Format

1. Format • Short Cases • A series of short questions • Review of answers • Discussions

2. Case 1 • 28 y.o. male • Front seat passenger • Car ran into lamp post • Brought to A&E • No other injury except for severe pain in right hip

3. 28 y.o. male Front seat passenger

4. Questions • What is the diagnosis? • What is the usual position of the limb in this condition? • What are the radiological signs? • What other investigations? • What are the potential complications? • What is the definitive treatment?

5. What is the diagnosis? • What is the usual position of the limb in this condition? • What are the radiological signs? • What other investigations? • What are the potential complications? • What is the definitive treatment?

6. Anatomy:Hip Joint Ball and socket joint. Femoral head: slightly asymmetric, forms 2/3 sphere. Acetabulum: inverted “U” shaped articular surface. Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”.

7. Hip Dislocation: Mechanism of Injury Almost always due to high-energy trauma. Most commonly involve unrestrained occupants in MVAs. Can also occur in pedestrian-MVAs, falls from heights, industrial accidents and sporting injuries.

8. Physical Examination: Classical Appearance Posterior Dislocation: Hip flexed, internally rotated, adducted.

9. Position of Limb Diagnosis: Posterior Dislocation Adducted, flexed and Internally Rotated

11. What are the radiological signs? How do you know that this hip is internally rotated? Shenton’s Line Head is higher Less trochanter is higher

16. Potential Complications • Recurring instablility • Traumatic degenerative arthritis • Avascular Necrosis • Sciatic Nerve injury • High energy injury – watch out for other blunt trauma that may not be apparently initially

17. Blood Supply to Femoral Head • Artery of Ligamentum Teres • Ascending Cervical Branches

18. Sciatic Nerve Composed from roots of L4 to S3. Peroneal and tibial components differentiate early, sometimes as proximal as in pelvis. Passes posterior to posterior wall of acetabulum. Generally passes inferior to piriformis muscle, but occasionally the piriformis will split the peroneal and tibial components

19. Associated Injuries Mechanism: high-energy, unrestrained occupants Thus, associated injuries are common: • Head and facial injuries • Chest injuries • Intra-abdominal injuries • Extremity fractures and dislocations

20. Clinical Management: Emergent Treatment • Dislocated hip is an emergency. • Goal is to reduce risk of AVN and DJD.

21. Emergent Reduction • Allows restoration of flow through occluded or compressed vessels. • Decreased AVN with earlier reduction. • Requires proper anesthesia. • Requires “team” (i.e. more than one person).

22. Summary of Posterior Dislocation of the Hip • Hip is very stable • Require high energy to dislocate • Reduce early with adequate sedate of GA • Patient usually young so complications has long lasting disability • AVN • Traumatic Arthritis • Recurrent instability • Sciatic nerve injury

23. Case 2Presenting complaints • 52/ F/ Chinese/ Hawker by profession had to give up her profession as she was having progressive right hip pain x 4/12 before seeking the consultation • No significant past medical history of taking any long term medication, trauma or steroid or alcohol use

24. Clinical examination • Could still squat with difficulty • Internal and external rotations grossly restricted and painful

25. TAH/52/F/Chinese

26. TAH/52/F/Chinese

27. Case 2 • What is the diagnosis? • What are the possible causes? • What are the radiological signs? • What are the treatment options?

28. Answer • What is the diagnosis? • Avascular Necrosis

29. Answer • What is the diagnosis? • Avascular Necrosis • What are the possible causes?

30. Answer • What is the diagnosis? • Avascular Necrosis • What are the possible causes? • Excessive Alcohol consumption • Steroid Use • Rapid Decompression • Trauma • Inflamatory Disease – Lupus (vasculitis) • Gaucher’s Disease

31. What are the radiological signs?

32. Crescent Sign

33. What is the reason for increase density in avascular necrosis? • Impaction of trabecular bone • New bone on dead trabecular bone • Relative disuse osteopenia

34. What are the treatment options? • Analgesic • Weight Reduction • Walking aids • Coring decompresion • Bone Graft • Osteotomy • Hip Replacement

35. Treatment – Hip Replacement

37. Case 3 70 y.o. patient with bilateral hip pain started about 10 years ago. He underwent right hip surgery 5 years ago and left hip surgery 3 years ago. What surgeries have been performed? What is the indication for surgery? Name 3 possible complications of this type of surgery?

38. Case 3 What surgeries have been performed?Bilateral Cement Total Hip Replacements

39. Case 3 What is the indication for surgery? Severe pain and limited walking

40. Case 3 • Name 3 possible complications of this type of surgery? • Neuro-vascular injury • Dislocation • Leg length discrepancy • Infection • Loosening of implant • Deep vein thrombosis

41. Case 4 • 80 yo women, fell at home and sustain this fracture • Except for hypertension she has no other medical problem • Lives at home with her daughter and grandchildren

42. Case 4 • What is the injury? • What are the risk factors for this type of injury? • What is the recommended treatment? • Name 3 factors that would affect this patient’s post-op recovery

43. Case 4 • What is the injury?Displaced femoral neck fracture.

44. Femoral Neck Fracture • Intracapsular • Subcapital, Transcervical, Basilar • Displaced vs Undisplaced

45. Un-displaced

46. Caution! • Elderly patient • Hx of fall • Subsequently unable to walk • Xray is negative for fracture Fracture until proven otherwise

47. Impacted

48. Displaced

49. Hip Fracture Femoral Neck

50. Hip Fracture • Leg is: • Shorten • Externally Rotated