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.