Fractures in the Hip Region + Arthroplasty Flashcards
High energy trauma (motor vehicle accidents)
Fall from a height
Direct impact from the femoral head due to impact on the greater trochanter
Indirect trauma (dashboard injury where in the posterior wall of the acetabulum was fractured off by a dislocating femoral head)
Acetabular Fracture
Signs and Symptoms of Acetabular Fracture
Pain over the hip area
Deformity depending on the mechanism of injury and degree of fracture displacement
Contusion and hematoma over the area affected
Sciatic nerve palsy-most common
Hemodynamic instability
Superior gluteal artery or vein may be injured by the fracture at the greater sciatic notch
Heterotrophic ossification especially after surgery
Avascular necrosis of the femoral head
Chondrolysis Post traumatic arthritis
Complications of Acetabular Fracture
Diagnosis of Acetabular Fracture
Radiographic x-ray (AP view of pelvis and hip, oblique view
CT scan
For minimally displaced and stable fracture
Skeletal traction 4-6 weeks
Conservative treatment for Acetabular Fracture
displaced and/or unstable fracture
Surgical treatment for Acetabular Fracture
Usually due to vehicular accidents or fall from height
Pelvic Fracture
Force is from anterior going posterior (force from front to back)
Pelvis spring open like a book, hanging on the posterior ligaments
Anteroposterior compression
Force is from one side of the pelvis (coming from side)
Lateral compression
Results in instability of the hemipelvis (like jump, vertical)
Vertical shear
After vigorous muscle contraction as in sports
Can affect iliac spine, ischium (hamstring), lesser trochanter (only a part is affected)
Avulsion fracture
Usually pubic rami due to fall from standing or seating position
Osteoporosis
stable (pelvic ring stable)
Type A Pelvic Fracture
rotationally unstable injury, vertically stable
Type B Pelvic Fracture
pelvic ring rotationally and vertically unstable
Type C Pelvic Fracture
Type A Pelvic Fracture
A1: fractures not involving the ring (i.e. avulsions, iliac wing, or crest fractures)
A2: stable minimally displaced fractures of the pelvic ring
Type B Pelvic Fracture
B1: open book
B2: lateral compression, ipsilateral
B3: lateral compression, contralateral, or bucket-handle type injury
Type C Pelvic Fracture
Dangerous because of the organs, and vessels in it that can be punctured.
C1: Unilateral
C2: Bilateral
C3: associated with acetabular fracture
Hemorrhage
Injury to the lumbosacral plexus and nerve roots
Bladder and urethral injuries
Bowel injuries
Infection
Deep venous thrombosis (one of the vein clotted and dilodged = sudden difficulty of patient: common cause of death in pelvic with pelvic fractures)
Malunion leading to chronic pain
Non union
High mortality rate (30-50% for open fracture, 10- 30% for close fracture)
Complications of Pelvic Fracture
Signs and symptoms of Pelvic Fracture
Pain over pelvic injury
Pain when stressing the pelvis in compression or distraction
Massive flank or buttock contusion with hematoma
Leg length discrepancy (do xray to see if there is fracture)
Signs and symptoms for Avulsions
Swelling over the involved area
Pain and tenderness of the involved area that is exacerbated by forceful contraction of involved muscle
Dx of Pelvic Fracture
X-ray
CT scan
Protected weight bearing, pain management, avulsion fractures are treated with rest and early mobilization
Type A and B
Conservative Treatment for Pelvic Fracture
External or internal fixation
Type C
Surgery Treatment for Pelvic Fracture
Can affect the following
Femoral head
Femoral neck
Intertrochanteric area
Femoral fracture
Usually occurs with dislocations of the hip
Femoral Head Fracture
Etiology of Femoral Head Fracture
Trauma
Fatigue fractures
In osteopenic patients or those starting a new exercise regimen
Called subchondral impaction or insufficiency fractures
Fatigue fractures
based on the location of the fracture and on the presence of associated fracture
Pipkin classification
Fx below fovea/ligamentum (small)
Does not involve the weight bearing portion of the femoral head
Type I Pipkin
Fx above fovea/ ligamentum (larger)
Involves the weight bearing portion of the femoral head
Type II Pipkin
Type I or II with associated femoral neck fx
High incidence of Avascular necrosis
Type III Pipkin
Type I or II with associated acetabular fx (usually posterior wall fracture)
Type IV Pipkin
Indication for conservative treatment of Femoral Head Fractture
Pipkin 1
Undisplaced Pipkin II with < 1 mm step off
No interposed ligaments
Stable hip joint
Reduction
- Acute dislocation
- Reduce hip dislocation within 6 hours
Touch down weight bearing within 4-6 weeks and restrict adduction and IR
Conservative Treatment for Femoral Head Fracture
ORIF
Arthroplasty (replace hip)
Surgical treatment for Femoral Head Fracture
Pipkin II with > 1mm step off
if performing removal of loose bodies in the joint
associated neck or acetabular fx (Pipkin type III and IV)
polytrauma (multiple trauma)
irreducible fracture-dislocation
Pipkin IV
Indications for ORIF
Pipkin I, II (displaced), III, and IV in older patients
fractures that are significantly displaced, osteoporotic or comminuted
Indications for Arthroplasty (Hip replacement
Common in osteoporotic elderly patients (because of ward’s area of the neck)
Can occur in younger individuals after high energy
Femoral Neck Fracture
Etiology of Femoral Neck Fracture
Fall (especially in osteoporotic individuals)
Major trauma
Classification of Femoral Neck Fracture
Garden Classification
incomplete fracture
Type 1 Garden Classification
complete but undisplaced fracture
Type 2 Garden Classification
complete fracture with partial displacement
Type 3 Garden Classification
complete fracture with complete displacement
Type 4 Garden Classification
Pain
Involved extremity is shortened and externally rotated
Inability to ambulate or ambulates with a limp
Tenderness with percussion of the greater trochanter
Signs and Symptoms of femoral neck fracture
Nonunion (after 6 months still did not unite)
Avascular necrosis
Infection
Deep venous thrombosis and pulmonary embolism
Mortality –14% to 50% in the first year
Complications of Femoral Neck Fracture
Dx of Femoral NECK Fracture
X-ray – AP and lateral view
MRI
For debilitated patient with high risk for mortality or patient who are nonambulatory with minimal discomfort
Must be mobilized from bed to wheelchair as soon as pain permits
Non-ambulatory for 6 wks
Conservative Treatment for Femoral Neck Fracture
For young patients to prevent risk of avascular necrosis
May involve use of screws or joint (hip) replacement
Surgical treatment for Femoral Neck Fracture
Usually involves older patient than those who sustain a femoral neck fracture (does not cause avascular necrosis because the blood supply to the trochanteric area come from nutrient artery)
Intertrochanteric Fracture
Etiology of Intertrochanteric Fracture
Low energy injury such as fall
High energy injury
- Usually in young patients
- Motor vehicular accidents or fall from height
Classification of Intertrochanteric Fracture
Evans Classification
Varus collapse
Wound infection
Non-union (rare)
Avascular necrosis (rare–not common)
Mortality (30% in the first year)
Complications of Intertrochanteric Fracture
Pain
Shortened limb in external rotation of fracture is displaced
Inability to ambulate
Tenderness to percussion on the greater trochanter
Ecchymosis
Signs and Symptoms of Intertrochanteric Fracture
Dx of Intertrochanteric Fracture
X-ray
MRI or bone scan
For patients with high risk for developing surgical complications
Traction and bed rest
Conservative treatment of Intertrochanteric Fracture
Close or open reduction followed by internal fixator (ORIF)
Surgical treatment for Intertrochanteric Fracture
Trochanteric and Subcapital Fracture
Position of the Foot
produce shortening and lateral rotation of the leg
Trochanteric and Subcapital Fracture
Shortening due to the strong muscles of the thigh
rectus femoris, the adductor muscles, and the hamstring (loss of attachment causes leg to shorten)
Trochanteric and Subcapital Fracture
Lateral rotation due to
distal fragment rotates (as seen with toes pointing outwards) because: gluteus maximus, piriformis, obturator internus, gemelli, and quadratus femoris
Trochanteric and Subcapital Fracture
If there is femoral fracture
he hip is shortened and ER.
to replace hip
Common procedure performed in cases of severe joint damage caused by arthritis, displaced femoral neck fractures, and avascular necrosis
Arthroplasty
Pain relief
Restoring motion to a stiffened joint
Maintain stability
Ambulate the patient early
Goals of Arthroplasty
3 types of Arthroplasty
Resectional Arthroplasty
Interpositional arthroplasty
Replacement Arthroplasty
removal of a segment of bone from one or both surfaces of the joint
Leaves a gap of 2cm or more which is subsequently filled up with fibrous tissue
Motion is improved and pain relieved but stability diminished
E.g Girdlestone excision (Floating Hip) for severe chronic infection
Resectional Arthroplasty
involves insertion of a substance like fascia, skin, plastic or metal between the two reconstructed joint surfaces
Only offered limited success
Interpositional arthroplasty
one or both joint surfaces are replaced by a prosthesis/implant made of metal, plastic or a combination
Replacement Arthroplasty
2 types of Replacement Arthroplasty
Total hip and Partial hip arthroplasty (hemiarthroplasty)
articular surfaces of femur and acetabulum is replaced (replace head and acetabulum)
Total hip arthroplasty
replacement of the articular surface of the femoral head only (replaces head only)
Partial hip arthroplasty (hemiarthroplasty
used in less active and older patients unlikely to outlive the hip implant
complication: predispose to acetabular erosion leading protrusio acetabuli
Unipolar hemiarthroplasty
replacement of the head and the neck with an additional acetabular cup that is not attached to the pelvis
Bipolar hemiarthroplasty
Types of arthroplasty fixation
Cemented
Cementless
relies on bone growth into the prosthesis for fixation
Younger and active patients.
Cannot do weight bearing immediately
Cementless Fixation
dislocation of the prosthesis
Fracture
Nerve impingement (Sciatic n.)
Complications of Arthroplasty
No flexion beyond 90 degrees (not sit on low chair: will go beyond 90)
No abduction beyond 45 degrees
No adduction beyond midline
No rotation
dislocation of the prosthesis
LCPD VS SCFE - Gender
Both Males
LCPD VS SCFE - Age
LCPD - < 7 yo
SCFE - > 7 yo
LCPD VS SCFE - Structure of Patient
LCPD - Thin
SCFE - Obese
LCPD VS SCFE - Pathology
LCPD - Avascular necrosis
SCFE - Slipping of the femoral head at epiphysis
LCPD VS SCFE - Treatment
LCPD - Braces (& traction)
SCFE - Traction
