1. TRUAMATIC DISLOCATION & FRACTUERS –DISLOCATION OF THE HIP JOINT.
BY Assistant Professor Dr.Zaid W. Al- Shahwanii. Consultant Orthopedic Surgeon

2. Trumatic Dislocation & Fracture–Dislocation Of The Hip Joint.  
Classification of Trumatic
hip dislocations as ) Posterior
2)Anterior Or Obtruter ) Central.
Trumatic Dislocation & Fracture–Dislocation Of The Hip Joint.
    
    
    

3. The magnitude of force needed to dislocate the hip joint particularly well-contained by virtue of its bony and soft-tissue anatomy, is so great that the dislocation is often associated with fractures – either around the joint or elsewhere in the same limb. Small fragments of bone are often chipped off, usually from the femoral head or from the wall of the acetabulum. If there is a major fragment, the injury is regarded as a fracture-dislocation.
Introduction
i.e high energy usually is required to produce these injuries. Usually complicated by injuries to other organ systems.

4. 1) Posterior Dislocation of the hip Joint
Mechanism of inj;- This injury typically occurs from a longitudinally directed force applied through the femur as falling from height ,or to a flexed hip, as when a patient's knee strikes the dashboard in an automobile on head collision, injury
The femur is thrust upwards and the femoral head is forced out of its socket; often a piece of bone at the back of the acetabulum (usually the posterior wall) is sheared off,making it a fracture dislocation , Seat-belt restraint limit such a truama.

5. Figure 6a. Dashboard injury.
Figure 6a. Dashboard injury. (a) Drawing shows a woman striking her knee against the dashboard during an automobile accident. This is the most common mechanism of injury resulting in disruption of the PCL. (b) Drawing shows that, during a dashboard injury, the tibia is forced posteriorly (open arrow) relative to the femur. The crosshatched region indicates the area of bone contusion on the anterior tibia caused by direct trauma. The PCL is usually tight when the knee is in 90° of flexion and is, therefore, at risk for disruption (solid arrow). The ACL, on the other hand, is normally lax while the knee is flexed and usually remains intact.
Sanders T G et al. Radiographics 2000;20:S135-S151
©2000 by Radiological Society of North America

6. The femur is thrust upwards and the femoral head is forced out of its socket; often a piece of bone at the back of the acetabulum (usually the posterior wall) is sheared off,making it a fracture dislocation , Seat-belt restraint If the hip is adducted at the time of injury, a pure dislocation occurs, whereas a neutral position or abduction leads to dislocation associated with a fracture of the femoral head or acetabulum
These injuries are orthopaedic emergencies; the dislocation of the hip should be reduced as quickly as possible as Most hip dislocations can be reduced by closed manipulation

7. Clinical features & Diagnosis
Patients with a posterior dislocation of the hip generally present with a painfull,,limition of movement ,shortened, internally rotated, adducted lower limb, knee in slight flexion. if one of the long bones is fractured – usually the femur – the injury can easily be missed as the limb can adopt almost any position , The lower limb should be examined for signs of sciatic nerve injury

8. Thompson and Epstein classified posterior dislocations of the hip into five types:
Classification of hip dislocation (Thompson and Epstein).
I Dislocation with or without a minor chip fractures
II Dislocation with single large fragment of posterior acetabular wall
III Dislocation with comminuted fragments of posterior acetabular wall
IV Dislocation with fracture through acetabular floor
V Dislocation with fracture through acetabular floor and femoral head

9. Pipkin Classification
I Fracture inferior to fovea
II Fracture superior to fovea
III Fracture of femoral head with acetabulum fracture
IV Fracture of femoral head with fracture of femoral neck

10. Pipkein classification of fractuers head femuer in (Post.Dis. Hip.J.)

11. Diagnosis ;-
1)Clinical presentaion + history of trauma.
2)X-ray ..of pelvis in every sever injury +
frct.feumer,, ,,,, CT-scann, MRI if needed

13. Treatment
The proper treatment of a dislocation or fracture-dislocation of the hip depends primarily on the type of injury, but regardless of the type of dislocation, some general guidelines apply:
(1) long-term results are directly related to the severity of the initial trauma;
(2) reduction, open or closed, should be performed within 12 hours;
(3) only one or two attempts at closed reduction should be made; if these fail, open reduction is indicated to prevent further damage to the femoral head.

14. Treatment Close reduction
1) under GA. With the patient supine , the pelvis is stabilized by an assistant applying pressure to the anterior superior iliac spines.     -
2) The surgeon applies longitudinal traction in the direct line of the deformity followed by flexion of the hip to 90 degrees
3) while continuing traction.
Internal and external rotations of the hip are performed until reduction is achieved.((Clunk heared)
4) Stabilized the reduction; skeletal traction buck or Thomas splint or abduction pillow For( 3-6 weeks)
(Allis Maneuver )

16. Open Reduction: indicated when unsuccessful 2-3 times of close reduction trial is performed

17. Complications
EARLY
1)Sciatic nerve injury The sciatic nerve is damaged in 10–20 per cent of cases but it usually recovers. Nerve function must be tested and documented before reduction is attempted. If, after reducing the dislocation, The sciatic nerve can be lacerated, stretched, compressed, or encased in heterotopic ossification these symptoms partially or entirely resolve in 60-70% of cases.
2)Vascular injury the superior gluteal artery is torn and bleeding may be profuse.ligation may be needed
3)Associated fractured femoral shaft
LATE
1) Avascular necrosis of the femoral head has been reported in about 10 per cent of traumatic hip dislocations; if reduction is delayed by more than 12 hours, the figure rises to over 40 per cent. Changes are seen first on MRI or isotope bone scans. X-ray features such as increased density of the femoral head may not be seen for at least 6 weeks,
2) Myositis ossificans This is an uncommon complication,
probably related to the severity of the injury.

18. Complication / late-cont.
Unreduced dislocation After a few weeks an untreated dislocation can seldom be reduced by closed manipulation and open reduction is needed. The incidence of stiffness or avascular necrosis is considerably increased and the patient may later need reconstructive surgery.
Osteoarthritis Secondary osteoarthritis is not uncommon
and is due to (1) cartilage damage at the time of dislocation, (2) the presence of retained fragments in the joint
(3) ischaemic necrosis of the femoral head.

19. Anterior Dislocation of the hip j.
1) when falls from hight, or from a blow to the back of patient while in squatted position as with weight falls onto the back of a miner or building labourer who is working with his legs wide apart, knees straight and back bent forwards. now a days the usual 2) cause is a road accident or air crash as when the knee strikes dashboard with the thigh abducted – even a posteriorly directed force on an abducted and externally rotated hip may cause the neck to impinge on the acetabular rim and lever the femoral head out in front of its socket The femoral head will then lie a)superiorly (type I - pubic) or b) inferiorly (type II - obturator).

20. CL.Featuers;- painful limited movement hip joint , mass in groin ,external rotated ,semi flexed knee, abducted limb. With No shortening Dx:X-ray, CT-scann. R ;- 1)by close method flexed knee is being pulled and the hip gently flexed upwards, it should be kept adducted; an assistant then helps by applying lateral pressure to the inside of the thigh. A clunk is usually heard and felt or by 2) open reduction

21. 3)Pathalogical fractuers ,due to carcinoma, infection ,poliomyelitis.
Fracture neck of femur is one of the most common injuries observed in the elderly leading to morbidity & mortality Majority of these patients (80%) were women. femal/male ratio is 3/1 Risk Factors ;-
1)Osteoporosis ; decrease bone mass per unit body volume Common in elderly women after menopause
2)High speed energy trauma ; as car accident , falling from height ,usually in young people
3)Pathalogical fractuers ,due to carcinoma, infection ,poliomyelitis. 

22. ((Gardens ))Classification of Fr. Neck femuer
Into four sub groups
grade 1: incomplete impacted fracture of the femoral neck grade 2: complete undisplaced fracture. 
grade 3: complete fracture with moderate displacement.(Post .attachment) 
grade 4: severely displaced fracture. 

23. Classification Gardens class. Into four sub groups
Read more: Fracture Neck of Femur - Symptoms and Diagnosis

24. Symptoms and Diagnosis
Hip fracture is very common in the elderly (women comprise 80% of the cases) who have tripped and fallen while walking. The main symptoms include:- • Pain in the hip region ,eccomyosis inner side of the thig• Difficulty & Inability in walking The diagnosis is confirmed by X-ray of the hip joint in both anterior and lateral position A 3D reconstruction shows the angle and displacement of the fracture. Bone scann indicated in pathological fractures

25. Treatment
There are, primarily, two treatment strategies for displaced fractures of the femoral neck.
• The fractures can be fixed by Multiple cancellous screws , pin plate,Dynamic hip screw , This is especially so in the case of young patients suffering from inter-trochanteric fracture or high basil fractuers • Surgically, a prosthesis can be used to replace the head and neck of the femur, in the case of femoral trans-cervical fractures, particularly in the elderly. The replacement is said to be complete (Total hip replacement) when the acetabulum, head and neck are replaced and is partial when the head and neck alone are replaced. (Austin moore replacement) Non-union of the fracture, avascular necrosis and the resulting Osteo-arthritis are the complications associated with fixing and reducing a fracture. Further surgeries might become inevitable if necrosis develops. Dislocation is a complication usually associated with the replacement method.