Orthopaedics - hip & thigh Flashcards
Acetabular fracture
Significant pain & swelling with an inability to weight bear
Associated injuries are common – associated hip dislocations or femoral neck fractures
Check neurovascular status of both limbs, evidence of open fracture & condition of the overlying skin
Morel Lavallee lesion
Internal degloving injury, whereby the skin and subcutaneous tissues are abruptly separated from the underlying fascia due to trauma
Potential space is produced superficial to the fascia that is then filled with fluid – resulting collection may spontaneously resolve or become encapsulated & persistent
Acetabular fracture investigation
Plain film radiographs – AP view, judet view (obtains by tilting the patient 45 degrees laterally in both directions)
CT scan – gold standard for fracture diagnosis
Acetabular fracture management
Associated hip dislocation should be reduced urgently if there is significant joint incongruity
Undisplaced/minimally displaced fractures can be managed conservatively with protected weight bearing for 6-8 weeks
Surgical management – young patients: surgery is performed to restore the anatomy, older patients: fracture fixation may be performed as a precursor to total hip replacement
Acetabular fracture complications
Secondary OA
VTE
Nerve injury (sciatic or obturator nerves) are less common
Distal femur fracture clinical features
Present following a fall/traumatic injury
Severe pain in distal thigh and inability to weight bear
Examination – obvious deformity, with associated swelling and ecchymosis of distal thigh, knee effusion may be present, open fracture
Full neurovascular examination
Distal femur fracture clinical features
Present following a fall/traumatic injury
Severe pain in distal thigh and inability to weight bear
Examination – obvious deformity, with associated swelling and ecchymosis of distal thigh, knee effusion may be present, open fracture
Full neurovascular examination
Distal femur fractures investigations
Urgent bloods – group & save
Imaging – AP and lateral plain film radiographs of the knee and entire femur, CT imaging is helpful to evaluate intra-articular involvement & assist in operative planning
Distal femur fractures surgical management
Retrograde nailing/ORIF
- Retrograde intramedullary nailing: more proximal extra-articular fractures or simple intra-articular fractures
- ORIF: more distal fractures or complex intra-articular fractures
Distal femur fracture complications
Malunion
Non-union
Secondary OA
Femoral shaft fractures clinical features
Pain or swelling in the thigh, hip and/or knee & unable to weight bear
Obvious deformity will be apparent from the end of the bed
Assess the skin (proximal fragment is pulled into flexion and external rotation – can tent the skin)
Full neurovascular examination
Femoral shaft fractures investigations
Urgent bloods – coagulation and group & save
Imaging – plain film radiograph AP and lateral of entire femur, including hip and the knee, CT can be done if polytrauma is suspected
Femoral shaft fractures conservative management
Stabilise the patient, A to E
Adequate pain relief – opioids +/- regional blockade
Immediate reduction and immobilisation, using in-line traction
Most require surgery, however long-leg casts may be indicated in undisplaced femoral shaft fractures in those who are unfit for surgery
Femoral shaft fractures surgical management
Surgically fixed within 24-48 hours
Antegrade intramedullary nail
External fixation may be used in unstable polytrauma or open fractures, to ensure patient is physiologically optimised prior to definitive fixation
Femoral shaft fractures complications
Nerve injury/vascular injury – pudendal nerve or femoral nerve
Malunion, delayed union, non-union
Infection
Fat embolism
VTE
Neck of femur fractures clinical features
Trauma, often low-energy, followed by pain and inability to weight bear
- Pain felt predominantly in the groin, thigh or referred to the knee
Examination – leg is classically shortened and externally rotated, due to the pull of the short external rotators, distal neurovascular deficits are rare
Neck of femur fractures investigations
Plain-film radiographic imaging – AP and lateral of hip, AP pelvis, full length femoral radiographs too
Routine blood tests – FBC, U&Es, coagulation screen, Group & save, creatinine kinase
Urine dip, CXR, ECG are useful in complete assessment
Neck of femur fractures management
Adequate analgesia – opioid analgesia and/or regional analgesia
Definitive management is surgical:
1) Displaced subcapital – hip hemiarthroplasty
2) Inter-trochanteric and basocervical – dynamic hip screw
3) Non-displaced intra-capsular – cannulated hip screws
4) Sub-trochanteric – antegrade intramedullary femoral nail
Post-operatively: early rehab through engagement with PTs and OTs
Neck of femur complications
Post-operatively – pain, bleeding, leg-length discrepancies, potential neurovascular damage
Joint dislocation
Aseptic loosening
Peri-prosthetic fractures
Deep infection/prosthetic joint infection
Mortality (30% at one year)
OA hip risk factors
Systemic – age, obesity, female gender, genetic factors, vitamin D deficiency
Local – history of trauma to the hip, anatomic abnormalities, muscle weakness/joint laxity, participation in high impact sports
OA clinical features
Pain most commonly felt in the groin , can also be present over lateral hip/deep in buttock
- Aggravated by weight-bearing and improved with rest
Stiffness, associated grinding, crunching sensation
Examination – antalgic gait, may walk with mobility aid, passive movement is painful, ROM reduced
OA investigations
Plain radiographs – LOSS
Other diagnoses being considered – MRI is gold standard
OA management
Initial – adequate pain control, lifestyle modifications, PT
Long-term – surgical intervention (total hip replacement or hemiarthroplasty)
Post-operative complications: thromboembolic disease, bleeding, dislocation, infection, loosening of the prosthesis & leg length discrepancy
Pelvic fractures clinical features
Most often caused by high energy blunt trauma – road traffic accidents/falls from height
Obvious deformity to their pelvis, pain & swelling
Full neurovascular assessment of lower limbs are required – anal tone, sacral nerve roots and iliac vessels
Pelvic fractures investigations
3 plain film radiographs (AP, inlet & outlet views) – assess the pelvic ring
CT is often performed in trauma setting
Pelvic fractures management
Can be conservative or operative
Indications for operative – life threatening haemorrhage, unstable fractures, open fractures & associated fractures with an associated urological injury
Pelvic fractures complications
Urological injury
VTE
Long-standing pelvic pain
Quadriceps tendon rupture
Loss of congruency of the quadriceps tendon
Typically occurs at the site of insertion with the superior pole of the patella
Quadriceps tendon rupture risk factors
Increasing age
CKD
Diabetes mellitus
RA
Medications (corticosteroids & fluoroquinolones)
Quadriceps tendon rupture clinical features
Typically report hearing a pop/feeling a tearing sensation
Immediately followed by pain in the anterior knee/thigh & difficulty in weight bearing
Typically following sudden and excessive loading of the quadriceps muscles eg. landing from a jump
Examination – localised swelling to the region, tender palpable defect above the superior pole of the patella, inability to straight leg raise
Quadriceps tendon rupture investigations
Can be diagnosed on clinical suspicion alone
Plain film radiographs of the affected knee can show a caudally displaced patella in complete tears
Definitive diagnosis – ultrasound imaging, esp. important in measuring the degree of rupture
MRI useful is diagnostic uncertainty
Quadriceps tendon rupture management
Partial tears – can be managed non-operatively -> immobilisation of the knee joint in a brace along with intensive rehab
Complete tears – surgical intervention, technique used depending on the position of the tear
Post-operatively – knee is immobilised in a brace before progressive strength and flexibility exercises are introduced at approximately 6 weeks post-repair
