Traumatic conditions Traumatic conditions of the hip of the hip

.

head

neck

lesser trochanter

Obturator foramenischium

ilium

pubis

sacrum

acetabulum

greater trochanter

ANTERIOR VIEW

POSTERIOR VIEW

AnatomyAnatomy Physeal closure age is 16Physeal closure age is 16

Normally Normally the femoral neck is rotated anteriorly 12 to 14 degrees with respect to the femur (angle of anteversion)

Neck-shaft angleNeck-shaft angle 130° 130° ± 7°± 7° Calcar FemoraleCalcar Femorale

(Postero-medial dense plate of (Postero-medial dense plate of bone)bone)

Blood SupplyBlood Supply

Bony Trabeculae pattern of the Proximal Femur

     - Greater Trochanteric Group

     - Secondary Compressive Group

     - Secondary Tensile Group

     - Principal Tensile Group

     - Principal Compressive Group 

- changes in the trabecular pattern of upper end of femur is an index of osteoporosis. (singh index)

Fractures of upper end of Fractures of upper end of femurfemur

1. Fracture of neck of femur

2. Fracture intertrochanteric femur

3. Fracture subtrochanteric femur

Risk factors: Risk factors:

1.1. Age: risk doubles over age of 50Age: risk doubles over age of 50

2.2. Sex: women > men 2-3 timesSex: women > men 2-3 times

3.3. Race: caucasian > negroes 2-3 timesRace: caucasian > negroes 2-3 times

4.4. Chronic Steroid useChronic Steroid use

5.5. Chronic Medical illness history Chronic Medical illness history

6.6. Medical history of previous hip fractureMedical history of previous hip fracture

Femur Neck FracturesFemur Neck Fractures The neck holds the femur away from the pelvis.

It is formed by cancellous trabecular bone and reinforced with cortical bone, particularly on the inferior portion.

Bimodal age distribution Elderly – low energy trauma, falls, often impactedElderly – low energy trauma, falls, often impacted Young – high energy trauma, impaction is unusualYoung – high energy trauma, impaction is unusual

Most fractures are displaced with distal fragment – externally rotated , adducted and proximally migrated. ( caused by the pull of powerful muscles)

Femur Neck FracturesFemur Neck Fractures

SubcapitalSubcapital

TranscervicalTranscervical

BasicervicalBasicervical

Pauwel’s ClassificationPauwel’s ClassificationBased on the angle of the fracture with the Based on the angle of the fracture with the

horizontalhorizontal

stable Less stable unstable

Garden ClassificationGarden Classification

I Valgus impacted or incomplete

II Complete Non-displaced

III Complete Partial displacement

IV Complete Full displacement

Based on the degree of valgus displacement and trabecular pattern

Clinical evaluation Clinical evaluation

Pain is evident on range of hip motion, Pain is evident on range of hip motion, with possible pain on axial compression with possible pain on axial compression and tenderness to palpation of groinand tenderness to palpation of groin

Tenderness over scarpa’s triangleTenderness over scarpa’s triangle

Active SLR not possibleActive SLR not possible

Characteristic deformity present along Characteristic deformity present along with limb length shorteningwith limb length shortening

Radiographic evaluationRadiographic evaluation

An anterioposterior (AP) view of An anterioposterior (AP) view of pelvis with both hips in 15 degrees pelvis with both hips in 15 degrees internal rotation and a cross table internal rotation and a cross table lateral view of the proximal femurlateral view of the proximal femur

Radiological findings Radiological findings Fracture neck of femurFracture neck of femur Proximal migration of greater Proximal migration of greater

trochantertrochanter Prominent lesser trochanterProminent lesser trochanter Broken shenton’s arcBroken shenton’s arc

Femur Neck Fractures: Femur Neck Fractures: ManagementManagement

Garden I and II’s don’t disrupt blood supply to Garden I and II’s don’t disrupt blood supply to femur head, so need only mechanical femur head, so need only mechanical stabilization (stabilization (compression screws).compression screws).

Garden III and IV’s disrupt blood supply in 30%-Garden III and IV’s disrupt blood supply in 30%-50%. Femur Neck Fractures: Management50%. Femur Neck Fractures: ManagementIn an elderly or chronically ill patient: In an elderly or chronically ill patient: Hemiarthroplasty because You don’t want to Hemiarthroplasty because You don’t want to operate again on these patients if AVN occurs.operate again on these patients if AVN occurs.

But in a younger healthy patient, might try But in a younger healthy patient, might try mechanical stabilization and do hemiathroplasty mechanical stabilization and do hemiathroplasty later if AVN occurs, because hip prostheses need later if AVN occurs, because hip prostheses need replacement every 10-12 years.replacement every 10-12 years.

Intertrochanteric fracturesIntertrochanteric fractures

Common in elderly peopleCommon in elderly people Extracapsular fractures of the proximal Extracapsular fractures of the proximal

femur between the greater and lesser femur between the greater and lesser trochanterstrochanters

Equal frequency in men & womenEqual frequency in men & women Often comminutedOften comminuted painful, shortened, externally rotated lower painful, shortened, externally rotated lower

extremity extremity Radiographs recommended views :Radiographs recommended views :

AP pelvis AP pelvis AP of hip, cross table lateral AP of hip, cross table lateral full length femur radiographs full length femur radiographs

CT or MRI useful if radiographs are negative CT or MRI useful if radiographs are negative but physical exam consistent with fracturebut physical exam consistent with fracture

Stability of fracture pattern is arguably the most reliable method of Stability of fracture pattern is arguably the most reliable method of classification classification

2 types –2 types –1.1. stablestable : Intact posteromedial cortex : Intact posteromedial cortex

clinical significance : will resist medial compressive loads clinical significance : will resist medial compressive loads once reduced once reduced

2. Unstable2. Unstable : Comminution of the posteromedial cortex : Comminution of the posteromedial cortex clinical significance : fracture will collapse into varus and clinical significance : fracture will collapse into varus and

retroversion when loadedretroversion when loaded Examples :Examples :

o Fractures with a large posteromedial fragment i.e., lesser Fractures with a large posteromedial fragment i.e., lesser trochanter is displacedtrochanter is displaced

o Subtrochanteric extension Subtrochanteric extension o Reverse obliquity (oblique fracture line extending from Reverse obliquity (oblique fracture line extending from

medial cortex both laterally and distally )medial cortex both laterally and distally )

Classification

Treatment : Treatment : Distal to blood supply to femur head, so need Distal to blood supply to femur head, so need mechanical stabilization only.mechanical stabilization only.

1. Nonoperative : observation with pain management

indications non-ambulatory patients with medical co-morbidities

that would not allow them to tolerate surgery limited role due to strong muscular forces displacing

fracture and inability to mobilize patients without surgical intervention

2. Operative :1. Compression screws and plate / proximal femoral nail1. Compression screws and plate / proximal femoral nail2. Early mobilization2. Early mobilization3.Early ambulation3.Early ambulation

Subtrochanteric fracturesSubtrochanteric fractures

Subtrochanteric typically Subtrochanteric typically defined as area from lesser defined as area from lesser trochanter to 5cm distal trochanter to 5cm distal

fractures with an associated fractures with an associated intertrochanteric component intertrochanteric component may be called :may be called :

intertrochanteric fracture intertrochanteric fracture with with subtrochanteric extension subtrochanteric extension

peritrochanteric fracture peritrochanteric fracture

•Nonoperative •observation with pain management

•indications •non-ambulatory patients with medical co-morbidities that would not allow them to tolerate surgery •limited role due to strong muscular forces displacing fracture and inability to mobilize patients without surgical intervention

•Operative •Intra-medullary nailing (usually cephalomedullary)•fixed angle plate  •Dynamic hip screw

Treatment

FRACTURE NECK FRACTURE NECK FEMURFEMUR

FRACTURE FRACTURE INTERTROCHANTERIC INTERTROCHANTERIC FEMURFEMUR

FRACTURE FRACTURE SUBTROCHANTERISUBTROCHANTERIC FEMURC FEMUR

INVOLVES NECK OF FEMURINVOLVES NECK OF FEMUR INVOLVES AREA BETWEEN GREATER INVOLVES AREA BETWEEN GREATER AND LESSER TROCHANTERAND LESSER TROCHANTER

INVOLVES AREA BELOW LESSER INVOLVES AREA BELOW LESSER TROCHANTER UPTO 5 CM BELOW TROCHANTER UPTO 5 CM BELOW LESSER TROCHANTERLESSER TROCHANTER

SWELLING AND FULLNESS SWELLING AND FULLNESS PRESENT OVER SCARPA’S PRESENT OVER SCARPA’S TRIANGLETRIANGLE

SWELLING AND BROADENING OF SWELLING AND BROADENING OF GREATER TROCHANTER IS PRESENTGREATER TROCHANTER IS PRESENT

SWELLING AND FULNESS IS SWELLING AND FULNESS IS PRESENT OVER THIGHPRESENT OVER THIGH

TENDERNESS PRESENT AT TENDERNESS PRESENT AT SCARPA’S TRIANGLESCARPA’S TRIANGLE

TENDERNESS PRESENT AT GREATER TENDERNESS PRESENT AT GREATER TROCHANTERTROCHANTER

TENDERNESS PRESENT AT SHAFT TENDERNESS PRESENT AT SHAFT FEMURFEMUR

DEFORMITY IS ABDUCTION DEFORMITY IS ABDUCTION AND EXTERNAL ROTATION BUT AND EXTERNAL ROTATION BUT LESS MARKEDLESS MARKED

DEFORMITY IS ABDUCTION AND DEFORMITY IS ABDUCTION AND EXTERNAL ROTATION BUT MORE EXTERNAL ROTATION BUT MORE MARKEDMARKED

DEFORMITY IS SEEN AT THIGH AS DEFORMITY IS SEEN AT THIGH AS SWELLING AND SHORTENINGSWELLING AND SHORTENING

NON-UNION IS MORE COMMONNON-UNION IS MORE COMMON MALUNION IS MORE COMMONMALUNION IS MORE COMMON MAY BE NONUNION OR MALUNIONMAY BE NONUNION OR MALUNION

MANAGED USUALLY BY MANAGED USUALLY BY CANNULATED CANCELLOUS CANNULATED CANCELLOUS SCREWS OR SCREWS OR HEMIREPLACEMENT HEMIREPLACEMENT ARTHROPLASTYARTHROPLASTY

MANAGED USUALLY BY DYNAMIC HIP MANAGED USUALLY BY DYNAMIC HIP SCREW OR PROXIMAL FEMORAL NAILSCREW OR PROXIMAL FEMORAL NAIL

MANAGED USUALLY BY PROXIMAL MANAGED USUALLY BY PROXIMAL FEMORAL NAIL OR FEMORAL FEMORAL NAIL OR FEMORAL INTERLOCKING NAILINTERLOCKING NAIL

AVASCULAR NECROSIS OF AVASCULAR NECROSIS OF HEAD OF FEMUR IS HEAD OF FEMUR IS COMMONCOMMON

AVASCULAR NECROSIS OF HEAD AVASCULAR NECROSIS OF HEAD OF FEMUR NOT OCCUR USUALLYOF FEMUR NOT OCCUR USUALLY

AVASCULAR NECROSIS OF AVASCULAR NECROSIS OF HEAD OF FEMUR DOES NOT HEAD OF FEMUR DOES NOT OCCUROCCUR

THANK YOUTHANK YOU