32 Dislocations and fracture dislocations of the hip SHANMUGANATHAN RAJASEKARAN, VAY KAMATH, JAYARAMARAJU DHEENADHAYALAN. Introduction 335 Posterior 25 Anterior dislocations 338 References 339 RN ean u ened ‘¢ Revise your knowledge of hip joint anatomy ‘© Understand the pathophysiology of hip dislocation ‘¢ Know the methods of closed reduction ‘¢ Be able to advise a patient on the prognosis and comaliations INTRODUCTION Nip dislocations almost always result from high-energy ‘wauma, such as motor vehicle accident or fill roma height. ‘The direction of the pathological force and the position of the lower extremity at the time of impact determines whether the hip dislocates anteriorly or posteriorly Posterior dislocations constitute 85-90% of traumatic dislocations, with anterior dislocations accounting forthe remainder. POSTERIOR DISLOCATIONS limb. This presentation may be altered by injuries to the ipsilateral extremity and acetabulum. Approximately 50% ‘of patients sustain concomitant fractures and major organ or other musculoskeletal injuries, and they should be care- fully looked for. Ipsilateral knee, patellar and fermur frac tures are the commonly associated injuries. Sciatic nerve injury is present in 10-20% of posterior dislocations: therefore, 2 neurovascular examination of the ipsilateral limb is essential. Radiographic evaluation Mechanism of injury Posterior dislocations result from trauma tothe flexed knee (eg. dashboard injury) with the hip in varying degrees of flexion, A neutral or an adducted hip will result ina dislo- cation without an acetabular fracture. Ifthe hip isin slight abduction atthe time of injury, an associated fracture of the posterior-superior rim of the acetabulum will occur li al evaluation ‘The (ypical presentation in a posterior dislocation is a shortened, slightly flexed, internally rotated and adducted ‘An anteroposterior radiograph of the pelvis with 2 cxoss- table lateral view of the affected hip is mandatory. Ina dis- located hip, the Shenton’ line is broken and the joint space is asymmetric. In a posterior dislocation the affected femoral head will appear smaller than the normal hip with the femoral shaft in adduction, while, in an anterior dislo~ cation, the femoral head will appear slightly larger than the normal with the shaft in abduction, The relative appear ance of the greater and lesser trochanters may indicate pathological internal or external rotation of the hip. The lateral view will help distinguish a posterior fom an ante- rior dislocation, Associated fractures of the femoral neck or acetabulum must be carefully ruled out, Judet (45° oblique) views of126. Dislocations and fracture dislocations of the hip the hip may be helpful to ascertain the presence of osteo- chondral fragments, the integrity of the acetabulum and the congruence of the joint spaces. CT scans are usually ‘obtained following closed reduction ofa dislocated hip. If closed reduction is not possible and an open reduction is planned, a CT scan should be obtained to detect associated Femoral head and acetabular fractures and the presence of intra-articular fragments, Classification ‘The most commonly followed classification of posterior dislocation is the Thompson and Epstein classification? (Table 32.1 and Fig. 32.1). Treatment ‘The treatment of a dislocation or fracture dislocation of the hip depends primarily on the type of injury. The dislo- cated hip should be reduced on an emergency basis to relieve pain and to decrease the risk of osteonecrosis of the femoral head as the incidence increase when reduction is delayed for more than 12 houss. Following reduction, the hip should be placed in traction if unstable, and definitive lueatment of femoral head and acetabular fractures can be deferred to the subacute phase ‘TYPE | POSTERIOR DISLOCATION Closed reduction should be performed preferably under general anaesthesia, and reduction under intravenous Table 32.1. Thompson and Epstein classification of posterior hip dislocations Type Description Type! Simple islacation with or without an Insignificant posterior wall ragment Typell Dislocation associated with a single large posterior wall ragment Typelll Dislocation with a comminutes posterior wall fragment TypelV Dislocation with fracture ofthe acetabular flor Type V Dislocation with fracture ofthe femoral head Typel Type ype tl sedation is attempted only rarely. Only one or two attempts at closed reduction should be made, fling which ‘open reduction is indicated to prevent further damage to the femoral head. Many methods of closed reduction have been described, namely the Stimson prone gravity tech nique, Allis method, Bigelow manoeuvre and the East Baltimore lift, Deseribed below are the Bigelow manoeuvre and the East Baltimore lif. Bigelow manoeuvre (Fig. 32.2) With the patent supine, the surgeon applies longitudinal traction onthe limb inthe line of deformity end the hip i flexed to at least 90". The femoral hea i then levered into the acetabulum by sbduction, external rotation and exten- sion ofthe hip. An audible ‘cunk i a sign ofa succesfal tlosed reduction, play Figure 32.2 Bigelow reduction manoeuve for posterior dislocation of hip. Figure 22.1. Thompson and Epstein clasifeation of, posterior dislocation of the hip. ypePosterior dislocations 237 East Baltimore lift ‘With the patient supine, the surgeon stands on the affected side with an assistant on the opposite side. The patient's leg is flexed so that the hip and knee are at 90°, The sur- igeon places his or her arm that is closest to the patient's hhead under the proximal calf of the patient, cradling the leg in his or her clbow with his or her hand resting on the shoulder of the assistant, The surgeon's other hand grips the patient's ankle, The assstant’s arm passes under the proximal calf ofthe patient (similar to the surgeon’) and rests on the surgeon's shoulder. The surgeon and assistant squat slightly with knees bent. They straighten up together to apply traction (o the hip without straining their backs ‘The surgeon rotates the leg a the ankle, A second assistant sxabilizes the pelvis, Radiographs should be obtained to confirm the ade- _quacy of reduction, Persistent widening of the distance between the radiographic teardrop and the femoral head ‘compared with the normal hip indicates entrapment of ‘osteocartilaginous fragments or the acetabular labrum. ‘Thin slice CT scan evaluation should be performed in such patients. Closed reduction is followed by immobi- lization in Buck's traction, an abduction pillow or "Thomas splint Failure of closed reduction may be due to (1) button- hholing of the femoral head through the posterior capsule; (2) interposition of the piriformis, obturator and gemelli muscles; (3) 2 torn acetabular labrum; or (4) osteachon- <éral acetabular fragments and fracture fragments from the femoral head. An open reduction should be performed immediately. ‘TYPE I, Ill AND IV POSTERIOR DISLOCATIONS. ‘The hip is reduced as an emergency procedure and the acetabular fracture can be treated within the next few days according to the guidelines lid down for the management of isolated acetabular fractures. In type I dislocations following closed reduction, the hip stability should be evaluated while the patient is still ‘under anaesthesia, In patients who have an acetabular frac- ‘ure that involves more than half ofthe articular surface of the posterior wall the stability testis avoided as these hips are assumed (o be inherently unstable, All patients with a failed stability test and type IIL or IV dislocations require surgical intervention for the acetabular fracture. (Open reduction of posterior dislocations is usually per- formed through a Kocher-Langenbeck approach. In the presence of an associated femoral head fracture, an ante- rior Smith-Petersen approach maybe preferred TYPE V POSTERIOR FRACTURE DISLOCATION WITH FEMORAL HEAD FRACTURE Fractures of the femoral head occur as a shearing injury as the flexed hip is driven across the posterior wall of the acetabulum during dislocation. Small inferior frag ments ofthe femoral head tend to be free of soft-tissue attachments, whereas larger fragments frequently are still connected to the acetabulum by the ligamentum teres Pipkin subclasifed EpsteinThomas type V fracture dislocations into four additional subtypes (Table 32.2 and Fig. 823) Treatment Factors that determine the nature of treatment inelude (1) the concentricity of the reduced femoral head in the acetabulum, (2) the accuracy of the reduction of the dis- placed femoral head fragment, (3) the size of the femoral Table 32.2. Pipkin classification of posterior dislocation of the hip with femoral hea fracture Type ——_Deseription Type! Posterior dislocation ofthe hip with fracture of the femoral eas caudad to the fovea capitis Typell Posterior dislocation ofthe hip with fracture of ‘the femoral head cephalad tothe foes capitis Typelll Type! orll posterior dislocation with associated fracture of the femoral neck TypelV——Typel, orl posterior dislocation with associated ‘Fracture of the acetabulum @ © @ Figure 32.2 Pipkin classification of posterior dislocation ofthe hip with femoral head fracture (8) Type 0 type type Il; (type238 Dislocations and fracture alslecations ofthe hip head fragment, (4) the stability of the reduction and (5) the age of the patient, Management after closed or open reduction ranges from short periods of bed rest to various durations of skeletal traction (Table 323), No correlation exists between early weight bearing and osteonecrosis. ‘Therefore, partial weight beating is advised. If reduction is concentric and stable, a short period of bed rest is followed by protected weight bearing for 4-5 weeks, Special uations fp the case of an ipsilateral displaced or non-displaced femoral neck fracture, closed reduction of the hip should not be attempted. The fracture should be provisionally sta- bilized through a lateral approach. A gentle reduction is then performed, followed by definitive Gxation of the femoral neck, Prognosi ‘The outcome following hip dislocation ranges from an ‘essentially normal hip toa slow deterioration to a severely painful and degenerated joint. Most authors report & 70-80% good or excellent outcome in simple posterior dislocations, When posterior dislocations aze associated with a femoral head or acetabular fracture, however, the anatuze of the associated fractures dictates the outcome. Complications the posteriorly dislocated femoral head, laceration by the posterior acetabular fracture fragments or ischaemia from pressure on it by the head. Usually, the peroneal port with lle if any dysfunction of the tial nerve, The prognosis is unpre- dietable and most authors report only 40-50% full recov- ery, If a sciatic nerve injury occurs following a closed reduction, then entrapment of the nerve is likely and sur- gical exploration is indicated, Osteonecrosis of varying degree is observed in 5-409 of injuries. The incidence increases with delay in reduction and repeated attempts at closed reduction, and the condition may become dlini- cally apparent only after a few years. Post-traumatic osteoarthritis is the most frequent long-term complica- tion and the incidence is higher with associated acetabu- lar fractures of transchondral fractures of the femoral head. Heterotopic ossification occurs in 2% of patients and is related to the initial muscular damage and haematoma formation, mn of the nerve is afl ANTERIOR DISLOCATIONS Anterior dislocations result from forced external rotation and abduction of the hip. Ifthe hip isin flexion during dis- location, it sesulls in an inferior (obturator) dislocation, and ifin extension a superior (pubic) dislocation occurs, Classification Sciatic nerve injury occurs in Sciatic nerve injury may occur by stretch ofthe nerve oves 1-209 of hip dislocations. Anterior hip dislocations were dassified by Epstein (Table 32.4) ¢oredueton stability rachiments tothe fragment, including the ligamencum teres, should be high rat of osteonecrosis ard post-traumatic Table 22.2 Management guidlines or posterir fracture dislocations of hip Type Description Typel i osed reduction results in a concentric stable reduction minor malalignment of the fragment is acceptable If losea reduction isnot concentric ori impossible, open reduction with excision of small fragments should te done immediately. Large fragments also are removed, provided that they do not alter the po Type ll Immetiate close reduction is attempted. Anatomical reduction of the superior head fragments is crucial an this should be assessed in the post-redution radiographs and CT. If the reduction is non-anatomical and non-concentve, open reduction should be done, Any soft-tissue preserved if possible, Internal fixation ofthe fragments is easly performed through an anterior Smith-Petersen approach. In elderly patients a replacement is indicated because of arthritis Type tl yung patients, open reduction and internal fxation of the fracture i indieated, while in older patents orn hip With pre-existing disease a replacement is insicated Type lV The treatment is dictated by the type of acetabular fracture In young patients, fcancentie reduction with reasonable Jit congritycanrot be obtained by closed means, open reduction and intemal fixation of all major fragments is performed, In older patients orn a hip with pre-existing disease a replacement is indReferences 399 Table 32.4 Epstein classification of anterior hip dislocations ype! Superior sislecations, including pubic and subspinous TA No associated fractures 18 Associated fracture orimpaction ofthe femoral head IC Associated fracture of the acetabulum ypell Inferior dislocations, including obturator and perineal WA Novassocated fractures IB Associated fracture or impacton ofthe femral hea Hic Associated fracture of the acetabulum Clinical evaluation Clinically the hip isin marked external zotation with mild flexion and abduction. Injury to the femoral artery, vein oF nerve may occur asa resull of an anterior dislocation and ‘must be looked for. Treatment ‘Closed reduction is achieved by longitudinal traction on the thigh with a lateral force on the proximal thigh waile simoltancously pushing the femoral head to the acctabu- Jum. The reverse Bigelow manoeuvre may also be used. Here the traction is applied in the line of the deformity, the hip is then adducted, internally rotated and extended. 1f closed reduction fails, open reduction is performed thor- ‘ough a Smith-Petersen approach. ‘Anterior dislocations ofthe hip have a high incidence of associated femoral head injuries, This ranges from 25% to 75% and may be transchondral or indentation types. Patients without an associated femoral head injury usually have a good outcome. REFERENCES: ‘61. Sahin V,KarakasE5, Ads 5, eto. Traumatic dislocation and fratute-dslocation ofthe hip long tem follow-up study. Journal of Teouma 2003;54:520-8, 1#2._ Thompson VP, Epstein HC. Traumatic islcation ofthe hip: 4 survey of two hundred and four cases covering a period ‘of twenty-one years, Journal of Rone and Joint Surgery (American) 1951:338:746, 3. Sehafer SI, Anglen JO. The East Baltimore It: a simple and efective methos for reduction of posterior hip sislocations Journal of Othopaedic Trauma 1898:13:56. ‘94, Stannard JP, Haris Hi, Volgal DA eta Functional ‘outcome of patients with femoral head fractures associated with hip dislocations, Clinical Orthopaedies and Related Research 2000;377°44.