Luxaia traumatic a oldului

DefiniieUrgenta ortopedica caracterizata prin parasirea permanenta a cotilului de catre capului femural fractura

Anatomiaarticulatiei olduluienartroza, cu grad mare de stabilitatecapul femural usor asimetric, 2/3 de sferaconducere ligamentaraacetabulum: suprafata articulara in forma de U inversat

labrum (2/3 ale circumferintei) + ligamentul transvers acetabular (1/3 ale circumferintei) inel fibros cu rol in cresterea acoperirii capului femuralcapsula (mai subtire in portiunea inferioara), cu forma de butoiligamente

ilio-femural (in Y, a lui Bertin/Bigelow) cu 2 fascicole: - ilio-pertrohanterian lim. E, RE, ABD, - ilio-pretrohantenian lim. E, rezista la 3.5- 6 kN,

ischiofemuralpubofemural (cel mai slab) ligamentul rotund al capului femural

musculatura: - coaptoare ms. pelvitrohanterieni scurti posteriori, fesier mijlociu si micul fesier in opozitie cu m. abductoare si flexoare.

Anteversia colului femural70 in medie la barbatii caucazienimai mare la sexul femininorientali pot avea un unghi de anteversie intre 140 si 160

Vascularizatia capului femuralA. ligamentului rotunddin sistemul obturatorA. iliaca interna

Vascularizatia capului femural2. Ramuri cervicale ascendenteartere cicumflexeartera femurala profundaartera femurala comunaartera iliaca externaaortarisc foarte mare de lezare in luxatia traumatica a soldului

Nervul sciaticformat din radacinile L4 - S3.trece posterior de peretele posterior acetabulartrece inferior de m. piriformis, cu variatii

FRECVENTA5% din totalul luxatiilorsex masculin > sex feminin, 20-45 ani, rar copii si exceptional batrani.

ETIOLOGIEconsecutiva unui traumatism de inalta energie (accidente rutiere, cadere de la mare inaltime, accidente miniere).low-energy trauma copii

Mecanism de producereindirect - accidente rutiere - sindromul tabloului de bord, accidente industriale direct traumatismul actioneaza asupra partii superioare a femurului, fortandu-l sa paraseasca articulatia printr-o bresa capsulara

F+ADD+RIdeplasarea posterioara a capului femural in FIE (85-90%) fractura sprancenei cotiloideF+ABD luxatie 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 pasareE+RE luxatie antero-superioara (pubiana)

Leziuni asociateleziuni ale capului si ale feteileziuni ale toraceluileziuni intra-abdominalefracturi ale extremitatilor si luxatii

ANATOMIE PATOLOGICAlig. rotund rupt/ smuls fragment ososcapul sfasie capsula + lig. inferioare (ischio-femural, pubo-femural)in portiunea inferioara grosimea capsulei=2-3mm, in portiunea superioara=8-12 mmlig. Bertin intactluxatie tipica (regulata), lig. Bertin ruptluxatie atipica(neregulata)

m. pelvitrohanterieni pot fi rupt /desirati; in luxatiile posterioare m. gemeni, obturatorul intern si patratul crural pot si dilacerati, in luxatiile anterioare pot fi lezati m. pectineu, micul si mijlociul adductorfrecvent sunt asociate leziuni osoase: fracturi ale sprancenei cotiloide posterioare,fracturi ale femurului: cap, col, masiv trohanterian, diafiza.leziuni vasculare (foarte rar), cu hematom foarte mare compresivelongarea/compresiunea n.sciatic

Efectele luxatiei asupra circulatiei capului femuralarterele cervicale ascendente sunt intinse/rupteartera ligementului rotund este ruptaunele artere cervicale sunt comprimatereducerea rapida poate imbunatati fluxul sanguin al capului femural

SIMPTOMATOLOGIEdureri vii in regiunea solduluiimpotenta functionala totala a membrului inferiorla indivizii slabi - diformitati ale soldului luxatatitudine vicioasa in raport cu forma anatomopatologicain luxatiile tipice:

LUXATIILE POSTERO-SUPERIOARA (ILIACA)F coapsei pe bazin (poate fi mascata de lordoza compensatoare); E aproape completaRI mica genunchiul se sprijina pe celalalt genunchi, halucele se sprijina pe fata dorsala a piciorului sanatoslargirea transversala a soldului (dizlocatia + tumefierea locala)in triunghiul lui Scarpa se constata o depresiunescurtarea poate atinge 6-7 cmla palpare: capul femural este in FIE, marele trohanter este ascensionat

Luxatiile postero-inferioare (ischiatica)ADD importanta a coapsei cu F a genunchiului si RI picior peste piciorscurtarea MI luxat la flexia 900 pe bazin 3-5cmla palpare capul femural se simte inapoia tuberozitatii ischiatice formatiune dura, mobila la mobilizarea pasiva a genunchiuluiABD, RE si E sunt imposibile, dureroase

Luxatiile antero-superioare (pubiene)

MI luxat in E, ADB si REla palpare: capul femural este in reg. inghinala sau in triunghiul lui Scarpacapul femural rupe capsula antero-superiorlig. pubo-femural plasandu-se inaintea ramurii orizontale a pubisuluise fixeaza sub m. ileaopsoasintinde n. femuralADD, RI, si F sunt imposibilescurtarea este de 1-2 cm

Luxatiile antero-inferioare (obturatorii)F exagerata, ADB si RE importantasold sters, turtitcapul femural se poate palpa in dreptul gaurii obturatoriicoarda m. adductori in tensiuneMI alungit cu 1-2 cm cand este bilaterala, pozitia clasica de batraciancompresiuni ale n. obturator

Luxatiile atipice

LuxatiaCapul femuralObservatiisupracotiloidianadeasupra cotiluluicapsula rupta in portiunea superioara+fractura sprancenei cotiloide. fascicolul extern al lig. in Y este ruptsubspinoasasub SIAIsuprapubianain partea mijlocie a arcadei femuraleperinealaplacat pe ramura ascendenta a ischionuluipoate ajunge in reg. scrotalasubischiaticala nivelul spinei ischiaticeintrapelvianain micul bazinluxatie centrala/protuzie acetabulara de cap femural

EXPLORARI PARACLINICEExamen radiografic Examen CTExamen IRMExamen scintigrafic

Examen radiografic fata si profil de bazin incidenta alara/ obturatorie incidenta Jutet

Examen CTsectiuni de 2-3 mm; deceleaza fracturi de cotil/cap femural reconstructie 3D, util in reducerile sangerandeprezenta bulelor de gazsubluxatie redusa spontan

Examen IRMT1 NACF, corp liber intraarticular, rupturi labrale, leziuni condrale, flebita vaselor bazinului, fracturi oculte; T2 edemul sprancenei acetabulare, nu e folosit curent

Examen scintigraficpermite aprecierea vitalitatii capului femural

Diagnostic diferentialentorsa de sold dureri mai putin intense si difuze, miscarile pasive sunt posibile, nefiind blocate in pozitii vicioasecontuzia de sold durri difuze, moderate, permit miscarile pasive, absent pozitiilor vicioase, marele trohanter nu este ascensionatfractura de col femural cu deplasare RE si scurtare, nu apare ADDfracturi acetabulare sau ale bazinuluifractura de cap femuralNACF

CLASIFICAREClasificarea EpsteinClasificarea Thompson si EpsteinClasificarea PipkinClasificarea LevinClasificarea Stewart and MilfordsClasificare AO/OTA

Clasificarea Epstein

Tip I: Luxatii superioare inclusiv pubiene sau suprapubieneTip IA: Fara fracturi asociateTip IB: Fracturi asociate sau tasari ale capului femuralTip IC: Fracturi asociate ale acetabululuiTip II: Luxatii inferioare inclusiv obturatorii si perinaleTip IIA: Fara fracturi asociateTip IIB: Fracturi asociate sau tasari ale capului femural Tip IIC: Fracturi asociate ale acetabulului

Clasificarea Thompson si Epstein Tip I: Luxatie cu/fara fractura minoraTip II: Luxatie cu un singur fragment major al peretului posterior acetabularTip III: Luxatie cu cominutia peretului posterior acetabular cu/fara fragment major Tip IV: Luxatie cu fractura tavanului acetabularTip V: Luxatie cu fractura capului femural

Clasificarea PipkinTip I: Luxatie posterioara a soldului cu fractura capului femural caudal de fovea capitisTip II: Luxatie posterioara a soldului cu fractura capului femural proximal de fovea capitisTip III: Tip I sau II luxatie posterioara cu fracura de col femural asociataTip IV: Tip I, II, sau III luxatie posterioara cu fractura acetabulara

Clasificarea Levin Tip I Fra fracturi importante, fara afectarea stabilitatii postreductionaleTip IILuxatie ireductibila fara fractura/tasare a capului femural/ acetabularaTip IIILuxatie incoercibila sau fagmente osteocondrale incarcerate Tip IVFractura acetabulara asociata ce necesita reconstructie pentru restabilirea congruentei articulareTip VLeziune asociata capului femural (fractura sau tasare)

Clasificarea Stewart si Milfords Tip I luxatie cu /fara fracturi insignifiante acetabulareTip II luxatie asociata fie cu fractura simpla sau cominutiva a peretelui posterior acetabular, fara pierderea stabilitatii soldului Tip III fractura-dizlocatie cu pierderea stabilitatii soldului consecutiv pierderii suportului structural Tip IV luxatie asociata cu fractura capului femural

Clasificarea AO/OTA30-D10Luxatie anterioara a soldului30-D11Luxatie posterioara a soldului30-D30Luxatie obturatorie a soldului

EVOLUTIE SI PROGNOSTICsunt mai favorabile in luxatiile simple decat in cele asociate cu fracturiprecocitatea reducerii amelioreaza prognosticul (luxatii simple reduse >24hcomplicatii 66%, luxatii+ fracturi acetabulare reduse >24hcomplicatii 100%) nu trebuie sa treaca nici un rasarit sau apus de soare

COMPLICATIIComplicatii generaleintretinerea/accentuarea tulb. circulatorii cerebrale(frecv. la pacienti cu TCC)leziune socogenatrombogenarisc de TVPEP grava, necesita trombopreventia cu HGMM

B. Complicatii locale imediatecompresiunea n. obturator, n. cruralelongarea 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 inferioareosteoartrita

Complicatii locale tardiveNACFcoxartrozaosificarile posttraumatice atrofii musculareatitudini vicioase permanente+impotenta functionala +dureri+retractii musculareingrosari si osificari ale capsuleitendinita m.rotatori ai solduluiluxatia recidivanta de sold

Cauze de ireductibilitateanterioara:interpunerea unui fragment din bureletul cotiloidian/ a capsului rupte/tendonul psoasuluidreptul anteriorstrangularea colului femural intr-o bresa capsulara mica ce a permis luxarea, dar nu mai pemite reducereaposterioara:fragment osostendonul m. piramidal, m. obturator internmarele fesiercapsula ligamentul rotundlig. iliofemurallabrum-ulperetele posterior

Luxatia traumatica recenta incoercibila de soldcapul femural se redisloca la incetarea tractiunii si a manevrelor ortopedicefrecvent este cauzata de o fractura acetabulara cu fragment mare posterior (tip III Thompson si Epstein)exceptional poate fi cauzata de interpunerea de capsula, burelet glenoidian sau alte leziuni de parti moinecesita interventia chirurgicala pt. preventia lezarii vaselor capsularep.o. este necesara extensia continua pe atela Braun-Bhlerunii autori se poate temporiza interventia 10-15 zile daca se mentine reduceea sub extensie

Managementul initialreducere trebuie efectuata rapid pentru preventia complicatiilordaca e posibil, reducerea trebuie efectuata in UPU/ sala de operatie, sub anestezie si relaxare muscularadaca anestezia generala nu este posibila, trebuie tentata reducerea sub sedare i.vindiferent de tipul de luxatie, tractiunea se face in pozitie vicioasa, cu pacientul in decubit dorsalin timpul reducerii se cauta stabilitateatrebuie efectuate Rx postreducere, pentru confirmare

Algoritmul postreductionalfara ADD sau RIfara flexie >60opentru luxatii simple extensie transosoasa 10-12 zile urmata de mobilizare activa inca 10-20 zile.mersul cu sprijin integral este permis dupa 3-4 saptamanicand nu poate efectuata extensia transscheletica continua imobilizare gipsata 2 saptamaniprogram de kineto pentru prevenirea atrofiilor musculare, redorilor posttraumatice si a calcificarilor periarticulare

Metoda Bhler

Metoda Allis

Metoda Stimson (Djanelidze)

Metoda tractiunii laterale

Metoda umarului (Marya si Samuel/Enhalt)

Metoda East Baltimore lift

Tehnica Nordt (1999)

Metoda Spitalului de UrgentaFloreasca

Reducerea luxatiilor atipiceSe transforma in luxatii posterioare prin miscari de circumductie apoi se reduc dupa tehnica cunoscutaExtensie continua 3-4 zile dupa care se face reducerea

Verificarea stabilitatii reduceriiSoldul este flectat la 90o Daca soldul ramane stabil, se aplica RI, ADD, si compresiune spre posteriorIn functie de gradul de flexie, ADD si RI se apreciaza stabilitatea postreductionala !!! Fracturile de perete posterior cotiloidian fac dificila aprecierea stabilitatii

Luxatia veche traumatica de soldfrecvent datorita nerecunoasterii ei la politraumatizati ( luxatii atipice)devin ireductibile intr-un interval de timp cateva saptamani-2 luninecesita extensie continua cu 10-15 kg/ 10-15 zile pt coborarea capului femural si prevenirea elongarii n. sciatic/ a vaselor femurale in momentul reducerii + reducere sangerandadupa 3 luni, cartilajul articular este compromisprotezare

Indicatia de reducere sangerandaluxatie ireductibilaleziunea iatrogenica a n. sciaticreducere incoercibila cu fragmente incarcerate/ interpozitie de parti moireducere incoercibila cu fractura tip I Pipkinfractura de femur controlateral

Anterior Smith-Petersen/ Hardinge Anterolateral Watson-Jones

permite vizualizarea si extragerea tesutului interpus plasarea unui cui Schanz in regiunea interetrohanteriana permite mobilizare extremitatii femurale superioareeste indicata repararea capsului fara disectia de amploare

Posterior Kocher-Langenbeckpermite vizualizarea si extragerea tesutului interpus permite repararea peretelui posterior acetabular

Type of Posterior Dislocation depends on:Direction of applied force.

Position of hip.

Strength of patients bone.

Physical Examination: Classical AppearancePosterior Dislocation: Hip flexed, internally rotated, adducted.

Physical Examination: Classical AppearanceAnterior Dislocation: Extreme external rotation, less-pronounced abduction and flexion.

Unclassical presentation (posture) if:femoral head or neck fracturefemoral shaft fractureobtunded patient

Physical ExaminationPain to palpation of hip.Pain with attempted motion of hip.Possible neurological impairment: Thorough exam essential!

Radiographs: AP Pelvis X-RayIn primary survey of ATLS Protocol.Should allow diagnosis and show direction of dislocation.Femoral head not centered in acetabulum.Femoral head appears larger (anterior) or smaller (posterior).Usually provides enough information to proceed with closed reduction.

Reasons to Obtain More X-Rays Before Hip ReductionView of femoral neck inadequate to rule out fracture.

Patient requires CT scan of abdomen/pelvis for hemodynamic instability and additional time to obtain 2-3 mm cuts through acetabulum + femoral head/neck would be minimal.

X-rays after Hip Reduction:AP pelvis, Lateral Hip x-ray.Judet views of pelvis.CT scan with 2-3 mm cuts.

CT ScanMost helpful after hip reduction.Reveals:Non-displaced fractures. Congruity of reduction. Intra-articular fragments. Size of bony fragments.

MRI ScanWill reveal labral tear and soft-tissue anatomy.Has not been shown to be of benefit in acute evaluation and treatment of hip dislocations.

Clinical Management: Emergent TreatmentDislocated hip is an emergency.

Goal is to reduce risk of AVN and DJD.

Evaluation and treatment must be streamlined.

Emergent ReductionAllows restoration of flow through occluded or compressed vessels.Literature supports decreased AVN with earlier reduction.Requires proper anesthesia.Requires team (i.e. more than one person).

AnesthesiaGeneral anesthesia with muscle relaxation facilitates reduction, but is not necessary.Conscious sedation is acceptable.Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, create muscle spasm, and make subsequent attempts at reduction more difficult.

General Anesthesia if:Patient is to be intubated emergently in Emergency Room.Patient is being transported to Operating Room for emergent head, abdominal or chest surgery.Take advantage of opportunity.

Reduction ManeuversAllis: Patient supine.Requires at least two people.

Stimson:Patient prone, hip flexed and leg off stretcher.Requires one person.Impractical in trauma (i.e. most patients).

Allis ManeuverAssistant: Stabilizes pelvisPosterior-directed force on both ASISsSurgeon: Stands on stretcherGently flexes hip to 900Applies progressively increasing traction to the extremityApplies adduction with internal rotationReduction can often be seen and felt

Reduced HipMoves more freelyPatient more comfortable

Requires testing of stabilitySimply flexing hip to 900 does not sufficiently test stability

Stability TestHip flexed to 90oIf hip remains stable, apply internal rotation, adduction and posterior force.The amount of flexion, adduction and internal rotation that is necessary to cause hip dislocation should be documented.Caution!: Large posterior wall fractures may make appreciation of dislocation difficult.

Irreducible HipRequires emergent reduction in O.R.Pre-op CT obtained if it will not cause delay.One more attempt at closed reduction in O.R. with anesthesia.Repeated efforts not likely to be successful and may create harm to the neurovascular structures or the articular cartilage.

Surgical approach from side of dislocation.

Hip Dislocation: Nonoperative TreatmentIf hip stable after reduction, and reduction congruent.Maintain patient comfort.ROM precautions (No Adduction, Internal Rotation).No flexion > 60o.Early mobilization.Touch down weight-bearing for 4-6 weeks.Repeat x-rays before allowing weight-bearing.

Hip Dislocation:Indications for Operative TreatmentIrreducible hip dislocationHip dislocation with femoral neck fractureIncarcerated fragment in jointIncongruent reductionUnstable hip after reduction

1.Irreducible Hip Dislocation: AnteriorSmith-Peterson approachWatson-Jones is an alternate approachAllows visualization and retraction of interposed tissue.Placement of Schanz pin in intertrochanteric region of femur will assist in manipulation of the proximal femur.Repair capsule, if this can be accomplished without further dissection.

Kocher-Langenbeck approach. Remove interposed tissue, or release buttonhole. Repair posterior wall of acetabulum if fractured and amenable to fixation.1.Irreducible Hip Dislocation: Posterior

Irreducible Posterior Dislocation with Large Femoral Head FractureFortunately, these are rare.

Difficult to fix femoral head fracture from posterior approach without transecting ligamentum teres.

Three OptionsDetach femoral head from ligamentum teres, repair femoral head fracture with hip dislocated, reduce hip.Close posterior wound, fix femoral head fracture from anterior approach (either now or later).Ganz trochanteric flip osteotomy.

Best option not known: Damage to blood supply from anterior capsulotomy vs. damage to blood supply from transecting ligamentum teres.

These will be discussed in detail in femoral head fracture section.

2. Hip Dislocation with Femoral Neck FractureAttempts at closed reduction potentiate chance of fracture displacement with consequent increased risk of AVN.

If femoral neck fracture is already displaced, then the ability to reduce the head by closed means is markedly compromised.

Thus, closed reduction should not be attempted.

2. Hip Dislocation with Femoral Neck FractureUsually the dislocation is posterior.Thus, Kocher-Langenbeck approach.If fracture is non-displaced, stabilize fracture with parallel lag screws first.If fracture is displaced, open reduction of femoral head into acetabulum, reduction of femoral neck fracture, and stabilization of femoral neck fracture.

3. Incarcerated FragmentCan be detected on x-ray or CT scan.

Surgical removal necessary to prevent abrasive wear of the articular cartilage.

Posterior approach allows best visualization of acetabulum (with distraction or intra-op dislocation).

Anterior approach only if: dislocation was anterior and, fragment is readily accessible anteriorly.

4. Incongruent ReductionFrom: Acetabulum Fracture (weight-bearing portion). Femoral Head Fracture (any portion). Interposed tissue.

Goal: achieve congruence by removing interposed tissue and/or reducing and stabilizing fracture.

5. Unstable Hip after ReductionDue to posterior wall and/or femoral head fracture.Requires reduction and stabilization fracture.

Labral detachment or tearHighly uncommon cause of instability.Its presence in the unstable hip would justify surgical repair.MRI may be helpful in establishing diagnosis.

Results of TreatmentLarge range: from normal to severe pain and degeneration.In general, dislocations with associated femoral head or acetabulum fractures fare worse.Dislocations with fractures of both the femoral head and the acetabulum have a strong association with poor results.Irreducible hip dislocations have a strong association with poor results.13/23 (61%) poor and 3/23 (13%) fair results.McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.

Complications of Hip DislocationAvascular Necrosis (AVN): 1-20%

Several authors have shown a positive correlation between duration of dislocation and rate of AVN.

Results are best if hip reduced within six hours.

Post-traumatic OsteoarthritisCan occur with or without AVN.May be unavoidable in cases with severe cartilaginous injury.Incidence increases with associated femoral head or acetabulum fractures.Efforts to minimize osteoarthritis are best directed at achieving anatomic reduction of injury and preventing abrasive wear between articular carrtilage and sharp bone edges.

Recurrent DislocationRare, unless an underlying bony instability has not been surgically corrected (e.g. excision of large posterior wall fragment instead of ORIF).Some cases involve pure dislocation with inadequate soft-tissue healing may benefit from surgical imbrication (rare).Can occur from detached labrum, which would benefit from repair (rare).

Recurrent Dislocation Caused by Defect in Posterior Wall and/or Femoral HeadCan 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 DislocationIncreased 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 InjuryOccurs 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:If No Improvement after 34 WeeksEMG and Nerve Conduction Studies for baseline information and for prognosis.

Allows localization of injury in the event that surgery is required.

Foot DropSplinting (i.e. ankle-foot-orthosis):

Improves gaitPrevents contracture

InfectionIncidence 1-5%Lowest with prophylactic antibiotics and limited surgical approaches

Infection: Treatment PrinciplesMaintenance of joint stability.Debridement of devitalized tissue.Intravenous antibiotics.Hardware removed only when fracture healed.

Iatrogenic Sciatic Nerve InjuryMost common with posterior approach to hip.

Results from prolonged retraction on nerve.

Iatrogenic Sciatic Nerve InjuryPrevention:Maintain hip in full extensionMaintain knee in flexionAvoid retractors in lesser sciatic notch? Intra-operative nerve monitoring (SSEP, motor monitoring)

ThromboembolismHip dislocation = high risk patient.

Prophylactic treatment with:low molecular weight heparin, or coumadin

Early postoperative mobilization.

Discontinue prophylaxis after 2-6 weeks (if patient mobile).

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