Traumatic conditions of the hip.

head neck lesser trochanter Obturator foramen ischium ilium pubis sacrum acetabulum greater trochanter ANTERIOR VIEW POSTERIOR VIEW

Anatomy Physeal closure age is 16 Physeal 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 angle Neck-shaft angle 130° ± 7° 130° ± 7° Calcar Femorale Calcar Femorale (Postero-medial dense plate of bone)

Blood 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 femur 1.Fracture of neck of femur 2.Fracture intertrochanteric femur 3.Fracture subtrochanteric femur

Risk factors: Risk factors: 1. Age: risk doubles over age of Sex: women > men 2-3 times 3. Race: caucasian > negroes 2-3 times 4. Chronic Steroid use 5. Chronic Medical illness history 6. Medical history of previous hip fracture

Femur 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 impacted Elderly – low energy trauma, falls, often impacted Young – high energy trauma, impaction is unusual Young – 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 Fractures Subcapital Subcapital Transcervical Transcervical Basicervical Basicervical

Pauwel’s Classification Based on the angle of the fracture with the horizontal stableLess stable unstable

Garden 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 Pain is evident on range of hip motion, with possible pain on axial compression and tenderness to palpation of groin Pain is evident on range of hip motion, with possible pain on axial compression and tenderness to palpation of groin Tenderness over scarpa’s triangle Tenderness over scarpa’s triangle Active SLR not possible Active SLR not possible Characteristic deformity present along with limb length shortening Characteristic deformity present along with limb length shortening

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

Radiological findings Fracture neck of femur Fracture neck of femur Proximal migration of greater trochanter Proximal migration of greater trochanter Prominent lesser trochanter Prominent lesser trochanter Broken shenton’s arc Broken shenton’s arc

Femur Neck Fractures: Management Garden I and II’s don’t disrupt blood supply to femur head, so need only mechanical stabilization (compression screws). Garden I and II’s don’t disrupt blood supply to femur head, so need only mechanical stabilization (compression screws). Garden III and IV’s disrupt blood supply in 30%-50%. Femur Neck Fractures: Management Garden III and IV’s disrupt blood supply in 30%-50%. Femur Neck Fractures: Management In an elderly or chronically ill patient: Hemiarthroplasty because You don’t want to operate again on these patients if AVN occurs. But in a younger healthy patient, might try mechanical stabilization and do hemiathroplasty later if AVN occurs, because hip prostheses need replacement every years. But in a younger healthy patient, might try mechanical stabilization and do hemiathroplasty later if AVN occurs, because hip prostheses need replacement every years.

Intertrochanteric fractures Common in elderly people Common in elderly people Extracapsular fractures of the proximal femur between the greater and lesser trochanters Extracapsular fractures of the proximal femur between the greater and lesser trochanters Equal frequency in men & women Equal frequency in men & women Often comminuted Often comminuted painful, shortened, externally rotated lower extremity painful, shortened, externally rotated lower 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 but physical exam consistent with fracture CT or MRI useful if radiographs are negative but physical exam consistent with fracture

Stability of fracture pattern is arguably the most reliable method of classification 2 types – 1.stable : Intact posteromedial cortex  clinical significance : will resist medial compressive loads once reduced 2. Unstable : Comminution of the posteromedial cortex  clinical significance : fracture will collapse into varus and retroversion when loaded  Examples : o Fractures with a large posteromedial fragment i.e., lesser trochanter is displaced o Subtrochanteric extension o Reverse obliquity (oblique fracture line extending from medial cortex both laterally and distally ) Classification

Treatment : Distal to blood supply to femur head, so need mechanical stabilization only. Treatment : Distal to blood supply to femur head, so need 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 nail 2. Early mobilization 3.Early ambulation

Subtrochanteric fractures Subtrochanteric typically defined as area from lesser trochanter to 5cm distal Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called : fractures with an associated intertrochanteric component may be called : intertrochanteric fracture with subtrochanteric extension intertrochanteric fracture with 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 FEMUR FRACTURE INTERTROCHANTERIC FEMUR FRACTURE SUBTROCHANTERIC FEMUR INVOLVES NECK OF FEMUR INVOLVES AREA BETWEEN GREATER AND LESSER TROCHANTER INVOLVES AREA BELOW LESSER TROCHANTER UPTO 5 CM BELOW LESSER TROCHANTER SWELLING AND FULLNESS PRESENT OVER SCARPA’S TRIANGLE SWELLING AND BROADENING OF GREATER TROCHANTER IS PRESENT SWELLING AND FULNESS IS PRESENT OVER THIGH TENDERNESS PRESENT AT SCARPA’S TRIANGLE TENDERNESS PRESENT AT GREATER TROCHANTER TENDERNESS PRESENT AT SHAFT FEMUR DEFORMITY IS ABDUCTION AND EXTERNAL ROTATION BUT LESS MARKED DEFORMITY IS ABDUCTION AND EXTERNAL ROTATION BUT MORE MARKED DEFORMITY IS SEEN AT THIGH AS SWELLING AND SHORTENING NON-UNION IS MORE COMMON MALUNION IS MORE COMMON MAY BE NONUNION OR MALUNION MANAGED USUALLY BY CANNULATED CANCELLOUS SCREWS OR HEMIREPLACEMENT ARTHROPLASTY MANAGED USUALLY BY DYNAMIC HIP SCREW OR PROXIMAL FEMORAL NAIL MANAGED USUALLY BY PROXIMAL FEMORAL NAIL OR FEMORAL INTERLOCKING NAIL AVASCULAR NECROSIS OF HEAD OF FEMUR IS COMMON AVASCULAR NECROSIS OF HEAD OF FEMUR NOT OCCUR USUALLY AVASCULAR NECROSIS OF HEAD OF FEMUR DOES NOT OCCUR

THANK YOU