Transcript HIP DISORDERS - Hastaneciyiz's Blog

Medical ppt http://hastaneciyiz.blogspot.com
By Bashar Al-Saify
I.
Slipped capital femoral
epiphysis (SCFE)
II.
Traumatic hip dislocation
III.
Osteoarthritis
aka "Slipped upper femoral epiphysis" is a
medical term referring to slippage of
the overlying epiphysis of proximal femur
posteriorly and inferiorly due to
weakness of the growth plate.
Most often, it develops during periods of
accelerated growth, shortly after the onset
of puberty.
A Klein line is a line drawn along
the superior border of the femoral
neck that would normally pass
through a portion of the femoral
head. If not, slipped capital
femoral epiphysis is diagnosed.
The patient's left hip (arrow)
shows that a slight shift of the
head of the femur occurred
through the growth plate.
1. Risk Factors

most common in the adolescent period
(boys aged 10-16 y, girls aged 12-14 y).



Males have 2.4 times the risk as females.
Obesity is a risk factor because it places more
shear forces around the proximal growth plate
in the hip at risk.
Bilateral slippage is common (but the left hip is
affected more commonly than the right).
2. Etiology
1. Overweight
2. Endocrine disorders (e.g adiposogenital dystrophy,
primary or secondary hypothyroidism).
3. Deficiency or increase of androgens.
4. Acute trauma.
 Slipping of the upper femoral epiphysis occurs
predominantly in obese children with underdeveloped
sexual characteristics and less commonly, in tall, thin
children.
3. Pathology
 The slip occurs in the hypertrophic zone of the growth plate.
 70% slow and progressive (This is gradual, with slowly
increasing symptoms over a period of weeks or even
months. In chronic slipping, there may be no history of
trauma and the symptoms are often quite mild).
 30% acute due to trauma (Least common, this usually follows
severe trauma such as a fall from a height ).
 If the slip is sever anterior retinacular vessels are torn →
avascular necrosis.
 Physeal slip → premature fusion of the epiphysis within 2
years.
4. Clinical Features
1.
2.
3.
4.
5.
6.
Pain : in the groin and around the knee.
Limp (intermittent).
Shortening of the affected limb (1-2 cm).
The limb is in external rotation.
Flexion, abduction, medial rotation are limited.
External rotation, adduction are increased.
5. Diagnosis

Ultra sound :

AP X-ray : (melting ice cream cone)
The diagnosis is a combination of clinical suspicion
plus radiological investigation. 20-50% of SCFE are
missed or misdiagnosed on their first presentation to
a medical facility. This is because the common symptom
is knee pain. This is referred pain from the hip. The
knee is investigated and found to be normal
1. Widening of the growth plate.
2. Trethowan’s sign : Line up superior margin of neck should intersect
epiphysis (usually 20% of the femoral head lateral
to this line)
3. Capeners sign : In pelvic AP view in the normal hip, the posterior
acetabular margin cuts across the medial corner of the upper
femoral metaphysis. With slipping, the entire metaphysis is
lateral to the posterior acetabular margin

Lateral X-ray :
Slip
Posterior horn of the neck is lower than anterior horn.
Grading Severity
of SCFE according
to AP and Lateral
X-ray views
 It is important to determine if the lesion is stable or unstable :
1. "Stable" SCFEs
allow the patient to
(walk) with or without
crutches (walking aids).
2. "Unstable" SCFEs
do not allow the patient
to ambulate at all; these
cases carry a higher
rate of complication,
particularly of AVN.
6. Complications
1.
2.
3.
4.
Avascular necrosis.
Chondrolysis.
Osteoarthritis.
Coxa vara (is a deformity of the
hip, whereby the angle between the
ball and the shaft of the femur is
reduced to less than 120 degrees).
5. Slipping of the opposite
hip ≈ 20% of cases
NOTE :
Coxa Vara
a deformity of the hip, whereby
the angle between the ball and
the shaft of the femur is reduced
to less than 120 degrees. This
results in the leg being shortened,
and therefore a limp occurs. It is
commonly caused by injury, such
as a fracture. It can also occur
when the bone tissue in the neck
of the femur is softer than
normal, meaning it bends under
the weight of the body.
7. Treatment
1. Mild Cases :
Epiphysis fixation by
kirschner wires or
screws
2. Severe Cases :
In-situ pinning correction of
the deformity by
subtrochantric osteotomy
X-ray of a hip following operative percutaneous fixation of a
slipped capital femoral epiphysis
Occurs when the head of femur slips out of its socket in the
hip bone (pelvis).
In approximately 90% of patients femur is pushed out of its socket
posteriorly  This leaves the hip in a fixed position, bent and twisted
in toward the middle of the body.
Femur can also slip out of its socket anteriorly  the hip will be bent
only slightly, and the leg will twist out and away from the middle.
A hip dislocation is very painful. Patients are unable to move the leg and, if there is nerve
damage, may not have any feeling in the foot or ankle area.
Hip dislocations are relatively uncommon during athletic events.
Injuries to small joints (eg, finger, wrist, ankle, knee) are much more common.
However, serious morbidity can be associated with hip dislocations.
NOTE :

Direct force trauma (minor or major force) to the thigh

Large force traumas (e.g motor vehicle accidents,
is the most common cause of hip dislocation.
pedestrians being struck by automobiles). This type of
injury also is associated with high-energy impact
athletic events (e.g American football, rugby, water
skiing)
 Children may have a hip dislocation due to
relatively minor trauma.
1. Posterior Hip Dislocation (90%) :
• Posterior dislocations occur when the knee and hip are flexed and a
posterior force is applied at the knee while the leg is in adducted position.
• Posterior hip dislocations occur typically
during RTAs, when the knees of the frontseat occupant strike the dashboard.
Signs & Symptoms of Posterior Hip Dislocation :
1. pain in the hip and buttock area.
2. The affected limb is shortened, adducted, and internally
rotated, with the hip and knee held in slight flexion.
3. Patient may be unable to walk or adduct the leg.
4. Signs of vascular or sciatic nerve injury may be present :
- Pain in hip, buttock, and posterior leg
- Loss of sensation in posterior leg and foot
- Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial
branch)
- Loss of DTRs at the ankle.
- Local hematoma in vascular injury.
Management of Posterior Hip Dislocation :
the Bigelow
maneuver 
may be performed with minimal
assistance with the patient in the
supine position . Place the patient
supine on a stretcher that is elevated
to the height of the waist of the
practitioner performing the reduction.
The injured hip is initially held in a position of adduction and internal rotation,
with one practitioner applying longitudinal distraction and an assistant
applying pressure on the patient's anterior superior iliac spines so as to
stabilize the patient's pelvis.
Management of Posterior Hip Dislocation :
Allis maneuver
Under GA, place the patient in supine position.
While an assistant stabilizes the pelvis with direct
pressure, Flex the hip and knee to 90° and pulls
the thigh vertically upward.
Complications of Posterior Hip Dislocation :
1.
2.
3.
4.
Sciatic nerve injury.
Vascular injury (hematoma).
Avascular necrosis.
Osteoarthritis.
2. Anterior Hip Dislocation :
Anterior dislocation of the hip
occurs from a direct blow to the
posterior aspect of the hip or,
more commonly, from a force
applied to an abducted leg that
displace the hip anteriorly out
of the acetabulum.
Signs & Symptoms of Anterior Hip Dislocation :
1. Pain in the hip area and inability to walk or adduct the leg
2. The leg is externally rotated, abducted, and extended at the hip.
3. The femoral head may be palpated anterior to the pelvis.
 Signs of injury to the femoral nerve or artery may be present:
femoral nerve :
Paresis of lower extremity
Weak or absent DTR at knee
Paresthesias of lower extremity
femoral artery:
dull aching pain, pallor, paresthesias, and coldness.
Management of Anterior Hip Dislocation :
• Reduction : almost identical to post. dislocation, except while
the thigh is pulled upward it should be adducted then an
assistant helps by applying lateral traction to the thigh.
Complications of Anterior Hip Dislocation :
Avascular necrosis.
femoral nerve injury.
femoral artery injury.
3. Central Hip Dislocation :
The third type of hip
dislocation is a central
dislocation in which a direct
impact to the lateral
aspect of the hip forces the
hip centrally through the
acetabulum into the pelvis.
This is a fracture dislocation.
Indications for Open Reduction :
1. Irreducible dislocation
2. Persistent instability of the joint following
reduction (e.g fracture-dislocation of the posterior
acetabulum)
3. Fracture of the femoral head or shaft
4. Neurovascular deficits that occur after closed
reduction
Chronic degenerative disorder in which there is
progressive articular hyaline cartilage
destruction and new bone formation, with
remodeling of joint contour.
Accompanied by new cartilage and bone
proliferation at the joint margins.
Most common nontraumatic disorder of the hip in
middle and late age. Healthy fit
and over 50 years of age.
 In younger patients it may
appear as a sequel to acetabular
dysplasia, coxa vara ,slipped
epiphysis.
 Secondary osteoarthritis
arthritis is seen in older patients
after secondary RA, avascular
necrosis, or paget’s disease.
Pathology :
 Area of maximal loading (top of the joint) shows marked
changes:
1. Articular cartilage becomes soft and fibrillated.
2. underlying bone shows cyst formation and sclerosis.
 At the margins of the joint there are the characteristic
osteophytes.
 Synovial hypertrophy and capsular fibrosis.
Clinical features :
1. Pain : felt in the groin and radiates to the
knee typically after periods of activity, later it
becomes constant and disturbs sleep.
2. Stiffness.
3. Limping.
4. Muscle wasting.
5. Deep tenderness.
6. Restricted movements.
X – Ray :
 Earliest sign is a decreased joint space.
 Later signs are subarticular sclerosis, cyst
formation and osteophytes at the edges of the joint.

Osteoarthritis of the
hip showing joint
space narrowing at
the weight bearing
surface and
osteophyte
formation.

Osteophytosis
(arrow) is
noted at the
articular margin of
the femoral head.
Treatment :
Mainly symptomatic.
1. Analgesics.
2. Use of a walking stick.
3. Preserve movement and stability by performing exercises within
the range of comfort.
4. Joint manipulation sometimes relieves pain for long
periods.
5. changing life style to reduce impact loading on the
affected hip e.g Climbing up and down the stairs, carrying heavy weights
Operative Treatment :
Indicated in :
• Severe pain
• Progressive decrease in joint movement
• Increase difficulty with activities of daily living
• X-ray signs showing progressive joint deterioration.
 The procedure of choice is total hip
replacement.
Hip Replacement :
Hip replacement is a surgical procedure in which
the hip joint is replaced by a prosthetic implant. Hip
replacement surgery can be performed as a total
replacement or a hemi (half) replacement. Such
joint replacement orthopaedic surgery generally is
conducted to relieve arthritis pain or fix severe
physical joint damage as part of hip fracture
treatment. A total hip replacement (total hip
arthroplasty) consists of replacing both the
acetabulum and the femoral head while
hemiarthroplasty generally only replaces the
femoral head. Hip replacement is currently the most
successful and reliable orthopaedic operation with
97% of patients reporting improved outcome.
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Medical ppt http://hastaneciyiz.blogspot.com
Bashar