Rev. bras. ortop. vol.49 número1

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rev bras ortop.2014;49(1):94–97

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Case

Report

Open

dislocation

of

the

hip

in

an

adult:

a

case

report

and

review

of

literature

夽

,

夽夽

Anderson

Luiz

de

Oliveira

∗

_,

_Eduardo

_Gomes

_Machado

InstitutoJundiaiensedeOrtopediaeTraumatologia,FaculdadedeMedicinadeJundiaí,Jundiaí,SP,Brazil

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Articlehistory:

Received3April2013 Accepted23April2013

Keywords:

Hip

Hipdislocation Hipfractures Openfractures

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b

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t

Openanteriorhipdislocationisarareconditionandresultsfromhigh-energytrauma.Ten casesofopenanteriordislocationhavebeendescribedintheliteraturesofar.Itsrarityisdue totheinherentstabilityofthejoint,itsdeeppositioninthepelvis,withstrongligamentsand bulkymusclesaroundthearticulation.Severalfactorsinfluencetheprognosis,suchasthe degreeofcompounding,theassociatedsofttissueinjuries,theageofthepatientand,mainly, thedelayinreduction.Themaincomplicationsare:arthrosisofthehip,withincidenceof 50%ofcases,whenassociatedwithfracturesofthefemoralhead;andosteonecrosisofthe femoralhead,withincidencebetween1.7and40%(inclosedanteriordislocation).Because oftherarityandthepotentialdisabilityofthislesion,wereportacaseina46-year-oldman, involvedinanautomobileaccident.Thehipwasreduced(anteriorsuperiordislocation) inthefirstthreehoursofthetrauma.Thepatientwaskeptnon-weightbearinguntilsixth week,withcompleteweightbearingafter10thweek.Afteroneyearfollow-up,thefunctional resultwaspoor(HarrisHipScore:52),probablybecauseoftheassociatedlabraltear,but withoutsignsofosteonecrosisofthefemoralheadinmagneticresonanceimaging.

Luxac¸ão

exposta

do

quadril

em

um

adulto:

relato

de

caso

e

revisão

da

literatura

Palavras-chave:

Quadril

Luxac¸ãodoquadril Fraturasdoquadril Fraturasexpostas

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e

s

u

m

o

Aluxaçãoanteriorexpostadoquadrilécondiçãoraraeresultadetraumadealtaenergia. Atéomomento,foramdescritosnaliteratura10casos.Suararidadedeve-seàestabilidade inerentedaarticulaçãoeàposiçãoprofundanapelve,comfortesligamentosemusculatura volumosaaoseuredor.Influenciamoprognósticodessalesãodiversosfatores,taiscomo graudecontaminação,lesõesdepartesmoles,idadedopacientee,principalmente,atrasona redução.Asprincipaiscomplicaçõessão:artrosedoquadril,comincidênciaquepodechegar a50%doscasos,quandoassociadaafraturasdacabeçafemoral;eosteonecrosedacabeça

夽

Pleasecitethisarticleas:deOliveiraAL,MachadoEG.Luxac¸ãoanteriorexpostadoquadrilemumadulto:relatodecasoerevisãoda literatura.RevBrasOrtop.2014;49:94–97.

夽夽

StudyconductedatHospitaldeCaridadeSãoVicentedePaulo,Jundiaí,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:andersonluizoliveira@hotmail.com(A.L.deOliveira).

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dofêmur,comincidênciaentre1,7%e40%(noscasosdeluxaçãoanteriorfechada).Por causadararidadeedapotencialincapacidadefuncionaldecorrentedessalesão,relatamos ocasodeumhomemde46anosvítimadeacidenteautomobilístico.Foifeitareduçãodo quadril(luxaçãodotipoanterioralta)nasprimeirastrêshoraspós-trauma.Opacientefoi mantidosemcargaatéasextasemana,comcargatotalapósa10a

semana.Apósumanode seguimento,observou-seresultadofuncionalpobre(HarrisHipScore:52),provavelmente porcausadelesãolabralassociada,porémsemsinaisnaressonâncianuclearmagnéticade osteonecrosedacabec¸afemoral.

Introduction

Thehipjointisinherentlystable,whichrequiressignificant forcetopromoteitsdislocation.1_Thus,_hip_dislocations

usu-allyresultfromhigh-energytrauma.Cranio-cerebral,thoracic and abdominal injuries are commonly associated. Skeletal injuriesoftenassociatedincludefracturesofheadorfemoral neck,femoralshaft,acetabulumandpelvis,aswellasknee, ankleandfootinjuriesandneurologicallesions.1,2

Previoushipdislocations are uncommonand constitute 12%oftraumatichipdislocations.Theseinjuriesmayoccur inaccidentsbydeceleration,inthatthevehicleoccupantis withhis(her)legsbent,abducted,andexternallyrotated dur-ingimpact,aswellasinmotorcycleaccidentsinwhichthe legsareofteninhyperabduction.Thehippositiondetermines the type ofanterior dislocation: pubic/superior typewhen thehipisextended,andobturator/lowertypewhenitisin flexion.1–3

Sofar,researchindatabases(Lilacs,Medline,SciELOand Cochrane)revealedtencasesofopenanteriorhipdislocation reportedintheliterature,4–13_six_of_them_in_children_between

fiveand11years,oneinateenageraged15years,andthree inadults.Becauseoftherarityandthepotentialincapacity resultingfromthatinjury,wedescribethiscase.

Case

report

Malepatient,46yearsold,victimofanautomobileaccident, wasejectedfromthevehicle.Hewasadmittedinourhospital aboutanhouraftertheinjury,broughtbytherescueteam.

Onexamination,thefollowingwereobserved:hewas con-sciousandhemodynamicallystable;withawoundofabout 10cmontheleftinguinalregion,crossposition,with expo-sureoftheleftfemoralhead;hipinextension,abductionand externalrotation(Fig.1);distalpulsespresentand,apparently, nosignsofneurologicalimpairmentintheaffectedlimb.

Theinitialradiographsrevealedhighanteriordislocation oflefthip(Fig.2)andfractureoftheleftclavicle;novisceral injurywasdetected.

Thepatientwassenttotheoperatingroomtwohoursafter admission.A lesionofthe proximalrectus femorismuscle wasviewed.Cleaninganddebridement ofthewoundwere made;thejointreductionwasdonebytractionandinternal rotation,withoutdifficulties.Clinicalandradiographic eval-uationrevealed astable reduction(Fig. 3).Thewoundwas

Fig.1–Appearanceofwoundattherootoftheleftthigh, exposingthefemoralhead.

closed with introduction of broad-spectrum antibiotics for 72h.Wound healingwithoutneed forfurtherdebridement occurred.

The post-reduction computed tomography (CT) demon-stratedjointcongruenceandgreattrochanterfracturewithout deviation,treatedconservatively(Fig.4).Thepatientwaskept withoutloadingforsixweeks,followedbyprogressiveload, withfullloadafter10weeks.

Afteroneyearoffollow-up,thefunctional outcomewas poor(HarrisHipScore:52points)withlimitedrangeofmotion ofthehip(flexion90◦_,_extension₂₀◦_,_abduction₂₀◦_,_adduction

10◦_, _internal _rotation ₁₀◦_, _external _rotation ₃₀◦₎ _and

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Fig.2–APradiographofthepelvisdemonstrating

anterosuperiordislocationofthelefthip,withprominence ofthelessertrochanter.

Fig.3–Postreductionradiographshowinglefthipjoint congruency.

Fig.4–PostreductionCTshowingfractureofleftgreater trochanter.

anterosuperiorportionofthelabrum,associatedwith thick-eningofthetendonoftherectusfemorismuscle(Fig.5).

Discussion

Anteriortraumatichipdislocationisarareinjury.Theinjuryis classifiedaccordingtothepositiontakenbythefemoralhead: pubic (high)andobturator(low).2 _{Biomechanical}_studies_on

cadavershaveshownthatextension,abductionandexternal rotationofthehipproducespubicdislocationwiththefemoral headpositionedinfrontofthehorizontalramusofthepubis, withpossibilityoflacerationofpectineusandiliopsoas mus-clesandofinjurytotheneurovascularbundle.Ontheother hand,flexion,abductionandexternalrotationofthehip pro-ducedislocationofobturatortype,inwhichthefemoralhead isheldagainsttheanterolateralmarginoftheobturator fora-men,causing anindentationfracture intheanterosuperior aspectofthefemoralhead,withoutinjurytotheiliofemoral ligament.1,3,14

Radiographically, the high dislocation can be confused with posterior displacement in the AP view of the pelvis, as the femoralhead islocatedabove the acetabulum.The

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observation of the lesser trochanter helps to distinguish betweenthesetwotypes.Inanterosuperiordislocation,the hipisinexternalrotationandthelessertrochanteris promi-nent;inposteriordislocation,thefemurisinternallyrotated, withthetrochanterlessprominentorobscured.3

Thereductionisaccomplishedbytractionand countertrac-tion.Inthecaseofsuperiordisplacement,thetractionisdone tillthefemoralheadisleveledwiththeacetabulum,andthen asmoothinternalrotationisapplied.1

CT isuseful in operativeplanning,required incases of concomitantfractures,irreducibledislocationorincongruent reduction.Location,sizeandnumber offreeintra-articular fragmentsareoutlined,whichallowsanaccuratepreoperative planning.1

StudiesindicatethatMRIisnotconsistentinpredictingthe occurrenceofavascularnecrosisand,therefore,in determin-ingwhethertheearlyliberationofweightisariskfactorfor femoralheadcollapse.Inreducedhips,therateof osteonecro-sisofthefemoralheadishigheraftersixhoursofinjury.So, inthesecasesit may bereasonabletodelaythe liberation oftotalweight foreightto12 weeks.In caseswith reduc-tion in the first six hours, the treatment includes a short restperiod(twoweeks),followedbyprogressivemobilization andloading.Continuouspassivemotionisdesirable,toavoid intra-articularformationofadhesionsandarthrosis.Extremes ofmotionmustbeavoidedforsixtoeightweeks,toallow capsularhealing.1

Arthrosisisoneofthemostcommoncomplications,most frequentlyin casesofposterior versus anteriordislocation. Theassociationwithfracturesofthefemoralheadcancause arthritisin50%ofpatients.1

Incasesofclosedanteriordislocation,theriskof avascu-larnecrosisvariesfrom1.7%to40%indifferentseries.1_In_the

caseofopendislocations,therewasosteonecrosisoffemoral headinfiveofninecases(ofthetencasespreviouslydescribed intheliterature,onecaseofdeathintheimmediate postop-erativeperiodwasexcluded).Ofthesefivecases,threewere associatedwithdeepinfection.4–13

Despitetheabsenceofosteonecrosisofthefemoralhead and infection, the related case evolved to a poor clinical outcome,probably because of the associated labral lesion. Therefore,thedegreeofcontamination,thedelayinreducing thelesionandtheassociatedsofttissueinjuriesarekeyfactors inthetreatmentandprognosisofopenanteriordislocations ofthehip.4,5,7,8,11,12

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.EpsteinHC,HarveyJP.Traumaticanteriordislocationofthe hip:managementandresults.JBoneJointSurgAm. 1972;54:1561–70.

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http://www.webmedcentral.com/articleview/21705[cited 28.09.11].

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12.SadhooUK,TuckerGS,MaheshwariAV,KaulA.Openanterior fracturedislocationofthehip:acasereportandreviewof literature.ArchOrthopTraumaSurg.2005;125(8):550–4.

13.SabatD,SinghD,KumarV,GuptaA.Openperinealdislocation ofhipinachild.EurJOrthopSurgTraumatol.2009;19: 277–9.