Hip Dislocation: Current Treatment Regimens

A rare soccer-related injury: Traumatic posterior hip fracture-dislocation - Case series and overview of the literature

BACKGROUND

Soccer is one of the most popular sports with millions of active professional and non-professional players worldwide. Traumatic hip dislocations are rare in soccer but can lead to major sequelae both physically and psychologically. The aim of this review was to obtain insight into the outcomes after surgerically repaired hip fracture-dislocation in soccer players as well as rehabilitation and prevention.

METHODS

Two cases of a posterior hip fracture-dislocation that occurred during an amateur soccer match are presented and mechanism of injury, complications and rehabilitation were analysed. Follow-up of both patients was at least one year after surgery. Questionnaires and physical examinations were obtained to quantify and qualify outcome.

RESULTS

In both cases the hip-dislocations were reduced within 3 h after injury. Semi-elective open reduction and internal fixation was performed within seven days. In one case, there was a concomitant Pipkin fracture and sciatic nerve neuropathy. There were no postoperative complications. Follow-up showed full of range of motion and normal hip functionality in both cases. However, both patients indicated a reduced quality of life and anxiety related to the accident.

CONCLUSION

Traumatic hip fracture-dislocations during soccer practice are extremely rare. Despite uncomplicated fracture healing after surgery and return of hip function, both patients still suffer from psychological problems resulting in a decreased quality of life. Further research is required to enhance psychological outcomes, as well as to facilitate return to pre-injury levels of participation and engagement in sports following traumatic hip fracture-dislocations related to soccer.

Using Spinal Anesthesia and a Fracture Table for Closed Reduction of an Obturator Foramen Hip Dislocation: A Case Report

CASE

A 37-year-old man with a right obturator foramen hip dislocation underwent closed reduction under spinal anesthesia with the use of a fracture traction table.

CONCLUSION

This novel technique provides surgeons and anesthesiologists an alternative method of treating obturator foramen hip dislocations that provides a more controlled reduction and less need for assistants.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

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.

Anterior Hip Dislocation: Characterization of a Rare Injury and Predictors of Functional Outcome

BACKGROUND

Anterior native hip dislocation remains poorly studied due to the rarity of the injury. The aim of this study was to describe injury characteristics of anterior hip dislocation, detail its initial treatment, and determine the intermediate term outcomes including the rate of conversion to total hip arthroplasty (THA).

METHODS

A cross-sectional study was performed at a single urban academic Level 1 trauma center for patients who sustained traumatic anterior hip dislocations from 2010-2017. Baseline demographic, injury, and treatment data were recorded. Patients were contacted to inquire about subsequent surgery and complete functional outcome questionnaires. Available post-operative radiographs were also reviewed.

RESULTS

Thirty-two anterior hip dislocations met inclusion criteria and were included in the study. 69% of dislocations were obturator dislocations and 31% iliac dislocations. Only 22% were simple dislocations with the remainder having an associated femoral head fracture and/or acetabular fracture. Iliac dislocations were more likely to be associated with acetabular fractures and require surgical treatment while obturator dislocations were more likely to be simple dislocations or have femoral head fractures. Excluding two patients treated with acute THA at the time of injury, follow-up information was available for 16 patients at a minimum of eighteen months from the time of injury. Only one required subsequent conversion to THA. For the remaining fifteen patients, modified Harris hip scores (mHHS) averaged 82.6, PROMIS global physical health averaged 51.9, and PROMIS global mental health averaged 48.3 with mean follow-up of 4.2 years. mHHS was significantly higher for obturator dislocations and a negative association was seen with age.

CONCLUSIONS

Obturator dislocations occurred twice as frequently as iliac dislocations. Associated acetabular or femoral head fractures are common. Conversion to THA was low, occurring in only 1 of 16 patients not treated with acute arthroplasty. Obturator dislocations and age less than 45 years old at the time of injury were associated with better functional outcome at intermediate term follow-up.

Terrible triad of the hip: A case report

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Pipkin-III injury is rare, and its outcome is guarded.

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Significant number of Pipkin-III injuries are iatrogenic.

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Recognizing irreducibility of hip dislocation is important.

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Outcome can be improved with timely intervention.

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Minimizing dissection might affect the outcome.

Introduction

Pipkin-III femoral head fracture dislocation is a rare injury and its outcome is guarded. Some authors believe femoral neck fracture of Pipkin-III injury is largely iatrogenic. Recent literature showed none of these injuries had excellent outcome, and most patients end up with hip replacement.

Presentation of case

A 34-year-old man sustained a traumatic hip injury with fracture-dislocation and an iatrogenic femoral neck fracture during reduction. A modified Gibson approach was performed to reduce and fix the femoral head and neck fractures in a retrograde fashion. Follow-up at 26 months assessment showed viable femoral head, and excellent functional outcome.

Discussion

Iatrogenic femoral neck fracture in the setting of femoral head dislocation is not uncommon. Clinical and radiological signs of irreducible dislocation can easily be missed which might lead to devastating complications like iatrogenic femoral neck fracture. Recognition of this unique injury, timely intervention, and meticulous dissection might positively alter the patient’s outcome.

Conclusion

This case serves to enlighten orthopedists about the risk of iatrogenic femoral neck fracture, methods to avoid such complication, and the proper management.

Revascularization of the necrotic femoral head after traumatic open anterior hip dislocation in a child: a case report

INTRODUCTION

Avascular necrosis of the femoral capital epiphysis is the most serious complication after traumatic dislocation of the hip in children. This case report discusses the localization and revascularization of the necrotic femoral head following rarely experienced traumatic open anterior hip dislocation in children.

CASE PRESENTATION

Our patient was an 11-year-old Japanese boy who had open anterior hip dislocation sustained in a traffic accident. Reduction of the hip joint was performed in an emergency operation, and he was evaluated using serial gadolinium-enhanced magnetic resonance imaging. T1-weighted magnetic resonance images showed two bands with low signal intensity in the femoral capital epiphysis on coronal and oblique axial planes, indicating the existence of avascular osteonecrosis of the femoral head. We observed gadolinium enhancement in the central region of the epiphysis, where the area between the two bands with low signal intensity was located. Serial assessment with enhanced magnetic resonance images during a non-weight-bearing period of 1.5 years after injury showed revascularization starting from the central region and converging toward the peripheral region. Although the patient had leg-length discrepancy due to the early epiphyseal closure, non-weight-bearing treatment for the avascular osteonecrosis of the femoral head achieved a favorable outcome without any hip joint dysfunction, pain, or sign of secondary osteoarthritic change within 4.5 years after injury.

CONCLUSION

We confirmed the revascularization process of the necrotic lesion in the femoral capital epiphysis in an 11-year-old boy using serial gadolinium-enhanced magnetic resonance imaging. Conservative non-weight-bearing treatment achieved a favorable outcome.

Imaging Acetabular Fractures

Acetabular fractures are encountered by radiologists in a wide spectrum of practice settings. The radiologist's value in the acute and long-term management of acetabular fractures is augmented by familiarity with systematic computed tomography-based algorithms that streamline and simplify Judet-Letournel fracture typing, together with an appreciation of the role of imaging in initial triage, operative decision making, postoperative assessment, prognostication, and evaluation of complications. The steep increase in incidence of acetabular fractures in the elderly over the past several decades places special emphasis on familiarity with geriatric fracture patterns.

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)

Dislocation of the Hip: A Review of Types, Causes, and Treatment

Background

Dislocation of the hip is a well-described event that occurs in conjunction with high-energy trauma or postoperatively after total hip replacement.

Methods

In this review, the types, causes, and treatment modalities of hip dislocation are discussed and illustrated, with particular emphasis on the assessment, treatment, and complications of dislocations following total hip replacement.

Results

Hip dislocations are commonly classified according to the direction of dislocation of the femoral head, either anterior or posterior, and are treated with specific techniques for reduction. Generally, closed reduction is the initial treatment method, usually occurring in the emergency room. Bigelow first described closed treatment of a dislocated hip in 1870, and since then many reduction techniques have been proposed. Each method has unique advantages and disadvantages. Anterior hip dislocation is commonly reduced by inline traction and external rotation, with an assistant pushing on the femoral head or pulling the femur laterally to assist reduction. Posterior hip dislocations are the most common type and are reduced by placing longitudinal traction with internal rotation on the hip.

Conclusion

Patients with hip dislocations must receive careful diagnostic workup, and the treating physician must be well versed in the different ways to treat the injury and possible complications. Timely evaluation and treatment, including recognizing the potential complications, are necessary to offer the best outcome for the patient.

Neglected traumatic hip dislocation: Influence of the increased intracapsular pressure

AIM

To investigate that the increased intracapsular pressure, during the delay period, can interrupt the blood flow to the femoral head.

METHODS

An observational retrospective study included a group of 17 patients with traumatic hip dislocation, their ages at time of injury averaged 26 (range from 3 to 70) years. Outcomes were assessed clinically and radiographically at a period averaged 11.5 (range from 4 to 20) years.

RESULTS

Minor trauma caused dislocation in seven and severe trauma in ten patients. All dislocations were posterior, six isolated dislocation and 11 were associated with other injuries. The negligence period averaged 2.5 (ranged from 1 to 4) d. At the latest visit, the radiography revealed normal hip in 11 and avascular necrosis (AVN) in six patients. Clinically, eight patients were rated as excellent, three good, three fair and three poor.

CONCLUSION

We believe the factors that contribute to increased intracapsular pressure also increase the influence of delayed reduction toward the development of AVN.

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.

Treatment of Hip Dislocations and Associated Injuries: Current State of Care

Hip dislocations, most often caused by motor vehicle accidents or similar high-energy trauma, traverse a large subset of distinct injury patterns. Understanding these patterns and their associated injuries allows surgeons to provide optimal care for these patients both in the early and late postinjury periods. Nonoperative care requires surgeons to understand the indications. Surgical care requires the surgeon to understand the benefits and limitations of several surgical approaches. This article presents the current understanding of hip dislocation treatment, focusing on anatomy, injury classifications, nonoperative and operative management, and postinjury care.

Junk in the joint: A trend for arthroscopic debridement to improve outcomes following closed reduction of traumatic hip dislocation

Purpose

To determine whether arthroscopic debridement following closed reduction of traumatic hip dislocation is associated with less persistent pain and functional impairment than closed reduction alone.

Methods

Retrospective comparative study, consisting of telephone interview, 2–14 years postinjury. Subjects were 15 patients aged 18 years or older at time of injury who received closed reduction of traumatic hip dislocation with arthroscopy (seven patients) or without arthroscopy (eight patients) at a level 1 trauma center between 2000 and 2012. The exposure was arthroscopic removal of intra-articular loose bodies following closed reduction. The primary outcome was the American Academy of Orthopaedic Surgeons® Hip & Knee Outcomes Questionnaire.

Results

Among the patients who received arthroscopy, the mean Hip & Knee Core Scale standardized score (0–100) was 98 (SD 2), as compared to 86 (SD 29) among patients who did not. These scores showed a statistical trend toward less pain and improved function in the arthroscopy group (p = 0.069). No patients in the arthroscopy group had scores below the average among healthy people, as compared to three of eight (38%) in the control group.

Conclusions

Patients who underwent arthroscopic debridement in addition to closed reduction had nonsignificant improvements in pain, stiffness, swelling, and functional impairment as compared to those who received closed reduction alone. Though not significant, these results warrant further study to determine whether arthroscopy is indicated for all patients suffering traumatic hip dislocation.

Level of Evidence

IV

Emergency department evaluation and treatment of acute hip and thigh pain

Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.

Epidemiology of traumatic hip dislocation in patients treated in Ceará, Brazil

OBJECTIVE:

To describe the epidemiological profile of patients with traumatic hip dislocation treated in our Institute from November/2012 to July/2013.

METHODS:

A descriptive cross-sectional study based on interviews and involving 43 patients who suffered traumatic hip dislocation was conducted.

RESULTS:

The mean age of patients was 34.4 years old and 90.7% were male. Regarding the mechanism of injury, 95% involved traffic accidents. The posterior dislocation of the hip was the most common injury (93%). Associated lesions were observed in 74.4% of patients, hip fractures being the most frequent. The time span between accident and dislocation reduction was less than 6 hours in 37.2% of patients, between 6 and 12 hours in 32.5% and over 12 hours in 30.3%, ranging from 1 hour to 15 days. A fraction of 90.7% of patients was submitted to closed reduction.

CONCLUSION:

Traumatic hip dislocation affected mostly young adults, victims of traffic accidents. The posterior dislocation of the hip was the most frequent injury and closed reduction was performed in 90.7% of patients. The time span between accident and dislocation reduction was less than 12 hours in most patients.

Level of Evidence III, Study of Nonconsecutive Patients.

Extremity trauma: field management of sports injuries

Traumatic injuries to the extremities are common in athletic competitions. The practitioner providing coverage of sporting events must be prepared to diagnose and provide initial treatment of these injuries. A thorough history and physical examination should result in a provisional diagnosis. Many injuries will require subsequent radiographs or orthopedic consultation. Limb threatening emergencies are rare but must be promptly recognized and referred to a hospital. Early treatment can protect athletes from further injury and may hasten their return to competition. Some athletes with extremity trauma can return to the contest, but this decision must be made on an individual basis.

Bilateral asymmetric hip dislocation: A case series and literature review of a rare injury pattern

BACKGROUND

Bilateral asymmetric hip dislocation, with one hip dislocated posteriorly and with anterior dislocation of the contralateral hip, is a rare injury pattern. A total of 34 cases have been reported in English literature, but only 24 cases detail injury mechanism and patient demographic factors, 3 of which reported bilateral asymmetric hip dislocation in female patients. Only one report describes more than one example. We describe four patients with bilateral asymmetric hip dislocation, including one example in a female patient, which represents the largest case series to date. Pertinent anatomy, injury mechanism, treatment options, and prognosis are also discussed.

METHODS

A literature review was conducted via PubMed using the term bilateral asymmetric dislocation. Review of additional reports cited by articles found by our search resulted in what we think to be an exhaustive list of cases reported to date.A medical record review of four patients treated at our institution, a Level I trauma center, was performed to compare our treatment methods and outcomes to those previously described.

RESULTS

All four patients in our case series had satisfactory outcomes. Motor vehicle collision is the most common cause of bilateral asymmetric hip dislocation.

CONCLUSION

Timely, accurate reduction of bilateral asymmetric hip dislocation is recommended for optimal outcomes. An understanding of pertinent anatomy about the hip joint allows the orthopedic surgeon to perform a safe, timely reduction. In the absence of an associated acetabular fracture, conservative management with weight-bearing restrictions typically leads to good outcomes without complications such as aseptic necrosis of the femoral head.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Femoroacetabular impingement and low energy posterior hip dislocation: a case report

We report a case of a 28-year-old male who sustained an indirect injury of his left hip while playing soccer, which resulted in a posterior fracture-dislocation. Radiological examination showed signs of combined femoroacetabular impingement (FAI). We discuss the role of FAI as a risk factor for hip dislocation in low energy sport injuries.

Surgical management of posterior hip dislocations associated with posterior wall acetabular fracture: a study with a minimum follow-up of 15 years

OBJECTIVES

To evaluate the long-term outcome after surgical management of posterior hip dislocations associated with posterior wall acetabular fracture and to depict prognostic factors that may affect surgical results.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS AND METHODS

Between 1983 and 1991, 19 patients with traumatic posterior hip dislocation associated with posterior wall fracture of the acetabulum were retrospectively reviewed. The clinical criteria proposed by Merle d'Aubigne were used for the evaluation of the patient's clinical status. Matta's radiologic scoring system was used for the analysis of the radiologic data. The Brooker scoring system was used to assess the extent of heterotopic ossification after acetabular fracture surgery.

RESULTS

There were 17 male patients and two female. The age range at the time of injury was 16 to 54 years with a mean age of 36 years. Follow-up ranged from 15 to 23 years (mean, 18.5 years). At final follow-up, radiographic outcomes were excellent in six patients (31.58%), good in 11 (57.89%), and fair in two (10.53%) patients. The mean clinical score was 15, ranging from 9 to 18. Clinical outcome was excellent in 10 cases (52.63%), good in six cases (31.58%), and fair in three cases (15.79%). When an anatomic reduction was achieved intraoperatively, excellent or good radiographic and clinical results were shown in 100% and 87.50% of the patients, respectively.

CONCLUSION

The adequacy of surgical reduction will determine the long-term outcome of surgically managed posterior hip dislocations associated with posterior wall acetabular fracture.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Avascular necrosis following fracture-dislocation of the hip and spontaneous relocation

Injuries occurring during soccer tend to occur with lower energy transfer than in some other contact sports. Tibial and femoral shaft fractures occasionally occur, but pelvic fractures are rare. We report a case of a missed posterior acetabular rim fracture, caused by a low energy trauma playing soccer, complicated by the development of avascular necrosis (AVN) of the femoral head and subsequent osteoarthritis.

Fixation of marginal posterior acetabular wall fractures using locking reconstruction plates and monocortical screws

Marginal posterior wall fractures are often fixed by lag screws, which may be technically difficult and risks articular penetration. Spring plates are used to avoid articular penetration. Both lag screws and spring plates are usually buttressed by reconstruction plates. The aim of this report is to describe a technique for fixing those fractures using locking reconstruction plate and monocortical screws avoiding articular penetration and sparing spring plates. A locking reconstruction plate is placed in a position that allows buttressing of the fracture fragment and fixed proximally and distally first using non-locking screws. The marginal fracture is fixed using monocortical locking head screws. This technique has been performed on three patients; none had secondary displacement or nonunion. Fixing marginal posterior acetabular wall fractures using locking reconstruction plates and monocortical screws saves additional lag screws or spring plates without risking articular penetration.

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.

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.

Intra-articular fragments in acetabular fracture-dislocation

Acetabular fractures are often associated with dislocation of the femoral head. When the dislocation is reduced, > or = 1 fragments may remain inside the joint, especially in posterior dislocation. In this kind of dislocation, the fracture of the posterior wall of the acetabulum may be comminuted. The fragments attached to the joint capsule or free may remain between the femoral head and the acetabulum. During reduction, these fragments are dragged inside the joint. The presence of the fragments in the hip joint may prevent complete reduction of the dislocation. Surgery should be performed early to reduce the risk of aseptic necrosis of the femoral head. Sometimes the fragments derive from a fracture of the femoral head without involving the posterior wall. Fragments are difficult to detect by conventional radiography; therefore, computed tomography scans are always indicated in fracture-dislocations pre- and postoperatively to check that all intra-articular fragments have been removed and the fracture has been reduced. We observed 373 cases of acetabular fracture between January 1, 1997 and December 31, 2007. One hundred twenty-seven cases presented a dislocation: 5 anterior, 13 central, and 109 posterior. In 45 cases, after reduction of the dislocation, 2 anterior and 43 posterior intra-articular fragments were observed. Removing a loose body inside the joint is always necessary because movement causes damage of the cartilage and therefore an early arthritis. The strategy to remove and the approach differs according to the kind of dislocation observed.

Ipsilateral anterior then irreducible posterior hip dislocation without fracture: a case report

Anterior hip dislocations and posterior hip dislocations are injuries that commonly result from high-energy trauma. Different mechanisms of injury and forces are typically required for anterior and posterior hip dislocations. We present the case of a patient who sustained an injury that initially resulted in an anterior hip dislocation. After reduction and without experiencing further significant trauma, the patient dislocated posteriorly while being transferred from a stretcher to a table in radiology some 14 hours later. To our knowledge, there have been no such presentations in the literature.

Results of operative treatment of acetabular fractures from the Third World--how local factors affect the outcome

The objective of this study was to assess the outcome of operations on acetabular fractures from a developing country in the presence of locally available facilities. Sixty-three acetabular fractures were assessed at an average follow up of 52.94 months after operation. Twenty-six patients operated upon in the first three years and 37 operated thereafter were separately studied to discover the effect of the learning curve. Regarding the fractures, 47 of 63 (74.6%) had excellent/good results (Harris Hip Score>80). The complications included broken drill bit in eight patients (12.69%), deep infection and heterotopic ossification in five patients (7.93%), avascular necrosis and sciatic nerve palsy in two patients (3.17%) and implant failure in one patient (1.58%). The results collected during the learning curve were inferior in the complex fractures (p value<0.001). Complications were common in patients opting for local implants and in those operated after over 2 weeks delay.

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.

Displaced acetabular fractures: indications for operative and nonoperative management

Displaced acetabular fractures are a challenging problem. In contradistinction to most conditions in which surgery is based on specific operative indications, displaced acetabular fractures should be considered an operative problem unless specific criteria for nonoperative management are met. These include a congruent hip joint on the anteroposterior and oblique (Judet) radiographs, an intact weight-bearing surface (as defined by roof arc and subchondral arc measurements on computed tomographic scans), and a stable joint. The final decision about the treatment method must also consider the patients functional demands, expectations, and physical condition and the physicians experience and institutional support for dealing with this type of injury. Displaced both-column fractures with secondary congruence may have better results than other displaced fractures. In older patients, nonoperative management may be effectively utilized. Understanding the current criteria for effective use of nonoperative treatment will help the surgeon make these difficult decisions.

Initial treatment of traumatic hip dislocations in the adult

The initial treatment of traumatic hip dislocations is critical to successful treatment of this injury. It generally is agreed that prompt reduction with the patient under anesthesia or sedation is required. Delay in reduction of posterior hip dislocations is associated with avascular necrosis of the hip. Occasionally the hip dislocation will be irreducible. Various methods to reduce hip dislocations have been described in the literature. The superiority of one particular technique has not been shown and the choice of reduction maneuver must be tailored to the condition of the patient. Traumatic hip dislocations often are associated with multiple injuries that may limit the options available for initial treatment of the hip dislocation. Adherence to general principles of skeletal reduction will increase the ease of reduction and decrease the risk of iatrogenic injury during reduction. Additional clinical and radiographic evaluation of the hip that was reduced often is necessary to determine whether subsequent open treatment is required.

A review of the treatment of hip dislocations associated with acetabular fractures

Traumatic dislocation of the hip is an extremely severe injury. Although previously considered an uncommon lesion, it now is seen more often as a result of motor vehicle accidents. In most cases, dislocation of the hip is associated with fractures of the acetabulum, which ultimately can result in a higher incidence of complications than the complications observed in pure simple dislocations. Early recognition and prompt closed reduction of the dislocated hip constitute the cornerstone of proper treatment of this injury. Once the dislocation is reduced, definitive treatment of the acetabular fracture can be delayed to obtain a precise diagnostic evaluation. If surgical reconstruction of the acetabular fracture is indicated, it is done best in the first 10 days after the injury. A few patients in whom nonconcentric reduction, failed closed reduction, or impaired neurologic status occurs after reduction will require early open reduction and internal fixation of the fracture. Complications can be caused by the initial injury or by the treatment. Avascular necrosis of the femoral head, degenerative osteoarthritis, and heterotopic ossification are the main complications encountered in patients with unsatisfactory final results. Despite a perfect reduction of the hip dislocation and anatomic reduction of the acetabular fracture, a significant degenerative process of the hip is expected when the patient is assessed at long-term followup.

Irreducible fracture-dislocation of the hip: a severe injury with a poor prognosis

OBJECTIVE

To determine the outcome of and prognostic factors associated with irreducible fracture-dislocations of the hip.

DESIGN

Retrospective review of a prospectively gathered trauma database.

METHODS

Using a prospectively gathered trauma database, we identified twenty-five patients with fracture-dislocations of the hip that were irreducible with closed means under a general anaesthetic. All were victims of high-energy trauma with severe injuries (mean Injury Severity Score = 25, range 9 to 54). Eighteen patients had multiple fractures, fifteen had associated systemic injury, and only four sustained the hip injury in an isolated fashion. There were seven associated sciatic nerve injuries (28 percent) and nine associated femoral head or neck fractures (36 percent). The mean time from injury to open reduction was 15.3 hours (range 3 to 58 hours).

RESULTS

Twenty-three patients (92 percent) were followed to definitive outcome. Despite accurate reduction, only six patients had satisfactory results (Thompson-Epstein = good or excellent). Poor results were associated with delay in reduction and an associated femoral head or neck fracture. Reasons for the poor results include avascular necrosis, posttraumatic arthritis or chondrolysis, persisting sciatic nerve injury, and heterotopic ossification.

CONCLUSIONS

An irreducible fracture-dislocation of the hip is a severe injury with a poor prognosis and a high incidence of associated injuries. Outcome is best in patients who do not have an associated femoral head or neck fracture and those whose dislocation is promptly reduced.