Hip And Thigh Trauma And Procedures

Front 1

Causes of Hip Dislocations

Back 1

High-energy trauma: MVA/ Dashboard injury or significant fall

Front 2

Thigh position in anterior and posterior hip dislocation

Back 2

Posterior: adducted, flexed and IR
Anterior: abducted, flexed and ER

Front 3

Posterior Hip Dislocation Classification (I-V)

Back 3

THOMPSON Classification
I: No or minor posterior wall fx
II: Large posterior wall fx
III: Comminuted acetabular fx
IV: Acetabular floor fx
V: Femoral head fx

Front 4

Anterior Hip Dislocation Classification

Back 4

EPSTEIN Classification
I (A,B,C): Superior
II (A,B,C): Inferior

A: No associated fx
B: Femoral head fx
C: Acetabular fx

Front 5

Why is hip dislocation an ortho emergency?

Back 5

Early reduction is essential (< 6hrs) in order to reduce risk of femoral head AVN

Front 6

Which hip dislocation is MC?

Back 6

Posterior

Front 7

Complications of Hip dislocations

Back 7

Posttraumatic osteonecrosis (AVN)
Sciatic nerve injury (post dislocations)
femoral nerve. artery injury (ant dislocation)
OA
heterotopic ossification

Front 8

Pt w a femoral neck fx presents w...

Back 8

LE shortened, abducted, and externally rotated

Front 9

MC cause of femoral neck fx

Back 9

elderly falling
MVA

Front 10

Femoral Neck Fracture Classification

Back 10

GARDEN Classification
I: Impacted fx - incomplete fx; valgus impaction
II: Nondisplaced fx - complete fx; nondisplaced
III: Partially displaced fx - complete fx; partial displacement (varus)
IV: Displaced fx - complete fx; total displacement w vertical fx line

Front 11

Complications of Femoral Neck Fractures

Back 11

Osteonechrosis (risk increases w displacement and time)
nonunion
hardward failure

Urgent reduction necessary to preserve femoral head vascularity

Front 12

Pt with intertrochanteric fx presents w...

Back 12

LE shortened and externally rotated (no abduction like in femoral neck fx)

Pain w "log rolling"

Front 13

Intertrochanteric Fx Classification

Back 13

EVANS/ JENSEN Classification
IA: Nondisplaced
IB: 2 Part displaced
IIA: 3 part, greater trochanter fragment
IIB: 3 part, lesser trochanter fragement
III: 4 part fx

Front 14

Why are femoral shaft fractures an ortho emergency?

Back 14

Potential source of significant blood loss
Compartment syndrome may occur

Front 15

What must you rule out for femoral shaft fx?

Back 15

ipsilateral femoral neck fx

Front 16

This is very important to check in femoral shaft fx

Back 16

Check distal pulses

Front 17

Femoral Shaft Fx Classification

Back 17

WINQUIST/ HANSEN Classification
Stable --
0: No comminution
I: Minimal comminution
II: Comminuted or "Butterfly fx" (>50% of cortex intact)
Unstable --
III: Comminuted or "Large Butterfly fx" (<50% cortex intact) -- Zero rotational control
IV: Complete/ Severe comminution. no intact cortex

Front 18

Where do subtrochanteric fx occur?

Back 18

Within 5 cm of lesser trochanter

Front 19

Subtrochanteric Fx Classification

Back 19

RUSSELL-TAYLOR Classification
I (A/B): No piriformis fossa extension/ involvement
II (A/B): Fx involves piriformis fossa

A: intact lesser trochanter
B: detached lesser trochanter

Front 20

Distal Femur Fx types

Back 20

Transverse supracondylar fracture (extraarticular types)
Intercondylar (T or Y) fx (bicondylar)
Comminuted Fx etending into shaft
Unicondylar fracture

Front 21

DDx for affected Lateral hip/ thigh

Back 21

Bursitis
Lateral femoral cutaneous nerve entrapment (LFCN entrapment)
snapping hip syndrome (Coxa saltans)

Front 22

DDx for affected Buttocks/ posterior thigh

Back 22

Spine etiology

Front 23

DDx for affected groin/ medial thigh

Back 23

Hip joint or acetabular etiology (most likely not from spine)

Front 24

Ddx for affected anterior thigh

Back 24

Proximal femur etiology

Front 25

Numbness and tinging of the leg

Back 25

Think LFCN entrapment or spine etiology

Front 26

DDx when pt presents w:
Shortened + ER LE
Adducted + IR LE
Abducted + ER LE
Flexed LE

Back 26

Femoral neck fx; intertrochanteric fx
Posterior dislocation
Anterior dislocation
Hip flexion contracture

Front 27

List 7 disorders of the hip and femur

Back 27

1. Femoroacetabular Impingment
2. Femoral Neck Stress (Fatigue) Fx
3. Meralgia Paresthetica (LFCN entrapment)
4. Snapping Hip (Coxa Saltans)
5. Trochanteric Bursitis
6. Osteoarthritis
7. Osteonecrosis (AVN/ Avascular necrosis)

Front 28

Types of Femoral Neck Stress Fractures + Rx

Back 28

Tension (superior neck) - urgent percutaneous pinning to prevent displacement/ fx
Compression (inferior neck) - limited weight bearing

Front 29

What is the best study for early detection of fracture in stress fx pts?

Back 29

MRI

Front 30

Femoral neck stress fx are common in what population?

Back 30

military recruits

Front 31

What is the first noticeable change in ROM for osteoarthritis?

Back 31

Decreased internal rotation

Front 32

Workup and findings in OA

Back 32

1. Joint space narrowing
2. Osteophytes
3. Subchondral sclerosis
4. Bony cysts

Front 33

Which side should an OA pt use their cane?

Back 33

contralateral side to hip pain

Front 34

What is the most sensitive study for AVN?

Back 34

MRI shows early changes in femoral head

Front 35

Absolute contraindications in Total Hip Arthroplasty (THA)

Back 35

• Neuropathic joint
• Infection
• Medically unstable pt (severe cardiopulmonary disease - won't survive procedure)

Front 36

Relative contraindication in THA

Back 36

Young, active pts - will run through prosthesis many times in their lives

Front 37

THA Steps

Back 37

Acetabulum:
• Remove labrum and osteophytes
• Ream to a cortical rim
• Implant cup (35-45° coronal tilt, 15-30° anterversion)

Femur:
• Dislocate head
• Cut neck and remove head
• Find and broach canal (lateralize as needed) - stem cannot be in varus
• Implant stem
• Trial Head & Neck
• Implant the appropriate head, neck and acetabular liner
REDUCTION OF HIP

Front 38

Pt comes in w "start up" pain after having THA
What does this indicate?
What's the mechanism?
What does the x-ray show?

Back 38

"Start up" pain is indicative of acetabular cup loosening most often caused by osteolysis - macrophages responding to submicro-sized wear particles (ultra high molecular weight polyethylene liner)

X-ray shows radioluscent lines

Front 39

What medical complications can follow THA?

Back 39

DVT and PE, so prophylaxis must be initiated

Front 40

Rx for periprosthetic fracture of femur with unstable implant?

Back 40

Replace stem with a longer stem that passes the Fx site

Front 41

Define "stress shielding" and what can cause it in the femur

Back 41

Stress shielding is when the periprosthetic bone is osteopenic d/t the load or stress being removed preventing normal bone remodeling (Wolff's Law).

A stainless steel or cobalt-chrome stem implant may be too stiff and cause stress shielding.

Front 42

Drawback of using a ceramic (alumina) head implant

Back 42

Excellent wear rates and can be used in either PE liner or ceramic cup, but it is BRITTLE (could fracture)

Front 43

What is the current GOLD standard THA implant?

Back 43

Uncemented (ingrowth) acetabular cup and cemented femoral steel

Front 44

Cement fixation
Name of compound?
Pros?
compression v tension?

Back 44

• Cement = Methylmethacrylate
• Provides immediate static fixation, no remodeling potential
• Resists compression better than tension - used more for stem for this reason

Front 45

Uncemented/ biologic fixation

Back 45

has remodeling potential and gives dynamic fixation -- requires initial fixation

Front 46

Initial Fixation for uncemented/ biologic fixation

Back 46

1. Press fit: implant is 1-2 mm larger than reamed cup size; Bone hoop stresses provide initial fixation

2. Line to line: Implant and reamed bone cup size are the same size; Screws provide initial fixation

Front 47

Head size v stability & wear rate

Back 47

Larger head is more stable, but w greater wear rate

Front 48

Optimal femoral implant head size

Back 48

28 mm

Front 49

Optimal porous ongrowth pore size

Back 49

50-150 micrometers

Front 50

Anterior Approach to Hip

Back 50

Smith-Peterson Approach to Hip

Front 51

Internervous Plane of Smith-Peterson Approach to Hip

Back 51

Superficial:
• Sartorius (femoral nerve)
• Tensor fasciae latae (SGN)

Deep:
• Rectus femoris (femoral n)
• Gluteus medius (SGN)

Front 52

Dangers to Smith-Peterson Approach to Hip

Back 52

Lateral femoral cutaneous nerve
Femoral nerve
Ascending branch of lateral femoral circumflex a

Front 53

Vigorous medial retraction in Smith-Peterson & Watson-Jones approaches can injure what structure?

Back 53

femoral n

Front 54

Medial Approach to Hip

Back 54

Ludloff Approach to Hip

Front 55

Internervous plane of Ludloff approach to hip

Back 55

Superficial:
• Adductor longus (obturator n)
• Gracilis (obturator n)

Deep
• Adductor brevis (obturator n)
• Adductor magnus (obturator n and sciactic n (tibial portion))

Front 56

Dangers to Ludloff Approach

Back 56

Obturator n (ant division)
Medial femoral circumflex a
Obturator n (post division)
External pudendal a (proximal)

Front 57

Anterolateral Approach to Hip

Back 57

Watson-Jones Approach to HIp

Front 58

Internervous plane of Watson-Jones Approach to Hip

Back 58

Tensor fasciae latae (SGN)
Gluteus medius (SGN)

Front 59

Dangers of Watson-Jones Approach to Hip

Back 59

Descending branch of lateral femoral circumflex artery (LFCA)
Femoral n

Front 60

Lateral approach to hip

Back 60

Hardinge Approach to hip

Front 61

Internervous plane for Hardinge approach to hip

Back 61

Split gluteus medius (superior gluteal n)
Split vastus lateralis distally (femoral n)

Front 62

Dangers to Hardinge approach

Back 62

Superior Gluteal artery
Femoral n
Femoral artery and vein
SGN

Front 63

Posterior Approach to Hip

Back 63

Moore/ Southern Approach to hip

Front 64

Internervous plane of Moore/ Southern approach to hip

Back 64

Split gluteus maximus (inferior gluteal n)

Front 65

Dangers to Moore/ Southern Approach to hip

Back 65

Sciatic nerve
Inferior gluteal artery
Medial femoral circumflex artery (under quadratus femoris)

Front 66

Internervous plane for lateral approach to thigh

Back 66

Split vastus lateralis (femoral n)
OR
Elevate it off intermuscular septum

Front 67

Dangers to lateral approach to thigh

Back 67

Descending branch of lateral femoral circumflex artery
Perforating branches from profunda femoris
Superior lateral geniculate a

avoid or ligate these arteries

Front 68

What are the 3 hip arthroscopy portals and their dangers?

Back 68

Anterior Portal
• Lateral femoral cutaneous n
• Femoral n
• Ascending branch of LFCA

Anterolateral Portal
• Superior gluteal nerve (safest portal - pierce 1st)

Posterolateral
• Sciatic nerve