CHAPTER 1 INTRODUCTION
1.1 Background
normal hip joint is one of the most stable joints in humans. Stability of the hip joint depe depend ndss on the the surf surfac acee that that is invo involv lved ed.. It take takess grea greatt forc forcee to disl disloc ocat atee the the hip hip joint. Dislocation of the hip joint can occur in anteriorly or posteriorly (can be followed by fracture of the part related or not. Moreover, it can occur centrally (which centrally (which is always followed by fracture. (!ruce Salter Dislocation of the hip joint happens when the caput of of "he femur is detached from its socket socket called called the acetabulum. acetabulum. In general, joint dislocation can be classified into two types, congenital and traumatic. #ongenital dislocation of the hip joint is rather subtle and re$uire special e%amination on a newborn baby to be able to detect it. &owever, many cases of this type went undetected. ' of ) infants born alive had congenital hip joint looseness that may be caused by genetic factors (de *ong "here are + types of traumatic dislocation of the hip joint, anterior and posterior dislocation dislocation.. )- of the cases are posterior posterior dislocation dislocation which causes the pelvis to be bent, stiff and looks close to the medial side of the body. hereas the anterior dislocation, the pelvic would become stiff and looks rotated laterally.
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Dislocation of the hip joint could be very painful. If it involves the nerve fibers, it can cause loss of sensory function from the distal part of the leg, and of course this will make it difficult to move the leg. /urthermore, dislocation of the hip joint can be a serious problem , and should be treated with the proper treatment.
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1.2 Objectie!
"his paper describes the dislocation of the hip joint especially traumatic dislocation of the hip joint in order to fulfill the task of clinical work at the surgery departement. /aculty of Medicine, #hristian 1niversity of Indonesia
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CHAPTER 2 #ITERATURE RE$IE%
2.1 De&inition and Etio'og(
Dislocation of the hip joint is a condition in which the femoral head detached from its socket in the hip bone (pelvis. "he most fre$uent causes of dislocation of the hip joint is blatant force2pressure to the hip such as motor accidents, pedestrian car crash, or falling from the height. Dislocation of the hip joint is usually accompanied by injuries on the other parts around the hip, such as the pelvis and leg fractures, back injuries, or head injuries.
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"raumatic dislocation of the hip joint could be described as medical emergency and must be treated immediately, ideally within si% hours. "his is due to the cessation of blood flow from the distal area to the caput of femur bone could caused many bad conse$uences. If the dislocation is not repositioned immediately and the vascularisation couldnt be repaired, the upper part of the femur can be damaged permanently called avascular necrosis.
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2.2 Anato)(
"he hip joint is formed by the connection of the femoral head and the acetabulum of the pelvis, and the type of this joint is called the ball4and4socket. "he femur in the acetabulum is maintained by 3 separate ligaments which are5 •
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Iliofemoral ligaments connected to the anterior inferior iliac spine of the
pelvis and intertrochanteric line of the femur. + " & i p * o i n t D i s l o c a t i o n
•
6ubofemoral ligaments originate from the superior pubic ramus, was also connected
to the intertrochanteric line of the femur. •
Ischiofemoral ligaments connecting the ischium to the greater trochanter of the femur.
•
"ransverse acetabular ligament.
•
7igaments connect the femoral head and the acetabular transverse ligament notch. Sciatic nerve is located in inferoposterior side of the hip joint , while the femoral
nerve lies on the anterior side of the pelvic. 6ro%imal part of the femur and femoral neck blood supplied by the medial circumflex femoral artery and its branches. /emoral head, on the contrary, get very little blood supply from small branches of the obturator artery through the common femoral ligament.
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2.* +u!c'e! and +oe)ent
6elvic muscle that work on three main a%es are mutually perpendicular, all of which pass through the center of the femoral head , which resulted in three degrees of movement and three pairs of principal directions5 /le%ion and e%tension around the transverse a%is ( left4right , lateral rotation and medial rotation around the longitudinal a%is (along the thigh, and abduction and adduction around the sagittal a%is (forward4backward, and the combination of these movements (ie circumduction , a compound movement where the foot 0 " & i p * o i n t D i s l o c a t i o n
draws an irregular conical shape it is important to be remembered that some of the pelvic muscles also work on spinal joints or knee joints, and based on the area of their origin and 2 or insertion, different parts of the muscles participate in the movements, and that the range of motion varies with position of the hip joint. In addition, the inferior and superior parts can be called Triceps coxae together with the obturator internus , and its function is only to help the last muscle. Movement of the hip joint is performed by series of muscle presented here and is based on the 8ero degree position of the hip joint5 •
#atera' or e,terna' rotation (0) 9 with hip e%tended, with hip fle%ed 3) 95 gluteus
ma%imus, $uadratus
femoris, obturator
internus,
medius and minimus, iliopsoas (including m. column, obturator
dorsal
psoas
fiber
of gluteus
the
vertebral
major of
e%ternus, adductor
magnus , longus , brevis ,
and minimus , piriformis , and Sartorius . •
+edia' or interna'
rotation (:)95
anterior
fiber
of gluteus
medius and minimus, tensor fascia latae, portion of the adductor magnus inserted into the adductor tubercle. •
E,ten!ion or retroer!ion (+)95 gluteus
ma%imus , the
back
parts
of
gluteus
medius and minimus fiber ; adductor magnus , and piriformis .
-'e,ion or anteer!ion (':)95 iliopsoas (with m. psoas major of the spine, tensor
fascia latae , pectineus , adductor longus , adductor brevis , and gracilis . thigh muscles act as the hip fle%ors5 rectus femoris ands artorius . •
Adduction (0)9
with
magnus with adductor ma%imus with
the
hip
e%tended,
minimus ; adductor
attachment
tibia, pectineus, $uadratus
to
femoris,
+)9
with
hip
fle%ed5 adductor
longus , adductor
brevis , gluteus
the gluteal tuberosity, gracilis (e%tend and obturator
eksternus . /rom
to
the thigh
muscles, semitendinosus mainly involved in hip adduction
2. Pat/o0/(!io'og(
"he hip joint is a ball-socket joint. /emoral head is located within the acetabulum socket ne%t to the cartilaginous labrum. "he hip joint is also supported by a fibrous joint : " & i p * o i n t D i s l o c a t i o n
capsule, ischiofemoral ligaments, and the muscles of the groin and gluteus.
"raumatic dislocation of the hip joint can occur with or without fracture of the pro%imal end of the femur or acetabulum. "his is usually caused by high4energy trauma, unless there is previous disease of the femoral head, acetabulum, or the neuromuscular system. /emoral head can not be completely separated from normal acetabulum, e%cept when there is ligament rupture e%ist. "raumatic dislocation classified by the shift direction of the femoral head from the acetabulum, the posterior, anterior and central.
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Po!terior Di!'ocation
6osterior dislocation is the case which happen the most, about )4)-, usually due to car accidents.
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"here are several classifications that are used to describe the posterior dislocation. "hompson4>pstein classification is based on radiographic findings, namely 5
0.?
•
Type I Simple dislocation with or without an insignificant posterior wall fragment
•
Type II islocation associated with a single large posterior wall fragment
•
Type III islocation with a comminuted posterior wall fragment
•
Type I! islocation with fracture of the acetabular floor
•
Type ! islocation with fracture of the femoral head Steward and Milford classification is based on the stability of the pelvic function,
which is 5
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•
Type " #o fracture or fracture insignificant
•
Type $ %ssociated with a single or comminuted posterior wall fragment, but the hip remains stable through a functional range of motion
•
Type & %ssociated with gross instability of the hip joint secondary to loss of structural support
•
Type ' %ssociated with femoral head fracture
Anterior Di!'ocation
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/emoral head is located at the anterior acetabulum.
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#lassification of anterior dislocation of the hip joint by the >pstein 5 Type I
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Superior dislocations, Including pubic and subspinous
I%
#o associated fractures
I(
%ssociated fracture or impaction of the femoral head
I)
%ssociated fracture of the acetabulum
Type II
Inferior dislocations, Including obturator, and perineal
II%
#o associated fractures
II(
%ssociated fracture or impaction of the femoral head
II)
%ssociated fracture of the acetabulum
Centra' di!'ocation
#entral fracture4dislocation is a dislocation, where the femoral head located in the medial parts of fractured acetabulum. "his is due to the lateral pressure against the adducted femur found in most of motor vehicle accidents.
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2. C'inica' ()0to)!
&ip joint dislocation, whatever the cause, could be classified as an orthopedic emergency that re$uires immediate diagnosis, evaluation and treatmen. "o determine the diagnosis, trauma survey is important. Aeurovascular test including evaluation of the sciatic nerve (the most fre$uently affected parts of the tibia and nerve 2 femoris artery needs to be done.3 ? " & i p * o i n t D i s l o c a t i o n
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6osterior dislocation 4
6osition of the hip joint in fle%ion, adduction and internal rotation
4
Shortening of the legs
4
6alpable head of the femur on the pelvic
+.
6osition of the hip joint in e%tension, abduction and e%ternal rotation
4
"here was no shortening of limbs
4
mass in the inguinal area where the femoral head can be palpated easily
4
Difficult to move the hip joint #entral dislocatiom
0.
4
"he position of the pelvic appeared normal, just a little scuffed on lateral section
4
Movement of the hip joint is limited
2.3 Additiona' E,a)ination
Bn radiological e%amination can be found5 '.
6osterior dislocation
"he head of the femur is outside and above the acetabulum and the femoral positioned on internal rotation and adduction +.
"he head of the femur is seen in front of the acetabulum 0.
#entral dislocation
Cisible shift of the femoral head pelvis, and2or breaking through the acetabulum 2.4 Treat)ent
'. 6osterior dislocation with fracture "reatment is performed with $uick reposition in general anesthesia and enough muscle rela%ant.
5.16
post reposition treatment is skin traction for :4= weeks,
moreover, the patient couldnt use the leg on the inflicted side and should use crutches for 0 months.
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In children aged 3 years, acetabulum is mostly composed of soft cartilage and there is a rift in the joints including the hip joint. If muscles is in a rela% state, then mild trauma is enough to cause hip dislocation. "here may also differences between the hip and femoral head space. ith increasing age, the hip joint will become stronger, so that dislocation only occur with greater trauma. "he clinical picture of posterior dislocation appears in an upper limb fle%ion, internal rotation and adduction. "reatment of this type with closed reduction and can be done by several methods including !igelow, Stimson, and
Figure 1. Stimson method
Figure 2. Bigelow method " & i p * o i n t D i s l o c a t i o n
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Figure 3. Allis methods +.
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0. #entral dislocation #entral dislocation occurs when the femoral head pushed to the medial wall of acetabulum in the pelvis. "he capsule remain intact.
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In the central dislocation that accompanied with acetabulum fracture, the deformity of the lower limbs is not visible, there are only movement disorder of the hip joint. "his type of
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dislocation can be treated with reduction that re$uire bone traction with 4wire for a few weeks
5
Indications of surgery 5 4
#losed reposition failed or couldnt be done
4
1nstable femoral head position
4
/emoral column fracture found
4
7esion in A.Ischiadicus found
2.7 Co)0'ication!
#omplications were divided into 5 '.
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Immediate #omplications a. Ilio4femoral venous thrombosis "hese complication are commonly happen and very dangerous. If there any doubt arise or indications found, then prophylactic anticoagulation should be given routinely. b. !ladder laceration "ear may occur when there is disruption of the symphysis pubis or punctures from the sharp pelvic bone. c. 1rethral tear < torn urethra due to disruption of the symphysis pubis in the membranous urethra area. d. @ectal and vaginal trauma e. 7arge blood vessel trauma that would cause massive bleeding f.
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"rauma of the nerve
/urther complications a. &eterotrophic bone formation "his kind bone formation usually happen after severe soft tissue injury or after a dissection surgery. b.
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2.5 Progno!i!
6rognosis of dislocation of the hip joint depend on the presence of other tissue damage, early management of dislocation and severity of dislocation. If a closed dislocation without any fracture found then - of chances it will have a good prognosis. then if there is any damage inflicting other tissue, there is only 3:- of chances it will have a good prognosis. If dislocation of the hip joint repaired within '+ hours then it will improve the prognosis significantly. !ased on the position of the dislocation, anterior dislocation has a better prognosis than posterior dislocation. @esearch indicates poor prognosis occurs in +3of patients with anterior dislocation and 30- in the posterior dislocation. "he prognosis can also be determined from the Stewart and Milford classification. In the first grade, long4term complications fre$uently occur.
CHAPTER * '+ " & i p * o i n t D i s l o c a t i o n
CONC#UION
Dislocation of the hip joint is a condition in which the femoral head out of its socket called acetabulum in the hip bone (pelvic. "he most fre$uent cause of dislocation of the hip joint is traumati8ed by force 2 pressure such as motor vehicle accidents, pedestrian car accident, or falling from a height. "raumatic dislocation classified by the shift direction of the femoral head toward the acetabulum, that is the posteriorly, anteriorly and centrally. 6osterior dislocation is the most dislocation case found, about )4)-, and its usually due to motor vehicle accidents. &ip joint dislocation, no matter what the etiology is, can be classified as orthopedic emergency that re$uires immediate diagnosis, evaluation and treatment. "o determine diagnosis truma survey is very is important. 6rognosis of dislocation of the hip joint depends on the presence of other tissue damage, early management of dislocation and severity of dislocation. If a closed dislocation without any fracture found then - of chances it will have a good prognosis. then if there is any damage inflicting other tissue, there is only 3:- of chances it will have a good prognosis.
RE-ERENCE '0 " & i p * o i n t D i s l o c a t i o n
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dward ". +)'). *ip islocation in +mergency edicine. 0. Gammons,Matthew. *ip islocation. Downloaded from5 http522emedicine.medscape.com2article2=0)4clinical H showall :. Shu, !eatrice. +)''. *ip Instability %natomic and )linical )onsiderations of Traumatic and %traumatic Instability.#lin Sports Med 0) (+)'' 0:40=? 3. Salter, @obert !. '.Textbook of isorders and Injuries of the usculosceletal System &rd +ditiion. 7ippincott illiams ilkins. 3:4333 =. Skinner, &arry. , +))0. )urrent iagnosis Treatment in /rthopedics &rd edition. Mc Graw4&ill5 G#5 *akarta. =3; ?=4?. ''. >vans, Gareth #harles, +)). Traumatic *ip islocation. Downloaded from www.veterans4uk.info2...2 traumatic hip dislocation
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