An orthopaedic overview

Characteristic Hip Pains: ◦ Dull ache- OA, degenerative, tendinitis/

bursitis◦ Sharp – Impingement, acute sprain, labrum

tear, subluxation/dislocation, fracture Pain frequently noted in groin and

medial thigh Symptoms: pain, weakness,

numbness, clicking, giving way Referred Pain from: Back, Abdomen,

Pubic symphysis Refers Pain to: knee

Mechanism: High energy:◦ Motor vehicle crash (50-60%) ◦ Motorcycle crash (10-20%) ◦ Pedestrian versus car (10-20%) ◦ Falls (8-10%) ◦ Crush (3-6%)

Physical examination is specific for pelvic instability, but it has a low sensitivity: high level of suspicion

Pain, swelling, WB/NWB, deformity, crepitus, Consider Blood loss and signs of shock GU exam: rectal tone, bladder control,

perineum, boggy prostate, scrotal hematoma, hematuria

digital rectal examination has a very low sensitivity for diagnosing pelvic fractures

Management: pelvic binder (T-pod), IV, analgesia, Blood,

Evacuation for surgical assessment X-ray: pelvic ring- usually disrupted

in 2 places Tile classification: based on the

integrity of the posterior sacroiliac complex

Young classification system is based on mechanism of injury

Death most commonly due to hemorrhage or multiple injuries

Mechanism: high velocity trauma, MVA, falls from height

Multiple fracture patterns: MOI Pain, non WB, presentations of

hip, Neurovascular exam, abdominal

exam, LLD, position of lower limb Stabilize, IV, analgesic, Evacuation for X-ray, surgical

assessment 20% concomitant pelvic fracture

“People come into this world under the brim of the pelvis and leave it by the neck of the femur.”

MOI: Young- MVA, fall from height◦ Older: simple fall, Osteoporosis: abrupt

step, Runners: stress fractures Acute onset hip pain, unable to

WB O/E: shortened leg, external

rotation, painful ROM, crepitus Neurovascular exam Stabilize, IV, analgesia Evacuation for X-ray and surgical

assessment

Garden Classification: 1-4

Treatment: ◦ Young: internal

fixation (+/- reduction)

◦ Older: internal fixation non displaced, hemi-arthroplasty

Extra-capsular fracture including the greater and lesser trochanter (b/w neck and shaft)

Traumatic force to trochanteric area

Acute pain, unable to WB, shortened, ER

Stabilize, IV, analgesic Evacuation for X-ray, surgical

assessment Treatment: Dynamic Hip Screw

fixation

Mechanism: high energy trauma Pain, deformity, Non WB Neurovascular status: urgent

reduction? Procedural sedation, blood loss into fracture site…1000mL

Reduction, immobilize, IV, analgesia, Blood products, +/- antibiotics

Evacuation to surgical capability Surgery: internal fixation- IM nail/

plate

Complications: ◦Haemorrhage requiring transfusion◦Fat embolism – ARDS◦Increased risk of open fracture◦Nerve injury◦Infection

Supracondylar: above condyles Condylar, Inter-condylar= intra-

articular involvement Mechanism: high energy force,

axial load Pain, hemarthrosis, non WB, ER,

shortened Immobilize, IV, analgesia Evacuation for surgical fixation Complication: femoral artery tear

A.Anterior

B.Posterior

***Orthopaedic Emergency

Mechanism: blow to knee in hip abduction

Shortened, abducted, ER limb Neurovascular exam Stabilize, IV, analgesia, Urgent Evacuation for X-ray,

reduction under sedation/GA Complications: as per posterior

***Orthopaedic Emergency Mechanism: high force through

femur with hip in flexion and adduction (dashboard )

Pain, Shortened, Add and IR of hip

Stabilize, IV, analgesia, Urgent Evacuation for X-ray- r/o

fracture, reduction under sedation/ GA, ORIF

risk of AVN with delayed reduction (>6 hrs)

Slow onset degenerative change often following injury or prolonged exposure to impact, poor biomechanics, congenital hip disorder

Pain into groin and medial thigh worse with activity, intermittent flares

with acute pain and swelling

O/E: trendelenberg gait, decreased ROM, strength deficit, ligament laxity

X-ray: decreased joint space, osteophyte formation, sclerosis of femoral head, subchondral cysts

Treatment: NSAIDS for acute flare, Tylenol/NSAID for long-term analgesia

Physiotherapy: ROM, strengthening, gait aids

Partial/Total hip replacement

Etiology: Loss of vascular supply to femoral head

Primarily distal to proximal intra-osseous blood supply

Predisposing factors: systemic steroid, dislocation of femur, fracture of femoral neck, chronic alcohol use, sickle cell, septic arthritis, “the Bends”

Symptoms: Pain in groin, worse with WB O/E: abnormal range of motion if collapse of

cartilage on femoral head Normal strength on manual muscle testing Pain on compression testing X-ray may show crescent sign Treatment: Non WB until new bone

formation

Etiology: trauma to hip, abnormal gait mechanics, muscle tightness, over-training

Rule out cellulitis or infection Pain at lateral aspect of hip, worse with

weight bearing/ walking/ direct pressure O/E: pain on palpation over greater

trochanter, +/- tight ilio-tibial band, muscle imbalance, pain on single leg stance

Treatment: Rest, Ice, NSAIDS Physiotherapy for stretching, muscle

imbalance Consider corticosteroid injection for

refractive conditions

Abnormal contact between the acetabulum and femoral head-neck junction

Primarily an impingement issue Groin pain with activity or extreme ROM Usually younger active people Can lead to labral tears

A. Rectus femoris

B. Vastus lateralis

Adductors: groin pull Hip flexors: Rectus femoris strain Snapping hip: iliopsoas Piriformis syndrome Iliotibial band syndrome Gluteal strain

Let’s take a break.