47. Femur and Hip Flashcards
Major arterial supply for the femoral head and neck
med and lat circumfelx a
branches of em a
Femur predominant artery supplt
deep femoral a
Which m are innervated by anterior branch of femoral n?
pectineus
sartorius
Posterior branch of femoral n gives off saphenous n- where does this give off sensation?
motor function of posterior to?
skin along medial aspect of lower leg
motor function of posterior to quads fem
Sciatic n innervation in the thigh ?
motro for add magnus
hamstring
Sciatic nerve becomes which nerves
prox to pop fossa = tibial and common peroneal
Leading cause of hip fracture?
osteoporosis
Anterior compartment of the thigh - which m, n and vessels?
quad fem
sartorius
ilacus
psoas
pectineus
lat fem cutaneous
fem a and v
Medial compartment of the thigh - which m, n and vessels?
gracilis
add longus and magnus
obturator ext
obturator n
profundus fem a
obturator a and vein
Posterior compartment of the thigh - which m, n and vessels?
bicep fem
semit, semim
add magnus
sciatic, posterior femoral cutaneous n
profundus fem a branches
RF for osteoporosis
aging
genetics
vitamin d defic
lack of PA
smoking
AVN: what is this?
ischemic death of boe of fem head after blood supply compromise
Causes of AVN
chronic CS therapy
chr etoh
hemoglobinopathy
dysbarism
chronic pancreatits
HIV
What is the most cause of traumatic avn of the hip?
hip dislocation or femoral neck fracture - disrupts blood supply to fem head
Why is a hip dislocation an orthopedic emergency
due to after 6h, risk of AVN develops in about 5% of pt and <12h = 60%
Femoral neck vs intertrochanteric and subtrochanteric fractures - which is risk of AVN moreso?
neck –> as bleeding can tamponade effect as well
intertroch and sub: have rich blood supply so less risk
Who is at risk for myositis ossificans?
bleeding post trauma
hemophilia/blood disorder
MC site of calcific bursitis?
trochanteric bursa
Which cancers cause bony mets most often?
breast
kidney
lung
thyroid
prostate
MC primary bony neoplasm of the hip?
osteoid osteoma
What kind of hip fracture?
External rotation, abduction, and short- ening
displaced femoral neck
What kind of hip fracture?
External rotation with shortening
intertrochanteric
Name 10 causes of a painful hip without obvious fracture
Referred pain (lumbar spine, hip, or knee) Avascular necrosis (AVN) of the femoral head Degenerative joint disease or osteoarthritis Herniation of a lumbar disk
Diskitis
Transient synovitis of the hip
Septic arthritis
Bursitis
Tendonitis
Ligamentous injuries of the knee or hip Occult fracture
Slipped capital femoral epiphysis (SCFE) Perthes’ disease
Tumor (lymphoma)
Deep venous thrombosis
Arterial insufficiency
Osteomyelitis
Iliopsoas abscess
Retroperitoneal hematoma
Inguinal hernia
Inguinal lymphadenopathy Genitourinary complaints Sports-related hernia
What lines on XR can you use to ID a hip fracture for subtle fractures
shenton line
ormal S and reverse S
trabecular lines fmeoral shaft to femoral head
XR hip: describe the normal S and reverse S
In normal anatomic posi- tion, the convex outline of a normal femoral head smoothly joins the concave outline of the femoral neck. This produces an “S” curve and a reverse “S” curve, regardless of the orientation of the radio- graphic projection. In searching for a fracture of the femoral neck, the medial and lateral cortical margins of the femoral head and neck should be carefully examined for these curves (Fig. 47.12). A fracture produces a tangential or sharp angle, indicating disruption of the normal anatomic relationship.
XR hip fracture: trabecular lines - how are these helpful in finding fractures?
tracing the trabecular lines as they pass from the femoral shaft to the femoral head. Disruption of these lines as they pass through the fracture site is often the only subtle clue.
How much blood can you lose into your hip in a fracture?
up to 3 units
Hip fracture splinting - options in prehospital
Hare splint
Sager splint
Contraindications to use of traction splint for hip in prehospital
suspected pelvic fracture
patellar fracture
ligament knee injury
tib fib fracture
Hip fracture traction - which two nerves more likely to be injured during transport or surgery than fracture itself?
femoral
sciatic
What constitutes a type I open fracture?
wound size <1cm
minimal soft tissue damage
bone edge pierces outward
What constitutes a type II open fracture?
wound size 1-10cm
or moderate soft tissue damage without nerve, article or periosteal stripping
variable mechanism
What constitutes a type III open fracture?
wound size >10cm
extensive m devitalization, n and arterial involvement
high e mechanism like blast, shotgun
what nerve block is helpful in hip fracture?
femoral n block
Hip pain in a teenage athl/someone <25 with acceraltion or sudden change in speed/direction, pop at site
avulsion fracture concern
ASIS avulsion fracture - m?
sartorius
AIIS avulsion m?
rec fem
which m avulsion from ishical tuberosity?
hamstrings
Displacement of avulsion injury 2cm vs >2cm
<2cm conservation
>2 operative to prevent noniunion or union with ++ callus
Proximal femur neck fracture: 3 ways to describe?
intracapsular or not
anatomic loc (troch, nec, intertroch, subtroch, shaft)
degree of displacment
Position of leg with a femoral neck fracture
limb ER
abd
slightly shortened
With a femoral neck #, should you ROM?
no - further disrupt blood supply
Tx of femoral neck #
ORIF
hemi or tha
two major complications of femoral neck fractures?
avn
nonunion
Intertroch fracture: where?
between g and lesser trochanter femur - extracapslar
Intertroch fracture - requires full r___ prior to op
resusc
Greater or lesser troch isolated fracture - 2 common mechanisms
fall directly onto troch
avulsion of iliopsoas
Subtrochanteric fracture region?
below lesser and proximal 5cm of femoral shaft
Subtrochanteric fracture - why often so deformed?
displaced fractures - iliopsoas, glut and ER consistently produce flex, abd and ER of proximal fragment
Subtrochanteric fracture - name 4 pathologic causes
paget
mets
renal osteodystrophy
osteogenesis imperfecta
osteomalacia
Subtrochanteric fracture - cause of shock?
yes!
but also still look elsewhere
Subtrochanteric fracture management
ORIF
Subtrochanteric fracture complications
fat embolism
Nontraumatic causes of femoral shaft fracture
unicameral bone cyst
fibrous dysplasia
osteogenesis imperfecta
malignancy
3 hip/.femur fractures that can cause significant bleed
femoral shaft
intertroch
subtroch
Femoral shaft fracture fixation?
IM rod
Hip dislocations often have what elsewhere?
fractures
MC direction of hip dislocation?
posterior
mechanism of movement for anterior hip dislocation?
fored ext
abd and
ER of femoral head
mechanism of movement for posterior hip dislocation?
with hip adducted, flexed and IR at impact
What is a luxatio ereta femoris?
rare inferior dislocation of the hip associated with inversion of the femoral shaft with our without assoc trochanteric fracture
Posterior dislocation hip position - what will you see in patient?
hip flex adducted and IR, may appear short
vs anterior: abd, flexed, ER, may appear lengthened
What nerve are people worried about in a posterior hip dislocation?
sciatic and femoral vessels
Most sn clinical sign of peroneal n weakness - which m?
ext hallucis longus
also weak dorsiflexion and numbling/tingling over same
XR findings of hip dislocation
lesser troch not seen in posterior vs prominent in ant
femoral head smaller vs larger in anterior
disruption of shenton line
Hip dislocation management in the ED
need to be reduced within 6h
Contraindication to hip dislocation
femoral neck fracture
traction in another distal extremity
Allis technique for hip relocation
pt supine
assistant stabilize pelvis
knee flexed and traction in line with deformity
bring hip to 90 deg flexion with upward and rotation
assistant push gr troch forward to acetabulum
then extend hip one reduced
Stimson technique for hip relocation
pt prone
downtraction on glut by assistant
doc push down behind knee and 90 deg
rotate hem head will assitant pushes greater troch anterior
Captain morgan techn for hip dislocation
- With the patient supine on the stretcher in its lowest position,
secure the pelvis to the stretcher with a bed sheet or strap. Place the strap over the ischial wings and pubic symphysis. This prevents the clinician from lifting the patient off the bed and is more effective than having an assistant try to secure the pelvis. - Stand at the side of the bed and place one foot up on the bed (like Captain Morgan standing on a rum barrel). If additional height is needed, consider using a stable cardiopulmonary resuscitation (CPR) stool.
- Place the patient’s ipsilateral leg over the clinician’s leg so the knee is resting in the patient’s popliteal fossa.
- While holding the ankle in position with slight downward pressure (this is done only to lock the patient’s leg onto the clinician’s leg and is not meant to be a fulcrum), lift up with both legs to apply traction on the femur and reduce the hip.
- If traction alone does not work, the clinician’s hands are used to internally and externally rotate the leg to achieve the reduction.
Whistler techn for hip dislocation
- Start with the patient lying supine on the bed, and secure the patient’s hips to the bed, as for the Captain Morgan technique.
- Bend the contralateral leg so that the patient’s knee is flexed 90 degrees and the foot is on the bed.
- Bend the ipsilateral leg to the same position.
- The clinician’s arm is placed under the ipsilateral knee and rests on
top of the contralateral knee. - The clinician’s body is rotated perpendicular to the patient and
looking at their feet. This causes the clinician to assume a squatting
position. - While holding the patient’s ipsilateral ankle with other hand, the
clinician slowly lifts up with the legs, while keeping the arm straight and strong. This puts traction on the femur and should reduce the dislocation. - If reduction is not achieved with traction alone, the hand that is on the ankle can be used to internally or externally rotate the leg to achieve the reduction.
Pubic dislocation reduction
- Place the patient in the supine position.
- Apply longitudinal traction in line with the deformity.
- Hyperextend and internally rotate the hip while an assistant applies
downward pressure on the femoral head.
Post hip reduction to do
test for stability and try to knee immob to avoid repeat dislocation
xr
Hip dislocation - risk of which ? fracture
femoral head
Early hip dislocations - how many mo?
up to 3
Hip reduction of a prosthesis - what should you do?
in conjunction with ortho consultation
Hamstring strain injury ddx ?
ischial avulsion fractures
Hamstring strain injury management
Crutches and toe-touch weight bearing are recommended until the patient is evaluated
by a physician trained in sports medicine. Appropriate weight- training programs speed rehabilitation of this injury.
Quadriceps tear ddx
patellar fracture can give similar issues with ext
Quadriceps tear: clinical features
Ambulation is significantly affected. There is pain with active and pas- sive knee extension. In significant tears, the patient might be unable to actively extend the knee or main- tain its extension against gravity. A palpable depression just proximal to the superior pole of the patella suggests a complete tear.
Quadriceps tear management in ED
Knee immobilizer and urgent surgical referral for operative repair
Iliopsoas strain - epidemiology?
Gymnasts and dancers are the athletes most likely to experience an injury to the iliopsoas as a result of sudden forceful hip flexion against resistance
Iliopsoas strain - clinical features?
Severe pain often is experienced in the groin, thigh, or low back. Severe intra-abdominal pain is common at the muscle origin and might domi- nate the clinical picture. Examina- tion reveals groin tenderness and pain with active hip flexion.
Iliiopsoas strain: ddx
pelvic fractures
sacroilitis
Iliopsoas: management
bed rest with partial flexion at knee and hip generally RQ for 7-10d
Hip adductor strain: clinical features?
Pain in the groin, the pubic region, and the medial proximal aspect of the thigh. Abduction and adduction often are limited because of pain. Swelling and skin discoloration may confirm presence of the tear. If the tear is complete, a defect in the muscle can be felt by the examiner along the medial aspect of the thigh near the groin.
Hip adductor strain management
Treatment is conser- vative, with patients initially benefiting from rest, with gradual pro- gression in a stretching and strengthening program.
Glute m strain epi
Vigorous or forced hip extension, as seen in track-and-field jumping events.
Glute m strain: tx
Treatment is conser- vative, with patients initially. benefiting from rest, with gradual pro- gression in a stretching and strengthening program.
Pain over greater troch: which m?
glut med
glute min
tfs
piriformis
Lesser troch: m?
iliopsoas
Osteitits pubis: what is this?
pubic symphysis pain and joint disruption and is most common in distance runners and soccer players. The adductor muscles act as a “compression strut,” displacing forces across the hip. The most likely mechanism is repetitive pulling of the adductor muscles, causing increased shearing at the pubic symphysis.
Osteitits pubis: management
self-limited. Patients benefit from activity modification, wearing supportive shoes, and from therapy addressing flexibility and strength of the pelvic and hip musculature. Average time to heal has been reported to be up to 9 months.
Vascular injuries of the hip - which dislocation and fracture may have assoc arterial injury?
hip dlisoc
femoral fractures
Femoral neuropathy features
weak knee extension
sensation decreased along anterior thigh and medial/lower aspect of leg
Sciatic neuropathy features
paralysis of hamstrings and all m below knee
partial injury = weakness of ext HL m most sn
senosry loss below knee and along posterior aspect of hip
