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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