Hip 2

Question 1

Remind yourself of the bony landmarks of the humerus

Answer 1

Question 2

What is the common mechanism of injury for #femoral shaft?

Answer 2

• High energy trauma
• Fragility fracture (low energy)
• Pathological fracture
• Bisophosphonate-related fractures (classically this is a transverse fracture in proximal femur)

Question 3

The femur is not highly vascularised; true or false?

Answer 3

False; it is highly vascularised due to its role in haematopoesis. It is supplied by penetrating branches of the profunda femoris. Consequently large volumes of blood (1500mL) can be lost when it fractures

Question 4

Describe the typical presentation of someone with #femoral shaft

Answer 4

• Pain in thigh, +/- hip, +/- knee
• Inability to weight bear
• +/- deformity
  
  • Proximal femur: abducted & flexed
  • Distal: adducted & extended

Question 5

Explain why the leg takes the following position during #femoral shaft

• Proximal: abducted & flexed
• Distal: adducted & extended

Answer 5

• Proximal: abducted due to gluteus medius & minimus, flexed due to iliopsoas action on lesser trochanter
• Distal: adducted due to adductor omuscles (adductor magnus, gracilis) and extended deu to pull of gastrocnemius on posterior femur

Question 6

What classification is used for #femoral shaft?

Describe this classification

Answer 6

Winquist & Hansen (used to classify degree of comminution of femoral shaft fractures)

Question 7

What investigations are required for a suspected #femoral shaft?

Answer 7

• Plain film radiograph (AP & lateral. Must include entire femur, hip & knee)
• ?CT is polytrauma
• Routine urgent bloods (including coagulation & group and save)

Question 8

Discuss the management of a #femoral shaft, include:

• Immediate management
• Definitive management

Answer 8

Immediate Management

• Stabilise pt using ATLS
• Pain relief (e.g. opiods, fascia iliac block)
• Immediate reduction & immobilisation (traction splinting is used in isolated femoral shaft fractures)

Definitive Management

• Most require surgery
  
  • Antegrade intramedullary nail
  • Or retrograde IM nail if have hip replacement or concurrent lower limb fractures
  • May do external fixation followed later by IM nail if pt unstable/needs optimising before defintive surgery
• Long-leg cast may be indicated in undisplaced #femoral shaft in pts not fit for surgery

Question 9

Why is it important that we reduce fractures to near-anatomical alignment using in line traction?

Answer 9

• Ensures appropriate haematoma formation (part of healing process)
• Reduces pain

*In suspected or isolated femoral shaft fractures can use Kendrick traction splint

Question 10

State some contraindications to traction splinting in #femoral shaft

Answer 10

• Hip or pelvic fracturs
• Supracondylar fractures
• Fractures of ankle & foot
• Partial amputation

Question 11

Femoral fractures should be surgically fixed within how many hours?

Answer 11

24-48hrs (sooner if open fracture)

Question 12

State some potential complications of femoral shaft fractures

Answer 12

• Neurovascular injury
  
  • Pudendal nerve injury (10%)
  • Femoral nerve injury
• Mal-union, delayed union or non-union
• Infection
• Fat embolism
• Hip flexor weakness
• Knee extensor weakness
• Limb stiffness
• Re-fracture

Question 13

What symptoms would someone have if they had sustained a pudendal nerve injury during #femoral shaft?

Answer 13

Question 14

Discuss the prognosis of femoral shaft fractures

Answer 14

• Pts who survive initial trauma typically heal well
• Early mobilisation reduces complications
• Pts >60yrs have mortality of 17% and overall complication rate of 54%

Question 15

What is meant by a distal femoral fracture?

Answer 15

Fracture between the distal metaphyseal-diaphyseal junction of femur to the articular surface of femoral condyles

Question 16

State some common mechanisms of injury for distal femoral fractures

Answer 16

• High energy tauma in younger
• Low energy trauma in older/pathological fracture
• Peri-prosthetic fracture

Question 17

How do we classify distal femoral fractures?

Answer 17

Classify into:

• A= extra-aritcular
• B= partial articular
• C= complete articular

Partial articular can be further classified into sagittal and coronal fractures of each condyle

Question 18

What is a Hoffa fracture?

Answer 18

Subtype of a type B distal femoral fracuture in which there is fracture of the posterior aspect of the femoral condyles in coronal plane. More commonly unicondylar affecting lateral condyle.

Question 19

Describe the typical presentation of someone with a distal femoral fracture

Answer 19

• Pain in thigh
• Inability to weight bear
• Swelling of distal thigh
• Ecchymosis of distal thigh
• Knee effusion (if fracture extends intra-articular then haemarthrosis may be present causing knee effusion)
• Deformity

Question 20

What investigations should you do in suspected distal femoral shaft fracture?

Answer 20

• Plain radiographs (AP & lateral. Must include entire femur and knee)
• CT if suspect intra-articular invovlement
• Urgent routine bloods including coagualtion & group and save

Question 21

Discuss the management of distal femoral fractures

Answer 21

Initial

• ATLS
• Analgesia
• Reduction
• Immobilisation using skin traction

Definitive

• Most managed surgically
  
  • ORIF using retrograde IM nail or plate
• Non-operative managmenet if not suitable for surgery or is non-ambulatory. Long period of immobilisation (using splints, casts, traction etc…) and non-weight bearing

Question 22

State some potential complications of distal femoral fractures

Answer 22

• Malunion
• Nonunion
• OA

Question 23

What are peri-prosthetic fractures?

Answer 23

• Distal femur fracture related to knee replacement
• Management more complex and may include IM nailing, revision to prosthesis or distal femoral replacement

Question 24

What is meant by quadriceps tendon rupture?

Answer 24

Loss of congruency, either partial or complete, of quadriceps tendon

Question 25

What is the most common mechanism of injury for quadriceps tendon rupture?

Answer 25

* Sudden excesssive loading of quadriceps e.g. landing from jump

Question 26

State some risk factors for quadriceps tendon rupture- highlighted the main one

Question 27

Describe the typical presentation for quadriceps tendon rupture

Answer 27

* Heard a pop or tearing sensation * Pain in atnerior knee or thigh * Difficulty weight bearing * Localsied swelling in distal thigh * Tender palpable defect superior to patella * Knee extension compromised: * Complete tear: inability to extend knee * Partial tear: decreased ability or inability to extend knee

Question 28

What investigations are required if you suspect a quadriceps tendon rupture?

Answer 28

**Can be diagnosed clinically-** especially complete tears as the clinical signs are more apparent. May do investigations to aid diagnosis e.g: * USS: *definitive diagnosis & assess degree of rupture* * Plain film radiograph: *caudally displaced patella in complete tears* * MRI can be helpful if still uncertainty

Question 29

Discuss the management of quadriceps tendon rupture

Answer 29

Treatment depends on degree of rupture: * **Partial tears with extensor mechanism intact** * **_​_**Manage non-operatively with immobilisation in a brace in tandem with intensive rehabilitation * **Complete tears or partial tears with extensor mechanism not intacted** * Surgial mangement * Tears at insertion: longitudinal drill holes or suture anchors * Intra-tendinous tears: end to end sutures * Chronic ruptures may require tendon lengthening due to tendon retraction * Post-operatively knee immobilised in brace for approximately 6 weeks; at which point start doing physio

Question 30

Which joint is most commonly affected by OA?

Answer 30

1. Knee 2. Hip

Question 31

State some risk factors fo rhip OA, consider: * Systemic risk factors * Local risk factors

Answer 31

_Systemic_ * Age * Obesity * Female * Vit D deficiency * Genetics _Local_ * History of trauma to hip * Muscle weakness * Joint laxity * Participation in high impact sports * Anatomical abnormalities

Question 32

Describe typical presentation of hip OA

Answer 32

* Pain * Aggravated by activity * Relieved by rest * Stiffness * Crepitus * Passive & active movement painful * Reduced range of motion * Fixed flexion deformity

Question 33

What investigations would you do if you suspect hip OA?

Answer 33

* Plain radiograph of hip

Question 34

Remind yourself of cardinal signs of OA on x-ray

Answer 34

* Loss of joint space * Osteophytes * Subchondral bony cysts * Subchondral sclerosis

Question 35

What tools can be used to classify OA progression?

Answer 35

* **Oxford hip score**- *looks at pain & function* * **Western Ontario & McMaster Universities Arthritis index (WOMAC)**- *looks at pain, stiffness and function* \*image shows result interpretation for oxford hip score

Question 36

Discuss the management of hip OA

Answer 36

* Lifestyle modifications * Analgesia * Physiotherapy * Surgical * Hemiathroplasty * Total hip replacement

Question 37

Discuss the 3 different approaches to hip replacement surgery

Answer 37

Approach is defined by relation to gluteus medius: * **Posterior:** * Most comon * Rehabilitation fast due to preserving abductor mechanism * Greatest risk of damage to sciatic nerve & of dislocation * **Anterolateral** * Abductor mechanism detached allowing full exposure of acetabulum * Superior retinacular vessels not interupted lowering risk of AVN * Risk of damage to gluteal nerve * **Anterior** * Rarely used for athroplasty * Most commonly used for hip wash-outs

Question 38

State some potential post-operative comlplications of hip athroplasty

Answer 38

* VTE * Bleeding * Dislocation * Infection * Lossening of prosthesis * Leg length discrepancy

Question 39

How long does an artificial hip typically last?

Answer 39

15-20yrs

Question 40

What does this x-ray show?

Answer 40

Total hip relacement

Question 41

What does this x-ray show?

Answer 41

Hemi-athroplasty of hip

Question 42

For femoracetabular syndrome, state: * What it is * Different types * Symptoms & signs * Investigations * Management

Answer 42

* Extra bone grows either on acetabulum or femoral head resulting in the bones of the hip joint not fitting together as they should; hence, the bones rub against each other during movement * Types: * Pincer: *extra bone extends out of rim of acetabulum* * Cam: *extra bone forms on femora head so it is no longer round* * Combined: *both of the above* * Symptoms: * Pain (worse on hip flexion) * Stiffness * Limping * Investigations: * Plain radiographs * MRI (look for damage to labrum & cartilage) * Management: * Non-surgical: *activity modification, NSAIDs, physio, corticosteroid joint injections* * Surgical: *arthroscopy to remove the extra bone or athroplasty*

Question 43

For Perthes disease, discuss: * What it is * Presentation * Investigations * Management * Complications

Answer 43

* Disruption of blood flow to the epipyses resulting in avascular necrosis of epiphyses * Common between 4-12yrs, boys\>girls: * Pain in the hip or groin * Limp * Restricted hip movements * There may be referred pain to the knee * Investigations: x-ray * Management (aim is to maintain good position/alignmen to reduce risk of damage to femoral head): * Bed rest * Traction * Crutches * Analgesia * Physiotherapy * Regular xrays are used to assess healing. * Surgery (if bone not healing) * Over time there is revascularisation or neovascularisation and healing of the femoral head. There is remodelling of the bone as it heals. The main complication is a soft and deformed femoral head, leading to early hip osteoarthritis. This leads to an artificial total hip replacement in around 5% of pa

Question 44

For SUFE, discuss: * What it is * How it presents * Investigations * Management

Answer 44

* Head of femur 'slips off'/displaces off the femur along the growth plate * Usually an obese 10-14yr old boy presenting with: * Hip, groin, thigh or knee pain * Painful limp * Restricted ROM (particualarly internal rotation) * Prefer to keep hip externally rotated * X-ray * Surgical screw to fix head of femur to femur. Non-weight bearing for 6 weeks.

Question 45

Compare Perthe's and SUFE, consider: * Ages * What problem is * Treatment

Answer 45