Traumatic hip dislocation in childhood. A report of 26 cases and review of the literature

Clinical treatment of traumatic hip dislocation in children: a single-centre retrospective study

This study aimed to analyse the treatment and outcomes of traumatic hip dislocation (THD) in children. Clinical data of children with THD were collected at our clinical centre from 1 June 2012 to 1 January 2023. Demographic data, injury mechanism, type of dislocation, combined injuries, reduction time, reduction method, and radiographs were analysed. The Merle d'Aubigné-Postel hip score was used to evaluate hip function and complications at the final follow-up. A total of 19 children with THD were enrolled, including 12 male and seven female patients, with an average age of 8.28 ± 0.99 years. Posterior dislocation was the main type of dislocation (89.47%). Fifteen patients (78.95%) had experienced high-energy injuries and traffic accidents were the main causes of injury (47.37%). Closed reduction was performed as soon as possible, and open reduction was performed if necessary. The hip scores of 18 patients (94.74%) were excellent. One patient had osteonecrosis of the femoral head, with a hip function score of 10 (moderate). High-energy injuries, such as traffic accidents, have gradually become the main cause of injury. The prognosis for THD in children is generally good.

Clinical Outcomes and Associated Pathologies Following Pediatric Traumatic Hip Dislocations: A Systematic Review of the Literature

INTRODUCTION

Pediatric traumatic hip dislocations are a rare condition that can have devastating short and/or long-term outcomes and associated pathologies (APs), including associated injuries (AIs) and long-term adverse events (LTAEs), with negative long-term sequelae. Currently, there are little data that exist on the rate of APs, with the most notable being avascular necrosis (AVN), for pediatric traumatic hip dislocations. The purpose of this systematic review is to evaluate the outcome relative frequency of dislocation direction, reduction type, and rate of APs for traumatic hip dislocations in the pediatric population.

METHODS

A systematic review on the topic of traumatic hip dislocations in the pediatric population was performed using PubMed, ScienceDirect, Web of Science, CINAHL, and MEDLINE databases from database inception to March 30, 2023. Inclusion criteria was full-text English articles, addressed traumatic hip dislocations, and pediatric patients (<18 y old).

RESULTS

A total of 24 articles (n=575 patients) met final inclusion criteria from a total of 219 articles retrieved from the initial search. For the average age of the included patients with reported age (n=433 patients), the frequency weighted mean was 9.50 years±1.75 years with a frequency weighted mean follow-up time of 74.05 months ±45.97 months (n=399 patients). The most common dislocation direction was posterior (86.4%), the most common treatment type was closed reduction (84.5%), AVN was the most common type of LTAEs (15.5% of APs), and labral/capsular injuries and acetabular fractures were the most common type of AIs (14.0% and 9.4% of APs, respectively). There were a combined total of 414 APs (72%) out of 575 total patients.

CONCLUSION

Pediatric traumatic hip dislocations are associated with a high rate of AIs and LTAEs (72%, 414 APs out of 575 patients). AVN, labral/capsular injuries, and acetabular fractures are the most common APs after pediatric traumatic hip dislocations. Pediatric hip dislocations are usually posterior and commonly managed through closed reduction.

LEVEL OF EVIDENCE

III, Systematic Review.

Epidemiology and injury morphology of traumatic hip dislocations in children and adolescents in Germany: a multi-centre study

OBJECTIVE

Traumatic hip dislocations are very rare in childhood and adolescence. The aim of this multi-centre study is to analyse the current epidemiology and injury morphology of a large number of traumatic hip dislocations in children. This can provide a better understanding of childhood hip dislocations and contribute to the development of a therapeutic approach in order to prevent long-term impacts.

METHODOLOGY

This retrospective, anonymised multi-centre study included patients, aged up to 17 years, with acute traumatic hip dislocations and open growth plates. The patients came from 16 German hospitals. Exclusion criteria included insufficient data, a positive history of hip dysplasia, or an association with syndromal, neurological or connective tissue diseases predisposing to hip dislocation. An analysis was carried out on the patients' anthropometric data and scans (X-ray, MRI, CT), which were collected between 1979 and 2021. Gender, age at the time of dislocation, associated fractures, mechanism of injury, initial treatment including time between dislocation and reduction, method of reduction, treatment algorithm following reduction and all documented complications and concomitant injuries were evaluated.

RESULTS

Seventy-six patients met the inclusion criteria. There were two age peaks at 4-8 years and 11-15 years. There was an increased incidence of girls in the under-eight age group, who had mild trauma, and in the group of over-eights there were more boys, who had moderate and severe trauma. Dorsal dislocation occurred in 89.9% of cases. Mono-injuries dominated across all age groups. Concomitant injuries rarely occurred before the age of eight; however, they increased with increasing ossification of the acetabulum and appeared as avulsion injuries in 32% of 11-15-year-olds. Of the 76 patients, 4 underwent a spontaneous, 67 a closed and 5 a primary open reduction. A reduction was performed within 6 h on 84% of the children; however, in around 10% of cases a reduction was not performed until after 24 h. Concomitant injuries needing intervention were identified in 34 children following reduction. Complications included nerve irritation in the form of sensitivity disorders (n = 6) as well as avascular necrosis (AVN) of the femoral head in 15.8% of the patients (n = 12).

CONCLUSIONS

Traumatic hip dislocations are rare in childhood and adolescence and have high complication rates. The most severe complication, femoral head necrosis, occurred in 16% of cases. Minor injuries, especially in younger children, are enough to cause a dislocation. Posterior dislocation was more frequent and primarily occurred as a mono-injury; however, concomitant injuries must be considered with increasing age. Children continue to experience delayed reductions. The length of time until reduction, age and the severity of the concomitant injury play a role in the development of femoral head necrosis; however, this topic requires additional investigation.

A Rare Case of a Traumatic Posterior Hip Dislocation in a 3-Year-Old Boy: A Case Report and Review of the Literature

We present a rare case of neglected hip dislocation in a 3-year-old boy. Hip dislocations in childhood represent less than 6% of all injuries. The boy presented to the ED with ongoing hip pain after his leg got stuck in a carousel. The physical and radiologic examination revealed a posterior right hip dislocation. The closed reduction failed, so open reduction during surgery was performed. The postoperative protocol included 3 days of immobilization with early mobilization and pain-adapted weight bearing. No signs of femoral head malperfusion occurred 2 months after the injury. The patient did not complain of any limitations such as weight bearing problems or loss of range of motion. In comparison to adults, there are several specialties such as the fact that minor trauma can lead to hip dislocations due to the laxity of the ligaments, and due to the limited direct anamnestic options, neglected hip dislocations can occur. The treatment should focus on immediate proper reduction. The main complications after traumatic hip dislocation are avascular necrosis of the femoral head, redislocation, and early osteoarthritis.

Open reduction capsular arthroplasty using a modified Codivilla-Hey Groves-Colonna procedure augmented with tensor fascia lata graft, supported by Ilizarov hinged external fixator in a patient with chronic traumatic posterior hip dislocation

Untreated traumatic hip dislocation is a rare condition in children. Capsular arthroplasty is a previously abandoned surgical technique in dealing with developmental dysplasia of the hips but not described in traumatic dislocations. We present a 2-year follow-up of a 7-year-old boy who sustained chronic traumatic posterior hip dislocation treated as a first case in published literature combining a modified version of the Codivilla-Hey Groves-Colonna procedure, using tensor fascia lata graft and application of a hinged Ilizarov frame. The patient is currently independent on all activities of daily living.

Traumatic anterior hip dislocation with associated bilateral femoral fractures in a child: a case report and review of the literature

Traumatic anterior hip dislocation is rare, because the hip joint is a highly stable joint. It is extremely rare for the anterior hip dislocation with combined bilateral femoral fracture in children. We present a case of 7-year-old boy with traumatic anterior hip dislocation with associated bilateral femoral fractures. Radiographic examination showed the right femoral head was dislocated anteroinferiorly. The ipsilateral femoral shaft showed a transverse femoral shaft fracture and proximal and distal femoral bifocal fractures of the contralateral femur. The dislocation of the right hip was reduced 10 hours after the injury in local hospital. One week later, the right femoral shaft fracture and left proximal femoral fracture were open reduced and internally fixed with plate and screws and the distal left femoral fracture was closed reduced and fixed with Kirschner wires. Postoperatively, active hip flexion and extension to recover hip and knee movement were then permitted but without weight bearing for 3 months. Radiographs at 3 months, at 6 months showed the fractures healed well and hardware were removed respectively. However, irregularities of the femoral head meaned avascular necrosis of the femoral head. This case stresses the importance of a rapid evaluation and treatment for the dislocation of the hip, providing a stable reduction and a firm internal fixation of the associated fractures.

Traumatic Obturator Hip Dislocation with Marginal Femoral Head Fracture in a 15-Year-Old Adolescent: A High-Energy Trauma-A Case Report and a Review of the Literature

We report the case of a 15-year-old boy brought to the emergency department after a bike accident, complaining of an isolated left hip pain. The X-rays showed an obturator hip dislocation treated by closed reduction under general anaesthesia, followed by 6 weeks of discharge. The follow-up MRI performed 6 weeks after the trauma showed an avascular femoral head necrosis, for which we performed multiple retrograde femoral head drilling, completed by the injection of autologue stem cells from the iliaq crest. One year later, the patient has no hip pain, no joint limitation, and can practice BMX at a high level again. The purpose of this report is to make the physicians aware of this rare problem that may be damaging for hip function, especially in young people.

Arthroscopic Treatment of Traumatic Hip Dislocations in Children and Adolescents: A Preliminary Study

INTRODUCTION

Traumatic hip dislocations in children and adolescents require prompt concentric reduction. Incomplete reduction with or without retained osteochondral fragments has traditionally been addressed with open reduction. We report on the use of arthroscopy to remove loose bodies and reduce enfolded soft tissues to obtain concentric reduction in the pediatric and adolescent population. Specific note is made of underlying pathology and arthroscopic intervention.

METHODS

After obtaining Institutional Review Board approval, we performed a retrospective review of patients under the age of 19 who were treated with hip arthroscopy following hip dislocation reduction at a single children's hospital from 2006 to 2013. Clinic notes, operative reports, radiographic images, and arthroscopic photographs were reviewed.

RESULTS

Seven patients were identified (aged 8 to 17) who underwent hip arthroscopy after a posterior hip dislocation. Intra-articular bone fragments were found in 6 of 7 patients and 5 of 7 patients had an incongruent hip joint identified by imaging before surgery. The predominant pathology was avulsion of a small bony fragment attached to the posterior capsular labral soft-tissue complex, which became enfolded and blocked reduction (5 of 7 patients). In all cases, the enfolded soft tissue was reduced without soft tissue or bone repair. Additional loose osteochondral fragments were removed, and in 2 cases an avulsed ligamentum teres was debrided. Average follow-up was 10 months. No avascular necrosis or recurrent instability was identified in any case.

CONCLUSIONS

When incongruent hip joints were arthroscopically evaluated after traumatic dislocation, a consistent pattern of interposition of avulsed posterior bone fragment with attached capsule and labrum was found. Reduction of the capsulolabral complex without repair provided satisfactory short-term outcomes. Arthroscopic treatment of such cases was effective and well tolerated and could lead to considerably less postoperative pain and surgical morbidity than open surgical treatment.

LEVEL OF EVIDENCE

Level IV-case series.

Closed reduction of a traumatic hip dislocation in children: case report

Traumatic dislocation of the hip in children is a rare disease. It only represents 5% of hip dislocations in all age groups. Before 10 years, the mechanism is often a minimal domestic accident; after 10 years, the dislocation occurs with the waning of an accident of the public highway. It is different from that of the adult by its rarity, its ease of reduction and better prognosis. This is an emergency trauma: risk necrosis of the femoral head (If delayed reduction). We report a rare case of a 3 year old boy, who suffered from bipolar trauma after a fall near his height of his house causing him a detachment of the right humerus and post-traumatic dislocation of the left hip. The diagnosis was clinically confirmed by the results of standard radiographs and CT scans of the pelvis. The consultation period to emergencies was 5 hours after the trauma. We performed an hour after a closed reduction under general anesthesia for hip dislocation with establishment of a splint pelvic-pedal for analgesic keep for three weeks. The radiological outcome was satisfactory. Peeling Salter I humerus was reduced by orthopedic manner and immobilized by thoracoabdominal plaster to keep for a month. The child was discharged the next day. Reviewed in consultation after a month, the clinical examination showed a steady left hip. Traumatic dislocation of the hip in children is a rare diagnosis, the management should as urgent as possible to overcome the different possible subsequent complications dominated by coxa magna.

Update review and clinical presentation in adult inferior dislocation of hip

Inferior dislocation of the hip is a rare clinical entity, wherein closed reduction maneuver could be challenging, especially if the attending surgeon is not familiar with the specific anatomy associated with this injury. Due to the rarity of this type of injury, large case series are lacking in the literature; hence, case reports form the major source of our knowledge regarding the clinical presentation and management. An extensive literature search revealed a change in age group presenting with this specific injury, with a male predilection. They were frequently cited in the pediatric age group of less than 16 years in the last century. Recently, the cases have been documented in adults. An up-to-date review of the current literature on the mechanism of injury, clinical presentation, management, outcomes and complications of inferior dislocation of hip has been highlighted in this article. In addition, we share our experience with three such dislocations presenting in adult males with an age range of 38-62 years.

Ipsilateral obturator type of hip dislocation with fracture shaft femur in a child: a case report and literature review

The incidence of traumatic hip dislocations in children is rising in this fast developing world along with increasing numbers of high-velocity road traffic accidents. Anterior dislocation of the hip has a lower incidence compared with posterior dislocation of the hip. We encountered a rare case of the obturator type of anteriorly dislocated hip associated with ipsilateral fracture of the shaft femur in an 11-year-old child. This is a highly unusual injury combination and the mechanism of injury is obscure. Only two similar cases have been reported in the English literature to date. Closed reduction of the hip using a hitherto undescribed technique and an intramedullary interlocking nail was performed in this case. At 6 months of follow-up, the fracture shaft femur has united and the child is bearing full weight on the limb.

Surgical Hip Dislocation is Safe and Effective Following Acute Traumatic Hip Instability in the Adolescent

BACKGROUND

A traumatic hip dislocation in the pediatric patient is a rare but potentially catastrophic injury. The purpose of this study was to review our early clinical results and radiographic morphology of hips treated with a surgical hip dislocation (SHD) approach for intra-articular hip pathology resulting from traumatic instability in pediatric and adolescent patients.

METHODS

This is a retrospective analysis of a consecutive series of patients presenting with nonconcentric reduction after traumatic hip instability. All patients were treated with a transtrochanteric SHD with concomitant procedures based on intra-articular findings. Radiographic evaluations and Harris Hip Scores were completed at final follow-up.

RESULTS

Eleven male patients, mean age of 12.3 years (range, 9.3 to 16.1 y) and mean body mass index 19.6 kg/m (range, 15.4 to 28.0 kg/m). Intraoperative findings included: labral tear (8), femoral cartilage injury (5), acetabular rim fracture (4), acetabular cartilage delamination (3), loose body (2), and femoral head osteochondral fracture (1). Postoperatively, 1 patient developed a transient peroneal nerve palsy. At a mean 24.5 months (range, 12.0 to 48.1 mo) postoperatively, no hips have radiographic evidence of osteonecrosis. The mean lateral center edge angle was 20 degrees (range, 9 to 38 degrees) with 6 hips of <20 degrees; mean acetabular index 9 degrees (range, -2 to 23 degrees) with 5 hips of >10 degrees; mean α-angle 56 degrees (range, 48 to 62 degrees) with 6 hips of >55 degrees; mean acetabular version 12 degrees (range, 8 to 16 degrees) with 8 hips of <15 degrees. At 1-year follow-up, the mean Harris Hip Score was 95.8 (range, 84.7 to 100).

CONCLUSIONS

Early results suggest that SHD is a safe approach to treat an incomplete reduction following posterior hip instability and is effective for identification and treatment of acute intra-articular pathology. Acetabular dysplasia, relative acetabular retroversion, and/or decreased femoral offset may be risk factors for posterior hip instability in adolescents.

LEVEL OF EVIDENCE

Level IV.

Traumatic hip dislocation in children

The aim of this study was to evaluate the outcomes of reduction in the treatment of traumatic posterior hip dislocation in children. Data of 22 pediatric patients (22 hips) with traumatic hip dislocation from January 1995 to December 2007 were analyzed. The clinical evaluation focused on symptoms, physical findings, and range of motion. Radiographs identified the type of hip dislocation. The hip dislocation classification was based on Thompson and Epstein. The reduction procedure was performed according to three variants: variant 1, closed reduction; variant 2, release of the adductor longus, lengthening of the psoas tendon, and insertion of a Kirschner wire through the femoral head into the acetabulum; and variant 3, removal of the soft-tissue interposition of the hip. After reduction, radiography was used to determine whether the hip is concentric and to check whether any other injuries might have been caused after manipulation. There were six females (27.3%) and 16 males (72.7%) in this study. All had type I posterior dislocation of the hip. The ages of the patients at diagnosis ranged from 3 years, 2 months to 9 years, 10 months. The reduction procedure was performed according to variant 1 in 16, variant 2 in five, and variant 3 in one. We attained excellent results in eight hips (36.4%), good results in seven hips (31.8%), fair results in four hips (18.2%), and poor results in three hips (13.6%). There was avascular necrosis in three hips (13.6%), coxa magna in two hips (9.1%), deficient limb of 2 cm in two hips (9.1%), and a limp in two hips (9.1%). The hip scores were 82.4 points on average (range 62-100). Children with traumatic hip dislocation should undergo reduction as soon as possible. If the interval from injury to reduction exceeds 3 weeks, we suggest that the surgeon release the adductor longus, lengthen the psoas tendon, and insert a Kirschner wire. This simple and safe surgical procedure results in marked improvement in hip function and prevents complications later.

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.

Traumatic anterior dislocation of hip in a teenager: an open unusual type

Traumatic anterior open dislocation of hip is rare in children and prone to be associated with injuries, extensive soft tissue damage and avascular necrosis of the femoral head. We report a hitherto undescribed anterior open dislocation of the hip joint in a 14-year-old boy. The dislocated head finished up in the contralateral obturator foramen. The management of the case and its relation to published classifications of anterior hip dislocations in children are discussed.

Traumatic hip dislocation in childhood

We report the outcome of closed reduction of traumatic hip dislocation in 28 children younger than 16 years of age (average age, 8 years 10 months). At an average follow-up of 8 years and 10 months (range, 2 years - 42 years), 18 patients were asymptomatic and enjoying a normal life, and some of them returned to practice sport activities. The remainder had complications related to associated injuries. There were no cases of avascular necrosis of the femoral head during follow-up. The majority of dislocations were attributable to low energy injuries in children younger than 10 years of age. Traumatic hip dislocation in children is uncommon. Management after reduction is not clearly defined in the literature. It is important to perform reduction as soon as possible to avoid later avascular necrosis.

[Traumatic hip dislocations in children]

PURPOSE OF THE STUDY

Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment.

MATERIAL AND METHODS

This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis.

RESULTS

The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3h in eight cases, 3-6h in five and greater than 6h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, all hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femoral head cover persisted. Coxa valga persisted in two patients.

DISCUSSION

Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults.

Traumatic hip dislocation in childhood

Traumatic dislocation of the hip in childhood is uncommon and can be a consequence of minor trauma. The authors report a series of 35 dislocations in skeletally immature patients. Most were isolated posterior dislocations without acetabular lesions. In 75% of cases, reduction of the dislocation was easy. Nine children required surgery to remove interposed joint capsule and/or osteochondral fragments to achieve anatomic reduction. Outcomes were generally good, except in one patient in whom a displaced fracture of the femoral physis was followed by total head avascular necrosis. One case of partial necrosis had a satisfactory outcome. Epiphyseal necrosis, though uncommon, appeared to be inconsistent to prevent and hard to predict. Bone scan seems to be more effective than MRI for the detection of necrosis.

Imaging of traumatic dislocation of the hip in childhood

BACKGROUND

Traumatic hip dislocation in childhood is a rare consequence of violent trauma. After reduction, outcome is usually favourable although epiphyseal necrosis can occur. Reduction must be carried out as soon as possible and is achieved easily, although if the labrum is involved, surgery may be required to achieve complete reduction.

OBJECTIVE

To analyze a retrospective series of traumatic hip dislocations in children, describing the therapeutic and imaging strategy.

MATERIALS AND METHODS

A total of 42 patients were studied. Their mean age was 10 years 3 months. All relevant radiographic, CT, MRI and radionuclide bone scan examinations were reviewed. Special attention was paid to associated lesions.

RESULTS

In 22 patients the dislocation was caused by low-energy trauma. Road traffic accidents accounted for 17 dislocations. An acetabular fracture was present in six patients and the femoral head was fractured in three. Reduction was easily achieved in 31 patients. In 11 patients the postreduction radiograph and CT showed joint space asymmetry secondary to labral entrapment. Only two patients developed epiphyseal necrosis.

CONCLUSIONS

It has been difficult to define and evaluate accurate principles for a medical imaging strategy in this group of patients. Analysis of plain radiographs is essential before and after reduction of the joint, and it is important to perform postreduction CT in every patient whose joint space remains widened. A radionuclide bone scan should be performed between the second and third weeks after injury to assess epiphyseal vascularity. With the use of specific sequences, MRI may be an alternative modality to assess epiphyseal vitality.

Traumatic anterior dislocation of the hip associated with ipsilateral femoral shaft fracture in a child: a case report

Traumatic anterior dislocation of the hip joint in children is rare, and only one case with ipsilateral femoral fracture has been reported in Japan. We report a case of such dislocation and a review of the literature. The patient was a 31-month-old girl who was injured in a car accident while asleep on a tilted front passenger seat. Radiographic examination showed dislocation of the right obturator foramen and transverse fracture of the ipsilateral femoral shaft. The dislocation of the right hip was easily reduced without anaesthesia during radiography. We applied Bryant traction after reduction for 4 weeks, followed by cast application for 3 weeks. Walking with support and full weightbearing were permitted 14 weeks and 16 weeks after the injury, respectively. Radiography at 4.5 years after the injury showed a mildly enlarged right femoral head and femur overgrowth of approximately 8 mm. Magnetic resonance imaging showed no evidence of suspected avascular necrosis of the femoral head. The patient has no subjective or objective symptoms, and is able to engage in all usual activities. The detailed mechanism of the injury is unknown. We assume that the lower leg was dislocated through abduction during flexion, or abducent, external flexion, considering that the child was sleeping at the time of the accident. Since she was hurled to the back seat, it was assumed that strong external force was vertically added to the femur, which caused the abducent force.

Traumatic hip dislocation with spontaneous incomplete reduction: a diagnostic trap

We are reporting three children and adolescents who presented with incongruous reduction of the hip following injury. In each case, the diagnosis was initially missed. None of the patients presented with a hip dislocation, but two gave a history consistent with transient hip subluxation or dislocation. Low-energy trauma was the cause in two cases. Treatment consisted of arthrotomy to remove interposed capsule and labrum to obtain concentric reduction. When reduction of a hip dislocation occurs spontaneously, the condition may be misjudged. Any child or adolescent who complains of hip pain following injury should have radiographs scrutinized for asymmetric widening of the hip joints. Any asymmetry should be evaluated by appropriate imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI). Removal of any interposed tissue is recommended, even when the diagnosis is delayed by several months.

Traumatic posterior dislocation of hip in children

Traumatic posterior dislocation of the hip joint in children is an uncommon injury. It constitutes a true orthopedic emergency. It makes up over 80% of pediatric hip dislocations. In children, it can occur as a result of minimal trauma, which is attributed to a soft pliable acetabulum and ligamentous laxity. In skeletally mature adolescents, a greater force is required to dislocate the hip joint. Delay in reduction is associated with long-term complications such as avascular necrosis and degenerative arthritis. Avascular necrosis is related to the duration of dislocation. A poorer prognosis is associated with delay in reduction beyond 6 hours, advanced skeletal maturity, or multiple traumas. Prompt reduction minimizes complications. We report two cases of traumatic posterior dislocation of hip in children aged 3 and 14 years. Both were reduced within 6 hours of dislocation, and review at 6 months revealed normal examination and no evidence of any post-traumatic changes. Post-reduction treatment remains without a consensus. This review highlights the clinical presentation, management, and time-sensitive complications of the injury.

Nerve injury in traumatic dislocation of the hip

Neurologic injury often accompanies traumatic dislocation and fracture-dislocation of the hip. A review of the literature reveals an incidence of approximately 10% in adults and 5% in children. The sciatic nerve, usually the peroneal branch, is most often injured, and this complication can be seen after all types of posterior fracture-dislocations and simple posterior dislocations. The sciatic nerve can be acutely lacerated, stretched, or compressed, or later encased in heterotopic ossification. Neurologic examination at the time of injury often is difficult but is extremely important. Once a nerve injury is discovered, prompt closed reduction must be attempted to relieve distortion of the nerve from a dislocated femoral head or displaced acetabular fracture. Considerable controversy surrounds the recommendations for additional treatment of nerve injury once the hip has been reduced. At least partial recovery of nerve function occurs in 60% to 70% of patients, with no clear correlation with injury or treatment type. Rehabilitation of patients with sciatic nerve injury must begin as early as possible and should focus on the prevention of an equinus foot deformity. Magnetic resonance neurography may become useful in the future for initial evaluation of patients with this injury.

Avascular necrosis following traumatic hip dislocation in an 8-year-old boy

Avascular necrosis of the femoral head as a complication of a hip location that is caused by minor trauma and is promptly reduced is uncommon in young children. The incidence appears to be from 3% to 6% if reduction is performed within the first 4 h. However, if it does occur, a significant incidence of degenerative joint disease should be anticipated in the patient's later life. As a possible way of surgical treatment, an intertrochanteric and periacetabular osteotomy should be considered to minimise sequelae. Follow-up must be continued until skeletal maturity is reached.

Traumatic hip dislocation in children. Follow up of 13 cases

Thirteen cases of traumatic anterior and posterior hip dislocations in children were treated during a period of 25 years. All of them were available for follow up from 5 to 26 years postinjury. Twelve of the patients had their dislocation reduced within six hours after the injury. None of them developed any complication, and the range of movement was the same as in the noninjured hip. One patient, who had his hip reduced 37 hours after the injury, experienced pain due to osteoarthritis 7 years after the injury at the age of 21 years.

Computed tomography arthrography in traumatic hip dislocation. Intra-articular and capsular findings

The newer diagnostic modalities such as computed tomography and magnetic resonance imaging are becoming increasingly used in the evaluation of joint trauma. The combination of computed tomography and arthrography can also be of significant diagnostic value in certain specific situations. In our case report, we describe its use in post-traumatic recurrent hip dislocation and its value, not only in depicting a posterior capsular tear, but also in the diagnosis of an internal joint derangement which may contribute to incongruous reduction of the hip joint.

Traumatic anterior dislocation of the hip

A discussion is presented of traumatic anterior dislocation of the hip joint on the basis of three representative case reports. One patient had an iliac or pubic dislocation, the other two were obturator dislocations, including one with an associated femoral head fracture. All three patients were treated without surgery. After an average follow-up time of twenty-seven months, the results were excellent. Therapeutic guide-lines and recommendations are given for this infrequent type of injury.

Delayed presentation of posterior fracture dislocation of the hip in a child

A case of delayed presentation of posterior fracture dislocation of the hip in a child is reported. Only four similar adult cases have been described in the English medical literature. This case is even more perplexing than those already reported in thAT AP and lateral X-rays of the affected hip were performed on initial presentation and were normal. The mechanism of such a phenomenon, explanations for failure to detect such an injury and methods of avoiding this complication are presented.

A vascular necrosis following traumatic hip dislocation in childhood: factors of influence

An evaluation was made of the factors possibly influencing the incidence of vascular necrosis in a collected series of 412 traumatic hip dislocations in children. This series consisted of 145 cases with necrosis, and 267 dislocations in which this complication had not developed after a follow-up period of 2 years or more. The age of the patient, the severity of the injury, the type of dislocation and the interval before reduction proved to be influencing factors. The reduction procedure appeared to play a similar role, but this could not be definitely assessed. The post-reduction immobilization and the interval before weight-bearing had no influence. Therapeutic principles are indicated.

Natural history of avascular necrosis following traumatic hip dislocation in childhood: a review of 145 cases

One hundred and forty-five cases of traumatic hip dislocation in children, complicated with avascular necrosis, were reviewed. Necrosis involved the capital epiphysis and the growth plate, and the resulting changes followed different patterns. These changes in younger children were mostly dependent on the disturbance of the growth plate, and resembled Calvé-Perthes' disease in most of its features. In older children necrosis of the femoral head occurred, as in adults. Analysis of long-term results suggest that the frequency of deformities is extremely high, and a significant incidence of degenerative joint disease can be anticipated.

Luxatio erecta of the hip. A case report and review of the literature

Luxatio erecta of the hip is an exceptional injury. This is the report of one such case in a 10-year-old boy, and a review of 7 other cases collected from the literature. Luxatio erecta seems to result of an injury forcing the hip in extreme flexion together with further trauma displacing the femur in caudal direction. The femoral head is dislocated below the acetabulum. Reduction is to be achieved by cephalad traction, though internal rotation may have to be added in certain cases. Post-reduction treatment, as well as the incidence of complications, are not different from those concerning the other topographic varieties of traumatic hip dislocation.

Traumatic anterior dislocation of the hip in childhood

One hundred and eleven traumatic anterior dislocations of the hip in children were collected from the literature and statistically evaluated together with 4 cases treated at our institute. The incidence of open dislocations, associated lesions (avulsion of the greater trochanter, damage to the femoral vessels, and fracture on the shaft of the ipsilateral femur), and irreducible recent dislocations was noteworthy, demanding special methods of primary management. In 41 patients, with follow-up averaging 5 years, the incidence of complications, especially avascular necrosis, was also high. Anterior dislocation of the hip in this age group is to be considered a serious injury. Concerning the final state of the hip-joint, factors giving a poor prognosis appear to be severe injury, open dislocation, associated fractures near the joint, delayed reduction, and, possibly, open procedures.

Traumatic hip dislocation with fracture of the ipsilateral femoral shaft in childhood. Report of a case and review of the literature

Ipsilateral concomitant hip dislocation and femoral shaft fracture in childhood is extremely rare. A further case and a literature review, with 35 additional observations are presented. The dislocation was initially missed in more than 50% of cases, but when immediately diagnosed, closed reduction manoeuvres were effective in all observations but one, and results were rated normal. As delayed reduction predisposes to avascular necrosis, every child with a femoral shaft fracture should be given a routine X-rays of pelvis, including lateral hip views, as a safeguard against missing an associated hip dislocation. If present, its urgent closed reduction is imperious. In case of failure, closed or open purchasing of the proximal shaft fragment to allow a sort of skeletal-handling is to be used. Open reduction of the dislocation is to be regarded as the third-line procedure.