Download Injuries of the HIP

Injuries of the HIP
Dr.Sadeq Al-Mukhtar
Consultant Orthopaedic Surgeon
HIP Stability •
Factors responsible for hip •
stability are:
Ball &Socket shape •
Thickness of hip capsule. •
Arrangement of the bone lamellae in the line •
of stress of the femoral neck.
The joint is susceptable to injury at •
three stages of life.
Adolescence; Before closure of •
epiphysis ( avulsion of epiphysis)
Middle age; (hip dislocation,fracture •
dislocation).
Elderly: osteoporosis( fracture neck •
femur).
Avulsion of Epiphysis at Hip
joint
Avulsion of lesser trochanters: •
Mechanism: Active contraction of •
powerful iliopsoas muscle against
resistance in opposite direction.
Avulsion after 18 year is rare. •
On examination : local tenderness in the •
groin, brusing( ludloffs sign is diagnostic),
inability to lift the thigh when the patient is
in sitting position.
Treatment
Conservative: •
Flexion of the hip 90 degree, the ends of •
the bone become in contact& maintain this
position by pillow,bed rest for 2 weeks.
Surgical treatment is not indicated. •
Avulsion of the greater
trochanter
Mechanism •
Direct blow over the greater trochanter leads to •
fracture of the GT,but
GT,but complete
complete seperation
seperation and
and
displacement of GT epiphysis can occur from
muscular violence(abductor and lateral rotator
muscles)
Treatment •
1-children and adolescents : abduction of the hip •
leads to accurate position and maintain this by
hip spica for 6 weeks.
2-Young adults and elderly:if •
simple displacement
like above
If wide displacement •
surgery(internal fixation)
Displacement of upper femoral
epiphysis
Also called (Adolescent Epiphytseal coxa •
Vara or epiphseolysis capitis).
It is common in boys in adolescence •
years, some showing evidence of
hypopituitarism, or hypogonadism with
obesity& sexual immaturity while others
give a history of recent rapid growth so
that the child is tall & slender.
Mechanism:
Torsional slip around an axis lying in the •
intertrochanteric region causing separation
of epiphysis so that the epiphysis become in
backward displacement. 50% occurs without
any recognized injury& sometime both hips
are involved. The onset is insidious with
slowly increasing pain &limp. Sex hormone
reduces the shearing of the epiphyseal plate
while growth hormone reduces it. Growth
hormone increases the widith of hypertrophy
the cartilage cells.
On Examination
An adolescent boy ,sexual •
deformity,obese,or tall&slender
Limitation of all hip movements especially •
medial rotation.
Slight shortening in the limb.40-80 degree •
lateral rotation with 20-30 degree
extension.
Extreme lateral rotation, •
extension&abduction deformity.
Radiological findings
Lateral film may show a step between •
epiphysis &metaphysis.
Marginal blurring of proximal metaphysis in A.P film. •
In normal hip the lower margin of the metaphysis is •
included within the acetabulum but excluded in early
slip.
Line drawn along the superior margin of the neck •
transects the epiphysis but will be above it if there is
slip
Depth of epiphysis can be measured&compared with •
normal side if normal it become small if there is
slipping.
Treatment
Displaced epiphysis but still in •
accepted position (early diagnosis is
very important i.e irritable hip in early
days) treated by surgery: internal
fixation by pin in situ without any
attempt to alter the position (good
result is expected in 90% of cases)
Severe acute slip or acute on chroic slip; •
Restore to a position under •
anaesthesia&screen or by a period of skin
traction then pinning by a special pins(60%
good result)
Irreducible slip: Treated by cervical or •
subtrochanteric osteotomy.
Slip with fused epiphyseal line: Treated by •
subtrochanteric osteotomy.
Traumatic Dislocation of Hip
Types; •
Simple dislocation usually posterior, •
more rarely anterior.
Fracture dislocation •
Central dislocation. •
Mechanism
It is caused by a powerful thrust in the long •
axis of femur in a flexed & adducted femur(
dashboard injury). This brings the head of
femur to the dorsum of ilium. You must
differentiate this type of dislocation from
pathological dislocation which occurs in
paralytic type e.g. poliomyelitis& spina bifida
( active flexors& adductors with paralyzed
extensor& abductor muscles)
Also occurs in cerebral palsy; due to •
over action of flexor & adductor
muscles.
Infection or tuberculous arthritis •
leading to spasm of flexors& adductors
inaddition to stretching & softening of
capsule.
On examination
Restriction of all movements, the limb •
in adduction &medial rotation.
X-Ray to exclude fracture of •
acetabulum& prove diagnosis.
Treatment
Reduction is usually under GA & good muscle •
relaxation. Hip is turned into the neutral position &
lift
With the patient lying on table or blanket on the •
floor, the flexed hip is turned into the neutral
position & lifting into acetabulum. Failure of
reduction means that there is obstraction by a bony
fragment or detached labrum. If the patient is unfit
for GA.Stimons maneuver can be used (the patient
laid prone on the table with the lower limbs hanging
over the ends of the table so that the head is pushed
into the acetabulum.
After reduction: skin traction of the •
stable hip for 3 weeks then partial
weight bearing by crutches. 6 weeks
after dislocation, full weight bearing is
allowed. If there was failure of
reduction by these methods, then do
open reduction& internal fixation ORIF
by big bony fragment of acetabulum is
indicated.
In cases of comminuted acetabulum •
after reduction of dislocation better
treatment by conservative skin traction
or skeletal traction (better) for 6-8
weeks.
Complications
Injury to sciatic nerve
Damage to femoral head( chondritis). 
Painful hip after reduction of
dislocation.
Avascular necrosis.
Post-traumatic ossification.
Osteoarthritis
Anterior dislocation
It is rare with a ratio anterior to •
posterior 1:20
Mechanism: Blow from behind in high •
type.
Moyor cycle accident mostly nin low •
type which is produced by forced
external rotation&abduction in flexion
while in high btype the same force but
in extension.
Types
High type: The head infront the superior •
ramus of pelvis opposite the iliopectineal
eminence.
Low type: the head near the obturator •
foramen.
On examiation: Low type: full external •
rotation,abduction up to 60 degree with some
flexion.
High type: full external rotation, abduction in •
extension.
Treatment
The same as that of posterior dislocation but –
we push the head into the acetabulum instead
of lifting the flexed limb.
Complications: The same as that of •
posterior one except sciatic nerve injury
that is not occur here.
Central dislocation
The femoral head is driven through the •
medial wall of acetabulum(floor) towards
the pelvic cavity. The capsule is intact.
The drgree of displacement depends on •
the severity of the trauma ranging from
few millimeters displacementr to severe
type where the head passed into pelvis
throughg fractured acetabulum.
Mechanism
Direct:Lateral blow upon the femur. •
Dashboard injury where the hip in flexion •
&abduction force along the longitudinal axis of femur.
Treatment: This depends on the severity of •
comminution& the size of bony fragments& whether the
roof of acetabulum(weighe-bearing site) is intact or not &
if we can preserve it by skeletal traction through the
greator trochanter through the greater
trochanter(outward&downward traction) or by OR IF by
screw.
If severely comminuted, acetabulum is •
better treated by conservative method for
6-8 weeks
Complication •
Osteoarthritis appears after months or •
years. This is treated by arthrodesis of hip
if the patient age is below 45 or THR
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