Reference: Current Diagnosis and Treatment in Orthopedics
HIP FRACTURES AND DISLOCATION
I. Epidemiology and Social Costs
Hip fractures include: Intetrochanteric fractures Femoral Neck Fractures Ambulation is almost impossible in all fractures except femoral neck fractures until they have been treated surgically Primarily common in older patients, unable to care for themselves Prompt and effective care is necessary to avoid the all too frequent occurrence of death in elderly patient with hip fracture
II. Anatomy and Biochemical Principles
Hip joint - the articulation between the acetabulum and the femoral head Trabecular pattern of the femoral head and neck, and that of the acetabulum, is oriented to optimally accept forces crossing the joint Total force across the joint is the vector sum of body weight and active muscle force Hip capsule - a strong thick fibrous structure that attaches on the intertrochanteric line anteriorly and somewhat more proximally posteriorly Intracapsular portion of the neck is not covered with periosteum Note: Fractures of the intracapsular part of the neck cannot heal with periosteal callus formation, only with endosteal union Note: Interposition of the synovial fluid between fracture fragments, as any joint, can delay or prevent bony union Vascular supply is of paramount importance Trueta: 3 main sources of vascular supply: Retinacular vessels arising from the lateral epiphyseal aretery and the inferior metaphyseal artery (penetrate proximally both anteriorly and posteriorly) Interosseous circulation crossing the marrow spaces from distal to proximal Ligamentum teres artery Note: Fractures of the femoral neck always disrupt the interosseous circulation Femoral head then relies only on the retinacular arteries, which may also be disrupted or thrombosed Secondary avascular necrosis of part or all of the femoral head can result Union of fracture can occur in the presence of avascular fragment, but the incidence of non-union is higher Revascularization of the necrotic fragment occurs through the process of creeping substitution Part of these process involves replacement of necrotic bony structure with a “softer” granulation tissue and sets the stage for delayed segmental collapse Intertrochanteric fractures do not suffer the same fate The capsule (and vessels) are still attached to the proximal fragment after fracture, and blood supply remains patent
A. Femoral Neck Fractures
Femoral neck fractures - intracapsular fractures At high risk of Non-union or Avascular necrosis of the femoral head; incidence increases with: The amount of fracture displacement The amount of time before the fracture is reduced Note: Occurs most commonly in patients over 50 years Involved extremity may be slightly shortened and externally rotated Hip motion is painful Except in rare cases of nondisplaced or impacted fractures where pain may be evident only at the extremes of motion Note: Good quality anteroposterior and lateral radioraphs are mandatory 1. Classification Garden classification for acute fractures is the most widely used systems: Type 1: Valgus impaction of the femoral head Type 2: Complete but non-displaced Type 3: Varus displacement of the femoral head Type 4: Complete loss of continuity between both fragments This classification is of prognostic value for the incidence of avascular necrosis: The higher the Garden number, the higher the incidence Once diagnosis is confirmed, patient should be placed in gentle skin traction while awaiting definitive treatment 2. Stable Femoral Neck Fractures Includes: Stress fractures - may be difficult to diagnose P.E nd initial radiographs may be normal Repeat radiographs, radionuclide imaging and MRI may be necessary to confirm diagnosis Toe-touch bearing (with crutches) until radiologic evidence of healing is usually successful for the complaint patient Healing: complete in 3-6 months Rare: prophylactic internal fixation is necessary and is indicated by failure of pain resolution with toe-touch weight bearing or by displacement Garden Type 1 fractures Usually stable Impaction must be demonstrated on both anterposterior and lateral views Risk of displacement is significant Most surgeons recommend internal fixation to maintain reduction and allow earlier ambulation and weight bearing If surgery is contraindicated: closed treatment with toe-touch crutch ambulation and frequent radiographic follow-up until healing can be successful
3. Unstable Femoral Neck Fractures
Garden Type 2 femoral neck fracture (although non-displaced) is unstable because displacement is probable under physiologic loading Garden type 3 and 4 are displaced and often comminuted Note: Can be life-threatening injuries, especially in elderly patients Treatment: directed toward preservation of life and restoration of hip function, with early mobilization Best maintained by rigid internal fixation or by primary arthroplasty as soon as the patient is ready for surgery Note: Closed treatment with spica cast is almost always bound to fail Definitive treatment by skeletal traction requires prolonged recumbency with constant nursing care Associated with numerous complications Mal-union Non-union Bed sores Deep vein thrombosis Pulmonary embolus Osteoporosis Hypercalcemia If surgery is not possible: It is better to mobilize the patient just as soon as pain permits Accept a non-union that can be treated later at a later stage is symptom justify it Surgical options are: Internal fixation Primary arthroplasty Note: the younger the patient, the greater the effort is justified to save the femoral head 4. Treatment a. Internal Fixation Goal: To preserve a viable femoral head fragment Provide the optimal setting for bony healing of the fracture while allowing the patient to be as mobile as possible Surgery must be ASAP General or spinal anesthesia is used Fracture is reduced under fluoroscopic imaging as anatomically as possible Gentle manipulation is usually sufficient Rarely: open reduction may be necessary before fixation Rigid internal fixation is obtained using: Multiple parallel partially threaded pins or screws Sliding hip screw and plate Combination of both Patient can be mobilize the following day Weigh bearing is allowed according to the stability of the construct b. Primary Arthroplasty Indicated in the elderly patient for Garden type 4 fractures (avascular necrosis is highly possible) For Garden type 3 fractures that cannot be satisfactorily reduced For femoral heads with pre-existing disease Femoral head is sacrificed, but a definitive procedure is performed Internal fixation of Garden type 4 fractures frequently fails and repeat surgery is required If acetabulum is undamaged: hemiarthroplasty is most commonly accepted technique Using a femoral stem stabilized with methyl methacrylate or a surface that allows biologic fixation with bony in-growth If hip joint is already damaged by pre-existing disease: total hip replacement may be indicated Girdlestone arthroplasty - primary head and neck resection may be rarely indicated in the presence of infection or local malignant growth 5. Complications Most common sequelae of femoral neck fractures are: Loss of reduction Hardware failure Non-union or mal-unions Avascular necrosis of femoral head Can appear as late as 2 years after injury Secondary degenerative joint disease appears somewhat later Infection is rare B. Trochanteric Fractures 1. Lesser Trochanteric Fracture Note: Isolated fracture of the lesser trochanter is rare When it occurs, it is the result of the avulsion force of the iliopsoas muscle Rarely: symptomatic non-union may require fragment fixation or excision 2. Greater Trochanteric Fracture Note: May be caused by: Direct injury or May occur indirectly as a result of the activity of the gluteus medius and gluteus minimus Occurs most commonly as a component of intertrochateric fracture If displacement of the isolated fragment is less than 1 cm and there is no tendency to displacement Treatment: bed rest until acute pain subsides As symptom permit, activity can increase gradually to protected weight bearing with crutches Full weight bearing is permitted as soon as healing is apparent ( in 6-8 weeks) If displacement is greater than 1 cm and increases on adduction of thigh Extensive tearing of surrounding tissues may be assumed Open reduction and internal fixation is indicated 3. Intertrochanteric Fractures Usually occur along the line between the greater and lesser trochanter Typically occur at a later age than do femoral neck fractures Most often extracapsular and occur through cancellous bone Bone healing: with 8-12 weeks (regardless of the treatment) Note: nonunion and avascular necrosis of the femoral head are not significant problems Clinically: involved extremity is usually shortened and can be internally or externally rotated The degree of displacement and comminution will determine the instability of the fracture Wide spectrum of fracture patterns is possible, from the non-displaced fissure fracture to the highly comminuted fracture with major fragments: Head and neck Greater trochanter Lesser trochanter Femoral shaft Selection of the definitive treatment depends upon: The general condition of the patient The fracture pattern Rates of illness is lower when the fracture is internally fixed, allowing early mobilization Operative treatment is indicated as soon as the patient is medically able to tolerate surgery Initial treatment in the hospital should be by gentle skin traction to minimize pain and further displacement Skeletal traction as the definitive treatment is rarely indicated and is fraught with complications such as: Bed sores Deep vein thrombosis Pulmonary embolus Deterioration of mental status Varus union If surgery is contraindicated: it may be preferable to mobilize the patient as soon as pain permits and accept the eventual malunion or nonunion Great majority of these fractures are amenable to surgery Goal: To obtain a fixation secure enough to allow early mobilization Provide an environment for sound fracture healing in a good position Reduction of the fracture is usually accomplished by closed methods, using traction on the fracture table, and monitored on fluoroscopic imaging Internal fixation is most widely obtained with a sliding screw and sideplate Screw can slide in the barrel of the sideplate, allowing the fracture to impact in a stable position Patient can be taken out of bed the next day Weight bearing with crutches or a walker is begun as soon as pain allows Fracture usually heals in 6-12 weeks Other devices used to treat intertrochanteric fractures include: Flexible nails Interlocked nails Prosthetic replacement Complications include: Infection Hardware failure Loss of reduction Irritation bursitis over the tip of the sliding screw
C. Traumatic Dislocation of the Hip Joint
Note: May occur with or without fracture of the acetabulum or the proximal end of the femur Most common during the active years of life Usually the result of severe trauma, unless there is preexisting disease of the: Femoral head Acetabulum Neuromuscular system Head of the femur cannot be completely displaced from the normal acetabulum, unless the ligamentum teres is ruptured or deficient Traumatic dislocation are classified according to the direction of displacement of the femoral head from the acetabulum
1. Posterior Hip Dislocation
The head of the femur is dislocated posterior to the acetabulum when the thigh is flexed Significant clinical finding: Shortening Adduction Internal rotation of extremity Radiographic required: Anteroposterior Transpelvic Oblique radiographic projection (if fracture of the acetabulum is demonstrated) Common associated injuries include: Fractures of the acetabulum Fractures of the femoral head: Femoral head may be displaced through: A rent in the posterior hip joint capsule, or In the glenoid lip may be avulsed from the acetabulum Fractures of the femoral shaft Sciatic nerve injury ?Short external rotation muscles of the femur are commonly lacerated ?Farcture of the posterior margin of the acetabulum can create instability If acetabulum is not fracture / if the fragments are small: reduction by closed reduction is indicated General anesthesia provides maximum muscle relaxation and allows gentle reduction Reduction should be achieved ASAP, preferably within the first few hours after injury, as the incidence of avascular necrosis of the femoral head increases with time until reduction Main feature of reduction is traction in the line of deformity followed by gentle flexion of the hip to 90 degrees with stabilization of the pelvis by an assistant While manual traction is continued, the hip is gently rotated into internal and then external rotation to obtain reduction Complications include: Infection Avascular necrosis of the femoral head Note: Avascular necrosis occurs because of the disruption of the retinacular arteries providing blood to the femoral head Incidence increases with the duration of the dislocation Can occur as late as 2 years after the injury MRI studies enabling early diagnosis and protected weight bearing until revascularization has occurred are recommended Malunion Posttraumatic degenerative joint disease Recurrent dislocation Sciatic nerve injury - occur 10-20% of patients with posterior hip dislocation Associated injury: fracture of the femoral head Small fragments or those involving the non-weight bearing surface should be ignored if they do not disturb hip mechanics, otherwise they should be excised Large fragments of the weight-bearing portion of the femoral head should be reduced and fixed if at all possible
2. Anterior Hip Dislocation
Much rarer Occurs when the hip is extended and externally rotated at the time of impact Associated fractures of the acetabulum and the femoral head or neck rarely occur Femoral head remains lateral to the obturator externus muscle, but can be: Found rarely beneath it (obturator dislocation) or Under the iliopsoas muscle in contact with the superior pubic ramus (pubic dislocation) Hip is classically Flexed Abducted Externally rotated Closed reduction under general anesthesia is generally successful Patients starts mobilization within a few days when pain is tolerable Note: Active and passive hip motion, excluding external rotation, is encouraged, Patient is fully weight bearing by 4-6 weeks Skeletal traction or spica casting may rarely be useful for uncooperative patients
D. Rehabilitation of Hip Fracture Patients
Goal of rehabilitation after hip injuries: to return the patient as rapidly as possible to the pre-injury functional level Factors influencing rehabilitation potential include: Age Mental status Associated injuries Previous medical status Myocardial function Upper extremity strength Balance Motivation Rehabilitation Rare patient treated at bed rest: rehabilitation focuses early at preventing stiffness and weakness of the other extremities Focused toward early range of motion, muscle strengthening, and weight bearing Early full weight bearing as tolerated is encouraged For patients with prosthetic replacements, cemented or not For patients with stable fixation of an intertrochanteric fracture to allow compression of the fracture fragments Some still prefer partial weight bearing until radiologic evidence of bone healing is present to prevent hardware failure When internal fixation does not provide stable fixation of the fracture fragments: Supplemental protection may be added with spica castor brace If not, restricted range of motion or weight bearing may be allowed according to the surgeon’s specifications III. Pelvic Fractures and Dislocations A. Clinical Findings B. Treatment C. Associated Injuries 1. Hemorrhage 2. Thrombosis 3. Neurologic Injury 4. Urogenital Injuries D. Injuries to the Pelvic Ring 1. Classification and Treatment 2. Complications E. Fractures of the Acetabulum 1. Classification 2. Treatment 3. Complications