1. Format Short Cases A series of short questions Review of answers Discussions

2. Case 1 28 y.o. male Front seat passenger Car ran into lamp post Brought to A&E No other injury except for severe pain in right hip

3. 28 y.o. male Front seat passenger

4. Questions 1.What is the diagnosis? 2.What is the usual position of the limb in this condition? 3.What are the radiological signs? 4.What other investigations? 5.What are the potential complications? 6.What is the definitive treatment?

5. 1.What is the diagnosis? 2.What is the usual position of the limb in this condition? 3.What are the radiological signs? 4.What other investigations? 5.What are the potential complications? 6.What is the definitive treatment?

6. Anatomy: Hip Joint Ball and socket joint. Femoral head: slightly asymmetric, forms 2/3 sphere. Acetabulum: inverted “U” shaped articular surface. Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”.

7. Hip Dislocation: Mechanism of Injury Almost always due to high-energy trauma. Most commonly involve unrestrained occupants in MVAs. Can also occur in pedestrian-MVAs, falls from heights, industrial accidents and sporting injuries.

8. Physical Examination: Classical Appearance Posterior Dislocation: Hip flexed, internally rotated, adducted.

9. Position of Limb Adducted, flexed and Internally Rotated Diagnosis: Posterior Dislocation

11. What are the radiological signs? Shenton’s Line Head is higher Less trochanter is higher How do you know that this hip is internally rotated?

16. Potential Complications 1.Recurring instablility 2.Traumatic degenerative arthritis 3.Avascular Necrosis 4.Sciatic Nerve injury 5.High energy injury – watch out for other blunt trauma that may not be apparently initially

17. Blood Supply to Femoral Head 1.Artery of Ligamentum Teres 2.Ascending Cervical Branches

18. Sciatic Nerve Composed from roots of L4 to S3. Peroneal and tibial components differentiate early, sometimes as proximal as in pelvis. Passes posterior to posterior wall of acetabulum. Generally passes inferior to piriformis muscle, but occasionally the piriformis will split the peroneal and tibial components

19. Associated Injuries Mechanism: high-energy, unrestrained occupants Thus, associated injuries are common: Head and facial injuries Chest injuries Intra-abdominal injuries Extremity fractures and dislocations

20. Clinical Management: Emergent Treatment Dislocated hip is an emergency. Goal is to reduce risk of AVN and DJD.

21. Emergent Reduction Allows restoration of flow through occluded or compressed vessels. Decreased AVN with earlier reduction. Requires proper anesthesia. Requires “team” (i.e. more than one person).

22. Summary of Posterior Dislocation of the Hip Hip is very stable Require high energy to dislocate Reduce early with adequate sedate of GA Patient usually young so complications has long lasting disability – AVN – Traumatic Arthritis – Recurrent instability – Sciatic nerve injury

23. Case 2 Presenting complaints 52/ F/ Chinese/ Hawker by profession had to give up her profession as she was having progressive right hip pain x 4/12 before seeking the consultation No significant past medical history of taking any long term medication, trauma or steroid or alcohol use

24. Clinical examination Could still squat with difficulty Internal and external rotations grossly restricted and painful

25. TAH/52/F/Chinese

27. Case 2 1.What is the diagnosis? 2.What are the possible causes? 3.What are the radiological signs? 4.What are the treatment options?

28. Answer What is the diagnosis? – Avascular Necrosis

29. Answer What is the diagnosis? – Avascular Necrosis What are the possible causes?

30. Answer What is the diagnosis? – Avascular Necrosis What are the possible causes? – Excessive Alcohol consumption – Steroid Use – Rapid Decompression – Trauma – Inflamatory Disease – Lupus (vasculitis) – Gaucher’s Disease

31. What are the radiological signs?

32. Crescent Sign

33. What is the reason for increase density in avascular necrosis? Impaction of trabecular bone New bone on dead trabecular bone Relative disuse osteopenia

34. What are the treatment options? Analgesic Weight Reduction Walking aids Coring decompresion Bone Graft Osteotomy Hip Replacement

35. Treatment – Hip Replacement

37. Case 3 70 y.o. patient with bilateral hip pain started about 10 years ago. He underwent right hip surgery 5 years ago and left hip surgery 3 years ago. 1.What surgeries have been performed? 2.What is the indication for surgery? 3.Name 3 possible complications of this type of surgery?

38. Case 3 What surgeries have been performed? Bilateral Cement Total Hip Replacements

39. Case 3 What is the indication for surgery? Severe pain and limited walking

40. Case 3 Name 3 possible complications of this type of surgery? 1.Neuro-vascular injury 2.Dislocation 3.Leg length discrepancy 4.Infection 5.Loosening of implant 6.Deep vein thrombosis

41. Case 4 80 yo women, fell at home and sustain this fracture Except for hypertension she has no other medical problem Lives at home with her daughter and grandchildren

42. Case 4 1.What is the injury? 2.What are the risk factors for this type of injury? 3.What is the recommended treatment? 4.Name 3 factors that would affect this patient’s post-op recovery

43. Case 4 What is the injury? Displaced femoral neck fracture.

44. Femoral Neck Fracture Intracapsular Subcapital, Transcervical, Basilar Displaced vs Undisplaced

45. Un-displaced

46. Caution! Elderly patient Hx of fall Subsequently unable to walk Xray is negative for fracture Fracture until proven otherwise

47. Impacted

48. Displaced

49. Hip Fracture Femoral Neck

50. Hip Fracture Leg is: -Shorten -Externally Rotated

51. Case 4 What are the risk factors for this type of injury? Smoking Estrogen Deficiency Low Calcium Intake Sedentary lifestyle Recurrent Fall Impaired Eyesight Alcoholism

53. Osteoporosis Singh Index

54. Case 4 What is the recommended treatment? Hemiarthroplasty

56. Un-displaced femoral neck fracture

57. Pinning for Undisplaced or Impacted Fracture of the Femoral Neck

58. Case 4 Name 3 factors that would affect this patient’s post-op recovery 1.Pre-morbid ambulatory status 2.Pre-morbid medical condition 3.Pre-morbid mental status

59. Complications of Femoral Neck Fractures Fracture – Avascular Necrosis – Non-union Patient – Morbidity – Mortality

60. Case 5 75 y.o. man slip and fell at shopping mall Previously healthy. On no medication Lives alone in HDB flat

61. Case 5 1.What are characteristics of this fracture that determine its prognosis? 2.What is the standard of care for this type of fracture? 3.What are the potential complications directly related to the fracture?

62. Case 5 What are characteristics of this fracture that determine its prognosis? Stable versus unstable As determined by the fragmentations of the fracture.

63. Stable vs Unstable Fractures Stable Unstable

64. Stable vs Unstable Fractures StableUnstable

65. Case 5 What is the standard of care for this type of fracture? Closed reduction and internal fixation with dynamic hip screw

66. Treatment of Inter-trochanteric Fractures Fracture – Closed Reduction and Internal Fixation Patient – Early mobilization – Medical management

67. Closed Reduction

68. Internal Fixation with Sliding Hip Screw

70. Case 5 What are the potential complications directly related to the fracture? Failure of fixation Malunion

71. Complications of Intertrochanteric Fractures Fracture – Stability – Failure of Fixation Patient – Morbidity – Mortality

72. Failure of Fixation 5% in Stable Fractures 20% in Unstable Fractures

73. Patients with Hip Fractures General Principle of Treatment

74. Principles of Treatment of Hip Fractures Fracture – Provide Stability of Fracture Patient – Early mobilization – Day 1 post-operative – Minimize medical complications

75. Aim is to Decrease Medical Complications Bed sore Confusion Proactive management of bowel and bladder function (UTI and Constipation) Deep vein thrombosis Pneumonia Careful management of co-morbid medical condition Adherence to “Pathways” Protocol

76. Factors influencing Hip Fracture Outcome Pre-injury physical status Pre-injury mental status Home companion Nutrition Independent community ambulation Post-op ambulation Post-op complication

77. Factors Influencing Discharge to Home General Medical Condition Living with someone at Home Ability to walk 2 weeks after surgery Mental status Range from 95% to 25%

78. Mortality About 20% Stabilize after 12 months Highly age related Mental status and general medical conditions are important factors