What other types of PSO you know of? What is the role of PSO? Surgically shifts the shaft of femur near the center of gravity of the body so that the wt. Supports pelvis by creating medial fulcrum 3. Improves adductor function by causing valgus 4.
Abduction of distal fragment causes of gain of length. What is Phemister triad? Ans: Classically described for tuberculosis of hip consists of: 1. Juxtaarticular osteoporosis 2. Peripherally located osseous lesion 3. Gradual narrowing of joint space. What triangles you know in relation to hip joint? Ans: Learn the following: 1. Wards triangle: Between primary tensile, primary compressive trabeculae and calcar portion of neck relevant in osteoporosis and fixation of hip fractures 3.
Fairbanks triangle: Coxa vara 4. Bryants triangle 5. Scarpas triangle femoral triangle 6. Abductor triangle: formed between gluteus medius, ilium, neck of femur displays abductor mechanism. What is the role of manipulation under anesthesia? Ans: Manipulation under anesthesia is indicated in healing disease with less severe deformities to: 1.
Attempt gaining mobility of hip while on treatment when articular cartilage is supposedly preserved 2. Provide a functional position correcting the deformity to hip lest it goes in fibrous ankylosis when cartilage is irreparably damaged and functions cannot be regained. Diagnosis The patient is a 52 year old male with 7 months old non-union fracture of femoral neck following trauma treated conservatively.
There is 30 fixed flexion deformity with 20 external rotation deformity and 20 adduction deformity and true supratrochanteric shortening of 3 cm. The patient is unable to do his routine activities. What makes you think this is a case of old fracture neck of femur? Desaults sign positive Telescopy test positive, trendelenburgs positive.
Shortening and external rotation. Why is it not non-union fracture intertrochanteric? Ans: There should be irregularity over trochanter with broadening and thickening. Tenderness should be at trochanteric region rather than mid-inguinal point. Why is it not old anterior dislocation of hip considering the deformity?
Ans: There is often extension deformity with lengthening in low types of dislocation. Moreover, head is not palpable in the classical sites. Why do you think that head is located in this patient? Ans: Femoral pulses are bilaterally comparable Naraths sign. Also see examination for palpable head in dislocated hip. What will be your differential diagnosis? Ans: I will put forward the following differentials It is always better to speak your answer and diagnosis itself this way as I presented a very hypothetical and classic case for understanding which is hardly the case in exams, although I cannot predict or present here all pathological presentations!
Old ununited Fracture intertrochanteric right femur 2. Old Fracture head of right femur: Telescopy often absent or minimal 3. What are the causes of non-union in fracture neck femur?
Ans: Non-union here is predominantly due to combination of mechanical points below and biological points disruptions: 1. Morphologic features: High fracture angle shear angle 2. Fracture comminution Posterior comminution affects adequacy of reduction, angulation and stability of fixation 4.
Inadequate reduction and stability of fixation 5. Poor bone quality osteoporosis 6. Injury to vascularity: Direct and tamponade effect Deyerle : Remember head of femur is already a hypovolemic bone PET studies even small disturbances put vascularity at risk. Absence of cambium layer in periosteum 8.
Chondrogenic factors in synovial fluid that inhibit callus formation and consolidation 9. Lack of hematoma formation: Synovial fluid prevent hematoma formation Washing away and dilution of osteogenic factors. Patients age It only decides treatment! How does duration of non-union affect planning? Ans: Increased duration of fracture is counterproductive in the following ways: 1. Resorption at fracture ends Resorption begins as early as 3 weeks 2.
Contractures prevent adequate lengthening and reduction 3. Acetabular cartilage damage. How do you radiographically assess the fracture? Osteopenia 3. Bone loss 4. Osteonecrosis 5. Calcar comminution 6. Varus angulation Lateral projection: 1. How do you radiographically assess osteoporosis? Ans: Singh and Maini index on AP radiographic evaluation of trabeculae: Grade 6 normal : All trabeculae present Grade 5: Loss of trochanteric and secondary tensile, attenuated secondary compressive Grade 4: Loss of secondary compressive, attenuation of primary tensile Grade 3 definite osteopenia : Break in primary tensile Grade 2: Marked loss of primary tensile Grade 1: Only primary compressive seen but they are also reduced.
When do you call a fracture neck of femur to be a Non- Union? Ans: 3 months following fracture. What are the various treatment options available? Ans: The followings have been successfully practiced And should be individualistically given to the patient!
ORIF with cancellous bone grafting 2. ORIF with fibular grafting 3. ORIF with vascularized bone grafting a. Free vascularized fibula b.
Muscle pedicle bone grafting 4. Osteotomy 6. Arthrodesis 7. Arthroplasty 8. Girdlestone type of resection arthroplasty. How do you plan surgery? Ans: Clinical assessment: 1. Age of patient 2. Presence of Osteonecrosis 3. Prior hip symptoms: Osteoarthritis etc.
Co morbidities: Smoking etc. Duration from injury 6. Fracture variables: a. Site of fracture b. Fracture configuration. How would you classify non-union fracture neck femur? What are the guidelines? Ans: First look for Osteonecrosis: 1. ORIF with vascularized grafting ii. ORIF with fibular grafting b. Non-union with destroyed anatomy e. What are the various muscle pedicle grafts described?
Ans: There are various muscle based grafting techniques described: 1. Muscle pedicle bone grafting a. Quadratus femoris based Judet, Meyers et al b. Gluteus medius based Hibbs c. Anterior trochanteric bone grafting Das and Balasubramaniam modified Hibbs d. Sartorius based Li et al e. Tensor fascia lata based Bakshi f. Gluteus maximus based Onosun et al 2. Muscle pedicle grafting a. Gluteus medius based Frankel and Derian b.
Vastus lateralis based Stuck and Hinchey 3. Muscle pedicle periosteal Myoperiosteal graft a. Quadratus femoris based periosteal grafting 4. Often used in eastern Asian countries i. Neck reconstruction a. Devising a trough like rectangular box in the region of resorbed neck and filling with bone graft b. What is the advantage of muscle pedicle bone grafting? Ans:Following are the advantages of using these grafts: There is no substitute for original biological joint Always give a fair chance to save a salvageable joint Vascularized bone graft may additionally take care of Osteonecrosis Pedicle grafts are less cumbersome than free grafts with comparable results.
What are the principles of this grafting technique? What is the role of osteotomy in treating Non-union fracture neck of femur? Ans: Osteotomy alters both mechanical and biological environment around non-union site which may enhance healing or at least provide relief to the patient McMurrays concept : 1.
Altering mechanics Medial shift of line of weight bearing 2. Correction of deformity: Rotational deformity can be corrected, shortening compensated by apparent lengthening Pauwels 3. Realignment of limb during movement 4. Relaxation of joint capsule 5. Increased vascularity 6. Psoas relaxation providing pain relief by a mechanism similar to hanging hip of Voss 7.
Improved congruity of joint surfaces only if deformed due to Osteonecrosis 8. Relief of pressure by muscles Re-distribution of tensile forces at line to compressive forces Arm chair effect. What is arm chair effect? Ans: As above I understand that this does not explain what one is curious about. In McMurrays osteotomy the distal fragment is placed directly under the head so weight is directly transmitted from head to shaft bypassing neck so tensile shearing forces are converted to compressive forces.
Now just imagine and compare yourself getting up from a chair without arms and a chair with arms. In the first instance forces are concentrated around knee in a tensile manner unless you support them with your hand whereas in the second instance you will get off the chair pushing at the arms which are more or less situated at knee level or sometimes even in front, dissipating in effect the shearing stresses across knee.
This is the effect of an arm-chair dissipating the tensile forces at the lateral border of fracture which was recommended originally for osteoarthritis of knee and hip. What are the various osteotomies described around hip for treating Non-union?
Ans: Classically two landmark osteotomies with various modifications are cited: 1. Lineal osteotomy: Medial displacement osteotomy first described by Haas revised by McMurray and Leadbetter 2. Angulation osteotomy described by Schanz with modification by Pauwels. What is McMurrays osteotomy? Ans: It is aptly described as medial displacement oblique intertrochanteric pelvic support osteotomy.
What are the principles of McMurrays osteotomy? Ans: Conditions for success: 1. Upper end of shaft must be just below the edge of acetabulum 2. There must be union between portions of divided femur. For what condition did he describe this osteotomy and what are the prerequisites? Ans: Osteoarthritis of hip joint with pain, stiffness and deformity. There should be a minimum of 70 flexion at hip joint 90 general anesthesia.
It should not be done in coxa magna, loss of sphericity of head both in AP and lateral projections, dysplastic acetabulum, subluxation of head, inflammatory disease, and ankylosing spondylitis. How do you do this osteotomy and how to fix it? Ans: The line of osteotomy goes from the base of greater trochanter obliquely up to exit just above lesser trochanter. After doing medial displacement of distal fragment fixation was done by Wainwright-Hammond spline plate.
By doing adduction it used to tilt the proximal fragment into valgus making the fracture line horizontal. What are the disadvantages of this osteotomy? What is Pauwels osteotomy? Ans: Pauwels repositioning valgus intertrochanteric osteotomy re-places the pseudoarthrosis site to remove the shear forces. The osteotomy is aimed to enhance fracture healing and other benefits like: 1.
Equalizing limb lengths virtually 2. Lateralization reducing tendency to genu valgum 3. Early mobilization by fixing osteotomy.
Planning: Body forces subtend an angle of 16 at hip joint. The anatomical axis is at an angle of to body forces, so the pseudoarthrosis site is subjected to forces at around Subtract this from the pseudoarthrosis angle vide Pauwels classification. This gives the wedge angle to be resected at osteotomy site. Murrays modified osteotomy classically described for pseudoarthrosis of femur neck. Which test would you use to decide instability at hip joint? Telescopy is seen due to absorbed neck, comminution at fracture site, tearing of capsule in high impact injuries.
Which other test can you use? This test may however be fallacious false negative in impacted fragments, capsular contracture, and leverage of distal fragment on acetabular margin. It may be absent false positive in a frail patient and cannot be done in hemiplegia or paraplegic patient. What are various closed Reduction maneuvers for fracture neck of femur? Ans: Maneuvers in extension: 1.
Whitman 2. Deyerle 3. Maneuvers in flexion: 1. Leadbetter: flexion internal rotation circumduction to abduction and extension; check by resting heel on palm, if it rests without externally rotation then it is a secure reduction. Flynn 3. Smith-Peterson method gentle Leadbetter method. How do you make an assessment of alignment?
Gardens index: AP and lateral , radiographs required acceptable 2. Lowells S-curves: image intensification 3. McElvenny: Hat on hook position 4. What is the shape of fracture line in fracture neck of femur? Ans: Spiral. How do you classify fracture neck of femur?
Incomplete, Valgus impacted fracture with trabecular displacement Gardens index in AP, may be normal in lateral ii. Complete, undisplaced impaction iii. Lintons classification: i. Intermediate type. Pauwels higher the shear angle more will be the stresses and hence unstable fracture : i. Angle of line 30 to 50 iii. Anatomical: subcapital, transcervical, basicervical 5. Current classification Caviglia; Osorio and Commando : 5 types depending upon completeness, contact, angulation and comminution.
Stress fracture neck of femur Fulkerson and Snowdy i. Tension stress fracture superolateral aspect of neck, risk of displacement ii. Compression stress fracture inferomedial aspect, risk of displacement iii. Completely displaced fracture neck of femur displaced. Classification in children Delbet and Collona : i. Flexion, abduction and external rotation deformity.
Transcervical : most common Most are displaced and unstable. Osteonecrosis proportional to degree of displacement iii. Cervicotrochanteric: 2nd commonest, similar to basicervical iv. Intertrochanteric: Good fracture. What is the blood supply of femoral head? Ans: The blood supply to femoral head is derived from three primary sources as described by Crock , the metaphyseal system, retinacular system and the foveolar system as follows: 1.
Extracapsular arterial ring [ECA]: This is the chief system giving rise to both intramedullary and extramedullary arterial systems. The ECA gives less prominent metaphyseal branches to intertrochanteric region which also supply the head through neck intramedullary metaphyseal system. Ascending cervical branches of ECA aka Epiphyseal arteries of Trueta or retinacular arteries arise from ECA more prominent system and ascend up the neck partly also supplying the neck in due course i.
Divided into anterior, posterior, medial, and lateral groups ii. Anteriorly these vessels penetrate the capsule at intertrochanteric line while posteriorly they pass underneath the orbicularis fibers of the capsule iii. Lateral group lateral ascending cervical vessels is the most important group carrying major portion of blood supply to head and neck of femur 2. Sub-synovial intraarticular arterial ring of Chung Circulus articuli vasculosus of Hunter is formed from lateral ascending cervical vessels: Located at the margins of articular cartilage on surface of neck of femur It is either a complete or incomplete ring Provides epiphyseal vessels that penetrate the head just outside the articular cartilage to supply major portion of head 3.
Artery of ligamentum teres Branch of obturator artery more often or medial circumflex femoral artery Variable supply in adults Supply head around the region of fovea The metaphyseal femoral neck is supplied by a cruciate shaped anastomosis between: Branches from ascending cervical arteries Branches from sub-synovial intraarticular arterial ring Intramedullary branches of superior nutrient artery system Metaphyseal vessels from intertrochanteric region This rich anastomosis makes the neck a very unlikely site for avascular necrosis.
How do you look for protrusio acetabuli and what are the various causes of the same? Causes 1. Rheumatoid arthritis and JCA 3. Osteoporosis 4. Osteomalacia and Rickets 5. Pagets disease 7. Ankylosing Spondylitis 8. Osteoarthritis occasionally 9. Acetabular fractures Osteogenesis Imperfecta. Diagnosis The patient is a 32 year old male with Rt. I would like to give a differential diagnosis of: 1. Osteonecrosis, 2,3,4, The deformities are not characteristic and with development of secondary osteoarthritis the movements are also lost early!
So as a rule always try to give the diagnosis as a differential diagnosis and be safe. Ans: Typical differential diagnoses include: 1. Tuberculosis of hip: Old cases of Osteonecrosis only with restriction of most movements 2. Transient osteoporosis of hip in females. Primary osteoarthritis of hip once the osteoarthritic changes develop in Osteonecrosis : deformity of head and sectoral signs absent. Old Femoral head fracture with secondary osteoarthritis.
Monoarticular rheumatoid is as such rare and if mentioned then should be last as it is a diagnosis of exclusion! Why do you keep Osteonecrosis as your first differential? Ans: History: 1. Single joint involvement ankylosing spondylitis , Insidious onset, slow progression 2.
Characteristic course 3. No constitutional symptoms 4. Deformities do not match with staging of TB hip viz. No history of trauma. What are the diagnostic criteria for osteonecrosis of hip? Radiological depression of femoral head, demarcating sclerosis in the femoral head, crescent sign 2. Bone scan cold-in-hot 3.
MRI low intensity band on T1-weighted image 4. Histology trabecular and marrow necrosis. Minor: 1. Bone scan cold or hot 3. Symptom hip pain with weight bearing 5. What are the causes of Osteonecrosis of hip? Ans: Idiopathic form Chandlers disease is the most common? The other causes are: 1. Trauma: a. Powered by Discuz! Enable Auxiliary Access Wide screen. View: Reply: 2. Post time Show all posts Read mode. Rheumatology, Orthopaedics and Trauma at a Glance.
Catherine Swales. Pocket Tutor Orthopaedics. Nicola Blucher. Hypermobility of Joints. Peter H. Basic Orthopaedic Sciences. Manoj Ramachandran. Postgraduate Paediatric Orthopaedics. Sattar Alshryda. Winged Scalpel. Richard N. Deborah M. This book helps students prepare for the big day. It includes some more unusual questions and the flow needed to be practised in advance to place students in as comfortable a situation as possible.