Traumatic conditions of the hip

Dislocation of the hip Anterior dislocation Posterior dislocation, more common Central dislocation (direct thrust along the line of the femoral neck → fracture acetabulum → femoral head displaced into the pelvic cavity

Posterior dislocation of the hip Longitudinal thrust along shaft of femur when hip is flexed & adducted (dash board accident) → head of femur displaced backward out of the acetabulum Clinically: The affected leg is: Internally rotated Adducted Shortened (fig.)

Complications Immediate complications: Sciatic nerve injury → drop foot & numbness over the outside of the calf Late complications: avulsion of ligamentum teres from the acetabulum → cut off blood supply to femoral head → avascular necrosis → OA

TREATMENT Manipulative reduction Traction (4 weeks) → healing of capsular tear Weight bearing Regular x rays monthly for the 1st 4 months for early detection of avascular necrosis

Treatment of complications Operation may be necessary to free the sciatic nerve Avascular necrosis is treated in early stages by avoidance of WT bearing until texture of femoral head returns to normal. In late stages by total hip replacement, arthrodesis, osteotomy, or bone grafting

Anterior dislocation of the hip Force that abducts the extended hip → femoral head displaced below & in front of the acetabulum Clinically: the affected leg is: Abducted Externally rotated Treatment: Manipulative reduction 3 weeks traction

Central dislocation of the hip Direct violence → drives femoral head through floor of acetabulum → Damage of articular surfaces Intrapelvic haemorrhage Hypovolemic shock Conservative treatment Longitudinal traction for 6 weeks Mobility of the hip Surgical treatment Reconstruction of the destroyed acetabulum Total hip replacement

Fractures of upper end of femur Risk factore: Age: risk doubles over age of 50 Sex: women > men 2-3 times Race: caucasian > negroes 2-3 times Medical history of previous hip fracture

Subcapital fracture of the femoral neck Grade I Head of femur is abducted & impacted with the neck Clinically: Little pain Trivial injury No shortening or rotational deformity Active movement may be possible

Grade II Undisplaced fracture ST are attached providing blood supply Grade III Femur is adducted at fracture site Head is separated from the neck Severe pain in hip when standing or moving the affected limb Injured foot & leg are externally rotated

Grade IV Gross rotation of both fragments with complete loss of contact between the fragments

Treatment Grade II → - compression screws 2. Grade III & IV → hemiarthroplasty (Austin-more prosthesis) Total hip replacement

Intertrochanteric fractures Common in elderly people Equal frequency in men & women Often comminuted Lesser trochanter frequently avulsed & pulled upwards by iliopsoas Treatment Compressiom screws and plate Early mobilization Early ambulation

Fractures of femoral shafts in adults Vigorous trauma Hypovolaemic shock Fracture line is transverse or comminuted Severe displacement residual stiffness of knee Non-union with open fractures

Conservative treatment Temporary traction for 8 weeks (fixed or balanced- skin or skeletal) (fig.) Followed by hinged cast brace Weight bearing is then encouraged Operative treatment Locked intramedullary nail

Femoral shaft fractures in infancy Causes: Indirect rotatory twisting strain Difficult delivery with breech presentation Treatment: 3-4 weeks fixed traction on Thomas splint In infants less than 3 years → gallows traction

Supracondylar fractures Treated by Thomas splint with knee flexion Fractures of femoral condyles Intra-articular fracture Internal fixation with plate and screws is necessry to: Reduce the fractured articular surfaces accurately Allow early mobilization

Physical therapy program during immobilization period To prevent respiratory complications → breathing exercises. To prevent circulatory complications → - circulatory exercises - changing position every 2 hours - alternating air mattress 3. To prevent stiffness, weakness & atrophy of the free parts → - ROM exercises - strengthening exercises 4. To prevent weakness of immobilized parts → static & isometric exercises

Rehabilitation after ORIF of hip fractures Bed mobility while maintaining proper alignment of the operative limb Lying flat on back for 1 hour/day to avoid hip flexion contractures. Forced hip flexion or rotation (e.g. twisting forward or to either side)is to be avoided for the 1st 7-10 days postoperatively. Patients are allowed to assume a semireclined position after 24 houurs.

5. Patients are assisted into protectively positioned side-lying as soon as possible(2-3 days postoperatively). Side lying position greatly aids in: - toiletry - pulmonary postural drainage - prevention of decubitus ulcers 6. An over head trapeze is essential during the 1st few days postoperatively (using elbows & heels to elevate hips→ 4 times body weight force acts on the hip).

7. Gait training with walker or crutches if balance & mobility are good. (touch down gait takes about 90-95% of load off hip joint, compared to 80% weight reduction with NWB gait 8. Over 12-16 weeks gait pattern will evolve into full weight bearing based on: - surgical procedure - area of fracture - radiographic findings - patient comfort

Nb. 9. Active exercises through a comfortable range 10. Pool exercises to regain strength, proprioceptive sense & mobility. Nb. Tying a shoe with foot on floor requires 124o hip flexion Ascending stairs requires 67o hip flexion Sitting down on a chair requires 104o hip flexion

Physical therapy program after immobilization OKC EXERCISES E.G. - isometrics - knee ROM exercises - SLR - terminal knee extension - free weight exercises - Isokinetic exercises CKC EXERCISES (NWB, PWB & FWB) e.g. - mini-squats - lunges - leg press - step-ups - proprioception training - stationary bicycle

Fractures of upper end of femur(ORIF) Day 1: Quadriceps sets hamstrings sets gluteal sets ankle pumps

Active assisted hip abduction & adduction Supine leg slides for flexion of hip & knee Upper extremity exercise

Days 3-7 Day 2: Ambulation with TDWB with walker, then PWB with walker SLR in all directions Thomas stretch of anterior capsule and hip flexors

1-2 weeks 2 -6 weeks Discharge criteria: Get out of bed independently Able to ambulate 50 feet with assistive device In & out of bathroom independently. Standing hip abduction, adduction, flexion, and extension & hip and knee flexion exercises. 2 -6 weeks Stationary bicycle, pool exercises, and treadmill Progress ambulation from walker to use of a cane (if Trendelendburg test is –ve)

Femoral shaft fracture treated with intramedullary nail Phase 1: 0-6 weeks: Quadriceps, hamstrings, gluteal sets & ankle pumps SLR in all planes Knee active ROM exercises Stationary bicycle Weight bearing to tolerance (if nail diameter is 12mm or more) an progress to full weight bearing as tolerated within 6-12 weeks. If nail diameter is less, begin weight bearing with 25kg.

Phase 2 (6 weeks -3 months) Phase 3 (3-6 months) Scale technique for weight bearing (5-10 kg increase weekly) Isokinetic exercises CKC exercises Phase 3 (3-6 months) Full weight bearing Full knee & hip ROM Full squat Ascend & descend stairs full weight bearing Thigh circumference = uninjured side Phase 4 (> 6 months) Return to athletic activity Full work & recreational activity

Femoral shaft fracture treated with plate & screws Same as for intra-medullary nail with exception that: NWB for 8-12 weeks Weight bearing is not progressed until radiological union (3-6 months)

Intraarticular fractures with IF Phase 1 (0-6 weeks) CPM in first 24-48 hours (0-90 degrees) OKC exercise e.g. SLR, quadriceps sets TDWB Phase 2 (6-12 weeks) Stationary bicycle PWB using the scale technique CKC exercises

Phase 3 (3-6 months) FWB Phase 4 (>6 months) Return to work & recreational activity Avoid excessive squatting & jumping & contact sports for 6-12 months