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Traumatic anterior dislocation of the hip in childhood
Injury, 13.435-440
435
Printed in Great Britain
Traumatic childhood*
anterior
dislocation
of the hip in
Antonio Barquet lnsiituie
and Department
ofOrthopaadics
and Traumatology, Montevideo, Uruguay
Summary
hundred and eleven traumatic anterior dislocations of the hip in children were collected from the literature and statistically evaluated together with 4 cases treated at our institute. The incidence of open One
dislocations, associated lesions (avulsion of,the greater trochanter, damage to the femoral vessels, and fracture of the shaft of the ipsilateral femur), and irreducible recent dislocations was noteworthy, demanding special methods of primary management. In 41 patients, with follow-up averaging 5 years, the incidence of complications, especially avascular necrosis, was also high. Anterior dislocation of the hip in this age group is to be considered a serious injury. Concerning the fmal state of the hip-joint, factors giving a poor prognosis appear to be severe injury, open dislocation, associated fractures near the joint, delayed reduction, and, possibly, open procedures. INTRODUCTION TRAUMATIC anterior dislocation of the hip under 16 years of age is extremely infrequent. Most
previous studies have either been isolated case reports or have included anterior together with posterior dislocations. Few articles have been devoted to discussion of this injury in children (Litton and Workman, 1958; Bonnemaison and Henderson, 1968), and as far as we could determine no detailed study of a large series of cases has been published. In a previous paper on traumatic hip dislocation in this age group, 2 anterior dislocations were included (Barque& 1979). Since then 2 further cases of this variety were treated at our *This article is dedicated to Professor Dr Oscar Guglielmone, who retired from the Department of Orthopaedics and Traumatology at Montevideo at the endofl98l.
Fig. I. Obturator dislocation of right hip in a 7-yearold girl injured while falling from a tree. Closed reduction was achieved I2 hours later and a spica cast applied for 4 weeks. One year later she is free from
symptoms and X-rays are normal. institute (Figs. 1 and 2). Subsequently it was decided to study this rare injury in detail. Undoubtedly 4 cases were too few for this purpose. After a thorough review of the world literature 111 additional cases were collected, these were accurately documented and thus useful for statistical evaluation. STATISTICAL Patients
EVALUATION
The number of collected traumatic anterior dislocations of the hip in children, including my own series, totals 115 (Table I). The ages at the time of the dislocation were known in 87 patients and ranged between 6 months and 15 years, with a mean of 10 years.
436
ln~ury the British Journal of Accident
Surgery Vol 1 ~/NO. 5
The variety of dislocation was known in 80 patients. Dislocations were obturator in 67.9 per cent of cases; pubic in 13.5 per cent; supraacetabular in 6.1 per cent; suprapubic in 4.9 per cent; pre-acetabular in 3.7 per cent; and scrotal, perineal and intrapelvic in one case each. The information concerning the type of dislocation is provided in 85 patients. The dislocation was not associated with fractures of the acetabulum, femoral head, femoral neck or trochanter, in 87 per cent of the cases. In 3.5 per cent of cases there was a fracture of the acetabular rim; there was a fracture of the femoral neck in 1.2 per cent; and in the remaining 8.3 per cent there was associated avulsion of the greater trochanter. Open dislocation occurred in 3.5 per cent of the whole series. An associated fracture of the shaft of the ipsilateral femur occurred in 8.7 per cent. There was damage to the femoral vessels in 8 cases (7 per cent), including vascular compression in 6, compression of the artery and laceration of the vein in 1, and section of artery and vein in another. The vascular damage occurred in pubic, suprapubic and pre-acetabular dislocations. Another associated lesion was contusion of the femoral nerve, which occurred in a pubic and in a suprapubic dislocation. Treatment b
Fig. 2. n and b, Frontal and alar radiological views of a supracotyloid anterior dislocation with associated fracture of the acetabular rim in an 8-year-old boy, injured in a traffic accident. Six hours later the dislocation was reduced by closed manoeuvres and proved to be stable. Skin traction was provided for 4 weeks, followed by weight bearing. Three months later clinical and radiological examination disclosed no abnormalities.
Three were aged between 6 months and 3 years. Most patients were equally distributed in the other 4-year periods between 4 and I5 years. The sex was known in 88 patients: boys were affected four times as often as girls. As in a previous paper, injuries were grouped into slight, such as falls on the same level; moderate, such as athletic injuries; and severe (Barquet, 1979). This series, investigated from the standpoint of severity of injury, provided enough information in 75 patients. The force had been slight in 8.5 per cent, moderate in 34.6 per cent, and severe in 56.9 per cent.
The time between injury and treatment of the dislocation is known in 73 of the 115 patients. In 52 patients the interval was less than 24 hours. Among these patients, the dislocation was not associated with fracture of the femoral shaft in 36: closed reduction was achieved in 35 cases, but in 1 patient manipulation was ineffective because of a buttonhole tear of the capsule and interposition of psoas and rectus femoris. In 3 patients with associated minor fractures of the acetabulum, closed reduction was achieved in 2; in the other case reduction was blocked by a fragment of bone and cartilage. There were 6 recent dislocations with associated avulsion of the greater trochanter: closed reduction of the dislocation was achieved in 4 cases, but in 1 patient interposition of fascia lata and the external rotators led to open reduction. The other case was primarily reduced by open procedures. In 3 cases. the avulsed trochanteric fragment fell back in its place when the dislocation was reduced, and was not internally fixed: open reduction was used for 2 cases of fracture of the greater trochanter; one was
437
Elarquet:Dislocation of the Hip Table/. Pertinent data of 1 15 collected cases of traumatic anterior dislocation of the hip in childhood Author
Year
Cases
Author
Year
Cases
Bloxham Vetu Ormerod Dupuis Sedillot Cooke Powdrell Birkett Lawrence Hamilton Berendes Schomann Pinault Kummer Liber Mouczy Rosenberg Endlich Bajardi Perrando Borchard Seiderer Streissler Weil Froelich Higgins Pietrzikowski Princeteau Campbell Maffei Watkins Harris Glynn Goetz Cuche Rocher et al. Pfab Banks Paus
1833 1836 1847 1855 1861 1864 1868 1869 1877 1884 1886 1889 1890 1891 1891 1896 1897 1898 1900 1900 1902 1904 1908 1910 1911 1920 1921 1921 1922 1922 1923 1924 1932 1934 1937 1937 1938 1941 1951
1 1 1 1 2 1 1 1 1 3 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 1
Grobelski Hamada Economu et al. Litton et al. Rampoldi et al. Emmola et al. Morton Tronzo Funk Ulloa Koszla Liuboshits Fernandez Titze Giglio et al. Byram et al Bonnemaison et al. Chavatte Pennsylvania Orthopaedic Society Rigault et al. Fina et al. Boitzy Pizio Laskowski et al. Pearson et al. Bijlsma Rowe Schwartz et al. M’Bamali Nerubay Rinke et al. Johner et al. Kanan et al Barquet Klasen Epstein Cases reported here
1957 1957 1958 1958 1958 1959 1959 1961 1962 1962 1963 1964 1965 1965 1966 1967 1968 1968
1 2 1 1 1 1 1 1 3 1 1 5 1 1 1 1 1 1
1968 1968 1970 1971 1971 1973 1973 1974 1974 1974 1975 1976 1976 1977 1978 1979 1979 1980
8 1 1 1 2 1 4 1 1 1 1 1 1 1 2 2 2 8 2
with chromic catgut and and the other fixed with a cerclage wire. There were also 7 dislocations with associated fractures of the femoral shaft in which initial attempts at closed reduction were performed: the dislocation was reduced by closed manipulation in 5 patients, but I needed open reduction. In 5 patients open reduction was performed within the first 24 hours, without previous attempts at closed reduction. Included in this group there were 3 open dislocations, in which reduction followed surgical cleansing of the wound. One of these had an associated shaft fracture of the same femur. Another case consutured
sisted of a dislocation with associated fracture of the femoral neck: this patient was operated on, the dislocation was first reduced and then the fracture was reduced and fixed with pins. The last case, with damage to the femoral vessels. also underwent initial open reduction of the dislocation. In the 6 patients with compression of the femoral vessels, primary closed reduction of the dislocation produced immediate regression of the distal ischaemia in 5 patients; in the sixth case the vessels were initially explored, the artery being stripped of its adventitia and bathed with procaine solution. There was 1 case which
438
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
underwent open reduction because of soft-tissue interposition: the pulses returned to normal when the deformity was corrected, but there was also a laceration of the vein, which was ligated. The patient with section of artery and vein, with an open dislocation, was initially treated by open reduction of the dislocation and end-toend anastomosis. In 17 patients the period before treatment was over 24 hours. In 6 of these patients, the delay ranged from 4 days to 3 weeks, with a mean of 6 days, after which closed reduction was achieved, even in 1 patient with fracture of the shaft of the same femur. In 1 patient attempts at closed reduction on the eighth day failed: 17 days later open reduction was performed and a buttonhole tear of the psoas was found. In another patient with an associated fracture of the femoral shaft, the dislocation went unrecognized for 6 months: the dislocation was reduced by Jones’ well-leg traction combined with adductor tenotomy. In 5 further patients open reduction was performed between 6 weeks and 2 years after the injury. There remain 4 old dislocations: in 3 cases osteotomy at the trochanteric level was performed to correct the deformity and to improve the gait; in the other patient a total hip prosthesis was the chosen procedure.
weeks, weight bearing being avoided for 4 months. He also developed avascular necrosis. Arthrosis occurred within 10 years in 4 patients who had developed avascular necrosis. This degenerative joint disease was moderate in 1 case, and severe in the other 3, and each patient was between 10 and 15 years old.
Complications
Forty-one patients have been followed for 4 months to 30 years, with an average of 5 years and in these, complications were found in 9. Avascular necrosis of the head of the femur occurred in 9 patients. This complication may not be diagnosed until 18 or 24 months after the injury (Barquet. 1979). In this series, only 29 patients have been followed up for 2 years or more, including 7 of the 9 cases with avascular necrosis. Although it is rather difficult to establish definite conclusions about the incidence of avascular necrosis in traumatic anterior hip dislocations in children, it must be appreciable, even in fresh dislocations. Analysis of the provided information also seems to show that severe injury, open dislocation, associated fractures near the joint, delayed reduction and possibly open reduction, may be factors in the development of avascular necrosis following traumatic anterior dislocation of the hip in children. Myositis ossificans occurred in one case. which needed open reduction because of soft tissue interposition. In this patient there had been several ineffective closed attempts, and after reduction he remained in plaster for 6
RESULTS
Fourteen patients in this series have been followed to skeletal maturity, and their final result is known. At final evaluation, the state of the hip was designated either normal or abnormal. A hip was judged abnormal if there was pain in the joint, reduced motion, shortening of the limb, or limp, or if there was any X-ray abnormality (Pennsylvania Orthopaedic Society, 1968). Results were normal in 10 cases and abnormal in 4. These abnormal results corresponded with X-ray films of degenerative joint disease following avascular necrosis. DISCUSSION
Traumatic anterior dislocation of the hip is an uncommon injury: in a series of 755 traumatic hip dislocations in adults, Epstein (1980) found 11 per cent of anterior dislocations. Similar findings have been presented by Niloff and Petrie (1950) Stewart and Milford (1954) and Lehtonen (1968). A proportionately higher incidence of anterior dislocation in children than in adults has been considered a special feature of traumatic hip dislocation (Giraud, 1927; Barcat and Testas, 1958). However, Brug and Ziegelmuller (1974) reported an incidence of 10 per cent of anterior dislocations after reviewing 42 1 cases of previously published traumatic hip dislocation in children. In addition, in 923 such injuries collected from the world literature we found the frequency of anterior dislocation to be 12 per cent. Therefore it can be stated that the incidence of traumatic anterior hip dislocation as compared to posterior dislocation shows no difference between children and adults. It has also been considered that the frequency of obturator dislocation is proportionately higher in children than in adults (Chavatte, 1968; Fischer et al., 1971). From present data it seems that this topographical variety has a higher incidence than the other anterior dislocations in children. However, if compared with the recorded series of traumatic anterior hip dislocations in adults (Stewart and Milford, 1954; Lehtonen, 1968; Epstein, 1980), no difference can be found between adults and children in the frequency of obturator dislocations.
Barquet: Dislocation of the Hip
439
Traumatic hip dislocation in children may diagnosis of the vascular condition (Schwartz result from slight force, especially in the younger and Haller, 1974). group, and this obviously applies to anterior Although an associated fracture of the shaft of dislocations. However, if compared with prethe same femur is considered extremely rare, viously published series, mostly dealing with this series suggests that it occurs in 8.7 per cent. posterior dislocations (Glass and Powell, 196 1; This combination of injuries must be feared Funk, 1962; Barquet, 1979; Epstein, 1980) this because the risk of missing a dislocation is very series suggests that the proportion of traumatic high (Helal and Skevis, 1967; Schoenecker et al., hip dislocation in children occurring after slight 1978). force is higher in posterior than in anterior Although closed manoeuvres are usually dislocations. effective in reducing fresh dislocation, interConcerning the mechanism of injury, we position of soft tissues and osteocartilaginous endorse the opinion of Niloff and Petrie (1950) loose bodies may be responsible for their failure. Bado (personal communication, 1967) and This condition can be definitely diagnosed by Epstein (1980) who consider that the factors radiography (Barquet, 1980) and is an absolute producing an anterior dislocation are forcible indication for open reduction. Another indication for open procedures is dislocation with external rotation and abduction. External rotation tends to propel the femoral head fractured neck of the femur: treatment will forward through the capsule, while as a result of include reduction of the dislocation and also reduction and internal fixation of the fracture abduction the femoral neck impinges upon the acetabular rim and consequently the head is with pins or screws. Most fresh dislocations levered out of its socket through the anterior with associated fracture of the shaft of the femur in this collected series have been reduced by capsule. A number of fresh anterior dislocations in children, which have had to be openly closed procedures: however, it must be borne in reduced because of soft-tissue interposition, mind that the fracture may render manipulation provide information confirming that the head of ineffective, thus demanding some form of skeletal traction applied to the proximal fragthe femur does dislocate through the anterior ment of the femur, either by closed methods or part of the capsule (Bonnemaison and Henderson, 1968; Nerubay, 1976). by exposing the proximal fragment without Fracture-dislocation of the hip in children is opening the hip. If those measures fail open extremely rare (Glass and Powell, 196 1; Piggot, reduction of the dislocation is to be performed in these cases. An avulsed trochanter may fall back 196 1; Schlonsky and Miller, 1973). Most previous papers discussing this injury have referred in its place when the dislocation is reduced. to associated fractures of the acetabulum. HowHowever, this is not the rule, and open proever, we feel that a factor which should be cedures are indicated if reduction is to be emphasized is the not infrequent occurrence of achieved or whenever stable fixation of the fracan associated avulsion of the greater trochanter, ture is demanded. Associated damage to the femoral vessels may require special measures. In as found in this series. This combined lesion may be explained as a result of driving the vascular compression, conservative managetrochanter against the acetabular rim, it may be ment after primary closed reduction of the dislocation has been effective in most cases. detached as the head and neck move forward Whenever the circulation has not improved after and inward while the dislocation occurs. An open anterior dislocation, though exhip-joint reduction, early exploration of the vessels is an absolute indication. If vascular tremely infrequent, may occur considering that damage is diagnosed, immediate operation and when the trochanter impinges upon the appropriate treatment of the vessels is manacetabular rim. datory. An open dislocation demands primary Another factor, not observed in posterior dislocations, is damage to the femoral vessels, wound excision before reduction. Nevertheless, especially in pubic and suprapubic cases. This this is a serious condition, with a poor prognosis. associated lesion usually consists of vascular With associated injury of the femoral nerve, the compression between the femoral head and standard initial management should still be the inguinal ligament (Bonnemaison and followed. Certain technical details dealing with reducHenderson, 1968). In addition, a few cases of tion procedures emerge from this review. The section or laceration of one or both major vessels have been reported. Therefore arterimethod of Allis (1896) is extremely useful in achieving closed reduction. The patient is ography is very helpful in making an accurate
440
Injury:
placed on the floor, the pelvis is held down by an assistant with the thigh and the leg flexed at right angles and then traction is applied to the thigh. While traction is maintained, the thigh is gently adducted and internally rotated to bring the head over the rim and into the acetabulum. When open procedures are necessary in anterior dislocations, an anterior approach must be used. The incidence of avascular necrosis after anterior dislocations has been considered low compared with posterior cases (Litton and Workman, 1958; Cros, 1959; Lehtonen, 1968). Because the main vessels supplying the head run in the posterior capsule, it has been argued that these could remain without damage in anterior dislocations. However, in this large series of anterior dislocations, avascular necrosis occurred as often as in posterior cases. This may be explained by realizing that when the head dislocates forwards, the vessels are elongated and torn as well, the distance between the posterior capsule and head is considerably increased. Delayed reduction seems to favour avascular necrosis: therefore, traumatic hip dislocation is to be considered an emergency, and reduction carried out immediately. The incidence of deformities after avascular necrosis is high; consequentIy arthrosis frequently develops, especially in older children. As stated in several previous reports, postreduction treatment did not seem to influence results in simple dislocations in this series. Therefore, immobilization should be advised during the soft-tissue healing period only, and weight bearing permitted after 4 to 6 weeks. In fracture-dislocations, the management following reduction should depend on the fracture’s type and the primary treatment given.
Barquet A. (1979) Traumatic hip dislocations in childhood. Acta Orlhop. &and. 50,549. Barquet A. (I 980) Luxations irreductibles de la hanche chez I’enfant. Lyon Chir. 76,329. Bonnemaison F. and Henderson D. (I 968) Traumatic
Acknowledgements
The author would like to thank Miss R. Zabala and Miss J. Thoeni for secretarial help, and Mr A. Corder0 for the photographs.
the British
Journal
of Acadent
Surgery
Vol.
1 ~/NO.
5
anterior dislocation of the hip with acute common femoral occlusion in a child. J. Bone Joint Suez. 50A, 753. Brug E. and Ziegelmuller F. (I 974) Die traumatischen Huftgelenksluxation im Kindesalter. Meunch. Med Wschr. 116,3 15.
Chavatte J. (1968) Luxations Traumatiques de la Hanche chez I’Enfant. These Lyon. Cros A. (I 959) Osteochondrosis of the upper femoral epiphysis following traumatic dislocation of the hip joint. J. Bone Joint Surg. 41A, 1335. Epstein H. (1980) Traumatic Dislocation ofthe HiD. ‘Baltimore, Williams and Wilkins. Fischer L.. Venouil J.. Baulieux J. et al. (197 I) Luxations traumatiques de la hanche chez I’Enfant. Cah. M&d. Lyon. 47,.3325.
Funk F. (1962) Traumatic dislocation of the hip in children. J. Bone Joint Surg. 44A, I 135. Giraud D. (1927) Contribution a I’Etude de la Luxation Traumatiaue de la Hanche chez I’Enfant. These Bordeaux. . Glass A. and Powell H. (I 96 I ) Traumatic dislocation of the hio in children. J. Bone Joint Sura. 43B. 29. Helal B. and Skevis X. (1967) Unrecognised dislocation of the hip in fractures of the femoral shaft. J. Bone Joint Surg. 49B, 293.
Lehtonen R. (I 968) A study of traumatic dislocation of the hip joint and fractures of the acetabulum. ilnn. Chir. Gynaecol. Fenn. 57 Suppl. 163. Litton L. and Workman C. (I 958) Traumatic anterior dislocation of the hip in children. J. Bone .Joinr Surg. 40A, 14 19.
Nerubay J. (1976) Traumatic anterior dislocation of hip joint with vascular damage. Clin. Orthop. 116, 129.
Niloff P. and Petrie J. (1950) Traumatic anterior dislocation ofthe hip. Can. Med. Assoc. J. 62,574. Pennsylvania Orthopaedic Society (1968) Traumatic dislocation of the hio in children. J. Bone Joint Surg. 50A, 79.
.
Barcat J. and Testas P. (I 958) A propos des luxations traumatiques recentes de la hanche chez I’enfant. Mem. Acad. Chir. 84,659.
Piggot J. (1961) Traumatic dislocation of the hip in children. J. Bone Joint Surp. 43B. 38. Schlonsky J. and Miller P.’ (1973) Traumatic hip dislocation in children. J. Bone Joint Surg, 55A, 1057. Schoenecker P., Manske P. and Sertl G. (1978) Traumatic hip dislocation with femoral shaft fractures. Clin. Orthop. 130,233. Schwartz D. and Haller J. (1974) Open anterior hip dislocation with femoral vessel transection in a child. J. Trauma 14, 1054. Stewart M. and Milford L. (I 954) Fracture-dislocation ofthe hip joint. J. Bone Joim Surg. 36A, 3 15.
Rrqucstrlbr reprfnt\ \houldhe addwred IO:Dr
Avda.
REFERENCES
0. (I 896) An Inquiry info the D@cuDies Encountered in the Reduction of Dislocation of the Hip. Philadelphia? Doran.
Allis
Antonno
Barque.
Joaquin
Sukz
3 132. Montewdeo.
Uruguay.
435
Printed in Great Britain
Traumatic childhood*
anterior
dislocation
of the hip in
Antonio Barquet lnsiituie
and Department
ofOrthopaadics
and Traumatology, Montevideo, Uruguay
Summary
hundred and eleven traumatic anterior dislocations of the hip in children were collected from the literature and statistically evaluated together with 4 cases treated at our institute. The incidence of open One
dislocations, associated lesions (avulsion of,the greater trochanter, damage to the femoral vessels, and fracture of the shaft of the ipsilateral femur), and irreducible recent dislocations was noteworthy, demanding special methods of primary management. In 41 patients, with follow-up averaging 5 years, the incidence of complications, especially avascular necrosis, was also high. Anterior dislocation of the hip in this age group is to be considered a serious injury. Concerning the fmal state of the hip-joint, factors giving a poor prognosis appear to be severe injury, open dislocation, associated fractures near the joint, delayed reduction, and, possibly, open procedures. INTRODUCTION TRAUMATIC anterior dislocation of the hip under 16 years of age is extremely infrequent. Most
previous studies have either been isolated case reports or have included anterior together with posterior dislocations. Few articles have been devoted to discussion of this injury in children (Litton and Workman, 1958; Bonnemaison and Henderson, 1968), and as far as we could determine no detailed study of a large series of cases has been published. In a previous paper on traumatic hip dislocation in this age group, 2 anterior dislocations were included (Barque& 1979). Since then 2 further cases of this variety were treated at our *This article is dedicated to Professor Dr Oscar Guglielmone, who retired from the Department of Orthopaedics and Traumatology at Montevideo at the endofl98l.
Fig. I. Obturator dislocation of right hip in a 7-yearold girl injured while falling from a tree. Closed reduction was achieved I2 hours later and a spica cast applied for 4 weeks. One year later she is free from
symptoms and X-rays are normal. institute (Figs. 1 and 2). Subsequently it was decided to study this rare injury in detail. Undoubtedly 4 cases were too few for this purpose. After a thorough review of the world literature 111 additional cases were collected, these were accurately documented and thus useful for statistical evaluation. STATISTICAL Patients
EVALUATION
The number of collected traumatic anterior dislocations of the hip in children, including my own series, totals 115 (Table I). The ages at the time of the dislocation were known in 87 patients and ranged between 6 months and 15 years, with a mean of 10 years.
436
ln~ury the British Journal of Accident
Surgery Vol 1 ~/NO. 5
The variety of dislocation was known in 80 patients. Dislocations were obturator in 67.9 per cent of cases; pubic in 13.5 per cent; supraacetabular in 6.1 per cent; suprapubic in 4.9 per cent; pre-acetabular in 3.7 per cent; and scrotal, perineal and intrapelvic in one case each. The information concerning the type of dislocation is provided in 85 patients. The dislocation was not associated with fractures of the acetabulum, femoral head, femoral neck or trochanter, in 87 per cent of the cases. In 3.5 per cent of cases there was a fracture of the acetabular rim; there was a fracture of the femoral neck in 1.2 per cent; and in the remaining 8.3 per cent there was associated avulsion of the greater trochanter. Open dislocation occurred in 3.5 per cent of the whole series. An associated fracture of the shaft of the ipsilateral femur occurred in 8.7 per cent. There was damage to the femoral vessels in 8 cases (7 per cent), including vascular compression in 6, compression of the artery and laceration of the vein in 1, and section of artery and vein in another. The vascular damage occurred in pubic, suprapubic and pre-acetabular dislocations. Another associated lesion was contusion of the femoral nerve, which occurred in a pubic and in a suprapubic dislocation. Treatment b
Fig. 2. n and b, Frontal and alar radiological views of a supracotyloid anterior dislocation with associated fracture of the acetabular rim in an 8-year-old boy, injured in a traffic accident. Six hours later the dislocation was reduced by closed manoeuvres and proved to be stable. Skin traction was provided for 4 weeks, followed by weight bearing. Three months later clinical and radiological examination disclosed no abnormalities.
Three were aged between 6 months and 3 years. Most patients were equally distributed in the other 4-year periods between 4 and I5 years. The sex was known in 88 patients: boys were affected four times as often as girls. As in a previous paper, injuries were grouped into slight, such as falls on the same level; moderate, such as athletic injuries; and severe (Barquet, 1979). This series, investigated from the standpoint of severity of injury, provided enough information in 75 patients. The force had been slight in 8.5 per cent, moderate in 34.6 per cent, and severe in 56.9 per cent.
The time between injury and treatment of the dislocation is known in 73 of the 115 patients. In 52 patients the interval was less than 24 hours. Among these patients, the dislocation was not associated with fracture of the femoral shaft in 36: closed reduction was achieved in 35 cases, but in 1 patient manipulation was ineffective because of a buttonhole tear of the capsule and interposition of psoas and rectus femoris. In 3 patients with associated minor fractures of the acetabulum, closed reduction was achieved in 2; in the other case reduction was blocked by a fragment of bone and cartilage. There were 6 recent dislocations with associated avulsion of the greater trochanter: closed reduction of the dislocation was achieved in 4 cases, but in 1 patient interposition of fascia lata and the external rotators led to open reduction. The other case was primarily reduced by open procedures. In 3 cases. the avulsed trochanteric fragment fell back in its place when the dislocation was reduced, and was not internally fixed: open reduction was used for 2 cases of fracture of the greater trochanter; one was
437
Elarquet:Dislocation of the Hip Table/. Pertinent data of 1 15 collected cases of traumatic anterior dislocation of the hip in childhood Author
Year
Cases
Author
Year
Cases
Bloxham Vetu Ormerod Dupuis Sedillot Cooke Powdrell Birkett Lawrence Hamilton Berendes Schomann Pinault Kummer Liber Mouczy Rosenberg Endlich Bajardi Perrando Borchard Seiderer Streissler Weil Froelich Higgins Pietrzikowski Princeteau Campbell Maffei Watkins Harris Glynn Goetz Cuche Rocher et al. Pfab Banks Paus
1833 1836 1847 1855 1861 1864 1868 1869 1877 1884 1886 1889 1890 1891 1891 1896 1897 1898 1900 1900 1902 1904 1908 1910 1911 1920 1921 1921 1922 1922 1923 1924 1932 1934 1937 1937 1938 1941 1951
1 1 1 1 2 1 1 1 1 3 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 1
Grobelski Hamada Economu et al. Litton et al. Rampoldi et al. Emmola et al. Morton Tronzo Funk Ulloa Koszla Liuboshits Fernandez Titze Giglio et al. Byram et al Bonnemaison et al. Chavatte Pennsylvania Orthopaedic Society Rigault et al. Fina et al. Boitzy Pizio Laskowski et al. Pearson et al. Bijlsma Rowe Schwartz et al. M’Bamali Nerubay Rinke et al. Johner et al. Kanan et al Barquet Klasen Epstein Cases reported here
1957 1957 1958 1958 1958 1959 1959 1961 1962 1962 1963 1964 1965 1965 1966 1967 1968 1968
1 2 1 1 1 1 1 1 3 1 1 5 1 1 1 1 1 1
1968 1968 1970 1971 1971 1973 1973 1974 1974 1974 1975 1976 1976 1977 1978 1979 1979 1980
8 1 1 1 2 1 4 1 1 1 1 1 1 1 2 2 2 8 2
with chromic catgut and and the other fixed with a cerclage wire. There were also 7 dislocations with associated fractures of the femoral shaft in which initial attempts at closed reduction were performed: the dislocation was reduced by closed manipulation in 5 patients, but I needed open reduction. In 5 patients open reduction was performed within the first 24 hours, without previous attempts at closed reduction. Included in this group there were 3 open dislocations, in which reduction followed surgical cleansing of the wound. One of these had an associated shaft fracture of the same femur. Another case consutured
sisted of a dislocation with associated fracture of the femoral neck: this patient was operated on, the dislocation was first reduced and then the fracture was reduced and fixed with pins. The last case, with damage to the femoral vessels. also underwent initial open reduction of the dislocation. In the 6 patients with compression of the femoral vessels, primary closed reduction of the dislocation produced immediate regression of the distal ischaemia in 5 patients; in the sixth case the vessels were initially explored, the artery being stripped of its adventitia and bathed with procaine solution. There was 1 case which
438
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
underwent open reduction because of soft-tissue interposition: the pulses returned to normal when the deformity was corrected, but there was also a laceration of the vein, which was ligated. The patient with section of artery and vein, with an open dislocation, was initially treated by open reduction of the dislocation and end-toend anastomosis. In 17 patients the period before treatment was over 24 hours. In 6 of these patients, the delay ranged from 4 days to 3 weeks, with a mean of 6 days, after which closed reduction was achieved, even in 1 patient with fracture of the shaft of the same femur. In 1 patient attempts at closed reduction on the eighth day failed: 17 days later open reduction was performed and a buttonhole tear of the psoas was found. In another patient with an associated fracture of the femoral shaft, the dislocation went unrecognized for 6 months: the dislocation was reduced by Jones’ well-leg traction combined with adductor tenotomy. In 5 further patients open reduction was performed between 6 weeks and 2 years after the injury. There remain 4 old dislocations: in 3 cases osteotomy at the trochanteric level was performed to correct the deformity and to improve the gait; in the other patient a total hip prosthesis was the chosen procedure.
weeks, weight bearing being avoided for 4 months. He also developed avascular necrosis. Arthrosis occurred within 10 years in 4 patients who had developed avascular necrosis. This degenerative joint disease was moderate in 1 case, and severe in the other 3, and each patient was between 10 and 15 years old.
Complications
Forty-one patients have been followed for 4 months to 30 years, with an average of 5 years and in these, complications were found in 9. Avascular necrosis of the head of the femur occurred in 9 patients. This complication may not be diagnosed until 18 or 24 months after the injury (Barquet. 1979). In this series, only 29 patients have been followed up for 2 years or more, including 7 of the 9 cases with avascular necrosis. Although it is rather difficult to establish definite conclusions about the incidence of avascular necrosis in traumatic anterior hip dislocations in children, it must be appreciable, even in fresh dislocations. Analysis of the provided information also seems to show that severe injury, open dislocation, associated fractures near the joint, delayed reduction and possibly open reduction, may be factors in the development of avascular necrosis following traumatic anterior dislocation of the hip in children. Myositis ossificans occurred in one case. which needed open reduction because of soft tissue interposition. In this patient there had been several ineffective closed attempts, and after reduction he remained in plaster for 6
RESULTS
Fourteen patients in this series have been followed to skeletal maturity, and their final result is known. At final evaluation, the state of the hip was designated either normal or abnormal. A hip was judged abnormal if there was pain in the joint, reduced motion, shortening of the limb, or limp, or if there was any X-ray abnormality (Pennsylvania Orthopaedic Society, 1968). Results were normal in 10 cases and abnormal in 4. These abnormal results corresponded with X-ray films of degenerative joint disease following avascular necrosis. DISCUSSION
Traumatic anterior dislocation of the hip is an uncommon injury: in a series of 755 traumatic hip dislocations in adults, Epstein (1980) found 11 per cent of anterior dislocations. Similar findings have been presented by Niloff and Petrie (1950) Stewart and Milford (1954) and Lehtonen (1968). A proportionately higher incidence of anterior dislocation in children than in adults has been considered a special feature of traumatic hip dislocation (Giraud, 1927; Barcat and Testas, 1958). However, Brug and Ziegelmuller (1974) reported an incidence of 10 per cent of anterior dislocations after reviewing 42 1 cases of previously published traumatic hip dislocation in children. In addition, in 923 such injuries collected from the world literature we found the frequency of anterior dislocation to be 12 per cent. Therefore it can be stated that the incidence of traumatic anterior hip dislocation as compared to posterior dislocation shows no difference between children and adults. It has also been considered that the frequency of obturator dislocation is proportionately higher in children than in adults (Chavatte, 1968; Fischer et al., 1971). From present data it seems that this topographical variety has a higher incidence than the other anterior dislocations in children. However, if compared with the recorded series of traumatic anterior hip dislocations in adults (Stewart and Milford, 1954; Lehtonen, 1968; Epstein, 1980), no difference can be found between adults and children in the frequency of obturator dislocations.
Barquet: Dislocation of the Hip
439
Traumatic hip dislocation in children may diagnosis of the vascular condition (Schwartz result from slight force, especially in the younger and Haller, 1974). group, and this obviously applies to anterior Although an associated fracture of the shaft of dislocations. However, if compared with prethe same femur is considered extremely rare, viously published series, mostly dealing with this series suggests that it occurs in 8.7 per cent. posterior dislocations (Glass and Powell, 196 1; This combination of injuries must be feared Funk, 1962; Barquet, 1979; Epstein, 1980) this because the risk of missing a dislocation is very series suggests that the proportion of traumatic high (Helal and Skevis, 1967; Schoenecker et al., hip dislocation in children occurring after slight 1978). force is higher in posterior than in anterior Although closed manoeuvres are usually dislocations. effective in reducing fresh dislocation, interConcerning the mechanism of injury, we position of soft tissues and osteocartilaginous endorse the opinion of Niloff and Petrie (1950) loose bodies may be responsible for their failure. Bado (personal communication, 1967) and This condition can be definitely diagnosed by Epstein (1980) who consider that the factors radiography (Barquet, 1980) and is an absolute producing an anterior dislocation are forcible indication for open reduction. Another indication for open procedures is dislocation with external rotation and abduction. External rotation tends to propel the femoral head fractured neck of the femur: treatment will forward through the capsule, while as a result of include reduction of the dislocation and also reduction and internal fixation of the fracture abduction the femoral neck impinges upon the acetabular rim and consequently the head is with pins or screws. Most fresh dislocations levered out of its socket through the anterior with associated fracture of the shaft of the femur in this collected series have been reduced by capsule. A number of fresh anterior dislocations in children, which have had to be openly closed procedures: however, it must be borne in reduced because of soft-tissue interposition, mind that the fracture may render manipulation provide information confirming that the head of ineffective, thus demanding some form of skeletal traction applied to the proximal fragthe femur does dislocate through the anterior ment of the femur, either by closed methods or part of the capsule (Bonnemaison and Henderson, 1968; Nerubay, 1976). by exposing the proximal fragment without Fracture-dislocation of the hip in children is opening the hip. If those measures fail open extremely rare (Glass and Powell, 196 1; Piggot, reduction of the dislocation is to be performed in these cases. An avulsed trochanter may fall back 196 1; Schlonsky and Miller, 1973). Most previous papers discussing this injury have referred in its place when the dislocation is reduced. to associated fractures of the acetabulum. HowHowever, this is not the rule, and open proever, we feel that a factor which should be cedures are indicated if reduction is to be emphasized is the not infrequent occurrence of achieved or whenever stable fixation of the fracan associated avulsion of the greater trochanter, ture is demanded. Associated damage to the femoral vessels may require special measures. In as found in this series. This combined lesion may be explained as a result of driving the vascular compression, conservative managetrochanter against the acetabular rim, it may be ment after primary closed reduction of the dislocation has been effective in most cases. detached as the head and neck move forward Whenever the circulation has not improved after and inward while the dislocation occurs. An open anterior dislocation, though exhip-joint reduction, early exploration of the vessels is an absolute indication. If vascular tremely infrequent, may occur considering that damage is diagnosed, immediate operation and when the trochanter impinges upon the appropriate treatment of the vessels is manacetabular rim. datory. An open dislocation demands primary Another factor, not observed in posterior dislocations, is damage to the femoral vessels, wound excision before reduction. Nevertheless, especially in pubic and suprapubic cases. This this is a serious condition, with a poor prognosis. associated lesion usually consists of vascular With associated injury of the femoral nerve, the compression between the femoral head and standard initial management should still be the inguinal ligament (Bonnemaison and followed. Certain technical details dealing with reducHenderson, 1968). In addition, a few cases of tion procedures emerge from this review. The section or laceration of one or both major vessels have been reported. Therefore arterimethod of Allis (1896) is extremely useful in achieving closed reduction. The patient is ography is very helpful in making an accurate
440
Injury:
placed on the floor, the pelvis is held down by an assistant with the thigh and the leg flexed at right angles and then traction is applied to the thigh. While traction is maintained, the thigh is gently adducted and internally rotated to bring the head over the rim and into the acetabulum. When open procedures are necessary in anterior dislocations, an anterior approach must be used. The incidence of avascular necrosis after anterior dislocations has been considered low compared with posterior cases (Litton and Workman, 1958; Cros, 1959; Lehtonen, 1968). Because the main vessels supplying the head run in the posterior capsule, it has been argued that these could remain without damage in anterior dislocations. However, in this large series of anterior dislocations, avascular necrosis occurred as often as in posterior cases. This may be explained by realizing that when the head dislocates forwards, the vessels are elongated and torn as well, the distance between the posterior capsule and head is considerably increased. Delayed reduction seems to favour avascular necrosis: therefore, traumatic hip dislocation is to be considered an emergency, and reduction carried out immediately. The incidence of deformities after avascular necrosis is high; consequentIy arthrosis frequently develops, especially in older children. As stated in several previous reports, postreduction treatment did not seem to influence results in simple dislocations in this series. Therefore, immobilization should be advised during the soft-tissue healing period only, and weight bearing permitted after 4 to 6 weeks. In fracture-dislocations, the management following reduction should depend on the fracture’s type and the primary treatment given.
Barquet A. (1979) Traumatic hip dislocations in childhood. Acta Orlhop. &and. 50,549. Barquet A. (I 980) Luxations irreductibles de la hanche chez I’enfant. Lyon Chir. 76,329. Bonnemaison F. and Henderson D. (I 968) Traumatic
Acknowledgements
The author would like to thank Miss R. Zabala and Miss J. Thoeni for secretarial help, and Mr A. Corder0 for the photographs.
the British
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anterior dislocation of the hip with acute common femoral occlusion in a child. J. Bone Joint Suez. 50A, 753. Brug E. and Ziegelmuller F. (I 974) Die traumatischen Huftgelenksluxation im Kindesalter. Meunch. Med Wschr. 116,3 15.
Chavatte J. (1968) Luxations Traumatiques de la Hanche chez I’Enfant. These Lyon. Cros A. (I 959) Osteochondrosis of the upper femoral epiphysis following traumatic dislocation of the hip joint. J. Bone Joint Surg. 41A, 1335. Epstein H. (1980) Traumatic Dislocation ofthe HiD. ‘Baltimore, Williams and Wilkins. Fischer L.. Venouil J.. Baulieux J. et al. (197 I) Luxations traumatiques de la hanche chez I’Enfant. Cah. M&d. Lyon. 47,.3325.
Funk F. (1962) Traumatic dislocation of the hip in children. J. Bone Joint Surg. 44A, I 135. Giraud D. (1927) Contribution a I’Etude de la Luxation Traumatiaue de la Hanche chez I’Enfant. These Bordeaux. . Glass A. and Powell H. (I 96 I ) Traumatic dislocation of the hio in children. J. Bone Joint Sura. 43B. 29. Helal B. and Skevis X. (1967) Unrecognised dislocation of the hip in fractures of the femoral shaft. J. Bone Joint Surg. 49B, 293.
Lehtonen R. (I 968) A study of traumatic dislocation of the hip joint and fractures of the acetabulum. ilnn. Chir. Gynaecol. Fenn. 57 Suppl. 163. Litton L. and Workman C. (I 958) Traumatic anterior dislocation of the hip in children. J. Bone .Joinr Surg. 40A, 14 19.
Nerubay J. (1976) Traumatic anterior dislocation of hip joint with vascular damage. Clin. Orthop. 116, 129.
Niloff P. and Petrie J. (1950) Traumatic anterior dislocation ofthe hip. Can. Med. Assoc. J. 62,574. Pennsylvania Orthopaedic Society (1968) Traumatic dislocation of the hio in children. J. Bone Joint Surg. 50A, 79.
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Barcat J. and Testas P. (I 958) A propos des luxations traumatiques recentes de la hanche chez I’enfant. Mem. Acad. Chir. 84,659.
Piggot J. (1961) Traumatic dislocation of the hip in children. J. Bone Joint Surp. 43B. 38. Schlonsky J. and Miller P.’ (1973) Traumatic hip dislocation in children. J. Bone Joint Surg, 55A, 1057. Schoenecker P., Manske P. and Sertl G. (1978) Traumatic hip dislocation with femoral shaft fractures. Clin. Orthop. 130,233. Schwartz D. and Haller J. (1974) Open anterior hip dislocation with femoral vessel transection in a child. J. Trauma 14, 1054. Stewart M. and Milford L. (I 954) Fracture-dislocation ofthe hip joint. J. Bone Joim Surg. 36A, 3 15.
Rrqucstrlbr reprfnt\ \houldhe addwred IO:Dr
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