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Okay, We're going live now. Okay. Yep. Um, so that's us in now. So Hello, everyone. Thank you all for joining, um, today's session. So today we're going to be covering, um, the hip. So this would involve both the anatomy and, um, some of the conditions that we can accept Expect to know as a medical student. Um, so we have on a first to cover cover the anatomy of the hip so over to you wanna? Yeah. Thank you very much. Uh, so hello, everyone. I'm just going to cover the hip anatomy. Um, today. So, um, if we go to the first slide, the next one, Yeah. So, um, here we can see the bones of the lower limp, um, altogether. So at the top of the well, on the left of the picture, we see the anterior view, and then on the right hand side, um, we see the posterior view. So at the top, we can see the hip bones, um, and then followed on. We have the femur, um, the knee joint, the tibia and the fibula, and then going down to the uncle and we can see part of the football's. Uh we're mainly going to focus on the hip and on the hip joint. So where the hip bone connects to the femur? Okay, so next slide. All right. So, in terms of the hip bone, um, on the left, we can see, um, the hip bone it Nate off and on the right, We can see part of the, um, femur. So the proximal part of the femur, uh, in terms of the hip bone, um, we can see it's three parts, which are the ileum, um, the east PM and the pubis. And they're color coded on the, um, slide. Um, and we can also see the acetabulum, uh, just in the middle. Um, and that is, um, where the head of the femur, um, interlocks with the hip bones and forms the hip joint. Um, on the right, we can see the head of the femur, the neck of the femur, um, the great toe counter in green and the lesser trochanter and, um, blue. And, um, those are going to be of importance in terms of, um, disease is that can occur around the hip joint. Okay, so next slide. Um, the hip joint is a ball and socket joint. So that is one of the types of joints that we encounter on this slide. You can see, um, a picture of a hip replacement or metallic hip. Um, that would be placed in patient's who needed, um, this is going to be covered later on. Um, and it's a good replica to understand how the hip joint works. So we can see the as fabulous er component. Um, we should be basically the acetabulum. Um, and then we can see the femoral head, um, and the femoral neck, Um, and the rest of the femur and the plastic liner would basically be the, um, highly in cartilage. Uh, that would, uh, cover both the acetabular, um, surface and the femoral head. Um, and on the right picture, we can see the hip joint. How we could look, um, all put together. Um, And one of the advantages to remember about the ball and socket joint is the fact that it gives a great mobility, and it has a big range of movement compared to other types of, um, joint. All right, so next slide, Um, in terms of the stability of the hip joint, um, it is the ball and socket joints are the types of joints that, um are quite easy to come apart. So they need a lot of ligaments and muscles around them in order to form, um, their stability. And it's the same case with the hip joint. So in terms of the ligaments around the hip joint, we're going to have the, um, intracapsular ligament, which is inside the joint capsule. So around the acetabulum in former head, uh, in between the two and then we're going to, um, talking a bit about the extracapsular ligaments as well, which just run around the joint. So all these will give stability to the joint. Um, in terms of the ligament of the head of the femur, that is an intracapsular ligament. Um, and it runs between the acetabular notch and the transverse acetabular ligament, Um, up to the phobia capitalist on the head of the femur. So basically, from the acetabulum to the head of the femur. Um, and it is very important because it transmits the artery to the head of the femur, um, which is the brand the obturator artery. And it will play a role, an important role in terms of when we're discussing, um uh uh. Hip well, fractures around the hip joint. All right, um, and now going on to the extracapsular ligaments. Um, so, first of all, we're going to talk about the iliofemoral ligament, which you can see on the, um, slide. It's also called the Y ligament of, um, excuse me for betraying the name y ligament of Bage low. Um, and it arises from the anterior inferior iliac spine, um, which is also shown on the slide. And then it different Cates, which is why it's called the Y Ligament. And it inserts into the intertrochanteric line of the femur. So in between the greater and the lesser trochanter. Um, and the role of this ligament is to prevent hyper extension of the hip joint. Um, and it is one of the strongest of the three extracapsular. Um, ligaments actually, is the strongest out of the three extracapsular ligaments. The next one we're going to talk about is the pupa femoral, um, ligament, um, and that's balance between the superior pubic creme boy and the intertrochanteric client of the femur. Um, and what it does, it reinforces the capsule interiorly and interiorly. Um, which can also be seen on the slide. So the easiest way to remember what they do is understanding where they start form and where they're going and how they give stability to the joint. Um, and this one running kind of underneath, um, we remember it because, um, again, it reinforces the capsule interiorly and imperially. Um, and it prevents excessive abduction, um, and extension of the, um, hip. And then, um lastly, the ischiofemoral, uh, ligament. It's balance between the body of the PM and the greater trochanter of the femur, and it just reinforces the capsule posteriorly. So the capsule, as you can see, it's reinforced by the extra capsular ligaments from all sides just to give that good stability to the ball and socket judgment. Okay, uh, next slide. Yeah, um, in terms of the blood supply of the hip joint, Um, well, the arterial supply is, um, mainly via the medial and lateral circumflex femoral arteries. Um, which are the, um, the yellow, um, ones on the diagram. Um, and they branch from the deep femoral artery. They anastomosis at the base of the femoral neck. Uh, and they kind of form a rink around the um, femoral neck. Um, and this is again important in terms of talking about fractures. Um, the medial circumflex femoral artery is responsible for the majority of the arterial supply. Um, well, the lateral circumplex, um, has to, um, penetrate through the thick a Leo femoral ligament, as we, um, discussed And, um, damage. It's really important to remember that damage to the medial circumflex femoral artery can result in a vascular in courses, but again, this is going to cover it afterwards. Um, and also, we have the artery to the head of the femur, um, and, um, superior. And the fear gluteal arteries that provides provides some additional and supply, but the circumplex arteries are the main ones. Okay, next slide. Um, in terms of the innovation of the hip, um, it is primarily innovated by the sciatic nerves and femoral nerve and the oct aerator nerves so we can see them, um, on the slide, um, you can see on the left hand side picture the first of all the femoral nerve, then the obturator nerve. And, um, on the right hand side, you can see the sciatic nerve. Okay, um, and now, talking about the, uh, movement of the hip. Um, again, we discussed it being, uh, ball and socket joint. Um, and that means that it has a great range of movement. So, um, we're going to discuss, firstly the reflection. So, um, that would be, um, your leg from the, um, anatomical position going forward. Um, and the muscles that are involved, um, are the psoas major Delia, kiss the territory ists the direct, uh, memory wrists, the tensor fasciae a lot. Um, a doctor, Magnus and the doctor longest. The pectineus. And the gracilis. Uh um Then we're going to discuss, uh, extension. So the leg, the leg moving backwards and the muscles involved in this are going to be the gluteus maximus, the semi tenderness tendinosis, um, the semimembranosus iss, the biceps memories, um, and the doctor Magnus, um, in terms of up production, uh, so that would be the like, moving laterally and the way from the midline. Um, the muscles that are involved are the gluteus medius blood test minimus tensor, fasciae latte, gluteus maximus, and, um, generally muscles, muscles superior and inferior. Um, and in terms of abduction, so bring the leg, um, immediately towards the center of the body. Um, the muscles would be a doctor. Longest a doctor Berbice, a doctor, Magnus Gracilis and operator excess. Um, these are bit easier to remember. You have free a doctor's and then Brazil's and obturator extremists. Um, and then we have external and internal rotation. So, um, that would be whenever external rotation would be whenever your, um, leg moves well, your your foot is moving laterally with your leg staying in position. Um, and that makes the hip joint externally rotate. Um, and internal rotation will be the other way around, and we can see the muscles there. So we have the gluteus medius gluteus minimus, um, tensor fasciae latte. Generalized, superior and inferior again. Um, uh, doctors madness, longest and brevis. And then the pectineus. Um Okay, so, uh, that would be my presentation. What they can say in terms of the muscles. I know they can be daunting in terms of learning. Um, but if you understand where they're coming from, where they're going approximately, it's quite it makes it a bit easier in terms of, um, understanding the movements they're involved in. Mhm. Thank you. Um, sorry to interrupt. I'm not exactly sure if it's just me, but we couldn't hear you. Sorry. I think I was muted up there. Yeah, we can hear, you know. Terrific. Sorry. I'm just gonna start over again. So I'm sorry. Just thank you, Anna, for the whistle structure of the anatomy of the hip. Uh, so today we're just gonna be covering a bit, uh, some of the conditions of the hip that we can see, uh, and that were expected to know, as a medical student. Um, so starting off, we're going to start off with some of the fractures that we can see in the hip. So, as with any orthopedic presentation or any clinical presentation of any condition for that matter, we start off by taking history and with hip fractures, we tend to get, uh, we tend to find similar patterns amongst most patient's in terms of the history of, uh, or the mechanism of injury. Uh, usually, we expect a low energy fall in, uh, much older population. And predominantly, um, women are affected by this. Uh, the main reason for this is due to, um, uh, something called osteoporosis. And this often occurs. Uh, there's an increased incidence of this in the elderly population and, uh, postmenopausal women as well. Uh, we can also expect to find this pattern of fractures amongst, uh, in the younger population who are involved in road traffic accidents or other major trauma as well. When examining the patient, we always use the look field move. Uh, method. Um, uh, the first thing that we see is that they're, uh they're unable to weight bear. And this is often indicated that there is a fracture present. Uh, some of the signs that we can see an examination include that the limb is often shortened and external irritated. Um, there will be pain on movement of the hip, and you can often expect bruising, especially in extracapsular extracapsular fractures just around the lateral aspect of the outer aspect of the upper thigh. With any fracture, it is very important to examine the neurovascular uh, status. In this case, the most important, uh, nerve That would be, um, that can be damaged would be the sciatic nerve. So therefore, um, assessing the motor function of the ankle and great Oh, dorsiflexion that is bending it towards, um, the patient would be very important. Other nerves and other vessels that need to be tested include the the the peripheral pulses, including popliteal pulse, your dorsalis pedis and your posterior tibialis pulse as well, and just doing a full neurovascular examination of the lower limb. Now, when it comes to imaging in the main, uh, so when it comes to investigations, the main, uh, main stay would be your imaging modalities. And, uh, in that in that as well your X rays would be your first line, uh, imaging modality. It is always good practice to take two, um, views of x ray to, um get a full picture as to what is going on. So in this case, we would take both a p, which is anterior posterior view of the pelvis and hips and the lateral hip X ray as well, which allows us to paint a better picture as to what exactly the fracture pattern is in how displaced or how stable or unstable the fracture is. If if if the diagnosis is still in doubt after taking, uh, the X ray, um, then an MRI scan would be our next line mode of investigation. Uh, this is considered to be more sensitive than a C. T N is, uh, thus recommended as the second line. Uh, second line. Um uh, mode of investigation. However, we can perform a CT scan. If an MRI is not well, if neither of them are available, then the next best option is to repeat the X ray and, um, uh, place the position. Place the patient in certain positions such as internal and external rotation, to accentuate the fracture and get a better, um, get a better view of the fracture itself. Now, when you see a patient with who is suspected whom who is suspected to have a hip fracture or has been confirmed using an X ray, the first line management of these patient's include the following. So you would need to admit them. They would need a bed rest, and they would need adequate and analgesia. As with any fracture, they're going to be in a lot of pain. And analgesia is one of the most important management, um, options. Uh, you have, uh, as a doctor, um, it can either be through, uh, oral opioid medications, uh, such as morphine. Or you can, uh, with seniors with senior support, you can get, um, uh, Elio femoral. Uh, inguinal block, uh, as well does numbing the whole, um, uh, innovation of the hip joint. If that makes sense now, the other things that need to be done is written bloods, and the main thing would be a group and hold, as I mentioned earlier, Um, there can be incidences where patient's come in through major trauma accidents and would have lost a lot of blood. Hence, group is very important for them. It would also come into play when we're looking at the treatment modality in terms of surgery, Uh, and most surgical approaches would involve a lot of blood loss and hence would require blood transfusion. If this is the case, and therefore group and hold is very important in all these patient's G G and a chest X ray is good to be done in oil patient's that come in, especially who have come in with a fall or major trauma, as this allows us to identify the underlying cause. If present as well, most patient's again are going to be elderly, patient's and because of and would have fallen and broken their hip, most of them again are going to have local I and because of which can undergo rhabdomyolysis or dehydration as well. And therefore you need to carefully replace the lost fluids as well with hip fractures. Again, you're going to be immobile, which increases your risk for DVT S and P E s. And therefore it is essential that we, uh, start them on anti coagulation as soon as possible. Again. You need to optimize existing medical conditions as these patient's need to go to surgery, uh, and thus reduce, um, the anesthetic interests and improve overall survival as well. Again good nursing to avoid pressure source because they're going to be a mobile. And we don't want this these complications occurring. And finally just identifying the underlying reason for the fall and managing them medically or surgery surgically as well. In terms of the mainstay treatment of the fracture itself, almost all of them would require surgery, and the aims of the surgery are going to be reducing pain, regaining mobility and reducing the risk of complications of bed being bedbound such as chest infection, DVT, PE and pressure source, as well as mentioned earlier. Now, this is something that Anna had briefly mentioned something called avascular necrosis. So this is very important in all types of hip Proctor's, and we're going to go a little more in detail about this. So as the name suggests, avascular necrosis means the dying of tissue due to lack of blood supply. Now, this can happen in various regions of the body. Um, and the common link between all of them is the retrograde blood supply. What this means is that instead of the blood supply being a proximal to distill the blood supply is distilled approximal. If you look at the hip in more detail over here, we can see that the main, um, the main the main blood supply is through the medial and lateral circumflex femoral arteries, as mentioned by ANA, which is a branch of the deep femoral artery. And these have branches called the retinacular arteries that go up the femoral head and supply the femoral head. Therefore, if there's a disruption and these, uh, these retinacular arteries that supply the femoral head, there would be complete cut off of the blood supply, therefore leading to, um, lack of blood flow and then ultimately death of the tissue causing avascular necrosis. And there's various parts of the body, including the shoulder, the hip, the tailors and the Steph Oil which, um in which, Uh, this phenomenon occurs, but we're going to be focusing on the hip now. This is again an important concept as this changes the way we manage patient's, uh, based on the fracture pattern. Now, firstly, the classification of hip fractures can be done based on this as well. Firstly, extracapsular would be, um So if we look at this black line over here, your capsule attaches from the acetabulum across, uh, till here and anything that is outside of this capsule is considered to be extracapsular. Now, all fractures that occur extracapsular early are going are not going to be affected by, uh, avascular necrosis because because the blood supply is going, uh, is not going to be disrupted. So if you go back to the previous slide over here, we can see that the the retinacular arteries that supply the femoral head all are present within the capsule of the femur and therefore only intracapsular fractures are going to disrupt this blood supply and cause avascular necrosis. And this is why the management of intracapsular hip fractures is going to be much different than extracapsular hip fractures. And the timing of this is also going to be much different. Just looking at the types of fractures that we can get first again. Extracapsular we can get something known as an intern intertrochanteric fracture, which runs between the greater and the lesser trochanter. As the name suggests, we can get a subtrochanteric fracture, which is below the level of the, um track Inter's now again subtrochanteric fractures. There is another subgroup which is known as reversibly, where in the fracture pattern is just, uh, in the opposite direction we can we will go. We will go through that in more detail and the coming slides as well. In terms of your intracapsular, uh, fractures, you can get subcapital fracture, which is below the level of the femoral head, and transfers cervical fracture, which is just along the femoral neck. And you can get a femoral head fracture as well as indicated by the top Most, uh, fracture line moving on to the extra capsule of fractures. Then, uh, so, as I said earlier, the blood supply to the femoral head is maintained. This low risk of, uh, avascular necrosis a non union the method of fixation depends on the stability of the fracture pattern. So we have two different types of, uh, fixation that we that we can perform. And the first thing is called a dynamic hip screw or a sliding hip screw. And the second one is called a Cephalomedullary nail or an intermediate intramedullary nail or a gamma nail. But so D h S r A D H s or a dynamic hip screw is for intertrochanteric fractures, which runs between the creator and lesser trochanter, whereas the cephalometer medullary nail is for, uh, subtrochanteric fractures or reverse oblique fractures. So looking at the radiograph of what an intertrochanteric fracture looks like as we can see over here, there is a fracture that runs across from the greater to the lesser trochanter. So that is going to be called an intertrochanteric fracture. And the management of this is going to be a DHS. So DHS has two components. Firstly, the lag screw, which is inserted into the center of the head. And now that is attached to a four hole Plett that is attached, uh, to the femoral shaft. Now then why is it called a dynamic hip screw is because this like this combination of the lag Screw on the plate allows compression of the fracture, and this dynamic movement, or micromotion, allows adequate bone healing. So if we can, if we look at the picture on the right over here there is a screw that goes up on the femoral head and is attached to, uh, an angulated body. Now, this crew with movement off the hip undergoes micro movements, which allows the from the fracture site to heal adequately because of secondary point healing. If that makes sense, I'm just gonna have a look at the chat to see if there are any questions at this point. No, I don't see any questions. All right, um, so the next thing is subtrochanteric and reverse oblique fractures. So, as I mentioned earlier, SUBTROCHANTERIC is going to be below the level of the truck winters, if you just ignore this, uh, if you just ignore the fracture of the lesser trochanter over there and just focus on this one over here. So this is your greater trochanter on the left hand side of the left hand side. Picture. This is your greater trochanter. That is your lesser trochanter. And the fracture is going to be below the level of the truck hunters. Uh, now, the fracture pattern that we see over here is gonna be, uh is gonna be the fracture is going to be superior on the lateral side, an inferior on the medial side. And the reverse oblique pattern is again going to be below the level of the trochanter. So it's still going to be a subtrochanteric fracture. However, the lateral aspect of the fracture is going to be much inferior compared to the medial aspect of the fracture. And that is the only, uh, difference between the two when coming, when coming to the definite of management of these types of fractures an intramedullary nail or a gamma nail or a cephalomedullary nail is going to be your mainstay treatment. What this involves is a nail that is, um, uh inserted into the femur through the greater trochanter, uh, along Medalla, and therefore it's known as an intramedullary nail all the way, running all the way to the bottom of the female. There are two screws that are attached, as you can see on the top, over here into the femoral head that keeps the nail in position. And there are two screws, uh, that are bicortical that has passes through the court, both the cortices of the digital FEMA, um, through the through the nail as well for stabilization and prevent rotation of the fracture. As I said, this usually runs the whole length of the FEMA. And the main reason for this is that with shorter nail, there's an increased risk of paraprosthetic fractures where in the urine of fracture occurs below the level of, uh, the nail. This this type of fixation is often required for unstable patterns of extra cap capsular, uh, fractures and below the level of the chalk interest as well. Now moving on to something that is a little more complicated than the previous, um, section is gonna be the intracapsular fractures. So the main risk, as I keep mentioning over here, is the risk of avascular necrosis where in the blood supply through the red retinacular arteries are disrupted again. The method of fixation is dictated by the stability of fracture pattern, and the fracture patterns are further classified based on the garden classification. So if you're not listening to anything but just, uh, if you're not listening to anything so far, I'd highly suggest please pay attention to this particular, uh, slide. So the garden classification is very important in determining what type of fixation would be required for intracapsular. Uh, fractures. So there are four types, uh, of intracapsular fractures. Based on this classification, type one is an incomplete, um, fracture of, uh, incomplete intracapsular fracture, which is undisplaced as well. Type two is going to be a complete fracture. I e. It passes through the, uh, through both the courtesies of the FEMA. Um, but it's going to still be undisplaced. Type three is a complete fracture, however, is partially displaced. Or in this case, as we can see from this figure, just angulated and type four is going to be a complete fracture with full, uh, dislocation, Uh, displacement and dislocation as well. Now, moving on to the actual management of these fractures again gardened one, as I mentioned earlier, is going to be an incomplete fracture. Undisplaced fracture. So what this means is that the cortex is still intact and the capsule is not disrupted as well now, because the capsule is not disrupted, there's no disruption of the actual, uh, blood supply and there's a low risk of nonunion or avascular necrosis and therefore, uh, internal fixation. Using either cannulated screws or to hold the ages would be ideal for this type of fracture. Garden, too. On the other side is again undisplaced fracture, but it's complete, but it's a complete fracture. In this case, there's no angulation of the trabecula. There's no displacement, and therefore there's no disruption of the capsule again, and therefore the blood supply is still maintain. The treatment would against, um, be the same as the previous one internal fixation using cannulated screws already as us. Now, the problem over here comes in elderly patients who are extremely frail. Yeah, although the risk of avascular necrosis or nonunion, it's low. It's not, um, zero. And therefore, uh, despite fixation, this can proceed on progress on to, um, avascular, necrosis and, uh, non union, and therefore an elderly patient. In order to, um, make them undergo only one operation. Uh, and their increased risk of avascular necrosis hemiarthroplasty would be more, um, ideal in these in this particular population for a garden to, uh, fracture. Now, this is what a cannulated screw looks like. So there's often 3 to 4 screws that, uh, go from the lateral aspect of the FEMA, most likely the greater trochanter into the head of the femur. And this just allows, um, the the bone to stay in the an anatomical position, uh, and allow bone healing. And we We spoke about the DHS earlier on, so I'm not going to go over that again now, coming on to the displaced fractures, which are going to be a Garden three and gotten four. So Garden three, As I said earlier, complete fracture partially partially displaced example can be angulated as well as we saw. The picture and garden for is a complete fracture that is fully displaced, and the trabecular are not are parallel due to a degree of, uh, displacement. And there's little angulations as well. Now, in this case, the capsule is always disrupted, and there's severe damage to blood vessels, and there's a high risk of non union and the vascular necrosis coming to the treatment of these types of fractures. This can again be differentiated based on whether the patient is young or old, so in young patient's, generally less than at the age of 65 an emergency surgery would often be warranted. And we would, uh, perform a close reduction, which is getting back getting the bone back in the anatomical position, an internal fixation, which is just placing the bone in that particular position. And this can either be done through cannulated screws or, uh, the address as well, depending on the extent of the injury. Now we want to preserve the native femoral head for these patient's because they are young and mobile and active as well. Although there is a high risk of non union in the avascular necrosis, approximately 30% there are better, uh, long term results If, uh, the bone heals in, um, if the native bone heals, which is approximately 70% and therefore this, um, this risk benefit ratio, uh, tells us that preserving the native femoral head would be better in the long term, um, effects. Now again, if these patient's were to get where to get a total hip replacement, for example, or a hemiarthroplasty, for example, their life expectancy is going to be much higher than the expected durability of the prosthesis, and therefore what they would require another surgery, no matter what that because of, because uh, there is, uh, there is a possibility that the native femoral head is going to heal by itself without needing further surgery. That is often the preferred surgical approach. However. If patient's do suffer from, um, nonunion an avascular necrosis, then they can be considered for a total hip replacement in the future. But the first primary goal would be to preserve the native femoral head. In older patient's, however, there's a higher risk of nonunion any vascular necrosis and therefore the femoral head needs to be replaced as soon as possible again. This can further be divided if they're elderly and frail. Uh, cemented hemiarthroplasty would be used, however, if the patient was able to walk alone by themselves. Outdoors Pre injury with no cognitive impairment and are medically fit to undergo. Undergo the procedure and anesthetic, then total hip replaced be used in this case. Now, this is what a hemiarthroplasty is going to look like. Uh, in a hemiarthroplasty. As the name suggests, it's Hemi, meaning half arthro, meaning joint and plastic meaning, um, fixing or changing. Um, therefore, on the, uh, the ephemeral head, only half of this joint is being fixed or replaced. What that means is just the femoral head is being replaced with a metal or a prosthesis along with its blood supply. And now the stem is going to be inserted into the femoral shaft and is often supported by cement and therefore just known as a cemented hemiarthroplasty. As you can see on the X ray on the right hand side, it's just, um, the the ball aspect of the ball and socket joint that is being replaced over here. And that is fixed into, uh, the the femoral shaft. As we can see here, the the femoral head along with its neck is completely removed, and this is replaced by this prosthesis. A total hip replacement, on the other hand, is, uh, is where the femoral head, along with the acetabulum, is being replaced. So as we saw earlier, the both the ball and the socket aspect of the joint is being replaced over here. Now, why would you want to replace the acetabulum? And why would you not want to replace the acetabulum? Is a great question to ask, and in patient's that are often that are mobile and are able to, um, carry out their day to day tasks, and we're not frail. It is better to replace the acetabulum as the as in a hemiarthroplasty. If the native acetabulum is present, the prosthesis goes going to irritate the lining of that and cause damage and can can further lead, uh, two pain and other complications as well. And therefore it would be better for patient's who are out and about to get a total hip replacement. Compared to hemiarthroplasty, however, in patient's that are less mobile were bedbound, for example, are, uh, not, uh, completely mobile or just stay at home. Uh, and don't go outside. Uh, for example, then hemiarthroplasty would be much, uh, suited because, uh, they would they wouldn't be moving the joint as much. And the procedure is comparatively, um, smaller than a total hip replacement. So, as I said, the total hip replacement over here is going to be a bigger operation, which means that there is greater blood loss and therefore we did the group and hold in the first half itself. And there's more physiological stress on the patient, uh, as well. And therefore this is reserved, as I said, only for the most mobile and healthy patient's again this slide is very important. As it just, uh, summarizes what I've, uh, spoken about for the last. Uh uh, 15 to 20 minutes. Um, just says that a proximal femoral fracture can be divided into intracapsular and extracapsular fracture. Intracapsular fracture can be displaced or non displaced. A non displaced one is going to be a garden one and two. And the management is going to be an internal fixation using candidates, cruise or DHS. Displaced fracture can be further divided into, uh, rather than less than 65 years old. Uh, and whether they're above that and whether they're frail or if they're, um, mobile. So in less than 60 in this in this slide, it shows less than 60. But you can use 65 as well. An internal fixation would be done. Uh, if they are mobile, then you can get, um, a total hip replacement. And if they're, um, not mobile, if they're elderly, if they're very frail, then Arthur Hemiarthroplasty would be done. Extracapsular can either be, um intertrochanteric subtrochanteric stable. Unstable. Um, intertrochanteric is gonna be fixed using uh, d h s, whereas the rest is gonna be using, um, a nail. Um so again, any questions regarding that? I'm just gonna have a look at the chat here. No. All right. Um, okay, um, so the next thing we're going to talk about is once we're done with our tikka is very important. So all patient's need to be mobilized from day one itself, as this allows adequate bone healing events, Uh, the risk of various complications that we have mentioned already and allows them to get back to their normal function as soon as possible in elderly population, especially early, that weight bearing is very important, as this allows proper bone healing and prevents, uh, complications from occurring as well. Um, again, these patient's can either be discharged home or rehab, and this depends on the progress they've made in the hospital. They're social circumstances. And, um, other factors, uh, that that come into, uh, players, uh, that come into play as well That will be discussed with the entire team, including the occupation therapists, as well. Some of the complications that we can get. Uh, So gender complications include bleeding and infection. As with all, um uh, as with all surgeries and all fractures, pain, stiffness, reduced mobility, and limp again with all fractures. This is expected. Um, you can get leg length discrepancy. Where in, Um, the fractured legacy consider to is going to be shorter than the other. Um is going to be shorter than the other. However, uh, adequate rehabilitation would help patients' overcome, uh, problems associated with that. And as I said earlier, Paraprosthetic, uh, fractures as well. If the prosthesis is not long enough or in the case of, uh, total hip replacement or hemiarthroplasty as well DVT and PE because they're not going to be mobilizing and thus increasing their, uh, coagulation. Um does increase the coagulable coagulum bility, uh, and thus predisposing them to DVT S and P s. And as with any surgical procedures, anesthetic complications can occur, including, um, cardiovascular. Um um cardiovascular respiratory complications such as M I A, C V A and lower respiratory tract infection and, uh, death as well. Some specific complications with certain types of, uh, fixation, such as for the first one intracapsular fracture with internal fixation. As I said, avascular necrosis and non union enter capsule of fracture with treated with a hemiarthroplasty or a total hip replacement, you can get dislocation of the prosthesis, which is very common, um, and would often require another would require their manipulation. Um uh, And we would require manipulation under surgery sometimes, uh, and then revision of the fracture as well, because of various reasons such as dislocation or sepsis, leg length discrepancy and sciatica. And this is purely based on the, um, on the approach for surgery as the sciatic nerve is just present, um, at the posterior aspect and can, um, be damaged during surgery as well. Extracapsular fractures delayed union where in the fracture does not heal in time. Nonunion, where it just does not heal the cut off of lag. Screw where in the lag screw comes off and then malunion where in it is not in the anatomical position, but heels in a different position, which can lead to various problems as well. Now, that was, uh, the the chunk of what we're going to talk today. Uh, but some other hip conditions that that can come up in exams or that we need to know as medical students can be meralgia paresthetica. Um not sure if I'm pronouncing that correct and trochanteric bursitis. So the first one meralgia paresthetica is, um you know, Mona neuropathy of the lateral femoral cutaneous nerve. So as the name suggests, as the name suggests, it is the lateral femoral cutaneous now, So it supplies the lateral aspect of the, uh of the thigh, which is the outer thigh. And it's supplying only the cutaneous, uh, providing the cutaneous innovation, which is, uh, just around the skin. And therefore would be, uh, therefore, you would expect to get sensitivity definite deficits predominantly, So you get local s symptoms of the outer thigh. And as I said earlier, it's going to be sensory deficits predominantly. And these can include burning sensation, numbness, pins and needles, cold sensation or just no sensation at all. It is often aggravated by walking or standing for long periods of time, an extension of, uh, the hip. As the nerve is stretched, this is usually a self limiting condition. But if it is very debilitating, then we can use various medical and surgical approach, uh, and management as well. So analgesic would be your primary medical, uh, management. And these could include simple pain relief such as paracetamol and, uh, ancestor as well. Or you can use, uh, neuropathic pain relief such as amitriptyline, gabapentin and pregabalin as well. If it if it gets too, uh, unbearable. And if the patient is having this for a long period of time, Surgical approach can be a surgical management can also be considered. And these would include decompression or transactions of resection of, um, I don't know, but we will not be going more into that because, um, at this, uh, stage, we just need to know what it is and the fact that it is self limiting or simple energy. Analgesics are help. Next one is trochanteric bursitis. So as the name suggests, it's it is inflammation of the bursa, which is a synovial membrane with synovial fluid over the creator. Talking to no bursas are present along various, uh, present, um, around various joints and act like shock. Absorb those. So they due to the extensive movements of these joints, um, they can cause irritation around the area, especially cutaneous lee around the skin. And therefore these, um, um, these pads are, um, synovial membranes of fluid. Uh, prevent, um, this from occurring and act as shock absorbers. Basically. So when this information of, uh, the bus around the greater trochanter you can get pain and tenderness of the outer thigh. And there's restricted motion in all planes, especially abduction, internal and external rotation of hip. This again is managed conservatively, uh, such as rest, eyes, analgesia, some physiotherapy. And if it's very severe, steroid steroid injections can also be given. So, um, that's it, Uh, for today, I'm just going to have a look at the chat again to see if any, Um, if you have any questions or if you want me to go over anything else in particular or if anything else didn't make sense, right, So is that restricted range of movement or pain on resisted movement? Um, so you you get both essentially, so there is pain. And so the main thing that we expect is pain on resisted movement. However, if this becomes too severe, you can get a restricted range of movement due to pain, if that makes sense. But predominantly, it is going to be pain on resisted movement. Um, any other questions, um or is that us for today? And please fill in the feedback form. Uh, I shall be sending them through to your through your medical accounts, or you should get an email from Medal as well at the end of the session to fill in the feedback form. So please fill in the feedback form just helps us to prepare better for upcoming sessions as well. And try and taking your feedback to see what exactly you need and how we can, uh, improve the quality of our sessions, if that's it. Thank you, everyone for joining us today. Uh, we hope to see you next week for our next session. And that would be on, uh, the anatomy and, um, pathology of the knee. Thank you so much.