Arch Orthop Trauma Surg (1992) 111 : 345-347
Ah"s°fOrthopaedic a.dXrauma urgery © Springer-VerIag 1992
Current problem cases
Open traumatic posterior dislocation of the hip A case report A. Hamzaoglu, H. C. Aydinok, H. Pmar, M. Asik, and M. Cakmak Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, 34390 ~apa, lstanbul, Turkey
Summary. A case o f o p e n t r a u m a t i c p o s t e r i o r dislocat i o n o f t h e hip is p r e s e n t e d . T h e f e m o r a l h e a d a n d n e c k w e r e c o m p i e t e l y o u t o f t h e skin a n d t h e r e w e r e a c c o m p a n y i n g fractures of the a c e t a b u l a r floor, the ischial r a m u s a n d t h e g r e a t e r t r o c h a n t e r . T o o u r k n o w l e d g e , such a case has n o t b e e n r e p o r t e d p r e v i o u s l y a n d this, t o g e t h e r with its i n t e r e s t i n g m e c h a n i s m , has l e d us to r e p o r t t h e case. It was f o l l o w e d for 18 m o n t h s a n d r o e n t g e n o g r a p h i c a n d 99mtechnetium sulphur colloid scanning studies showed a v a s c u l a r necrosis a n d o s t e o a r t h r i t i s .
Posterior dislocations of the hip are becoming more c o m m o n d u e to t h e i n c r e a s i n g i n c i d e n c e of h i g h - e n e r g y t r a u m a . T h e y c o m p r i s e 6 5 % - 8 5 % o f t r a u m a t i c hip disl o c a t i o n s [1, 4 - 8 , 18, 20]. O n t h e o t h e r h a n d , o p e n disloc a t i o n s o f the h i p a r e e x t r e m e l y r a r e , o n l y o n e o p e n ant e r i o r d i s l o c a t i o n h a v i n g b e e n r e p o r t e d to d a t e [17]. T o the best of our knowledge, open posterior dislocation of t h e hip has n o t b e e n p r e v i o u s l y r e p o r t e d . T h e m e c h a nism a n d t h e a c c o m p a n y i n g i p s i l a t e r a l f r a c t u r e s of t h e g r e a t e r t r o c h a n t e r , t h e a c e t a b u l a r f l o o r a n d t h e ischial ramus render the injury even more interesting. The poor o u t c o m e was n o t surprising.
Case report In July 1987, a 34-year-old male pedestrian was brought to the emergency room after being struck by a car. He was conscious at admission. A detailed history disclosed that he had received the blow to the back of his right hip, rotated around his axis and fallen down on his left side. A careful multisystem evaluation for probable life-threatening injuries was undertaken immediately. Respiratory and cardiovascular status were normal and the extremities had no neurovascutar deficits. The right lower extremity was shortened, flexed, adducted and internally rotated. Posterior to the right hip, there was an approximately 20-cm-long contaminated wound with irregular margins through which the proximal femur was buttonholed (Fig. 1). The surface of the femoral head and neck was covered with dust and soil. The roentgenograms revealed accompanying ipsilatCorrespondence to: Halit Plnar, MD, 168 sok. No: 54, Basin Sitesi, Izmir, Turkey
Fig. 1. The proximal femur completely exposed posteriorly
eral fractures of the acetabular floor, greater trochanter and ischial ramus (Fig. 2). The operation was undertaken within 2 h after admittance and 6 h after the accident. The wound was irrigated with copious amounts of saline, debrided and then extended to become a posterolateral incision. Following debridement of contaminated and partially necrotic gluteal and external rotator muscles, the sciatic nerve was explored and seen to be intact. The acetabulum was full of many osteocartilaginous loose bodies and the labrum was inverted into the acetabulum. They were removed. There was a defect at the posterior rim of the actabulum which was thought to have been the source of the loose bodies. Surprisingly, no defects of the femoral head were seen. Following reduction, the trochanteric fracture was fixed by tension-band wiring. No attempt was made to fix the acetabular fracture for fear of subsequent infection. A Hemovac drain was inserted before wound closure. Femoral supracondylar skeletal traction which continued for 12 weeks was initiated immediately. Two different antibiotics were administered parenterally for 10 days. Rehabilitation started at the end of 12 weeks and by the end of the 5th month, the patient was ambulatory on crutches with partial weight-bearing. Full weight-bearing was possible at the end of 7 months. Clinical and roentgenographic examinations were done at four, nine, twelve and eighteen months after surgery. In February 1989, he could only walk with a cane and had pain after walking about half a mile. On examination, he had 60° flexion, 10° abduction and adduction and no rotational mobility at all. He also had a fixed external rotational deformity of 10°. There was a significant degree of atrophy of the thigh and gluteal musculature. The roentgenograms
346
Fig. 2. Roentgenogram of the pelvis taken at admission. Note that the right femoral head seems smaller than the uninvolved left one Fig. 3. Roentgenogram 18 months after the accident Fig. 4. a 99Technetium sulphur colloid bone scan demonstrating decreased uptake of isotope in the right femoral head. b Bone scan of the normal left hip revealed non-union of the acetabular fracture, increased sclerosis of the femoral head compared to the uninvolved side, and flattening of the superior portion of the head (Fig. 3). The latter two findings suggested avascular necrosis and this was verified by a 99mtechnetium bone scan (Fig. 4).
Discussion The hip joint is a ball-and-socket joint. The acetabulum contains two-thirds of the femoral head. Furthermore, it is surrounded by strong ligaments. Due to the inherent stability of this arrangement, therefore, significant trauma is needed to dislocate the hip joint [1, 2, 4-8, 10, 11, 16, 19, 21]. The majority of traumatic hip dislocations reported in the literature occur in automobile accidents. The mechanism of posterior dislocations is usually a force applied to the flexed knee with the hip in varying degrees of flexion. We think the mechanism in this case is worth mentioning, as it is extremely rare. If the blow had been directly to the back of the hip joint, we believe it is reasonable to postulate that it would have caused the femoral head to dislocate anteriorly. The greater trochanteric fracture suggests that the blow was directly to this region posterolaterally, creating three different components for forces. One of these was directed to the acetabulum, leading to the fracture of its floor. The other two components forced the proximal femur to internal rotation and adduction, tearing the posterior capsule and the external rotators, and eventually the dislocation took place. The combination of these fractures and the open nature of the dislocation indicate without any doubt that the sever-
ity of the trauma was even more than is usual in highenergy traumata. This case may be classified as grade 4 or grade 3 according to the Thompson-Epstein or Stewart-Milford classification respectively, but neither of these systems makes any mention of a greater trochanteric fracture. The prognosis worsens and the complication rates increase with the grade [1, 2, 4-8, 10, 11, 16, 18-21]. Coventry [3] and Garret et al. [9] recommended primary hip arthroplasty for Thompson-Epstein grade 4 and 5 and Stewart-Milford grade 3 and 4 injuries. Obviously, this is not valid for open injuries. Traumatic hip dislocation is an emergency and reduction, whether closed or open, should be achieved as soon as possible, preferably within 6 h after the event. Most authors agree that if d o s e d reduction fails after at most two attempts under general anaesthesia, the surgeon should proceed to an open reduction with the idea of removing the offending obstruction [1, 4, 10, 18, 19, 20]. Occasionally, reduction is obtained, but it may not be concentric. The obstructions to concentric reduction are usually osteocartilaginous fragments in the joint or an inverted limbus, both of which were encountered in this case. The incidence of finding osteocartilaginous fragments in the joint during open reduction was 91% in Epsteins's series [5-8]. We did not use internal fixation for the acetabular fracture for fear of subsequent infection. No infection was seen but despite 12 weeks of skeletal traction, non-union developed. No early complications were seen, but as to the late complications we encountered avascular necrosis, which is reported in 6 % - 4 0 % of cases [1, 2, 4-8, 16]. Meyers et al. [15], and later Kirschner et al. [12] reported that
347 99mtechnetium s u l p h u r c o l l o i d s c a n n i n g was i n v a l u a b l e in d e t e c t i n g a v a s c u l a r n e c r o s i s b e f o r e c o l l a p s e h a d dev e l o p e d . D e s p i t e fairly e a r l y r e d u c t i o n , a v a s c u l a r n e c r o sis was i n e v i t a b l e b e c a u s e all t h e b l o o d s u p p l y to t h e f e m o r a l h e a d was i n t e r r u p t e d . L a t e r e c o n s t r u c t i o n a n d i n t e r n a l fixation has b e e n adv o c a t e d for r e a l - u n i o n a n d n o n - u n i o n o f a c e t a b u l a r fractures w i t h o u t a s s o c i a t e d a v a s c u l a r n e c r o s i s of t h e f e m o ral h e a d a n d s e v e r e d e g e n e r a t i v e arthritis [13, 14]. L a t e r e c o n s t r u c t i o n m a y b e i n d i c a t e d in y o u n g adults with m i l d o s t e o a r t h r i t i s [14]. This p a t i e n t h a d a v a s c u l a r necrosis of the f e m o r a l h e a d , so he was scheduled to u n d e r g o t o t a l hip a r t h r o p l a s t y , b u t he did n o t r e t u r n .
References 1. Bray E A (1962) Traumatic dislocations of the hip. Army experience and results over a twelve year period. J Bone Joint Surg [Am] 44 : 1115-1134 2. Canale ST, Manugian A H (1979) Irreducible traumatic dislocations of the hipl J Bone Joint Surg [Am] 61 : 7-14 3. Coventry MB (1974) The treatment of fracture-dislocations of the hip by total hip arthroplasty. J Bone Joint Surg [Am] 56:1128-1134 4. De Lee JC (1984) Dislocation and Fracture-dislocation of the hip. In: Rockwood CA, Green DP (eds) Fractures, vol 2. Lippincott, Philadelphia, pp 1287-1356 5. Epstein HC (1961) Posterior fracture-dislocation of the hip. Comparison of open and closed methods of treatment in certain types. J Bone Joint Surg [Am] 43 : 1079-1089 6. Epstein HC (1964) Posterior fracture-dislocations of the hip. J Bone Joint Surg [Am] 46 : 695-714 7. Epstein HC (1973) Traumatic dislocations of the hip. Clin Orthop 92 : 116-142 8. Epstein HC (1974) Posterior fracture-dislocations of the hip. Long-terra follow-up. J Bone Joint Surg [Am] 55 : 1103-1127
9. Garret JCI Epstein HC, Harris WH, Harvey JP, Nickel VL (1979) Treatment of unreduced traumatic posterior dislocations of the hip. J Bone Joint Surg [Am] 61 : 2-6 10. Hunter GA (1969) Posterior dislocation and fracture-dislocation of the hip. A review of fifty-seven patients. J Bone Joint Surg [Br] 51:38-44 11. King D, Richards V (1941) Fracture-dislocations of the hip joint. J Bone Joint Surg 23 : 533-551 12. Kirschner PT, Simon MA (1981) Current concepts review: radioisotopic evaluation of skeletal disease. J Bone Joint Surg [Am 1 63:673-681 13. Letournel E (1979) Surgical repair of acetabular fractures more than three weeks after injury, apart from total hip replacement. Int Orthop 2 : 305-313 14. Letournel E (1990) Diagnosis and treatment of nonunions and malunions of acetabular fractures. Orthop Clin North Am 21 : 769-788 15. Meyers MH, Teller N, Moore TM (1977) Determination of the vascularity of the femoral head with technetium 99-m sulphur colloid. J Bone Joint Surg [Am] 59 : 658-664 16. Moll JH (1973) Fractures and dislocations of the hip joint. In: Tronzo RG (ed) Surgery of the hip joint. Lea & Febiger, Philadelphia, pp 450-472 17. Schwartz DL, Haller JA (1974) Open anterior hip dislocation with femoral vessel transection in a child. J Trauma 14 : 10541059 18. Stewart MJ, McCarroll HR (1970) Fracture-dislocation of the hip. A follow-up and comparative study. J Bone Joint Surg [Br] 52: 773 19. Stewart MJ, Milford LW (1954) Fracture-dislocation of the hip. J Bone Joint Surg [Am] 36:315-342 20. Stewart MJ, McCarroll HR, Mulhollan JS (1975) Fracture-dislocations of the hip. Acta Orthop Scand 46 : 507-525 21. Urist MR (1948) Fracture-dislocation of the hip joint: the nature of the traumatic lesion, treatment, late complications and end results. J Bone Joint Surg [Am] 30 : 699-727
Received March 18, 1992
Ah"s°fOrthopaedic a.dXrauma urgery © Springer-VerIag 1992
Current problem cases
Open traumatic posterior dislocation of the hip A case report A. Hamzaoglu, H. C. Aydinok, H. Pmar, M. Asik, and M. Cakmak Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, 34390 ~apa, lstanbul, Turkey
Summary. A case o f o p e n t r a u m a t i c p o s t e r i o r dislocat i o n o f t h e hip is p r e s e n t e d . T h e f e m o r a l h e a d a n d n e c k w e r e c o m p i e t e l y o u t o f t h e skin a n d t h e r e w e r e a c c o m p a n y i n g fractures of the a c e t a b u l a r floor, the ischial r a m u s a n d t h e g r e a t e r t r o c h a n t e r . T o o u r k n o w l e d g e , such a case has n o t b e e n r e p o r t e d p r e v i o u s l y a n d this, t o g e t h e r with its i n t e r e s t i n g m e c h a n i s m , has l e d us to r e p o r t t h e case. It was f o l l o w e d for 18 m o n t h s a n d r o e n t g e n o g r a p h i c a n d 99mtechnetium sulphur colloid scanning studies showed a v a s c u l a r necrosis a n d o s t e o a r t h r i t i s .
Posterior dislocations of the hip are becoming more c o m m o n d u e to t h e i n c r e a s i n g i n c i d e n c e of h i g h - e n e r g y t r a u m a . T h e y c o m p r i s e 6 5 % - 8 5 % o f t r a u m a t i c hip disl o c a t i o n s [1, 4 - 8 , 18, 20]. O n t h e o t h e r h a n d , o p e n disloc a t i o n s o f the h i p a r e e x t r e m e l y r a r e , o n l y o n e o p e n ant e r i o r d i s l o c a t i o n h a v i n g b e e n r e p o r t e d to d a t e [17]. T o the best of our knowledge, open posterior dislocation of t h e hip has n o t b e e n p r e v i o u s l y r e p o r t e d . T h e m e c h a nism a n d t h e a c c o m p a n y i n g i p s i l a t e r a l f r a c t u r e s of t h e g r e a t e r t r o c h a n t e r , t h e a c e t a b u l a r f l o o r a n d t h e ischial ramus render the injury even more interesting. The poor o u t c o m e was n o t surprising.
Case report In July 1987, a 34-year-old male pedestrian was brought to the emergency room after being struck by a car. He was conscious at admission. A detailed history disclosed that he had received the blow to the back of his right hip, rotated around his axis and fallen down on his left side. A careful multisystem evaluation for probable life-threatening injuries was undertaken immediately. Respiratory and cardiovascular status were normal and the extremities had no neurovascutar deficits. The right lower extremity was shortened, flexed, adducted and internally rotated. Posterior to the right hip, there was an approximately 20-cm-long contaminated wound with irregular margins through which the proximal femur was buttonholed (Fig. 1). The surface of the femoral head and neck was covered with dust and soil. The roentgenograms revealed accompanying ipsilatCorrespondence to: Halit Plnar, MD, 168 sok. No: 54, Basin Sitesi, Izmir, Turkey
Fig. 1. The proximal femur completely exposed posteriorly
eral fractures of the acetabular floor, greater trochanter and ischial ramus (Fig. 2). The operation was undertaken within 2 h after admittance and 6 h after the accident. The wound was irrigated with copious amounts of saline, debrided and then extended to become a posterolateral incision. Following debridement of contaminated and partially necrotic gluteal and external rotator muscles, the sciatic nerve was explored and seen to be intact. The acetabulum was full of many osteocartilaginous loose bodies and the labrum was inverted into the acetabulum. They were removed. There was a defect at the posterior rim of the actabulum which was thought to have been the source of the loose bodies. Surprisingly, no defects of the femoral head were seen. Following reduction, the trochanteric fracture was fixed by tension-band wiring. No attempt was made to fix the acetabular fracture for fear of subsequent infection. A Hemovac drain was inserted before wound closure. Femoral supracondylar skeletal traction which continued for 12 weeks was initiated immediately. Two different antibiotics were administered parenterally for 10 days. Rehabilitation started at the end of 12 weeks and by the end of the 5th month, the patient was ambulatory on crutches with partial weight-bearing. Full weight-bearing was possible at the end of 7 months. Clinical and roentgenographic examinations were done at four, nine, twelve and eighteen months after surgery. In February 1989, he could only walk with a cane and had pain after walking about half a mile. On examination, he had 60° flexion, 10° abduction and adduction and no rotational mobility at all. He also had a fixed external rotational deformity of 10°. There was a significant degree of atrophy of the thigh and gluteal musculature. The roentgenograms
346
Fig. 2. Roentgenogram of the pelvis taken at admission. Note that the right femoral head seems smaller than the uninvolved left one Fig. 3. Roentgenogram 18 months after the accident Fig. 4. a 99Technetium sulphur colloid bone scan demonstrating decreased uptake of isotope in the right femoral head. b Bone scan of the normal left hip revealed non-union of the acetabular fracture, increased sclerosis of the femoral head compared to the uninvolved side, and flattening of the superior portion of the head (Fig. 3). The latter two findings suggested avascular necrosis and this was verified by a 99mtechnetium bone scan (Fig. 4).
Discussion The hip joint is a ball-and-socket joint. The acetabulum contains two-thirds of the femoral head. Furthermore, it is surrounded by strong ligaments. Due to the inherent stability of this arrangement, therefore, significant trauma is needed to dislocate the hip joint [1, 2, 4-8, 10, 11, 16, 19, 21]. The majority of traumatic hip dislocations reported in the literature occur in automobile accidents. The mechanism of posterior dislocations is usually a force applied to the flexed knee with the hip in varying degrees of flexion. We think the mechanism in this case is worth mentioning, as it is extremely rare. If the blow had been directly to the back of the hip joint, we believe it is reasonable to postulate that it would have caused the femoral head to dislocate anteriorly. The greater trochanteric fracture suggests that the blow was directly to this region posterolaterally, creating three different components for forces. One of these was directed to the acetabulum, leading to the fracture of its floor. The other two components forced the proximal femur to internal rotation and adduction, tearing the posterior capsule and the external rotators, and eventually the dislocation took place. The combination of these fractures and the open nature of the dislocation indicate without any doubt that the sever-
ity of the trauma was even more than is usual in highenergy traumata. This case may be classified as grade 4 or grade 3 according to the Thompson-Epstein or Stewart-Milford classification respectively, but neither of these systems makes any mention of a greater trochanteric fracture. The prognosis worsens and the complication rates increase with the grade [1, 2, 4-8, 10, 11, 16, 18-21]. Coventry [3] and Garret et al. [9] recommended primary hip arthroplasty for Thompson-Epstein grade 4 and 5 and Stewart-Milford grade 3 and 4 injuries. Obviously, this is not valid for open injuries. Traumatic hip dislocation is an emergency and reduction, whether closed or open, should be achieved as soon as possible, preferably within 6 h after the event. Most authors agree that if d o s e d reduction fails after at most two attempts under general anaesthesia, the surgeon should proceed to an open reduction with the idea of removing the offending obstruction [1, 4, 10, 18, 19, 20]. Occasionally, reduction is obtained, but it may not be concentric. The obstructions to concentric reduction are usually osteocartilaginous fragments in the joint or an inverted limbus, both of which were encountered in this case. The incidence of finding osteocartilaginous fragments in the joint during open reduction was 91% in Epsteins's series [5-8]. We did not use internal fixation for the acetabular fracture for fear of subsequent infection. No infection was seen but despite 12 weeks of skeletal traction, non-union developed. No early complications were seen, but as to the late complications we encountered avascular necrosis, which is reported in 6 % - 4 0 % of cases [1, 2, 4-8, 16]. Meyers et al. [15], and later Kirschner et al. [12] reported that
347 99mtechnetium s u l p h u r c o l l o i d s c a n n i n g was i n v a l u a b l e in d e t e c t i n g a v a s c u l a r n e c r o s i s b e f o r e c o l l a p s e h a d dev e l o p e d . D e s p i t e fairly e a r l y r e d u c t i o n , a v a s c u l a r n e c r o sis was i n e v i t a b l e b e c a u s e all t h e b l o o d s u p p l y to t h e f e m o r a l h e a d was i n t e r r u p t e d . L a t e r e c o n s t r u c t i o n a n d i n t e r n a l fixation has b e e n adv o c a t e d for r e a l - u n i o n a n d n o n - u n i o n o f a c e t a b u l a r fractures w i t h o u t a s s o c i a t e d a v a s c u l a r n e c r o s i s of t h e f e m o ral h e a d a n d s e v e r e d e g e n e r a t i v e arthritis [13, 14]. L a t e r e c o n s t r u c t i o n m a y b e i n d i c a t e d in y o u n g adults with m i l d o s t e o a r t h r i t i s [14]. This p a t i e n t h a d a v a s c u l a r necrosis of the f e m o r a l h e a d , so he was scheduled to u n d e r g o t o t a l hip a r t h r o p l a s t y , b u t he did n o t r e t u r n .
References 1. Bray E A (1962) Traumatic dislocations of the hip. Army experience and results over a twelve year period. J Bone Joint Surg [Am] 44 : 1115-1134 2. Canale ST, Manugian A H (1979) Irreducible traumatic dislocations of the hipl J Bone Joint Surg [Am] 61 : 7-14 3. Coventry MB (1974) The treatment of fracture-dislocations of the hip by total hip arthroplasty. J Bone Joint Surg [Am] 56:1128-1134 4. De Lee JC (1984) Dislocation and Fracture-dislocation of the hip. In: Rockwood CA, Green DP (eds) Fractures, vol 2. Lippincott, Philadelphia, pp 1287-1356 5. Epstein HC (1961) Posterior fracture-dislocation of the hip. Comparison of open and closed methods of treatment in certain types. J Bone Joint Surg [Am] 43 : 1079-1089 6. Epstein HC (1964) Posterior fracture-dislocations of the hip. J Bone Joint Surg [Am] 46 : 695-714 7. Epstein HC (1973) Traumatic dislocations of the hip. Clin Orthop 92 : 116-142 8. Epstein HC (1974) Posterior fracture-dislocations of the hip. Long-terra follow-up. J Bone Joint Surg [Am] 55 : 1103-1127
9. Garret JCI Epstein HC, Harris WH, Harvey JP, Nickel VL (1979) Treatment of unreduced traumatic posterior dislocations of the hip. J Bone Joint Surg [Am] 61 : 2-6 10. Hunter GA (1969) Posterior dislocation and fracture-dislocation of the hip. A review of fifty-seven patients. J Bone Joint Surg [Br] 51:38-44 11. King D, Richards V (1941) Fracture-dislocations of the hip joint. J Bone Joint Surg 23 : 533-551 12. Kirschner PT, Simon MA (1981) Current concepts review: radioisotopic evaluation of skeletal disease. J Bone Joint Surg [Am 1 63:673-681 13. Letournel E (1979) Surgical repair of acetabular fractures more than three weeks after injury, apart from total hip replacement. Int Orthop 2 : 305-313 14. Letournel E (1990) Diagnosis and treatment of nonunions and malunions of acetabular fractures. Orthop Clin North Am 21 : 769-788 15. Meyers MH, Teller N, Moore TM (1977) Determination of the vascularity of the femoral head with technetium 99-m sulphur colloid. J Bone Joint Surg [Am] 59 : 658-664 16. Moll JH (1973) Fractures and dislocations of the hip joint. In: Tronzo RG (ed) Surgery of the hip joint. Lea & Febiger, Philadelphia, pp 450-472 17. Schwartz DL, Haller JA (1974) Open anterior hip dislocation with femoral vessel transection in a child. J Trauma 14 : 10541059 18. Stewart MJ, McCarroll HR (1970) Fracture-dislocation of the hip. A follow-up and comparative study. J Bone Joint Surg [Br] 52: 773 19. Stewart MJ, Milford LW (1954) Fracture-dislocation of the hip. J Bone Joint Surg [Am] 36:315-342 20. Stewart MJ, McCarroll HR, Mulhollan JS (1975) Fracture-dislocations of the hip. Acta Orthop Scand 46 : 507-525 21. Urist MR (1948) Fracture-dislocation of the hip joint: the nature of the traumatic lesion, treatment, late complications and end results. J Bone Joint Surg [Am] 30 : 699-727
Received March 18, 1992
