Fractures of a hip make about 6% of number of all fractures of bones. Allocate three main groups of fractures of hip: changes of the top end of a hip, diafizarny fractures and changes of the lower end of a hip. Depending on the place of a fracture of hip it can be shown by pain, restriction of mobility of a hip, shortening and deformation of the injured extremity. At an open change considerable blood loss is possible. The main way of diagnosis of fractures of hip are a X-ray analysis. At intra articulate fractures of a hip joint MRT is in addition carried out. Treatment of a fracture of hip consists in a repozition of otlomk and their fixing by spokes, a three-blade nail or the device of external fixing; according to indications skeletal extension is applied.
Fractures of a hip make about 6% of number of all fractures of bones. Allocate three main groups of fractures of hip:
- changes of the top (proximal) end of a femur. Fractures of a neck of a hip and vertelny changes concern to this group;
- diafizarny fractures of a hip (femur body fractures);
- changes of the lower (disteel) end of a femur.
The listed groups of fractures of hip differ on the trauma mechanism, clinical symptomatology, tactics of treatment and the remote forecast.
The femur, as well as all other tubular bones, consists of a body (diaphysis) and two ends (epifiz). In its top part the head which enters an articulate hollow of pelvic bones is located, forming together with them a coxofemoral joint.
Below a head of a femur thinner neck is located. The neck of a femur connects to a body at an angle. Outside in the place of their connection there are ledges (a big and small spit). The lower end of a femur extends and forms two condyles (internal and external). Condyles border by the articulate surfaces on a tibial bone and a patella, forming a knee joint.
(hip neck fractures, vertelny changes)
The line of a fracture of hip can pass in a joint or be beyond its limits. In the first case the fracture of a hip is called intra articulate, in the second – extra articulate.
In traumatology allocate the following types of intra articulate fractures of hip:
- Capital. The line of a change passes in area of a head of a hip.
- Subcapital. The line of a change is located under a head at once.
- Chrezsheechny (transtservikalny). The line of a change is located in a neck.
- Bazistservikalny. The line of a change is located on border of transition of a neck to a femur body.
Extra articulate fractures of a hip in its top part are located at the level of spits. Allocate chrezvertelny and mezhvertelny changes. At a certain mechanism of a trauma (direct stroke or falling on area twirled) the separation of a big spit is possible. The isolated separation of a small spit meets very seldom.
- The contributing factors
Changes of the top end of a hip are, as a rule, observed at people of advanced age. More often women suffer. Developing of such fractures of hip is promoted by osteoporosis and the lowered tone of muscles. The increased frequency of fractures of neck of a hip at women is explained by bigger expressiveness of osteoporosis and some anatomic features of a female body. A corner between a neck and a body of a bone at women sharper, and a hip neck thinner and weak.
- Reasons of changes
At persons of young and middle age hip fractures in its top part (as a rule, vertelny) result from a considerable trauma (at a car accident, falling from height). Elderly people the reason of a fracture of hip can have a direct stroke or falling on area of a coxofemoral joint. At senile age hip neck fractures sometimes result from a usual spotykaniye when the patient, trying to keep, sharply transfers the weight of all body to a leg.
The patient with a fracture of a neck of a hip is disturbed by pains in a coxofemoral joint and inguinal area. At intra articulate changes pain at rest weak or moderate, sharply amplifies at the movements. The palpation of area of a change is followed by deaf morbidity in the depth of a coxofemoral joint. At vertelny fractures of a hip of pain intensive, amplify at palpation and the slightest attempt of movements in a coxofemoral joint. Patients with vertelny fractures of a hip are less mobile, than patients with fractures of a neck of a hip and unlike them suffer from sharp pains therefore subjectively their trauma is perceived as heavier.
The patient's leg on the party of defeat is turned knaruzh. At changes with shift the sore leg is shorter than healthy. At the driven changes shortening of an extremity can be absent. A characteristic symptom of a fracture the top part of a hip – "a symptom of the stuck heel" at which the patient in a prone position on a back cannot raise a direct leg. The driven changes quite often are shown by smoothed clinical symptomatology. Sometimes patients can freely lean on a sore leg. Vertelny fractures of a hip are followed by more expressed hypostasis and bruises in the field of a trauma. At fractures of a neck of a hip swelled less, bruises, as a rule, are absent.
The neck of a femur is not covered with a periosteum. Blood supply of a neck and a head is complicated therefore fractures of a neck of a hip grow together badly. Because of insufficient food of a full-fledged union in most cases does not come. Over time otlomk are partially fixed by a dense soyedinitelnotkanny hem. There is a so-called fibrous union. The forecast at fractures of a neck of a hip of subjects is worse, than the line of a change is located above. Without expeditious treatment by an outcome of "high" fractures of neck of a hip it becomes frequent disability.
The area of spits is well supplied with blood that creates favorable conditions for formation of a full-fledged bone callosity. Vertelny fractures of a hip at adequate treatment in most cases well grow together without operation. The forecast worsens at multisplintered chrezvertelny fractures of a hip with the shift of otlomk.
At receipt for anesthesia into the area of a change enter local anesthetic (novocaine). Further tactics of treatment is defined by the traumatologist according to the level of a change and the general condition of the patient. At intra articulate changes preferably expeditious treatment providing an union in 70% of cases. Contraindications to operation are serious associated diseases and senile age of the patient.
Advanced age of patients with a fracture of a neck of a hip and existence of associated diseases cause the big frequency of complications at a long bed rest. At patients decubituses and pneumonia quite often develop. The thrombembolia is possible. Due to a large number of complications at the choice of tactics of treatment of such patients it is necessary to adhere to the general principle – ensuring the maximum mobility of the patient in combination with a possible extremity immobilization in these conditions. If the condition of the patient allows to perform operation, carry out fixing by a three-blade nail or a bone autoplasty.
In the subsequent at patients with fractures of a neck of a hip the false joint can be created or develop an aseptic necrosis of a head at which endoprosthesis replacement of a coxofemoral joint is shown. At vertelny fractures of a hip skeletal extension for a period of 8 weeks is used. After removal of extension the plaster bandage is applied. It is allowed to step on the injured leg 3-4 months later. Vertelny fractures operation allows to reduce terms of treatment and to increase mobility of the patient. The osteosynthesis is carried out by a three-blade nail, plates or screws. Full load of a leg is resolved in 6-10 weeks.
(femur body fractures)
Diafizarny fracture of a hip – the severe injury which is followed by painful shock and considerable blood loss.
- Reasons of fractures of hip
As a rule, fractures of a hip result from a direct trauma (falling, blow). The hip fracture at an indirect trauma (twisting, bending) is possible. Falling from height, a car accident, a production or sports injury can become the reason of damage. More often people of young and middle age suffer.
At a direct trauma there are cross, slanting and splintered fractures of a hip, at indirect – spiral. At a hip fracture otlomk are influenced by a large number of the muscles which are attached to a femur. Muscles pull otlomk in the parties, causing their shift. The direction of shift depends on change level.
The patient with a fracture of a hip shows complaints to severe pain in the place of damage. In the field of a change puffiness, hemorrhage, deformation of an extremity and pathological mobility is observed. The leg is, as a rule, shortened. The fracture of a hip can be followed by injury of a nerve or a large vessel. Development of the traumatic shock caused by sharp pain and the expressed blood loss is possible.
- First aid
The injured extremity needs to be recorded, having imposed Diteriks's tire or Kramer's tires. To the patient enter anesthetic. Then it is covered with a blanket and transported in a hospital.
At a fracture of a hip there is a danger of development of traumatic shock. Preventive antishock actions include adequate anesthesia. At considerable blood loss blood transfusion and blood substitutes is carried out. The plaster bandage at the initial stage of treatment is not applied as with its help it is impossible to hold otlomk in the correct situation. As the main methods of treatment skeletal extension, devices of external fixing and operation (osteosynthesis) is used.
Contraindication to expeditious treatment at a fracture of a hip are the serious associated diseases infected wounds and the general serious condition of the patient as a result of the combined trauma. In the presence of contraindications to operation skeletal extension for a period of 6-12 weeks is shown. The spoke for skeletal extension is carried out through condyles of a hip or a bugristost of a tibial bone. The patient is stacked on a board, the injured leg is put on Beler's tire. Freight size at a fracture of a hip is defined by change level character of shift.
Freight can be increased at young patients with well developed muscles. The average size of freight in an initiation of treatment – about 10 kg. In process of elimination of shift freight is reduced. After removal of extension apply a plaster bandage for a period of up to 4 months the injured extremity. At conservative treatment a knee and coxofemoral joint long time remain motionless. Expeditious treatment allows to increase mobility of the patient and to prevent development of contractures. Operation is performed after normalization of a condition of the patient. The osteosynthesis is carried out, using plates, pins and cores.
(myshchelkovy fractures of a hip)
Myshchelkovy fractures of a hip result from falling or direct stroke to the area of a knee joint. Can be followed by the shift of otlomk. More often elderly people suffer.
The change of one or both condyles is possible. Characteristic shift of otlomk at a myshchelkovy fracture of a hip – up and aside. The line of a change passes in a joint. Blood from the place of a change streams in a joint, arises .
The patient shows complaints to sharp pain in a knee and the lower departments of a hip. The movements in a joint are limited and sharply painful. The knee joint is increased in volume. The change of an external condyle is followed by a deviation of a shin of a knaruzha. At a change of an internal condyle the shin of the patient deviates knutr. In diagnosis of myshchelkovy fractures of hip along with a X-ray analysis in addition apply MRT of a knee joint.
The area of a change is anesthetized, at a gemartroza carry out a joint puncture. At myshchelkovy fractures of a hip without shift apply a koksitny plaster bandage (from a groin to anklebones) for the term of 4-8 weeks. At the shift of otlomk before imposing of a bandage carry out their repozition (comparison). If otlomk cannot be compared, operation is performed. For fixing of otlomk use screws. In certain cases apply skeletal extension.