Emergent Management of Hip Dislocations: Treatment and Complications

1. Lower Extremity Trauma

2. Lower Extremity Trauma • Hip Fractures / Dislocations • Femur Fractures • Patella Fractures • Knee Dislocations • Tibia Fractures • Ankle Fractures • Foot Fracture

3. Hip Fractures • Hip Dislocations • Femoral Head Fractures • Femoral Neck Fractures • Intertrochanteric Fractures • Subtrochanteric Fractures

4. Hip Dislocations • Significant trauma, usually MVA • Posterior: Hip flexion, IR, Add • Anterior: Extreme ER, Abd/Flex

5. Anatomic classification • posterior dislocation (90%) • occur with axial load on femur, typically with hip flexed and adducted • axial load through flexed knee (dashboard injury)  • associated with • osteonecrosis • posterior wall acetabular fracture • femoral head fractures • sciatic nerve injuries  • ipsilateral knee injuries (up to 25%)  • anterior dislocation  • associated with femoral head impaction or chondral injury • occurs with the hip in abduction and external rotation

6. Anterior Dislocation 7-10% of hip dislocations Mechanism: • Forced abduction with external rotation of hip. • Anterior hip capsule is torn or avulsed. • Femoral head is levered out anteriorly.

7. Epstein Classificationof Anterior Hip Dislocations Type I Superior (pubic and subspinous) Type II Inferior (obturator and perineal) A No associated fracture B Associated fracture of the femoral head/neck C Associated fracture of the acetabulum

8. Thompson and Epstein Classificationof Hip Dislocations Type I Pure dislocation with at most a small posterior wall Type II Dislocation with large posterior wall Type III Dislocation with comminuted posterior wall Type IV Dislocation with “acetabular floor” fracture Type V Dislocation with femoral head fracture

9. Hip Dislocations • Emergent Treatment: Closed Reduction • Dislocated hip is an emergency • Goal is to reduce risk of AVN and DJD • Allows restoration of flow through occluded or compressed vessels • Literature supports decreased AVN with earlier reduction • Requires proper anesthesia • Requires “team” (i.e. more than one person)

10. Hip Dislocations • Emergent Treatment: Closed Reduction • General anesthesia with muscle relaxation facilitates reduction, but is not necessary • Conscious sedation is acceptable • Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult

11. Hip Dislocations • Emergent Treatment: Closed Reduction • Allis Maneuver • Assistant stabilizes pelvis with pressure on ASIS • Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle adduction and internal rotation • Reduction can often be seen and felt Insert hip Reduction Picture

12. Hip Dislocations • Following Closed Reduction • Check stability of hip to 90deg flexion • Repeat AP pelvis • Judet views of pelvis (if acetabulum fx) • CT scan with thin cuts through acetabulum • R/O bony fragments within hip joint (indication for emergent OR trip to remove incarcerated fragment of bone)

13. Hip Dislocations • Following Closed Reduction • No flexion > 60deg (Hip Precautions) • Early mobilization with • P.W.B. for 4-6 weeks • MRI at 3 months (follow risk of AVN)

14. Complications • Post-traumatic arthritis  • up to 20% for simple dislocation, markedly increased for complex dislocation • Femoral head osteonecrosis • 5-40% incidence • Increased risk with increased time to reduction • Sciatic nerve injury • 8-20% incidence • associated with longer time to reduction • Recurrent dislocations • less than 2%

15. Femoral Head Fractures • Concurrent with hip dislocation due to shear injury

16. Femoral Head Fractures • Pipkin Classification • I: Fracture inferior to fovea • II: Fracture superior to fovea • III: Femoral head + acetabulum fracture • IV: Femoral head + femoral neck fracture

17. Femoral Head Fractures • Treatment Options • Type I • Nonoperative: non-displaced • ORIF if displaced • Type II: ORIF • Type III: ORIF of both fractures • Type IV: ORIF vs. hemiarthroplasty

18. Epidemiology • 250,000 Hip fractures annually • Expected to double by 2050 • At risk populations • Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition • Young: high energy trauma

19. Femoral Neck Fractures • Garden Classification • I Valgus impacted • II Non-displaced • III Complete: Partially Displaced • IV Complete: Fully Displaced • Functional Classification • Stable (I/II) • Unstable (III/IV) I II III IV

20. Femoral Neck Fractures • Treatment Options • Operative • ORIF • Hemiarthroplasty (Endoprosthesis) • Total Hip Replacement

21. Femoral Neck Fractures • Young Patients • Urgent ORIF (<6hrs) • Elderly Patients • ORIF possible (higher risk AVN, non-union, and failure of fixation) • Hemiarthroplasty • Total Hip Replacement

22. Hemi ORIF THR

23. Intertrochanteric Hip Fx • Intertrochanteric Femur Fracture • Extra-capsular femoral neck • To inferior border of the lesser trochanter

24. Intertrochanteric Hip Fx • Intertrochanteric Femur Fracture • Physical Findings: Shortened / ER Posture • Obtain Xrays: AP Pelvis, Cross table lateral

25. Intertrochanteric Hip Fx • Classification • # of parts: Head/Neck, GT, LT, Shaft • Stable • Resists medial & compressive Loads after fixation • Unstable • Collapses into varus or shaft medializes despite anatomic reduction with fixation • Reverse Obliquity

26. Intertrochanteric Hip Fx Reverse Obliquity Stable Unstable

27. Intertrochanteric Hip Fx • Treatment Options • Stable: Dynamic Hip Screw • Unstable/Reverse: IM Recon Nail

28. Subtrochanteric Femur Fx • Classification • Located from LT to 5cm distal into shaft • Intact Piriformis Fossa? • Treatment • IM Nail • Cephalomedullary IM Nail • ORIF

29. Femoral Shaft Fx Winquist • Type 0 - No comminution • Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture • Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact • Type 3 - Larger butterfly leaving less than 50% of the cortex in contact • Type 4 - Segmental comminution

30. Femoral Shaft Fx • Treatment Options • IM Nail with locking screws • ORIF with plate/screw construct • External fixation • Consider traction pin if prolonged delay to surgery

31. Distal Femur Fractures • Distal Metaphyseal Fractures • Look for intra-articular involvement • Plain films • CT

32. Distal Femur Fractures • Treatment: • Retrograde IM Nail • ORIF open vs. MIPO • Above depends on fracture type, bone quality, and fracture location

33. Knee Dislocations • High association of injuries • Ligamentous Injury • ACL, PCL, Posterolateral Corner • LCL, MCL • Vascular Injury • Intimal tear vs. Disruption • Obtain ABI’s  (+)  Arteriogram • Vascular surgery consult with repair within 8hrs • Peroneal >> Tibial N. injury

34. KNEE DISLOCATION • Devastating injury resulting from high or low energyhigh-energy • usually from MVC or fall from height • commonly a dashboard injury resulting in axial load to flexed knee • low-energy • often from athletic injury • generally has a rotational component  • morbid obesity is a risk-facto

35. Associated Injuries • vascular injury 5-15% in all dislocations • 40-50% in anterior/posterior dislocations  • due to tethering at the politeal fossa • proximal - fibrous tunnel at the adductor hiatus • distal - fibrous tunnel at soleus muscle • nerve injury • usually common peroneal nerve injury (25%) • tibial nerve injury is less common • fractures • present in 60% • tibia and femur most common

36. Classification • Anteriormost common type of dislocation (30-50%) • due to hyperextension injury • arterial injury is generally an intimal tear due to traction • posterior • 2nd most common type (25%)highest rate of complete tear of popliteal artery • lateral  • 13% of knee dislocationsdue to varus or valgus force • highest rate of peroneal nerve injury Medial • rotational

37. Schenck Classification

38. vascular exam • Rule out vascular injury on exam both before and after reduction • palpate the dorsalispedis and posterior tibial pulses • if pulses are present and normal  • measure Ankle-Brachial Index (ABI)  • if ABI >0.9   then monitor with serial examination (100% Negative Predictive Value) • if ABI <0.9 perform arterial duplex ultrasound or CT angiography • if arterial injury confirmed then consult vascular surgery • If pulses are absent or diminished  • confirm that the knee joint is reduced or perform immediate reduction and reassessment • immediate surgical exploration if pulses are still absent following reduction • ischemia time >8 hours has amputation rates as high as 86% • if pulses present after reduction angiography

39. Initial Treatment • reduce knee and re-examine vascular status • considered an orthopedic emergency • splint knee in 20-30 degrees of flexion  • confirm reduction is held with repeat radiographs in brace/splint • vascular consult indicated if

40. Complications • Stiffness (arthrofibrosis) • is most common complication (38%) • more common with delayed mobilization • Laxity and instability(37%) • Peroneal nerve injury (25%) • most common in posterolateral dislocations • Vascular compromise • in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur

41. Patella Fractures • History • MVA, fall onto knee, eccentric loading • Physical Exam • Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?) • Pain, swelling, contusions, lacerations and/or abrasions at the site of injury • Palpable defect

42. Patella Fractures • Radiographs • AP/Lateral/Sunrise views • Treatment • ORIF if ext mechanism is incompetent • Non-operative treatment with brace if ext mechanism remains intact

43. Tibia Fractures • Proximal Tibia Fractures (Tibial Plateau) • Tibial Shaft Fractures • Distal Tibia Fractures (Tibial Pilon/Plafond)

44. Tibial Plateau Fractures • MVA, fall from height, sporting injuries • Mechanism and energy of injury plays a major role in determining orthopedic care • Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries) • Be aware for compartment syndrome • Check for knee ligamentous instability

45. Tibial Plateau Fractures • Xrays: AP/Lateral +/- traction films • CT scan (after ex-fix if appropriate)

46. Schatzker Classification of Plateau Fxs Lower Energy Higher Energy

47. Tibial Plateau Fractures • Treatment • Definitive ORIF for patients with varus/valgus instability, >5mm articular stepoff • Non-operative in non-displaced stable fractures or patients with poor surgical risks

48. Tibial Plateau Fractures • Treatment • Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries Insert blister Pics of ex-fix here

49. Tibial Shaft Fractures • Mechanism of Injury • Can occur in lower energy, torsion type injury (e.g., skiing) • More common with higher energy direct force (e.g., car bumper) • Open fractures of the tibia are more common than in any other long bone

50. Tibial Shaft Fractures • Open Tibia Fx • Priorities • ABC’S • Associated Injuries • Tetanus • Antibiotics • Fixation