Fracture-dislocation of the Hip-kaizar

8/6/2019 Fracture-dislocation of the Hip-kaizar

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FRACTUREFRACTURE--DISLOCATIONDISLOCATION

OF THE HIPOF THE HIP IN ADULTSIN ADULTS

Dr.E.Kaizar EnnisDr.E.Kaizar Ennis


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DefinitionDefinition

A dislocation is a separationA dislocation is a separation ofof two bonestwo bones

where they meet at a joint. A dislocated bonewhere they meet at a joint. A dislocated bone

is no longer in its normal position. Ais no longer in its normal position. Adislocation may also cause ligament or nervedislocation may also cause ligament or nerve

damage. Dislocations may be associated with adamage. Dislocations may be associated with a

periarticular fractureperiarticular fracture


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IntroductionIntroduction

Hip joint injuries commonly are complicatedHip joint injuries commonly are complicated

by injuries to other organ systems or to theby injuries to other organ systems or to the

pelvis, which can result in hemorrhage andpelvis, which can result in hemorrhage andshock. Displacement of the femoral head orshock. Displacement of the femoral head or

acetabulum may injure the sciatic, femoral, oracetabulum may injure the sciatic, femoral, or

obturator nerve.obturator nerve.


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Anatomy: Hip JointAnatomy: Hip Joint

Ball and socket joint.Ball and socket joint.

Femoral head: slightlyFemoral head: slightly

asymmetric, forms 2/3asymmetric, forms 2/3

sphere.sphere.Acetabulum: inverted UAcetabulum: inverted U

shaped articular surface.shaped articular surface.

Ligamentum teres, withLigamentum teres, with

artery to femoral head,artery to femoral head,

passes through middlepasses through middle

of inverted U.of inverted U.


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Joint Contact AreaJoint Contact Area

Throughout ROM:Throughout ROM:

40% of femoral40% of femoral

head is in contacthead is in contact

with acetabularwith acetabular

articular cartilage.articular cartilage.

10% of femoral10% of femoral

head is in contacthead is in contactwith labrum.with labrum.


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Acetabular LabrumAcetabular Labrum

Strong fibrous ringStrong fibrous ring

Increases femoral headIncreases femoral head

coveragecoverage

Contributes to hip jointContributes to hip joint

stabilitystability


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Hip Joint CapsuleHip Joint Capsule

Extends from intertrochanteric ridge ofExtends from intertrochanteric ridge of

proximal femur to bony perimeter ofproximal femur to bony perimeter of

acetabulumacetabulum Has several thick bands of fibrous tissueHas several thick bands of fibrous tissue


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Femoral NeckAnteversionFemoral NeckAnteversion

Males and Females have been noted to haveMales and Females have been noted to have

anteversion of 14anteversion of 1400 and 16and 1600 respectively.respectively.

Slightly higher in femalesSlightly higher in females


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Blood Supply to Femoral HeadBlood Supply to Femoral Head

1 - artery of ligamentum teres

2 - retinacular vessels

3 - metaphyseal blood supply

Blood supply to the

femoral head


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ContCont


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Sciatic NerveSciatic Nerve

Composed from roots of L4 to S3.Composed from roots of L4 to S3.

Peroneal and tibial componentsPeroneal and tibial components

differentiate early, sometimesdifferentiate early, sometimes

as proximal as in pelvis.as proximal as in pelvis.

Passes posterior to posterior wallPasses posterior to posterior wall

of acetabulum.of acetabulum.

Generally passes inferior toGenerally passes inferior topiriformis muscle, butpiriformis muscle, but

occasionally the piriformis willoccasionally the piriformis will

split the peroneal and tibialsplit the peroneal and tibial

componentscomponents


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Mechanism of InjuryMechanism of Injury

Almost always due to highAlmost always due to high--energy trauma.energy trauma.

Most commonly involve unrestrained occupantsMost commonly involve unrestrained occupantsin MVAs.in MVAs.

Can also occur in pedestrianCan also occur in pedestrian--MVAs, falls fromMVAs, falls fromheights, industrial accidents and sportingheights, industrial accidents and sporting

injuriesinjuries


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Clinical EvaluationClinical Evaluation--HistoryHistory

ABC sABC s

Evaluation of hip dislocationEvaluation of hip dislocation

Associated injuries are common:Associated injuries are common:

Head and facial injuriesHead and facial injuries

Chest injuriesChest injuries

IntraIntra--abdominal injuriesabdominal injuries

Extremity fractures and dislocationsExtremity fractures and dislocations


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Associated InjuriesAssociated Injuries

Dashboard injuryDashboard injury

Contusions of distal femurContusions of distal femur

Patella fracturesPatella fracturesFoot fractures, if knee extendedFoot fractures, if knee extended


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Associated InjuriesAssociated Injuries

Sciatic nerve injuries occur in 10% of hipSciatic nerve injuries occur in 10% of hip

dislocations.dislocations.

Most commonly, these resolve with reduction ofMost commonly, these resolve with reduction ofhip and passage of time.hip and passage of time.

Stretching or contusion most common.Stretching or contusion most common.

Piercing or transection of nerve by bone canPiercing or transection of nerve by bone canoccur.occur.


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Physical ExaminationPhysical Examination

Classical AppearanceClassical Appearance

Posterior Dislocation:Posterior Dislocation:

Hip flexed,Hip flexed,

internallyinternally rotated,rotated,

adducted.adducted.


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Unclassical presentation (posture)Unclassical presentation (posture)

femoral head or neck fracturefemoral head or neck fracture

femoral shaft fracturefemoral shaft fracture

obtunded patientobtunded patient


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Physical ExaminationPhysical Examination

Pain to palpation of hip.Pain to palpation of hip.

Pain with attempted motion of hip.Pain with attempted motion of hip.

Possible neurological impairment:Possible neurological impairment:Thorough exam essential!Thorough exam essential!


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InvestigationsInvestigations--XX--raysrays

AP pelvis, Lateral HipAP pelvis, Lateral Hip

xx--ray.ray.

Judet views of pelvis.Judet views of pelvis.

CT scan with 2CT scan with 2--3 mm3 mm

cutscuts


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AP view of normal pelvisAP view of normal pelvis


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CT ScanCT Scan

Most helpfulMost helpful afterafter hiphip

reduction.reduction.

Reveals:Reveals:

NonNon--displaced fractures.displaced fractures.

Congruity of reduction.Congruity of reduction.

IntraIntra--articular fragments.articular fragments.

Size of bony fragments.Size of bony fragments.


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MRI ScanMRI Scan

Will reveal labral tearWill reveal labral tear

and softand soft--tissue anatomy.tissue anatomy.

Has not been shown toHas not been shown to

be of benefit in acutebe of benefit in acuteevaluation and treatmentevaluation and treatment

of hip dislocations.of hip dislocations.


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Effect of Dislocation on FemoralEffect of Dislocation on Femoral

Head CirculationHead Circulation

When capsule tears, ascending cervical branchesWhen capsule tears, ascending cervical branches

are torn or stretched.are torn or stretched.

Artery of ligamentum teres is torn.Artery of ligamentum teres is torn.Some ascending cervical branches may remainSome ascending cervical branches may remain

kinked or compressed until the hip is reduced.kinked or compressed until the hip is reduced.

Thus, early reduction of the dislocated hip canThus, early reduction of the dislocated hip canimprove blood flow to femoral head.improve blood flow to femoral head.


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Clinical Management:Clinical Management:

Emergent TreatmentEmergent Treatment

These injuries are orthopaedic emergencies;These injuries are orthopaedic emergencies;

the dislocation of the hip should be reduced asthe dislocation of the hip should be reduced as

quickly as possible.quickly as possible.

Operative reduction is indicated if satisfactoryOperative reduction is indicated if satisfactory

closed reduction cannot be obtained promptly.closed reduction cannot be obtained promptly.

Goal is to reduce risk of AVN and DJD.Goal is to reduce risk of AVN and DJD.


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Older classification systems described hipOlder classification systems described hip

dislocations as posterior, anterior, obturator, ordislocations as posterior, anterior, obturator, or

central. True central fracturecentral. True central fracture--dislocation is rare. In adislocation is rare. In a

few patients with significant metabolic bone disease,few patients with significant metabolic bone disease,a true central dislocation may occur through the floora true central dislocation may occur through the floor

of the acetabulum without fracture of the anterior orof the acetabulum without fracture of the anterior or

posterior columns. More commonly, a centralposterior columns. More commonly, a central

fracturefracture--dislocation actually is a transverse fracture ofdislocation actually is a transverse fracture ofthe acetabulum, a boththe acetabulum, a both--column acetabular fracture.column acetabular fracture.


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Posterior DislocationPosterior Dislocation

90% of all hip dislocations.90% of all hip dislocations.

Patients with a posterior dislocation of the hipPatients with a posterior dislocation of the hipgenerally present with a shortened, internally rotated,generally present with a shortened, internally rotated,

adducted limb in slight flexion. This position can beadducted limb in slight flexion. This position can bealtered if the femoral head is impaled on a fracturedaltered if the femoral head is impaled on a fracturedposterior acetabular wallposterior acetabular wall

If the hip is adducted at the time of injury, a pureIf the hip is adducted at the time of injury, a pure

dislocation occurs, whereas a neutral position ordislocation occurs, whereas a neutral position orabduction leads to dislocation associated with aabduction leads to dislocation associated with afracture of the femoral head or acetabulum.fracture of the femoral head or acetabulum.


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Radiographic featuresRadiographic features

Femoral head lateral andFemoral head lateral and

superior to the acetabulum.superior to the acetabulum.

Fracture of the posterior rimFracture of the posterior rim

of the acetabulum in mostof the acetabulum in mostcases.cases.

Femur in internal rotationFemur in internal rotation

and adduction.and adduction.

Affected femoral head mayAffected femoral head mayappear smaller secondary toappear smaller secondary to

magnification.magnification.


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Thompson and Epstein classifiedThompson and Epstein classified

posterior dislocations of the hipposterior dislocations of the hip Type I:Type I: Dislocation with or without minor fractureDislocation with or without minor fracture

Type II:Type II: Dislocation with a large single fracture of theDislocation with a large single fracture of theposterior acetabular rimposterior acetabular rim

Type III:Type III: Dislocation with comminution of the posteriorDislocation with comminution of the posterioracetabular rim with or without a major fragmentacetabular rim with or without a major fragment

Type IV:Type IV: Dislocation with fracture of the acetabular floorDislocation with fracture of the acetabular floor

Type V:Type V: Dislocation with fracture of the femoral headDislocation with fracture of the femoral head


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The proper treatment of a dislocation or fractureThe proper treatment of a dislocation or fracture--

dislocation of the hip depends primarily on the typedislocation of the hip depends primarily on the type

of injury, but regardless of the type of dislocation,of injury, but regardless of the type of dislocation,

some general guidelines apply: (1) longsome general guidelines apply: (1) long--term resultsterm resultsare directly related to the severity of the initialare directly related to the severity of the initial

trauma; (2) reduction, open or closed, should betrauma; (2) reduction, open or closed, should be

performed within 12 hours; and (3) only one or twoperformed within 12 hours; and (3) only one or two

attempts at closed reduction should be made; if theseattempts at closed reduction should be made; if thesefail, open reduction is indicated to prevent furtherfail, open reduction is indicated to prevent further

damage to the femoral head.damage to the femoral head.


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Type I Posterior DislocationType I Posterior Dislocation

General anesthesiaGeneral anesthesia

A type I dislocation is treated by closed reduction, ifA type I dislocation is treated by closed reduction, if

possible, followed by immobilization in Buckpossible, followed by immobilization in Buck

traction, an abduction pillow, knee immobilizertraction, an abduction pillow, knee immobilizer(preventing hip flexion), or Thomas splint.(preventing hip flexion), or Thomas splint.

If reduction cannot be performed under theseIf reduction cannot be performed under these

conditions, repeated attempts are not advisableconditions, repeated attempts are not advisable

because of the risk of additional damage to thebecause of the risk of additional damage to the

femoral head.femoral head.


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Before open or closed reduction, the patient should beBefore open or closed reduction, the patient should beexamined carefully for injury to the sciatic nerve. Aexamined carefully for injury to the sciatic nerve. Acomplete or partial palsy of this nerve occurs incomplete or partial palsy of this nerve occurs in

approximately 10%

to 15%

of patients with posteriorapproximately 10%

to 15%

of patients with posteriordislocationsdislocations

Direct nerve trauma from the force of the dislocation,Direct nerve trauma from the force of the dislocation,bone fragments, or nerve ischemia from pressure on itbone fragments, or nerve ischemia from pressure on itby the headby the head

partial recovery occurred in 60% to 70% of patients.partial recovery occurred in 60% to 70% of patients.Sciatic nerve function should be documented afterSciatic nerve function should be documented afterreduction.reduction.


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After closed reduction of the hip is performed,After closed reduction of the hip is performed,

another anteroposterior pelvic radiograph isanother anteroposterior pelvic radiograph is

obtained to ensure that the reduction of the hipobtained to ensure that the reduction of the hip

is concentricis concentric

nonconcentric reduction can be shown as anonconcentric reduction can be shown as a

persistent widening of the distance between thepersistent widening of the distance between the

radiographic teardrop and the femoral headradiographic teardrop and the femoral headcompared with the normal hipcompared with the normal hip


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Bone fragments that are interposed betweenBone fragments that are interposed between

the articular surfaces of the femoral head andthe articular surfaces of the femoral head and

the acetabulum require operative dbridementthe acetabulum require operative dbridement


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Bigelow ManeuverBigelow Maneuver

The femoral head isThe femoral head is

levered into thelevered into the

acetabulum by theacetabulum by thecombination ofcombination of

abduction, externalabduction, external

rotation, and extensionrotation, and extension

of the hip.of the hip.


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After Treatment for CRAfter Treatment for CR

Mobilizing patients after they have regainedMobilizing patients after they have regained

the ability to perform a straight leg raise,. Theythe ability to perform a straight leg raise,. They

are mobilized with crutches initially withare mobilized with crutches initially with

touchtouch--down weight bearing and resumption ofdown weight bearing and resumption of

weight bearing to tolerance as pain subsides.weight bearing to tolerance as pain subsides.

Patients observe these precautions for 6 weeksPatients observe these precautions for 6 weeks


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Type II, III, or IV PosteriorType II, III, or IV Posterior

DislocationDislocation

reduced by the same closed techniques used forreduced by the same closed techniques used for

uncomplicated dislocationsuncomplicated dislocations

The dislocation should be reduced as soon as possibleThe dislocation should be reduced as soon as possible

because delay of more than 12 hours makesbecause delay of more than 12 hours makessubsequent osteonecrosis of the femoral head muchsubsequent osteonecrosis of the femoral head much

more likely.When the femoral head has been reducedmore likely.When the femoral head has been reduced

accurately within the intact part of the acetabulum,accurately within the intact part of the acetabulum,

open reduction of the acetabular fragments, ifopen reduction of the acetabular fragments, ifindicated, can be delayed for 5 to 10 days.indicated, can be delayed for 5 to 10 days.


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In type II fractureIn type II fracture--dislocations involvingdislocations involving

smaller posterior wall fragments, stability mustsmaller posterior wall fragments, stability must

be evaluated after reduction of the dislocation.be evaluated after reduction of the dislocation.

Test of stability : the hip is flexed to 90Test of stability : the hip is flexed to 90

degrees with neutral rotation and abduction. Ifdegrees with neutral rotation and abduction. If

the hip is stable with this test, initiallythe hip is stable with this test, initially

advocated by Gregory, no surgery is indicatedadvocated by Gregory, no surgery is indicated


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Type V Posterior FractureType V Posterior Fracture--DislocationDislocation

with Femoral Head Fracturewith Femoral Head Fracture

Fractures of the femoral head associated withFractures of the femoral head associated with

posterior dislocation of the hip are uncommon.posterior dislocation of the hip are uncommon.

They occur as a shearing injury as the flexedThey occur as a shearing injury as the flexed

hip is driven across the posterior wall of thehip is driven across the posterior wall of the

acetabulum during dislocation.acetabulum during dislocation.


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Pipkin classificationPipkin classification

Pipkin subclassified EpsteinPipkin subclassified Epstein--Thomas type V fractureThomas type V fracture--dislocations into fourdislocations into fouradditional subtypesadditional subtypes

Type I:Type I: Posterior dislocation of the hip with fracture of the femoral headPosterior dislocation of the hip with fracture of the femoral headcaudad to the fovea capitiscaudad to the fovea capitis

Type II:Type II: Posterior dislocation of the hip with fracture of the femoral headPosterior dislocation of the hip with fracture of the femoral headcephalad to the fovea capitiscephalad to the fovea capitis

Type III:Type III: Type I or II posterior dislocation with associated fracture of theType I or II posterior dislocation with associated fracture of thefemoral neckfemoral neck

Type IV:Type IV: Type I, II, or III posterior dislocation with associated fracture ofType I, II, or III posterior dislocation with associated fracture ofthe acetabulumthe acetabulum


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Brumback classificationBrumback classification

Brumback et al.Brumback et al.

further classifiedfurther classified

femoral head fracturesfemoral head fractures

emphasizing hipemphasizing hipstability, with typestability, with type

B injuries beingB injuries being

unstableunstable


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Closed reduction of the hip dislocation usually isClosed reduction of the hip dislocation usually is

successful in Pipkin types I and II injuries.successful in Pipkin types I and II injuries.

Occasionally, the femoral head fragmentOccasionally, the femoral head fragment

spontaneously reduces to an anatomical position asspontaneously reduces to an anatomical position aswell.well.

The Pipkin classification scheme was a usefulThe Pipkin classification scheme was a useful

predictor of outcomes. Patients with less severepredictor of outcomes. Patients with less severe

Pipkin type I or II injuries had significantly betterPipkin type I or II injuries had significantly betteroutcomes than patients with type III or IV injuries.outcomes than patients with type III or IV injuries.


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If the hip dislocation is irreducible, immediate CTIf the hip dislocation is irreducible, immediate CT

scanning of the pelvis is indicated to determine thescanning of the pelvis is indicated to determine the

size of the femoral head fracture fragment and tosize of the femoral head fracture fragment and to

evaluate the impediments to reduction. Openevaluate the impediments to reduction. Openreduction is performed immediately, with fixation orreduction is performed immediately, with fixation or

excision of the fracture fragment as indicated byexcision of the fracture fragment as indicated by

Pipkin type.Pipkin type.

Arthroscopic treatment of these injuries, removingArthroscopic treatment of these injuries, removingsmall fragments or torn sections of the acetabularsmall fragments or torn sections of the acetabular

labrum, has been reported with encouraging resultslabrum, has been reported with encouraging results


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If the reduction is concentric, and the dislocation isIf the reduction is concentric, and the dislocation is

stable, the size of the head fragment in Pipkin type Istable, the size of the head fragment in Pipkin type I

fractures is unimportant, and results have beenfractures is unimportant, and results have been

excellent with small and large head fragments.excellent with small and large head fragments. If closed reduction is impossible or if the reduction isIf closed reduction is impossible or if the reduction is

not concentric, open reduction with excision of smallnot concentric, open reduction with excision of small

fragments should be done immediately. Largefragments should be done immediately. Large

fragments also are removed, provided that they do notfragments also are removed, provided that they do notalter the postreduction stability.alter the postreduction stability.


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After internal fixation, the patient is mobilizedAfter internal fixation, the patient is mobilizedwith touchwith touch--down weight bearing for 3 months.down weight bearing for 3 months.Hip precautions, or avoiding the positions ofHip precautions, or avoiding the positions of

potential redislocation, are crucial. Thepotential redislocation, are crucial. Theinsertion of a femoral head prosthesis insteadinsertion of a femoral head prosthesis insteadof internal fixation should be considered inof internal fixation should be considered inolder patients because of the high rate ofolder patients because of the high rate of

osteonecrosis of the fracture fragment andosteonecrosis of the fracture fragment andposttraumatic arthritis after internal fixation inposttraumatic arthritis after internal fixation inthese patientsthese patients


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Pipkin Type IV Dislocation withPipkin Type IV Dislocation with

Acetabular FractureAcetabular Fracture In Pipkin type IV injuries, treatment usually isIn Pipkin type IV injuries, treatment usually is

determined by the type of acetabular fracture .Opendetermined by the type of acetabular fracture .Openreduction and reconstruction of the acetabulumreduction and reconstruction of the acetabulumusually are recommended, but late problems may beusually are recommended, but late problems may be

encountered. In young patients, if concentricencountered. In young patients, if concentricreduction with reasonable joint congruity cannot bereduction with reasonable joint congruity cannot beobtained by closed means, open reduction andobtained by closed means, open reduction andinternal fixation of all major fragments are justified.internal fixation of all major fragments are justified.In older patients or in patients with significantIn older patients or in patients with significant

preexisting disease within the joint, some type ofpreexisting disease within the joint, some type ofreplacement arthroplasty may be considered,replacement arthroplasty may be considered,depending on the type of fracture and the extent ofdepending on the type of fracture and the extent ofacetabular involvementacetabular involvement


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Siebenrock et al. and Ganz et al. described aSiebenrock et al. and Ganz et al. described a

surgical hip dislocation technique for femoralsurgical hip dislocation technique for femoral

head fractures with posterior hip dislocation.head fractures with posterior hip dislocation.

Inspection of the entire femoral head and fullInspection of the entire femoral head and full

circumference of the acetabulum is possible,circumference of the acetabulum is possible,

and the risk of osteonecrosis is minimizedand the risk of osteonecrosis is minimized


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PresentationPresentation

At presentation in the emergency department, theAt presentation in the emergency department, thelower extremity is externally rotated, and the hip islower extremity is externally rotated, and the hip isextended (pubic dislocation) or flexed and abductedextended (pubic dislocation) or flexed and abducted(obturator dislocation).(obturator dislocation).

Because of their anterior relationship to the hip, theBecause of their anterior relationship to the hip, thefemoral vessels and nerve may be injured, especiallyfemoral vessels and nerve may be injured, especiallywith pubic dislocations. An anterior dislocationwith pubic dislocations. An anterior dislocationusually can be reduced without surgery by pullingusually can be reduced without surgery by pulling

longitudinally on the thigh with appropriate tractionlongitudinally on the thigh with appropriate tractionand applying lateral force on the proximal thigh whileand applying lateral force on the proximal thigh whilepushing the femoral head toward the acetabulum.pushing the femoral head toward the acetabulum.


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In obturator dislocations, the femoral headIn obturator dislocations, the femoral head

rests against the sharp anterolateral margin ofrests against the sharp anterolateral margin of

the obturator foramen, causing an indentationthe obturator foramen, causing an indentation

fracture on the anterosuperior aspect of thefracture on the anterosuperior aspect of the

femoral head.femoral head.


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Posterior vs Anterior ApproachPosterior vs Anterior Approach

Support for Posterior ApproachSupport for Posterior Approach Sarmiento, CORR 1973Sarmiento, CORR 1973

Epstein, JBJS 1974 (0 good results with ant. approach)Epstein, JBJS 1974 (0 good results with ant. approach)

Support for Anterior ApproachSupport for Anterior Approach Swiontkowski, Thorpe, Seiler, Hansen,Swiontkowski, Thorpe, Seiler, Hansen, JOrthop TraumaJOrthop Trauma 1992:1992:

12 anterior, 12 posterior.12 anterior, 12 posterior.

Less blood loss and operative time with anterior approach.Less blood loss and operative time with anterior approach.

Improved visualization anteriorly.Improved visualization anteriorly.

67% good and excellent in each group.67% good and excellent in each group.

Nork, Routt et al, OTA 2001: 21 cases, ? one AVNNork, Routt et al, OTA 2001: 21 cases, ? one AVN


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Reconstruct HeadWheneverReconstruct HeadWhenever

PossiblePossible


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THANK YOUTHANK YOU

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Fracture-dislocation of the Hip-kaizar