1. MC, 26yo male Unrestrained driver Late night accident
Collided head-on with wall at 60kmph

2. MC, 26yo male Brought to ED by ambulance
Isolated left lower limb injury
Hip flexed, adducted, internally rotated
Severe pain on attempted motion of hip
No peripheral neurological/vascular deficit

6. Diagnosis Posterior dislocation of left hip Loose bone fragment
from ?posterior wall of acetabulum vs. femoral head
Immediate attempt of reduction in ED under sedation – failed
Brought to OR
Hip reduced under GA

7. Post-manipulation CT Hip joint reduced Acetabulum intact
Fracture of femoral head below the fovea (insertion of ligamentum teres)
Rotation of fractured fragment noted

8. Treatment Patient brought to OR ORIF of femoral head
Anterolateral approach to hip with trochanteric slide osteotomy
Circulation-sparing approach

9. Treatment Fragment anatomically reduced and fixed with three screws
Troch osteotomy closed with screws
Mobilised postoperatively
Well at two months follow-up

12. Dislocations of hip High-energy trauma
Usually unrestrained occupants in MVA
Also pedestrian MVA, falls from height, industrial accidents
50% associated with fractures elsewhere

13. Posterior Dislocation
Most common – over 90%
Axial load applied to femur while hip flexed
Impact of knee on dashboard

14. Associated Injuries Head, neck, face Chest /intra-abdominal injuries
50% have fractures elsewhere!
Sciatic nerve injuries 10% to 20%!
Thorough exam essential

15. Vascular supply Branches of profunda femoris
medial and lateral femoral circumflex
Ascending branches are kinked/compressed in hip dislocation

16. Dislocated hip is an emergency
Management
Dislocated hip is an emergency
Full trauma survey
Reduction restores blood flow through compressed vessels
Goal to decrease risk of AVN and DJD
AVN 5% with early reduction within 6 hours
AVN 15% with reduction within 12 hours
AVN 30% when reduction delayed >12 hours

17. Reduction manoeuvre (Allis)
Patient supine
Assistant stabilises pelvis
Slowly flex hip to 900
Traction in line of femur
Adduction and internal rotation
Reduction often seen and felt

18. Post-reduction management
CT of affected hip (thin 2mm cuts)
Look for congruency of reduction, loose fragments
Mobilise early
Touch down weight-bearing 4-6 weeks
ROM precautions: no adduction, no internal rotation, no flexion > 60o
AVN can occur up to 2-5 years

19. Open reduction Rarely needed Dislocations irreducible by closed means
Soft tissue interposition
Femoral head buttonholed through capsule
Nonconcentric reduction
Fracture of femoral neck/head/acetabulum

20. Prognosis AVN 5% to 30% Posttraumatic OA most frequent
Recurrent dislocation 2%
Neurovascular injury 10%-20%
Sciatic nerve
Prognosis unpredictable but 50% full recovery
Heterotopic ossification 2%
VTE 50%

21. Femoral head fractures
Rare injuries
Almost all complicate hip dislocations
10% of posterior hip dislocations
Fracture occurs by shear as femoral head dislocates
History and presentation as in hip dislocation
Patient posture may be less extreme

22. Pipkin Classification JBJS, 1957
I Fracture inferior to fovea
II Fracture superior to fovea
III Fracture of femoral head with fracture of femoral neck
IV Fracture of femoral head with fracture of acetabulum

23. Pipkin, JBJS, 1957

24. Femoral head fractures - treatment
Pipkin 1 – closed treatment
If reduction adequate (<1mm step-off)
If reduction not adeuate – ORIF
Small fragments can be excised
Pipkin 2 – involve weighbearing surface
Same recommendations but only anatomical reduction can be accepted with closed treatment
Prognosis for AVN same as in simple dislocations

25. Approach to hip for fractures of femoral head Helfet, Lorich et al, J Orthop Trauma, 2005
Trochanteric slide osteotomy

26. Femoral head fractures - treatment
Pipkin 3 – femoral head fracture with associated fracture of neck
Prognosis is poor - 50% AVN
Pipkin 4 – femoral head fracture with associated fracture of acetabulum
Acetabular fracture must be treated with ORIF
Femoral head must also be treated with ORIF to allow early motion
Prognosis variable - depends on acetabular fracture

27. Literature
1. Yoon TR et al Clinical and radiographic outcome of femoral head fractures: 30 patients followed for 3-10 years. Acta Orthop Scand Aug;72(4):348-53
2. Asghar FA, Karunakar MA. Femoral head fractures: diagnosis, management, and complications. Orthop Clin North Am Oct;35(4):463-72
3: Brooks RA, Ribbans WJ. Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop Relat Res Aug;(377):15-23
4: DeLee JC, Evans JA, Thomas J. Dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am Sep;62(6):960-4
5. Henle P, Kloen P, Siebenrock KA. Femoral head injuries: Which treatment strategy can be recommended? Injury (4):478-88