Download - 19.Luxatia Traumatica a Soldului
-
8/10/2019 19.Luxatia Traumatica a Soldului
1/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
2/113
Definiie
Urgenta ortopedica caracterizata prin
parasirea permanenta a cotilului de catre
capului femural fractura
-
8/10/2019 19.Luxatia Traumatica a Soldului
3/113
Anatomia
articulatiei oldului
enartroza, cu grad mare de stabilitate
capul femural usor asimetric, 2/3 de sfera
conducere ligamentara
acetabulum: suprafata articulara in forma de U inversat
-
8/10/2019 19.Luxatia Traumatica a Soldului
4/113
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
i l i f l
-
8/10/2019 19.Luxatia Traumatica a Soldului
5/113
il io-femural n , a u
Bertin/Bigelow) cu 2
fascicole: -ilio-
pertrohanterianlim. E, RE,
ABD,
-ilio-pretrohantenianlim.
E, rezista la 3.5- 6 kN,
ischiofemural
pubofemural(cel mai slab)
l igamentul rotund al capului
femural
-
8/10/2019 19.Luxatia Traumatica a Soldului
6/113
musculatura: - coaptoarems.
pelvitrohanterieni scurti posteriori,fesiermijlociusi micul fesier in opozitie cu m.
abductoare si flexoare.
-
8/10/2019 19.Luxatia Traumatica a Soldului
7/113
Anteversia colului femural
70in medie la barbatii caucazieni
mai mare la sexul feminin
orientali pot avea un unghi de anteversie intre 140si
160
-
8/10/2019 19.Luxatia Traumatica a Soldului
8/113
Vascularizatia
capului femural
1. A. ligamentului rotund
din sistemul obturator
A. iliaca interna
-
8/10/2019 19.Luxatia Traumatica a Soldului
9/113
Vascularizatia
capului femural
2. Ramuri cervicale ascendente
artere cicumflexeartera femurala profunda
artera femurala comuna
artera iliaca externa
aorta
risc foarte mare de lezare in luxatia traumatica a
soldului
-
8/10/2019 19.Luxatia Traumatica a Soldului
10/113
Nervul sciatic
format din radacinile L4 - S3. trece posterior de peretele
posterior acetabular
trece inferior de m. piriformis,cu variatii
-
8/10/2019 19.Luxatia Traumatica a Soldului
11/113
FRECVENTA
5% din totalul luxatiilor
sex masculin > sex feminin,
20-45 ani, rar copii si exceptional batrani.
-
8/10/2019 19.Luxatia Traumatica a Soldului
12/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
13/113
Mecanism de producere
indirect- accidente rutiere - sindromul tabloului
de bord, accidente industriale
direct
traumatismul actioneaza asupra partiisuperioare a femurului, fortandu-l sa paraseasca
articulatia printr-o bresa capsulara
-
8/10/2019 19.Luxatia Traumatica a Soldului
14/113
F+ADD+RIdeplasarea posterioara a capului femural inFIE (85-90%) fractura sprancenei cotiloide
F+ABDluxatie anterioara (10-15%)
F+ usoara ABDluxatie 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)
-
8/10/2019 19.Luxatia Traumatica a Soldului
15/113
Leziuni asociate
leziuni ale capului si ale fetei
leziuni ale toracelui
leziuni intra-abdominale
fracturi ale extremitatilor si luxatii
-
8/10/2019 19.Luxatia Traumatica a Soldului
16/113
ANATOMIEPATOLOGICA
lig. rotund rupt/ smuls fragment osos
capulsfasie capsula + lig. inferioare (ischio-femural, 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)
-
8/10/2019 19.Luxatia Traumatica a Soldului
17/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
18/113
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 alcapului femural
-
8/10/2019 19.Luxatia Traumatica a Soldului
19/113
SIMPTOMATOLOGIE
durerivii in regiunea soldului
impotenta functionala totala a membrului inferior
la indivizii slabi - diformitatiale soldului luxat
atitudine vicioasa in raport cu forma
anatomopatologica in luxatiile tipice:
-
8/10/2019 19.Luxatia Traumatica a Soldului
20/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
21/113
LUXATIILEPOSTERO-SUPERIOARA(ILIACA)
F coapsei pe bazin (poate fi mascata de lordoza
compensatoare); E aproape completa
RImicagenunchiul 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
scurtareapoate atinge 6-7 cm
la palpare: capul femural este in FIE,
marele trohanter este ascensionat
-
8/10/2019 19.Luxatia Traumatica a Soldului
22/113
Luxatiile postero-inferioare (ischiatica) ADDimportanta a coapseicu F a genunchiuluisi RI
picior peste picior scurtarea MI luxatla flexia 900pe bazin3-5cm
la palpare capul femural se simte inapoia tuberozitatii
ischiaticeformatiune dura, mobila la mobilizarea pasiva
a genunchiului ABD,REsi Esunt imposibile, dureroase
-
8/10/2019 19.Luxatia Traumatica a Soldului
23/113
Luxatiile antero-superioare (pubiene)
MI luxat in E, ADBsi RE
la palpare: capul femural este in reg. inghinala sau
in triunghiul lui Scarpa
capul femural rupe capsula antero-superior
lig. pubo-femuralplasandu-se inaintea ramurii
orizontale a pubisului
se fixeaza sub m. ileaopsoas
intinde n. femural ADD, RI, si Fsunt imposibile
scurtareaeste de 1-2 cm
-
8/10/2019 19.Luxatia Traumatica a Soldului
24/113
Luxatiile antero-
inferioare (obturatorii)
Fexagerata, ADBsi 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
-
8/10/2019 19.Luxatia Traumatica a Soldului
25/113
Luxatiile atipice
Luxatia
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
26/113
EXPLORARIPARACLINICE
Examen radiografic Examen CT
Examen IRM
Examen scintigrafic
-
8/10/2019 19.Luxatia Traumatica a Soldului
27/113
Examen radiografic
fata si profil de bazin
incidenta alara/
obturatorie
incidenta Jutet
-
8/10/2019 19.Luxatia Traumatica a Soldului
28/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
29/113
Examen CT
sectiuni de 2-3 mm;
deceleaza fracturi de cotil/cap femural
reconstructie 3D, util in reducerile
sangerande
prezenta bulelor de gazsubluxatie
redusa spontan
-
8/10/2019 19.Luxatia Traumatica a Soldului
30/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
31/113
Examen IRM
T1NACF, corp liber intraarticular, rupturilabrale, leziuni condrale, flebita vaselor
bazinului, fracturi oculte;
T2
edemul sprancenei acetabulare, nu e
folosit curent
-
8/10/2019 19.Luxatia Traumatica a Soldului
32/113
Examen scintigrafic
permite aprecierea vitalitatii capului
femural
-
8/10/2019 19.Luxatia Traumatica a Soldului
33/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
34/113
CLASIFICARE
Clasificarea Epstein
Clasificarea Thompson si Epstein Clasificarea Pipkin
Clasificarea Levin
Clasificarea Stewart and Milfords
Clasificare AO/OTA
-
8/10/2019 19.Luxatia Traumatica a Soldului
35/113
Clasificarea Epstein
-
8/10/2019 19.Luxatia Traumatica a Soldului
36/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
37/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
38/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
39/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
40/113
Clasificarea Levin
Tip IFra 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 IVFractura acetabulara asociata ce necesita reconstructie pentru
restabilirea congruentei articulare
Tip V
Leziune asociata capului femural (fractura sau tasare)
-
8/10/2019 19.Luxatia Traumatica a Soldului
41/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
42/113
Clasificarea Stewart si Milfords
Tip I luxatie cu /fara fracturi insignifiante
acetabulare
Tip II luxatie asociata fie cu fractura simpla saucominutiva 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
-
8/10/2019 19.Luxatia Traumatica a Soldului
43/113
Clasificarea AO/OTA
30-D10 Luxatie anterioara a soldului
30-D11 Luxatie posterioara a soldului
30-D30 Luxatie obturatorie a soldului
-
8/10/2019 19.Luxatia Traumatica a Soldului
44/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
45/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
46/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
47/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
48/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
49/113
Cauzede 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
-
8/10/2019 19.Luxatia Traumatica a Soldului
50/113
Luxatia traumatica recenta incoercibila de sold
capul femural se redisloca la incetarea tractiunii si amanevrelor ortopedice
frecvent este cauzata de o fractura acetabulara cu fragment
mare posterior (tip III Thompson si Epstein)
exceptionalpoate fi cauzata de interpunerea de capsula,burelet glenoidian sau alte leziuni de parti moi
necesita interventia chirurgicalapt. preventia lezarii
vaselor capsulare
p.o. este necesara extensia continua pe atela Braun-Bhler
unii autorise poate temporiza interventia 10-15 zile daca
se mentine reduceea sub extensie
-
8/10/2019 19.Luxatia Traumatica a Soldului
51/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
52/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
53/113
MetodaBhler
-
8/10/2019 19.Luxatia Traumatica a Soldului
54/113
Metoda Allis
-
8/10/2019 19.Luxatia Traumatica a Soldului
55/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
56/113
Metoda tractiunii laterale
-
8/10/2019 19.Luxatia Traumatica a Soldului
57/113
Metoda umarului (Marya si Samuel/Enhalt)
-
8/10/2019 19.Luxatia Traumatica a Soldului
58/113
Metoda East Baltimore lift
-
8/10/2019 19.Luxatia Traumatica a Soldului
59/113
Tehnica Nordt (1999)
-
8/10/2019 19.Luxatia Traumatica a Soldului
60/113
Metoda Spitalului de UrgentaFloreasca
-
8/10/2019 19.Luxatia Traumatica a Soldului
61/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
62/113
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 cotiloidianfac dificila aprecierea stabilitatii
-
8/10/2019 19.Luxatia Traumatica a Soldului
63/113
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 zilept
coborarea capului femural si prevenirea elongarii n. sciatic/
a vaselor femurale in momentul reducerii + reducere
sangeranda dupa 3 luni, cartilajul articular este compromisprotezare
-
8/10/2019 19.Luxatia Traumatica a Soldului
64/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
65/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
66/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
67/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
68/113
Type of Posterior Dislocation
-
8/10/2019 19.Luxatia Traumatica a Soldului
69/113
Type of Posterior Dislocation
depends on:
Direction of applied force.
Position of hip.
Strength of patients bone.
Physical Examination: Classical
-
8/10/2019 19.Luxatia Traumatica a Soldului
70/113
Physical Examination: Classical
Appearance
Posterior Dislocation: Hip flexed, internally
rotated, adducted.
Physical Examination: Classical
-
8/10/2019 19.Luxatia Traumatica a Soldului
71/113
Physical Examination: Classical
Appearance
Anterior Dislocation: Extreme external rotation,
less-pronounced abduction
and flexion.
-
8/10/2019 19.Luxatia Traumatica a Soldului
72/113
Unclassical presentation
(posture) if:
femoral head or neck fracture femoral shaft fracture
obtunded patient
-
8/10/2019 19.Luxatia Traumatica a Soldului
73/113
Physical Examination
Pain to palpation of hip.
Pain with attempted motion of hip. Possible neurological impairment:
Thorough exam essential!
Radiographs: AP Pelvis X-Ray
-
8/10/2019 19.Luxatia Traumatica a Soldului
74/113
g p y
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
75/113
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 throughacetabulum + femoral head/neck would be minimal.
X-rays after Hip Reduction:
-
8/10/2019 19.Luxatia Traumatica a Soldului
76/113
X rays after Hip Reduction:
AP pelvis, Lateral Hip x-ray.
Judet views of pelvis.
CT scan with 2-3 mm cuts.
-
8/10/2019 19.Luxatia Traumatica a Soldului
77/113
MRI Scan
-
8/10/2019 19.Luxatia Traumatica a Soldului
78/113
MRI Scan
Will reveal labral tear and soft-tissueanatomy.
Has not been shown to be of benefit in acute
evaluation and treatment of hip dislocations.
-
8/10/2019 19.Luxatia Traumatica a Soldului
79/113
Clinical Management:
Emergent Treatment
Dislocated hip is an emergency.
Goal is to reduce risk of AVN and DJD.
Evaluation and treatment must be streamlined.
-
8/10/2019 19.Luxatia Traumatica a Soldului
80/113
Emergent Reduction
Allows restoration of flow through occluded or
compressed vessels.
Literature supports decreased AVN with earlierreduction.
Requires proper anesthesia.
Requires team (i.e. more than one person).
Anesthesia
-
8/10/2019 19.Luxatia Traumatica a Soldului
81/113
Anesthesia
General anesthesia with muscle relaxation facilitatesreduction, 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.
-
8/10/2019 19.Luxatia Traumatica a Soldului
82/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
83/113
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).
-
8/10/2019 19.Luxatia Traumatica a Soldului
84/113
Allis Maneuver
Assistant: Stabilizes pelvis Posterior-directed force on both ASISs
Surgeon: Stands on stretcher Gently flexes hip to 900
Applies progressively increasing traction tothe extremity
Applies adduction with internal rotation
Reduction can often be seen and felt
-
8/10/2019 19.Luxatia Traumatica a Soldului
85/113
Reduced Hip
Moves more freely
Patient more comfortable
Requires testing of stability
Simply flexing hip to 900does notsufficiently test stability
-
8/10/2019 19.Luxatia Traumatica a Soldului
86/113
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 maymake appreciation of dislocation difficult.
-
8/10/2019 19.Luxatia Traumatica a Soldului
87/113
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. withanesthesia.
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:
-
8/10/2019 19.Luxatia Traumatica a Soldului
88/113
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:
-
8/10/2019 19.Luxatia Traumatica a Soldului
89/113
p
Indications for Operative Treatment
1. Irreducible hip dislocation
2. Hip dislocation with femoral neck fracture3. Incarcerated fragment in joint
4. Incongruent reduction
5. Unstable hip after reduction
-
8/10/2019 19.Luxatia Traumatica a Soldului
90/113
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 theproximal femur.
3. Repair capsule, if this can be accomplishedwithout further dissection.
-
8/10/2019 19.Luxatia Traumatica a Soldului
91/113
Irreducible Posterior Dislocation
-
8/10/2019 19.Luxatia Traumatica a Soldului
92/113
Irreducible Posterior Dislocation
with Large Femoral Head Fracture
Fortunately, these are rare.
Difficult to fix femoral head fracture from
posterior approach without transectingligamentum teres.
Three Options
-
8/10/2019 19.Luxatia Traumatica a Soldului
93/113
ee Op o s
1. Detach femoral head from ligamentum teres,repair femoral head fracture with hip dislocated,reduce hip.
2. Close posterior wound, fix femoral head fracturefrom anterior approach (either now or later).
3. Ganz trochanteric flip osteotomy.
Best option not known: Damage to blood supplyfrom anterior capsulotomy vs. damage to blood supply
from transecting ligamentum teres.
These will be discussed in detail in femoral headfracture section.
2 Hi Di l ti ith F l
-
8/10/2019 19.Luxatia Traumatica a Soldului
94/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
95/113
2. Hip Dislocation with Femoral
Neck Fracture
Usually the dislocation is posterior.
Thus, Kocher-Langenbeck approach.
If fracture is non-displaced, stabilize fracturewith parallel lag screws first.
If fracture is displaced, open reduction of
femoral head into acetabulum, reduction offemoral neck fracture, and stabilization offemoral neck fracture.
-
8/10/2019 19.Luxatia Traumatica a Soldului
96/113
4. Incongruent Reduction
-
8/10/2019 19.Luxatia Traumatica a Soldului
97/113
g
From:
Acetabulum Fracture (weight-bearingportion).
Femoral Head Fracture (any portion).
Interposed tissue.
Goal: achieve congruence by removing interposed
tissue and/or reducing and stabilizing fracture.
-
8/10/2019 19.Luxatia Traumatica a Soldului
98/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
99/113
Results of Treatment
Large range: from normal to severe pain and degeneration.
In general, dislocations with associated femoral head oracetabulum 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 poorresults.
13/23 (61%) poor and 3/23 (13%) fair results.
McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation ofthe hip: a severe injury with a poor prognosis.J Orthop Trauma.1998.
-
8/10/2019 19.Luxatia Traumatica a Soldului
100/113
Complications of Hip Dislocation
Avascular Necrosis (AVN): 1-20%
Several authors have shown a positivecorrelation between duration of dislocation and
rate of AVN.
Results are best if hip reduced within six hours.
-
8/10/2019 19.Luxatia Traumatica a Soldului
101/113
Post-traumatic Osteoarthritis
Can occur with or without AVN.
May be unavoidable in cases with severecartilaginous injury.
Incidence increases with associated femoral heador acetabulum fractures.
Efforts to minimize osteoarthritis are best directedat achieving anatomic reduction of injury and
preventing abrasive wear between articularcarrtilage and sharp bone edges.
Recurrent Dislocation
-
8/10/2019 19.Luxatia Traumatica a Soldului
102/113
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 healingmay benefit from surgical
imbrication (rare).
Can occur from detached labrum, which wouldbenefit from repair (rare).
Recurrent Dislocation Caused by
D f t i P t i W ll d/ F l
-
8/10/2019 19.Luxatia Traumatica a Soldului
103/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
104/113
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
-
8/10/2019 19.Luxatia Traumatica a Soldului
105/113
Sciatic Nerve Injury
Occurs in up to 20% of patients with hip
dislocation.
Nerve stretched, compressed or transected.
With reduction: 40% complete resolution25-35% partial resolution
Sciatic Nerve Palsy:
-
8/10/2019 19.Luxatia Traumatica a Soldului
106/113
y
If No Improvement after 34 Weeks
EMG and Nerve Conduction Studies for
baseline information and for prognosis.
Allows localization of injury in the event that
surgery is required.
-
8/10/2019 19.Luxatia Traumatica a Soldului
107/113
Foot Drop
Splinting (i.e. ankle-foot-orthosis):
Improves gait
Prevents contracture
-
8/10/2019 19.Luxatia Traumatica a Soldului
108/113
Infection
Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches
-
8/10/2019 19.Luxatia Traumatica a Soldului
109/113
-
8/10/2019 19.Luxatia Traumatica a Soldului
110/113
Iatrogenic Sciatic Nerve Injury
Most common with posterior approach to hip.
Results from prolonged retraction on nerve.
-
8/10/2019 19.Luxatia Traumatica a Soldului
111/113
Iatrogenic Sciatic Nerve Injury
Prevention:
Maintain hip in full extension
Maintain knee in flexionAvoid retractors in lesser sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)
Thromboembolism
-
8/10/2019 19.Luxatia Traumatica a Soldului
112/113
Hip dislocation = high risk patient.
Prophylactic treatment with:
low molecular weight heparin, or
coumadin
Early postoperative mobilization.
Discontinue prophylaxis after 2-6 weeks (ifpatient 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
-
8/10/2019 19.Luxatia Traumatica a Soldului
113/113
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 locomotorDinu 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 XOrtopedie-TraumatologieDinu 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