MDS1008

CTS 4A Fractures and dislocation of the hip, congenital dislocation

of the hip
Case 1
A 72 year old widow who lives with her oldest daughter is found on the floor
of her
bedroom, having tripped on a carpet. She complains of severe pain in her
right hip and is unable to get up. An ambulance is called to take her to
the hospital. On examination she appears frail and thin. Her right leg is
externally rotated and 2. 5 cm shorter than the left leg. She is unable
to lift up the right heel. The greater trochanter on the right side
appears higher and more prominent than on the left. On palpation
there is tenderness in the femoral triangle in front of the hip joint. A
provisional diagnosis of fracture through the femoral neck is confirmed
by AP and lateral X Rays of both hips.
Questions
1. Explain the anatomical basis for the clinical findings.
Leg externally rotated: depends of change of muscles activity. Main
flexor of the hip is the iliopsoas (attaches to the lesser trochanter).
Also causes medial rotation (also due to adductors. Fulcrum
normally pulls inwards but in fracture the fulcrum pulls outwards.
Leg shorter on one side: to measure length of the leg: use
landmark. pelvis and distal leg... use medial malleolus...
Pull of muscle Rectus femoris, Adductor muscles, Quadriceps...
attached proximal to the hip joint... therefore pull distal part
proximally. Normally head of femur in actebulum therefore cannot
be pulled proximally.

Tenderness in fem triangle: has the head of the femur... can be

palpated... pain in arthritis. Reason for tenderness.
Higher greater trochanter: more obvious due to pushing out...
normally attached to gluteus medius and minimus (medial
roation/abduction)... bone not attached so pulled outwards.
2. Assuming that the X Ray shows the fracture is just below the head
of the femur (subcapital), describe the position of the fragments.
The strong muscles of the thigh - including the rectus femoris, the
adductor muscles, and the hamstring muscles, pull the distal
fragment upward thus the reason why the leg is shortened.
Head remains where it is but medially rotated.
3. Why is it important to X Ray both hips?
To compare the right and left hip - one injured hip and one normal
(normal as in this particular woman) hip.
Weak bones... Osteoporosis... Arthritis...
Fracture hip: want to get patient walking again as soon as possible...
Normally have to replace the head of the femur in a painful,
expensize and extensive surgery, therefore better to know of risk to
both hips so you can know what action to take early on.

4. What is Shentons Line?

A curved, continuous artificial line formed by the top of the obturator

foramen and the neck of the femur, seen on an AP radiograph of a
normal hip joint. It is a rapid way of testing dislocation and fractures.
Smooth: nothing wrong.
Not smooth: dislocation/fracture.

o 5. What else might you expect to find on X Ray examination of the hip?
How may this be related to the history in this case?
In Osteoporosis: a simple trip in a young person is not that serious
and normally will not cause fractures of this type... (DARKER
decreased density)
In elderly: a small fall can result in fractures... due to weaker bones.
Common areas are hip, vertebrae and colles.
Tenderness on the femoral triangle shows signs of arthritis. Arthritis
can be seen on the X-ray - this is observed by the bones being close to
each other due to the wearing out of the smooth cartilage between
bones - the function of this cartilage allows the bones to move
smoothly against each other.
6. Explain how the blood supply to the femoral head may become
compromised by a subcapital fracture. What are the possible
consequences?
Fractures of the femoral neck interfere with or completely interrupt
the blood supply from the root of the femoral neck to the
femoral head. The scant blood flow along the small artery that
accompanies the round ligament may be insufficient to sustain the
viability of the femoral head and ischaemic necrosis gradually takes
place.
o Blood supply: no connection between top and bottom part due to the
epiphyseal line made of cartilage (which is avascular) in under 14
y/o.
o Bottom part 2 big anastamoses: cruciate/trochanter anastomosis
o 14y/o and over when there is formation of bone connection restored
due to bone marrow

o In elderly: BM yellow marrow. Artery has now shrunk. Only small

part is supplied small artery runs along reflective part.
o Reflected capsule edges of acetabulum to lesser and greater
trochanter and is reflected along the neck blood vessel then
runs along the reflected part runs close to the neck
o in fracture blood vessels are torn AVN/ischaemic necrosis
(unlikely they will line up and heal even after in hemiarthroplasty).
7. How do intertrochanteric and subcapital fractures differ from each
other?
Intertrochanteric fracture occurs in young and middle-aged
people due to direct trauma. There will be no avascular necrosis
complication as in subcapital fractures as the fracture line is
extracapsular and both fragments will have a profuse blood supply.
Subcapital fracture occurs in elderly even with a minor trip,
especially in postmenopausal women as the oestrogen deficiency
causes the bone to thin more than in elderly males. Complication:
avascular necrosis of head of femur. Risk of AVN is higher. Occurs
mostly due to osteoporosis.

8. Assuming that the hip is pin and plated or the joint is replaced,
what factors are likely to help or hinder her recovery?
Help recovery: early mobilization, physical therapy, using a walking
aid, not putting too much stress on the affected area not spending a
lot of time on her feet and exerting herself. Encourage movement and
activity to prevent atrophy of the muscles take into consideration
lifestyle.
Hinder recovery: the fact that she suffers from arthritis, any tumour
or metabolic condition (eg: osteomalacia) developing in bones,

development of osteoporosis, increased weight, side effects of certain

drugs she may be taking.

Case 2
A 65 year old overweight woman complains of pain in the right hip area for
several
months. She is unable to walk to church and to the shops because of pain,
and is now house-bound. On examination she weighs 150 kg. Movements of
the hip are limited. An X Ray examination shows decreased joint space,
erosion of the articular cartilage and osteophytes at the joint surface.
Questions
1. Explain the clinical findings in anatomical terms.
The hip bone consists of 3 bones: ilium, ischium and pubis. These
meet at the acetabulum which articulates with the head of the femur
to form the hip joint. The restricted hip movement and Xray findings
indicate osteoarthritis. Age is the main contributing factor for
degeneration of the protein in cartilage while the water content
increases. Another factor that makes her susceptible to this condition
is the fact that she is overweight.
Pain: bone rubbing against bone occurs in osteoarthristis rubbing
hard on the bones eventually removes the cartilage stem cells of
cartilage are found on the surface therefore eventually lead to bone
rubbing against bone. The lack of cartilage results in friction on
movement as joint space is reduced and so bones are closer together.
This causes swelling and pain, as well as limited joint mobility.
Limited movement: decreased joint space indicative of cartilage

being eaten away The inflammation results in osteophytes.

osteophytes: extra bone outgrowths forming. In a fracture: callus tries
to fix fracture where cartilage is lost, breakdown of the
periosteum... Body thinks it has a fracture so produces more bone
which then keeps getting eaten at get extra pieces of bone growing
on the side of the bone pain.
2. What is the normal range of movements of the hip? How are these
movements tested?
Flexion = up 180 degrees
Extension = 0 to 30 degrees (backward movement of flexed thigh)
limited due to iliofemoral ligament very strong.
Adduction = 0 to 30 degrees.
Abduction = 0 to 45 degrees:
Used for walking by abducting body on leg and also balancing.
External rotation = 0 to 60 degrees.
Internal rotation = 0 to 40 degrees.
Movement of rotation is used to change direction when walking
Circumduction:

3. In what ways does her weight negatively impact this disease?

Her weight increases the load on her hip which is already arthritic due
to her increasing age, as well as loss of bones due to rubbing.
The excess weight also creates more mechanical stress on the
degenerating cartilage.
4. Assuming she uses a stick to assist in walking, in which hand would
she hold the stick and why?

In her left hand since her right hip is affected and one should always
hold a stick/cane on the opposite side of the body to the affected
joint. This takes some pressure off the affected joint and relieves
some of the symptoms. Always used the opposite hand to the leg
affected. Due to push of center of gravity when walking.
Case 3
An 18 year old law student is involved in a head-on road traffic accident. He
is not wearing a seat belt. When he is extracted from the vehicle, he
complains of being unable to move the left ankle and foot. The left leg
is 3 cm shorter than the right and it is adducted and medially
rotated. The left hip is very painful. There is contusion over the left knee. On
examination, he is unable to extend the hip joint, flex the leg or move
the ankle and foot in any direction (Hamstrings). There is loss of
sensation over the posterolateral part of the leg (sural / lateral
cutaneous nerve of the thigh) and almost the whole foot. There is a large
painful mass in lateral gluteal area.
Questions
1. What might you expect to find on X Ray examination of the hip?
Indicative of a hip dislocation.
Would see medial rotation: therefore NOT a fracture (fractures cause
external rotation) caused by femoral head not moving (causes the
mass in gluteal region). Head of femur has come of out of the
acetabulum
2. Describe how this injury occured in this case? How else could this
injury have happened?

Since he wasnt wearing a seatbelt, the patient ended up hitting his

knee against a part of the car (explains the knee contusion). The force
of the collision was transmitted to the head of the femur pushing it
out of place and possible fracturing the acetabulum in the process.
Could have also been caused by a fall from height, such as falling
from a ladder.
Some congenital disorders may also result in hip dislocation. These
include Chromosome 9 trisomy, Cutis Laxa Debre Type, and De Barsy
Syndrome.
3. Describe the anatomical basis for the clinical findings in this case.
Medial rotation
The fact that he cannot move his left ankle and foot shows that there
is damage to the nerve supplying the muscles responsible for this
movement. This nerve is the sciatic nerve supplies post thigh and
muscles below the knee head of femur squashing sciatic nerve
no movement below the knee.
4. Why is he unable to extend the hip joint? Which hip extensor might
still be functional and why?
This is because maybe the sciatic nerve has been injured and the hip
extensors (biceps femoris, semitendinosus and semimembranosus)
are all supplied by the sciatic nerve.
The only remaining extensor is the Gluteus maximus. It can still
extend the hip since it is supplied by a different nerve, the inferior
gluteal nerve.
Quiet extension: hamstrings main extensor

Running/jumping/climbing: Gluteus Maximus main extensor pulls

more distally. Due to its insertion allows for larger burst of extension.
5. Why is the leg shortened, adducted and medially rotated?
The leg is shortened since the hip has been dislocated pushed
inwards by the impact.
It is adducted and medially rotated due to injury to the abductors and
lateral rotators which cannot contract, leaving the abductors and
medial rotators unopposed.
6. What factors may affect the clinical features in this case?
Whether there are other injuries such as vertebral column fractures
pinching on the nerve roots which would impair function of the
muscles but hide the sciatic nerve injury.
7. If this nerve were to be involved in disc prolapse, in what ways
would the clinical features be the same, and how would they differ?

They would be the same since:

3 flexors and extensors of the leg would still not function,
as would the ankle and foot since the tibial nerve and deep
fibular nerve (from the common fibular nerve) are both
derived from the sciatic nerve.
They would differ since the patient would also suffer from

back pain.
Besides the sciatic nerve other nerves would be injured such
as the pudendal nerve, the nerve to inferior gluteus and the
nerve to piriformis.
8. Apart from disc prolapse, how else could this nerve be affected?
The Sciatic nerve may be injured in a number of ways
commonly by compression or section (slicing of).
Compression may be caused by Pirriformis syndrome in which
the small gluteal muscle, pirriformis, hypertrophies and starts
to spasm compressing on the sciatic nerve when this nerve
passes through it, Pelvic fractures at the Pelvic brim region,
and tumors medial to said sciatic nerve, in this case the tumor
would compress the nerve against the pelvic girdle increasing
damage as the tumor grows.
Section of the Sciatic nerve is uncommon and can either arise
from physical attack(stab wounds) or it may be iatrogenic,
caused during a surgery in the medial side of the buttock. In
each case different levels of loss of function may occur, from
loss of inferior gluteal movement and posterior femoral
cutaneous nerve sensation, up to complete loss of extension
and flexion, with loss of function of knee and ankle joints.
9. What ligaments support the hip joint? In a patient with posterior
dislocation of the hip, which of these would be torn and why? Which
artery is the main blood supply to the hip joint?
The Hip joint is supported by three intrinsic joints, which

restrict its movement while keeping it in place. They are the

iliofemoral ligament (anteriorly and superiorly to the hip joint,
extension), pubofemoral ligament (anterioly and inferiorly to
the hip joint, extension and abduction) and ischiofemoral
ligament (posteriorly to the hip joint). It is also held by the
transverse acetubular ligament (acetubular labrum) and the
femoral head ligaments (found circumferential around the
head of the femur), these two ligaments fuse to help in
general stability.
In posterior dislocation the anterior ligaments must be torn to
allow for posterior movement, since if they are still fully
functioning they would not allow the head to dislocate
backwards. Since the most powerful anterior ligamnents are
the iliofemoral and the pubofemoral, they must be torn to
accommodate this type of injury.
The hip joint is supplied by the circumflex arteries of the
femoral head. It is supplied by both lateral and medial
branches.
10. What is congenital dislocation of the hip? How should this be
checked in a newborn?
Congential dislocation of the hip is a type of Developmental
Dyslapsia of the Hip(DDH) in which the different parts of the
hip joint do not develop completely resulting in lack of
contact between the femoral head and the acetabulum. It can
arise from both abnormal growth of the femur and due to
extremely lax ligaments, in each case the hip joint is made
null due to defective components.

The condition in a newborn can be diagnosed by following

simple procedures. The Ortolani maneuver in which the
abducted hip is reduced into the joint, will cause a palpable
low pitched clunk in infants with DDH. Also in unilateral
dislocation leg legth differences and abduction of affected leg
may be observed. (A child at an older age(3-6 months can be
diagnosed using the Galeazzi sign).
Different treatments are recommended for different types of
dislocations at different age groups depending on their
relative percentage of success.
Surgery for the hip joint is only recommended in cases in
severe cases of DDH in which natural repair is not viable.
Normally with infants if instability is found a brace (Pavlik's
harness is used).
In unilateral dislocation(w/o pain) the child, if the dislocation
is mild would probably walk normally with a slight limp.
Indeed a case of a 74 year old man who was diagnosed with
bilateral congenital dislocation only a few months prior to his
death.
11. What treatment would be recommended? If the dislocation is not
diagnosed at treated at birth, describe the way a patient with this
condition would walk as a child.