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Yr3 Surgery: Orthopaedics > Hip 2 > Flashcards

Hip 2 Flashcards

1
Q

Remind yourself of the bony landmarks of the humerus

A
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2
Q

What is the common mechanism of injury for #femoral shaft?

A
  • High energy trauma
  • Fragility fracture (low energy)
  • Pathological fracture
  • Bisophosphonate-related fractures (classically this is a transverse fracture in proximal femur)
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3
Q

The femur is not highly vascularised; true or false?

A

False; it is highly vascularised due to its role in haematopoesis. It is supplied by penetrating branches of the profunda femoris. Consequently large volumes of blood (1500mL) can be lost when it fractures

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4
Q

Describe the typical presentation of someone with #femoral shaft

A
  • Pain in thigh, +/- hip, +/- knee
  • Inability to weight bear
  • +/- deformity
    • Proximal femur: abducted & flexed
    • Distal: adducted & extended
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5
Q

Explain why the leg takes the following position during #femoral shaft

  • Proximal: abducted & flexed
  • Distal: adducted & extended
A
  • Proximal: abducted due to gluteus medius & minimus, flexed due to iliopsoas action on lesser trochanter
  • Distal: adducted due to adductor omuscles (adductor magnus, gracilis) and extended deu to pull of gastrocnemius on posterior femur
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6
Q

What classification is used for #femoral shaft?

Describe this classification

A

Winquist & Hansen (used to classify degree of comminution of femoral shaft fractures)

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7
Q

What investigations are required for a suspected #femoral shaft?

A
  • Plain film radiograph (AP & lateral. Must include entire femur, hip & knee)
  • ?CT is polytrauma
  • Routine urgent bloods (including coagulation & group and save)
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8
Q

Discuss the management of a #femoral shaft, include:

  • Immediate management
  • Definitive management
A

Immediate Management

  • Stabilise pt using ATLS
  • Pain relief (e.g. opiods, fascia iliac block)
  • Immediate reduction & immobilisation (traction splinting is used in isolated femoral shaft fractures)

Definitive Management

  • Most require surgery
    • Antegrade intramedullary nail
    • Or retrograde IM nail if have hip replacement or concurrent lower limb fractures
    • May do external fixation followed later by IM nail if pt unstable/needs optimising before defintive surgery
  • Long-leg cast may be indicated in undisplaced #femoral shaft in pts not fit for surgery
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9
Q

Why is it important that we reduce fractures to near-anatomical alignment using in line traction?

A
  • Ensures appropriate haematoma formation (part of healing process)
  • Reduces pain

*In suspected or isolated femoral shaft fractures can use Kendrick traction splint

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10
Q

State some contraindications to traction splinting in #femoral shaft

A
  • Hip or pelvic fracturs
  • Supracondylar fractures
  • Fractures of ankle & foot
  • Partial amputation
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11
Q

Femoral fractures should be surgically fixed within how many hours?

A

24-48hrs (sooner if open fracture)

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12
Q

State some potential complications of femoral shaft fractures

A
  • Neurovascular injury
    • Pudendal nerve injury (10%)
    • Femoral nerve injury
  • Mal-union, delayed union or non-union
  • Infection
  • Fat embolism
  • Hip flexor weakness
  • Knee extensor weakness
  • Limb stiffness
  • Re-fracture
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13
Q

What symptoms would someone have if they had sustained a pudendal nerve injury during #femoral shaft?

A
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14
Q

Discuss the prognosis of femoral shaft fractures

A
  • Pts who survive initial trauma typically heal well
  • Early mobilisation reduces complications
  • Pts >60yrs have mortality of 17% and overall complication rate of 54%
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15
Q

What is meant by a distal femoral fracture?

A

Fracture between the distal metaphyseal-diaphyseal junction of femur to the articular surface of femoral condyles

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16
Q

State some common mechanisms of injury for distal femoral fractures

A
  • High energy tauma in younger
  • Low energy trauma in older/pathological fracture
  • Peri-prosthetic fracture
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17
Q

How do we classify distal femoral fractures?

A

Classify into:

  • A= extra-aritcular
  • B= partial articular
  • C= complete articular

Partial articular can be further classified into sagittal and coronal fractures of each condyle

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18
Q

What is a Hoffa fracture?

A

Subtype of a type B distal femoral fracuture in which there is fracture of the posterior aspect of the femoral condyles in coronal plane. More commonly unicondylar affecting lateral condyle.

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19
Q

Describe the typical presentation of someone with a distal femoral fracture

A
  • Pain in thigh
  • Inability to weight bear
  • Swelling of distal thigh
  • Ecchymosis of distal thigh
  • Knee effusion (if fracture extends intra-articular then haemarthrosis may be present causing knee effusion)
  • Deformity
20
Q

What investigations should you do in suspected distal femoral shaft fracture?

A
  • Plain radiographs (AP & lateral. Must include entire femur and knee)
  • CT if suspect intra-articular invovlement
  • Urgent routine bloods including coagualtion & group and save
21
Q

Discuss the management of distal femoral fractures

A

Initial

  • ATLS
  • Analgesia
  • Reduction
  • Immobilisation using skin traction

Definitive

  • Most managed surgically
    • ORIF using retrograde IM nail or plate
  • Non-operative managmenet if not suitable for surgery or is non-ambulatory. Long period of immobilisation (using splints, casts, traction etc…) and non-weight bearing
22
Q

State some potential complications of distal femoral fractures

A
  • Malunion
  • Nonunion
  • OA
23
Q

What are peri-prosthetic fractures?

A
  • Distal femur fracture related to knee replacement
  • Management more complex and may include IM nailing, revision to prosthesis or distal femoral replacement
24
Q

What is meant by quadriceps tendon rupture?

A

Loss of congruency, either partial or complete, of quadriceps tendon

25
Q

What is the most common mechanism of injury for quadriceps tendon rupture?

A
  • Sudden excesssive loading of quadriceps e.g. landing from jump
26
Q

State some risk factors for quadriceps tendon rupture- highlighted the main one

A
27
Q

Describe the typical presentation for quadriceps tendon rupture

A
  • Heard a pop or tearing sensation
  • Pain in atnerior knee or thigh
  • Difficulty weight bearing
  • Localsied swelling in distal thigh
  • Tender palpable defect superior to patella
  • Knee extension compromised:
    • Complete tear: inability to extend knee
    • Partial tear: decreased ability or inability to extend knee
28
Q

What investigations are required if you suspect a quadriceps tendon rupture?

A

Can be diagnosed clinically- especially complete tears as the clinical signs are more apparent. May do investigations to aid diagnosis e.g:

  • USS: definitive diagnosis & assess degree of rupture
  • Plain film radiograph: caudally displaced patella in complete tears
  • MRI can be helpful if still uncertainty
29
Q

Discuss the management of quadriceps tendon rupture

A

Treatment depends on degree of rupture:

  • Partial tears with extensor mechanism intact
    • ​Manage non-operatively with immobilisation in a brace in tandem with intensive rehabilitation
  • Complete tears or partial tears with extensor mechanism not intacted
    • Surgial mangement
      • Tears at insertion: longitudinal drill holes or suture anchors
      • Intra-tendinous tears: end to end sutures
      • Chronic ruptures may require tendon lengthening due to tendon retraction
      • Post-operatively knee immobilised in brace for approximately 6 weeks; at which point start doing physio
30
Q

Which joint is most commonly affected by OA?

A
  1. Knee
  2. Hip
31
Q

State some risk factors fo rhip OA, consider:

  • Systemic risk factors
  • Local risk factors
A

Systemic

  • Age
  • Obesity
  • Female
  • Vit D deficiency
  • Genetics

Local

  • History of trauma to hip
  • Muscle weakness
  • Joint laxity
  • Participation in high impact sports
  • Anatomical abnormalities
32
Q

Describe typical presentation of hip OA

A
  • Pain
    • Aggravated by activity
    • Relieved by rest
  • Stiffness
  • Crepitus
  • Passive & active movement painful
  • Reduced range of motion
  • Fixed flexion deformity
33
Q

What investigations would you do if you suspect hip OA?

A
  • Plain radiograph of hip
34
Q

Remind yourself of cardinal signs of OA on x-ray

A
  • Loss of joint space
  • Osteophytes
  • Subchondral bony cysts
  • Subchondral sclerosis
35
Q

What tools can be used to classify OA progression?

A
  • Oxford hip score- looks at pain & function
  • Western Ontario & McMaster Universities Arthritis index (WOMAC)- looks at pain, stiffness and function

*image shows result interpretation for oxford hip score

36
Q

Discuss the management of hip OA

A
  • Lifestyle modifications
  • Analgesia
  • Physiotherapy
  • Surgical
    • Hemiathroplasty
    • Total hip replacement
37
Q

Discuss the 3 different approaches to hip replacement surgery

A

Approach is defined by relation to gluteus medius:

  • Posterior:
    • Most comon
    • Rehabilitation fast due to preserving abductor mechanism
    • Greatest risk of damage to sciatic nerve & of dislocation
  • Anterolateral
    • Abductor mechanism detached allowing full exposure of acetabulum
    • Superior retinacular vessels not interupted lowering risk of AVN
    • Risk of damage to gluteal nerve
  • Anterior
    • Rarely used for athroplasty
    • Most commonly used for hip wash-outs
38
Q

State some potential post-operative comlplications of hip athroplasty

A
  • VTE
  • Bleeding
  • Dislocation
  • Infection
  • Lossening of prosthesis
  • Leg length discrepancy
39
Q

How long does an artificial hip typically last?

A

15-20yrs

40
Q

What does this x-ray show?

A

Total hip relacement

41
Q

What does this x-ray show?

A

Hemi-athroplasty of hip

42
Q

For femoracetabular syndrome, state:

  • What it is
  • Different types
  • Symptoms & signs
  • Investigations
  • Management
A
  • Extra bone grows either on acetabulum or femoral head resulting in the bones of the hip joint not fitting together as they should; hence, the bones rub against each other during movement
  • Types:
    • Pincer: extra bone extends out of rim of acetabulum
    • Cam: extra bone forms on femora head so it is no longer round
    • Combined: both of the above
  • Symptoms:
    • Pain (worse on hip flexion)
    • Stiffness
    • Limping
  • Investigations:
    • Plain radiographs
    • MRI (look for damage to labrum & cartilage)
  • Management:
    • Non-surgical: activity modification, NSAIDs, physio, corticosteroid joint injections
    • Surgical: arthroscopy to remove the extra bone or athroplasty
43
Q

For Perthes disease, discuss:

  • What it is
  • Presentation
  • Investigations
  • Management
  • Complications
A
  • Disruption of blood flow to the epipyses resulting in avascular necrosis of epiphyses
  • Common between 4-12yrs, boys>girls:
    • Pain in the hip or groin
    • Limp
    • Restricted hip movements
    • There may be referred pain to the knee
  • Investigations: x-ray
  • Management (aim is to maintain good position/alignmen to reduce risk of damage to femoral head):
    • Bed rest
    • Traction
    • Crutches
    • Analgesia
    • Physiotherapy
    • Regular xrays are used to assess healing.
    • Surgery (if bone not healing)
  • Over time there is revascularisation or neovascularisation and healing of the femoral head. There is remodelling of the bone as it heals. The main complication is a soft and deformed femoral head, leading to early hip osteoarthritis. This leads to an artificial total hip replacement in around 5% of pa
44
Q

For SUFE, discuss:

  • What it is
  • How it presents
  • Investigations
  • Management
A
  • Head of femur ‘slips off’/displaces off the femur along the growth plate
  • Usually an obese 10-14yr old boy presenting with:
    • Hip, groin, thigh or knee pain
    • Painful limp
    • Restricted ROM (particualarly internal rotation)
    • Prefer to keep hip externally rotated
  • X-ray
  • Surgical screw to fix head of femur to femur. Non-weight bearing for 6 weeks.
45
Q

Compare Perthe’s and SUFE, consider:

  • Ages
  • What problem is
  • Treatment
A

Yr3 Surgery: Orthopaedics (14 decks)

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