Hip Trauma

Question 1

Examples of hip trauma

Answer 1

-Neck of femur fractures
-Pubic rami fractures
-Femoral fractures
=Femoral diaphysis

Question 2

General principles of hip trauma and pain

Answer 2

-Pain from the hip joint is felt in the groin or the buttock; it is not felt over the lateral aspect of the thigh
-It may be referred to the knee, particularly in extremes of age
-Always consider the spine

Question 3

Describe neck of femur fracture (NOF#)

Answer 3

-Very common, 3: 1 F:M
-Associated with frailty
-Poor outcomes: 1/3 die within year, 1/3 decline in independence, 1/3 return to previous baseline function

Question 3

Presentation and investigation of NOF#

Answer 3

-Short, externally rotated leg
-Pain on pin rolling
-Patients with non-displaced or incomplete neck of femur fractures may be able to weight bear

Question 3

Management of NOF#

Answer 3

-Early surgery in all cases
-Joint care under geriatricians and orthopaedics
-Extensive MDT involvement to help rehabilitate the patient

Question 3

Surgical principals of NOF# surgical management

Answer 3

-Intracapsular (circumflex arteries? Blood supply to femoral head)
=Displaced: replace, total or hemi
=Un-displaced: fix (screws), hemiarthroplasty if unfit

-Extracapsular (trochanteric/ subtrochanteric)
=Fix (dynamic hip screw/ intramedullary nail)

Question 3

Overview of pubic rami fracture

Answer 3

-Similar presentation as NOF # (demographic, mechanism of injury, symptoms)

-However:
=Leg is not shortened or ER
=No pain on pin rolling
=Palpation over the rami is painful
=Mostly breaks in two/ several places so also check posteriorly
-Rx:
=Conservative -> FWB, analgesia, PT
=Mobilise

Question 4

Overview of femoral #

Answer 4

-Bimodal:
=High energy injuries in the young
=Low energy injuries in the elderly

-If high energy, ~5% have an ipsilateral femoral neck fracture

-Characteristic appearance:
=Proximal segment flexed and abducted
=Distal segment varus and extended

Question 5

Hemi vs total

Answer 5

-Functional outcomes

-Total: walk independently, no comorbidities, live beyond 2 years

Question 6

Classification of hip fracture

Answer 6

-Location
=intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
=extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)

-The Garden system is one classification system in common use.
=Type I: Stable fracture with impaction in valgus
=Type II: Complete fracture but undisplaced
=Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
=Type IV: Complete boney disruption

-Blood supply disruption is most common following Types III and IV.

Question 7

Indication for hemi over total replacement

Answer 7

=were able to walk independently out of doors with no more than the use of a stick and
=are not cognitively impaired and
=are medically fit for anaesthesia and the procedure.

Question 8

Types of hip dislocation

Answer 8

-Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.
-Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening.
-Central dislocation

Question 9

Management of hip dislocation

Answer 9

ABCDE approach.
Analgesia
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.

Question 10

Complications of hip dislocation

Answer 10

Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments

Question 11

Prognosis for hip dislocation

Answer 11

It takes about 2 to 3 months for the hip to heal after a traumatic dislocation
the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.