Initial treatment of traumatic hip dislocations in the adult

Evaluating the utility of post-reduction imaging for simple hip joint dislocations: Is computed tomography always necessary?

Introduction

Following closed reduction of hip dislocations, computed tomography (CT) is considered standard of care to identify occult fractures or intra-articular loose bodies that may be missed on X-ray. The purpose of this study was to evaluate the sensitivity of post-reduction X-rays and the usefulness of subsequent post-reduction CT imaging.

Methods

All patients presenting to our hospital system for traumatic hip dislocations from 2013 to 2022 were retrospectively reviewed. Participants were included if they had a simple dislocation of a native hip, underwent closed reduction, and received post-reduction X-ray and CT imaging. A sensitivity analysis was performed for the detection of associated fractures and intraarticular loose bodies by post-reduction X-ray, using CT as a reference standard.

Results

Thirty-five subjects with a mean age of 26 years were included. Post-reduction CT revealed 6 fractures and 3 loose bodies, whereas post-reduction X-ray identified 3/6 (50%) fractures and 3/3 (100%) loose bodies. Four cases received operative management, all of which were identified by X-ray. Post-reduction X-ray had a sensitivity of 67% for identifying pathology that was subsequently found on CT, and a sensitivity of 100% for identifying pathology requiring surgery. Of the 13 cases with pre-reduction CT scans, none had new findings identified on post-reduction CT.

Conclusions

Post-reduction X-rays are effective in the evaluation of acute pathology associated with closed reduction of traumatic hip dislocations, especially for cases requiring operative management. Our findings suggest that if a fracture or loose body was not identified on post-reduction X-ray, a post-reduction CT added no value in surgical decision-making and was not necessary.

A bilateral asymmetrical hip dislocation: A rare case report

A 17‐year‐old male was ejected from the motorcycle and brought to the Emergency Department with bilateral hip dislocation and absence of pelvic or femur fractures or sciatic nerve injury. Closed reduction and postreduction examination were performed with a bilateral stable full range of motion in all directions.

Transverse and transverse-variant acetabular fractures with ipsilateral sacroiliac joint injuries: A technical note for reduction and stabilization

Transverse and T-type acetabular fractures are high energy fractures that may be associated with a disruption of the pelvic ring. While several studies report upon clinical findings and outcomes associated with combination injuries of the pelvic ring and acetabulum, there are limited reports discussing surgical treatment strategies for reduction and stabilization. Herein we focus on describing reduction and stabilization techniques of transverse or transverse-variant acetabular fractures with an associated ipsilateral partial disruption of the sacroiliac joint.

Diagnosis, preoperative evaluation, classification and total hip arthroplasty in patients with long-term unreduced hip joint dislocation, secondary osteoarthritis and pseudoarthrosis

Background

Neglected long-term unreduced hip joint dislocation with secondary osteoarthritis and pseudoarthrosis poses a great challenge to hip surgeons. However, as this is an uncommon injury, few studies have systematically investigated these patients.

Methods

We retrospectively reviewed 16 patients from 2010 to 2017. The diagnostic values of three different types of common radiological examinations were evaluated. We evaluated the bone conditions of the original acetabulum and classified the patients into three types (four subtypes). The surgical procedures and prognosis of the patients were also investigated.

Results

With the combined application of X-ray, CT scans and 3D reconstruction, 93.8% of these patients (sensitivity = 93.8%, Youden’s index = 0.93, intraclass correlation coefficient = 0.95) could be diagnosed correctly. There were 6/16 (37.5%) type A patients, 4/16 (25.0%) type B1 patients, 5/16 (31.3%) type B2 patients and 1/16 (6.3%) type C patient. For patients with type A injury, the surgical procedures for total hip arthroplasty were similar to “standard” total hip arthroplasty. For patients with type B injury, due to atrophy or partial bone deficiency of the original acetabulum, the surgical procedure for total hip arthroplasty was probably similar to those for patients with developmental dysplasia of the hip. For patients with type C injury, the situation was similar to that of revision surgery. The average Harris hip score postoperatively was 89.94 ± 5.78 points (range: 79–98 points).

Conclusions

The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. The prognosis of most patients after total hip arthroplasty is expected to be excellent or good.

Asymmetric bilateral hip dislocation in young man: a case report

Bilateral hip dislocation is a rare event, asymmetric dislocation is even rarer. Due to the intrinsic stability of the hip joint this lesions usually follow a high energy trauma. Because of the common associated lesions, the initial clinical assessment should be performed thoroughly. CT scan rather than x-rays offers a complete survey of these possible associated injuries such as thoracic or abdominal bleedings, neurologic lesions or fractures directly associated with the hips dislocations. The first goal should be reduction of the dislocation to prevent avascular necrosis (AVN) of the femoral head and arthritis. We report a case of a young man with right anterior hip dislocation and left posterior hip dislocation with associated fracture of the posterior wall. (www.actabiomedica.it)

Asymmetric bilateral traumatic hip dislocation: A case report

INTRODUCTION

Traumatic hip dislocation is a severe injury with the potential for significant morbidity and mortality. Bilateral hip dislocation is rare representing 1.25% of all hip dislocations.

PRESENTATION OF THE CASE

A 19-year-old male had a high-speed motor vehicle accident. After stabilizing the patient, it was noticed that the position of the right lower limb was in adduction and internal rotation while the left was in external rotation and abduction. Pelvis x-ray showed right superior posterior and left anterior inferior hip dislocations. Closed reduction was performed within 3 hours from the trauma for both sides. The post reduction CT scan showed adequate reduction of both hips with no associated fractures. During his three-year follow-up, he never had any complaints and the clinical examination and radiographs did not reveal any abnormalities.

DISCUSSION

Early reduction of hip dislocations minimizes the risk of osteonecrosis of the femoral head. The current recommendations state that a hip dislocation must be reduced within 6 hours.

CONCLUSION

This is a rare case of bilateral asymmetric hip dislocations with no concomitant fractures. It is important to reduce hip dislocation within 6 hours from the time of injury to prevent osteonecrosis of the femoral head.

Posterior hip dislocation in a non-professional football player: a case report and review of the literature

The majority of injuries during a football game are contusions, sprains and/or strains in the thigh, knee and ankle. Hip dislocations account for 2-5% of total hip dislocations, and they can be posterior or anterior. Major complications of traumatic hip dislocation include avascular necrosis of femoral head, secondary osteoarthritis, sciatic nerve injury and heterotopic ossification. On the occasion of a case of a 33-year-old football player, who suffered a posterior hip dislocation, associated with a posterior wall fracture of the acetabulum, while playing football, we review the literature and analyze the various mechanisms of injury, the possible complications and the management including surgery and rehabilitation.

Hip Dislocations in the Emergency Department: A Review of Reduction Techniques

BACKGROUND

Hip dislocations are a common presentation in the Emergency Department (ED) and require urgent reduction to reduce the risk of avascular necrosis. Over 90% of all dislocations can successfully be reduced in the ED and there is evidence that cases awaiting operative reduction result in significant delays.

DISCUSSION

While there is limited data comparing specific techniques, the individual success rates of most maneuvers range from 60-90%. Additionally, each technique has distinct advantages and limitations associated with its use.

CONCLUSIONS

It is important for Emergency Physicians to be familiar with several different reduction techniques in case the initial reduction attempt is unsuccessful or patient characteristics limit the use of certain maneuvers. This article reviews a number of reduction techniques for hip dislocations, variations on these techniques, and advantages and disadvantages for each approach.

An unusual case of traumatic bilateral hip dislocation without fracture

Bilateral traumatic hip dislocations are extremely rare. Most of these are related to acetabular or proximal femoral fractures, consisting of complex lesions, and are rarely pure ligamentous injuries. Posterior dislocation is the most frequent. Some dislocations are accompanied by sciatic nerve palsy. The present case is a posterior bilateral hip dislocation with no other associated lesions, there are very few reports published with this clinical setting. The patient had good functional outcome.

Inferior hip dislocation after falling from height: A case report

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Traumatic inferior hip dislocations are high energy traumas with multiple organ damage.

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Traumatic inferior hip dislocation is the least common of all hip dislocation.

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The ischial type is more common than the obturator type.

Introduction

Traumatic inferior hip dislocation is the least common of all hip dislocations. Adult inferior hip dislocations usually occur after high-energy trauma, very few cases are reported without fracture.

Presentation of case

A 26-year-old female was brought to the emergency department with severe pain in the left hip, impaired posture and restricted movement following a fall from 15 m height. The hip joint was fixed in 90° flexion, 15° abduction, and 20° external rotation. No neurovascular impairment was determined. On radiologic examination, a left ischial type inferior hip dislocation was detected. Hemorrhagic shock which developed due to acute blood loss to thoracic and abdominal cavity and patient died at third hour after she was brought to the hospital.

Discussion

Traumatic hip dislocations have high morbidity and mortality rates due to multiple organ damage, primarily of the extremities, chest and abdomen. In the treatment of traumatic hip dislocation, closed reduction is recommended through muscle relaxation under general anesthesia or sedation. This procedure should be applied before any intervention for concomitant extremity injuries. A detailed evaluation on emergency presentation, a multi-disciplinary approach and early diagnosis with the rapid application of imaging methods could be life-saving for such patients.

Rocket launcher: A novel reduction technique for posterior hip dislocations and review of current literature

OBJECTIVE

We provide a review of literature on reduction techniques for posterior hip dislocations and present our experience with a novel technique for the reduction of acute posterior hip dislocations in the ED, 'the rocket launcher' technique.

METHODS

We present our results with six patients with prosthetic posterior hip dislocation treated in our rural ED. We recorded patient demographics. The technique involves placing the patient's knee over the shoulder, and holding the lower leg like a 'Rocket Launcher' allow the physician's shoulder to work as a fulcrum, in an ergonomically friendly manner for the reducer. We used Fisher's t-test for cohort analysis between reduction techniques.

RESULTS

Of our patients, the mean age was 74 years (range 66 to 85 years). We had a 83% success rate. The one patient who the 'rocket launcher' failed in, was a hemi-arthroplasty patient who also failed all other closed techniques and needed open reduction. When compared with Allis (62% success rate), Whistler (60% success rate) and Captain Morgan (92% success rate) techniques, there was no statistically significant difference in the successfulness of the reduction techniques. There were no neurovascular or periprosthetic complications.

CONCLUSION

We have described a reduction technique for posterior hip dislocations. Placing the patient's knee over the shoulder, and holding the lower leg like a 'Rocket Launcher' allow the physician's shoulder to work as a fulcrum, thus mechanically and ergonomically superior to standard techniques.

Potential contribution of femoroacetabular impingement to recurrent traumatic hip dislocation

A 16-year-old boy sustained a traumatic posterior dislocation of the right hip. After initial closed reduction, the hip spontaneously redislocated within 2 days. Four days after the initial dislocation, the patient was transferred to the authors' institution, where a radiographic workup showed a severe capsular and labral disruption from the posterior aspect of the acetabulum. Subsequently, the patient underwent operative treatment using the technique of surgical hip dislocation through a digastric osteotomy as described by Ganz. Using this approach, the avulsed capsulolabral complex as well as the pathological head-neck junction, which is suspected to be a lever for the femoral head, could be fully addressed. The authors recommend further radiographic studies to evaluate the underlying pathology in traumatic dislocation of the hip as well as the described surgical approach, which leads to successful treatment of the entire pathology.

The Captain Morgan technique for the reduction of the dislocated hip

STUDY OBJECTIVE

We present our experience with a novel technique for the reduction of acute hip dislocation in the emergency department (ED).

METHODS

We searched the medical records of all patients with a hip dislocation treated in our ED during a 4-year period. We recorded patient demographics, reduction technique, outcome and disposition, and whether the patient had a prosthetic hip. We reported characteristics of the entire study group and of the subset of patients for whom the Captain Morgan technique was used. Briefly, the technique involves placing the physician's knee behind the supine patient's flexed knee and lifting with anterior force, with rotation as needed.

RESULTS

Of 77 patients meeting criteria, the mean age was 46 years (range 5 to 91 years), 35 (45%) had a prosthetic hip, and 67 (87%; 95% confidence interval 77% to 93%) received successful reduction in the ED. In 13 cases, the Captain Morgan technique was specifically described and was successful in 12 (92%; 95% confidence interval 64% to 100%). The single technique failure occurred in a patient with an acetabular fracture with an intra-articular fragment requiring open reduction. There were no described neurovascular complications or injuries to the knee.

CONCLUSION

We describe an interesting and novel technique for the reduction of a hip dislocation. Physicians should consider this method a primary technique for the acute management of hip dislocation in the ED.

Henry Jacob Bigelow (1818-1890): his contributions to anatomy and surgery

There have been many advances in the medical world over time that have greatly contributed to ameliorating and prolonging human life. The employment of surgical anesthesia is arguably one of the greatest medical discoveries of all time, and has immensely broadened our ability to treat the ill. While Dr. Henry Jacob Bigelow (1818-1890) was not the inventor of anesthesia, he was the first to publish and advocate its use in the 19th century (Bigelow and Bigelow [1894] A Memoir of Henry Jacob Bigelow, Boston: Little, Brown, and Company; Harrington and Mumford [1905] The Harvard Medical School: A History, Narrative and Documentary, Vol 2, New York: Lewis Publishing Company). Bigelow also contributed to revolutionizing the fields of orthopedic and urologic surgery, publishing extensive research on subjects where there was previously very little knowledge, and even developing new techniques. He also impacted the field of neuropsychiatry in his publication regarding Phineas Gage. His contributions to the medical field have set him apart as one of the most influential and famous surgeons of America in the 19th century. Anatomically, he will be remembered eponymously for his iliofemoral ligament and septum in the femur.

Combined injuries of the pelvis and acetabulum: nature of a devastating dyad

OBJECTIVES

To describe the clinical characteristics of combined injuries of the pelvis and acetabulum, which have not been previously described. We hypothesize that this combination of injuries affects not only the postinjury hemodynamics of the patient, but the outcome of subsequent acetabular fracture treatment.

DESIGN

Retrospective study.

SETTING

Level I trauma center.

METHODS

The data collected included patient demographics, fracture classification, Injury Severity Score, systolic blood pressure on arrival, amount of packed red blood cells transfused, time to operation, perioperative complications, and radiographic outcomes. Age- and sex-matched control groups of patients with pure pelvic fractures and pure acetabular fractures were compared with the combined injury group to assess injury severity characteristics. To determine the independent factors influencing the postoperative residual displacement of the acetabulum, multiple linear regression analysis was used.

RESULTS

Between January 1, 1998, and December 31, 2007, there were 1612 patients with either pelvic or acetabular fractures requiring admission to our institution, of which 82 (5.1%) had the combination of an unstable pelvic injury (Orthopaedic Trauma Association [OTA] 61 Types B/C) and a displaced acetabular fracture (OTA 62). Eighty-two patients with an isolated unstable pelvic injury and 82 patients with an isolated displaced acetabular fracture were chosen from the same study period to act as control groups. Patients in the combined group were significantly more injured as compared with the displaced acetabular fracture control group with regard to Injury Severity Score (P < 0.001), systolic blood pressure (P < 0.001), and packed red blood cells (P < 0.001). In the combined group, the most common pelvic fracture patterns were OTA 61.B1 and B2. Transverse-type acetabular fractures patterns (OTA 62.B1 and B2) accounted for 61.2% of all acetabular fractures in the combined group. The most frequent injury combination was a transverse-type acetabular fracture with an associated ipsilateral anterior disruption of the sacroiliac joint. Sixty-eight patients underwent surgical intervention at a mean time of 5.7 days. The mean postoperative displacement of acetabular fracture reduction was 2.2 mm as evaluated by radiographs. Multiple regression analysis revealed that the amount of postoperative posterior pelvic displacement, Type B2 acetabular fractures, and patient age were significant predictors of the amount of residual acetabular displacement found postoperatively.

CONCLUSION

Patients with combined pelvic and acetabular fractures represent a serious injury that includes the resuscitative challenges of pelvic injuries coupled with the difficulties of precise reduction of acetabular fractures. To obtain optimal reduction of the acetabulum, initial accurate reduction of the posterior pelvic lesion appears to be necessary.

Hip dislocations--epidemiology, treatment, and outcomes

Traumatic dislocations of the hip appear to be on the rise in North America. Multidetector CT, hip arthroscopy, and high field MRI have further defined the pathoanatomy of hip dislocations. They can be divided into simple and complex dislocations. At the University of Louisville, an algorithm has been developed to facilitate rapid and accurate diagnosis and treatment of simple hip dislocations. In contrast to the treatment of simple hip dislocations, the treatment of complex hip dislocations (fracture-dislocations) is generally predicated on specific treatments of the associated fracture (e.g., femoral head fracture, femoral neck fracture, acetabular fracture, etc.). This review includes the mechanism of injury, epidemiology, associated injuries, evaluation, treatment, and functional outcomes of simple hip dislocations.

[Internal fixation of acetabular posterior wall fractures]

OBJECTIVE

Open anatomic reduction and stable internal fixation of a posterior wall fracture of the acetabulum by screw and plate osteosynthesis via the Kocher-Langenbeck appoach.

INDICATIONS

Displaced fractures or fracture-dislocations of the posterior wall of the acetabulum in combination with an unstable hip joint, presence of an additional femoral head fracture or intraarticular fragments, reduction inability in fracture-dislocations or deterioration of an additional sciatic nerve injury.

CONTRAINDICATIONS

Poor general condition (due to additional injuries or medical disease). Local soft-tissue damage. Presence of only small bony avulsion fragments of the posterior capsule with hip joint stability.

SURGICAL TECHNIQUE

Open reduction of the posterior wall fracture with stable internal fixation by screw and plate osteosynthesis. Depending on their presence: reduction and fixation of marginal impaction zones.

POSTOPERATIVE MANAGEMENT

Partial weight bearing of the injured side with 15 kg body weight for 6 weeks. Thereafter, pain-dependent weight bearing. In cases of marginal impaction partial weight bearing is extended to 12 weeks.

RESULTS

Between January 1, 1972 and December 31, 2005, 137 patients with fractures of the posterior wall of the acetabulum were treated operatively. A high-velocity trauma was the cause of injury in 91.1% of cases. 94.1% of these patients had an additional hip dislocation, which was reduced within 6 h post injury in 83.7%. A primary sciatic nerve injury was present in 22.2%. Additional injuries to the acetabular cartilage were found in 43%, additional femoral head lesions in 27.4%, and Pipkin fractures in 14.1%. Anatomic joint reconstruction (0-1 mm) was observed in 96.3%, the other five patients had near anatomic reconstructions (2-5 mm). All hip joints were congruent on conventional radiography. The overall complication rate was 11.8%. Osteosynthesis-related complications were seen in 6.7%. 86 patients had follow-up results after a mean of 52 months. A perfect or good functional result (Merle d'Aubigné Score) was observed in 73.3% of cases, a posttraumatic arthrosis of the hip joint was present in 31.4%.

Traumatic hip dislocation in adults

Traumatic hip dislocation occurs during high-energy trauma and is often associated with other life threatening injuries. Dislocation can be anterior or posterior and urgent reduction is mandatory to reduce the risk of avascular necrosis of the femoral head. Undisplaced femoral neck fractures should be excluded prior to attempted reduction. Various closed reduction techniques have been described and most dislocations can be reduced with a closed technique. Failure to achieve reduction makes open reduction mandatory. This review describes the diagnosis, investigation and management of this complex and challenging injury.

Traumatic simultaneous asymmetric hip dislocations and motor vehicle accidents

Hip dislocations are becoming more frequent with increasing numbers of motor vehicle accidents. Bilateral hip dislocations are a rare injury, and simultaneous asymmetric dislocations are even more rare. Of the 20 cases described in the English literature, 16 have been sustained by occupants of motor vehicle accidents. This article presents the first case of a female with traumatic simultaneous asymmetric hip dislocations, as well as the first patient with associated asymmetric acetabular wall fractures.

Traumatic dislocation of the hip in a high school football player

BACKGROUND

Although traumatic dislocation of the hip often occurs as a result of automobile accidents, dislocations have been reported to occur during sports activities.

OBJECTIVE

Using the experience in treating a 17-year-old high school football player with a posterior dislocation, complicated by involvement of the sciatic nerve, this case report provides background information on hip dislocations and provides a description of the immediate treatment by the physician, followed by 6 weeks of immobilization, and a detailed account of the 5-month intervention.

CASE DESCRIPTION

The patient was injured while making a tackle during a high school football game when another player fell on him from behind. The case report describes his plan of care after immediate hip reduction surgery and 6 weeks on crutches. Generally, the program utilized a progression of non-weight-bearing resistance training and stretching in the initial stages of intervention and progressed to weight-bearing activities (on land and in the pool) as the patient was able to tolerate more stress. In addition, the treatment of the sciatic nerve using electrical stimulation during treadmill walking is described.

OUTCOMES

The patient was seen in an outpatient physical therapy clinic an average of 2 times per week for 5 months. At the end of 5 months, results of the Lower Extremity Functional Scale (LEFS) indicated that recreational and sporting activities were within normal limits, and the patient was able to return to playing on his high school football team the next year.

CHONDROCYTE APOPTOSIS IN RESPONSE TO DISLOCATION OF THE HIP IN THE RAT MODEL

BACKGROUND

Joint dislocation is a traumatic event that can lead to osteoarthritis. The purpose of this paper is to study cartilage changes following prolonged joint dislocation for 1, 2 or 8 h.

METHODS

Sprague-Dawley rats (n = 27) were used in this study. Surgical dislocation of the hip under anaesthesia was carried out on the animals. The joints remained dislocated for 1, 2 or 8 h. The joints were subsequently harvested and terminal deoxnucleotidyl transferase-mediated dUTP nick-end labelling testing was carried out to show chondrocyte apoptosis in the femoral head and acetabulum. Using this test, the apoptotic index, which is the proportion of apoptotic chondrocytes to total number of chondrocytes, was calculated. A comparison of apoptotic indices was made among the three groups.

RESULTS

The mean apoptotic indices for the femoral head for the 1-, 2- and 8-h groups were 0.065 +/- 0.025, 0.162 +/- 0.031 and 0.201 +/- 0.030, respectively. There was a significant difference (P < 0.05) in the mean apoptotic indices between each of the three groups. For the acetabulum, the mean apoptotic indices were 0.046 +/- 0.012, 0.051 +/- 0.023 and 0.057 +/- 0.031 for the 1-, 2- and 8-h groups, respectively. There was no significant difference (P > 0.05) between each of the three groups.

CONCLUSIONS

Dislocation of a joint causes chondrocyte apoptosis. There is a progressive increase in the apoptotic index with prolonged dislocation of the rat hip.

Diagnosis and Management of Traumatic and Atraumatic Hip Instability in the Athletic Patient

Although relatively uncommon compared with the shoulder, hip instability can be a source of significant disability and is a commonly unrecognized injury. Hip instability can be traumatic or atraumatic in origin. Our understanding and treatment plan for hip instability due to traumatic events is well established. However, our understanding and treatment modalities for hip instability due to atraumatic events or repetitive motion in high level athletes are not as well defined. In this article, we will review the spectrum of traumatic and atraumatic hip instability and discuss the relevant anatomy, history, and physical examination findings, imaging studies, and treatment options with a focus on hip arthroscopy, and review of the literature.

Bilateral asymmetric hip dislocation: case report and literature review

Simultaneous anterior and posterior hip dislocation is an unusual injury. A unique case is presented, consisting of bilateral asymmetric hip dislocation with associated femoral head, femoral shaft, and acetabular fractures resulting from a motorcycle collision. The mechanisms of injury, management, role of imaging, and complications of this injury complex are discussed, with a review of the relevant literature.