Considerations in Hip anatomy

1. Femoral neck anteverted 10-15', angled approximately 125'
2. Coxa valga > 125; Coxa vara <125'

Blood supply to Femoral head

1. Nutrient artery (profunda femoris)
2. Artery of ligamentum teres (from obturator artery)
3. Retinacular branches of medial (most important) and lateral circumflex femoral arteries (from profunda)

Attachments of femoral capsule

Femoral Musculature

Movements of the Hip

1. Flexion
   • Psoas, iliacus (femoral nerve)
   • Assisted by rectus femoris, sartorius, pectineus
2. Extension
   • Gluteus maximus [inserts iliotibial tract, into gluteal tuberosity of femur // inferior gluteal nerve]
   • Hamstrings (semimembranosus, semitendinosis, biceps femoris // tibial nerve)
3. Abduction
   • Gluteus medius, gluteus minimus (superior gluteal nerve)
4. Adduction
   • Adductor longus, magnus, brevis (obturator nerve)
5. Internal rotation
   • Anterior fibres of gluteus medius and minimus (Weakest)
6. External rotation
   • Gluteus maximus
   • Obturators
   • Gemelli
   • Pyriformis
   • Quadratus femoris

Classification

1. Intracapsular / extracapsular
   • Intracapsular - Garden: based on AP of hip

     

   • Extracapsular - intertrochanteric, pertrochanteric, subtrochanteric
2. Angulation / alignment
   • Oblique / spiral / transverse
3. Displacement
4. Parts
   • Comminuted
5. Aetiology: trauma, pathological

Complications of fractures

1. From fracture
   • Avascular necrosis
   • Non-union
   • Malunion
   • Secondary osteoarthritis
2. Damage to surrounding tissues
   • Bleeding - can loose 1-2litres of blood
   • Nerve injury
3. Loss of function
   • DVT / PE
   • Chest infection
   • Pressure sores

Surgical Treatment options

1. Intracapsular
   • Aim to preserve femoral head if undisplaced, otherwise remove
   • Internal fixation - cannulated screws
   • Replacement of femoral head - hemiarthroplasty
2. Extracapsular
   • Internal fixation

Surgical Approaches to the Hip

1. Lateral approach
   • Split tensor fascia lata, gluteus medius, gluteus minimus
   • Detaching greater trochanter [ends up with really bad trendelenburg!]
2. Anterior approach
   • Passess between gluteus medius and minimus laterally + sartorius medially
   • Divide reflected head of rectus femoris to expose anterior aspect of hip joint
   • More room may be provided by detaching gluteii
3. Posterior approach
   • Angled incision commencing at posterior superior iliac spine to greater trochanter
   • split gluteus maximus
   • Detach gluteus medius and minimus from insertion at greater trochanter (or trochanter detached and then re-wired into place)

Dynamic Hip screw Fixation

Indications: Extracapsular fractures of #NOF, Garden I-II

1. Mark, consent, X-rays, Image intensifer // GA or regional block
2. Traction table, ensure adequate reduction of fracture (traction + internal rotation)
3. Access bone
   • 15cm incision 2cm from greater trochanter
   • Split fascia lata
   • Expose vastus lateralis; retract or split fibres + lift from bone with periosteal elevator
4. Insert internal fixation
   • Use 135' guide to place guidewire into femoral neck (aim to get into femoral head, just "inferiorly") - tip of wire should sit in subchondral bone of femoral head
   • Measure lenght of insertion
   • Ream with reamer -5mm of measured
   • Insert screw + 4-hole plate to femoral shaft
   • Confirm position with image intensifier
5. Finish
   • Close fascia lata with absorbable sutures
   • Clips to skin
   • Check X-rays post-operatively

Trendelenburg sign / gait

Failure of contralateral pelvis to rise when weight is taken on the the affected side

Causes:

1. Mechanical
   • Short femoral neck
   • Medial migration of femoral head
2. Neuromuscular
   • Pain
   • Neuropathy
   • Myopathy