Fractures around the hip

Risk Factors
 Age: incidence  Physical
doubles for inactivity
each decade  Low body
after 50ys
 Sex: 2-3 times
weight
higher in  Previous hip
women fracture
 2-3 times  Dementia
higher in white  Psychotropic
women than in
meds
nonwhite
women  Visual
 impairment
 FRACTURES OF
THE PROXIMAL FEMUR
 Fractures around the
hip
 250.000 hip fractures/year
 90% in patients >50ys old
 Mortality related to hip fracture –
25% at one year
 80% of patients recover their
walking ability,
 Only 70% recover their ability to
perform ADLs (activities of daily
living)
 Risk Factors
 Age: incidence doubles for each decade
after 50ys
 Sex: 2-3 times higher in women
 Race 2-3 times higher in white women
than in nonwhite women
 Habits Excessive alcohol or caffeine
 Physical inactivity
 Low body weight
 Previous hip
fracture Osteoporosis
 Dementia
 Psychotropic meds
 Visual impairment
 Hip Fractures
 Femoral neck 45%
 intracapsular,
 disruption of blood supply to
femoral head,
 high incidence of healing
complications (nonunion,
osteonecrosis)
Intertrochanteric 45%
 extracapsular,
 no interference with the
blood supply of the femoral
head,
 less complications
 Malunion
Subtrochanteric
 extracapsular
 Malunion
 Clinical Assessment
History:
H/o
fall – in a small percentage
it occurs
spontaneously
C/o
pain and inability to move
the hip or put weight
H/o other osteoporotic
fractures: Colles
 TRAUMA
Direct
Indirect
 Vehicular accedents
 Fall from height
 Crushing accidents
 Avulsion fractures
Clinical Assessment – Physical
Exam
 Leg externally rotated
 Shortening
 May show trochanteric ecchymosis
 Inability to lift the extended leg
 ROM is limited and painful
 Distal neurovascular exam
 Check the pelvis
- Move posterior to anterior at the level
of iliac crests
- Lateral to medial through the iliac
crests
CLINICAL PICTURE SYMPTOMS:
History of trauma,
Pain,
Swelling,
Limited
movements.
SIGNS
:LOCAL
,Swelling
,Ecchymosis
,Tenderness
Limited
movements EXTERNAL ROTATION
,Deformity INABILITY TO LIFT EXTENDED
LEG
Length
,discrepancy
 DIAGNOSTIC
Xray:
AP and lateral.

Check the neck shaft angle 120-

130°.
No results but fracture still
suspected:
AP rotated 10-12° - best
visualization of femoral neck
CT for osteoporosis
Check
Femoral Neck
fracture
Femoral Neck fracture
Trochanteric
Fracture
Subtrochanteric Fracture
.PATHOLOGICAL FR
 Diagnostic Imaging
 Xray:
 AP and lateral.
 Check the neck shaft
angle 120-130°.
 No results but fracture
still suspected: AP
rotated 10-12° - best
visualization of femoral
neck
MRI
 most sensitive
 order if Xray negative
but fracture still
suspected
 Bone scan: sensitive, but
has many interferences
with the degenerative
 Treatment Principles
 Early surgery / 24-48h in patients
who are medically stable
 May wait up to 72h to stabilize the
pt.
 Assess cardiac risk
 Delay in surgery/prolonged bed
rest means:
increased risk of DVT, UTI, pulmonary
complications, skin breakdown,
delayed functional recovery
 Treatment Principles
DVT Prophylaxis
 Fatal PE in 4-7% of patients
undergoing hip surgery,
 Risk of bleeding 3.5% compared to
2.9% without anticoagulation
 Heparin 5000U q12h or LMWH upon
admission
 Pneumatic compression additional
to heparin
 Continue prophylaxis until patient
is fully ambulatory
 treatment
Coservative
tractoin: skin traction
skeletal traction

Operative
reduction and internal fixation
arthroplasty : Hemiarthroplasty
total arthroplasty
TREATMENT OF CLOCED FRACTURES
UNDISPLACED
REDUCIBLE
 CONSERVATIVE TREATMENT
1-TRACTION
SKELETAL TRACTION
 Types of Surgery

Minimally displaced Internal fixation

femoral neck with multiple
fracture screws
 Prosthetic
replacement

Displaced Femoral neck

Fracture esp. in elderly
pt.
HEMIARTHROPLASTY

TOTAL ARTHROPLASTY
Prosthetic replacement:
HIP PROSTHESIS

TOTAL ARTHROPLASTY

HEMIARTHROPLASTY
 Types of Surgery

Displaced Femoral neck Prosthetic

Fracture replacement
 Types of Surgery

Intertrochanteric Internal fixation

fracture with dynamic hip
screw
INTER TROCHANTERIC FRACTURE
DHS
DCS GAMMA NAIL
 Post-operative Care
 Nutrition: oral protein supplementation
with shorter hospital stay
 Foley - for 24h only,
- early removal is a/w less
retention, earlier spontaneous
voiding, less UTI
 Anticoagulant prophylaxis
 Total hip precautions:
- No adduction past midline – use
abduction pillows,
- No hip flexion beyond 90° (tall comode,
no bending >90 °
- No internal rotation – keep toes upright in
bed
 Rehabilitation

 Goal – independent living

 Rehabilitation should begin first
day after surgery with transfer
from bed to chair
 Progress as soon as possible to
standing and walking (2nd day post
op)
 Promote weight bearing with
assistance – walker
 SYSTEMIC COMPLICATIONS

 LONG RECOMBANCY IN BED

 DVT, PE,…,…,…
 MORTALITY
 LOCAL COMPLICATIONS

 Loss of fixation – 15%of patients:

internal fixation for displaced fractures
 Malunion – COXA VARA
 Nonunion – mo/years after internal
fixation for displaced fractures
 Avascular necrosis of femoral head
(osteonecrosis)
 Dislocation of the prosthesis – early,
related to infections or mal-insertion
 Loosening of prosthesis – years after
surgery
Coxa vara

Neck shaft angle

 HIP
DISLOCATIONS
- Posterior
(most
common)
- Anterior

- Central
 posterior Hip Dislocation
(most common)
POSTERIOR
· 80% of hip dislocations
· Limb internally rotated and
adducted
· Neutral/adduction at time of
injury - simple dislocation only
·  Abduction at time of injury -
fracture posterior acetabular
wall
Complications
· Associated knee ligament
injuries especially PCL,
posterolateral complex
· Sciatic nerve injury 10-14%
· AVN (Osteonecrosis)
. Myositis ossificans
POSTERIOR DISLOCATION OF THE HIP
FRACTURE - DISLOCATION
CT & 3D-CT
 FRACTURE PELVIS
FR. ACETABULUM
CENTRAL HIP DISLOCATION
ANTERIOR DISLOCATION OF THE HIP
THANK YOU