296
Case report
Open posterior dislocation of hip in a 6-year-old boy: a rare case report Pankaj Mahindraa, Ashwani Sonib, Mohd Yamina, Harpal S. Selhia and Vimlesh Sonic Open hip dislocation in pediatric patients is a rare injury. Open posterior dislocation because of soft tissue damage is unstable after reduction. There is no treatment protocol in the literature for this injury in pediatric patients. We treated a 6-year-old boy presented with open posterior hip dislocation. Thorough debridement was performed and antibiotics were administered to prevent infection, and fixation of reduction with Kirschner-wires (K-wires) was performed. Nonthreaded K-wires were used under an image intensifier to minimize the risk of physeal injury. A hip spica cast was used to prevent the breakage of K-wires into the joint because of movements at the hip. J Pediatr Orthop B
Introduction Traumatic hip dislocation in children is uncommon. In young children, it usually occurs because of trivial trauma because the acetabulum is cartilaginous and the ligaments are elastic. When this condition is diagnosed in pediatric patients, it is most frequently seen as a closed unilateral posterior dislocation. This can be reduced easily and heals satisfactorily, although complications such as osteonecrosis may manifest later [1,2]. Open hip dislocation is an additional risk factor of infection. Although open anterior hip dislocation in the pediatric age group has been reported in the literature as rare case reports, to the best of our knowledge, there are no data on the open posterior dislocation of the hip in the pediatric age group. Here, we report a case of a 6-year-old boy who presented with traumatic open posterior dislocation of the hip. The damage of soft tissue posteriorly rendered the joint unstable even after reduction unlike previously reported open anterior dislocations. We had to fix the hip joint with Kirschner-wires (K-wires), with an additional risk of injury to the physis.
24:296–298 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Journal of Pediatric Orthopaedics B 2015, 24:296–298 Keywords: dislocation, hip, open, pediatric, posterior a Department of Orthopaedics, Dayanand Medical College and Hospital, Ludhiana, Departments of bOrthopaedics and cPediatrics, GGS Medical College and Hospital, Faridkot, Punjab, India
Correspondence to Ashwani Soni, MS, Department of Orthopaedics, GGS Medical College and Hospital, Faridkot 151203, Punjab, India Tel: + 0172 2601023 x4326; fax: + 0172 2608488; e-mail: [email protected]
signs of vascular damage. Note of foot drop was made and a possibility of a transected sciatic nerve was considered. Hip joint was reduced, but was found to be unstable. Urgent portable radiographies were performed (Fig. 1). Without further delay, the boy was resuscitated and rushed to the operating room for emergency reduction and exploration of the wound. Time elapsed since injury was 5 h when the patient was admitted for surgery. In the operating room, under general anesthesia, the wound was thoroughly debrided and the hip joint was irrigated with normal saline. Exploration was carried out under direct vision and the sciatic nerve was found to be intact. All gluteal muscles along with short external rotators were found to be cut. The femoral head and neck Fig. 1
Case report A 6-year-old boy presented to the emergency room with a history of a farmyard accident, in which he was accidently run over by a tractor. He sustained an open injury to his left gluteal region along with lacerations over his face, hand, and leg. Physical examination showed a lacerated wound over his left gluteal region extending from the anterior superior iliac spine to the perineum with underlying muscles cut, with exposed proximal femur visible dislocated femoral head. The limb was in flexion, adduction, and internal rotation at the hip. There were no
Radiograph showing dislocation of the femoral head.
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPB.0000000000000128
Open posterior hip dislocation in child Mahindra et al. 297
Fig. 2
Fig. 3
Kirschner-wire fixation of the hip after reduction.
were visible and posterior and superior to the acetabulum. No defect was found in the articular cartilage. No intra-articular fragments were present. The hip was reduced, but reduction was found to be unstable. The joint was fixed with nonthreaded K-wires under an image intensifier, preventing damage to the physis (Fig. 2). Soft tissue was repaired and primary closure of the wound was performed. A hip spica cast was used to prevent the breakage of K-wires into the joint because of movements at the hip joint. A foot drop splint was applied. Intravenous antibiotics were started. Daily dressings were performed and sutures were removed on the 14th postoperative day. The wound healed uneventfully (Fig. 3). One month after reduction, both K-wires and the spica were removed, after which progressive rehabilitation was initiated in the form of nonweight-bearing walking with a walker. An active range of motion was allowed at 8 weeks and strengthening exercises at 12 weeks after surgery. At the 1-year follow-up, the patient had full range of motion with no evidence of post-traumatic articular degenerative disease, osteonecrosis, or physeal damage radiographically (Fig. 4).
Discussion Traumatic hip dislocations in the pediatric population are uncommon, accounting for less than 10% of all traumatic dislocations [3]. It can be posterior, anterior, central, and inferior. In children, posterior dislocations constitute about 80% of hip dislocations [4]. Although uncommon, there may be associated fractures of the acetabulum and femur. Femoral transepiphyseal separation has been reported in about 2% of cases with traumatic hip dislocation with open physis [5,6]. The force required to dislocate the hip increases with age. In children younger than 6 years, only a trivial trauma is required to dislocate the femoral head. This is because of the generalized ligamentous laxity and cartilaginous acetabulum, which
Healed wound extending from the anterior superior iliac spine to the perineum.
Fig. 4
Radiographic pelvis with both hips at the 1-year follow-up. There is no evidence of osteonecrosis.
allow hip dislocation. In adolescents and young adults, the acetabulum becomes bony and ligaments become stiffer; thus, a larger force is required to dislocate the femoral head [7]. Traumatic posterior hip dislocation in children often presents as the classic lower limb deformity. The hip lies in flexion, adduction, and internal rotation. The affected limb appears shorter than the opposite limb. With these physical findings the diagnosis on spot but many a times delayed and missed cases have been reported [8,9]. Associated injuries such as ipsilateral femur fracture and inaccessibility of medical services in developing countries cause a delay in diagnosis [10]. Hip dislocation, once diagnosed, is considered an orthopedic emergency and prompt reduction is mandatory.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
298 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4
Avascular necrosis is the most common complication. The incidence of avascular necrosis of the femoral head is reported to be as high as 52.9% in cases where reduction is delayed more than 6 h compared with 4.8%, where reduction is performed within 6 h [11]. In our case, we reduced the hip joint within 6 h of injury and there were no signs of avascular necrosis at the 1-year follow-up. Zrig et al. [12] reported that avascular necrosis is related to the severity of initial trauma and occurred despite hip reduction within 5 h. The injury in our case was severe, leading to open dislocation, but in contrast to Zrig and colleagues we did not encounter avascular necrosis. Reduction within 6 h might have a preventive effect as described by Hougaard and Thomsen [11].
treatment with antibiotics to prevent infection. Open posterior dislocation is associated with significant soft tissue loss, making the reduction unstable, and requires fixation. Nonthreaded K-wires under an image intensifier along with a hip spica cast may be a good option. Further study is required to establish a treatment protocol for this injury.
Open dislocations of the joint are an additional risk factor of infection. Thorough washing of the joint and debridement along with treatment with antibiotics has been advised to prevent the infection. Although we did not find any literature on open posterior dislocations of the hip in the pediatric age group, open anterior hip dislocations in children have been reported in the literature [13–17]. All these previously reported cases were managed without fixation of reduction. In our case, there was damage to the posterior soft tissue, which made the joint unstable. The joint was fixed with K-wires to maintain the reduction. We applied a spica cast to prevent further movement at the hip joint, which might cause breakage of K-wires into the joint. Moreover, there were chances of injury to the physis while placing K-wires. To minimize this damage, we used nonthreaded K-wires under an image intensifier. At 1 year of follow-up, we did not find any sign of physis injury.
References
The incidence of sciatic nerve injury after a posterior dislocation of the hip is reported to be around 2–13%. Nerve function returns spontaneously in most patients with supportive treatment. Exploration should be performed where laceration or incarceration is suspected. In our case, although foot drop was present, the sciatic nerve was found to be intact intraoperatively. Foot drop was managed with a foot drop splint and recovered with time.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
1 2 3
4 5 6
7 8 9
10 11
12 13 14 15
Conclusion
16
Open dislocation of the hip is an emergency that requires, along with prompt reduction, thorough debridement and
17
Offierski CM. Traumatic dislocation of the hip in children. J Bone Joint Surg Br 1981; 63-B:194–197. Schlonsky J, Miller PR. Traumatic hip dislocations in children. J Bone Joint Surg Am 1973; 55:1057–1063. Barquet A. Natural history of avascular necrosis following traumatic hip dislocation in childhood: a review of 145 cases. Acta Orthop Scand 1982; 53:815–820. Kutty S, Thornes B, Curtin WA, Gilmore MF. Traumatic posterior dislocation of hip in children. Pediatr Emerg Care 2001; 17:32–35. Walls JP. Hip fracture-dislocation with transepiphyseal separation. Case report and literature review. Clin Orthop Relat Res 1992; 284:170–175. Barquet A, Vécsei V. Traumatic dislocation of the hip with separation of the proximal femoral epiphysis. Report of two cases and review of the literature. Arch Orthop Trauma Surg 1984; 103:219–223. Craig CL. Hip injuries in children and adolescents. Orthop Clin North Am 1980; 11:743–754. Bunnell WP, Webster DA. Late reduction of bilateral traumatic hip dislocations in a child. Clin Orthop Relat Res 1980; 147:160–163. Dehne E, Immermann EW. Dislocation of the hip combined with fracture of the shaft of the femur on the same side. J Bone Joint Surg Am 1951; 33-A:731–745. Kumar S, Jain AK. Neglected traumatic hip dislocation in children. Clin Orthop Relat Res 2005; 431:9–13. Hougaard K, Thomsen PB. Traumatic posterior dislocation of the hip – prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 1986; 106:32–35. Zrig M, Mnif H, Koubaa M, Abid A. Traumatic hip dislocation in children. Acta Orthop Belg 2009; 75:328–333. Schwartz DL, Haller JA Jr. Open anterior hip dislocation with femoral vessel transection in a child. J Trauma 1974; 14:1054–1059. Grundy M, Kumar N. Open anterior dislocation of the hip. Injury 1982; 13:315–316. Renato L. Open anterior dislocation of the hip in a child. Acta Orthop Scand 1987; 58:669–670. García Mata S, Hidalgo Ovejero A, Martinez Grande M. Open anterior dislocation of the hip in a child. J Pediatr Orthop B 1998; 7:232–234. Khan SA, Sadiq SA, Abbas M, Asif N, Gogi N. Open anterior dislocation of the hip in a child. J Trauma 2001; 51:773–776.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Case report
Open posterior dislocation of hip in a 6-year-old boy: a rare case report Pankaj Mahindraa, Ashwani Sonib, Mohd Yamina, Harpal S. Selhia and Vimlesh Sonic Open hip dislocation in pediatric patients is a rare injury. Open posterior dislocation because of soft tissue damage is unstable after reduction. There is no treatment protocol in the literature for this injury in pediatric patients. We treated a 6-year-old boy presented with open posterior hip dislocation. Thorough debridement was performed and antibiotics were administered to prevent infection, and fixation of reduction with Kirschner-wires (K-wires) was performed. Nonthreaded K-wires were used under an image intensifier to minimize the risk of physeal injury. A hip spica cast was used to prevent the breakage of K-wires into the joint because of movements at the hip. J Pediatr Orthop B
Introduction Traumatic hip dislocation in children is uncommon. In young children, it usually occurs because of trivial trauma because the acetabulum is cartilaginous and the ligaments are elastic. When this condition is diagnosed in pediatric patients, it is most frequently seen as a closed unilateral posterior dislocation. This can be reduced easily and heals satisfactorily, although complications such as osteonecrosis may manifest later [1,2]. Open hip dislocation is an additional risk factor of infection. Although open anterior hip dislocation in the pediatric age group has been reported in the literature as rare case reports, to the best of our knowledge, there are no data on the open posterior dislocation of the hip in the pediatric age group. Here, we report a case of a 6-year-old boy who presented with traumatic open posterior dislocation of the hip. The damage of soft tissue posteriorly rendered the joint unstable even after reduction unlike previously reported open anterior dislocations. We had to fix the hip joint with Kirschner-wires (K-wires), with an additional risk of injury to the physis.
24:296–298 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Journal of Pediatric Orthopaedics B 2015, 24:296–298 Keywords: dislocation, hip, open, pediatric, posterior a Department of Orthopaedics, Dayanand Medical College and Hospital, Ludhiana, Departments of bOrthopaedics and cPediatrics, GGS Medical College and Hospital, Faridkot, Punjab, India
Correspondence to Ashwani Soni, MS, Department of Orthopaedics, GGS Medical College and Hospital, Faridkot 151203, Punjab, India Tel: + 0172 2601023 x4326; fax: + 0172 2608488; e-mail: [email protected]
signs of vascular damage. Note of foot drop was made and a possibility of a transected sciatic nerve was considered. Hip joint was reduced, but was found to be unstable. Urgent portable radiographies were performed (Fig. 1). Without further delay, the boy was resuscitated and rushed to the operating room for emergency reduction and exploration of the wound. Time elapsed since injury was 5 h when the patient was admitted for surgery. In the operating room, under general anesthesia, the wound was thoroughly debrided and the hip joint was irrigated with normal saline. Exploration was carried out under direct vision and the sciatic nerve was found to be intact. All gluteal muscles along with short external rotators were found to be cut. The femoral head and neck Fig. 1
Case report A 6-year-old boy presented to the emergency room with a history of a farmyard accident, in which he was accidently run over by a tractor. He sustained an open injury to his left gluteal region along with lacerations over his face, hand, and leg. Physical examination showed a lacerated wound over his left gluteal region extending from the anterior superior iliac spine to the perineum with underlying muscles cut, with exposed proximal femur visible dislocated femoral head. The limb was in flexion, adduction, and internal rotation at the hip. There were no
Radiograph showing dislocation of the femoral head.
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BPB.0000000000000128
Open posterior hip dislocation in child Mahindra et al. 297
Fig. 2
Fig. 3
Kirschner-wire fixation of the hip after reduction.
were visible and posterior and superior to the acetabulum. No defect was found in the articular cartilage. No intra-articular fragments were present. The hip was reduced, but reduction was found to be unstable. The joint was fixed with nonthreaded K-wires under an image intensifier, preventing damage to the physis (Fig. 2). Soft tissue was repaired and primary closure of the wound was performed. A hip spica cast was used to prevent the breakage of K-wires into the joint because of movements at the hip joint. A foot drop splint was applied. Intravenous antibiotics were started. Daily dressings were performed and sutures were removed on the 14th postoperative day. The wound healed uneventfully (Fig. 3). One month after reduction, both K-wires and the spica were removed, after which progressive rehabilitation was initiated in the form of nonweight-bearing walking with a walker. An active range of motion was allowed at 8 weeks and strengthening exercises at 12 weeks after surgery. At the 1-year follow-up, the patient had full range of motion with no evidence of post-traumatic articular degenerative disease, osteonecrosis, or physeal damage radiographically (Fig. 4).
Discussion Traumatic hip dislocations in the pediatric population are uncommon, accounting for less than 10% of all traumatic dislocations [3]. It can be posterior, anterior, central, and inferior. In children, posterior dislocations constitute about 80% of hip dislocations [4]. Although uncommon, there may be associated fractures of the acetabulum and femur. Femoral transepiphyseal separation has been reported in about 2% of cases with traumatic hip dislocation with open physis [5,6]. The force required to dislocate the hip increases with age. In children younger than 6 years, only a trivial trauma is required to dislocate the femoral head. This is because of the generalized ligamentous laxity and cartilaginous acetabulum, which
Healed wound extending from the anterior superior iliac spine to the perineum.
Fig. 4
Radiographic pelvis with both hips at the 1-year follow-up. There is no evidence of osteonecrosis.
allow hip dislocation. In adolescents and young adults, the acetabulum becomes bony and ligaments become stiffer; thus, a larger force is required to dislocate the femoral head [7]. Traumatic posterior hip dislocation in children often presents as the classic lower limb deformity. The hip lies in flexion, adduction, and internal rotation. The affected limb appears shorter than the opposite limb. With these physical findings the diagnosis on spot but many a times delayed and missed cases have been reported [8,9]. Associated injuries such as ipsilateral femur fracture and inaccessibility of medical services in developing countries cause a delay in diagnosis [10]. Hip dislocation, once diagnosed, is considered an orthopedic emergency and prompt reduction is mandatory.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
298 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4
Avascular necrosis is the most common complication. The incidence of avascular necrosis of the femoral head is reported to be as high as 52.9% in cases where reduction is delayed more than 6 h compared with 4.8%, where reduction is performed within 6 h [11]. In our case, we reduced the hip joint within 6 h of injury and there were no signs of avascular necrosis at the 1-year follow-up. Zrig et al. [12] reported that avascular necrosis is related to the severity of initial trauma and occurred despite hip reduction within 5 h. The injury in our case was severe, leading to open dislocation, but in contrast to Zrig and colleagues we did not encounter avascular necrosis. Reduction within 6 h might have a preventive effect as described by Hougaard and Thomsen [11].
treatment with antibiotics to prevent infection. Open posterior dislocation is associated with significant soft tissue loss, making the reduction unstable, and requires fixation. Nonthreaded K-wires under an image intensifier along with a hip spica cast may be a good option. Further study is required to establish a treatment protocol for this injury.
Open dislocations of the joint are an additional risk factor of infection. Thorough washing of the joint and debridement along with treatment with antibiotics has been advised to prevent the infection. Although we did not find any literature on open posterior dislocations of the hip in the pediatric age group, open anterior hip dislocations in children have been reported in the literature [13–17]. All these previously reported cases were managed without fixation of reduction. In our case, there was damage to the posterior soft tissue, which made the joint unstable. The joint was fixed with K-wires to maintain the reduction. We applied a spica cast to prevent further movement at the hip joint, which might cause breakage of K-wires into the joint. Moreover, there were chances of injury to the physis while placing K-wires. To minimize this damage, we used nonthreaded K-wires under an image intensifier. At 1 year of follow-up, we did not find any sign of physis injury.
References
The incidence of sciatic nerve injury after a posterior dislocation of the hip is reported to be around 2–13%. Nerve function returns spontaneously in most patients with supportive treatment. Exploration should be performed where laceration or incarceration is suspected. In our case, although foot drop was present, the sciatic nerve was found to be intact intraoperatively. Foot drop was managed with a foot drop splint and recovered with time.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
1 2 3
4 5 6
7 8 9
10 11
12 13 14 15
Conclusion
16
Open dislocation of the hip is an emergency that requires, along with prompt reduction, thorough debridement and
17
Offierski CM. Traumatic dislocation of the hip in children. J Bone Joint Surg Br 1981; 63-B:194–197. Schlonsky J, Miller PR. Traumatic hip dislocations in children. J Bone Joint Surg Am 1973; 55:1057–1063. Barquet A. Natural history of avascular necrosis following traumatic hip dislocation in childhood: a review of 145 cases. Acta Orthop Scand 1982; 53:815–820. Kutty S, Thornes B, Curtin WA, Gilmore MF. Traumatic posterior dislocation of hip in children. Pediatr Emerg Care 2001; 17:32–35. Walls JP. Hip fracture-dislocation with transepiphyseal separation. Case report and literature review. Clin Orthop Relat Res 1992; 284:170–175. Barquet A, Vécsei V. Traumatic dislocation of the hip with separation of the proximal femoral epiphysis. Report of two cases and review of the literature. Arch Orthop Trauma Surg 1984; 103:219–223. Craig CL. Hip injuries in children and adolescents. Orthop Clin North Am 1980; 11:743–754. Bunnell WP, Webster DA. Late reduction of bilateral traumatic hip dislocations in a child. Clin Orthop Relat Res 1980; 147:160–163. Dehne E, Immermann EW. Dislocation of the hip combined with fracture of the shaft of the femur on the same side. J Bone Joint Surg Am 1951; 33-A:731–745. Kumar S, Jain AK. Neglected traumatic hip dislocation in children. Clin Orthop Relat Res 2005; 431:9–13. Hougaard K, Thomsen PB. Traumatic posterior dislocation of the hip – prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 1986; 106:32–35. Zrig M, Mnif H, Koubaa M, Abid A. Traumatic hip dislocation in children. Acta Orthop Belg 2009; 75:328–333. Schwartz DL, Haller JA Jr. Open anterior hip dislocation with femoral vessel transection in a child. J Trauma 1974; 14:1054–1059. Grundy M, Kumar N. Open anterior dislocation of the hip. Injury 1982; 13:315–316. Renato L. Open anterior dislocation of the hip in a child. Acta Orthop Scand 1987; 58:669–670. García Mata S, Hidalgo Ovejero A, Martinez Grande M. Open anterior dislocation of the hip in a child. J Pediatr Orthop B 1998; 7:232–234. Khan SA, Sadiq SA, Abbas M, Asif N, Gogi N. Open anterior dislocation of the hip in a child. J Trauma 2001; 51:773–776.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
