hip dislocation and fracture head femur
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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.