Case Report on Anterior Hip Dislocations PROF N. DEEN MUHAMMAD ISMAIL Director I/C Institute of Orthopaedics & Traumatology MMC-RGGGH CHENNAI DR.NALLI .R.GOPINATH & DR. Senthil sailesh Senior Assistant Professor Ortho 1 unit Institute of Orthopaedics & Traumatology : MMC-RGGGH Presentor - DR.NAVEENKUMAR.K M.S.ORTHO POST GRADUATE UNIT ORTHO 1

Case history-1 H/o RTA : collision over median while driving an 3 wheeler Position of limb during injury- Abducted & Externally rotated C/o pain, deformity & swelling over left hip

On examination Inspection: Palpation: Movements Limb in abduction & externally rotation deformity Marked shortening of left lower limb Swelling over scarpa’s triangle Ecchymoses around knee joint Palpation: Hard bony swelling over scarpa’s triangle Tenderness present Femoral pulse more prominent on the affected side No Neurologic deficits Movements Restricted & Painful

On presentation

Radiographic findings

Radiographic findings Loss of congruence of femur head with roof of acetabulum Femoral head was located anterosuperiorly Femural neck not seen Greater & lesser trochanters not visible

PRE OP CT

PRE OP CT

PRE OP CT

PRE OP CT

PRE OP CT

Diagnosis & management Anterior dislocation of left hip – Epstein Superior Pubic type Closed manual reduction under general anaesthesia (Allis method- walker modification)

PRE OP

Post reduction xray

Post reduction xray

Post reduction xray

Post reduction CT

Case history-2 80 year female H/o RTA : hit by an 2 wheeler from behind while crossing the road Position of limb- not known C/o pain, deformity & swelling over left hip

On examination Inspection: Palpation: Movements Limb in abduction & externally rotation deformity shortening of left lower limb Swelling over scarpa’s triangle Palpation: Hard bony swelling over scarpa’s triangle Tenderness present Femoral pulse more prominent on the affected side No Neurologic deficits Movements Restricted & Painful

Radiographic findings Loss of congruence of femur head with roof of acetabulum Prominent lesser trochanter & Femoral neck Dislocated femur head

Diagnosis & management Anterior dislocation of left hip Epstein- Inferior Obturator type Closed manual reduction under general anaesthesia (Allis method- walker modification)

Post reduction xray

Post reduction Ct

Post reduction protocol Skeletal traction Non weight bearing for 2 weeks Static quadriceps & patellar gliding exercises Continuous passive motion Walking with support after 1st week Avoid extremes of movement for 6 to 8 weeks Full weight bearing after 6 weeks For femur head / Acetabulum # - non weight bearing for 8 to 12 weeks

results Both hips reduced within 6 hours of presentation Reduction method applied- Walker modification of Allis method No post reduction neurological deficits One patient post reduction CT shows Acetabulum fracture

HIP dislocations Hip dislocations account for 0.8% of all dislocations Anterior hip dislocation accounts for 9 % of all hip dislocations Common in young population with high energy trauma. Unrestrained motor vehicle accident occupants are at significant higher risk for sustaining a hip dislocation

HIP dislocations Traumatic dislocation of the hip is broadly classified into anterior and posterior dislocations on the basis of a dividing line that connects the anterior superior iliac spine with the ischial tuberosity. Anterior and posterior dislocations are further classified into superior and inferior dislocations based on a line connecting the superior pubic ramus withthe greater sciatic notch.

Superior Dislocation This injury is associated with forced abduction, external rotation, and extension of the femur. The femoral head ruptures through the anterior capsule between the iliofemoral (bigelow) And pubofemoral ligaments or avulses the anterior inferior iliac spine, the site of proximal attachment of the iliofemoral ligament Superior dislocations are frequently referred to as pubic dislocations, although these injuries are more appropriately classified as pubic and iliac types on the basis of the resulting position of the femoral head

Inferior (Obturator) Dislocation Inferior anterior hip dislocation is associated with forced Abduction, external notation, and flexion of the hip. In this Injury, the femoral head extrudes through the anterior capsule Beneath the pubofemoral ligament and comes to rest Anterior to the obturator ring Inferiorhip dislocation is easily recognized on plain nadiognaphs by the position of the femoral head over the obturator foramen and by abduction and external Rotation of the femur

Epstein Classification of Anterior Hip Dislocations Type I: Superior dislocations, including pubic and subspinous IA: No associated fractures IB: Associated fracture or impaction of the femoral head IC: Associated fracture of the acetabulum Type II: Inferior dislocations, including obturator, &perineal IIA: No associated fractures IIB: Associated fracture or impaction of the femoral head IIC: Associated fracture of the acetabulum

Features distinguishing A feature that may help distinguish the superior type of anterior hip dislocation from posterior hip dislocation is the appearance of the lesser trochanter. In cases of anterior hip dislocation, the hip is predictably held in external notation and the lesser trochanter is prominent With posterior hip dislocation, the femur is typically rotated internally and the lesser trochanter is less prominent or is completely obscured by the overlying femur. Magnification of the femonal head on anteroposterior radiographs of the pelvis in anterior hip dislocation has been described but

CT Scan Most helpful after hip reduction. Reveals: Non-displaced fractures. Congruity of reduction. Intra-articular fragments. Size of bony fragments.

MRI Scan Will reveal labral tear and soft-tissue anatomy Has not been shown to be of benefit in acute evaluation and treatment of hip dislocations.

Clinical Management: Emergent Treatment Dislocated hip is an emergency. The goal is to reduce risk of avn and degenerative joint disease.

Benefits of early Reduction Allows restoration of flow through occluded or compressed vessels. Literature supports decreased avn with earlier reduction(< than 6 hours)

Irreducible anterior hip dislocation Smith-peterson approach ,watson-jones approach, extended iliofemoral, ilioinguinal approach. Allows visualization and retraction of interposed tissue. Placement of schanz pin in intertrochanteric region of femur will assist in manipulation of the proximal femur. Repair capsule, if this can be accomplished without further dissection.

Complications Early: Late: Sciatic nerve injury (posterior dislocation) Femoral-nerve injury Fractures of head and neck Femoral-artery injury (in anterior dislocations) Late: AVN of the hip Osteoarthritis Heterotopic calcification Recurrent dislocation Ligamentous injury of the knee, other fractures

Conclusion It is highly stable joint that needs high energy trauma to dislocate Early reduction of the dislocated hip (within 6 hrs) can improve blood flow to femoral head. Up to 5 views of xrays/c-t may be needed for proper evaluation( pre and post reduction)

References M. Stewart and L. Milford, “Fracture-dislocation of the hip: an end-result study,” Journal of Bone and Joint Surgery, vol. 36, pp. 315–342, 1954 2. Gillespie WJ. The incidence and pattern of knee injury associated with dislocation of the hip. J Bone Joint Surg Br 1975;57:376–8. Izquierdo RJ, Harris D. Obturator hip dislocation with subcapital fracture ofthe femoral neck. Injury 1994;25:108– 10 MACFARLANE, J. A. (1936): Anterior Dislocation of the Hip. British Journal of Surgery