neglected dislocation of hip : a case report · hip dislocation: mechanism of injury the hip joint...
TRANSCRIPT
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Neglected Dislocation of Hip : A Case Report
DR . NITIN WADHWA (RESIDENT)
Dr AMIT KALE (HOU & PROFESSOR)
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CASE REPORT
• A 20 year old male patient with complaints of pain in left knee since 3 months
• History of trauma 3 months back for which he did not take any medical treatment but massage and prolonged immobilization was done.
• The patient was on complete bed rest for two months.
• After two months the patient was walking with the help of a stick but was unable to squat and sit cross-legged.
• The activities of daily living were hampered and the patient was unable to carry on with his job.
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• On examination : • Attitude of the limb was abduction and external rotation .• Inspection : ASIS is at a lower level as compared to the normal
side.• Apparent lengthening of 2cm of the affected limb(left lower
limb)• Narath’s sign : the pulsation of the femoral artery was not
palpable .• Rom : fixed flexsion deformity of 20 degree
left hip is fixed in abduction of 20 degree further abduction upto 40 degree was possible.
• Power :5/5 • Bilateral dorsalis pedis present , equal and normal .
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MANAGEMENT
• Radiological evaluation was done in the form of X-ray and CT Scan.
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FIGURE 1: PRE OPERATIVE X-RAY OF THE PATIENT SHOWING INFERIOR DISLOCATION OF THE HIP
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FIGURE 2
CT SCAN SHOWING POSTERIO-INFERIOR DISLOCATION OF THE HIP
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MANAGEMENT
• Initially skeletal traction was given.
• Lateral traction was given using schanz screw which was inserted in greater trochanter and 10 kg of weight was applied.
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FIGURE 3:CLINICAL PICTURE SHOWING PATIENT GIVEN TRACTION
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FIGURE 4
POST TRACTION X-RAY
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OPTIONS FOR TREATMENT
• IDEAL option of treatment in this case will be ARTHROPLASTY .
• Hemiarthroplasty ( uncemented modular bipolar)
• Total hip arthroplasty (uncemented): depending upon the condition of the acetabular cartilage .
• We planned for open reduction and relocation of the femoral head as patient was not willing for arthroplasty .
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CHALLENGES IN OPEN REDUCTION AND RELOCATION
• Relocation of the head due to surrounding soft tissue fibrosis.
• Associated femoral head fracture .
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Impending neurovascular damage
Sciatic Nerve
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SURGERY
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The head of femur on dissection was lying postero inferior
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Subchondral fracture of the femoral head
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FIGURE 5: POST RELOCATION OF HIP X-RAY
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Post operative plan
• Patient was advised for continued traction for 2 weeks .
• He has been allowed for non weight bear walking for 4 weeks.
• And a close follow up will be kept for osteoarthritic changes in the femoral head and acetabulum .
• And reconsiderstion for arthroplasty as further line of management.
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DISCUSSION:Anatomy
asymmetric, forms 2/3 sphere.
• Acetabulum: inverted “U” shaped articular surface.
• Ligamentum teres, with artery to femoral head, passes through middle of inverted “U”.
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Joint ContactArea
Throughout ROM:
• 40% of femoral head is in contact with acetabulum.
• 10% of femoral head is in contact with labrum.
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AcetabularLabrum
Strong fibrous ring
Increases femoral head coverage
Contributes to hip joint stability
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The Capsule & ligaments of hip joint
• The primary capsular fibers run longitudinally and are supplemented by much stronger ligamentous condensations that run in a circular and spiral fashion.
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Hip Dislocation: Mechanism of Injury
The hip joint is inherently stable, requiring significant force to dislocate.Thus pure hip dislocation or dislocation with femoral head fracture is generally a result of high-energy trauma and is often accompanied by associated injuries.
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• POSTERIOR DISLOACTION is the commonest type of dislocation.
• It has been well documented that delayed reduction of traumatic dislocation of the hip increases the risk of avascular necrosis and secondary arthritis.
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REFERENCES
• [1] Bucholz Robert W., Heckman James D., Court-Brown Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. Philadelphia, Lippincott Williams & Wilkins; 2006; Vol (2): p1714-1752.
• [2] Phillips AM, Konchwalla A. The pathologic features and mechanism of traumatic dislocation of the hip. Clin Orthop RelatRes 2000;377:7-10.
• [3] Epstein HC. Traumatic dislocations of the hip. Clin Orthop Relat Res 1973;92:116-42.• [4] DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am
1980;62:960-4.• [5] Canale Terry S., Beaty James H. Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Mosby Elvesier 2007;
vol(3):p3227-3296.• [6] Aggarwal S., Kumar V., Bhagwat K., Shashikanth V.S., Ravikumar H. Inferior dislocation of the hip: a case series and
literature review. Chinese J of Traumatology 2012;15(5):317-320. • [7] DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am
1980;62:960-4.• [8] Phillips AM, Konchwalla A. The pathologic features and mechanism of traumatic dislocation of the hip. Clin Orthop Relat
Res 2000;377:7-10.• [9] Garret JC, Epstein HC, Harris WH, Harvey JP, Nickel VL. Treatment of unreduced traumatic posterior dislocations of the
hip. J Bone Joint Surg 1979;61-A: 2-6.• [10] Salisbury RD, Eastwood DM. Traumatic dislocation of the hip in children. Clin Orthop Relat Res 2000;(377):106-11.• [11] Yamamoto K, Ko M, Masaoka T, Shishido T, Imakiire A. Traumatic anterior dislocation of the hip associated with
ipsilateral femoral shaft fracture in a child: a case report. J Orthop Surg 2004;12:126-32.• [12] Agarwal N.D., Singh H. Unreduced anterior dislocation of hip. A report of seven cases. JBJS 1967;49(B):288-92.• [13] Singaravadivelu V, Mugundhan M, Sankaralingam K. Neglected intrapelvic dislocation of femoral head. Indian J of
Orthopaedics 2010;44:224-26. • [14] Alva A, Shetty M, Kumar V. Old unreduced traumatic anterior dislocation of the hip. BMJ case reports 2013;
doi:10.1136/bcr-2012-008068.
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