luxa ţ ia traumatic ă a ş oldului
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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
Anatomiaarticulatiei 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-ilio-pertrohanterianpertrohanterian – lim. E, RE, ABD, - ilio-pretrohantenianpretrohantenian – 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
1.1. A. ligamentului rotundA. ligamentului rotund• din sistemul obturator• A. iliaca interna
Vascularizatia capului femural
2. Ramuri cervicale ascendenteRamuri 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.
ETIOLOGIEETIOLOGIE
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-Luxatiile antero-inferioare (obturatorii)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 atipiceLuxatia Capul femural Observatii
supracotiloidiana deasupra cotilului
capsula rupta in portiunea superioara+fractura sprancenei cotiloide. fascicolul extern al lig. in „Y” este rupt
subspinoasa sub SIAI
suprapubianain partea mijlocie a arcadei femurale
perinealaplacat pe ramura ascendenta a ischionului
poate ajunge in reg. scrotala
subischiatica la nivelul spinei ischiatice
intrapelviana in micul bazinluxatie centrala/protuzie 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 ireductibilitateanterioara:• 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 ScanMost 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
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.
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).• No flexion > 60o.• 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. Kocher-Langenbeck approach.
1.Remove interposed tissue, or release buttonhole.
1.Repair posterior wall of acetabulum if fractured and amenable to fixation.
1. Irreducible Hip Dislocation: Posterior
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,
fragment is readily accessible anteriorly.
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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