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Round 3 Orthopedics Inpatient
Round 3 Orthopedics Inpatient
Round 3 Orthopedics Inpatient
Introduction:-
Joint stability:-
Joint stabilizers include:
o Active stabilizers:
Strong muscles supporting the joint. (The active tension of muscles).
o Passive stabilizers: (anything but the active tension of muscles)
Bony configuration
Labrum
Thick capsule
Strong ligaments
بتاعهاtension زي العضالت القوٌة والactive stabilizersً ف.stabilizer بتاعت اي مفصل بتعتمد على كذاstabilityٌعنً ال
بتاعها زي شكل العضم المكون للمفصل وزيactive tension ودول اي حاجة غٌر العضالت والpassive stabilizers ًوف
.ligaments والlabrum والcapsuleال
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The hip joint is a very stable joint. Hip joint stabilizers include:
o Active stabilizers:
Strong muscles such as gluteal muscles, short external
rotators (attached to the capsule posteriorly) and
rectus femoris.
o Passive stabilizers:
Deep acetabulum (bony configuration that favors
stability unlike the shoulder joint)
Acetabular labrum (increases the depth of the
acetabulum)
Thick capsule (parts of acetabulum) هنحتاجها فً حاجات تحت
Strong ligaments:
Anteriorly → iliofemoral ligament (the strongest ligament in the body)
Posteriorly → ischiofemoral ligament.
ً وفdeep بتبقىacetabulum اللً حوالٌه وبسبب ان الstrong muscles جدا جدا بسبب الstable مفصلhip jointال
منfemoral head قدام تمنع الiliofemoral ligament ووجود الthick capsule اكتر وبسبب الdeep بٌخلٌهاlabrum
. من وراischiofemoral ligamentانها تطلع من قدام وال
N.B.:
Iliofemoral ligament (located anteriorly) is stronger than ischiofemoral ligament (located posteriorly)
so posterior dislocation is more common than anterior dislocation:
Incidence of posterior dislocation is 80%-90%
Incidence of anterior dislocation is 10%-15%
posterior اللً موجود ورا عشان كدا الischiofemoral ligament اللً موجود قدام اقوى من الiliofemoral ligament ال
)%15-%19 (بٌحصل بنسبةanterior dislocation) اشهر من ال%99-%8 (بٌحصل بنسبةdislocation
Prosthetic Native
Posterior Central
Early Late Anterior
Congenital dislocation (dislocation of neonates in the uterus during pregnancy)
Acquired dislocation:
o Prosthetic dislocation: dislocation of prosthesis (hip arthroplasty prosthesis )مثال. It doesn't
require violent injury. Classified to:
Early dislocation: Happens within the first 3 months (which is more common), due to
patient not following precautions (and the soft tissue is still not completely healed in the
first 3 months) or incorrect positioning (malpositioning of prosthetic component)
(surgeon's fault)
Late dislocation: prosthetic wear ()تآكل المفصل مع الوقت
o Native dislocation: dislocation of the original joint component that the patient was born
with. It requires violent injury (high force) because the joint is very stable. It's classified
(according to direction of force or direction of exit of the head of femur) to:
Posterior dislocation (most common)
Anterior dislocation (less common than posterior dislocation)
Central dislocation (rare)
dislocation بٌحصل بعد الوالدة عادي واما ٌبقىacquired بٌحصل للجنٌن وهو فً الرحم والcongenitalال
شهور او3 [ او بسبب ان المرٌض عمل حركة غلط فً اولlate] مركبٌنها (بسبب ان المفصل تآكلprosthesisل
عالٌةforce اللً اتولدنا بٌه ودي محتاجةnative joint للdislocation [) او انهearly] الجراح ركب المفصل غلط
.central وanterior وposterior لfemoral head ٌتخلع ودي بنقسمها حسب اتجاه خروج الhipعشان ال
( اكثرهم حدوثposterior(ال
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Posterior dislocation Anterior dislocation
-Less common (10%-15% of dislocations)
because iliofemoral ligament (anterior)
- Most common (90% of dislocations) because is stronger than ischiofemoral ligament
iliofemoral ligament (anterior) is stronger than (posterior)
ischiofemoral ligament (posterior) - The femoral head is pushed out of the
Description
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Thompson and Epstein classification system 1) Obturator anterior (inferior anterior)
2) Pubic anterior (superior anterior)
I (simple) only dislocation, no fracture The obturator foramen is located under the
pubic bone so if the femoral head is pushed
Dislocation with fracture in posterior wall of forward (anterior) and superiorly then it's
II
called pubic anterior dislocation and if it's
Classification
acetabulum
pushed forward (anterior) and inferiorly
Dislocation with comminution of acetabular then it's called obturator anterior
III dislocation.
ring
Obturator anterior is less common
IV Dislocation with fracture of acetabular floor pubic طلعت لقدام ولفوق ٌبقى راٌحة ناحٌة الheadلو ال
ولو طالعة لقدام ولتحتpubic anterior فنسمٌهاbone
Dislocation with fracture of femoral head and ٌبقى نسمٌهاobturator foramenٌعنً ناحٌة ال
V neck .obturator anterior
زي اللً مكتوب النه ممكن ٌبقىappearance وارد جدا ماشوفش الfracture زي الassociated injuries لو العٌان عنده
.angulation اوrotation وحصلfracture in femoral shaft حصل
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N.B.:
It's very common for a violent injury like hip dislocation to cause associated injuries such
as fractures in femur or acetabulum (simple pure injury is less common than complex
injury with associated injuries)
Dashboard injuries are most common mechanism of injury.
Internal rotation causes posterior dislocation, external rotation causes anterior dislocation.
Surgical management:-
Complete survey:
In case of a violent injury like hip dislocation, a complete survey will show the surgeon if there
are any associated injuries in the epsilateral or contralateral limb and whether the surgeon
will perform closed or open reduction (because we can't perform a closed reduction if there
are any associated injuries like fractures in the epsilateral limb even if the fracture isn't
displaced). A complete survey includes:
o History
o Appearance of the limb
o Radiology
o Neurovascular examination
Radiology:
o X-ray (AP and lateral)(hip profile):
To confirm diagnosis, direction of dislocation and any associated injuries like fractures.
How to differentiate between anterior and posterior dislocation in X-ray film?
In anterior view, The X-ray machine is usually put in front of the patient and
normally, the 2 femoral heads should have the same size.
So if one femoral head is pushed anteriorly (anterior dislocation), this means that the
distance between the head and the machine is smaller, so this head will appear
bigger than the other normal head.
And if one femoral head is pushed posteriorly (posterior dislocation), this means that
the distance between the head and the machine is bigger, so this head will appear
smaller than the other normal head.
There is also other landmarks we look at to detect rotation of the limb such as the
lesser trochanter ()شاٌفٌنها فً االشعة وال أل
o CT scan:
To detect loose fragments in the joint.
anterior والposterior فنعرف ازاي ان دا. فً اي اتجاه ونشوف لو فً اصابات تانٌةdislocation عشان نشوف الX-ray بنعمل
posterior ً اصغر ٌعنً بعٌدة لورا ٌعنhead ولو الanterior dislocation ً اكبر من التانٌة ٌعنً مقربة ٌعنhead؟ لو الdislocation
عشانCT scan ونعمل. وال ألangulation هل شاٌفٌنها وال أل عشان نحدد حصلlesser trochanter وممكن نبص على.dislocation
فً المفصل وال ألloose نشوف هل فً حاجة
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Neurovascular examination:
o To detect avascular necrosis.
o To detect nerve injury. Common Sciatic nerve injury manifestations are:
Drop foot.
Affected sensation in dorsum of foot.
.open or closed reduction بٌكون معانا معلومات تساعد الجراح ٌقرر هٌعملcomplete surveyبعد ال
Reduction:
Open reduction:
o Open reduction is indicated in case of:
Prolonged time since dislocation (being a time sensitive injury means that reduction
must be performed as soon as possible in order to avoid avascular necrosis, but if
prolonged time had passed then open reduction is indicated)
In case of associated injuries (such as fractures of femoral shaft, head, neck or
acetabulum even if the fracture isn't displaced)
Failed closed reduction (due to soft tissue interposition, which means that parts of
the capsule, labrum or muscle got detached and entered the joint space)
Recurrent dislocation (a previous dislocation caused persistive instability causing
more dislocations)
Prosthetic dislocation (due to incorrect positioning of prosthetic component or
mechanical loosening. So the surgeon must open and put prosthesis in accurate
position)
o In case of prosthetic dislocation, open reduction is done from the same incision site.
o In case of native dislocation, some surgeons prefer to do the incision in the direction of
the exit of the femoral head from the acetabulum (which means the surgeon performs
posterolateral approach [posterolateral incision] in case of posterior dislocation and
anterolateral in case of anterior dislocation) to avoid avascular necrosis because if the
dislocation already injured the arteries in one side, why damaging arteries of the other
side by performing the surgery in different direction of the exit of the head. But some
researches proved that it has no such effect and doesn't cause avascular necrosis so it's
up to the surgeon and what incision site the surgeon prefers.
فً اقربdislocation النه كان المفروض ٌترد بعد الdislocation؟ لو عدى وقت طوٌل على الopen reduction امتى ٌعمل
closed ولو عمل.displacement حتى لو ماحصلشdislocationوقت ممكن ولو فً اي اصابات او كسور تانٌة مع ال
كتٌر بسبب انه عندهdislocation ولو بٌحصله. متجمع جوا المفصلsoft tissue ً بس مانفعش عشان فreduction
. ٌعنً فكتloosening اتحركت من مكانها وتخلعت او حصلهاprosthesisاو انه ال. مستمرة وبٌتخلع كتٌرinstability
ٌبقى فً جراحٌن بٌفضلو ٌعملو منnative ولوincision site ٌبقى الجراح هٌفتح من نفس الprosthetic dislocation لو
لٌه فً الجمبdamage النه خالص لو فً جانب متؤثر اعملavascular necrosis عشان نتجنب الheadنفس اتجاه خروج ال
. من قدام وورا متؤثر؟ ولكن فً ابحاث بتقول انه الموضوع دا مابٌاثرش وعلى حسب تفضٌل الجراحblood supplyالتانً وٌبقى ال
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Closed reduction under sedation:
o Closed reduction is indicated if the X-ray showed that there is no condition requiring
open reduction.
o It must be under sedation so that the muscles are relaxed (if the muscles are tensed, the
protective action will make the reduction fail) or the patient may push the surgeon due to
severity of the pain.
o There are several reduction techniques such as Allis maneuver for posterior dislocation
reduction.
o After closed reduction, X-ray is performed to make sure that the reduction is successful
and no nerve injury occurred during reduction, then a CT scan is performed.
والزم العٌان ٌبقى متخدر عشان العضالت تبقى مرٌحة النها لوclosed ٌبقى نعملclosed reductionلو مافٌش حاجة تمنع ال
. صح والوجع اصال ٌخلً العٌان ٌزق الدكتورreduction تعٌق الدكتور انه ٌعملprotective action مش مرٌحة ٌبقى هتعمل
.CT scan وبعدها نعمل. nerve injury نتؤكد انه كله تمام وماحصلشX-ray بنعملreduction وبعد الtechnique وفً كذا
وال ٌمشٌه من بدري واٌاtraction تانً وال أل وعلى اساسه ٌشوف ٌحطه علىdislocation الجراح بٌشوف العٌان وارد ٌحصله
عشان خاٌف لوtraction ولو الجراح قرر انه هٌعملdislocation كان قرار الجراح الزم اتجنب اي حركة عنٌفة عشان ماٌحصلش
عادي زي ماخدنا الترم اللً فات فً الراوندtraction ٌبقى هنتعامل معاه كعٌان علىavascular necrosis العٌان اتحرك ٌحصل
ولو الجراح قرر انه هٌمشً العٌان من بدري عشان خاٌف انstrengthening وROM نعمله تمارٌن زيtractionولما نشٌل ال
فزي ماقولنا دا قرارweight bearing وبالنسبة لل.strengthening ٌبقى هنعمله تمارٌن زيadhesion تعملimmobilityال
.الجراح عشان لو حصل مشاكل ماٌبقاش اللوم علٌك وهو الجراح عارف عمل اٌه فً العملٌة وعلى حسب قراره هنتعامل معاه
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In case of complex injury with open reduction:
o There is the same debate about immobilization and weight bearing options and it's up to
the surgeon to decide and we will deal with the patient according to the decision of the
surgeon.
o In case of complex injuries, there are other associated injuries (like fractures or ligaments
injuries) we should consider while dealing with the patient. For example in case of
fracture in femoral shaft and the surgeon fixed it with internal fixation:
If the surgeon inserted plate and screw, the patient will be immobilized for 3
months.
If the surgeon inserted unlocking intramedullary nail, the patient will walk non-
weight-bearing for 1.5 months then partial weight-bearing 20%-25% according to
the nail diameter and increase the weight-bearing 5-10 Kg every week. After 3
months, the patient will be walking full weight-bearing.
o We also deal with the patient according to incision site. For example if the surgeon did a
postero-lateral incision, we deal with the patient with the same precautions and program
of postero-lateral incision (as discussed in round 1, avoid hyperflexion, adduction,
internal rotation…etc) and same thing goes for lateral and anterolateral incisions
(avoiding external rotation….etc). In case of hip resurfacing, the precautions are the
precautions of all incision sites (avoiding both internal and external rotation) because it's
an extensive incision.
بردو قرار الجراح بس نراعً ان بٌبقى المرٌض عنده اصابات تانٌة نتعاملweight-bearing والimmobilizationال
ٌبقى نتعاملposterolateral incision اللً الدكتور عملها ٌعنً لو عملincision معاه على اساسها وعلى حسب ال
اللً شوفناه فً اول راوند ونفسposterolateral incision بتاع الprogram والprecautionsمعاه بنفس ال
هتبقى بتاعت كله سواءprecautions ٌبقى الhip resurfacing ونراعً انه لو عاملincisionsالشًء لباقً ال
.posterior approach او الanterior approach ال
رجلهlimb appearance (الposterior dislocation لعٌان عندهAllis maneuver الدكتور عرضت فٌدٌو فٌه
فعشان كدا قرر انه هٌعملهfemur فً الfracture ) وماعندوشflexion, adduction, internal rotation ًداخلة ف
traction, extension, external هٌعملreduction والناس بتثبت العٌان والجراح بٌعملclosed reduction
fractured لقاه ماتردش مظبوط وشاكك ان فً جزء... تانٌة عشان ٌتؤكد اترد وال ألX-ray وبعدها ٌعملrotation
.open reduction عشان ٌتؤكد ولو كدا ٌبقى هٌعملCT فهٌعملjoint فً الloose موجود
لٌنك الفٌدٌو اللً الدكتور عرضته موجود فً البوست اللً نازل فٌه الملخص
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