Luxaţia traumatică a şoldului

Gheorghevici T. Ştefan, MD
sub coord. Sef lucr.Dr. Cozma Tudor

Universitatea de Medicină şi Farmacie Gr. T. Popa Iaşi

Spitalul Clinic de Recuperare Iaşi
2011
 Definiţie

Urgenta ortopedica caracterizata prin

parasirea permanenta a cotilului de catre
capului femural ± fractura
 Anatomia
articulatiei şoldului

 enartroza, cu grad mare de stabilitate

 capul femural usor asimetric, 2/3 de sfera
 conducere ligamentara
 acetabulum: suprafata articulara in forma de “U” inversat
 labrum (2/3 ale circumferintei) + ligamentul
transvers acetabular (1/3 ale circumferintei) – inel
fibros cu rol in cresterea acoperirii capului femural
 capsula (mai subtire in portiunea inferioara), cu forma
de „butoi”
 ligamente
  ilio-femural (in „Y”, a lui
Bertin/Bigelow) cu 2
fascicole: - ilio-
pertrohanterian – lim. E, RE,
ABD,
- ilio-pretrohantenian – lim.
E, rezista la 3.5- 6 kN,

 ischiofemural
 pubofemural (cel mai slab)
 ligamentul rotund al capului
femural
• musculatura: - coaptoare – ms.
pelvitrohanterieni scurti posteriori, fesier
mijlociu si micul fesier in opozitie cu m.
abductoare si flexoare.
 Anteversia colului femural

• 70 in medie la barbatii caucazieni

• mai mare la sexul feminin
• orientali pot avea un unghi de anteversie intre 140 si
160
 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

• 5% din totalul luxatiilor

• sex masculin > sex feminin,
• 20-45 ani, rar copii si exceptional batrani.
 ETIOLOGIE

consecutiva unui traumatism de inalta energie

(accidente rutiere, cadere de la mare inaltime, accidente
miniere).
low-energy trauma – copii <6 ani, datorita laxitatii
ligamentare si batrani cu proteza de sold (10%)
 Mecanism de producere

• indirect - accidente rutiere - sindromul tabloului

de bord, accidente industriale
• direct – traumatismul actioneaza asupra partii
superioare a femurului, fortandu-l sa paraseasca
articulatia printr-o bresa capsulara
• F+ADD+RI→deplasarea posterioara a capului femural in
FIE (85-90%) ±fractura sprancenei cotiloide
• F+ABD →luxatie anterioara (10-15%)
• F+ usoara ABD→luxatie centrala/intrapelvina – protuzia
capului femural in bazin, cu fractura acetabulului; rezulta 2
fragmente: superior si inferior care „incarcereaza” capul
femural asemeni uni cioc de pasare
• E+RE → luxatie antero-superioara (pubiana)
 Leziuni asociate

 leziuni ale capului si ale fetei

 leziuni ale toracelui
 leziuni intra-abdominale
 fracturi ale extremitatilor si luxatii
 ANATOMIE PATOLOGICA

• lig. rotund rupt/ smuls ±fragment osos

• capul sfasie capsula + lig. inferioare (ischio-
femural, pubo-femural)
• in portiunea inferioara grosimea capsulei=2-3mm,
in portiunea superioara=8-12 mm
• lig. Bertin intact→luxatie tipica (regulata), lig.
Bertin rupt→luxatie atipica(neregulata)
• m. pelvitrohanterieni pot fi rupt /desirati; in luxatiile
posterioare m. gemeni, obturatorul intern si patratul
crural pot si dilacerati, in luxatiile anterioare pot fi lezati
m. pectineu, micul si mijlociul adductor
• frecvent sunt asociate leziuni osoase: fracturi ale
sprancenei cotiloide posterioare,
• fracturi ale femurului: cap, col, masiv trohanterian,
diafiza.
• leziuni vasculare (foarte rar), cu hematom foarte mare –
compresiv
• elongarea/compresiunea n.sciatic
 Efectele luxatiei asupra circulatiei
capului femural

 arterele cervicale ascendente sunt intinse/rupte

 artera ligementului rotund este rupta
 unele artere cervicale sunt comprimate
 reducerea rapida poate imbunatati fluxul sanguin al
capului femural
 SIMPTOMATOLOGIE

 dureri vii in regiunea soldului

 impotenta functionala totala a membrului inferior
 la indivizii slabi - diformitati ale soldului luxat
 atitudine vicioasa in raport cu forma
anatomopatologica
 in luxatiile tipice:
 LUXATIILE POSTERO-SUPERIOARA (ILIACA)
• F coapsei pe bazin (poate fi mascata de lordoza
compensatoare); E aproape completa
• RI mica – genunchiul se sprijina pe celalalt genunchi, halucele
se sprijina pe fata dorsala a piciorului sanatos
• largirea transversala a soldului (dizlocatia + tumefierea locala)
• in triunghiul lui Scarpa se constata o depresiune
• scurtarea poate atinge 6-7 cm
• la palpare: capul femural este in FIE,
• marele trohanter este ascensionat
 Luxatiile postero-inferioare (ischiatica)
• ADD importanta a coapsei cu F a genunchiului si RI –
picior peste picior
• scurtarea MI luxat – la flexia 900 pe bazin – 3-5cm
• la palpare capul femural se simte inapoia tuberozitatii
ischiatice – formatiune dura, mobila la mobilizarea pasiva
a genunchiului
• ABD, RE si E sunt imposibile, dureroase
 Luxatiile antero-superioare (pubiene)
• MI luxat in E, ADB si RE
• la palpare: capul femural este in reg. inghinala sau
in triunghiul lui Scarpa
• capul femural rupe capsula antero-superior
• lig. pubo-femural plasandu-se inaintea ramurii
orizontale a pubisului
• se fixeaza sub m. ileaopsoas
• intinde n. femural
• ADD, RI, si F sunt imposibile
• scurtarea este de 1-2 cm
 Luxatiile antero-
inferioare (obturatorii)

• F exagerata, ADB si RE importanta

• sold „sters”, turtit
• capul femural se poate palpa in dreptul gaurii
obturatorii
• coarda m. adductori in tensiune
• MI alungit cu 1-2 cm
• cand este bilaterala, pozitia clasica de ”batracian”
• compresiuni ale n. obturator
 Luxatiile atipice
Luxatia Capul femural Observatii

capsula rupta in portiunea

superioara+fractura
supracotiloidiana deasupra cotilului
sprancenei cotiloide. fascicolul
extern al lig. in „Y” este rupt

subspinoasa sub SIAI

in partea mijlocie a arcadei

suprapubiana
femurale

placat pe ramura ascendenta

perineala poate ajunge in reg. scrotala
a ischionului

subischiatica la nivelul spinei ischiatice

luxatie centrala/protuzie
intrapelviana in micul bazin
acetabulara de cap femural
 EXPLORARI PARACLINICE

• Examen radiografic
• Examen CT
• Examen IRM
• Examen scintigrafic
 Examen radiografic

• fata si profil de bazin±

incidenta alara/
obturatorie
• incidenta Jutet
 Examen CT

• sectiuni de 2-3 mm;

• deceleaza fracturi de cotil/cap femural ±
reconstructie 3D, util in reducerile
sangerande
• prezenta bulelor de gaz→subluxatie
redusa spontan
 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 Milford’s
• Clasificare AO/OTA
Clasificarea Epstein
• Tip I: Luxatii superioare inclusiv pubiene sau
suprapubiene
• Tip IA: Fara fracturi asociate
• Tip IB: Fracturi asociate sau tasari ale capului
femural
• Tip IC: Fracturi asociate ale acetabulului
• Tip II: Luxatii inferioare inclusiv obturatorii si
perinale
• Tip IIA: Fara fracturi asociate
• Tip IIB: Fracturi asociate sau tasari ale capului
femural
• Tip IIC: Fracturi asociate ale acetabulului
Clasificarea Thompson si Epstein

• Tip I: Luxatie cu/fara fractura minora

• Tip II: Luxatie cu un singur fragment major
al peretului posterior acetabular
• Tip III: Luxatie cu cominutia peretului
posterior acetabular cu/fara fragment major
• Tip IV: Luxatie cu fractura tavanului
acetabular
• Tip V: Luxatie cu fractura capului femural
 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 Stewart si Milford’s

• Tip I luxatie cu /fara fracturi insignifiante

acetabulare
• Tip II luxatie asociata fie cu fractura simpla sau
cominutiva a peretelui posterior acetabular, fara
pierderea stabilitatii soldului
• Tip III fractura-dizlocatie cu pierderea stabilitatii
soldului consecutiv pierderii suportului structural
• Tip IV luxatie asociata cu fractura capului femural
Clasificarea AO/OTA

• 30-D10 Luxatie anterioara a soldului

• 30-D11 Luxatie posterioara a soldului
• 30-D30 Luxatie obturatorie a soldului
 EVOLUTIE SI PROGNOSTIC
• sunt mai favorabile in luxatiile simple decat
in cele asociate cu fracturi
• precocitatea reducerii amelioreaza
prognosticul (luxatii simple reduse
>24h→complicatii 66%, luxatii+ fracturi
acetabulare reduse >24h→complicatii
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 socogena±trombogena
• risc de TVP→EP grava, necesita
trombopreventia cu HGMM
•
 B. Complicatii locale imediate
• compresiunea n. obturator, n. crural
• elongarea n. sciatic
• comprimarea vaselor femurale
• ruperea a. femurale
• luxatia deschisa
• luxatia deschisa
• retentia de urina
• leziunile osoase
• tromboza venoasa masiva a regiunii bazinului si a
membrelor inferioare
• osteoartrita
 Complicatii locale tardive
• 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:
• interpunerea unui fragment din bureletul cotiloidian/ a capsului rupte/
• tendonul psoasului
• dreptul anterior
• strangularea colului femural intr-o bresa capsulara mica ce a permis luxarea, dar nu
mai pemite reducerea
posterioara:
• fragment osos
• tendonul m. piramidal, m. obturator intern
• marele fesier
• capsula
• ligamentul rotund
• lig. iliofemural
• labrum-ul
• peretele posterior
 Luxatia traumatica recenta incoercibila de sold

• capul femural se redisloca la incetarea tractiunii si a

manevrelor ortopedice
• frecvent este cauzata de o fractura acetabulara cu fragment
mare posterior (tip III Thompson si Epstein)
• exceptional – poate fi cauzata de interpunerea de capsula,
burelet glenoidian sau alte leziuni de parti moi
• necesita interventia chirurgicala pt. preventia lezarii
vaselor capsulare
• p.o. este necesara extensia continua pe atela Braun-Böhler
• unii autori – se poate temporiza interventia 10-15 zile daca
se mentine reduceea sub extensie
 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 Böhler
Metoda Allis
Metoda Stimson (Djanelidze)
Metoda tractiunii laterale
Metoda „umarului” (Marya si Samuel/Enhalt)
Metoda East Baltimore lift
Tehnica Nordt (1999)
Metoda Spitalului de Urgenta”Floreasca”
 Reducerea luxatiilor atipice
• Se transforma in luxatii posterioare prin
miscari de circumductie apoi se reduc dupa
tehnica cunoscuta
• Extensie continua 3-4 zile dupa care se face
reducerea
Verificarea stabilitatii reducerii
• Soldul este flectat la 90o
• Daca soldul ramane stabil, se aplica RI,
ADD, si compresiune spre posterior
• In functie de gradul de flexie, ADD si RI se
apreciaza stabilitatea postreductionala
• !!! Fracturile de perete posterior cotiloidian
fac dificila aprecierea stabilitatii
 Luxatia veche traumatica de sold
• frecvent datorita nerecunoasterii ei la politraumatizati
( luxatii atipice)
• devin ireductibile intr-un interval de timp cateva
saptamani-2 luni
• necesita extensie continua cu 10-15 kg/ 10-15 zile – pt
coborarea capului femural si prevenirea elongarii n. sciatic/
a vaselor femurale in momentul reducerii + reducere
sangeranda
• dupa 3 luni, cartilajul articular este compromis→protezare
Indicatia de reducere sangeranda

• luxatie ireductibila
• leziunea iatrogenica a n. sciatic
• reducere incoercibila cu fragmente
incarcerate/ interpozitie de parti moi
• reducere incoercibila cu fractura tip I Pipkin
• fractura de femur controlateral
 Anterior Smith-Petersen/ Hardinge
Anterolateral Watson-Jones

• permite vizualizarea si extragerea tesutului

interpus
• plasarea unui cui Schanz in regiunea
interetrohanteriana permite mobilizare
extremitatii femurale superioare
• este indicata repararea capsului fara disectia
de amploare
 Posterior Kocher-Langenbeck

• permite vizualizarea si extragerea tesutului

interpus
• permite repararea peretelui posterior
acetabular
 Type of Posterior Dislocation
depends on:

Direction of applied force.

Position of hip.

Strength of patient’s bone.

 Physical Examination: Classical
Appearance

Posterior Dislocation: Hip flexed, internally

rotated, adducted.
 Physical Examination: Classical
Appearance

Anterior Dislocation: Extreme external rotation,

less-pronounced abduction
and flexion.
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!
 Radiographs: AP Pelvis X-Ray

• In primary survey of ATLS Protocol.

• Should allow diagnosis and show direction of dislocation.
– Femoral head not centered in acetabulum.
– Femoral head appears larger (anterior) or smaller (posterior).
• Usually provides enough information to proceed with closed
reduction.
 Reasons to Obtain More
X-Rays Before Hip Reduction
• View of femoral neck inadequate to rule out
fracture.

• Patient requires CT scan of abdomen/pelvis for

hemodynamic instability
– and additional time to obtain 2-3 mm cuts through
acetabulum + femoral head/neck would be minimal.
X-rays after Hip Reduction:

• AP pelvis, Lateral Hip x-ray.

• Judet views of pelvis.
• CT scan with 2-3 mm cuts.
 CT Scan
Most helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.
 MRI Scan

• Will reveal labral tear and soft-tissue

anatomy.
• Has not been shown to be of benefit in acute
evaluation and treatment of hip dislocations.
 Clinical Management:
Emergent Treatment

• Dislocated hip is an emergency.

• Goal is to reduce risk of AVN and DJD.

• Evaluation and treatment must be streamlined.

 Emergent Reduction
• 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).
 Anesthesia

• 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, create muscle
spasm, and make subsequent attempts at reduction
more difficult.
 General Anesthesia if:
• Patient is to be intubated emergently in
Emergency Room.
• Patient is being transported to Operating
Room for emergent head, abdominal or
chest surgery.
• Take advantage of opportunity.
 Reduction Maneuvers
Allis: Patient supine.
Requires at least two people.

Stimson: Patient prone, hip flexed and

leg off stretcher.
Requires one person.
Impractical in trauma (i.e. most
patients).
 Allis Maneuver
• Assistant: Stabilizes pelvis
• Posterior-directed force on both ASIS’s
• Surgeon: Stands on stretcher
• Gently flexes hip to 900
• Applies progressively increasing traction to
the extremity
• Applies adduction with internal rotation
• Reduction can often be seen and felt
 Reduced Hip

• Moves more freely

• Patient more comfortable

• Requires testing of stability

• Simply flexing hip to 900 does not
sufficiently test stability
 Stability Test
o
1. Hip flexed to 90
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.

Surgical approach from side of dislocation.

 Hip Dislocation:
Nonoperative Treatment

• If hip stable after reduction, and reduction congruent.

• Maintain patient comfort.
• ROM precautions (No Adduction, Internal Rotation).
o
• No flexion > 60 .
• Early mobilization.
• Touch down weight-bearing for 4-6 weeks.
• Repeat x-rays before allowing weight-bearing.
 Hip Dislocation:
Indications for Operative Treatment

1. Irreducible hip dislocation

2. Hip dislocation with femoral neck fracture
3. Incarcerated fragment in joint
4. Incongruent reduction
5. Unstable hip after reduction
1. Irreducible Hip Dislocation: Anterior

Smith-Peterson approach
• Watson-Jones is an alternate approach
1. Allows visualization and retraction of interposed
tissue.
2. Placement of Schanz pin in intertrochanteric
region of femur will assist in manipulation of the
proximal femur.
3. Repair capsule, if this can be accomplished
without further dissection.
1. Irreducible Hip Dislocation: Posterior

1. Kocher-Langenbeck approach.

1.Remove interposed tissue, or

release buttonhole.

1.Repair posterior wall of acetabulum if

fractured and amenable to fixation.
 Irreducible Posterior Dislocation
with Large Femoral Head Fracture

Fortunately, these are rare.

Difficult to fix femoral head fracture from

posterior approach without transecting
ligamentum teres.
 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.

Best option not known: Damage to blood supply

from anterior capsulotomy vs. damage to blood supply
from transecting ligamentum teres.

These will be discussed in detail in femoral head

fracture section.
 2. Hip Dislocation with Femoral
Neck Fracture

Attempts at closed reduction potentiate chance of fracture

displacement with consequent increased risk of AVN.
If femoral neck fracture is already displaced, then the
ability to reduce the head by closed means is markedly
compromised.
Thus, closed reduction should not be attempted.
 2. Hip Dislocation with Femoral
Neck Fracture
Usually the dislocation is posterior.
Thus, Kocher-Langenbeck approach.
If fracture is non-displaced, stabilize fracture
with parallel lag screws first.
If fracture is displaced, open reduction of
femoral head into acetabulum, reduction of
femoral neck fracture, and stabilization of
femoral neck fracture.
 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,
 4. Incongruent Reduction

From:
• Acetabulum Fracture (weight-bearing
portion).
• Femoral Head Fracture (any portion).
• Interposed tissue.

Goal: achieve congruence by removing interposed

tissue and/or reducing and stabilizing fracture.
 5. Unstable Hip after Reduction
• Due to posterior wall and/or femoral head fracture.
• Requires reduction and stabilization fracture.

• Labral detachment or tear

– Highly uncommon cause of instability.
– Its presence in the unstable hip would justify surgical repair.
– MRI may be helpful in establishing diagnosis.
 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.
Complications of Hip Dislocation
• Avascular Necrosis (AVN): 1-20%

– Several authors have shown a positive

correlation between duration of dislocation and
rate of AVN.

– Results are best if hip reduced within six hours.

 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).
Recurrent Dislocation Caused by
Defect in Posterior Wall and/or Femoral
Head

Can occur after excision of fractured fragment.

Pelvic or intertrochanteric osteotomy could alter the
alignment of the hip to improve stability.
Bony block could also provide stability.
Delayed Diagnosis of Hip Dislocation

Increased incidence in multiple trauma patients.

Higher if patient has altered sensorium.
Results in: more difficult closed reduction.
higher incidence of AVN.

In NO Case should a hip dislocation be treated

without reduction.
 Sciatic Nerve Injury
Occurs in up to 20% of patients with hip
dislocation.

Nerve stretched, compressed or transected.

With reduction: 40% complete resolution

25-35% partial resolution
 Sciatic Nerve Palsy:
If No Improvement after 3–4 Weeks
EMG and Nerve Conduction Studies for
baseline information and for prognosis.

Allows localization of injury in the event that

surgery is required.
 Foot Drop

Splinting (i.e. ankle-foot-orthosis):

• Improves gait
• Prevents contracture
 Infection

Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches
 Infection: Treatment Principles

Maintenance of joint stability.

Debridement of devitalized tissue.
Intravenous antibiotics.
Hardware removed only when fracture healed.
 Iatrogenic Sciatic Nerve Injury

Most common with posterior approach to hip.

Results from prolonged retraction on nerve.

 Iatrogenic Sciatic Nerve Injury
Prevention:
Maintain hip in full extension
Maintain knee in flexion
Avoid retractors in lesser sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)
 Thromboembolism
Hip dislocation = high risk patient.

Prophylactic treatment with:

• low molecular weight heparin, or
• coumadin

Early postoperative mobilization.

Discontinue prophylaxis after 2-6 weeks (if

patient mobile).
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