Injuries of the HIP

1. Injuries of the HIP Dr.Sadeq Al-Mukhtar Consultant Orthopaedic Surgeon

2. HIP Stability • Factors responsible for hip stability are: • Ball &Socket shape • Thickness of hip capsule. • Arrangement of the bone lamellae in the line of stress of the femoral neck.

3. The joint is susceptable to injury at three stages of life. • Adolescence; Before closure of epiphysis ( avulsion of epiphysis) • Middle age; (hip dislocation,fracture dislocation). • Elderly: osteoporosis( fracture neck femur).

4. Avulsion of Epiphysis at Hip joint • Avulsion of lesser trochanters: • Mechanism: Active contraction of powerful iliopsoas muscle against resistance in opposite direction. • Avulsion after 18 year is rare. • On examination : local tenderness in the groin, brusing( ludloffs sign is diagnostic), inability to lift the thigh when the patient is in sitting position.

5. Treatment • Conservative: • Flexion of the hip 90 degree, the ends of the bone become in contact& maintain this position by pillow,bed rest for 2 weeks. • Surgical treatment is not indicated.

6. Avulsion of the greater trochanter • Mechanism • Direct blow over the greater trochanter leads to fracture of the GT,but complete seperation and displacement of GT epiphysis can occur from muscular violence(abductor and lateral rotator muscles) • Treatment • 1-children and adolescents : abduction of the hip leads to accurate position and maintain this by hip spica for 6 weeks. • Mechanism • Direct blow over the greater trochanter leads to fracture of the GT,but complete seperation and displacement of GT epiphysis can occur from muscular violence(abductor and lateral rotator muscles) • Treatment • 1-children and adolescents : abduction of the hip leads to accurate position and maintain this by hip spica for 6 weeks.

7. 2-Young adults and elderly:ifsimple displacement like above • If wide displacement surgery(internal fixation)

8. Displacement of upper femoral epiphysis • Also called (Adolescent Epiphytseal coxa Vara or epiphseolysis capitis). • It is common in boys in adolescence years, some showing evidence of hypopituitarism, or hypogonadism with obesity& sexual immaturity while others give a history of recent rapid growth so that the child is tall & slender.

9. Mechanism: • Torsional slip around an axis lying in the intertrochanteric region causing separation of epiphysis so that the epiphysis become in backward displacement. 50% occurs without any recognized injury& sometime both hips are involved. The onset is insidious with slowly increasing pain &limp. Sex hormone reduces the shearing of the epiphyseal plate while growth hormone reduces it. Growth hormone increases the widith of hypertrophy the cartilage cells.

10. On Examination • An adolescent boy ,sexual deformity,obese,or tall&slender • Limitation of all hip movements especially medial rotation. • Slight shortening in the limb.40-80 degree lateral rotation with 20-30 degree extension. • Extreme lateral rotation, extension&abduction deformity.

11. Radiological findings • Lateral film may show a step between epiphysis &metaphysis. • Marginal blurring of proximal metaphysis in A.P film. • In normal hip the lower margin of the metaphysis is included within the acetabulum but excluded in early slip. • Line drawn along the superior margin of the neck transects the epiphysis but will be above it if there is slip • Depth of epiphysis can be measured&compared with normal side if normal it become small if there is slipping.

12. Treatment • Displaced epiphysis but still in accepted position (early diagnosis is very important i.e irritable hip in early days) treated by surgery: internal fixation by pin in situ without any attempt to alter the position (good result is expected in 90% of cases)

13. Severe acute slip or acute on chroic slip; • Restore to a position under anaesthesia&screen or by a period of skin traction then pinning by a special pins(60% good result) • Irreducible slip: Treated by cervical or subtrochanteric osteotomy. • Slip with fused epiphyseal line: Treated by subtrochanteric osteotomy.

14. Traumatic Dislocation of Hip • Types; • Simple dislocation usually posterior, more rarely anterior. • Fracture dislocation • Central dislocation.

15. Mechanism • It is caused by a powerful thrust in the long axis of femur in a flexed & adducted femur( dashboard injury). This brings the head of femur to the dorsum of ilium. You must differentiate this type of dislocation from pathological dislocation which occurs in paralytic type e.g. poliomyelitis& spina bifida ( active flexors& adductors with paralyzed extensor& abductor muscles)

16. Also occurs in cerebral palsy; due to over action of flexor & adductor muscles. • Infection or tuberculous arthritis leading to spasm of flexors& adductors inaddition to stretching & softening of capsule.

17. On examination • Restriction of all movements, the limb in adduction &medial rotation. • X-Ray to exclude fracture of acetabulum& prove diagnosis.

18. Treatment • Reduction is usually under GA & good muscle relaxation. Hip is turned into the neutral position & lift • With the patient lying on table or blanket on the floor, the flexed hip is turned into the neutral position & lifting into acetabulum. Failure of reduction means that there is obstraction by a bony fragment or detached labrum. If the patient is unfit for GA.Stimons maneuver can be used (the patient laid prone on the table with the lower limbs hanging over the ends of the table so that the head is pushed into the acetabulum.

19. After reduction: skin traction of the stable hip for 3 weeks then partial weight bearing by crutches. 6 weeks after dislocation, full weight bearing is allowed. If there was failure of reduction by these methods, then do open reduction& internal fixation ORIF by big bony fragment of acetabulum is indicated.

20. In cases of comminuted acetabulum after reduction of dislocation better treatment by conservative skin traction or skeletal traction (better) for 6-8 weeks.

21. Complications • Injury to sciatic nerve • Damage to femoral head( chondritis). Painful hip after reduction of dislocation. • Avascular necrosis. • Post-traumatic ossification. • Osteoarthritis

22. Anterior dislocation • It is rare with a ratio anterior to posterior 1:20 • Mechanism: Blow from behind in high type. • Moyor cycle accident mostly nin low type which is produced by forced external rotation&abduction in flexion while in high btype the same force but in extension.

23. Types • High type: The head infront the superior ramus of pelvis opposite the iliopectineal eminence. • Low type: the head near the obturator foramen. • On examiation: Low type: full external rotation,abduction up to 60 degree with some flexion. • High type: full external rotation, abduction in extension.

24. Treatment • The same as that of posterior dislocation but we push the head into the acetabulum instead of lifting the flexed limb. • Complications: The same as that of posterior one except sciatic nerve injury that is not occur here.

25. Central dislocation • The femoral head is driven through the medial wall of acetabulum(floor) towards the pelvic cavity. The capsule is intact. • The drgree of displacement depends on the severity of the trauma ranging from few millimeters displacementr to severe type where the head passed into pelvis throughg fractured acetabulum.

26. Mechanism • Direct:Lateral blow upon the femur. • Dashboard injury where the hip in flexion &abduction force along the longitudinal axis of femur. • Treatment: This depends on the severity of comminution& the size of bony fragments& whether the roof of acetabulum(weighe-bearing site) is intact or not & if we can preserve it by skeletal traction through the greator trochanter through the greater trochanter(outward&downward traction) or by OR IF by screw.

27. If severely comminuted, acetabulum is better treated by conservative method for 6-8 weeks • Complication • Osteoarthritis appears after months or years. This is treated by arthrodesis of hip if the patient age is below 45 or THR

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