Dynamic Hip Screw - DHS: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:User Name|User Name]]<br>
<div class="editorbox"> '''Original Editor '''- [[User:Rhiannon Clement|Rhiannon Clement]]<br>
  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
== Purpose  ==
== Introduction ==
[[File:DHS.jpg|thumb|Xray DHS]]
The dynamic [[Hip Anatomy|hip]] screw (DHS), a [[Femur|femoral]] head-sparing orthopaedic device, is used to treat [[Femoral Neck Fractures|femoral neck fractures]]. Alternately referred to as a pin and plate. 


The Dynamic Hip Screw (DHS) or Sliding Hip Screw can be used as a fixation for [https://physio-pedia.com/Hip_Fracture?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal neck of femur fractures]. This would usually be considered for fractures that occur outside the hip capsule (extracapsular), often stable intertrochaneric fractures<ref>Dodds ''et al'' (2004) The Sliding Hip Screw ''Current Opinion in Orthopaedics'' Volume 15, Issue 1 pp12-17</ref>. This is because there is a reduced chance of interrupting the blood supply to the head of the femur, and so it may be possible to preserve the joint. However, it may also be appropriate for younger patients with fractures within the hip capsule (intracapsular) if there is a good chance that the blood supply is preserved, reducing the risk of avasular necrosis.  
# Femoral neck fractures that are undisplaced ([[Femoral Neck Fractures, Garden Classification|Garden]] I and II fractures) can be treated with head-preserving surgery and internal fixation.
== Technique  ==
# In fractures with a high risk of [[Avascular necrosis of the femoral head|femoral head avascular necrosis]] ([[Femoral Neck Fractures, Garden Classification|Garden]] III and VI fractures), femoral head resection and [[Partial Hip Replacement|hip hemiarthroplasty]] is favoured.


== History of the DHS ==
Note: DHS is a trade name for the Synthes company, being one type of sliding hip screw. There are various types of sliding hip screws produced by various implant companies. <ref name=":2">Radiopedia DHS Available:https://radiopaedia.org/articles/dynamic-hip-screw (accessed 14.12.2022)</ref>  
Prior to the use of DHS sliding screws, angled blade plates were used<ref name=":0">Singh A.P. ''Dynamic Hip Screw Or Sliding Hip Screw''. [online] Available at: <<nowiki>http://www.boneandspine.com/dynamic-hip-screw/</nowiki>> [Accessed 19 September 2020].</ref>. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent osteotomies. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union<ref name=":0" />. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for [https://physio-pedia.com/Bone_Healing#sts=Stages%20of%20Indirect%20Healing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal bone healing].    <blockquote>NICE Guidelines recommend: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)<ref name=":1">NICE (2017) Hip Fracture: Management ''National Institute for Health and Care Excellence'' [online] <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia></ref>.</blockquote>
== Technique ==
== Physiotherapy Interventions ==
After reduction, the fracture is internally fixed by application a large lag screw through the neck, this is held laterally by a lateral femoral plate. The DHS can slide in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture hence aiding healing. If sliding takes place, the lateral end of the lag screw may project laterally from the plate.
Considerations post surgery:
* Post op instructions and '''[https://physio-pedia.com/Weight_bearing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal weight bearing status]'''
* Infections
* Neurovascular complications
* Pain
* Self-efficacy and motivation
* Fear of falling
<blockquote>Any transfer or mobility aids will be determined by the weight bearing status (usually highlighted in the op note). If the surgeon feels the hip needs protecting post surgery, they may advise partial or non-weight bearing for the patient.</blockquote>Physiotherapy interventions:
* Transfers (bed, chair, toiletting).
* Mobility (+/- appropriate aid).
* Goal setting
* Advising patient and team on pain management and expectations post-surgery
* Advised on swelling management
* Exercises
* Balance retraining and confidence building
* Gait retraining
* Considering home environment.
* Interactions with family and carer
<blockquote>It is important that the patient is transferred out of bed, within these limitations, as early as possible to avoid complications of bed rest (e.g. chest infections, DVT, muscle atrophy). NICE guidelines advise, unless contraindicated, for patient's to mobilise the day after surgery. <ref name=":1" /></blockquote>Physiotherapy exercises post hip surgery:
{| class="wikitable sortable"
!
!After surgery
!
!After 6 weeks
|-
|Supine
|Hip ABD and heel slides
(slide sheet can reduce friction)[[File:Hip abd.png|thumb]][[File:Heel slide.png|thumb]]
|Inner Range Quads[[File:Inner range quads.png|thumb]]
|Bridges (unless NWB) [[File:Bridge ex.png|thumb]]
|-
|Sitting
|Knee extension[[File:Knee ext in sitting.png|thumb]]
|Knee flexion[[File:Knee flexion.png|thumb]]
|Sit to stand (one balance optimised)[[File:Sit to stand.png|thumb]]
|-
|Standing
|
|
|
|}


#
Watch this 10 minute video on the technique.{{#ev:youtube|A3x0GmAHcKY|}} 
'''Standing Exercises'''


Do these once you’re able to stand safely. When doing these exercises, remember to stand straight and tuck in your pelvis and buttocks. Do these exercises with your '''operated leg only'''.
== History ==
[[File:Dynamic-hip-screw-sliding.png|thumb|Previous lag screw, has slid, indicating # compression. ]]
Prior to the use of DHS sliding screws, angled blade plates were used<ref name=":0">Singh A.P. ''Dynamic Hip Screw Or Sliding Hip Screw''. [online] Available at: <<nowiki>http://www.boneandspine.com/dynamic-hip-screw/</nowiki>> [Accessed 19 September 2020].</ref>. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent [[Osteotomy|osteotomies]]. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union<ref name=":0" />. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for [https://physio-pedia.com/Bone_Healing#sts=Stages%20of%20Indirect%20Healing?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal bone healing].   


Standing against a countertop or wall with bar for support is safer than a chair. If you do use a chair, make sure it’s sturdy.
NICE Guidelines recommends: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)<ref name=":1">NICE ''Hip Fracture: Management'' <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia> [accessed 19/9/20]</ref>.  
 
== Complications ==
Exercise #1
See also [[Fracture Complications|fracture complications]]
# Stand with support.
* Infection
# Slowly move your leg out to the side, and then back. Keep your leg straight at all times.
* Haematoma
# Repeat.
* Non-union or malunion
Exercise #2
* Implant complication, e.g. screw or plate fracture (2% 2)
# Stand with support.
* [[Avascular Necrosis|Avascular necrosis]]<ref name=":2" />
# Keeping your back and legs straight, slowly move your leg behind you. Keep the leg straight. Be careful not to lean forward.
# Repeat.
Exercise #3
# Stand with support.
# Lift your knee up as if going up a stair.
# Hold for a count of 3 to 5.
# Place your foot back on the floor.
# Repeat.
Exercise #4
# Stand with support.
# Bend your knee by lifting your heel up towards your buttocks. Don’t move your thigh forward.
# Hold for a count of 3 to 5.
# Slowly lower your foot to floor.
# Repeat.
 
=== Hip Exercises: Phase 2 ===
You can start these exercises 6 weeks after surgery '''and''' once you’re comfortable with all the Phase 1 exercises. If they hurt too much, check with your doctor or surgeon.
 
Start with a few at a time and do them often. Do them at least 2 times a day, repeating each exercise 5 to 10 times. Slowly increase to 4 times a day, repeating each exercise 30 times. Do all exercises slowly and with control.
 
'''Bed Exercises'''
 
Exercise #1
# Lie on your back with knees bent and feet shoulder-width apart.
# Lift hips toward the ceiling.
# Hold for a count of 3 to 5. Remember to breathe.
# Slowly return to the starting position.
# Repeat.
Exercise #2
# Lie on your side with hips and knees bent. You can add a pillow between your legs for comfort or if you were told to.
# Keep your feet together. Remember not to twist or use your back muscles.
# Lift the top knee, like a clamshell opening.
# Hold for a count of 3 to 5 and slowly lower the knee.
# Repeat.
Exercise #3
# Lie on your side, with the bottom leg bent to stop you from rolling onto your back.
# Keeping the top leg straight, lift it towards the ceiling, making sure not to roll forward or backward. Keep your knee facing forward.
# Slowly lower the leg.
# Repeat.
'''Standing Exercises'''
 
Do these exercises once you’re able to stand safely. When doing these standing exercises, remember to stand straight and tuck in your pelvis and buttocks.
 
Standing against a countertop or wall with bar for support is safer than using a chair. If you do use a chair, make sure it’s sturdy).
 
Exercise #1
# Stand with support.
# Gently rise up on your toes
# Hold for a count of 3 to 5.
# Return your feet flat on the ground.
# Repeat.
Exercise #2
# Stand with support.
# Keep your feet shoulder-width apart.
# Bend your hips and knees while keeping your back straight. Make sure your knees don’t go past your toes.
# Hold for a count of 3 to 5.
# Squeeze buttocks and thigh muscles to stand up straight.
# Repeat.
Exercise #3
# Sit on edge of chair, with your feet flat on floor.
# With your hands on your hips, stand up straight.
# Stand for a count of 3 to 5 and then sit back down.
# Repeat.
 
== Evidence  ==
 
Provide the evidence for this technique here
 
== Resources  ==
 
[https://www.youtube.com/watch?v=A3x0GmAHcKY Youtube] - DHS surgery


== Physiotherapy Interventions ==
See [[Femoral Neck Hip Fracture]]
== References  ==
== References  ==


<references />
<references />
[[Category:Hip]]
[[Category:Hip - Interventions]]
[[Category:Fractures]]
[[Category:Orthopaedic Surgical Procedures]]

Latest revision as of 02:18, 16 December 2022

Original Editor - Rhiannon Clement
Top Contributors - Rhiannon Clement, Lucinda hampton and Kim Jackson

Introduction[edit | edit source]

Xray DHS

The dynamic hip screw (DHS), a femoral head-sparing orthopaedic device, is used to treat femoral neck fractures. Alternately referred to as a pin and plate.

  1. Femoral neck fractures that are undisplaced (Garden I and II fractures) can be treated with head-preserving surgery and internal fixation.
  2. In fractures with a high risk of femoral head avascular necrosis (Garden III and VI fractures), femoral head resection and hip hemiarthroplasty is favoured.

Note: DHS is a trade name for the Synthes company, being one type of sliding hip screw. There are various types of sliding hip screws produced by various implant companies. [1]

Technique[edit | edit source]

After reduction, the fracture is internally fixed by application a large lag screw through the neck, this is held laterally by a lateral femoral plate. The DHS can slide in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture hence aiding healing. If sliding takes place, the lateral end of the lag screw may project laterally from the plate.

Watch this 10 minute video on the technique.

History[edit | edit source]

Previous lag screw, has slid, indicating # compression.

Prior to the use of DHS sliding screws, angled blade plates were used[2]. These fixed plates matched the angle of the femural head. These plates had a number of complications, including failure to purchase, requiring frequent osteotomies. They also did not allow any compression across the fracture site, leading to stress failures and frequent non-union[2]. Therefore, the DHS, with sliding barrel, was created to allow controlled compression across the fracture site. This is important for bone healing.

NICE Guidelines recommends: Use extramedullary implants such as a sliding hip screw in preference to an intramedullary nail in patients with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2)[3].

Complications[edit | edit source]

See also fracture complications

  • Infection
  • Haematoma
  • Non-union or malunion
  • Implant complication, e.g. screw or plate fracture (2% 2)
  • Avascular necrosis[1]

Physiotherapy Interventions[edit | edit source]

See Femoral Neck Hip Fracture

References[edit | edit source]

  1. 1.0 1.1 Radiopedia DHS Available:https://radiopaedia.org/articles/dynamic-hip-screw (accessed 14.12.2022)
  2. 2.0 2.1 Singh A.P. Dynamic Hip Screw Or Sliding Hip Screw. [online] Available at: <http://www.boneandspine.com/dynamic-hip-screw/> [Accessed 19 September 2020].
  3. NICE Hip Fracture: Management <available from: https://www.nice.org.uk/guidance/cg124/chapter/Recommendations#analgesia> [accessed 19/9/20]