Fractures in the Hip Region + Arthroplasty Flashcards by JOANN ENRICKE BALBOA

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

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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

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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

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Diagnosis of Acetabular Fracture

Radiographic x-ray (AP view of pelvis and hip, oblique view

CT scan

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For minimally displaced and stable fracture

Skeletal traction 4-6 weeks

Conservative treatment for Acetabular Fracture

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displaced and/or unstable fracture

Surgical treatment for Acetabular Fracture

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Usually due to vehicular accidents or fall from height

Pelvic Fracture

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Force is from anterior going posterior (force from front to back)

Pelvis spring open like a book, hanging on the posterior ligaments

Anteroposterior compression

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Force is from one side of the pelvis (coming from side)

Lateral compression

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Results in instability of the hemipelvis (like jump, vertical)

Vertical shear

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After vigorous muscle contraction as in sports

Can affect iliac spine, ischium (hamstring), lesser trochanter (only a part is affected)

Avulsion fracture

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Usually pubic rami due to fall from standing or seating position

Osteoporosis

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stable (pelvic ring stable)

Type A Pelvic Fracture

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rotationally unstable injury, vertically stable

Type B Pelvic Fracture

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pelvic ring rotationally and vertically unstable

Type C Pelvic Fracture

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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

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Type B Pelvic Fracture

B1: open book
B2: lateral compression, ipsilateral
B3: lateral compression, contralateral, or bucket-handle type injury

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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

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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

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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)

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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

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Dx of Pelvic Fracture

X-ray

CT scan

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Protected weight bearing, pain management, avulsion fractures are treated with rest and early mobilization

Type A and B

Conservative Treatment for Pelvic Fracture

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External or internal fixation

Type C

Surgery Treatment for Pelvic Fracture

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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