Orthopaedics - hip & thigh

Question 1

Acetabular fracture

Answer 1

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

Question 2

Morel Lavallee lesion

Answer 2

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

Question 3

Acetabular fracture investigation

Answer 3

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

Question 4

Acetabular fracture management

Answer 4

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

Question 5

Acetabular fracture complications

Answer 5

Secondary OA
VTE
Nerve injury (sciatic or obturator nerves) are less common

Question 6

Distal femur fracture clinical features

Answer 6

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

Question 7

Distal femur fracture clinical features

Answer 7

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

Question 8

Distal femur fractures investigations

Answer 8

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

Question 9

Distal femur fractures surgical management

Answer 9

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

Question 10

Distal femur fracture complications

Answer 10

Malunion
Non-union
Secondary OA

Question 11

Femoral shaft fractures clinical features

Answer 11

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

Question 12

Femoral shaft fractures investigations

Answer 12

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

Question 13

Femoral shaft fractures conservative management

Answer 13

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

Question 14

Femoral shaft fractures surgical management

Answer 14

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

Question 15

Femoral shaft fractures complications

Answer 15

Nerve injury/vascular injury – pudendal nerve or femoral nerve
Malunion, delayed union, non-union
Infection
Fat embolism
VTE

Question 16

Neck of femur fractures clinical features

Answer 16

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

Question 17

Neck of femur fractures investigations

Answer 17

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

Question 18

Neck of femur fractures management

Answer 18

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

Question 19

Neck of femur complications

Answer 19

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)

Question 20

OA hip risk factors

Answer 20

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

Question 21

OA clinical features

Answer 21

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

Question 22

OA investigations

Answer 22

Plain radiographs – LOSS
Other diagnoses being considered – MRI is gold standard

Question 23

OA management

Answer 23

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

Question 24

Pelvic fractures clinical features

Answer 24

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

Question 25

Pelvic fractures investigations

Answer 25

3 plain film radiographs (AP, inlet & outlet views) – assess the pelvic ring
CT is often performed in trauma setting

Question 26

Pelvic fractures management

Answer 26

Can be conservative or operative
Indications for operative – life threatening haemorrhage, unstable fractures, open fractures & associated fractures with an associated urological injury

Question 27

Pelvic fractures complications

Answer 27

Urological injury
VTE
Long-standing pelvic pain

Question 28

Quadriceps tendon rupture

Answer 28

Loss of congruency of the quadriceps tendon
Typically occurs at the site of insertion with the superior pole of the patella

Question 29

Quadriceps tendon rupture risk factors

Answer 29

Increasing age
CKD
Diabetes mellitus
RA
Medications (corticosteroids & fluoroquinolones)

Question 30

Quadriceps tendon rupture clinical features

Answer 30

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

Question 31

Quadriceps tendon rupture investigations

Answer 31

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

Question 32

Quadriceps tendon rupture management

Answer 32

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