Luxaţia traumatică a şoldului

Gheorghevici T. Ştefan, MD

sub coord. Sef lucr.Dr. Cozma Tudor

Universitatea de Medicină şi Farmacie Gr. T. Popa Iaşi

Spitalul Clinic de Recuperare Iaşi

2011

Definiţie

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

Anatomiaarticulatiei şoldului

enartroza, cu grad mare de stabilitate capul femural usor asimetric, 2/3 de sfera conducere ligamentara

acetabulum: 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 femural

capsula (mai subtire in portiunea inferioara), cu forma de „butoi”

ligamente

ilio-femural (in „Y”, a lui Bertin/Bigelow) cu 2 fascicole: - ilio-ilio-pertrohanterianpertrohanterian – lim. E, RE, ABD, - ilio-pretrohantenianpretrohantenian – lim. E, rezista la 3.5- 6 kN,

ischiofemural pubofemural (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 femural

• 70 in medie la barbatii caucazieni• mai mare la sexul feminin• orientali pot avea un unghi de anteversie intre 140 si

160

Vascularizatia capului femural

1.1. A. ligamentului rotundA. ligamentului rotund• din sistemul obturator• A. iliaca interna

Vascularizatia capului femural

2. Ramuri cervicale ascendenteRamuri cervicale ascendente

artere cicumflexe

artera femurala profunda

artera femurala comuna

artera iliaca externa

aorta• risc foarte mare de lezare in luxatia traumatica a

soldului

Nervul sciatic

• format din radacinile L4 - S3.• trece posterior de peretele

posterior acetabular• trece inferior de m. piriformis,

cu variatii

FRECVENTA

• 5% din totalul luxatiilor• sex masculin > sex feminin, • 20-45 ani, rar copii si exceptional batrani.

ETIOLOGIEETIOLOGIE

consecutiva unui traumatism de inalta energie (accidente rutiere, cadere de la mare inaltime, accidente miniere).low-energy trauma – copii <6 ani, datorita laxitatii ligamentare si batrani cu proteza de sold (10%)

Mecanism de producere

• indirect - 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+RI→deplasarea posterioara a capului femural in FIE (85-90%) ±fractura sprancenei cotiloide

• F+ABD →luxatie anterioara (10-15%)• F+ usoara ABD→luxatie 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)

Leziuni asociate

leziuni ale capului si ale fetei leziuni ale toracelui leziuni intra-abdominale fracturi ale extremitatilor si luxatii

ANATOMIE PATOLOGICA

• lig. rotund rupt/ smuls ±fragment osos• capul sfasie capsula + lig. inferioare (ischio-

femural, pubo-femural)• in portiunea inferioara grosimea capsulei=2-3mm,

in portiunea superioara=8-12 mm• lig. Bertin intact→luxatie tipica (regulata), lig.

Bertin rupt→luxatie 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 adductor

• frecvent 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 – compresiv

• elongarea/compresiunea n.sciatic

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 al

capului femural

SIMPTOMATOLOGIE

dureri vii in regiunea soldului impotenta functionala totala a membrului inferior la indivizii slabi - diformitati ale soldului luxat atitudine vicioasa in raport cu forma

anatomopatologica in luxatiile tipice:

LUXATIILE POSTERO-SUPERIOARA (ILIACA)

• F coapsei pe bazin (poate fi mascata de lordoza compensatoare); E aproape completa

• RI mica – genunchiul 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

• scurtarea poate atinge 6-7 cm

• la 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 picior

• scurtarea MI luxat – la flexia 900 pe bazin – 3-5cm

• la palpare capul femural se simte inapoia tuberozitatii ischiatice – formatiune dura, mobila la mobilizarea pasiva a genunchiului

• ABD, RE si E sunt imposibile, dureroase

 Luxatiile antero-superioare (pubiene)

• MI luxat in E, ADB si RE• la palpare: capul femural este in reg. inghinala sau

in triunghiul lui Scarpa• capul femural rupe capsula antero-superior• lig. pubo-femural plasandu-se inaintea ramurii

orizontale a pubisului• se fixeaza sub m. ileaopsoas• intinde n. femural• ADD, RI, si F sunt imposibile• scurtarea este de 1-2 cm

Luxatiile antero-Luxatiile antero-inferioare (obturatorii)inferioare (obturatorii)

• F exagerata, ADB si 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

Luxatiile atipiceLuxatia 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

EXPLORARI PARACLINICE

• Examen radiografic

• Examen CT

• Examen IRM

• Examen scintigrafic

Examen radiografic

• fata si profil de bazin± incidenta alara/ obturatorie

• incidenta Jutet

Examen CT

• sectiuni de 2-3 mm;

• deceleaza fracturi de cotil/cap femural ± reconstructie 3D, util in reducerile sangerande

• prezenta bulelor de gaz→subluxatie redusa spontan

Examen IRM

• T1 – NACF, corp liber intraarticular, rupturi labrale, leziuni condrale, flebita vaselor bazinului, fracturi oculte;

• T2 – edemul sprancenei acetabulare, nu e folosit curent

Examen scintigrafic

• permite aprecierea vitalitatii capului femural

Diagnostic diferential• entorsa de sold – dureri mai putin intense si

difuze, miscarile pasive sunt posibile, nefiind blocate in pozitii vicioase

• contuzia de sold – durri difuze, moderate, permit miscarile pasive, absent pozitiilor vicioase, marele trohanter nu este ascensionat

• fractura de col femural cu deplasare – RE si scurtare, nu apare ADD

• fracturi acetabulare sau ale bazinului• fractura de cap femural• NACF

CLASIFICARE

• Clasificarea Epstein

• Clasificarea Thompson si Epstein

• Clasificarea Pipkin

• Clasificarea Levin

• Clasificarea Stewart and Milford’s

• Clasificare AO/OTA

Clasificarea Epstein

• Tip I: Luxatii superioare inclusiv pubiene sau suprapubiene

• Tip IA: Fara fracturi asociate• Tip IB: Fracturi asociate sau tasari ale capului

femural• Tip IC: Fracturi asociate ale acetabulului• Tip II: Luxatii inferioare inclusiv obturatorii si

perinale• Tip IIA: Fara fracturi asociate• Tip IIB: Fracturi asociate sau tasari ale capului

femural • Tip IIC: Fracturi asociate ale acetabulului

Clasificarea Thompson si Epstein

• Tip I: Luxatie cu/fara fractura minora

• Tip II: Luxatie cu un singur fragment major al peretului posterior acetabular

• Tip III: Luxatie cu cominutia peretului posterior acetabular cu/fara fragment major

• Tip IV: Luxatie cu fractura tavanului acetabular

• Tip V: Luxatie cu fractura capului femural

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

Clasificarea Levin • Tip I

Fra 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 IV

Fractura acetabulara asociata ce necesita reconstructie pentru restabilirea congruentei articulare

• Tip V

Leziune asociata capului femural (fractura sau tasare)

Clasificarea Stewart si Milford’s

• Tip I luxatie cu /fara fracturi insignifiante acetabulare

• Tip 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/OTA

• 30-D10 Luxatie anterioara a soldului• 30-D11 Luxatie posterioara a soldului• 30-D30 Luxatie obturatorie a soldului

EVOLUTIE SI PROGNOSTIC

• sunt mai favorabile in luxatiile simple decat in cele asociate cu fracturi

• precocitatea reducerii amelioreaza prognosticul (luxatii simple reduse >24h→complicatii 66%, luxatii+ fracturi acetabulare reduse >24h→complicatii 100%)

• „nu trebuie sa treaca nici un rasarit sau apus de soare”

COMPLICATII

Complicatii generale

• intretinerea/accentuarea tulb. circulatorii cerebrale(frecv. la pacienti cu TCC)

• leziune socogena±trombogena

• risc de TVP→EP grava, necesita trombopreventia cu HGMM

•  

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

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

Cauze de ireductibilitateanterioara:• 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

Luxatia traumatica recenta incoercibila de sold

• capul femural se redisloca la incetarea tractiunii si a manevrelor ortopedice

• frecvent 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 moi

• necesita interventia chirurgicala pt. preventia lezarii vaselor capsulare

• p.o. este necesara extensia continua pe atela Braun-Böhler

• unii autori – se poate temporiza interventia 10-15 zile daca se mentine reduceea sub extensie

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

Algoritmul postreductional• fara ADD sau RI

• fara flexie >60o

• pentru luxatii simple – extensie transosoasa 10-12 zile urmata de mobilizare activa inca 10-20 zile.

• mersul cu sprijin integral este permis dupa 3-4 saptamani

• cand nu poate efectuata extensia transscheletica continua – imobilizare gipsata 2 saptamani

• program de kineto pentru prevenirea atrofiilor musculare, redorilor posttraumatice si a calcificarilor periarticulare

Metoda Böhler

Metoda Allis

Metoda Stimson (Djanelidze)

Metoda tractiunii laterale

Metoda „umarului” (Marya si Samuel/Enhalt)

Metoda East Baltimore lift

Tehnica Nordt (1999)

Metoda Spitalului de Urgenta”Floreasca”

Reducerea luxatiilor atipice

• Se transforma in luxatii posterioare prin miscari de circumductie apoi se reduc dupa tehnica cunoscuta

• Extensie continua 3-4 zile dupa care se face reducerea

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 cotiloidian fac dificila aprecierea stabilitatii

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 zile – pt coborarea capului femural si prevenirea elongarii n. sciatic/ a vaselor femurale in momentul reducerii + reducere sangeranda

• dupa 3 luni, cartilajul articular este compromis→protezare

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 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

Posterior Kocher-Langenbeck

• permite 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 patient’s bone.

Physical Examination: Classical Appearance

Posterior Dislocation: Hip flexed, internally rotated, adducted.

Physical Examination: Classical Appearance

Anterior Dislocation: Extreme external rotation, less-pronounced abduction and flexion.

Unclassical presentation (posture) if:

• femoral head or neck fracture

• femoral shaft fracture

• obtunded patient

Physical Examination

• Pain to palpation of hip.

• Pain with attempted motion of hip.

• Possible neurological impairment:

Thorough exam essential!

Radiographs: AP Pelvis X-Ray

• 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 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 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 Scan

• Will 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 Treatment

• Dislocated hip is an emergency.

• Goal is to reduce risk of AVN and DJD.

• Evaluation and treatment must be streamlined.

Emergent Reduction

• Allows 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).

Anesthesia

• General 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 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).

Allis Maneuver

• Assistant: Stabilizes pelvis• Posterior-directed force on both ASIS’s

• Surgeon: Stands on stretcher• Gently flexes hip to 900

• Applies progressively increasing traction to the extremity

• Applies adduction with internal rotation• Reduction can often be seen and felt

Reduced Hip

• Moves more freely

• Patient more comfortable

• Requires testing of stability

• Simply flexing hip to 900 does not sufficiently test stability

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 may make appreciation of dislocation difficult.

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. 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 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:Indications for Operative Treatment

1. Irreducible hip dislocation

2. Hip dislocation with femoral neck fracture

3. Incarcerated fragment in joint

4. Incongruent reduction

5. Unstable hip after reduction

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 the proximal femur.

3. Repair capsule, if this can be accomplished without further dissection.

1. Kocher-Langenbeck approach.

1.Remove interposed tissue, or release buttonhole.

1.Repair posterior wall of acetabulum if fractured and amenable to fixation.

1. Irreducible Hip Dislocation: Posterior

Irreducible Posterior Dislocation with Large Femoral Head Fracture

Fortunately, these are rare.

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

Three Options

1.Detach femoral head from ligamentum teres, repair femoral head fracture with hip dislocated, reduce hip.2.Close posterior wound, fix femoral head fracture from anterior approach (either now or later).3.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 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 Neck Fracture

Usually 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 Fragment

Can 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 Reduction

From:• 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 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

• Large 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 Dislocation

• Avascular 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 Osteoarthritis

• Can 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 Dislocation

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 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 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

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

Occurs in up to 20% of patients with hip dislocation.

Nerve stretched, compressed or transected.

With reduction: 40% complete resolution

25-35% partial resolution

Sciatic Nerve Palsy:If No Improvement after 3–4 Weeks

EMG and Nerve Conduction Studies for baseline information and for prognosis.

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

Foot Drop

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

• Improves gait• Prevents contracture

Infection

Incidence 1-5%

Lowest with prophylactic antibiotics and limited surgical approaches

Infection: Treatment Principles

Maintenance of joint stability.

Debridement of devitalized tissue.

Intravenous antibiotics.

Hardware removed only when fracture healed.

Iatrogenic Sciatic Nerve Injury

Most common with posterior approach to hip.

Results from prolonged retraction on nerve.

Iatrogenic Sciatic Nerve Injury

Prevention:Maintain hip in full extension

Maintain knee in flexion

Avoid retractors in lesser sciatic notch

? Intra-operative nerve monitoring (SSEP, motor monitoring)

Thromboembolism

Hip 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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•  

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