77. Hip
From Primary Surgery
77.1 Rehabilitating a patient with an injured lower limb
Your ultimate objective after any lower limb injury is to get a patient walking again without a limp. There are three stages in doing this, and in the first two of these he needs crutches: (1) a non-weight bearing stage in which he does not put his foot to the ground, (2) a stage of partial weight bearing, and (3) a stage of full weight bearing in which he has no help, except perhaps from a stick.
If an injured patient learns to walk normally, he uses all his muscles, and stabilizes his injured limb. But if he limps, some of his muscles remain unused, with the result that he may limp permanently, and quite unnecessarily. So try to interest your ward staff in the way their patients walk, and make them into active physiotherapists.
REHABILITATING A PATIENT WITH AN INJURED LEG
The time at which a patient should be mobilized without weight bearing, and the time when he should start partial or full weight bearing depend mostly on the kind of injury he has, and are described later for each injury.
CRUTCHES FOR AN INJURED LEG
A plentiful supply of crutches is essential. Some hospitals find it convenient to ask the patient to leave a small deposit for them. Ask the hospital carpenter to make well padded axillary crutches with rubber tips, adjustable for height, and for the position of the hand grips, which should be about one third of the way down the crutches.
Fit crutches carefully so that when a patient is standing, his crutches are just short of his axillae. When his hands are on the hand grips, his elbows should be slightly flexed. A crutch which is slightly too short is better than one which is too long.
CAUTION! (1) A patient must bear weight on his hand rests, not his axillae, or he may get a crutch paralysis. Any of the nerves of his brachial plexus may be injured, usually his radial nerve, which may take 6 months to recover. (2) A comfortable crutch will do much to reduce the burden of his disability.
Stand behind him, tell him to put his crutches close to his side slightly in front of his feet, and to look straight ahead. Ask him to take his weight on his hands, to lean forwards, so that his weight is over his crutches, and then to transfer his weight to one crutch before moving the other one.
NON-WEIGHT BEARING Ask the patient to hop on his normal
leg while steadying himself with his crutches.
PARTIAL WEIGHT BEARING Ideally, you should use
bathroom scales to measure how much weight a patient is
putting on his injured leg. You will probably not have suitable
scales, so encourage him to bear as much weight as he can
without causing pain.
Three point walking Ask him to bring his crutches and his injured leg forward together, taking some weight on each.
Four point walking Ask him to advance his right crutch followed by his left leg, and then his left crutch followed by his right leg. This is slow at first, but is more like normal walking.
STICKS FOR LEARNING TO WALK
Two sticks are better than one, and less likely to cause a limp. Use the four point gait described above. Flat pieces of wood on the bottom of two sticks ('plonkers') will make them easier for a child to use.
WALKING IN A CAST
If a patient is in a cast, he should, if possible, start walking normally right from the start, erect and looking ahead. Teach him to lift his heel, to transfer his weight to his forefoot, to bend his knee, to move his leg forward, and to put his forefoot on the ground, to lower his heel, and to move his body forward, repeating these movements with both legs until he is walking normally.
After his cast has been removed, teach him to walk without a limp, using crutches at first to minimize the pain. Teach him to balance on his two feet. Let him start by holding with both hands on to the foot of his bed, then teach him to balance on one foot. This is the most important part of his training. Stand in front of him and let him put his hands on your shoulders. Ask him to hold tight and lift his injured leg first, then his good one. To start with, he may be unable to balance his body over his injured leg, but he soon learns to do so by abducting his hip on the injured side.
As soon as he can balance on one leg, ask him to bend his opposite knee to a right angle. This makes balancing more difficult.
Next, make him lift first one leg then the other, while standing in the same place. When he can do this, ask him to take short steps, putting his good foot down 10 cm in front of his bad one, and then his bad foot the same distance in front of his good foot. Like this, he learns to put equal weight on both legs to avoid a limp.
| TURN YOUR WARD STAFF INTO PHYSIOTHERAPISTS |
77.2 An overview of injuries to the hip joint and femur
Working from above downwards, and using the methods of treatment that are practical in a district hospital as the main guide in classifying them, you will encounter the injuries of the hip and femur shown in Fig. 77-2.
Dislocations are usually posterior (A), and occasionally anterior (B), or central through the acetabulum (C).
Fractures of the neck of the femur are of two kinds: the common unstable ones (D), which may be complete in that the fracture line runs all the way across the bone, or incomplete, in that it only runs part of the way across. There is also the rarer stable impacted valgus fracture (E). Fractures here unite badly, and conservative treatment is generally unsatisfactory, so that most of these fractures need internal fixation, if this is possible.
Slipping of the upper femoral epiphysis (F) occurs spontaneously in teenagers, either slowly or suddenly.
Intertrochanteric fractures (G) occur between the two trochanters. Fractures here unite well, so that conservative treatment is usually satisfactory.
Fractures of the greater trochanter are rare and not serious. A patient falls on his hip and breaks off his greater trochanter without breaking the shaft of his femur (H). Get him walking on crutches until he is free from pain. No other treatment is necessary.
Subtrochanteric fractures occur a few centimetres below the trochanters. The important distinction is between those fractures in which the fragments are approximately aligned, so that you can treat a patient in Perkins traction (I), and those fractures in which the proximal fragment has been so sharply flexed by his iliopsoas that he has to be treated by '90-90 traction' J).
Fractures of the central part of the shaft of the femur are common (K). Treatment varies with the patient's age: (1) At birth no treatment is strictly necessary, although some may be advisable. (2) From birth to 3 years use gallows traction or a plaster spica. (3) Between 3 and 18 years use extension traction. (4) If he is over 18 years use Perkins traction.
Supracondylar fractures occur just above the condyles. Their treatment parallels that for fractures just below the trochanters: (1) If the fragments are more or less aligned, you can treat a patient in Perkins traction, as for a fracture of the shaft of his femur (L). (2) If his gastrocnemius has flexed the distal fragment (M), you will have to treat him with his knee sharply flexed.
Fractures around the knee are of several kinds, only one of which ( N) is shown. They are discussed in Section 79.13. You can treat some of them by Perkins traction.
Displacement of the distal femoral epiphysis follows a violent injury in a teenager (O), or osteomyelitis (7.10).
| IF A PATIENT'S FEMUR IS FRACTURED, MAKE SURE HIS HIP IS NOT DISLOCATED ALSO |
EXAMINING THE HIP
As always, modify the methods which follow to suit your patient's needs. Some of them are not indicated in an acute injury. You will find them particularly useful if you don't have an X-ray.
Remove his clothes. If he can walk, watch him do so. Does he limp? If he can walk, he is unlikely to have a serious leg injury, but he can however have an impacted fracture of the neck of his femur.
Ask him to stand on one leg. When a normal person does this, his pelvis tilts so that his opposite hip lifts. This can only happen if the hip on which he is standing is normal. If his opposite hip falls, the hip mechanism of the leg he is standing on is abnormal. His gait may be abnormal in a similar way (Trendelenburg sign and gait).
WHAT IS THE ATTITUDE OF HIS HIP?
When a normal patient lies on his back, his legs rotate externally a little. if his leg is abnormally externally rotated after an injury, he has probably fractured the neck of his femur. if it is rotated 90° the fracture is probably low in the neck. if it is rotated only 45° it is likely to be high in the neck where it is partly retained by the capsule.
Is his hip flexed, adducted, and internally rotated after a violent injury? (posterior dislocation).
Is his hip flexed, abducted and externally rotated? (anterior dislocation, rare).
DOES HIS HIP MOVE NORMALLY?
Rotation in extension-testing for spasm. (1) Lie the patient flat with his pelvis level. With your hands on his thigh, gently rock his leg from side to side. Compare both sides. Any painful limitation of movement indicates muscle spasm. This i s such a sensitive test that if it is acutely painful, you may have to modify the remaining tests.
(2) Lie the patient on his front, bend his knee, grasp his foot, and rotate his leg from side to side.
Can he extend his hip normally? A patient can compensate for being unable to extend his hip by extending his lumbar spine. First exclude this. Lie him on his back. Put one hand palm upwards under his lumbar spine. With your other hand flex his normal hip. This will flatten the normal curve in his lumbar spine, and force it against the couch. if his other hip is able to extend normally, it will remain flat on the couch as you do this. if his other hip is unable to extend, it will flex.
Flexion Flex his knee on the affected side, and then carefully flex his hip as far as possible. if it rotates externally as it comes up in flexion, this is a sign of slipping of his femoral epiphysis.
Rotation in flexion While his hip and knee are flexed to 90° rotate his hip externally and internally, and compare its range with the opposite side. Any 'crunchy feeling' in this or any other movement is a sign that his hip joint is abnormal. It may indicate an acute massive slip of the head of his femur.
Abduction (1) Flex his normal knee and hook his normal leg over the edge of the couch. This will lock his pelvis and prevent it tilting. Now, keeping his other knee straight, grasp his ankle and then abduct his leg as far as it will go.
(2) As you abduct his leg, put one hand on the opposite anterior superior iliac spine to detect if his pelvis rotates. In a child, put one hand across both his anterior superior iliac spines.
Adduction. Still steadying his pelvis, bring one thigh as far as it will go over the other one. It should be able to cross the middle third of his other thigh.
WHERE ARE HIS GREATER TROCHANTERS? Stand over him, face his head, place your thumbs on his anterior superior iliac spines, and put your middle fingers on his trochanters. Compare both sides, and feel if the trochanter on the affected side is displaced.
Is his trochanter displaced upwards towards his anterior superior iliac spine? (posterior dislocation). Or, away from it? (fractured neck of femur, or slipped epiphysis, or anterior dislocation).
Has his greater trochanter moved medially towards his pelvis? (central dislocation of his hip).
WHERE IS THE HEAD OF HIS FEMUR? if a patient is very
thin, you may be able to feel it. if the position of his leg suggests
that the head of his femur might be displaced, feel for
it in his perineum, in his groin, or on the back of his ilium.
Make sure that what you feel really is the head of his femur
by feeling it move when you rotate the shaft. Remember that,
provided the neck of his femur is intact, its head points in
the same direction as its medial condyle.
Feel the base of his femoral triangle. if his hip has been dislocated posteriorly, this will feel soft, his femoral artery will be difficult to palpate, and there may even be a hollow.
WHERE IS THE POINT OF MAXIMUM TENDERNESS? in front of his hip joint? (fractured neck of femur). Over his greater trochanter? (trochanteric fracture).
IS HIS LEG SHORT? The measurement of true shortening is
useful in many hip and leg conditions. Method (1) is essential for adjusting Perkins traction if you have no X-rays. Method
(2) is not applicable to an acute injury.
(1) Put the patient's injured leg into exactly the same position as his normal one and compare measurements from each side. For example, if he has an abduction deformity, abduct the normal leg before you measure them both. if you don't measure both legs in the same position, you will make big errors. Use a tape measure to measure the distance between these three points: (a) The inferior edge of his anterior superior iliac spine. (b) The joint line of his knee. You can find this most easily when his leg is flexed, but take the measurement with his leg straight. (c) The tip of his medial malleolus.
(2) Sit, and ask him to stand in front of you. Put your thumbs on his anterior superior iliac spines. One may be higher than the other. You will be able to observe a centimetre or more of shortening.
SCIATIC NERVE Test this. Can he dorsiflex his foot?
X-RAYS
Always X-ray a patient's hip if he complains of pain on weight bearing after a fall. Take the AP film with his hip in as much internal rotation as possible, even if you have to hold his leg in this position yourself. Don't take it in external rotation which is the natural position of a resting injured hip. Also take a lateral view to see if the head of his femur has been displaced posteriorly. This should be a horizontal view with the tube in his groin and the plate pressed well into him above his iliac crest.
If the films are difficult to interpret, compare both sides.
If you suspect a slipped upper femoral epiphysis in a teenager, take an AP 'frog leg' view to include both his hips on the same film, as in Fig. 77-9.
If you suspect he has broken the neck of his femur, take an AP view and a lateral view with his leg extended, the tube pointing along his groin on the inside of his leg, and the Xray cassette pressed firmly into his flank and perpendicular to the axis of the tube.
CAUTION ! You can easily miss a fracture of the neck, especially if it is close to the head (subcapital). if you are in doubt, look all around the cortex for small breaks in continuity, a step, or an angular deformity.
THE MAJOR FEATURES OF SOME COMMON INJURIES
An unstable fracture of the neck of the femur The patient is in severe pain and cannot walk or lift his foot off the bed. His leg is externally rotated with 1 cm or more of shortening.
A stable impacted vaigus fracture of the neck of the femur The patient has little pain, he can lift his foot off the bed and he may be able to walk. His leg is not rotated and there is no shortening.
An intertrochanteric fracture He is in severe pain. He cannot walk or lift his foot off the bed. His leg Is externally rotated with shortening. Maximum tenderness is over his greater trochanter.
Posterior dislocation His hip is flexed, adducted, and internally rotated, and his leg is shortened.
Anterior dislocation His hip is flexed, abducted, and externally rotated, and his leg is shortened.
Central dislocation His trochanter is displaced medially. You may be able to feel the head of his femur rectally. There is no shortening.
77.3 A hip spica
You will sometimes find a plaster spica (figure of 8 bandage) useful to immobilise a patient's hip, or more often, his femur. Unfortunately, hip spicas are expensive because they need a lot of plaster. Also, they are inconvenient, because a patient has to be lifted on to a bedpan. But, provided a family is capable of this much nursing, you can use a spica to treat some patients, particularly children with fractures of the femur, at home or in a health centre for at least part of their illness, whereas they would otherwise need a hospital bed.
A HIP SPICA
INDICATIONS (1) Fractured femurs in children, preferably after union has occurred in gallows or extension traction. (2) Postoperatively following the relief of a flexion contracture of the hip. (3) Septic arthritis of the hip.
CONTRAINDICATIONS (1) Fractures of the femoral neck in
old people, in whom a spica may be lethal. (2) As the sole
method of treatment of fractures of the femur in adults.
EQUIPMENT You will need to support the patient on the
special support in Fig. 77-4, or on a low stool.
APPLYING THE SPICA Support the patient and pad his leg
and trunk. Put extra padding over his bony points, particularly
his sacrum.
Wrap several wide bandages around his trunk. Put a folded towel on his abdomen, and remove this when the cast is completed. This will leave a space into which his abdomen can expand after a full meal.
Pass bandages in a figure of eight round his trunk and upper leg.
If you are trying to fuse his hip, as in TB, take the spica down as far as his ankle, or if this is not advisable, insert a pin through the lower end of his femur and incorporate this in the cast. It will allow him to move his knee and stop his femur rotating at his hip.
If he has a fracture of his femur, continue the spica to his ankle.
Lay a slab from his thigh to his iliac fossa to strengthen the spica in his groin where it is most likely to break. Turn up the free edge of the padding in his other groin and bind it into the cast with another plaster bandage.
Remove the supports, turn him over, and inspect the back edge of the cast carefully to make sure it is comfortable and not pressing into him.
CAUTION ! (1) A hip spica must engage his lower ribs on each side. (2) There must be space for his stomach to expand, or ileus may follow. (3) Enough of'his buttocks must be free to enable him to sit on a bedpan.
If his hip spica is too tight, cut a large hole out of it over
his abdomen when it has dried.
Alternatively, you can apply a long leg cast first and then convert it into a spica.
77.4 Posterior dislocation of the hip
Fortunately, dislocation of a patient's hp is much less common than dislocation of his shoulder or elbow. His car has a head-on collision, his knee hits the dashboard and drives the head of his femur out of his acetabulum. At first the head lies behind his acetabulum, but it soon rides up on to the dorsum of his ilium. He usually has other serious injuries also, especially a fracture of the shaft of his femur, so that his dislocated hip is often missed.
He is likely to be severely shocked, and cannot stand. His leg lies in a highly characteristic position, with his thigh flexed, adducted, and internally rotated. His leg is shorter than on the other side. His knee rests on his opposite thigh and his greater trochanter and buttocks are abnormally prominent.
If your anaesthetist is not expert, use the first of the two methods described below in which the patient lies on the floor. If he is expert enough to prevent a tracheal tube falling out while the patient is lying on his face, the alternative method is likely to be best, because it uses gravity and the weight of the patient's leg to achieve reduction. It is also the least traumatic.
POSTERIOR DISLOCATION OF THE HIP
Reduce this injury early, because every hour's delay makes reduction more difficult and avascular necrosis of the head of the patient's femur more likely. Look for other fractures, especially a fracture of the posterior rim of his acetabulum. Check the function of his sciatic nerve before and after reduction (55.8), and examine his dorsalis pedis pulse.
You can reduce his dislocation by: (1) having him supine on the floor (Fig. 77-5), or (2) prone on the table (Fig. 77-6). A subarachnoid anaesthetic is suitable for either method. if he is prone on the table after a general anaesthetic, he must be intubated. Good relaxation is essential, ketamine is not enough.
THE FIRST METHOD FOR A POSTERIOR DISLOCATION OF THE HIP
Place the patient on the floor, as in Fig. 77-5. Stand over him and ask an assistant to push downwards on his anterior superior iliac spines (1).
Flex the patient's knee and his hip, and rotate his leg into a neutral position. Pull his leg upwards steadily and gently (2). While still pulling in the line of his femur, lower his leg to the floor (3). Reduction is usually obvious, but X-ray him to make sure.
If the above method falls to reduce the dislocation, ask your assistant to continue pressing firmly on the patient's anterior superior iliac spines (4).
With his knee partly flexed, pull on his leg in the line of the deformity (5).
Slowly bring his hip to 90° of flexion (6) and gently rotate it internally and externally (7) to disengage the head from the structures which are holding it.
Put the head back in place by further internal rotation and extension (8), or external rotation and extension (9).
While he is still anaesthetized, examine his knee for rupture of his posterior cruciate ligament (79.6).
AN ALTERNATIVE METHOD FOR A POSTERIOR DISLOCATION OF THE HIP
As soon as the patient is anaesthetized, place him face downwards on a table, as in Fig. 77-6, so that his injured thigh hangs downward with his knee at 90° and his foot resting on your knee. Ask an assistant to hold his normal thigh horizontally. This will prevent his pelvis tilting.
Press steadily downwards on his flexed knee until his muscles relax and the head of his femur drops into his acetabulum. if necessary, rock his knee slighty.
If reduction fails, refer him for open reduction.
TEST FOR STABILITY (both methods) While the patient is still
anaesthetized, flex his hip to 90° and check to see if the head
of his femur easily slips out of his acetabulum posteriorly,
or if it stays in place. if it slips out easily, suspect a fracture
of the posterior rim of his acetabulum (76.3).
POSTOPERATIVE CARE FOR A POSTERIOR DISLOCATION OF THE HIP
IF THE DISLOCATION IS STABLE management depends on whether or not movement is pain-free.
If movement is pain-free, there is no need for traction, so
start active movements i n bed, and after 10 days get the patient
up on crutches with partial weight bearing.
If movement is painful, put him in extension traction until
the pain has gone, then get him up on crutches, progressing
from partial to full weight bearing.
IF REDUCTION IS UNSTABLE, so that the head of the
patient's femur slips out of his acetabulum, X-ray him. if this
shows that a large chip has broken off the rim of his
acetabulum, refer him to have it repaired. Otherwise, try extension
traction with a tibial pin. if this controls the reduction,
continue to apply it for at least 6 weeks.
If extension traction fails to control his unstable hip, i t is probably because the posterior rim of his acetabulum has been shattered. Put him up in '90-90 traction' (77.12), with a pin through the upper end of his tibia, and treat him as for a fracture of the posterior rim of his acetabulum (76.3). Take an AP and a lateral X-ray to make sure the reduction is satisfactory. Take them while he is in bed in traction. After his hip has been held like this for 6 weeks, there will be enough scar tissue in his posterior acetabulum to hold it. Provided the range of movement in his hip and his ability to control it increase each day, allow him to move it as he wishes.
Explain that late complications may occur, and follow him up for 2 years.
DIFFICULTIES WITH DISLOCATED HIPS
If the patient's HIP IS PARTICULARLY PAINFUL immediately after reduction, consider aspirating it (7.17) if you are expert and can be sure not to infect it.
If he CANNOT DORSIFLEX HIS FOOT, test the sensation on its dorsum. if this is absent, he has a sciatic nerve palsy. A palsy is common, but fortunately it usually recovers. if he fractured the rim of his acetabulum, the displaced fragment may have impaled his sciatic nerve. Refer him so that his hip can be explored and the fragment fixed.
If his FOOT IS COLD, BLUE, AND SWOLLEN, his femoral artery or vein has thrombosed, so reduce his dislocation urgently. if his foot is swollen, raise his leg. if his artery is thrombosed, keep his leg cool. Refer him urgently for vascular surgery. if this is to be effective the operation must be done within 2 hours.
If he has DISLOCATED HIS HIP AND FRACTURED THE HEAD OF HIS FEMUR, there may be a loose fragment inside the joint. Refer him so that it can be removed. A chip can break off the head of his femur, instead of the rim of his acetabulum.
If he has DISLOCATED HIS HIP AND FRACTURED THE SHAFT OF HIS FEMUR, his dislocation can only be reduced at open operation, so refer him. With this combination of injuries a dislocated hip is often missed. So, always X-ray a patient's hip whenever his femur is fractured.
If the posterior DISLOCATION OF HIS HIP HAS BEEN MISSED, try to reduce it by closed methods up to 2 weeks after the injury. If you fail, refer him. Older dislocations are usually impossible to reduce by closed methods.
If his HIP BECOMES PROGRESSIVELY MORE PAINFUL some months or years after a dislocation, thIs is probably due to avascular necrosis and the osteoarthritis that follows it. Avascular necrosis shows itself on the X-ray as an increase in the density of the head of his femur. You may see this at 6 weeks but it usually occurs much later. if pain is unbearable, the patient's only hope is referral for the excision of the head of his femur or an arthroplasty.
| REDUCE DISLOCATED HIPS IMMEDIATELY |
77.5 Anterior dislocation of the hip
In this rare injury the patient falls from a height and displaces the head of his femur in front of his acetabulum. The earlier steps in this method convert an anterior dislocation into a posterior one.
ANTERIOR DISLOCATION OF THE HIP
Lie the patient on his back on the floor, and anaesthetize him as for a posterior dislocation.
Stand over him and ask a strong assistant to hold his pelvis firmly throughout the manoeuvre by its anterior superior iliac spines (1). Hold the patient's leg and bend his hip and his knee to 90° (2).
Rotate his leg into a neutral position (3). This will convert an anterior dislocation into a posterior one. Pull the patient's leg steadily upwards (4) so as to lift the head of his femur into his acetabulum.
If his hip is not reduced, lower his leg to the floor (5) while still maintaining traction (6). If his hip is still not reduced, apply traction (7) in the direction of the deformity (flexion and abduction). While maintaining traction, lift his leg (8) into vertical position so as to bring the head of his femur on to the anterior rim of his acetabulum (9).
Now, still maintaining traction, rotate his leg internally (10), and lower his thigh into an extended position (11).
If his hip is even now not reduced, ask one assistant to continue holding his pelvis firmly. Ask a second assistant to stand over him and pull very hard in the line of his femur. Abduct his normal hip and put your unbooted heel where you think the head of his femur is. Then press posterolaterally until the head goes 'clunk' into its socket.
If you fail to reduce his dislocation, refer him for open reduction.
POSTOPERATIVE CARE Keep the patient in bed until he has regained control of his hip. Then allow him up and let him bear weight. Watch the head of his femur for aseptic necrosis, as with a posterior dislocation. Provided he is lucky enough to avoid this, he should recover well.
77.6 Fractures of the neck of the femur
These are difficult fractures. The nearer they are to the head of a patient's femur, the less likely they are to unite (except in the case of a stable impacted valgus fracture), and the more likely the head is to undergo avascular necrosis. There are no satisfactory closed methods for most of these fractures, and no open ones that are practical in the district hospitals for which we write. The blood supply of the head of the femur is precarious, little callus is formed, and rigid internal fixation provides the only hope of union. Almost all such injuries should be treated by early internal fixation. If you cannot refer a patient to have this done, there is a chance that he will benefit from Perkins traction, but he will probably have to be content with crutches. Suprisingly, these fractures are often missed.
For the purposes of management in a district hospital, there are three kinds of fractures of the neck of the femur: (1) The common complete, unstable ones. (2) The rare incomplete unstable ones. (3) The less common, stable impacted valgus fractures. These are all shown in Fig. 77-8.
77.7 Unstable fractures of the neck of the femur (adults
Most fractures of the femoral neck are unstable and complete. The patient is either a young adult who has sustained a severe injury, or an old person who has fallen and injured his hip.
The patient cannot stand or lift his foot off the bed; moving his hip gives him great pain. His leg is externaly rotated so that his foot points laterally, and his leg is shortened about a centimetre. This is less shortening than with intertrochanteric fractures, so it is a useful point of differential diagnosis. Sometimes, his injury may seem to be trivial. Occasionally, he complains of pain in his knee, rather than in his hip.
Any patient who cannot walk after a fall must have his hip X-rayed, with his leg held in maximal internal rotation in order to get the best view of the neck of his femur. External rotation makes the neck look foreshortened. If his hip is not X-rayed, and you allow him to walk about, he can easily convert an incomplete fracture into a complete one. If the films are hard to interpret and the fracture line difficult to see, compare his injured hip with his normal one.
If possible, refer all patients with incomplete fractures for internal fixation or for the fitting of a prosthesis. If you cannot do this, put the patient into extension traction for 12 weeks.
If a patient has an unstable fracture and you cannot refer him for internal fixation, or a prosthesis, you have two choices: (1) You can do Girdlestone's operation. (2) You can get him up and around on crutches as best he can. A false joint will develop, and the final result will resemble that after a Girdlestone's operation, except that it may be somewhat less satisfactory. He will probably limp and need crutches always, or at the very least a walking stick, but he may do suprisingly well. There is no indication for excising the head of the femur immediately, and traction is useless. A hip spica in an old villager is likely to be a certain prescription for a slow and painful death.
UNSTABLE FRACTURES OF THE NECK OF THE FEMUR
If possible, refer the patient immediately for internal fixation or prosthetic replacement, especially if he is young. A Smith-Petersen nail should be inserted as soon as possible, but an Austin-Moore prosthesis can be inserted at any time, although it is not indicated in the young. If you can refer the patient, he will be more comfortable with his legs bandaged gently together with cotton wool between them. If you cannot refer him, proceed as follows.
If he has an incomplete unstable fracture (rare), it may
become complete at any moment. There is no way of testing
for clinical union, so apply Perkins traction or extension traction
for at least 12 weeks, but without the vigorous exercises
that are so necessary for fractures of the shaft of the femur.
If his unstable fracture is complete, keep him in bed for a week, until the pain is less, then sit him up daily. As soon as he can tolerate it, get him walking on crutches with very little weight bearing at first. if he is lucky, he will get a comparatively painless pseudoarthrosis, need a stick, and perhaps a raised shoe, and adapt his life style to his disability. if pain i s a problem later, you may be able to refer him for prosthetic replacement of the head of his femur or a Girdlestone femoral head resection.
77.8 Stable impacted valgus fractures of the neck of the femur (adults)
The fracture line runs across the proximal part of the neck of the patient's femur, the fragments are firmly impacted on one another, with the head in valgus. This makes the fracture stable and is a useful point in recognizing this particular fracture.
The patient is usually an old person. He may be able to walk after the accident, and with a little encouragement can lift his leg off the bed. There is no rotational deformity and no shortening.
Because the fracture line is mainly horizontal, there is little shearing stress across it, and a good chance that the head will not disimpact. Bearing a little weight on it is beneficial because it maintains the impaction. It is a useful rule that if a patient can walk into the hospital, his fracture is probably stable. If he is lucky it will remain so.
STABLE, IMPACTED VALGUS FRACTURES OF THE NECK OF THE FEMUR
If there is any doubt about the stability of the impaction and you can refer the patient immediately for internal fixation, do so. There is no case for the application of a hip spica, the complications are too great.
CAUTION ! Don't apply traction, because it will destroy the Impaction.
If the patient is already walking, let him continue, with partial weight bearing and crutches. The head is at its softest and most liable to displacement 10 to 14 days after the fracture. Supervise his walking carefully for the first 2 or 3 weeks before discharging him. Warn him that he must not trip or stumble.
If he cannot walk, keep him in bed, while doing vigorous quadriceps exercises, until the pain has subsided enough to let him walk on crutches, with partial weight bearing while he is careful supervised. He must walk with crutches for 3 to 4 weeks, but as the pain lessens he can bear progressively more weight on his injured leg. He must be very careful of it for at least 2 months.
Supervise him carefully as an out-patient.
DIFFICULTIES WITH IMPACTED FRACTURES OF THE NECK OF THE FEMUR
If a patient has been walking satisfactorily on an impacted valgus fracture, and his LEG NOW SUDDENLY BECOMES PAINFUL, so that he can no longer bear weight on it, the fragments have probably disimpacted. If internal fixation is impossible, treat him as if he had an unstable fracture, and get him up on crutches.
77.9 Fractures of the neck of the femur in children
Fractures of the neck of a child's femur are rare but serious. Subsequent moulding will not correct the femur's deformities. Changes in its angle persist, so if the fracture produces coxa vara (lessening of the angle between the neck of the femur and its shaft), this deformity will become worse and be permanent. Apply extension traction and try to get the angle of the neck of his femur correct. Overlapping and anteroposterior angulation are less important. Correct the deformity and then apply a plaster spica.
77.10 Separation of the upper femoral epiphysis
This is quite a common disease of middle to late teenagers, usually boys. It is an epiphyseal injury (Salter Harris Type 1, 69.6a) in which the patient's upper femoral epiphysis slips spontaneously backwards and downwards through the epiphyseal line, either gradually or suddenly, often after only a minor injury. In 20% of of cases, the other epiphysis slips too, even while the patient is in bed being treated for the first one. Try to diagnose and refer these patients for internal fixation early, because the results will be good. If you leave an epiphysis which has started to slip, it may slip completely, so that extensive and often unsuccessful major surgery is needed.
Gradual slipping A teenager complains of pain in his hip or knee, and starts to limp. Examine him carefuly, using the methods in Section 77.2, and compare his abnormal leg with his normal one, because the signs are not obvious. Look for: (1) limitation of abduction, (2) loss of internal rotation, and (3) external rotation of his hip while you are flexing it, as in Fig. 7-17.
Rapid slipping The patient may not have had symptoms of gradual slipping before. He falls to the ground with a severe pain in his leg, which is externally rotated and short. He cannot move his leg off the couch, and finds passive movements acutely painful.
Although the physical signs may be minimal, a suitable Xray is diagnostic-if you examine it carefully. You should be able to recognize an acute slip in an ordinary AP view, but an early slip is harder to recognize. So if you suspect an early slipped epiphysis, always take a frog leg view, as in Fig. 77-9. The epiphyseal line is widened and fluffy, and the epiphysis is displaced downwards. Normally, in an AP view the upper border of the femoral neck angulates sharply where it joins the head, but if the epiphysis has slipped, it continues on smoothly without a step. In a frog leg view the epiphysis projects below the neck as a sharp hook.
| DIAGNOSE SLIPPED FEMORAL EPIPHYSES EARLY |
SEPARATION OF THE UPPER FEMORAL EPIPHYSIS
If you cannot refer the patient, try to rest his hip in internal rotation and abduction, either in a hip spica or in extension skin traction (Fig. 78-3). A hip spica needs less supervision and is more convenient, especially in younger children.
HIP SPICA Flex the child's knee about 15°. This will enable you rotate his leg internally and abduct it. Then apply a spica to just above his ankle. Keep it on for not more than 6 weeks. Then keep him on crutches until there are X-ray signs that his epiphyses have fused, or there is no further slipping. His epiphyses may unite earlier, but he may need to be on crutches for a long time. if there are any signs of further slipping, do your best to refer him for internal fixation.
TRACTION Apply extension traction for 8 to 12 weeks, as in Fig. 78-3, but with his leg in abduction.
If neither form of treatment is practical, at least avoid further slipping by preventing him from bearing weight on his leg. Give him crutches.
| IF A PATIENT BETWEEN 10 AND 15 LIMPS, OR HAS PAIN IN HIS HIP OR KNEE, THINK OF A SLIPPED EPIPHYSIS |
77.11 Intertrochanteric fractures of the femur
In these common fractures the patient's femur breaks between its two trochanters. The lesser one sometimes separates as a third fragment, or there may be multiple fragments. Angulation reduces the normal 145° varus angulation of the neck of his femur on its shaft to 90°, and shortens his leg. Sometimes, there is little displacement when you look at the fracture from the front, and yet there may be considerable displacement in a lateral view.
Although the patient is commonly an old person who trips and falls, a more severe injury can cause this fracture in a young person. Typically, an old lady cannot walk after a fall. She lies in bed unable to lift her leg, with her foot turned outwards, and her leg as much as 3 cm short. The outer side of her thigh is painful, and moving her hip gives her great pain. After a few days, blood from the fracture site spreads to cause a bruise at the back of her thigh.
Although internal fixation greatly shortens the time in bed and reduces morbidity, these fractures usually unite with non-operative treatment. You can treat them with perkins traction, or less successfully, with extension traction. The advantage of Perkins traction is that, unlike extension traction, it allows the patient to sit up and exercise, and so reduces the incidence of pneumonia and bedsores. Even so, it is more than some very old patients can bear, so that an occasional one stops eating and dies.
Surgeons vary as to how long they keep a patient in bed. The critical milestone is the patient's ability to lift his leg off the bed. This may occur as early as 6 weeks, or not for 12 weeks. Most patients are partly weight bearing with two sticks or a walking frame by 12 weeks. If a patient bears weight on the fractured femur too soon, it may angulate or refracture.
Refracture and non-union will be much less likely if you displace the lower fragment medially under the head of the patient's femur. This sometimes happens spontaneously at the time of the injury, but if it does not, you can produce it.
INTERTROCHANTERIC FRACTURES OF THE FEMUR
If displacement is minimal, and the patient elderly, keep him in bed for 3 weeks, then get him up with partial weight bearing for another 2 weeks.
If the fracture is more than minimally displaced and is not comminuted, apply Perkins traction in abduction. If the fracture is more than minimally displaced and is comminuted, as in Types 2c and 2d in Fig. 78-5, displace the shaft of the femur medially under the head, as in Fig. 77-10, and then apply Perkins traction.
DISPLACING THE SHAFT OF THE FEMUR UNDER THE
HEAD if the shaft of his femur is not already displaced
medially under the neck, anaesthetize the patient, lie him on
his normal side, and ask an assistant to abduct his leg a little
and exert some traction. Put both your hands on his thigh
just below the fracture site. With one good push using your
full weight, move the lower fragment medially. You cannot
push it too far or too hard.
PERKINS TRACTION Put a Denham nail, or, less satisfactorily,
a Steinmann pin through the patient's tibia 3 cm below
his tibial tubercle, as described in Sections 70.11 and 78.4.
if you don't have a Steinmann pin, and so cannot put him into
Perkins traction, put him into extension traction.
Apply traction equal to one seventh of the patient's body weight (10 kg for a 70 kg patient), and raise the foot of his bed 40 cm. Make sure the pin is horizontal when his patella faces the ceiling.
Make sure he does breathing exercises and quadriceps exercises. if the pin holes become sore, remove the pin, and either put it in again 3 cm further down his tibia, or apply skin traction instead. Pin track infection is such a common problem in old people that some surgeons always incorporate the pin in a short leg cast (81.3). Skin traction is not a good first choice, because the skin of old people tolerates it badly (70.10).
Keep the patient in bed for 6 to 12 weeks with daily exercises until he can lift his leg off the bed with his knee straight. His fracture will now have united, but will not have consolidated. X-ray him and if this confirms union, remove the traction.
If X-rays show that the distal fragment is still medially
displaced, partial weight bearing in crutches can start
immediately.
If medial displacement has not occurred or been maintained,
or if the fragments have displaced into a varus position,
he must bear very little weight indeed. So ask him to walk
in crutches using only the heel and toe of his injured leg.
After 5 to 6 months of partial weight bearing his fracture will have consolidated. This is difficult to evaluate clinically, so evaluate it from the X-ray.
Alternatively, you can apply Russell traction; this is not described here.
CHILDREN WITH INTERTROCHANTERIC FRACTURES
A HIP SPICA is suitable forayoung child. With his hip in wide abduction, apply a plaster hip spica for 8 to 10 weeks.
GALLOWS TRACTION is described in Section 78.2 and is suitable for children up to about 3 years, or at the most 5 years if the child is thin.
77.12 Subtrochanteric fractures
Fractures of the shaft of the femur just below the trochanters can occur at any age if the force is severe enough. Provided the fragments remain more or less aligned, you can treat the patient in Perkins traction. If however his iliopasoas muscle flexes the proximal fragment, and his gluteal muscles abduct it, so that it no longer lies in line with the shaft, you will have to use some other method which will flex the shaft of his femur, and bring it into line with the proximal fragment. In young children gallows traction does this very well. Put an older patient into '90-90 traction' with his knee flexed to 90°. A merit of his method is that it also corrects rotation.
This is a part of the femur in which non-union is particularly likely to occur. It is even more likely to occur if you use extension traction, or traction in a Boehler-Braun frame.
'90-90 TRACTION'
INDICATIONS Fractures of the subtrochanteric part of the femur in which the upper fragment is flexed.
METHOD insert a Steinmann pin through the supracondylar region of the patient's femur or the upper end of his tibia (70.11, 78.3). Both have their disadvantages. A femoral pin is better placed mechanically, but tends to tear the soft tissues. A tibial pin loosens up his knee joint. Arrange traction so that his knee and hip are flexed to 90°. if convenient, support his lower leg in a light cast, and support this in a sling.
X-ray him, and if this shows that union is progressing, take the '90--90 traction' down after 4 to 5 weeks, and put him into Perkins traction.
Alternatively, you can apply Russell traction.
77.13 Girdlestone's operation for an ununited neck of the femur
If an arthrodesis or a prosthesis is impractical, Girdlestone's procedure
can be done, either as the definitive operation, or as a
temporary one before a prosthesis is fitted. There are two ways
of doing it: (1) The method to be used following infection is
described in Section 7.19. (2) The method following an ununited
fracture of the neck of the femur is described here. This is not
an easy operation, and is for more experienced operators only.
Refer the patient if you can.
GIRDLESTONE'S OPERATION
INDICATIONS A patient who is walking painfully as the result of: (1) An ununited fracture of the neck of his femur. (2) Osteoarthritis with a femoral neck which is too osteoporotic to allow a prosthesis to be fitted. (3) Avascular necrosis following the insertion of a pin or plate in sickle cell disease.
METHOD If you cannot refer the patient, start exactly as for Ober's incision (7.18), but extend the incision upwards almost to the iliac crest and downwards in a vertical incision through skin and fascia lata down to the bone on the outer surface of the patient's femur. This is Kocher's incision.
Use a periosteal elevator to detach the gluteal muscles from the femur so as to reflect an inferomedial flap of gluteal muscles and expose the patient's obturator internus, his two gemelli, and the upper fibres of quadratus. Divide these about 1 cm from their insertion into his femur, and swing them medially where they will protect his sciatic nerve.
Approach his hip joint from behind. Open it and check that it really is the hip joint by asking an assistant to move the patient's leg and seeing the head of his femur move too.
Dislocate the head of the patient's femur from his acetabulum, by asking your assistant to adduct his leg and forcibly rotate it internally, while you divide the remaining fibres of the capsule and the ligamentum teres. If necessary, use a sharpened spoon to divide these.
Cut the neck of his femur flush with the shaft using an osteotome or Gigli saw. Remove the head. If the neck is already fractured, trim it back with a rasp.
Wash out the the joint thoroughly to remove chips of bone. Control bleeding. Close the wound without drainage, and apply skin traction as above.
If you have difficulty removing the head of his femur, to get a Gigli saw under the neck of his femur. If you don't to help you do this. If this is difficult, use an osteotome to have the special retractors, use a pair of curved haemostats remove the head and neck of his femur piece by piece. The lower border of its neck will be the hardest piece to cut through.
