Jan 19th 2010 Clinical Series Hip by Widad

1. Dr. Widad Nasser

2. Introduction
Hip and femur fracture
Hip / femur dislocation
Other common condition of hip and femur
Special pead. consideration

4. Regarding anatomy of hip and femur ,, what's
FALSE :
The predominant bone in proximal part is cancellous and distal
to intertrochantric is cortical
The arterial supply to femoral head arise from 3 source , the major
source is the intraoasseous cervical arteries
The common femoral vein is posterior and medial to the common
femoral artery,,, at the inguinal ligament
Sciatica nerve arise from L 4 to S 3

6. compartments muscles nerves vesssels
Quadriceps,femoris
,sartorius,iliacus, Lat.femoral Femoral a/v
anterior
psous,pectineus cutanous
Gracilis,add. Longus
medial obturator Profounds
& magnus,obt.
femoris a.&
externus
obt. a/v
Biceps femoris
posterior Sciatica,pos. Profundus
,semitendinous,smi
femoral femoris
membranosus,add.
cutaneous branches
magnus

7. Age and gender are prediposing factors for specifi
injury (stress#/patho. #/oesteop.)
Mechanism of trauma may aid in predicting injury
pattern
Ch. medical condition predipose pt to certain
complication e.g. AVN in ch. Steroid used
Femoral /hip # may lead to hypotention ---
diagnosis of exclusion
After stabilizing pt --- examine limb for
asymerical , neurovascular

9. When femoral # supected ,, the pt will be transported
from the area to A/E with traction ,,,,, whats FALSE
regarding traction :
Traction should be discontinued once the pt arrives in the
A/E
Traction should not be used in open fracture with exposed bone
Traction should not be used in pt suggested to have
neurological involvement
Injured exterimities should be immobilized with traction when
moving the pt

11. Which of the following statements about femoral neck
fractures is FALSE?
The injury is most common in older women after a
minor fall, but it occurs at all ages with significant
trauma.
Stress fracture may not show on initial films; treat
conservatively and repeat x-rays in 10-14 days.
Rest pain and inability to walk are always present
With complete displaced fracture, the leg will be held in
slight external rotation and abduction and shortening will
be noted

13. displaced # rtFemoral Neck Subtle rt femoral neck #

14. Fig 53-16

15. Fig. 53-24

17. Which of the following statements describing the
treatment for femoral neck fractures is FALSE?
Nondisplaced: a prosthesis is always required
Displaced: open reduction and internal fixation or a
joint prosthesis
Stress fracture: either internal fixation or expectant
treatment may be used.
Non-displaced : early ambulation and internal fixation

18. Hip arthroplasty
Indication :
Joint damage 2ndry to arthritis
Hip #
AVN
Tumor
Complication :
Aspetic losning of prosthesis
Infection
DVT
Post op. femoral dislocation

20. Undisplaced # of neck
femur treated with
screw and plate

21. Intertrochentric fracture exetended between
greater and lesser trochenter of femur ,,, whats
FALSE :
Associated mortality rate is > 80 % due to risk of
hemodynamic instability
The leg apperas internaly rotated and shorter on examination
In patient with other medical condition mortality rate
increased if patient taken to OT on the day of injury
Internal fixation is preferable on urgent but not
emergent basis
10-30 % only

23. In trochentric fracture , whats FALSE :
Fracture of lesser and greater trochenter is
rare
Is more common on female than in male
Result of direct fall over trochenter or avulsed by
iliopsoas muscle
If avulsed, the fragment will be displaced superiorly and
anteriorly
Sup.& pos.

24. The treatment for trochanteric hip fracture (avulsion
of the trochanter) is __.
1. internal fixation
2. bed rest with progressive rehabilitation or internal
fixation depending on the degree of displacement
3. hip replacement
1 and 2 but not 3 since primary closure is best
1, 2, and 3 are correct

25. Subtrochentric fracture occur between the lesser
trochenter and proximal 5 cm of femoral shaft ,,, whats
FALSE :
The proximal fragment produce flexion,abduction and
external rotation
Often accompaine femoral nerve and artery injury
Its mostly comminuated fracture and increase the risk of
non-union
Fracture fastly heal because highly vascular region
Delay union and non-union are rare
It is poor vascular region

27. Classsification of subtrochentric fracture

28. Subtrochanteric hip fracture may occur with high-speed
trauma or due to a fall in elderly patients. Which of the
following statements regarding the treatment of
subtrochanteric hip fractures is correct?
Treatment of the fracture should take priority
regardless of the other injuries sustained.
Traction immobilization; it is usually followed by
internal fixation
Internal fixation is seldom required
Long-leg cast.
Surgical intervention is preferable in children < 10 years old

29. Rt Femur shaft # AP
view

30. Femoral shaft fracture are common injury
in young adult after high energy trauma ,,,
what is FALSE :
Open fracture are less frequent and often the result of
gunshot wound
Almost half are a/w ligmantous damage in knee , so knee
examination is unremarkable
Severly comminuted fracture are more likely to be treated
by open reduction and internal fixation
Refracture commonly occur during early healing and
period immediately after hardware removed
Severly comm. Rx mostly
close reduction

31. Fracture of the femoral shaft requires significant trauma, and is
most often caused by a motor vehicle accident, fall or child abuse.
The victim is most often a younger male. Several units of blood may
be lost into the thigh, resulting in hemorrhagic shock. Which of the
following statements regarding treatment is true?
An intramedullary rod or nail allows early
mobilization (within a few days) in uncomplicated
fractures.
A traction splint should never be applied in the
field
Prolonged bed rest with traction is the treatment of
choice
Treat with 6-8 weeks of skeletal traction progressing
to a cast brace
Plate fixation is never required for comminution

33. The capsule of the hip joint is weakest __, where it
inserts on the femoral neck rather than the
intertrochanteric crest. This partly explains why most
hip joint dislocations are __.
Anteriorly; anterior
Posteriorly; anterior
Posteriorly; posterior
Anteriorly ; posterior

34. Which of the following statements about the
classifications of hip dislocation is FALSE?
Anterior: less common than posterior dislocation
Posterior: the most common type (about 90%)
Central (impaction through the acetabulum): the second most
common type
Inferior : occur exculusively in children younger than 7 years
Post./ant./cent.

35. About 90% of hip dislocations are posterior. Which of
the following statements about posterior hip
dislocations is FALSE?
Use traction in line with the femoral axis with flexion of the hip
and gentle manipulation while an assistant fixates the pelvis.
The leg is shortened and internally rotated
It usually results from a posteriorly-directed force applied to the
flexed knee.
Posterior acetabular fracture is common and can be seen on
oblique views.
adducted
The thigh is abducted
Treat with closed reduction as soon as possible to avoid avascular
necrosis of the femoral head or neurovascular injury to the extremity

36. About 5-10% of hip dislocations are anterior. Which of
the following statements about anterior hip
dislocations is FALSE?
Apply persistent traction in line with the femur with gentle
manipulation while an assistant fixates the pelvis. Flexion,
adduction, and/or internal rotation manipulation while maintaining
in-line traction may be required
Closed reduction should be performed as soon as possible to
minimize the chance of avascular necrosis of the hip or
neurovascular injury to the extremity.
Rule out associated fracture prior to manipulation
The leg is abducted and externally rotated
The hip is extended
Hip is flexed

37. Fig. 53-21,,,,53-22

39. Post. Dislocation of hip with adduct thigh and
internally roated ansd shorten

40. Posterior Dislocation of the Left Hip - AP View

41. Posterior Dislocation of the Left Hip - Oblique View

42. Fig. 53-26 ,,,53-27

44. Femoral Shaft
Fracture &
Fracture/Dislocation
of the Hip - Hip X-
Ray

46. Myositis ossification is pathological bone formation at
a site where a bone is not normally found ,,, what is
FALSE :
Traumatic myositis result from # or direct severe trauma and
repaited minor trauma
The incidince is 2 % after treatment of close hip dislocation and
40 % in when open reduction required
In X-ray it appears as irregularly shaped masses of
hetarogeneous bone in the soft tissuearound the joint
Surgical intervention is contraindicated if the lession is near
joint
Its indicated not C.I.

47. Motion of the muscles, tendons and skin about the hip
joint is facilitated by more than a dozen bursae, any of
which can become inflamed. Which of the following
statements about hip bursitis is FALSE?
Usually due to overuse or trauma
Infection or gout: should also be considered as
possible causes
Seen on exam: hip or lateral thigh pain, increased with abduction
and external rotation, as well as with straight-leg raising or
impaction of the heel with the leg extended
Seen on exam: tenderness and possibly heat and swelling
over the greater trochanter
May be helpful: ice, rest, and anti-inflammatory medications;
intrabursal local anesthetic and steroid injections
Pain not with straight leg or impaction

49. Treatment of an open wound of the hip joint
includes:
1. irrigation and debridement in the operating
room
2. tetanus prophylaxis and antibiotics
3. secondary closure
1 and 2 but not 3 since primary closure is best
1, 2, and 3 are correct

50. Singh intreduce a grading system involving the
trabecular pattern of proximal end of femur that’s
useful in evaluating the degree of osteoprosis ,,,What is
FALSE regarding singh score :
X-ray of the head of femur can quantify the degree of osteoporosis
even n non-fractured bones
The singh score contains six score depend on five trabecular
groups,, the worses is grade VI
As osteoprosis progress,,the trabecular groups dissapear
one at a time in predictable pattern
All five grup of trabeculae are seen normally in AP view of
non-diseased head,neck ,proximal end of femur
Worser grade I

51. Fig. 53-6

53. Which statement is FALSE :
Hamstring muscle starin : toe-touch weight bearing
i.e. walking with crutches with toes of inj. Limb rest
on ground w/o wt bearing
Quadriceps tear : surgical repair and extensive rehabilitation
Iliopsoas strain : partial flexion at knee and hip for 7-10 D
Hip adductor strain : complete bed rest for 3 mnths

54. AVN result of ischemic bone death of femoral head after
compromise of its blood supply ,,,, whats FALSE :
On normal person ,,,,,, non-traumatic painful hip doesn’t R/O
AVN
Hip dislocation should reduced within 48-72 hrs to significantly
reduced incidence of AVN
AVN rarly complicated intertrochanteric fracture
With optimal treatment, femoral neck fracture are complicated
by AVN in 11% to 19% of cases
Within 24 hrs

55. Box 53-1

56. 86 male pt present with h/o hip pain since 3 months ,
no h/o recent trauma ,the pain is more in the morning
and progressivly increased with time , o/e no
deformities or shorthining , only minor active and
passive tenderness on motion ,,, whats best answer :
If plain film is negative ,, discharge pt with analgesia
If plain film is negative ,, discharge pt with analgesia and
to repait xray after 10-14 days
Addmit the pt for pain mangment
Order CT/MRI hip

58. Development of femoral head and neck with its growth palates and two
primary ossification center
New 4mnth 4 yr 6 yr
1 yr
born

59. Physis # transcervical
cervicotrochentric intertrochentric
Delbet classification of
femoral head fracture in peads

60. 2 years old child present with h/o fever,limp and pain
in lt hip , gram +ve bacteria are recovered from the
hip joint , which of the following is most correct :
Causative organism include Neisseria and group B
streptoccocus
Culture will be positive in approximatl 50 %
Girls are afftected more than boys
The hip is most commonly affected joint
Sed rate is superior to CRP in making diagnosis

61. 8 years boy with no h/o fever or trauma , present
with pain in his groin ,Legg-Calve- perthes disease
is suspected ,,, which of following is correct :
Disease is bilateral in 50 % of cases
Finding in initial LCP inclde widning of medial joint space and
irregularity of physis
Peak year of incidence is 10 – 12 yrs
Radionnuclear scan give more information than plain film
regarding femoral head necrosis
There is limited adduction and internl rotaion on examination

62. ☺ Perthes disease is AVN to femoral head of peads resulted in
softining and break down of femoral head
☺ B/w 2 -10 yrs of age. ,,,, male > female
☺ 20 % b/l ,, limitation abd. & ext. rotation
☺Rx immobilization or limitations on usual activities or surgical
☺ After 18 months to 2 years of treatment, most children return to
normal activities without major limitations.

65. 14 yrs old obese boy present with acute onset of pain
in his lt hip after a football injury ,, xray of affected
hip demonistrate a Slipped Cappital Femoral Head ,,,
which of following is most correct :
Xray of controlateral hip is indicated
AVN would not be a complication on this pateient
Boy present at younger age than girl
This injury can be classify as stable

66. ☺ SCFEis a Salter-Harris type 1 fracture through the proximal femoral
physis.
☺ Stress around the hip causes a shear force to be applied at the growth
plate and epiphysis to move posteriorly and medially.
☺ The almost exclusive incidence of SCFE during the adolescent growth
spurt indicates a hormonal role.
☺ Obesity is another key predisposing factor in the development of SCFE.
☺ Because the physis has yet to close, the blood supply to the epiphysis
still should be derived from the femoral neck; however, this late in
childhood, the supply is tenuous and frequently lost after the fracture
occurs.
☺ Clinical presentation often is misleading, with only 50% of patients
presenting with hip pain and 25% presenting with knee pain☺