Transcript Shortened and Internally Rotated Right Leg

Shortened and Internally
Rotated Right Leg
SEACSM Case Presentation
February 5, 2011
Catherine Rainbow MD
Moses Cone Sports Medicine Fellow
Initial History
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CC: Right hip pain and inability to move his right leg
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16 year old high school football player who was driven
backwards during a hard tackle with his right foot planted
while his hip and knee were flexed
Immediate onset of pain in his right hip and was unable to
move his right extremity
No changes in sensation of his right leg at the time of injury
Required complete assistance off of the field
Transported via EMS to the local hospital after being on the
sidelines for one and a half hours
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Past Medical History was significant for an open reduction and
internal fixation of his left clavicle. He did not take any regular
medications.
Physical Exam
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5’7” and 160 pounds
Gen: Lying on his left side in moderate distress
Musculoskeletal:
– Right leg was shortened with the hip flexed, adducted and
internally rotated
– No tenderness along his spine
– His right femoral head was palpable in his buttocks
– Muscle spasms were also palpated throughout his thigh and
buttocks
– He was unable to actively move his right hip and attempts at
moving his hip caused severe pain
– Range of motion could not be assessed due to pain
– He was able to dorsiflex and plantarflex his ankle
– 2 + pedal pulses bilaterally
– Normal sensation throughout his lower extremities
Similar Presentation
Panel Questions
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Any questions regarding the initial
presentation and physical exam?
Differential Diagnosis
Fracture of the femur
 Acetabular fracture
 Pelvic fracture
 Dislocated hip
 Slipped Capital Femoral Epiphysis (SCFE)
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Panel or Audience Questions
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Any further questions at this time?
Tests and Results
X-ray in the
Emergency
Department
showed a
posterior right
hip dislocation
without signs
of a fracture.
Tests and Results
Final Diagnosis
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Traumatic posterior hip dislocation
Treatment
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The patient was diagnosed with a posterior hip
dislocation on x-ray in the ED
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Orthopedic surgeon was consulted for reduction
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Patient was taken to the OR and placed under
general anesthesia
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The right hip was then carefully flexed, adducted
and internally rotated while longitudinal traction
was applied to the flexed hip (Bigelow maneuver)
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A palpable clunk occurred and concentric reduction
of the femoral head was verified on C-arm imaging
– Reduction took place approximately 5 hours after the injury occurred
Bigelow Maneuver
Treatment
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The patient stayed in the hospital
overnight due to pain and instability with
walking on crutches initially
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CAT scan of the right hip was performed
after the reduction to assess for loose
bodies in the joint and fractures
Tests and Results
No acute
osseous
injury of
the right
hip. No
intraarticular
loose
bodies.
Tests and Results
No fractures or loose bodies were identified.
Outcomes
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Patient was discharged home the following
morning non-weight bearing on crutches
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He slept in a hip buttress until pain and strength
improved
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Followed up by team physician 1 week later with
persistent weakness but improved pain
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MRI obtained 3 weeks after his injury showed no
occult fracture or avascular necrosis but a joint
effusion and adductor muscle tears were
identified
Outcomes
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Four weeks after his injury he started gentle
physical therapy and was starting to ambulate
without crutches
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His strength improved tremendously by two
months post closed reduction with formal
therapy and was then transitioned to home
therapy
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He returned to the last football game of the
season, three months after his injury
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X-rays are to be repeated six months after his
initial injury to assess for AVN
Why this is important
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90% of hip dislocations are posterior
– Most often occurs in motor vehicle collisions with dashboard injuries
– In athletics occurs in collision sports and high speed sports such as football and skiing
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Sciatic nerve palsies occur concomitantly 8-20% of the time with a
posterior dislocation
– Assess neurological exam before and after reduction
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Often associated with other injuries such as fracture of the ipsilateral
femur or acetabulum and ipsilateral knee injuries
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Osteonecrosis of the femoral head is the most common early complication
noted in about 10% of patients
– Believed to be due to disruption of blood supply to the femoral head via hematoma
formation or damage to the junction of the external iliac and common femoral artery or
circumflex vessels as seen in cadaver models
– Patients need to be followed for 2-3 years with x-rays to assess for AVN
– AVN develops in 50% of hips that are dislocated for >12 hours
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Other complications include post-traumatic arthritis, femoral nerve injury
and chronic pain
Further Questions
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Thank you
Judet View
To assess the acetabulum
Allis Maneuver
Assistant
stabilizes the
pelvis while
physician pulls
in-line traction,
flexes the hip to
90 degrees and
gently alternates
between internal
and external
rotation
Stimson Maneuver
Dislocated
extremity hang
over the side of
the table and
both knee and
hip are flexed to
90 degrees. A
downward force
is applied to the
calf.