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MC, 26yo male Unrestrained driver Late night accident

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Presentation on theme: "MC, 26yo male Unrestrained driver Late night accident"— Presentation transcript:

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

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