HIP DISLOCATION AND FRACTURE OF THE FEMUR HEAD

Orthopaedic and Traumatology DepartmentFaculty of MedicineHasanuddin University

TEXTBOOK PRESSENTATIONOctober 2015

CLINICAL STUDENT ASSIGNMENTORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

FACULTY OF MEDICINEHASANUDDIN UNIVERSITY

2015

Lily arfiani/Muna Munirah/Irma armiyah/Sawastika Asfarina/Ilzy jum

Ahmad/Geby Oktavia/Regi Anastasya/Saidah Mafisah

ADVISOR:dr. Syarif

dr. SebastianDr. Handoko

SUPERVISOR :dr. M. Andry Usman, Ph.D, Sp.OT

HIP DISLOCATION

Introduction

Hip dislocations and fracture-dislocations occur across all age groups and represent a spectrum of injuries that can result when abnormal load is placed on the hip

Dislocations of the hip usually result from moderate to severe trauma

Most dislocations without fractures are posterior (approximately 80%)

Classification

Hip dislocation

Anterior Posterior Central

The mechanism of trauma

much more commonly than

anterior dislocations (89%

to 92%)

Evaluation

Look in posterior dislocation: the leg is shortened and is held in flexion, adduction, and internal rotation. In anterior dislocation, the leg is held in external rotation, abduction, and mild flexion or extension

Palpation A feeling of fullness in the soft tissues in the direction of displacement of the femoral head may be palpable

Neurovascular examination

Radiographic evaluation

X-Ray conventional

AP Radiograph demonstrates typical appearance of an anterior hip dislocation on the patient’s right and a posterior fracture-dislocation on the left. The head of an anteriorly dislocated hip appears larger on plain radiographs than the contralateral normal hip; a posteriorly dislocated hip appears smaller

Cont.. CT Scan should be

obtained after reduction to assess the congruency of the hip joint for checking for free osteochondral fragments within the joint

Axial CT scan demonstrates an incarcerated femoral head fragment

MRI—MRI can be useful for assessing the hip that has been reduced and has been found to be incongruent but without interposed tissue on CT scan. better at evaluating the labrum, the muscles, and the capsule

Classification System For Posterior Dislocation Thompson and Epstein (1951)—The classification system of

Thompson and Epstein is based on the severity of the acetabular and/or femoral head fracture

Stewart and Milford (1954)—The classification system of Stewart and Milford is based on the stability of the hip after reduction and the condition of the femoral head

Classification of dislocation and associated fractures Comprehensive classification—The Comprehensive classification

system is based on the reducibility of the hip, the presence of interposed fragments, the stability of the reduced hip, and associated fractures

Brumback et al.—The classification of Brumback et al. is based on the direction of dislocation and associated fractures

Associated Injuries

2 categories:1. associated with the dislocation 2. associated with the precipitating

trauma

Injuries associated with the dislocationdetermined by :1.vector of the traumatic load2.the rate of load

transmission3.the point of load

transmission, and 4.the position of the leg at the

time of impact

centrally directed force on an abducted leg fractures the pelvis, the acetabulum, the femur, or a combination thereof.

if the force is directed more posteriorly and the leg moves into adduction and flexion posterior fracture-dislocation.

If the hip more adduction pure dislocation posterior

posterior impact or a force on an abducted and extended leg anterior dislocation

The incidence of femoral head fractures is higher with anterior dislocations

Treatment

Close Reduction :posterior dislocations

Allis and Bigelow techniques

Stimson technique

Techniques for anterior dislocations Anterior dislocations are harder to reduce than

posterior dislocations With the leg in external rotation, abduction, and

flexion, inline traction is applied The leg is rocked in internal and external rotation

to walk the head over the anterior acetabular rim A lateralizing force on the proximal femur may

assist with the reduction. This can be done by direct pressure over the femoral head in the inguinal region or if in the operating room a Schanz pin in the proximal femur

Assessment of stability

Posterior stability The hip is flexed to 90°, and while it is held in neutral rotation and neutral abduction, a posteriorly directed force is applied to the leg. If the hip subluxes, it is unstable.

Anterior stability The hip is abducted, flexed, and externally rotated. If gravity can dislocate the hip, it is unstable.

Hip instability If the hip is unstable, the bony injury producing the instability needs to be fixed by open reduction and internal fixation.

Open Reduction

Indication :1. Hips that cannot be reduced closed2. Hips with associated fractures that are

unstable after reduction, and 3. Hips that are not congruent after reduction

If the dislocation, the instability, or the interposed fragment is posterior Chose posterior approach

If the dislocation, the instability, or the interposed fragment is anterior Chose anterior

Postreduction management In a pure dislocation, weightbearing

is as tolerated with crutches until leg control has been regained.

Appropriate hip precautions are recommended for 6 weeks following dislocation.

Relevant Surgical Techniques Posterior (Kocher-

Langenbeck) ApproachAnterolateral (Watson-Jones,

Hardinge, Dall, or Trochanteric Slide) Approach

Anterior (Smith-Petersen) approach

Complications of Injury

Sciatic nerve injury AVN Arthritis Recurrent dislocations Heterotopic ossification Persistent pain

Complications of Treatment Infection Sciatic nerve injury AVN Thromboembolism

Outcomes

The most important prognostic factor in dislocations of the hip is the time to reduction (<6 to 12 hours) to avoid ongoing damage to the blood supply to the femoral head

Femoral Head Fractures

Overview

Femoral head fractures always occur as the result of hip dislocation or subluxation.

A total of 82% to 92% of hip dislocations are posterior and 4% to 18% are associated with femoral head fractures

Classification

Pipkin classification is an elaboration of the Thompson and Epstein Type V posterior hip dislocation. It includes associated injuries and provides prognostic information

Pipkin classification

Treatment

Pipkin type I Closed treatment can be considered for isolated and small infrafoveal fractures. Closed management consists of protected weight bearing with appropriate hip precautions

Pipkin type II These injuries are treated with open reduction and internal fixation if not anatomically reduced

Pipkin type III Closed reduction of the hip dislocation is contraindicated.

All patients should undergo surgical evaluation via an anterolateral (Watson-Jones) or anterior approach (Smith-Peterson) that allows access to both the anterior and posterior aspects of the hip joint The femoral neck fracture must be stabilized before reduction of the hip dislocation

If the head fragment is large, often reduction of the neck and head fragments must occur simultaneously

Pipkin type IV The type and location of the acetabular fracture dictates the surgical approach for the acetabulum.

The concomitant femoral head fracture can be treated through a separate anterior approach (Smith-Peterson) if necessary. However, often a posterior Kocher- Langenbeck approach will allow visualization of the posterior acetabulum

Rehabilitation

The patient should undergo aggressive ROM exercises after open fixation of a Pipkin fracture. Toe-touch weight bearing is typically used for the first 8 weeks and then progressed to weight bearing as tolerated

Thank you.