- See:
Posterior Frx Dislocations of the Hip
- Discussion:
- prognostic features:
- long term results are proportional to the degree of intial trauma
- this explains percentage of good results progressively decreasing from type II to type V injuries.
- reduction, either closed or open, should be performed within 12 to 24 hrs to ensure the best results.
- if
closed reduction is selected, it should be attempted only once;
- if this fails, one should proceed to an open reduction to prevent further damage to the femoral head.
- w/ type IV fractures (of the acetabular floor)
- pts w/ displaced frx of acetabular dome have uniformily poor results regardless of treatment;
- thompson / epstein classification:
-
type I:
w/ or w/o a minor fracture
- type II:
w/ large single frx of post. acetabular rim;
- type III: w/ comminution of rim of acetubulum w/ or w/o major frag;
- type IV:
w/ a fracture of the acetabular floor
- type V:
w/ a fracture of the femoral head;
- associated Injuries:
- Pre-Reduction Radiographs:
- AP of the Hip;
-
pelvic series radiographs (
AP,
inlet and outlet);
-
acetabular series radiographs (
Judet views);
- radiograph of the femur and knee;
- Management:
- attempt
closed reduction unless:
- bone fragment is noted in the acetabulum:
- it is essential to determine whether the hip is stable following reduction by stress testing;
- stress testing is especially important if
posterior wall frx is present;
- type II frx of significant size may be treated non operatively if there is no posterior hip instability;
- unstable reduction:
- hip redislocates w/ 90 deg flexion;
- frx of the femoral head prevents the reduction
- comminuted frx of acetabulum, esp.
posterior wall frx;
- Open Reduction of Posterior Fracture Dislocations:
- thompson-epstein type IV
- w/ type IV frx, primarily
closed reduction is performed, followed by careful x-ray evaluation of the associatted acetabular frx;
- decesion for open reduction of acetabular frx is similar as for
central fracture dislocations;
- one must remember that frxs communicating w/ the
greater sciatic notch have the potential to damage the superior
gluteal artery;
- life threatening
blood loss can occur once the tamponade effect of fracture is removed at the fracture reduction;
- abdominal approach of the hypogastric artery may be required;
- thompson-epstein type V - posterior fracture dislocations:
- there is an assoicatted fracture of the femoral head;
- subclassified according to Pipkin;
- subtype I: posterior dislocation of the hip w/ fracture of the femoral head cauded to the fovea centralis;
- subtype II: posterior dislocation of the hip w/ fracture of the femoral head cephalad to the fovea centralis;
- subtype III: type I or type II with assoc. frx of femoral neck
- subtype IV: type I, II, or, III w/ assoc. frx of acetabulum;
Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum.
Fractures of the femoral head.
Computed tomography evaluation of stability in posterior fracture dislocation of the hip.
Clin Orthop 1988;227:152-163.
Zych GA, Latta L, et al:
Stability of posterior fracture-dislocation of the hip.
Keith JE, Brashear HR Jr, Guilford WB: J Bone Joint Surg 1988;70A:711-714.
Reduction of posterior dislocation of the hip in the prone position.
Herwig-Kempers A.
Veraart BE.
Journal of Bone & Joint Surgery - British Volume. 75(2):328,1993 Mar.
Operative Management of Displaced Femoral Head Fractures: Case Matched Comparison of Anterior versus Posterior Approaches for Pipkin I and Pipkin II Fractures;
MF Swiontkowski, M Thorpe, JG Seiler, and ST Hansen.
J. Orthop Trauma. Vol 6. No 4. pp 437-442.
pp 1992.
Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis.
Functional outcome of patients with femoral head fractures associated with hip dislocations.
