19.Luxatia Traumatica a Soldului

8/10/2019 19.Luxatia Traumatica a Soldului

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Definiie

Urgenta ortopedica caracterizata prin

parasirea permanenta a cotilului de catre

capului femural fractura


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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


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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


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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


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musculatura: - coaptoarems.

pelvitrohanterieni scurti posteriori,fesiermijlociusi micul fesier in opozitie cu m.

abductoare si flexoare.


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Anteversia colului femural

70in medie la barbatii caucazieni

mai mare la sexul feminin

orientali pot avea un unghi de anteversie intre 140si

160


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Vascularizatia

capului femural

1. A. ligamentului rotund

din sistemul obturator

A. iliaca interna


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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


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Nervul sciatic

format din radacinile L4 - S3. trece posterior de peretele

posterior acetabular

trece inferior de m. piriformis,cu variatii


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FRECVENTA

5% din totalul luxatiilor

sex masculin > sex feminin,

20-45 ani, rar copii si exceptional batrani.


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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


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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)


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Leziuni asociate

leziuni ale capului si ale fetei

leziuni ale toracelui

leziuni intra-abdominale

fracturi ale extremitatilor si luxatii


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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)


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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


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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:


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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


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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


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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


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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


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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


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EXPLORARIPARACLINICE

Examen radiografic Examen CT

Examen IRM

Examen scintigrafic


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Examen radiografic

fata si profil de bazin

incidenta alara/

obturatorie

incidenta Jutet


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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


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Examen IRM

T1NACF, corp liber intraarticular, rupturilabrale, leziuni condrale, flebita vaselor

bazinului, fracturi oculte;

T2

edemul sprancenei acetabulare, nu e

folosit curent


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Examen scintigrafic

permite aprecierea vitalitatii capului

femural


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CLASIFICARE

Clasificarea Epstein

Clasificarea Thompson si Epstein Clasificarea Pipkin

Clasificarea Levin

Clasificarea Stewart and Milfords

Clasificare AO/OTA


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Clasificarea Epstein


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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


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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)


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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


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Clasificarea AO/OTA

30-D10 Luxatie anterioara a soldului

30-D11 Luxatie posterioara a soldului

30-D30 Luxatie obturatorie a soldului


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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


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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


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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


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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


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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


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MetodaBhler


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Metoda Allis


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Metoda tractiunii laterale


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Metoda umarului (Marya si Samuel/Enhalt)


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Metoda East Baltimore lift


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Tehnica Nordt (1999)


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Metoda Spitalului de UrgentaFloreasca


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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


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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


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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


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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


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Type of Posterior Dislocation


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Type of Posterior Dislocation

depends on:

Direction of applied force.

Position of hip.

Strength of patients bone.

Physical Examination: Classical


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Appearance

Posterior Dislocation: Hip flexed, internally

rotated, adducted.



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Appearance

Anterior Dislocation: Extreme external rotation,

less-pronounced abduction

and flexion.


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Unclassical presentation

(posture) if:

femoral head or neck fracture femoral shaft fracture

obtunded patient


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Physical Examination

Pain to palpation of hip.

Pain with attempted motion of hip. Possible neurological impairment:

Thorough exam essential!

Radiographs: AP Pelvis X-Ray


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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


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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:


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X rays after Hip Reduction:

AP pelvis, Lateral Hip x-ray.

Judet views of pelvis.

CT scan with 2-3 mm cuts.


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MRI Scan


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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.


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Clinical Management:

Emergent Treatment

Dislocated hip is an emergency.

Goal is to reduce risk of AVN and DJD.

Evaluation and treatment must be streamlined.


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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


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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.


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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).


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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


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Reduced Hip

Moves more freely

Patient more comfortable

Requires testing of stability

Simply flexing hip to 900does notsufficiently test stability


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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.


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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:


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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:


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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


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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.


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Irreducible Posterior Dislocation


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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


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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


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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


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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.


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4. Incongruent Reduction


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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.


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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


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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.


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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.


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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


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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


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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


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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


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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:


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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.


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Foot Drop

Splinting (i.e. ankle-foot-orthosis):

Improves gait

Prevents contracture


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Infection

Incidence 1-5%

Lowest with prophylactic antibiotics and

limited surgical approaches


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Iatrogenic Sciatic Nerve Injury

Most common with posterior approach to hip.

Results from prolonged retraction on nerve.


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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


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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


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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

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19.Luxatia Traumatica a Soldului

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