1. Traumatic conditions of the hip

2. 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

3. 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.)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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).

22. 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 weeks gait pattern will evolve into full weight bearing based on:
- surgical procedure
- area of fracture
- radiographic findings
- patient comfort

23. 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

24. 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

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

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

27. 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

28. 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)

29. 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.

30. 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

31. 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)

32. Intraarticular fractures with IF
Phase 1 (0-6 weeks)
CPM in first 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

33. 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