Documente Academic
Documente Profesional
Documente Cultură
19.luxatia Traumatica A Soldului
19.luxatia Traumatica A Soldului
Gheorghevici T. tefan, MD
sub coord. Sef lucr.Dr. Cozma Tudor
Universitatea de Medicin i Farmacie Gr. T. Popa Iai
Spitalul Clinic de Recuperare Iai
2011
Definiie
Anatomia
articulatiei oldului
ischiofemural
pubofemural (cel mai slab)
ligamentul rotund al capului
femural
Vascularizatia
capului femural
1. A. ligamentului rotund
din sistemul obturator
A. iliaca interna
Vascularizatia
capului femural
2. Ramuri cervicale ascendente
artere cicumflexe
artera femurala profunda
artera femurala comuna
artera iliaca externa
aorta
risc foarte mare de lezare in luxatia traumatica a
soldului
Nervul sciatic
format din radacinile L4 - S3.
trece posterior de peretele
posterior acetabular
trece inferior de m. piriformis,
cu variatii
FRECVENTA
ETIOLOGIE
Mecanism de producere
Leziuni asociate
ANATOMIE PATOLOGICA
lig. rotund rupt/ smuls fragment osos
capul sfasie capsula + lig. inferioare (ischiofemural, pubo-femural)
in portiunea inferioara grosimea capsulei=2-3mm,
in portiunea superioara=8-12 mm
lig. Bertin intactluxatie tipica (regulata), lig.
Bertin ruptluxatie atipica(neregulata)
SIMPTOMATOLOGIE
LUXATIILE POSTERO-SUPERIOARA
(ILIACA)
Luxatiile atipice
Luxatia
Capul femural
Observatii
supracotiloidiana
deasupra cotilului
subspinoasa
sub SIAI
suprapubiana
perineala
subischiatica
intrapelviana
in micul bazin
luxatie centrala/protuzie
acetabulara de cap femural
EXPLORARI PARACLINICE
Examen radiografic
Examen CT
Examen IRM
Examen scintigrafic
Examen radiografic
Examen CT
Examen IRM
T1 NACF, corp liber intraarticular, rupturi
labrale, leziuni condrale, flebita vaselor
bazinului, fracturi oculte;
T2 edemul sprancenei acetabulare, nu e
folosit curent
Examen scintigrafic
permite aprecierea vitalitatii capului
femural
Diagnostic diferential
entorsa de sold dureri mai putin intense si
difuze, miscarile pasive sunt posibile, nefiind
blocate in pozitii vicioase
contuzia de sold durri difuze, moderate, permit
miscarile pasive, absent pozitiilor vicioase, marele
trohanter nu este ascensionat
fractura de col femural cu deplasare RE si
scurtare, nu apare ADD
fracturi acetabulare sau ale bazinului
fractura de cap femural
NACF
CLASIFICARE
Clasificarea Epstein
Clasificarea Thompson si Epstein
Clasificarea Pipkin
Clasificarea Levin
Clasificarea Stewart and Milfords
Clasificare AO/OTA
Clasificarea Epstein
Clasificarea Pipkin
Tip I: Luxatie posterioara a soldului cu fractura
capului femural caudal de fovea capitis
Tip II: Luxatie posterioara a soldului cu fractura
capului femural proximal de fovea capitis
Tip III: Tip I sau II luxatie posterioara cu fracura
de col femural asociata
Tip IV: Tip I, II, sau III luxatie posterioara cu
fractura acetabulara
Clasificarea Levin
Tip I
Fra fracturi importante, fara afectarea stabilitatii
postreductionale
Tip II
Luxatie ireductibila fara fractura/tasare a capului femural/
acetabulara
Tip III
Luxatie incoercibila sau fagmente osteocondrale incarcerate
Tip IV
Fractura acetabulara asociata ce necesita reconstructie pentru
restabilirea congruentei articulare
Tip V
Leziune asociata capului femural (fractura sau tasare)
Clasificarea AO/OTA
30-D10
30-D11
30-D30
EVOLUTIE SI PROGNOSTIC
sunt mai favorabile in luxatiile simple decat
in cele asociate cu fracturi
precocitatea reducerii amelioreaza
prognosticul (luxatii simple reduse
>24hcomplicatii 66%, luxatii+ fracturi
acetabulare reduse >24hcomplicatii
100%)
nu trebuie sa treaca nici un rasarit sau
apus de soare
COMPLICATII
Complicatii generale
intretinerea/accentuarea tulb. circulatorii
cerebrale(frecv. la pacienti cu TCC)
leziune socogenatrombogena
risc de TVPEP grava, necesita
trombopreventia cu HGMM
NACF
coxartroza
osificarile posttraumatice
atrofii musculare
atitudini vicioase permanente+impotenta
functionala +dureri+retractii musculare
ingrosari si osificari ale capsulei
tendinita m.rotatori ai soldului
luxatia recidivanta de sold
Cauze de ireductibilitate
anterioara:
posterioara:
fragment osos
tendonul m. piramidal, m. obturator intern
marele fesier
capsula
ligamentul rotund
lig. iliofemural
labrum-ul
peretele posterior
Managementul initial
reducere trebuie efectuata rapid pentru preventia
complicatiilor
daca e posibil, reducerea trebuie efectuata in UPU/ sala de
operatie, sub anestezie si relaxare musculara
daca anestezia generala nu este posibila, trebuie tentata
reducerea sub sedare i.v
indiferent de tipul de luxatie, tractiunea se face in pozitie
vicioasa, cu pacientul in decubit dorsal
in timpul reducerii se cauta stabilitatea
trebuie efectuate Rx postreducere, pentru confirmare
Algoritmul postreductional
fara ADD sau RI
fara flexie >60o
pentru luxatii simple extensie transosoasa 10-12 zile
urmata de mobilizare activa inca 10-20 zile.
mersul cu sprijin integral este permis dupa 3-4
saptamani
cand nu poate efectuata extensia transscheletica
continua imobilizare gipsata 2 saptamani
program de kineto pentru prevenirea atrofiilor
musculare, redorilor posttraumatice si a calcificarilor
periarticulare
Metoda Bhler
Metoda Allis
Posterior Kocher-Langenbeck
Posterior Dislocation:
Anterior Dislocation:
Unclassical presentation
(posture) if:
femoral head or neck fracture
femoral shaft fracture
obtunded patient
Physical Examination
Pain to palpation of hip.
Pain with attempted motion of hip.
Possible neurological impairment:
Thorough exam essential!
CT Scan
Most helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.
MRI Scan
Clinical Management:
Emergent Treatment
Emergent Reduction
Anesthesia
Reduction Maneuvers
Allis:
Patient supine.
Requires at least two people.
Allis Maneuver
Assistant: Stabilizes pelvis
Posterior-directed force on both ASISs
Reduced Hip
Moves more freely
Patient more comfortable
Requires testing of stability
Simply flexing hip to 900 does not
sufficiently test stability
Stability Test
1. Hip flexed to 90o
2. If hip remains stable, apply internal rotation,
adduction and posterior force.
3. The amount of flexion, adduction and internal
rotation that is necessary to cause hip dislocation
should be documented.
4. Caution!: Large posterior wall fractures may
make appreciation of dislocation difficult.
Irreducible Hip
Requires emergent reduction in O.R.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in O.R. with
anesthesia.
Repeated efforts not likely to be successful and may create
harm to the neurovascular structures or the articular
cartilage.
Hip Dislocation:
Nonoperative Treatment
Hip Dislocation:
Indications for Operative Treatment
1.
2.
3.
4.
5.
1.
Smith-Peterson approach
Watson-Jones is an alternate approach
1.
Three Options
1.Detach femoral head from ligamentum teres,
repair femoral head fracture with hip dislocated,
reduce hip.
2.Close posterior wound, fix femoral head fracture
from anterior approach (either now or later).
3.Ganz trochanteric flip osteotomy.
3. Incarcerated
Fragment
Can be detected on x-ray or CT scan.
Surgical removal necessary to prevent abrasive wear of the
articular cartilage.
Posterior approach allows best visualization of acetabulum
(with distraction or intra-op dislocation).
Anterior approach only if:
dislocation was anterior and,
fragment is readily accessible anteriorly.
4. Incongruent Reduction
From:
Interposed tissue.
Goal: achieve congruence by removing interposed
tissue and/or reducing and stabilizing fracture.
Results of Treatment
Large range:
from normal to severe pain and degeneration.
In general, dislocations with associated femoral head or
acetabulum fractures fare worse.
Dislocations with fractures of both the femoral head and the
acetabulum have a strong association with poor results.
Irreducible hip dislocations have a strong association with poor
results.
13/23 (61%) poor and 3/23 (13%) fair results.
McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of
the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.
Post-traumatic Osteoarthritis
Can occur with or without AVN.
May be unavoidable in cases with severe
cartilaginous injury.
Incidence increases with associated femoral head
or acetabulum fractures.
Efforts to minimize osteoarthritis are best directed
at achieving anatomic reduction of injury and
preventing abrasive wear between articular
carrtilage and sharp bone edges.
Recurrent Dislocation
Rare, unless an underlying bony instability has not
been surgically corrected (e.g. excision of large
posterior wall fragment instead of ORIF).
Some cases involve pure dislocation with inadequate
soft-tissue healing may benefit from surgical
imbrication (rare).
Can occur from detached labrum, which would
benefit from repair (rare).
Foot Drop
Splinting (i.e. ankle-foot-orthosis):
Improves gait
Prevents contracture
Infection
Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches
Thromboembolism
Hip dislocation = high risk patient.
Prophylactic treatment with:
coumadin
Early postoperative mobilization.
Discontinue prophylaxis after 2-6 weeks (if
patient mobile).
Bibliografie
5-Minute Orthopaedic Consult 2 Ed - Franc J. Frasicca 2007
A-Z of Musculoskeletal and Trauma Radiology - James R. D. Murray, Cambridge University Press,
2008
Campbell's Operative Orthopaedics 11 Ed - S. Terry Canale, Elsevier, 2007
Chapman's Orthopaedic Surgery 3 Ed - Michael W.Chapman, Lippincott Williams & Wilkins, 2001
Emergencies Orthopedics - The Extremities 5 Ed - Robert R. Simon, McGraw-Hill
Encyclopdie Mdico-Chirurgicale - Luxations traumatiques de hanche: luxations pures et fractures de
tte fmorale - G. Burdin, 2004
Fractures Classification in Clinical Practice - Seyed Behrooz Mostofi, Springer, 2006
Handbook of Fractures 3 Ed - K. Koval, J. Zuckerman, Lippincott, 2006
Orthopedic Imaging - A Practical Approach 4 Ed - A. Greenspan, Lippincott Williams & Wilkins, 2004
Orthopedic Traumatology - A Resident Guide - David Ip, Springer, 2006
Patologia aparatului locomotor Dinu M. Antonescu, Ed. Medicala, Bucuresti, 2008
Rockwood and Green's Fractures in Adults 6 Ed - Lippincott Williams & Wilkins, 2006
Semiologia clinica a aparatului locomotor - Clement Baciu, Ed. Medicala, 1975
Skeletal Trauma - Basic Science, Management and Reconstruction 3 Ed - Bruce D. Browner, Saunders,
2002
Surgical Exposures in Orthopaedics 4 Ed - Stanley Hoppenfeld, Lippincott Williams & Wilkins, 2009
Tratat de Chirurgie vol X Ortopedie-Traumatologie Dinu Antonescu, Ed Academieir Romane,
Bucuresti, 2009
Tratat de patologie chirurgicala - Angelescu Vol 2 - N.Angelescu, Ed. Medicala, 2003
Tratat de patologie chirurgicala vol III Ortopedia A. Denischi, Ed. Medicala, Bucuresti, 1988
Traumatismele Osteoarticulare Gheorghe Floares, Umf Iasi, 1979
Traumatismele Osteoarticulare vol II Al.D.Radulescu, Ed. Academiei RSR, Bucuresti,1968