2-55 208 438602 00/0 ‘hr oun or Twat Cyr ik The Weim & Wiking Ca Vol 26 No.5 Distribution and Severity of Injuries Associated with Hip Dislocations Secondary to Motor Vehicle Accidents ALDO J. SURACI, MD. ‘The injuries associated with traumatic hip dislocations and their quantitated morbidities were evaluated in this retrospective study of 38 patients. Ninety- five per cent of the patients had associated juries severe enough for hospitalization on their own merit. Head, chest, and abdominal injuries were seen most frequently. Central dislocations wer morbidity, but were not different in different measurements of morbidity, associated with the most tribution of injuries. Using eight eluding the Injury Severity Score, hip dislocations, in general, had more morbidity than the national injury rates. Hip dislocations occur most commonly in vehicular accidents. Forces capable of disrupting the anatomy of the hip joint are likely to cause a variety of associated injuries. Knowledge of the type, distribution, and severity of associated injuries is important in treating victims of motor vehicle accidents, Although vehicular-caused hip dislocations usually oc cur with some major accompanying injury, information concerning the type and distribution of these associated injuries is not readily available. Rosenthal and Coker (10) have reported some information for a series of 45 posterior fracture-dislocations of the hip; Brav (4) pro- vvided some frequency data from 517 patients with ante: rior or posterior type dislocations; and Hunter (8) has also reported some data in connection with his followup, study of 57 posterior-dislocation cases. However, these studies do not report this information in much detail, and other studies of hip dislocations, generally focusing ‘on treatment and outcome, have reported complications, but not information concerning the other injuries sus- tained, ‘The purpose of this paper is to provide detailed infor mation on the extent of overall injury and the type and distribution of injuries associated with traumatic hip dislocations secondary to motor vehicle accidents, PATIENTS AND METHODS The Trauma Registry atthe Lehigh Valley Hospital Center, comprising 4,500 admissions during the period from January 1979 to dune 1983, was searched for all patients who had From the Department of Surgery, Lehigh Valley Hospital Center, Allentown, Pennsylvania, "The sue wishes to thank the Dorothy Rider Health Pool Care ‘Trust and Micheel Rhodes, M.D, Department of Surgery, for their support in prepring this por. ‘Adates for reprits Aldo J Surci, M.D, Rhode Island Hospitl— Brown University Department of Urology, Providence, Rhode Island 2901 sustained hip dislocations in motor vehicle accidents. Thirty eight patients were found. ‘There were 29 males and mine females, with ages ranging from 11 to 62 years (mean, 29.7 years). Seven patients had suffered accidents while riding mo ‘oreveies the remaining 31 patients were involved in automo: bile accidents Information concerning the type of dislocation (anteriar, posterior, central), and the details of all associated injuries were extracted from the patient records. (Overall severity of injury was assessed using eight different measures. One index was computed according tothe ISS system (@, 3), in which the body is divided into six regions: head and peck, face, chest, abdominal and pelvie contents, extremities tnd pelvie girdle, and external area, Within each region a rating from 1 (minor injury) to 6 (virtually unsurvivable) is assigned. ‘The largest score within each region is squared and the three highest of these values are added to generate the ISS index, Hospital length-of-stay, total units of packed red cells trans- fased, and days in ritcal care services were also Used as indices of injury severity (5). Finely, four other measures were com. puted as follows, As part of each patient’ records, an abstract was prepared for our Trauma Registry containing information describing: 1) the nature of all the patient's injuries; 2) all ‘procedures and operations performed; and 3) any complications that developed during treatment, based on the International Classification of Diseases, th Revision, Clinical Modification (ICD-9-CM) « method of indexing hospital records, by diseases and operations according to mortality and morbidity. The ‘numbers of ICD8CM codes listed in each category were totaled and used as indices, The last index was computed as the sum ofall the ICD9CM codes listed in all three ofthese categories. To summarize, eight measures of the extent and overall severity of injury, with the abbreviations used in this paper, ISS—Injury Severity Score LOS—Total length-of stay (days) in the hospital CC—Length-of-time (days) on critical care units Blood—Number of units of packed red cells transfused NUJ, OPT, COMP—Total number of ICD9CM codes used to describe the nature of the injury (NI), procedures and operations per formed (OPT), and any developing complications (COMP), as recorded on the Trauma Registry Abstract ‘Totel—Sum of NUJ, OPT, and COMP. 458Vol. 26, No. 5 Statistical analysis involved Chi-square tests to. compare frequencies and proportions across subgroups, and t-tests and analysis of variance (ANOVA) to compare means. RESULTS ‘The distribution of association injuries is displayed in ‘Table I. ‘Table I also shows comparable results from Rosenthal and Coker's (10) series of 48 posterior dislo- cations and the national injury rates for 1982, The 28 cases were distributed as three anterior, four central and 531 posterior dislocations. Thirty-six of the 38 patients sustained associated injures themselves severe enough to require hospitalization. ‘Two patients escaped any serious associated injuries. One death resulted from a cervical fracture at C2-8. ‘The distribution of injury by body site was as follows Cranio-tacial: 27 Concussion: 25 Facial fractures: 4 Chest: 18 “Myocardial contusion: 15 Pneumothorax: 13 Rib fracture: 4 Abdominal injury requiring laparotomy: 10 Large bowel: 2 Pelvis: 30 ‘Acetabulum fracture: 26 Hematuria: 31 extremities: 14 Femor: 5 ‘Tibia-fibula: Humerus: 5 Ulnar: 4 Sciatic nerve: 6 No statistically significant differences were found among the posterior, anterior, and central groups with TABLET Incidence rates for severe injuries associated with hip dislocations Aajaccre mead WRB Ta inure Cranitia | my OT mT Nek | 7 ad Chet er) xe ‘men ts 3 ms Pelvin Neo ah ay = GM akk NR Injuries Associated with Hip Dislocations 459 respect to frequency of associated injuries. The distr: bution of ISS scores ranged from 9 to 57 with a mean of 22.3 and a standard deviation of 12.4 ‘Table IT shows the mean and standard deviation for each of the eight measures of overall injury severity, broken down by type of dislocation. The last column in this table gives the probability level for the analysis of variance testing for differences among the three groups. In seven of the eight measurements there were a signif: icant differences (p < 0.05 or smaller), with the four cases of central dislocations averaging higher scores on each of these variables. ‘The analysis with ISS scores, although not significant (p < 0.19), was in this same direction, with the central dislocation group showing the highest mean score. ‘Table IIT gives the rank-order Spearman correlation coofficient matrix for these eight variables with p < 0.0002, ranging from 0.56 to 0.96. DISCUSSION We found no thorough evaluations of the injuries associated with hip dislocations in the literature, The present study quantitated the frequency of the severe injuries incurred to specific body areas and their morbid- ities, Associated injuries were found in 95% of the cases in this series, Rosenthal and Coker (10) reported 78% in their 46 cases. Reigstad (9) reported 55.4% of 56 anterior and posterior dislocations. Brav (4) reported 41.6% of TARE w ‘Mean scores on each of eight measures of overall severity of injury (# Standard Deviation) broken down by type of hip dislocation sal Peron Sa 7 LOS AIAE IB eS ma M028 p< oom Bled BAUS ISOETIS 20534 p< ONL ce 2 1os62 M7 pea NATINS 328 Yen 8a7 44 psoas PROCOP IK0-EI5 240259 16285 pent COMP Li21 i252 Iss26 poco SIRETS RATA BAsINE pono 22098 Lt peut ‘TABLE I Spearman rank-order correlation matrix for eight measures of overall severity of injury os = on 9.65 064 070 — O38 066 OST O78 — OR 066 074 O85 Om — OSL 049 O88 GS O95 OAD 056 O58 066 Ol 074072 os! — All coeelations significant p = 00a460 ‘The Journal of Trauma his 517 cases. Epstein (7) reported 34.7% of his 559 cases as having sustained associated injuries. The relative fre- ‘quency of anterior, posterior, and central dislocations for ‘our series closely matches the values reported in the literature and are similar to those given by Stewart and Milford (11). ‘When the distribution of injuries associated with hip dislocations was compared to the overall national injury rates, it was found that the hip dislocation patients \curred increased incidence of head, abdomen, and chest sjuries in this series. In comparison, Rosenthal’ series (20) revealed only an increased incidence of head injuries, comparable abdomen frequency, and no report of chest involvement associated with hip injuries. ‘The severity of the injuries incurred were quantitated using the ISS system. An overall score of 22.3 was calculated. ‘The national average ISS of all patients involved in ‘motor vehicle accidents who required hospitalization was 78. The morbidity association with hip dislocations in the present study was significantly more severe than that reported in the national morbidity rates, and tends to reflect the increased distribution of the head, abdomen, ‘and chest injuries. When the three types of dislocations were analyzed with respect to the distribution of associated injuries, there were no statistical differences noted. There was, however, an increased morbidity associated with central dislocations. Seven of the eight parameters showed the increased morbidity to be statistically significant as op- posed to the ISS which only showed an overall trend towards this. Patients who incurred central hip disloca- tions had a longer hospital stay, with an increased num- ber of intensive care (ICU) days, blood transfusions, complication rates, and hospital based procedures (Table Im. ‘When Spearman correlation coefficient analysis was performed on the data, the correlations were statistically significant, reflecting the overall homogeneity of these parameters and their direct relationship with each other. ‘The morbidity associated with central dislocations re- flects the increased force necessary to incur such an injury and that the overall force was not limited to the pelvis. ‘The injuries directly associated with a dislocation of the hip were sciatic nerve injury and femoral vessel May 1986 injury. Sciatic nerve damage has been reported to arise primarily from posterior dislocations. Seiatie nerve in- juries have been noted in posterior dislocations in 10% of the cases and have been associated more with fractures, of the acetabulum than with the mechanical dislocation itself (4, 7), The injuries in these cases were seen with posterior dislocations that had acetabular fractures. The peroneal branch of the sciatic nerve is the branch most frequently damaged, but 20% of the sciatic nerve injuries involved the tibial branch only (1). Ten per cent involve both branches. Of the six cases in this series, only two suffered permanent nerve damage. ‘Vessel damage has been described in anterior disloca- tions from impingement of the vessel in superior or pelvie dislocations. There have been reports of pulmonary em- boli following reduction of these dislocations after a prolonged delay. Isolated arterial damage from anterior ‘or posterior dislocations has been reported but was rarer (8,12) ‘This paper does not suggest that one should evaluate a victim for a hip dislocation in order to diagnose his subsequent injuries, but rather to alert the physician that hip dislocations may be associated, at times, with other life-threatening inju REFERENCES 4. Armstrong. J. R: Traumatic disloction ofthe hip eit. J. Bone ‘Te Sarg. 3B: 430-445, 1948. 2, Baker, 8B. O'Neil B, Haddon, W. Jr ctl: The Ijury Seventy ‘Score: A inethod for deverbing patients with multiple injures evaluating emergency cared. Trauma, 14: 187, 1974 8, Baker, SP, Oeil Bz The Inory Severity Scoe: An update J “Trauma, 16: 882 91 location ofthe hip: Army experience and eculs over twelve-ear period. J. Bone Jt. Surg, 44-At 1D, 1042, 5 Bl, 3. Ps Measures of severity of injury. 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