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Traumatic Traumatic conditions of the conditions of the hip hip

Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

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Page 1: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Traumatic Traumatic conditions of the conditions of the

hip hip

Page 2: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Dislocation of the hip Dislocation of the hip

1.1. Anterior dislocationAnterior dislocation

2.2. Posterior dislocation, more commonPosterior dislocation, more common

3.3. Central dislocation (direct thrust Central dislocation (direct thrust along the line of the femoral neck → along the line of the femoral neck → fracture acetabulum → femoral head fracture acetabulum → femoral head displaced into the pelvic cavitydisplaced into the pelvic cavity

Page 3: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Posterior dislocation of Posterior dislocation of the hipthe hip

• Longitudinal thrust along shaft of femur Longitudinal thrust along shaft of femur when hip is flexed & adducted (dash when hip is flexed & adducted (dash board accident)board accident)

→ → head of femur displaced backward out of head of femur displaced backward out of the acetabulumthe acetabulum

• Clinically: Clinically:

The affected leg is:The affected leg is:

1.1. Internally rotatedInternally rotated

2.2. Adducted Adducted

3.3. Shortened (fig.)Shortened (fig.)

Page 4: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Complications Complications

• Immediate complications:Immediate complications:

Sciatic nerve injurySciatic nerve injury → drop foot & → drop foot & numbness over the outside of the calfnumbness over the outside of the calf

• Late complications:Late complications:

avulsion of ligamentum teres from the avulsion of ligamentum teres from the acetabulum → cut off blood supply to acetabulum → cut off blood supply to femoral head → avascular necrosis → femoral head → avascular necrosis → OAOA

Page 5: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

TREATMENT TREATMENT

1.1. Manipulative reductionManipulative reduction

2.2. Traction (4 weeks) → healing of Traction (4 weeks) → healing of capsular tearcapsular tear

3.3. Weight bearing Weight bearing

4.4. Regular x rays monthly for the 1Regular x rays monthly for the 1stst 4 4 months for early detection of months for early detection of avascular necrosis avascular necrosis

Page 6: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Treatment of Treatment of complications complications

• Operation may be necessary to free the Operation may be necessary to free the sciatic nervesciatic nerve

• Avascular necrosis is treatedAvascular necrosis is treated

1.1. in early stages by avoidance of WT in early stages by avoidance of WT bearing until texture of femoral head bearing until texture of femoral head returns to normal.returns to normal.

2.2. In late stages by total hip replacement, In late stages by total hip replacement, arthrodesis, osteotomy, or bone graftingarthrodesis, osteotomy, or bone grafting

Page 7: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Anterior dislocation of Anterior dislocation of the hip the hip

• Force that abducts the extended hip → Force that abducts the extended hip → femoral head displaced below & in front femoral head displaced below & in front of the acetabulumof the acetabulum

• Clinically:Clinically:the affected leg is:the affected leg is:1.1. AbductedAbducted2.2. Externally rotatedExternally rotated• Treatment:Treatment:1.1. Manipulative reductionManipulative reduction2.2. 3 weeks traction3 weeks traction

Page 8: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Central dislocation of the Central dislocation of the hip hip • Direct violence → drives femoral head through floor of acetabulum →Direct violence → drives femoral head through floor of acetabulum →

1.1. Damage of articular surfacesDamage of articular surfaces2.2. Intrapelvic haemorrhageIntrapelvic haemorrhage3.3. Hypovolemic shockHypovolemic shock• Conservative treatmentConservative treatment1.1. Longitudinal traction for 6 weeksLongitudinal traction for 6 weeks2.2. Mobility of the hipMobility of the hip• Surgical treatmentSurgical treatment1.1. Reconstruction of the destroyed acetabulumReconstruction of the destroyed acetabulum2.2. Total hip replacementTotal hip replacement

Page 9: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Fractures of upper end of Fractures of upper end of femurfemur

• Risk factore: Risk factore:

1.1. Age: risk doubles over age of 50Age: risk doubles over age of 50

2.2. Sex: women > men 2-3 timesSex: women > men 2-3 times

3.3. Race: caucasian > negroes 2-3 Race: caucasian > negroes 2-3 timestimes

4.4. Medical history of previous hip Medical history of previous hip fracturefracture

Page 10: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Subcapital fracture of the Subcapital fracture of the femoral neck femoral neck

• Grade IGrade I

Head of femur is abducted & impacted with Head of femur is abducted & impacted with the neckthe neck

• Clinically:Clinically:

1.1. Little painLittle pain

2.2. Trivial injuryTrivial injury

3.3. No shortening or rotational deformityNo shortening or rotational deformity

4.4. Active movement may be possibleActive movement may be possible

Page 11: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

•Grade IIGrade IIUndisplaced fractureUndisplaced fracture

ST are attached providing blood supplyST are attached providing blood supply

• Grade IIIGrade III- Femur is adducted at fracture siteFemur is adducted at fracture site- Head is separated from the neckHead is separated from the neck- Severe pain in hip when standing or Severe pain in hip when standing or

moving the affected limbmoving the affected limb- Injured foot & leg are externally rotated Injured foot & leg are externally rotated

Page 12: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Grade IVGrade IVGross rotation of both fragments with Gross rotation of both fragments with complete loss of contact between the complete loss of contact between the

fragments fragments

Page 13: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Treatment Treatment

1.1. Grade II → - compression screwsGrade II → - compression screws

2. Grade III & IV → 2. Grade III & IV → - hemiarthroplasty (Austin-more hemiarthroplasty (Austin-more

prosthesis)prosthesis)- Total hip replacementTotal hip replacement

Page 14: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Intertrochanteric Intertrochanteric fracturesfractures

• Common in elderly peopleCommon in elderly people• Equal frequency in men & womenEqual frequency in men & women• Often comminutedOften comminuted• Lesser trochanter frequently Lesser trochanter frequently

avulsed & pulled upwards by avulsed & pulled upwards by iliopsoasiliopsoas

• TreatmentTreatment

1.1. Compressiom screws and plateCompressiom screws and plate

2.2. Early mobilizationEarly mobilization

3.3. Early ambulationEarly ambulation

Page 15: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Fractures of femoral shafts Fractures of femoral shafts in adultsin adults

• Vigorous traumaVigorous trauma• Hypovolaemic shockHypovolaemic shock• Fracture line is transverse or Fracture line is transverse or

comminutedcomminuted• Severe displacementSevere displacement• residual stiffness of kneeresidual stiffness of knee• Non-union with open fracturesNon-union with open fractures

Page 16: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Conservative treatmentConservative treatment

• Temporary traction for 8 weeks Temporary traction for 8 weeks (fixed or balanced- skin or (fixed or balanced- skin or skeletal) (fig.)skeletal) (fig.)

• Followed by hinged cast braceFollowed by hinged cast brace• Weight bearing is then Weight bearing is then

encouragedencouraged

Operative treatmentOperative treatment• Locked intramedullary nailLocked intramedullary nail

Page 17: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Femoral shaft fractures Femoral shaft fractures in infancy in infancy

• Causes:Causes:1.1. Indirect rotatory twisting strainIndirect rotatory twisting strain2.2. Difficult delivery with breech Difficult delivery with breech

presentationpresentation

• Treatment:Treatment:1.1. 3-4 weeks fixed traction on 3-4 weeks fixed traction on

Thomas splintThomas splint2.2. In infants less than 3 years → In infants less than 3 years →

gallows traction gallows traction

Page 18: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Supracondylar fractures Supracondylar fractures

• Treated by Thomas splint with knee flexionTreated by Thomas splint with knee flexion

Fractures of femoral condylesFractures of femoral condyles• Intra-articular fractureIntra-articular fracture• Internal fixation with plate and screws is necessry to:Internal fixation with plate and screws is necessry to:1.1. Reduce the fractured articular surfaces accuratelyReduce the fractured articular surfaces accurately2.2. Allow early mobilizationAllow early mobilization

Page 19: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Physical therapy program Physical therapy program during immobilization periodduring immobilization period

1.1. To prevent respiratory complications → breathing To prevent respiratory complications → breathing exercises.exercises.

2.2. To prevent circulatory complications →To prevent circulatory complications →

- circulatory exercises- circulatory exercises

- changing position every 2 hours- changing position every 2 hours

- alternating air mattress- alternating air mattress

3. To prevent stiffness, weakness & atrophy of the free parts →3. To prevent stiffness, weakness & atrophy of the free parts →

- ROM exercises- ROM exercises

- strengthening exercises- strengthening exercises

4. To prevent weakness of immobilized parts → static & 4. To prevent weakness of immobilized parts → static & isometric exercisesisometric exercises

Page 20: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Rehabilitation after ORIF of Rehabilitation after ORIF of hip fractureship fractures

1.1. Bed mobility while maintaining proper Bed mobility while maintaining proper alignment of the operative limbalignment of the operative limb

2.2. Lying flat on back for 1 hour/day to avoid Lying flat on back for 1 hour/day to avoid hip flexion contractures.hip flexion contractures.

3.3. Forced hip flexion or rotation (e.g. twisting Forced hip flexion or rotation (e.g. twisting forward or to either side)is to be avoided forward or to either side)is to be avoided for the 1for the 1stst 7-10 days postoperatively. 7-10 days postoperatively.

4.4. Patients are allowed to assume a Patients are allowed to assume a semireclined position after 24 houurs.semireclined position after 24 houurs.

Page 21: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

5. Patients are assisted into protectively positioned 5. Patients are assisted into protectively positioned side-lying as soon as possible(2-3 days side-lying as soon as possible(2-3 days postoperatively).postoperatively).

• Side lying position greatly aids in:Side lying position greatly aids in:

- toiletry- toiletry

- pulmonary postural drainage- pulmonary postural drainage

- prevention of decubitus ulcers- prevention of decubitus ulcers

6. An over head trapeze is essential during the 16. An over head trapeze is essential during the 1stst few days postoperatively (using elbows & heels few days postoperatively (using elbows & heels toto

elevate hips→ 4 times body weight force acts on the elevate hips→ 4 times body weight force acts on the hip).hip).

Page 22: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

7. Gait training with walker or crutches if balance 7. Gait training with walker or crutches if balance & mobility are good. (touch down gait takes & mobility are good. (touch down gait takes about 90-95% of load off hip joint, compared to about 90-95% of load off hip joint, compared to 80% weight reduction with NWB gait80% weight reduction with NWB gait

8. Over 12-16 weeks gait pattern will evolve into 8. Over 12-16 weeks gait pattern will evolve into full weight bearing based on:full weight bearing based on:

- surgical procedure- surgical procedure

- area of fracture- area of fracture

- radiographic findings- radiographic findings

- patient comfort- patient comfort

Page 23: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

9. Active exercises through a comfortable 9. Active exercises through a comfortable rangerange

10. Pool exercises to regain strength, 10. Pool exercises to regain strength, proprioceptive sense & mobility.proprioceptive sense & mobility.

Nb.Nb. • Tying a shoeTying a shoe with foot on floor requires with foot on floor requires

124124oo hip flexion hip flexion• Ascending stairsAscending stairs requires requires 6767oo hip flexion hip flexion• Sitting downSitting down on a chair requires on a chair requires 104104oo hip hip

flexionflexion

Page 24: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Fractures of upper end of Fractures of upper end of femur(ORIF)femur(ORIF)

Day 1:Day 1:- Quadriceps setsQuadriceps sets- hamstrings setshamstrings sets- gluteal sets gluteal sets - ankle pumpsankle pumps

Page 25: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

- Active assisted hip Active assisted hip abduction & abduction & adductionadduction

- Supine leg slides for Supine leg slides for flexion of hip & kneeflexion of hip & knee

- Upper extremity Upper extremity exerciseexercise

Page 26: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Day 2:Day 2:

• Ambulation with TDWB with walker, Ambulation with TDWB with walker, then PWB with walkerthen PWB with walker

Days 3-7Days 3-7- SLR in all directionsSLR in all directions- Thomas stretch of anterior capsule Thomas stretch of anterior capsule

and hip flexorsand hip flexors

Page 27: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

1-2 weeks1-2 weeks- Discharge criteria:Discharge criteria:

1.1. Get out of bed independentlyGet out of bed independently

2.2. Able to ambulate 50 feet with assistive deviceAble to ambulate 50 feet with assistive device

3.3. In & out of bathroom independently.In & out of bathroom independently.- Standing hip abduction, adduction, flexion, and Standing hip abduction, adduction, flexion, and

extension & hip and knee flexion exercises.extension & hip and knee flexion exercises.

2 -6 weeks2 -6 weeks- Stationary bicycle, pool exercises, and treadmillStationary bicycle, pool exercises, and treadmill- Progress ambulation from walker to use of a cane (ifProgress ambulation from walker to use of a cane (if

Trendelendburg test is –ve)Trendelendburg test is –ve)

Page 28: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Femoral shaft fracture Femoral shaft fracture treated with intramedullary treated with intramedullary

nailnail• Phase 1: 0-6 weeks:Phase 1: 0-6 weeks:- Quadriceps, hamstrings, gluteal sets & ankle Quadriceps, hamstrings, gluteal sets & ankle

pumpspumps- SLR in all planesSLR in all planes- Knee active ROM exercisesKnee active ROM exercises- Stationary bicycleStationary bicycle- Weight bearing to tolerance (if nail diameter is Weight bearing to tolerance (if nail diameter is

12mm or more) an progress to full weight bearing 12mm or more) an progress to full weight bearing as tolerated within 6-12 weeks. If nail diameter is as tolerated within 6-12 weeks. If nail diameter is less, begin weight bearing with 25kg.less, begin weight bearing with 25kg.

Page 29: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Phase 2 (6 weeks -3 Phase 2 (6 weeks -3 months)months)

- Scale technique for weight bearing (5-10 kg increase Scale technique for weight bearing (5-10 kg increase weekly)weekly)

- Isokinetic exercisesIsokinetic exercises- CKC exercisesCKC exercises

Phase 3 (3-6 months)Phase 3 (3-6 months)- Full weight bearingFull weight bearing- Full knee & hip ROMFull knee & hip ROM- Full squatFull squat- Ascend & descend stairs full weight bearingAscend & descend stairs full weight bearing- Thigh circumference = uninjured sideThigh circumference = uninjured side

Phase 4 (> 6 months)- Return to athletic activityReturn to athletic activity- Full work & recreational activityFull work & recreational activity

Page 30: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Femoral shaft fracture Femoral shaft fracture treated with plate & screwstreated with plate & screws

- Same as for intra-medullary nail with Same as for intra-medullary nail with exception that:exception that:

1.1. NWB for 8-12 weeksNWB for 8-12 weeks

2.2. Weight bearing is not progressed until Weight bearing is not progressed until radiological union (3-6 months)radiological union (3-6 months)

Page 31: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Intraarticular fractures Intraarticular fractures with IFwith IF

• Phase 1 (0-6 weeks)Phase 1 (0-6 weeks)- CPM in first 24-48 hours (0-90 degrees)CPM in first 24-48 hours (0-90 degrees)- OKC exercise e.g. SLR, quadriceps setsOKC exercise e.g. SLR, quadriceps sets- TDWBTDWB

Phase 2 (6-12 weeks)Phase 2 (6-12 weeks)- Stationary bicycleStationary bicycle- PWB using the scale techniquePWB using the scale technique- CKC exercisesCKC exercises

Page 32: Traumatic conditions of the hip. Dislocation of the hip 1.Anterior dislocation 2.Posterior dislocation, more common 3.Central dislocation (direct thrust

Phase 3 (3-6 months)Phase 3 (3-6 months)- FWBFWB

Phase 4 (>6 months)Phase 4 (>6 months)- Return to work & recreational activityReturn to work & recreational activity- Avoid excessive squatting & jumping & Avoid excessive squatting & jumping &

contact sports for 6-12 monthscontact sports for 6-12 months