Transcript hip - Pilgrims Hospital

MC, 26yo male
• Unrestrained driver
• Late night accident
• Collided head-on with wall at 60kmph
MC, 26yo male
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Brought to ED by ambulance
Isolated left lower limb injury
Hip flexed, adducted, internally rotated
Severe pain on attempted motion of hip
No peripheral neurological/vascular
deficit
Diagnosis
• Posterior dislocation of left hip
• Loose bone fragment
– from ?posterior wall of acetabulum vs.
femoral head
• Immediate attempt of reduction in ED
under sedation – failed
• Brought to OR
• Hip reduced under GA
Post-manipulation CT
• Hip joint reduced
• Acetabulum intact
• Fracture of femoral head below the
fovea (insertion of ligamentum teres)
• Rotation of fractured fragment noted
Treatment
• Patient brought to OR
• ORIF of femoral head
• Anterolateral approach to hip with
trochanteric slide osteotomy
• Circulation-sparing approach
Treatment
• Fragment anatomically reduced and
fixed with three screws
• Troch osteotomy closed with screws
• Mobilised postoperatively
• Well at two months follow-up
Dislocations of hip
• High-energy trauma
• Usually unrestrained occupants in MVA
• Also pedestrian MVA, falls from height,
industrial accidents
• 50% associated with fractures elsewhere
Posterior Dislocation
• Most common – over 90%
• Axial load applied to femur while hip flexed
• Impact of knee on dashboard
Associated Injuries
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Head, neck, face
Chest /intra-abdominal injuries
50% have fractures elsewhere!
Sciatic nerve injuries 10% to 20%!
Thorough exam essential
Vascular supply
• Branches of profunda
femoris
– medial and lateral femoral
circumflex
• Ascending branches are
kinked/compressed in hip
dislocation
Management
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• Dislocated hip is an emergency
Full trauma survey
Reduction restores blood flow through
compressed vessels
Goal to decrease risk of AVN and DJD
AVN 5% with early reduction within 6 hours
AVN 15% with reduction within 12 hours
AVN 30% when reduction delayed >12 hours
Reduction manoeuvre (Allis)
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Patient supine
Assistant stabilises pelvis
Slowly flex hip to 900
Traction in line of femur
Adduction and internal
rotation
• Reduction often seen and felt
Post-reduction management
• CT of affected hip (thin 2mm cuts)
• Look for congruency of reduction, loose
fragments
• Mobilise early
• Touch down weight-bearing 4-6 weeks
• ROM precautions: no adduction, no internal
o
rotation, no flexion > 60
• AVN can occur up to 2-5 years
Open reduction
• Rarely needed
• Dislocations irreducible by closed means
– Soft tissue interposition
– Femoral head buttonholed through capsule
• Nonconcentric reduction
• Fracture of femoral neck/head/acetabulum
Prognosis
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AVN 5% to 30%
Posttraumatic OA most frequent
Recurrent dislocation 2%
Neurovascular injury 10%-20%
– Sciatic nerve
– Prognosis unpredictable but 50% full recovery
• Heterotopic ossification 2%
• VTE 50%
Femoral head fractures
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Rare injuries
Almost all complicate hip dislocations
10% of posterior hip dislocations
Fracture occurs by shear as femoral head
dislocates
• History and presentation as in hip dislocation
• Patient posture may be less extreme
Pipkin Classification
JBJS, 1957
I
II
III
IV
Fracture inferior to fovea
Fracture superior to fovea
Fracture of femoral head with
fracture of femoral neck
Fracture of femoral head with
fracture of acetabulum
Pipkin, JBJS, 1957
Femoral head fractures - treatment
• Pipkin 1 – closed treatment
– If reduction adequate (<1mm step-off)
– If reduction not adeuate – ORIF
– Small fragments can be excised
• Pipkin 2 – involve weighbearing surface
– Same recommendations but only anatomical
reduction can be accepted with closed treatment
– Prognosis for AVN same as in simple
dislocations
Approach to hip for fractures
of femoral head
Helfet, Lorich et al, J Orthop Trauma, 2005
Trochanteric slide osteotomy
Femoral head fractures - treatment
• Pipkin 3 – femoral head fracture with
associated fracture of neck
– Prognosis is poor - 50% AVN
• Pipkin 4 – femoral head fracture with
associated fracture of acetabulum
– Acetabular fracture must be treated with ORIF
– Femoral head must also be treated with ORIF to
allow early motion
– Prognosis variable - depends on acetabular
fracture
Literature
• 1. Yoon TR et al Clinical and radiographic outcome of femoral head
fractures: 30 patients followed for 3-10 years. Acta Orthop Scand.
2001 Aug;72(4):348-53
• 2. Asghar FA, Karunakar MA. Femoral head fractures: diagnosis,
management, and complications. Orthop Clin North Am. 2004
Oct;35(4):463-72
• 3: Brooks RA, Ribbans WJ. Diagnosis and imaging studies of
traumatic hip dislocations in the adult. Clin Orthop Relat Res. 2000
Aug;(377):15-23
• 4: DeLee JC, Evans JA, Thomas J. Dislocation of the hip and
associated femoral-head fractures. J Bone Joint Surg Am. 1980
Sep;62(6):960-4
• 5. Henle P, Kloen P, Siebenrock KA. Femoral head injuries: Which
treatment strategy can be recommended? Injury. 2007 38(4):478-88