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FRACTURE
HIP ANATOMY
AMALESHWAREE
012011100118
Hip bones
Flat bones, form bony pelvis along with
sacrum and coccyx
Posteriorly articulate with the sacrum at
the sacroiliac joint
Anteriorly articulate with each other at a
joint called pubic symphyses
Contains 3 parts pubis, ilium and
ischium
Bony pelvis
- formed by sacrum, coccyx and pair of hip bones
Hip bone
sacrum
Acetabulum
coccyx
Obturator
foramen
Pubic symphysis
Posterior
Hip bone
Anterior
lateral view
Iliac crest
Posterior superior
iliac spine
Posterior inferior
iliac spine
Greater sciatic
notch
Tuberosity of
iliac crest
Anterior superior
iliac spine
Anterior inferior
iliac spine
Acetabulum
Ischial spine
Lesser sciatic
notch
Ischial tuberosity
Obturator foramen
Posterior
Anterior superior
iliac spine
Anterior inferior
iliac spine
Auricular surface
(articulates with
Sacrum to form
Sacroiliac joint)
Hip joint
Hip
bone
Hip Joint
Type: Synovial joint
Subtype: Ball and socket
Articular surfaces:
Head of femur and acetabulum of hip
bone
Head of femur:
Forms two thirds of a sphere
Is covered by the articular cartilage except
at the fovea capitis
Fovea capitis
(Pit for ligament of head of femur)
Head of femur
Lunate
surface
Acetabular
margin
Acetabular
Fossa
Acetabular
notch
Acetabulum
Head of femur
Acetabulum:
Hemispherical hollow on the lateral surface of hip bone
It is limited by the acetabular margin
Acetabulum has two parts lunate surface and acetabular
fosaa
Lunate surface: C shaped articular area covered by the
hyaline cartilage
Acetabular fossa: Deep non-articular part filled with
acetabular pad of fat
Acetabular margin is absent on the inferior aspect, here it is
replaced by the acetabular notch
Acetabular labrum:
Fibrocartilaginous ring attached to the
margins of acetabulum
Increases the depth of acetabulum
Replaced inferiorly at the acetabular notch
by the transverse acetabular ligament
Acetabular labrum
Lunate surface
Fibrous capsule
Acetabular fossa
Transverse acetabular
ligament
Fibrous capsule:
Surrounds the joint
Its inner surface is lined by the synovial
membrane
Medial attachment: to the hip bone
Attached to the acetabular margin and
transverse acetabular ligament
Lateral attachment: to neck the femur
Anteriorly to the intertrochanteric line
Posteriorly to the posterior surface of neck
of femur, just medial to intertrochanteric
crest
CLINICAL ASSESSMENT
MURUGAN MANIAM
0120090075
Rectal examination
carried out in every case.
The coccyx and sacrum can be felt and tested for tenderness.
If the prostate can be felt, which is often difficult due to pain
and swelling, its position should be gauged; an abnormally
high prostate suggests a urethral injury.
Enquire when the patient passed urine last and look for
bleeding at the external meatus.
An inability to void and blood at the external meatus are the
classic features of a ruptured urethra.
ACETABULAR FRACTURE
Buaneswaran Magendaran
012011100010
Mechanism of Injury
Occurs when head of femur is driven
into the pelvis, 2 mechanisms involved:
Fall from height (blow on the side)
Dashboard injury (blow on the front of
the knee
Patterns of Fracture
- Depends on the : Position of the femoral head at the
time of injury
- Hip externally rotated and abducted
( anterior column injury)
Magnitude of force
Age of patient
Classification of Fracture
Judet & Letournel Classification
5 elementary fracture types
5 associate fracture types
Classification of Fracture
5 main elements:
Acetabular wall fractures (ant or
post)
Anterior column fractures
Posterior column fractures
Transverse fractures
Types of Fracture
Acetabular wall fractures (ant or
post)
affects the depth of the socket
leads to hip instability unless
properly reduced
and fixed
Post wall fracture is the commonest
(dashboard injury)
Types of Fracture
Anterior column fractures
Runs through anterior part of
acetabulum, separating a segment
between anterior inferior iliac
spine & obturator foramen
Does not involve weightbearing area
Good prognosis
Uncommon
Types of Fracture
Posterior column fractures
Runs upwards from the obturator
foramen into the sciatic notch
Separates posterior ischiopubic column
of bone & breaking the weight-bearing
part of acetabulum
Associated with posterior dislocation
of hip may injure sciatic nerve
Treatment is more urgent
Types of Fracture
Transverse fractures
Uncomminuted fractures
Runs transversely through
acetabulum, separates iliac
portion above from pubic & ischial
portions below
May be associated with sacroiliac
joint injury
Types of Fracture
Associated fractures
Are combination of elemental fractures
Articular surface are more severely
disrupted
Associated Fractures
Type 1 - Posterior Column + Posterior
Wall
Type 2 - Transverse + Posterior wall
Type 3 - T-shape fracture
Type 4 - Anterior Column + Posterior
hemitransverse
Type 5 - Both column fractures
Associated Fractures
Clinical Features
Chernissha a/p Elan Cheliyan
012011100133
Clinical Features
- Severe injury (traffic accident/fall from height)
- Associated fractures
* any case of fractured femur, calcaneum or
severe knee injury
- Severe shock
- Skin local wounds, abrasion, bruising
- Attitude of the limb - lying in internal rotation
(if hip dislocated)
- Neurovascular assessment (Sciatic nerve
palsy )
Imaging
1) Plain X-Ray Pelvis
AP view : 6 cardinal lines of pelvis
Obturator oblique view
Iliac oblique view
2) CT Pelvis
Best demonstrates
posterior column (ilioishcial line) and
anterior wall.
CT Scan
Provide additional information
- size and position of column fractures
- impacted fractures of acetabular wall
- retained bone fragement in a joint
- degree of communition
- sacroiliac joint disruption
2D and 3D CT scans useful (evaluate intraarticular fragements as well as specific
morphologic characteristics of any given fracture
pattern)
Treatment
Christina a/p Jayaraj Paul
012011100134
Management
Goal of treatment
The goal of treatment is anatomic restoration of
the articular surface to prevent posttraumatic
arthritis.
Initial management
The patient is usually placed in skeletal traction
to 1. allow for initial soft tissue healing,
2. allow associated injuries to be addressed,
3. maintain limb length,
4. maintain femoral head reduction within the
acetabulum.
Definitive treatment :
2-5 days post injury
delay should not exceed 7 days
Emergency Treatment
Priority
a
dislocation.
1) Skeletal traction applied to distal femur
(10kg will suffice)
2) Next 3-4 days, patients general condition
is brought under control.
Treatment Option
Non operative
Operative
Relative contraindication
Advanced age
Associated medical condition
Associated soft tissue and visceral injuries
Multiple injured patient not stable for a big
acetabular surgery
Non-operative
Protected weight bearing for 6-8 weeks
- Longitudinal traction, if necessary,
supplemented by lateral traction
- Hip movement and exercises are
encouraged
- Patient then allowed up, using crutches
with minimal weight bearing for a further 6
weeks
*close monitoring
Indications
Minimal displacement of fracture
<3mm
Operative
Hip may be dislocated :
centrally, anteriorly and posteriorly
Approaches
Kocher-Langenbeck (Posterior): best access to
posterior wall and column (prone)
Ilioinguinal (Anterior): best access to anterior wall and
column fractures
and inner aspect of innominate bone (supine)
fracture types.
~Proper preoperative classification of the fracture
configuration is essential to selecting the best surgical approach
Kocher-Langenbeck Approach
Indications
Ilioinguinal approach
Indications
Anterior wall and
Anterior column
Transverse with significant anterior
displacement
Both-column fracture
Indications
Transverse fractures with extended posterior wall
T-shaped fractures with wide separations of the vertical
stem of the T or those with associated pubic symphysis
dislocations
Certain associated both column fractures
Associated fracture patterns or transverse fractures
operated on >21 days following injury
Other approaches
Stoppa approach (supine): Allows access
to the medial wall of acetabulum,
quadrilateral surface, & sacroiliac joint
Triradiate approach (prone): Alternate
exposure to the external aspect of
innominate bone, with almost same
exposure as iliofemoral but visualization of
the posterior part of ilium is not as good
Relative contraindication
Advanced age
Associated medical condition
Associated soft tissue and visceral injuries
Multiple injured patient not stable for a big
acetabular surgery
Complications
Surgical wound infection: Risk is increased
secondary to the presence of associated
abdominal and pelvic visceral injuries.
Nerve injury
Sciatic nerve: Kocher-Langenbach approach
with prolonged or forceful traction.
Femoral nerve: Ilioinguinal approach may result
in traction injury to femoral nerve. Rarely, the
nerve may be lacerated by an anterior column
fracture.
Pelvic
Fracture
Juanita a/p Henry
012011100159
Types of fracture
Isolated
fractures with an intact pelvic ring
Pelvis
fracture
Isolated Fractures
Isolated
Avulsion
Fractures
fractures
Avulsion Fracture
A piece of bone is pulled off by violent
muscle contraction.
Seen in sports participants and athletes.
Tx: Rest for few days and reassurance.
Avulsion Anterior
Superior
Iliac Spine (ASIS)
Avulsion Anterior
Inferior
Iliac Spine (AIIS)
Direct fracture
Stress fracture
Severely osteoporotic or osteomalacic
patients.
Fracture of the pubic rami (common &
painless)
Tile classification
A: stable
B - rotationally unstable,
vertically stable
C - rotationally and
vertically unstable
C1: unilateral
B2: lateral
compression injury
(internal rotation)
B3: bilateral
Anteroposterior
compression
Seen in MVAs
Pubic symphysis disrupted, continue
to posterior SIJ open book injury
Increase pelvic volume
May be torn SI ligaments, fracture
post. Ilium, vertical sacral fracture
Lateral compression
Side to side
compression of pelvic
ring
Side impact in
accidents
Anteriorly, pubic rami
fractured ( one/both),
Posteriorly SI
strain/fracture
If displaced, becomes
unstable
Vertical shear
Innominate bone vertically
displaced, fracturing pubic
rami and disrupt sacroiliac
region of same side
Fall from height on one leg
Severe, unstable, gross soft
tissue and retroperitoneal
hemorrhage
Combination injuries
Combination of either
type of injuries
Ex : lateral compression
with vertical shear/
anteroposterior
compression with
vertical shear
Hit from the front and
fall on the side
CLINICAL FEATURES
PRESHEELA KUMARAN
012010090125
UNSTABLE INJURIES
Severely shocked
Pain and unable to stand
Unable to pass urine
Blood loss the external meatus
Tenderness
Attempt to move the ilium will be painful
Foot drop due to L5 injury
Partial numbness of one side of the leg due to
sciatic nerve
High risk of visceral damage
TREATMENT OF HIP
FRACTURE
SHANGEETHA NAGARAJAN
O12011050742
PELVIC FRACTURES
Lateral
Compressio
n (LC)
Anteroposterior
Compression
(APC)
Vertical Shear
(VS)
LATERAL COMPRESSION
ANTEROPOSTERIOR
COMPRESSION
LATERAL COMPRESSION
Undisplaced ring fracture
Lateral compression involving pubic ramus
fracture anteriorly and undisplaced sacral
fracture posteriorly
Pain usually subsides after a few days
4 wks bed rest combined with traction
Allow using crutches for another few weeks
ANTEROPOSTERIOR
COMPRESSION
Ant disruption without sacroiliac
displacement
Open book injury (gap of <2cm): bed rest about
6 week, with post sling or elastic girdle to help
to close the book
IF > 2 cm, severe injury: External fixation (8-12
weeks)
-pubic ramus fracture: bed rest
-if the patient need laparotomy,so open
reduction and internal fixation by plates
and screws or by K. wire.
EARLY MANAGEMENT
OF HIP FRACTURE
SATISH KUMAR
012011100187
EARLY STEPS
BLEEDING
Complications of
Pelvic Fracture
By :
Vignavinashini
Mahaeswarren
Complications of Pelvic
Fracture
Hemorrhage and Shock
2. Urogenital damage
APC are the common cause!!
Symphyseal widening is associated with
urethal injury
Displaced rami fractures may cause bladder
injury
3. Bowel injury
Defunctioning colostomy
4. Vaginal injury
Displaced pubic ramus fractures can tear
the lateral wall of the vagina
5. Infection
6. Nerve injury
8. Venous thromboembolic
disease