DISLOCATION AND FRACTURES OF THE HIP. Dr Károly Fekete

Transcription

1 DISLOCATION AND FRACTURES OF THE HIP Dr Károly Fekete 1

2 OUTLINE Epidemiology Incidence Anatomy Patient s examination, clinical symptons Diagnosis Classification Management Special complications 2

3 EPIDEMIOLOGY, INCIDENCE 1,5/1000 hip frx./year in Hungary: 2/5 cervical fracture 3/5 trochanteric-subtrochanteric fr cervical fr./ year 1/100 in adolescents (60/year) 1/1000 in children (6/year) 3

4 hip fracture = fracture of the proximal end of the femur Per,-subtrochanteric fr. Femoral neck fr. Cervical fracture Subcapital fr. Fract.colli medialis femoris 4

5 femoral neck fr. trochanteric fracture 5

6 FEMORAL NECK FRACTURE: avascular necrosis % stable osteosynthesis? it is less dangerous to life. complications occur in % (based on the literature) recovery can be stated only after 3-5 years with absolute certainty. 6

7 TROCHANTERIC FRACTURE: necrosis of the femoral head occurs only in 2 % blood loss is more expressed. Blood transfusion is more frequently required full recovery occurs in 3 months complications are observed in 10 % 7

8 ANATOMY OF THE FEMORAL HEAD : cartilage in its 2/3 part 8

9 BLOOD SUPPLY is provided: aa. epiphysareae laterales from a. circumflexa medialis aa. metaphysareae inferiores a.epiphysarea medealis from a. obturatoria 9

10 lateral circumflex artery medial circumflex artery Blood supply 10

11 Anterior 11

12 OSTEOPOROSIS 12

13 CLASSIFICATION medial: within the capsule, enclosing the hip joint lateral: outside the capsule 13

14 CLASSIFICATION OF MEDIAL FEMORAL NECK FR.: Pauwels I. Pauwels II. Pauwels (1935) under 30 grades (compression force is acting) grades Pauwels III. over 70 grades (shearing force is acting predominantly). 14

15 CLASSIFICATION OF MEDIAL FEMORAL Garden I. Impacted, valgus, abduction fracture Garden II. Non-displaced fracture Stable NECK FR.: Garden (1961) Varus - adduction Garden III. Displaced fracture but the contact between the trabeculae is maintained Garden IV. Displaced fracture, there is no more contact between the fragments Unstable 15

16 AXIAL X-RAY Lateral angulation: ANTECURVATION G.I? G.III. G.IV. 16

17 CLINICAL SYMPTOMS Displaced medial cervical fracture (varus or adduction fracture) pain in the hip The limb is turned out (cadaver limb position) Shortening unable to lift this extremity 17

18 clinical symptoms The limb is turned out (cadaver limb position) Shortening 18

19 clinical symptoms unable to lift this extremity 19

20 CLINICAL SYMPTOMS Non-displaced (impacted, valgus or abduction) pain in the hip or knee patient can walk lift the limb with extended knee 20

21 SECONDARY DISPLACEMENT: When the impacted fracture is displaced. The patient has lost walking ability. Frequency: %. 21

22 DIAGNOSIS X-ray in two directions AP axial SPECT CT MRI (very rarely) 22

23 X-ray:A-P (Antero-Posterior) view 23

24 X-ray: axial view 24

25 MANAGEMENT TITANIUM! (Does not interfere with MRI!) 25

26 Importance of age MANAGEMENT In children K-wires; In adolescents K-wires or AO cancellous screws In adults up to years 6,5 mm AO cancellous screws 26

27 MANAGEMENT Over 50 years cannulated femoral neck screws; Importance of age Over 60 years for old fractures alternatively: cannulated screws or hip prosthesis. 27

28 SURGICAL TREATMENT: 1.Head saving surgery, i.e. internal fixation; 2.Implantation of endoprosthesis after removal of the femoral head. two main methods: 28

29 Implants: 29

30 OSTEOSYNTHESIS Nails (Lorenz) Böhler nail Smith-Petersen

31 AO screws 31

32 Cannulated screws 32

33 Combination of plate and screw DHS 33

34 IMPORTANT ASPECTS OF SURGICAL TREATMENT Urgency Correct surgical technique Proper screw positioning 34

35 URGENCY surgery within 6 or 12 hours diminishes the mortality rate diminishes the number of general complications special complications 35

36 ADVANTAGES for the injured: Easier reduction (there is no muscular tension, fracture surfaces are still not smoothed); Easier retention Coincidence of the effect of trauma and surgical stress, the stage of mobilization may be achieved earlier; Urgent reduction makes possible reversible normalisation of blood supply to the femoral head from financial aspect: Shorter hospital treatment Easier mobilization of the patient. 36

37 General complications Pneumony Urogenital infections Deep venous thrombosis Pulmonal embolism Presser shore Immobilization!!! 37

38 SPECIAL COMPLICATIONS Redisplacement Infection Local displacement of the implant (slipping out, perforation Pseudarthrosis Non-union Migrant pseudarthrosis. Necrosis of the femoral head 38

39 Special complications Redisplacement (tilting of the fracture into varus position), cut out 39

40 Special complications Local displacement of the implant (slipping out, perforation of the acetabulum) 40

41 Special complications Pseudarthrosis (rarely with screw fixation), non-union 41

42 Special complications Migrant pseudarthrosis. Regeneration of the necrotic head begins from the site of fracture in direction to the head. The fracture heals, the border of living and necrotic bone is displaced in central direction. 42

43 Necrosis of the femoral head Partial: collapse of the weightbearing surface is typical. Fracture healing occurs, but the femoral head with its damaged blood supply collapses. 43

44 Necrosis of the femoral head Total: necrosis of the complete femoral head, resorption of the neck. Solution: prosthetic replacement. 44

45 HIP PROSTHESES Hemiarhtroplasty: limited only the replacement of the fractured femoral head Total hip arthroplasty: replacement of the head and acetabulum 45

46 OSTEOSYNTHESIS OR PROSTHESIS? 46

47 Osteosynthesis or prosthesis? Prosthesis implantation is indicated if: the fracture is old (2-3 weeks or even older) reduction has failed early or late complication occured: redisplacement, head necrosis, slipping out of the metal, etc. Here, in Debrecen, we give preference to osteosyntheses. In young patients, up to about 50 years, OS is the method of choice MIO 47

48 Treatment algorithm - AO no significant co-morbidity displaced under over 85 48

49 49

50 Per,-subtrochanteric fr. necrosis of the femoral head occurs only in 2 % 50

51 Pertrochanteric fractures Stable Unstable 51

52 Dinamic Hip Screw 52

53 PROXIMAL FEMUR NAIL 53

54 PERTROCHANTERIC Frx. FI or Gamma nail 54

55 SUBTROCHANTERIC Frx. Angled blade DCS 55

56 56