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Complications
Immediate complications: Sciatic nerve injury drop foot & numbness over the outside of the calf Late complications: avulsion of ligamentum teres from the acetabulum cut off blood supply to femoral head avascular necrosis OA
TREATMENT
1. 2. 3. 4. Manipulative reduction Traction (4 weeks) healing of capsular tear Weight bearing Regular x rays monthly for the 1st 4 months for early detection of avascular necrosis
Treatment of complications
Operation may be necessary to free the sciatic nerve Avascular necrosis is treated 1. in early stages by avoidance of WT bearing until texture of femoral head returns to normal. 2. In late stages by total hip replacement, arthrodesis, osteotomy, or bone grafting
1. 2. 3. 1. 2. 1. 2.
Direct violence drives femoral head through floor of acetabulum Damage of articular surfaces Intrapelvic haemorrhage Hypovolemic shock Conservative treatment Longitudinal traction for 6 weeks Mobility of the hip Surgical treatment Reconstruction of the destroyed acetabulum Total hip replacement
Grade II
Undisplaced fracture ST are attached providing blood supply Grade III Femur is adducted at fracture site Head is separated from the neck Severe pain in hip when standing or moving the affected limb Injured foot & leg are externally rotated
Grade IV
Gross rotation of both fragments with complete loss of contact between the fragments
Treatment
1. Grade II - compression screws 2. Grade III & IV - hemiarthroplasty (Austin-more prosthesis) - Total hip replacement
Intertrochanteric fractures
Common in elderly people Equal frequency in men & women Often comminuted Lesser trochanter frequently avulsed & pulled upwards by iliopsoas Treatment 1. Compressiom screws and plate 2. Early mobilization 3. Early ambulation
Conservative treatment
Temporary traction for 8 weeks (fixed or balanced- skin or skeletal) (fig.) Followed by hinged cast brace Weight bearing is then encouraged
Operative treatment
Locked intramedullary nail
1. 2.
Causes:
Indirect rotatory twisting strain Difficult delivery with breech presentation
1. 2.
Treatment:
3-4 weeks fixed traction on Thomas splint In infants less than 3 years gallows traction
Supracondylar fractures
5. Patients are assisted into protectively positioned side-lying as soon as possible(2-3 days postoperatively). Side lying position greatly aids in: - toiletry - pulmonary postural drainage - prevention of decubitus ulcers 6. An over head trapeze is essential during the 1st few days postoperatively (using elbows & heels to elevate hips 4 times body weight force acts on the hip).
7. Gait training with walker or crutches if balance & mobility are good. (touch down gait takes about 9095% of load off hip joint, compared to 80% weight reduction with NWB gait 8. Over 12-16 weeks gait pattern will evolve into full weight bearing based on: - surgical procedure - area of fracture - radiographic findings - patient comfort
9. Active exercises through a comfortable range 10. Pool exercises to regain strength, proprioceptive sense & mobility.
Nb.
Tying a shoe with foot on floor requires 124o hip flexion Ascending stairs requires 67o hip flexion Sitting down on a chair requires 104o hip flexion
Day 1:
-
Day 2:
Ambulation with TDWB with walker, then PWB with walker
Days 3-7
- SLR in all directions - Thomas stretch of anterior capsule and hip flexors
1-2 weeks
1. 2. 3. Discharge criteria: Get out of bed independently Able to ambulate 50 feet with assistive device In & out of bathroom independently. Standing hip abduction, adduction, flexion, and extension & hip and knee flexion exercises.
2 -6 weeks
- Stationary bicycle, pool exercises, and treadmill - Progress ambulation from walker to use of a cane (if Trendelendburg test is ve)
Phase 2 (6-12 weeks) - Stationary bicycle - PWB using the scale technique - CKC exercises