Orthopedics

The Hip

Symptoms and Signs of Hip Injuries

Accurate examination of the hip is key to achieving a correct diagnosis. The hip is a joint that
is extreme complex in it's mechanics and notoriously difficult to examine accurately. Patients
with hip dysfunction may present with:

i) Pain
ii) Stiffness
iii) Alteration of gait
iv) Swelling
v) Alteration of walking distance
vi) Discolouration/Bruising

Examination of the hip should include:

i) Observation - scars, sinuses, bony alignment, swelling, discolouration etc.

ii) Palpation - bony and soft tissue contours, pain, swelling, temperature etc.
iii) Active movements - flexion, extension, rotation, abduction, adduction, abduction in
flexion
iv) Passive movements - as above
v) Muscle power
vi) Leg length discrepancy - structural or functional?
vii) Traction test for longitudinal movement
viii) Faber's & Trendelenberg's test
ix) Gait analysis

Remember, pain can be referred to the hip from other areas, these may include:

i) Lumbar spine
ii) Herniae
iii) Bursae
iv) Knee
v) Pelvis
vi) Foot and ankle
vii) Kidney - can refer into inguinal and proximal thigh regions

Articular conditions that affect the hip can often be differentiated by the age of the patient,
obviously this is a rough guide and there are exceptions. The age groups and conditions are:
 AGE CONDITION
0 to 2 developmental hip dysplasiour (DHD)
2 to 5 Infections, Transient Synovitis (Irritable Hip)
5 to 10 Perthe's Disease, Transient Synovitis
10 to 20 Slipped Femoral Epiphysis
Adults Osteoarthritis, Rheumatoid Arthritis, Avascular necrosis.

Developmental hip dysplasiour (previously known as Congenital Hip Dislocations CDH)

In the majority of new born infants, the hips are completely stable and tend to be held in some
degree of flexion. However, in some cases, the hips are unstable in that they have dislocated
or have to potential to dislocate. In the UK, the majority of these unstable hips are detected
immediately after birth by using some simple manipulative tests. Most unstable hips, once
correctly reduced if necessary, become stable within 3-4 weeks. In some cases,
approximately 1 in 500 births, the hip becomes persistently unstable and liable to persistent
dislocation. Generally, the condition is more common in girls and particularly those with a
family history of DHD. The left hip is more commonly affected than the right but in about
33% of cases, both hips are affected.

As previously mentioned, the majority of unstable hips should be detected soon after birth
which thereby limits any significant clinical features. However, should the condition go
undetected or occur later in life then some clinical features may become apparent. The most
common features are those of asymmetrical skin creases around the hip and thigh, the hip is
held in external rotation and slightly shorter than the un-affected hip. The child is unable to
fully abduct the hip. If the child is able to stand, then the Trendelenberg test will be positive.

If both hips are dislocated, the features are more difficult to detect as there is little difference
between the skin creases and the characteristic 'waddling' gait may appear to be normal for a
child of that age. On examination, abduction of the hip will be limited and X-ray
investigations will reveal the bilateral dislocation.

The two most common tests that are performed after birth to detect the presence of a hip
dislocation are Ortalani's test and Barlow's test.

Barlow's Test is performed by placing the examiners thumb in the groin and holding the
proximal part if the thigh. With the femur held securely, the examiner tries to move the
femoral head in and out of the acetabulum during abduction and adduction. If the hip is held
in it's normal position but can be moved out of the acetabulum and back again then the hip is
classed as unstable and potentially 'dislocatable'.

Ortalani's Test involves the examiner holding the infant's thighs with thumb along the medial
borders and the remainder of the fingers over the greater trochanters. The hips are then flexed
to 90 degrees and then abducted.
In a normal hip, this movement will be smooth and a range of 90 degrees may be possible. If
the hip is unstable, the movement will be impaired and if greater pressure is applied, a click
may be heard as the femoral head dislocates. If the examiner continues to abduct the thigh
then s further click may be heard as the hip dislocation reduces. If the second click does not
occur, then the hip may be irreducibly dislocated.

If there is any suggestion upon testing that the hip is unstable, then an ultrasound examination
of the hip is performed in order to ascertain the position of the femoral head and the shape of
the acetabulae.

The key to a good prognosis is rapid treatment. If treatment is started after the child is six
years old then the prognosis is not good. Untreated DHD may result in substantial deformity
and disability. Treatment between 6 months and six years can give good results with little
permanent disability. However, this often relies upon many months or even years of
treatment and even surgery. For the best results and prognosis, treatment should begin soon
after birth, preferably within 2-3 weeks.

Treatment is dependent upon the age of the child and the persistence of the dislocation. For
those infants up to 6 months old, treatment is very conservative and relies upon the use of
double nappies to stabilise the hip and a pillow to hold the hips in abduction whilst the infant
is asleep. Hopefully, these conservative measures will be sufficient to allow the hip and
surrounding soft tissues to strengthen and stabilise. This conservative treatment is tried for
the first six weeks. Those babies whose hips have stabilised are monitored for a six month
period. For those whose hips have failed to stabilise with these conservative measures, a
more formal method of abduction splintage is required. In these cases, splints are used to
hold the hips in abduction and flexion for between 3 and 6 months. Before applying the
splints, the hips must be properly reduced and scanned to confirm their correct alignment.
The hips will be scanned using ultrasound to ensure that the acetabulum has developed
properly before removing the splints.

For those patients who have persistent dislocations and for whom conservative treatment has
failed, or for those who have presented with DHD later in life (6 months to 6 years) a more
radical approach is required. If possible, the dislocation should be reduced externally.
However, manipulation under anaesthetic is often excluded as it carries a high risk of femoral
head necrosis. Alternatively, the hip is reduced slowly over a period of about three weeks by
the application of sustained and progressive traction. The traction is applied using a vertical
frame and is gradually increased until the child's legs are widely abducted. Hopefully, this
will attain full reduction of the dislocation and an arthrogram will confirm the position of the
femoral head. Once achieved, the child is placed in a plaster spica, in which the hips are held
in flexion, abduction and internal rotation, for 6 weeks. After this, the child is placed in a
splint that allows more movement but prevents adduction. Follow up X-rays are required in
order to show a normal joint and position. Once this has been attained, the splint can
gradually be removed.

If external reduction does not achieve successful re-alignment of the hip joint, then open
reduction id indicated and then subsequent immobilisation in a spica for 3 months. If
required, a femoral or acetabular osteotomy will be performed in order to stabilise the joint.
This may be done at the same time as the open reduction or 6 weeks later.

Open reduction and corrective osteotomy can be used up to the age of about 10 for unilateral
DHD. After this age, reduction is often difficult and the force required to reduce the hip may
damage it and cause avascular necrosis. In these cases, it may be advisable to limit treatment
until the symptoms become such that reconstructive hip surgery is necessary.

Perthe's Disease

This condition cause necrosis of the femoral head. It should be considered in the differential
diagnosis of young children presenting with hip pain although it's occurrence is quite rare,
being approximately 1 in 10,000. It is a condition that primarily affects boys by the ratio of
4:1. It may present with generalised skeletal immaturity. In approximately 50% of cases, an
initial trauma or synovitis of the hip is reported. It is believed that this trauma/inflammation
causes a local effusion which compresses the lateral epiphyseal vessels, from which the
femoral head receives almost all it's blood supply between 4 and 7 years old. This
avascularisation of the femoral head leads to bony death and stops the femoral head from
growing. At this point, X-ray would appear normal. At some point after the femoral head
has become avascular, new arteries enter and begin revascularisation and subsequent repair.
At this point, new bone is laid down and the femoral head becomes more opaque on X ray. If
the initial avascularisation has affected only a small part of the femoral head, then repair may
be complete. However, if a large proportion of the femoral head has been involved the this
may lead to collapse of the bone and subsequent deformity.

The patient will initially complain of pain in the hip that is made worse by walking and will
often cause a limp. The hip at the point will appear almost completely normal, even on
X-ray. There may be slight wasting of some of the muscle around the hip. The mobility of
the hip is reduced and if moved to extremes, pain will be provoked. In the later stages of the
condition, the pain may well have subsided and the movement will almost appear normal
however, abduction and internal rotation are almost always limited.

X-ray changes may not be apparent until quite late in the development of the condition and
may show flattening or even breaking up of the femoral head. The area of the diaphysis just
below the femoral head may reveal increased radio-lucency.

Treatment during the painful stage should be bed rest with the hip in traction until the pain
has subsided. This may take up to 3-4 weeks. After the pain has subsided, any further
treatment is dependent upon the likely prognosis of the condition.

Factors for a good prognosis are:

i) Child under 6 years old
ii) absence of disphyseal lucency
iii) minimal femoral head involvement
iv) normal femoral head shape

In these cases, no further treatment is required although they should be monitored for a period
of time.

Factors for a poor prognosis are:

i) Child over 6 years old
ii) severe diaphyseal lucency
iii) involvement of the whole femoral head
iv) displacement or fragmentation of the femoral head
In these cases, the hip needs to be contained. This means that the femoral head should be
held within the acetabulum as it is more likely to hold it's correct shape. This is achieved
either by splinting the hips into wide abduction for at least one year (the problems of walking
are quite apparent) or by surgical operation. The operation performed is either a femoral
and/or innominate osteotomy. This is the more rapid form of containment and so therefore
limits the child less.

Slipped Upper Femoral Epiphysis

This relatively uncommon condition tends to affect adolescent boys. It is often associated
with very tall or fat children with delayed sexual maturity. The exact cause is unknown, but it
has been suggested that there may be an underlying hormonal imbalance between growth
hormone secreted by the Pituitary gland and the sex hormones. Growth hormone stimulates
bone growth whilst the gonadal hormones stimulates ossification of the epiphyseal growth
plates. Therefore, during the pubertal growth spurt, the un-ossified growth plate may be
unable to cope with the extra weight bearing load due to the increased bone growth. In some
cases, the child is of normal build and shows no signs of hormonal disturbance. In
approximately 40% of cases, both hips will be involved.

Occasionally, the movement of the femoral head about the upper epiphysis may be initiated
due to trauma, however the majority of cases occur incidiously for no apparent reason.
Whatever the cause, the results are always the same with slippage of the femoral head
medially and posteriorly. The degree of slippage varies from patient to patient. If left
untreated, the femoral growth plate will fuse with the femoral head in an abnormal position.
This increases the likelihood of developing secondary osteoarthritis.

The patient will usually be a male between the age of 10 to 20 (peak age 14-15 years old) who
presents with a gradual onset of pain in the region of the hip and/or knee. Pain may also be
apparent in the anterior thigh. The patient will often exhibit a limp and may hold the hip in
external rotation. 50% of patients will be overweight with evidence of hormonal disturbance.
Examination of the affected limb will often show it to be 1-2cm shorter than it's counterpart.
The hip will often be limited in flexion, abduction and internal rotation. Forcing these
restricted ranges of movement will often exacerbate the pain. X-ray examination will reveal
the displacement even when only minimal movement has occurred. This is best seen on
lateral radiographs.

Treatment involves internal fixation of the femoral head. The method of treatment is
dependent upon the degree of displacement. In a mild case (displacement of less than one
third if the femoral epiphysis), the femoral head is fixed to the neck in it's displaced position
using 2-3 threaded pins. Moderate displacement (one third to one half of the width of the
epiphysis) is usually fixed in the same way but may be subsequently re-modelled at a later
date to limit permanent deformity. A severe slipped epiphysis requires surgical correction to
re-align the femoral head and neck and subsequent internal fixation.
In some cases, re-alignment of the femoral head and neck is too difficult or dangerous. In
these cases, the femoral epiphysis is pinned and the displaced position of the femoral head is
compensated by an osteotomy of the femoral shaft at a later date.

Complications associated with slipped upper femoral epiphysis may include:

» Secondary Osteoarthritis.
» Avascular Necrosis
» Coxa Vara
» Slippage of the other hip.

Transient Synovitis of the Hip (Irritable Hip)

The cause of this temporary condition is unknown although may follow a viral infection
affecting the upper respiratory tract. It presents in children usually under the age of 10 and is
more common in boys. It is a self limiting condition and the symptoms usually resolve in a
few days to a few weeks. The patient will often present with a recent history of hip pain, a
limp and limitation of hip movement. These symptoms often mimic those associated with the
initial symptoms of Perthe's disease and pyogenic arthritis. For this reason, transient
synovitis should be a retrospective diagnosis once the symptoms have cleared. All the time
that the patient has symptoms, it should be regarded as a possible case of Perthe's disease or
pyogenic arthritis. A diagnosis of pyogenic arthritis is even more likely if the patient has
pyrexia or the symptoms of a systemic disease.

The condition usually requires little treatment apart from reassurance, observation and
analgesics. In some cases, bed rest may be required for a short period of time. Once
resolved, the hip will return to normal function.

Pyogenic Arthritis of the Hip

This uncommon condition tends to occur in children under the age of 2. Occasionally,
Gonnococcal arthritis is seen in adults. Those patients such as diabetics who are
immunocompromised or those taking steroids have a greater predisposition to developing this
condition. However, it is most commonly due to a Staphylococcus infection either as a result
of direct spread from a more distant site of infection or as a result of the direct spread from
osteomyelitis of the femur. In rarer cases, a direct penetrating wound is responsible.

This condition takes hold rapidly and can result in the completely destruction of the femoral
head, which is mostly cartilaginous at this point. If left untreated for only 24 hours, the
articular cartilage of the hip will be completely destroyed.

The patient will be acutely ill and exhibit pyrexia. The hip and surrounding regions will be
painful, but exact location of the site of pain is often difficult. The hip will often be held rigid
and any attempt to move it is strongly resisted. The area may exhibit local heat and erythema.
In the initial stages, radiographic investigation may reveal little evidence of the acute
infection. Later in the course of the condition, destruction of the femoral head and
acetabulum may be visible. Aspiration of the joint will produce infected pus, from which the
causative agent can be indentified.

Treatment involves the use of intra-venous or intra-articular antibiotics as soon as a diagnosis

is reasonably certain. The hip should be aspirated on a regular basis until pus is no longer
being removed. The area should be rested and traction applied until the condition has
resolved. Complications include secondary osteoarthritis, dislocation of the hip, necrosis of
the femoral head.
Snapping Hip

This condition is a relatively common mechanical condition that requires no treatment other
than to reassure the patient that it is not uncommon and that their hip is not dislocating. The
patient will often present with a history of 'snapping' or 'clunking' in the hip region, usually
when they flex or extend the knee. The most common cause is the ilio-tibial tract snapping
across the greater trochanter. Occasionally, a 'clunking' noise may be heard on external
rotation.

Osteoarthritis of the Hip

This is an extremely common condition that affects the older population (50+ years). In
younger patients, it occurs as the result of another hip condition or injury. It is one of the
most common causes of disability in the Western world. Primarily, it is a degenerative
process that can be caused or accelerated by previous injury, infection or disease such as
Perthe's or slipped femoral epiphysis. If no underlying cause can be found, the condition is
called primary or idiopathic osteoarthritis.

The underlying pathology is no different from any other type of osteoarthritis. The articular
cartilage becomes softened and begins to fibrillate. Initially, cracks and fissures begin to
occur and subsequently the cartilage begins to fragment. The underlying bone becomes
sclerosed and often cysts will form in the bone just below the surface, this may lead to
collapse of the femoral head. The fragments of articular cartilage will often contribute to the
patients pain by irritating the synovium as the joint moves. In severe cases, the articular
cartilage is completely worn away and grooves will often form in the sub-chondral bone.

A patient with osteoarthritis of the hip will present with the characteristic symptoms of pain,
limitation of movement and an altered gait. In the majority of cases, the patient will be
elderly.
The pain tends to be initially described as a dull persistent ache. As the disease progresses or
if the hip is moved to it's extremes, this pain becomes more sharp in nature. The pain is often
made worse for walking and weight bearing but will also be apparent when the patient rests
and will often disturb their sleep pattern. In the early stages, the pain is often localised to the
groin. However, other sites of potential pain include the buttock, thigh and knee.

Hip movement will quickly become limited, with flexion, abduction and external rotation
often being the initial movements to become limited. The patient will often compensate for
this limitation, and the flexion deformity will result in hyperextension of the lumbar spine.
This in itself causes back pain and may further aggravate the hip symptoms. As the hip
becomes progressively immobile, actions such as tieing shoe laces and putting socks on
becomes increasingly difficult.
Walking will become more difficult and painful and the patient will be able to walk shorter
and shorter distances. When the patient does walk, often their gait will be altered. This is
due to several reasons. Firstly, they will try to walk in such a way as to put as little pressure
through the hip as possible thereby limiting the pain.
Secondly, the gait is altered due to the limitation of hip movement and thirdly, the Gluteus
medius muscle is often compromised making it difficult to lift the hip for the swing through
of the leg, instead the hip is swung around giving a characteristic gait.
Examination will reveal a restricted and painful range of hip movement. In the early stages,
the restriction may be minimal and the pain initiated only at the extremes. A positive
Trendelenberg's test almost always occurs except in the early stages. Thomas' test will reveal
a fixed flexion deformity, if one is not apparent on inspection. The hip will almost always be
held in adduction and external rotation giving the appearance of a short leg.

Diagnosis is made on clinical grounds and can be confirmed on X-ray. Radiographic findings
associated with osteoarthritis of the hip may include:
» Reduced joint space.
» Sub-chondral cyst formation.
» Sub-chondral sclerosis.
» Osteophyte formation.
» Sub-cortical sclerosis of the medial aspect of the femoral neck.

Treatment is dependent upon the degree of disability and the degree of joint degeneration.
The age and general health of the patient should also be taken into account when considering
a total hip replacement (THR).

Conservative measures for treatment of Osteoarthritis of the hip include:

» Analgesics and NSAID's
» Dietary advice to reduce weight
» Orthotics to correct apparent leg length discrepancy
» A walking stick, which should be of the correct length and held in the opposite hand.
» Aids to improve daily life.

Operative treatment for severe osteoarthritis of the hip involves surgical replacement of both
articular surfaces of the femoral head and acetabulum, a total hip replacement. The
acetabular articular surface is replaced with a cup shaped prosthesis whilst the femoral head is
replaced with a ball attached to a stem that is fixed into the shaft of the femur. In most cases,
the acetabular replacement is made of a hard wearing acrylic whilst the femoral prosthesis is
usually made of metal. In most cases, these prostheses are fixed into place using a bonding
compound however, occasionally they are fixed without being cemented and rely upon bony
growth to stabilise them completely. If the patient is relatively young and may require a
second THR, then the prostheses are not usually bonded, making removal at a later date
easier.

Operative replacement of the hip usually produces good results with approximately 98% of
patient reporting a good improvement in their condition. In most cases, the pain reduces and
the movement increases. THR's are not usually offered to those patient who are under the age
of 60, obese or have physically demanding jobs.

Post-operatively, the patient is encouraged to weight bear as soon as possible. All drain tubes
are usually removed within 2 days and the patient is encouraged to sit out of bed.
Physiotherapy is required to encourage the patient to become actively mobile with the use of
elbow crutches. The patient should not sit in low chairs that flex the hip to more than 90
degrees as this can cause the prosthesis to dislocate. driving should be avoided for at least 6
weeks. After 10 days, the patient is usually fit to discharge from hospital and can go about
normal activities such as climbing stair etc. (with the use of walking aids). After
approximately 3 months, the patient should have little pain and a relatively good range of
movement. High impact activities should be discouraged indefinitely.

Occasionally, total hip replacements are not a success and approximately 0.5 to 1% fail each
year. Causes of failure include:
» Infection
» Loosening of the prosthesis.

Coxa Vara Deformity

This condition is the term used for any condition that has resulted in an abnormal angulation
of the femoral neck-shaft complex. It applies to a reduction of the femoral neck angle to
below the usual 125 degrees. In some cases, the deformity results in the angle being 90
degrees or less. Causes include congenital deformity, slipped upper femoral epiphysis,
fracture and bone 'softening' conditions such as osteomalacia. It causes a true shortening of
the affected leg and may impair the function of the hip muscles, particularly the adductor
group. In severe cases, the Trendelenberg test will be positive. The patient may also exhibit a
limp. Treatment involves the correction of any underlying condition. A slight deformity is
usually left untreated although in severe cases, an osteotomy of the femoral shaft is required
to improve the angulation.

Fractures of the Hip

Name of Fracture: INTRACAPSULAR FRACTURES OF THE FEMORAL NECK

Bone(s) Involved: Femur.

Type of Impact: Often related to a fall, the patient may catch foot and twist the hip. In some
cases, the impact may be minimal or no impact at all.

Description of Fracture: The fracture is graded according to the type of fracture (complete
or incomplete) and the presence and degree of displacement. The fracture is graded 1 to 4
with grade 1 being an incomplete fracture of the femoral neck and grade 4 being a complete
fracture with complete displacement (see diagrams).
Intracapsular fractures will interrupt the blood supply to the femoral head, although because
the fracture site is within an intact capsule any bleeding will be contained within the joint.
This prevents any visible bruising occurring.

Type of Fracture: Transverse, oblique or comminuted.

Pathological if as the result of osteoporotic changes.

Predisposing Factors: Increasing age, osteoporosis, bone altering pathology.

Clinical features: Local pain, swelling and varying degrees of disability. The limb will be
held in external rotation and give the appearance of a short leg. If the patient has an impacted,
stable fracture, they may be able to walk on it with varying degrees of pain.

Diagnosis of Fracture: Clinical signs/symptoms. Radiographic confirmation (P-A and

lateral). Radiographs used to determine existence of fracture and any displacement. Fractures
that are not displaced or exhibit impacted displacement are likely to have a good prognosis.
However, displacement of the fragments in any other direction worsens the prognosis as there
is a high risk of avascular necrosis and non-union.

Treatment: If left untreated, a grade 1 femoral neck fracture can rapidly deteriorate into a
grade 4 fracture and complete displacement. Treatment of all but impacted, stable fractures
involves surgical intervention. If the fracture is stable and impacted then treatment is
conservative and relies upon protected weightbearing only until unification occurs. The
choice of treatment is determined by;
» the age and fitness of the patient.
» the type of fracture.
» the degree of displacement.

Displaced fractures can be treated in one of two ways, either the fracture site is fixed
internally (usually with the use of plates and screws (see diagram)) or the hip is replaced. If
hip replacement is considered to be the best option then either the femoral neck and head is
replaced or the entire joint, including the acetabulum is replaced. After internal fixation, the
patient must be kept immobile until the fracture surfaces have re-united.

If successful, then internal fixation will produce good results and the patient will have a near
normal hip. If however, the repair is not successful or the fracture does not re-unite properly
then a prosthetic replacement is indicated.

If replacement of the hip is the chosen option then early weightbearing mobilisation should be
encouraged after the hip is replaced. Complications associated with femoral head
replacement include the possibility of infection, loosening of the prosthesis, wearing of the
acetabulum leading to a total hip replacement (T.H.R.).

Complications: Some complications are directly attributable to the fracture process, whilst
others may occur as a result of the management of the fracture or due to the age of the patient.
They may include:
» PRESSURE SORES as a result of prolonged bed rest.
» PULMONARY EMBOLISM due to fracture and prolonged bed rest.
» PNEUMONIA
» AVASCULAR NECROSIS
» NON-UNION
» SECONDARY OSTEOARTHRITIS

Name of Fracture: EXTRACAPSULAR FEMORAL NECK FRACTURE.

Bone(s) Involved: Femur

Type of Impact: Usually associated with a fall.

Description of Fracture: Fracture site is outside the femoral capsule and therefore it is less
complicated than intracapsular fractures. This is due to preservation of the blood supply to
the femoral head, the fracture site has a larger area and therefore encourages unification and
the distal fragment is less mobile.
Type of Fracture: Transverse, oblique or comminuted.

Predisposing Factors: Osteoporosis or other bone altering conditions, elderly.

Description of Deformity: The deformity is often visible as the patient will present with the
hip held in external rotation producing a short leg.

Clinical Features: Pain in the region of the hip usually following a fall. As the fracture is
extracapsular there may be severe haematoma formation. Local swelling and disability.
Patient may be able to weight bear as often the fragments are impacted.

Diagnosis of Fracture: Clinical signs/symptoms. Radiographic confirmation (P-A and

lateral). In some cases, impacted fractures are missed due to the stable nature of the hip. In
many cases, they will re-unite without any problems however, some will become displaced
requiring treatment.

Treatment: Treatment of a stable, non-displaced fracture will include non-weightbearing

immobilisation until the fracture surfaces have re-united and then active mobilisation is
encouraged. Displaced fractures will usually require internal fixation followed by
immobilisation until healing occurs. Active mobilisation is then encouraged. Fixation is
usually secured with plate and screws. In rarer cases, especially those patient with
osteoporosis, it may not be possible to internally fix the fracture and then prosthetic
replacement of the humeral neck and head is indicated.

Complications: Complications are less common than those associated with an intra-capsular
fracture, however, NON-UNION and/or AVASCULAR NECROSIS can occur as the result of
an extracapsular femoral neck fracture.