fracture treated like intertrochanteric fracture
• Nonoperative management associated with higher complication and increased risk of
displacement
• If nondisplaced, internal fixation preferred
• If displaced fracture, elderly, arthroplasty preferred
• Most studies find improved function with THA compared to hemiarthroplasty
Miler BJ et al. J Bone Joint Surg Am 2013; Goh SK et al. J Arthroplasty 2009; Cserhati P et al. Injury 1996
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
26. Femoral Neck Fracture:
Treatment Algorithm
Nondisplaced
Displaced
Total Hip Arthroplasty
Hemiarthroplasty
OldYoung
PC Screw or ArthroplastyPercutaneous Cancellous (PC) Screw
Miler BJ et al. J Bone Joint Surg Am 2013
Open Reduction Internal Fixation
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
27. Intertrochanteric Fracture
Koval KJ et al. J Am Acad Orthop Surg 1994
Nondisplaced Intertrochanteric fracture (Evans I)
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Anatomy
• Intertrochanteric line: anterior ridge between greater and lesser trochanters
• Extracapsular, transition between femoral neck and shaft
• Iliofemoral ligament attaches above, vastus medialis attaches below
Mechanism
• Resulting from fall
Unstable features
• Loss of medial buttress
• 4-part fractures, and 3-part fractures with
lesser trochanter involvement
• Reverse obliquity
• Comminution
Stable features
• Near anatomic reduction achievable
• Lesser trochanter nondisplaced
• Medial cortices in alignment
• No comminution
28. Evans Classification
Trafton PG. Orthop Clin North Am 1987; Koval KJ et al. J Am Acad Orthop Surg 1994
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
I II III
Two part, undisplaced
Stable
Two part, displaced
Stable
Three part, posterolateral comminution
Unstable
Three part, posteromedial comminution
Unstable
Four Part
Unstable
Useful for deciding stability and treatment of intertrochanteric fractures. Also, reverse obliquity
fractures are unstable and treated like subtrochanteric fractures
IV V
29. Intertrochanteric Fracture:
Management
Incomplete
• Obtain MRI to ensure fracture not complete
• If incomplete and <50% fracture width,
potentially can treat conservatively
• Risk of fracture completion
Complete
• Stable: Dynamic plate and screw
• Unstable or reverse obliquity:
Intramedullary device
Management depends on completeness and stability
Risk of AVN and nonunion less than in femoral neck fractures
Again, basicervical fractures treated like intertrochanteric fractures
Su BW, Orthopedics 2006; Forte ML et al. J Bone Jint Surg Am 2008
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
30. Greater Trochanter Fracture
Anatomy
• Greater trochanter is the insertion site for hip
abductors (gluteus medius and minimus) and
external rotators (piriformis, gemelli, obdurators)
Mechanism
• Isolated greater trochanter fracture may be related
to impaction from fall, versus avulsion
Imaging
• If incomplete, obtain MRI to assess extent of
fracture
Management
• Most heal well with nonoperative management
• If significant displacement, then ORIF
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
31. Lesser Trochanter Fracture
Anatomy
• Lesser trochanter is attachment site for iliopsoas
Mechanism
• Fracture may be due to avulsion
• In the absence of injury, isolated lesser
trochanter fracture is highly suspicious for an
underlying malignancy
Imaging
• Obtain MRI to assess extent of fracture
• Evaluate for underlying malignancy
Management
• Nondisplaced fractures heal well with
nonoperative management
• If significantly displaced, then ORIF
James SL et al. Eur Radiol 2006
Mildly displaced lateral trochanter fracture
in a patient with prostate cancer and
diffuse blastic metastases. Also note the
extensive periosteal reaction.
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
32. Subtrochanteric and Proximal Femoral Shaft:
Traumatic Versus Atypical Fractures
Shane E et al. J Bone Miner Res 2010. Park-Wyllie LY et al. JAMA 2011
Atypical Fractures
Long-term bisphosphonate usage, o/minimal trauma
Imaging
Typically subtrochanteric or femoral shaft
Transverse or short oblique orientation
Lateral beaking (arrow)
Normal bone mineral density
Management
Evaluate contralateral femur
Treat with ORIF, intramedullary nail and screw0
It is important for the radiologist to recognize the different patterns of traumatic and
atypical subtrochanteric and proximal shaft fractures
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References Typical Fractures
Often traumatic, high impact
Imaging
Radiographs generally diagnostic
Oblique or spiral in orientation
Proximal piece is flexed, abducted, and externally rotated
MR/CT if concern for pathologic fracture
Management
ORIF
Higher rates of failure due to high stress anatomy
33. Conclusion
• Proximal femoral fractures can be classified as
femoral head, intracapsular, and extracapsular
• Increased concern for AVN and nonunion for
intracapsular fractures due to vascular compromise
• Important to understand how imaging features reflect
underlying mechanical forces and mechanisms of
injury, and how these in turn guide management
• If a patient has hip pain and negative x-rays, strongly
consider further imaging with MRI
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
34. References
• Trueta J, Harrison MH. The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg Br. 1953;35:442-61
• Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008;90:2. 254-66
• Byrne DP et al. The Open Sports Medicine Journal 2010;4;51-7.
• Bowman KF Jr, Fox J, Sekiya JK. A clinically relevant review of hip biomechanics. Arthroscopy 2010;26(8):1118-29.
• Dominguez S, Liu P, Roberts C et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial
standard radiographs—a study of emergency department patients. Acad Emerg Med 2005;12(4):366-9.
• Frihagen F, Nordsletten L, Tariq R, et al. MRI diagnosis of occult hip fractures. Acta Orthop 2005;76(4):524-30.
• Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol 2010;194(4):1054-60.
• Khurana B, Okanobo H, Ossiani M, et al. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol
2012;198(6):581-8.
• Ross JR, Gardner MJ. Femoral head fractures. Curr Rev Musculoskelet Med 2012;5(3):199-205.
• Rockwood and Green’s Fractures in Adults, 7th Edition. Wolters Kluwer/Lippincott Williams & Wiilkins, New York, 2010.
• Yamamoto T. Subchondral insufficiency fractures of the femoral head. Clin Orthop Surg. 2012:4(3):173-80.
• Ikemura S, Yamamoto T, Motomura G, et al. MRI evaluation of collapsed femoral heads in patients 60 years old or older: differentiation of subchondral
insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol 2010;195:W63-W68.
• Frandsen PA, Andersen PE Jr, Christoffersen H et al. Osteosynthesis of femoral neck fracture. The sliding-screw-plate with or without compression.
Acta Orthop Scand 1984;55(6):620-3.
• Kreder HJ. Arthroscopy led to fewer failures and more complications than did internal fixation for displaced fractures of the femoral neck. J Bone Joint
Surg Am 2002;84:2108.
• Miller BJ, Lu X, Cram P. The Trends in Treatment of Femoral Neck Fractures in the Medicare Population from 1991 to 2008. J Bone Joint Surg Am
2013:95(18):1-8.
• Goh SK, Samuel M, Su DHC et al. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur
fracture. J Arthroplasty. 2009:24(13):400-6.
• Koval KJ, Zuckerman JD. Hip fractures, II: evaluation and treatment of intertrochanteric fractures. J Am Acad Orthop Surg 1994;2(3):150-6.
• Trafton PG. Subtrochanteric-intertrochanteric femoral fractures. Orthop Clin North Am 1987;18(1):59-71.
• Su BW, Heyworth BE, Protopsaltis TS et al. Basicervical versus intertrochanteric fractures: an analysis of radiographic and functional outcomes.
Orthopedics 2006;29(10):919-25.
• Forte ML, Vimig BA, Kane RL. Geographic variation in device use for intertrochanteriic hif fractures. J Bone Joint Surg Am 2008;90(4):691-9.
• James Sl, Davies Am. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512-4
• Shane E, Burr D, Ebeling PR et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society of Bone
and Mineral Research 2010; 25(11):2267-94
• Park-Wyllie LY, Mamdani MM, Juurlink DN. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA
2011;305(8):783-9.
• Tornetta P III. Subtrochanteric femur fracture. J Orthop Trauma 2002;16(4);280-3
Thank You For Viewing Our Exhibit – Jeffrey Shyu (jshyu@partners.org)
Disclosures
Learning
Objectives
Organization
Anatomy
Imaging
Osteochondral
Subchondral
Femoral Neck
Intertrochanteric
Greater Troch.
Lesser Troch.
Subtrochanteric
Conclusion
References
Editor's Notes
Trueta J, Harrison MH. The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg Br. 1953;35-442-61
Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008;90:2. 254-66
24877631
F01136644
03233905
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24877631
F01136644
03233905
20025920
chart
Miller BJ, Lu X, Cram P. The Trends in Treatment of Femoral Neck Fractures in the Medicare Population from 1991 to 2008. J Bone Joint Surg Am 2013:95(18):1-8.
Goh SK, Samuel M, Su DHC et al. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture. J Arthroplasty. 2009:24(13):400-6.
Cserhati P, Kazar G, Manninger J, Fekete k, Frenyo S. Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases. Injury 1996;27;8:583-8.
Miller BJ, Lu X, Cram P. The Trends in Treatment of Femoral Neck Fractures in the Medicare Population from 1991 to 2008. J Bone Joint Surg Am 2013:95(18):1-8.
Sliding hip screw for nondisplaced fx
F00495342
Su BW, Heyworth BE, Protopsaltis TS et al. Basicervical versus intertrochanteric fractures: an analysis of radiographic and functional outcomes. Orthopedics 2006;29;10:919-25.
James Sl, Davies Am. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006 16(2):512-4
Park-Wyllie LY, Mamdani MM, Juurlink DN. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA 2011;305(8):783-9.