hip dislocation, anatomy, history, diagnosis, treatment and management.pptx

dislocation of hip

1. HIP DISLOCATION MOD : IY Team IV: TM/SG/NO/RN Spv : dr. Dewi Kurniati , MKes , SpOT Tuesday, august 13 th , 2019 Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

2. IDENTITY Name : A Age : 22 years old / female Admission : August 14 th , 2011 at 05.30 WITA Registration : 51 98 72 Status : Umum

3. AUTOANAMNESIS Chief Complain : pain at the right hip Suffered since about 30 minutes before admi tted to Wahidin hospital due to traffic Accident. She was a passenger of motorcycle. Suddenly her motorcycle got hit by a car from right direction. History of unconscious (-), nausea (-), vomit(-) Prior treatment (-).

4. PRIMARY SURVEY A : Clear B : RR = 24x/min, symmetric, spontaneous, thoracoabdominal type. C : BP: 120/80mmHg, HR: 88x/min, regular, strong D : GCS 15(E4M6V5), light reflex +/+ , pupil isochors, Ø : 2.5 mm/2.5mm, E : T = 36.7 C ( axillary )

5. SECONDARY SURVEY Pelvic region : Look : Deformity (+) , swelling (+), Hematoma (-), Wound (-), adduction and external rotation of the hip. Feel : Tenderness (+) Move : Active and passive motion at hip joint is limited due to pain NVD : sensibility is good, dorsalis pedis artery is palpable, capillary refill < 2”.

6. CLINICAL FINDINGS

7. RADIOLOGY FINDINGS

8. DIAGNOSIS Posterior dislocation of right hip joint

9. MANAGEMENT IVFD Analgesic Report to orthopedic senior, advice: Close reduction under narcose

10. RADIOLOGY FINDINGS POST REDUCTION

11. INTRODUCTION Hip dislocations almost always result from high energy trauma, such as MVA or fall from a height. Rare, but high incidence of associated injuries Posterior dislocations constitute 85-90% of traumatic dislocation. Sciatic nerve injury is present in 10% to 20% of posterior dislocations. Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

12. ANATOMY The hip articulation is a ball and socket joint. It has intrinsic stability due to : bony anatomy Soft tissue constrains including labrum , capsule (iliofemoral, ischiofemoral , pubofemoral) Ligamentum teres Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

13. The main vascular supply to the femoral head: Medial and lateral circumflex arteries, branches of the profunda femoral artery The artery of the ligamentus teres , a branch of the obturator artery, contribute blood supply to the epiphyseal region of the femoral head Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

14. CLASSIFICATION Simple vs complex simple = pure dislocation without associated fracture complex = dislocation associated with fracture of acetabulum or proximal femur Anatomic classification: posterior dislocation vs anterior dislocation Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

15. POSTERIOR DISLOCATION These comprise 85% to 90% of traumatic hip dislocations Occur with axial load on femur, typically with hip flexed and adducted ( e.g dashboard injury ) Position of hip determines associated acetabular injury: If the hip is in the neutral or slightly adducted position wil resultin a dislocation without an acetabular fracture If the hip is in the slight abduction , an associated fracture of the posterior superior rim of the acetabulum usually occurs Clinical evalution : pain, shortened, hip position in slightly flexed, internal rotated and adducted limb Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

16. CLASSIFICATION : Thompson and Epstein (posterior dislocation)

17. Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

18. ANTERIOR DISLOCATION Associated with femoral head impaction. These injuries result flexion, external rotation and abduction of the hip The degree of hip flexion determines whether a superior or inferior type of hip dislocation : Hip extension results in a superior (pubic) dislocation. Clinically hip appears in extension and external rotation Hip flexion results in inferior (obturator) dislocation. Clinically hip appears in flexion, abduction, and external rotation.

19. CLASSIFICATION : Thompson and Epstein (anterior dislocation) Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

20. IMAGING RADIOGRAPHS anteroposterior (AP) radiographs of the pelvis is essential, as well as a cross table lateral view of the affected hip. The shenton’s line is broken and the joint space is asymemetric Posterior dislocation : affected femoral head appear smaller than the normal femoral head (closer to plate=less magnification) Anterior dislocation : affected femoral head appear larger than the normal femoral head Associated fracture of femoral neck or acetabulum Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

21. IMAGING CT SCAN Helps determine direction of dislocation, loose bodies, and associated fractures : anterior vs posterior dislocation Post reduction CT must be performed for all traumatic hip dislocation to look for : femoral head fractures, loosebodies , and acetabular fracture MRI Controversialand routine use is not currently supported Useful to evaluate labrum , cartilage and femoral head vascularity Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

22. TREATMENT Non operative : Emerged closed reduction within 6 hours : Indication : acute anterior and posterior dislocation Contraindication : ipsilateral displaced or non displaced femoral neck fracture Operative : Open reduction and/or removal of incarcerated fragments indication : irreducible dislocation and radiographic evidence of incarcerated fragments ORIF indication : associated fractures of acetabulum, femoral head, and femoral neck was should be stabilizied prior to reduction Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

23. CLOSED REDUCTION ALLIS METHOD The patient is positioned supine The assistant stabilizes the pelvis The surgeon applies traction in the direction opposite the deformity While traction is being applied, the hip is flexed to 90 degrees Gentle rotational motions of the hip as well as slight adduction will often help the femoral head to clear the lip of the acetabulum An audible “clunk” is a sign of a successful closed reduction

24. CLOSED REDUCTION BIGELOW METHOD The patient is positioned supine The assistant stabilizes the pelvis The surgeon places one arm beneath the patient’s proximal calf and grasps the ankle with his or her other arm The surgeon applies longitudinal traction on the limb. The adducted and internally rotated thigh is then flexed at least 90 degrees. The femoral head is then leveres into the acetabulum by abduction, external rotation, and extension of the hip

25. EAST BALTIMORE LIFT STIMSON MANUVER Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

26. OPEN REDUCTION Indications for open reduction : Dislocation irreducible by closed means. Nonconcentric reduction. Fracture of the acetabulum or femoral head requiring excision or open reduction and internal fixation. Ipsilateral femoral neck fracture. Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

27. OPEN REDUCTION Approach Posterior dislocation : posterior (Kocher- Langenback ) approach Anterior dislocation : anterior (smith Peterson) approach Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

28. REHABILITATION Early mobilization With posterior dislocations, hyperflexion is avoided for 4 to 6 weeks. Immediate weight bearing is initiated for simple dislocations. Delayed weight bearing is used with large posterior wall or dome fracture fixation. Handbook of fractures. Hip Dislocation Fifth edition. 2015. hal 333-345 Orthobullets . Hip Dislocations. 2017 Mercer’s Textbook of Orthopaedics and Trauma.2012. Dislocation and fracture dislocations of the hip. Tenth Edition. Hal 335-339

29. Complications Post-traumatic arthritis up to 20% for simple dislocation, markedly increased for complex dislocation Femoral head osteonecrosis 5-40% incidence Increased risk with increased time to reduction Sciatic nerve injury 8-20% incidence associated with longer time to reduction Recurrent dislocations less than 2%

30. QUESTION A 41-year-old female sustains the injury shown in Figure A as a result of a high-speed motor vehicle collision. After a successful attempt at closed reduction in the emergency room using conscious sedation, repeat radiographs show a reduced hip joint. What is the next most appropriate step in treatment? Femoral skeletal traction CT scan of hip and pelvis Dynamic fluoroscopic examination under general anesthesia Hip spica dressing Touch down weight bearing mobilization

31. PREFERRED ANSWER : 2 The radiograph shown in Figure A reveals a left hip dislocation, with some obscuring of detail secondary to the trauma backboard . CT scans should be obtained following a hip dislocation to evaluate for fractures or impacted areas of the femoral head or acetabulum , as well as noncongruent reductions and free intraarticular joint fragments.  The referenced study by Brumback et al comments on the importance of post-reduction CT scans and found that 23% of their posterior wall fractures had associated marginal impaction, with 94% of these discovered via preoperative CT scan.

32. QUESTION A 30-year-old driver is involved in a motor vehicle collision and sustains the injury shown in Figure A. What is the most likely concomitant injury? Right knee meniscus tear Left knee ACL tear Subdural hematoma Right ankle fracture-dislocation Lumbar burst fracture

33. PREFERRED ANSWER : 1 Traumatic hip dislocation results from the dissipation of a large amount of energy about the hip joint. Clinically, these forces often are first transmitted through the knee en route to the hip. It is therefore logical to look for coexistent ipsilateral knee injury in patients with a traumatic hip dislocation.  Schmidt, et al, prospectively evaluated the ipsilateral knee of all patients who had a traumatic hip dislocation and found that 93% had abnormalities on MRI of the knee, with effusion (37%), bone bruise (33%), and meniscal tear (30%) being the most common findings. They suggest liberal use of MRI to the ipsilateral knee if injury is suspected.

34. Thank You

35. Posterior approach Landmarks : greater trochanter