Iw~v. 13.

39 l-394 Printedin Great Britain 391

Traumatic dislocation of the hip with

ipsilateral femoral shaft fracture: a method
of treatment

Marion C. Harper
Division of Orthopaedic Surgery, University of Missouri Medical Center, Columbia, USA

Summary
Two cases of posterior fracture-dislocation of the hip
associated with an ipsilateral femoral shaft fracture are
presented with a technique of reduction and
stabilization which allows for closed treatment of both
injuries. This approach is advantageous in the severely
injured patient.

THE importance of the early diagnosis and treat-

ment of traumatic dislocation of the hip has
been repeatedly emphasized in the literature.
When combined with an ipsilateral femoral
shaft fracture both prompt recognition and
management become more difficult. A fairly
simple initial approach to this injury has been
described and is repeated here in a slightly
modified form. This technique of closed Fig. 1. Dislocation of the left femur with fracture of the
reduction of the dislocation combined with proximal shaft.
closed medullary nailing of the shaft fracture
may be especially advantageous in the severely
injured individual. dislocation. A 9164~inch threaded Steinmann pin was
drilled in a posterior-anterior direction across the
greater trochanter taking care to stay lateral to the
sciatic nerve. A traction bow was attached to the pin
CASE REPORTS and the hip reduced by applying distal traction with
the proximal fragment adducted and moderately
Case 1 flexed (Fig. 2). Post-reduction films in skeletal traction
A I ‘I-year-old male was admitted to the University of revealed a congruous reduction and a Pipkin type I
Missouri Medical Center following an automobile fracture ofthe femoral head (Fig. 3).
accident with partial and full-thickness bums of the It was elected to stabilize internally the fracture of
face and lower limbs, severe facial wounds, closed the femoral shaft by closed medullary nailing and this
fractures of the left maxilla, left femur, left humerus, was done without complication 2 weeks after the
left second metacarpal, and right patella as well as a injury.
fracture-dislocation of the left hip (Fir. I ). Examination after I5 months revealed healed frac-
While under general anaesthesia to repair the facial tures ofthe head and shaft of the femur (Fig. 4) and full
wounds, an attempt was made to reduce the hip painless motion ofthe hip and knee.
 Injury:the Brltlsh Journal of Accident Surgery Vol. 1~/NO. 5

Fig. 2. Post-reduction, anteroposterior (a) and lateral

(b) views with Steinmann pin and traction bow in
place.

Fig. 3. Post-reduction tomogram showing fractures of Fig. 4. Anteroposterior radiograph 15 months aRer
the femoral head. injury.
Hamer: Traumatic Dislocation of the Hip
Fig. 5. Posterior dislocation with fracture of the
proximal shaft.
Case 2
A 19-year-old female was involved in an automobile
accident sustaining bilateral closed fractures of the
femur, a posterior dislocation of the left hip (Fig. S),
fractures of the right pubis and triquetrum as well as
blunt abdominal injury. Before laparotomy, which
revealed a ruptured spleen, and under general
anaesthesia, the posterior dislocation of the hip was
reduced by a traction bow attached to a large
Steinmann pin placed through the greater trochanter.
Radiographs revealed a satisfactory reduction.
Two days after the injury, weakened pulses were felt
in the left foot and an arteriogram revealed almost
complete occlusion of the superficial femoral artery.
Because of an acute respiratory distress syndrome,
operation was deferred for 8 days, when closed nailing
of the femoral fracture using a fluted rod was
undertaken followed by a saphenous vein graft for the
thrombosed superficial femoral artery.
Examination at 6 months revealed the femur to be
clinically and radiographically united (Fig. 6). Full
painless motion ofthe hip and knee were present.
D’SCUSSION
Traumatic dislocation of the hip associated with
an ipsilateral femoral shaft fracture is an injury
which poses several problems. The first is that
dislocation may be hidden by the fracture of the
Fig. 6. Anteroposterior radiograph 6 months after
injury.
shaft, masking the typical deformity of the lower
limb. In spite of the known association of these
injuries, major reviews have reported about 50
per cent of missed diagnoses (Henry and
Bayumi, 1934; Dehne and Immerman, 1951;
Helal and Skevis, 1967; Epstein, 1974).
A second problem concerns the initial
management of the dislocation. There is general
agreement that the prognosis for the hip relates
directly to the promptness of reduction. Stewart
and Milford (1954), Epstein (1974) and Brav
(1962) all noted the highest incidence of good
results in hips reduced in less than 24 hours.
Although primary open reduction of all
posterior fracture-dislocations is advocated by
Epstein (1974) in order to remove osteo-
cartilaginous fragments from the joint, most
authorities appear to favour an initial closed
reduction followed by reassessment of the frac-
ture pattern and stability of the joint (Stewart
and Milford, 1954; Watson-Jones, 1955; Brav,
1962; Clawson and Melcher, 1975). This injury
is also frequently associated with severe injury to
multiple organ systems thus often making an
early major operation on the hip inadvisable.
Assuming that prompt closed reduction is
generally advisable, the next question is how to
 394
accomplish it. Three basic approaches appear in
the literature. The first is to pull through the soft
tissues of the lower limb across the fracture site.
A review of the English literature reveals a
success rate ofapproximately 27 per cent for this
technique (Henry and Bayumi, 1934; Dehne
and Immerman, 1951; Ehtisham, 1976;
Schoenecker, et al., 1978). Traction of suflicient
force to reduce a hip dislocation across already
damaged soft tissues is mechanically unsound
and could lead to further soft tissue injury.
The second approach has been to fix the
femoral shaft fracture by plating or a nail
followed by closed reduction of the hip as
recommended by Watson-Jones (1955). While
mechanically efficient, this does involve a major
operation in an often severely injured patient
and calls for opening a fracture which could be
treated closed.
The third method is to apply skeletal traction
through the proximal fragment after obtaining
purchase with percutaneous insertion of a screw
or pins. Allis (1896) recommended the use of a
strong pointed awl, gimlet, or screw thrust into
the greater trochanter. King and Richards (194 1)
and Wiltberger et al. (1948) related cases in
which satisfactory reductions were accomp-
lished by the insertion of Steinmann pins
through the trochanteric region. lngram and
Turner (1954) described bilateral combined
injuries wherein Steinmann pins were placed
across the greater trochanter in an anterior-
posterior direction and closed reduction was
obtained by pulling through large vice-grip
pliers clamped to the pins. Helal and Skevis
(1967) as well as Lyddon and Hartman (1971)
advised using large traction screws inserted into
the proximal fragment.
In spite of this variety of described techniques,
reports of delayed open reductions often
following unsuccessful attempts at closed reduc-
tion via simple traction continue to appear
(Epstein, 1974; Ehtisham, 1976) It is felt that
this would occur much less frequently if prompt
reduction was attempted by skeletal traction.
The method described here is advocated for its
simplicity and ready availability. Most hospitals
have Steinmann pins and traction bows whereas
large traction screws and more complicated
devices may not be available.
Reyue~\ .for reprink\ should hr addressed Iu: Dr
University of Missouri Medical Center, Columbia,
Iqury: the Brltlsh Journal of Accident Surgery Vol. 1 ~/NO. 5
Closed nailing of the shaft fracture appears to
be advantageous in the seriously injured patient
and in addition allows for early active and
passive mobilization of the hip.
REFERENCES
Allis 0. H. (1896) An Inquiry into the DQ,kulties
Encountered in the Reduction of Dislocations of the
Hip. Philadelphia, Dorman.
Brav E. A. (1962) Traumatic dislocation of the hip. J.
Bone Joint Surg. 44A, 1115.
Clawson D. K. and Melcher P. J. (19751 Fractures and
dislocations of the hip. In: Rockwdod C. A. and
Green D. P. (eds.) Fractures. Philadelphia,
Lippincott.
Dehne E. and Immerman E. W. (I 95 1) Dislocation of
the hip combined with fracture of the shaft of the
femur on the same side. J. Bone Joint Suw. 33A.
Ehtisham S. M. A. (1976) Traumatic dislocation ofhip
joint with fracture ofshaft of femur on the same side.
J. Trauma 16, 196.
Epstein H. C. (I 974) Posterior fracture-dislocation of
the hip: long term follow-up. J. Bone Joint Surg.
56A, 1103.
Helal B. and Skevis X. (1976) Unrecognized dislo-
cation of the hip in fractures of the femoral
shaft. J. Bone Joint Surg. 49B, 293.
Henry A. K. and Bayumi M. (1934) Fracture of the
femur with luxation of the ipsilateral hip. Br. J.
Surg. 22,204.
Ingram A. J. and Turner T. C. (1954) Bilateral
traumatic posterior dislocation of the hip compli-
cated by bilateral fracture of the femoral shaft. J.
Bone Joint Surg. 36A, 1249.
King D. and Richards V. (1941) Fracture-dislocation
ofthe hip joint. J. Bone Joint Surg 23,533.
Lvddon W. D. and Hartman J. T. (1971) Traumatic
dislocation of the hip with ipsilatkral fkmoral frac-
tures. J. Bone Joint &rg. 53A, IO 12.
Schoenecker P. L.. Manske P. R. and Sertl G. 0.
(1978) Traumatic hip dislocation with ipsilateral
femoral shaft fractures. C/in. Orthop. 130,233.
Stewart M. J. and Milford L. W. 11954) Fracture-
dislocation of the hip. An end-result study. J. Bone
Joint Surg. 36A, 3 15.
Watson-Jones R. (1955) Fractures and Joint Iniuries.
Edinburgh, Livingstone.
Wiltberger B. R.. Mitchell C. L. and Hedrick D. W.
(I9485 Fracture of the femoral shaR complicated by
hip dislocation. A method of treatment. J. Bone
Joint Surg. 30A, 225.
Manon C. Harper, Assistant Professor, Division of Orthopaedic Surgery,
Missouri 652 12. USA.