Eur J Orthop Surg Traumatol (2002) 12: 102–104 DOI 10.1007/s00590-002-0018-5
CASE REPORT
Tomonori Baba Æ Kouhei Hitachi Æ Kazuo Kaneko
Fracture-dislocation of the hip with ipsilateral femoral neck fracture
Received: 20 May 2001 / Accepted: 12 February 2002 / Published online: 8 June 2002 Ó Springer-Verlag 2002
Abstract Fracture-dislocation of the hip associated with fracture of the femoral neck and intrapelvic intrusion of the femoral head is a rare injury. In this case we performed open reduction for the femoral neck fracture, and external fixation for the pelvic fracture by JudetMeyers method. As a result the patient has not complained of pain, although he developed arthrokleisis due to ectopic ossification around the femoral head, as well as femoral head necrosis. Keywords Fracture-dislocation Æ Femoral neck fracture Æ Judet-Meyers method Fracture-luxation de la hanche avec fracture ipsilate´rale du col de fe´mur Re´sume´ Nous rapportons un cas de fracture-luxation de la teˆte fe´morale avec migration dans le bassin chez un homme de 25 ans. La re´duction a e´te´ re´alise´e par fixation vis-plaque, le patient ne pre´sente actuellement aucune douleur, pas d’arthrose de la hanche, ni de ne´crose de la teˆte fe´morale, mais il a une petite raideur due a` des ossifications pe´ri-articulaires de sa hanche. Cinq ans apre`s, le patient est reste´ asymptomatique.
A case report In March 1998 a 36-year-old man was injured in an automobile accident. By the time he was admitted to the emergency room 30 min later he had lost consciousness and was suffering from traumatic shock. His blood pressure was 86/36 mmHg, pulse rate 115/min, and vital signs unstable. Abdominal pain and swelling of the right hip joint were identified. Radiographic examination revealed bilateral iliac fracture, bilateral pubic bone fracture, right femoral neck fracture, defect of the right anterior acetabulum, and intrapelvic intrusion of the femoral head. Sacroiliacal lesion was not present (Fig. 1). Computed tomography scanning (CT) revealed an acetabulum fracture of the anterior column in its superior part, and intrapelvic intrusion of the femoral head (Fig. 2). Other complications included a ruptured bladder, urethral injury, and mesentery injury of the small intestine. We performed an emergency cystostomy and partial resection of the small intestine; however, due to continuous low blood pressure associated with bleeding, we performed skeletal traction only of the fractured right femur.
Mots cle´s Fracture et dislocation Æ La fracture de col de fe´mur Æ La me´thode de Judet-Meyer
No benefits in any form have been received or will be received from a commercial party directly relating to the subject of this article T. Baba (&) Æ K. Hitachi Æ K. Kaneko Department of Orthopaedic Surgery, Juntendo University, Izunagaoka Hospital, 1129 Nagaoka, Izunagaoka, Tagata, Shizuoka, #410–2295, Japan E-mail: [email protected] Tel.: +81-559-483111 Fax: +81-559-460010
Fig. 1. Radiographic examination revealed bilateral iliac fractures, bilateral pubic bone fracture, right femoral neck fracture, defect of right anterior acetabulum, and intrapelvic intrusion of the femoral head
103
Fig. 2. CT scan revealed fracture of the acetabulum anterior column and intrapelvic intrusion of the femoral head
Fig. 4. After 2 years and 2 month, ectopic ossification around the femoral head and femoral head necrosis was visible attached quadratus femoris muscle, was fixed at the fracture site by Herbert screw. Ectopic ossification around the femoral head was visible 17 days after operation. We removed the external fixator 8 weeks postoperatively, and the patient was restricted to protective weight bearing for 3 months. Femoral head necrosis, associated with the irregular outline of the inside of the femoral head, began to appear after 9 months. After 2 years and 2 months ectopic ossification around the femoral head and femoral head necrosis were visible. However, the patient was able to walk, unaided, without pain (Fig. 4).
Discussion
Fig. 3. Femoral head was repositioned with a femoral head remover and fixed by three cannulated screws and a plate. A bone graft that included the posterolateral aspect of the intertrochanteric crest, along with the attached quadratus femoris muscle, was fixed at the fracture site by Herbert screw
Once the patient’s general condition stabilized (5 days after the injury) we performed open reduction for the femoral neck fracture, and external fixation for the pelvic fracture by Judet-Meyers method [2, 6] (Fig. 3). We approached the hip through a lateral incision and performed an extraarticular osteotomy of the greater trochanter to provide better visualization of the acetabulum. The femoral head was intruding into the pelvis from the point of acetabular fracture. It was repositioned with a femoral head remover and fixed by three cannulated screws and a plate. There was no fracture of the femoral head. A bone graft that included the posterolateral aspect of the intertrochanteric crest, along with the
Hip dislocation with osteopathy can be classified into: (1) Joint dislocation-fracture, causing fracture around the joint after dislocation; (2) fracture-joint dislocation, causing dislocation after fracture of the joint surface; and (3) joint dislocation and fracture, causing fracture of the limb that composes the joint due to continuation of the external force that caused the dislocation. Joint dislocation-fracture, in the broad sense, includes all of these scenarios. In this case hip joint dislocation-fracture resulted in the fracture of the anterior column of the acetabulum and was associated with a femoral neck fracture. Moreover, the femoral head intruded into the pelvis, making this case extremely rare. We found five cases only in the literature relating to fracture-dislocation of the hip associated with fracture of the femoral neck and intrapelvic intrusion of the femoral head [1, 4, 5]. Fracture of the anterior column of the acetabulum due to external force on the lateral greater trochanter has
104
been reported at hip flexion of 90° and external rotation of 25° [3]. Although details of our case are uncertain, it is likely that the patient’s hip joint at the time of impact was in a flexed and externally rotated position. Therefore, force on the outside of the lateral greater trochanter drove the femoral head into the acetabulum, fracturing the anterior column. The femoral head became impaled in the anterior column and the femoral neck fracture occurred because the greater trochanter acted as a fulcrum as the automobile overturned. Our therapeutic indication for femoral neck fracture is internal fixation rather than prosthesis. This also is the indication for pelvic fractures, unless the state is unstable due to multiple injuries. Then external fixation is indicated. However, because we had no previous experience with a case such as this, we felt it inappropriate to apply our usual indications, as the state of pelvic fracture was not stable and there were too few pieces of bone to apply internal fixation. We therefore chose external fixation to gain stability. As for the femoral neck fracture, because the femoral head intruded into the pelvis, we strongly suspected severance of the feeding artery. We therefore chose the Judet-Meyers muscle-pedicle grafting procedure, taking into consideration future risk of femoral head necrosis. A similar case treated by Meinhard [4] with the same method resulted in full range
of motion and a good result – which is normality of gait despite deformity of femoral head – 2 years after operation. In our case the patient has not complained of pain, although ectopic ossification around the femoral head caused arthrokleisis, and femoral head necrosis developed.
References 1. Arthur H, Michel D (1985) Anterior dislocation of the hip with ipsilateral basicervical fracture. J Bone Joint Surg [Am] 67:326– 329 2. Judet R (1962) Traitement des fractures du col du fe´mur par greffe pe´dicule´e. Acta Orthop Scand 32:421–427 3. Judet R, Judet J, Letournel E (1964) Fracture of the acetabulum. Classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg [Am] 461615–1646 4. Meinhard BP, Misoul C, Joy D, Ghillani R (1987) Central acetabular fracture with ipsilateral neck fracture and intrapelvic dislocation of the femoral head without major pelvic column disruption. J Bone Joint Surg [Am] 69:612–615 5. Mestdagh H, Butruille Y, Vigier PH (1991) Central fracturedislocation of the hip with ipsilateral femoral neck fracture: case report. J Trauma 31:1445–1447 6. Meyers MH, Havey JP, Moore TM (1973) Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle-pedicle-bone graft and internal fixation. J Bone Joint Surg [Am] 55:257–273
CASE REPORT
Tomonori Baba Æ Kouhei Hitachi Æ Kazuo Kaneko
Fracture-dislocation of the hip with ipsilateral femoral neck fracture
Received: 20 May 2001 / Accepted: 12 February 2002 / Published online: 8 June 2002 Ó Springer-Verlag 2002
Abstract Fracture-dislocation of the hip associated with fracture of the femoral neck and intrapelvic intrusion of the femoral head is a rare injury. In this case we performed open reduction for the femoral neck fracture, and external fixation for the pelvic fracture by JudetMeyers method. As a result the patient has not complained of pain, although he developed arthrokleisis due to ectopic ossification around the femoral head, as well as femoral head necrosis. Keywords Fracture-dislocation Æ Femoral neck fracture Æ Judet-Meyers method Fracture-luxation de la hanche avec fracture ipsilate´rale du col de fe´mur Re´sume´ Nous rapportons un cas de fracture-luxation de la teˆte fe´morale avec migration dans le bassin chez un homme de 25 ans. La re´duction a e´te´ re´alise´e par fixation vis-plaque, le patient ne pre´sente actuellement aucune douleur, pas d’arthrose de la hanche, ni de ne´crose de la teˆte fe´morale, mais il a une petite raideur due a` des ossifications pe´ri-articulaires de sa hanche. Cinq ans apre`s, le patient est reste´ asymptomatique.
A case report In March 1998 a 36-year-old man was injured in an automobile accident. By the time he was admitted to the emergency room 30 min later he had lost consciousness and was suffering from traumatic shock. His blood pressure was 86/36 mmHg, pulse rate 115/min, and vital signs unstable. Abdominal pain and swelling of the right hip joint were identified. Radiographic examination revealed bilateral iliac fracture, bilateral pubic bone fracture, right femoral neck fracture, defect of the right anterior acetabulum, and intrapelvic intrusion of the femoral head. Sacroiliacal lesion was not present (Fig. 1). Computed tomography scanning (CT) revealed an acetabulum fracture of the anterior column in its superior part, and intrapelvic intrusion of the femoral head (Fig. 2). Other complications included a ruptured bladder, urethral injury, and mesentery injury of the small intestine. We performed an emergency cystostomy and partial resection of the small intestine; however, due to continuous low blood pressure associated with bleeding, we performed skeletal traction only of the fractured right femur.
Mots cle´s Fracture et dislocation Æ La fracture de col de fe´mur Æ La me´thode de Judet-Meyer
No benefits in any form have been received or will be received from a commercial party directly relating to the subject of this article T. Baba (&) Æ K. Hitachi Æ K. Kaneko Department of Orthopaedic Surgery, Juntendo University, Izunagaoka Hospital, 1129 Nagaoka, Izunagaoka, Tagata, Shizuoka, #410–2295, Japan E-mail: [email protected] Tel.: +81-559-483111 Fax: +81-559-460010
Fig. 1. Radiographic examination revealed bilateral iliac fractures, bilateral pubic bone fracture, right femoral neck fracture, defect of right anterior acetabulum, and intrapelvic intrusion of the femoral head
103
Fig. 2. CT scan revealed fracture of the acetabulum anterior column and intrapelvic intrusion of the femoral head
Fig. 4. After 2 years and 2 month, ectopic ossification around the femoral head and femoral head necrosis was visible attached quadratus femoris muscle, was fixed at the fracture site by Herbert screw. Ectopic ossification around the femoral head was visible 17 days after operation. We removed the external fixator 8 weeks postoperatively, and the patient was restricted to protective weight bearing for 3 months. Femoral head necrosis, associated with the irregular outline of the inside of the femoral head, began to appear after 9 months. After 2 years and 2 months ectopic ossification around the femoral head and femoral head necrosis were visible. However, the patient was able to walk, unaided, without pain (Fig. 4).
Discussion
Fig. 3. Femoral head was repositioned with a femoral head remover and fixed by three cannulated screws and a plate. A bone graft that included the posterolateral aspect of the intertrochanteric crest, along with the attached quadratus femoris muscle, was fixed at the fracture site by Herbert screw
Once the patient’s general condition stabilized (5 days after the injury) we performed open reduction for the femoral neck fracture, and external fixation for the pelvic fracture by Judet-Meyers method [2, 6] (Fig. 3). We approached the hip through a lateral incision and performed an extraarticular osteotomy of the greater trochanter to provide better visualization of the acetabulum. The femoral head was intruding into the pelvis from the point of acetabular fracture. It was repositioned with a femoral head remover and fixed by three cannulated screws and a plate. There was no fracture of the femoral head. A bone graft that included the posterolateral aspect of the intertrochanteric crest, along with the
Hip dislocation with osteopathy can be classified into: (1) Joint dislocation-fracture, causing fracture around the joint after dislocation; (2) fracture-joint dislocation, causing dislocation after fracture of the joint surface; and (3) joint dislocation and fracture, causing fracture of the limb that composes the joint due to continuation of the external force that caused the dislocation. Joint dislocation-fracture, in the broad sense, includes all of these scenarios. In this case hip joint dislocation-fracture resulted in the fracture of the anterior column of the acetabulum and was associated with a femoral neck fracture. Moreover, the femoral head intruded into the pelvis, making this case extremely rare. We found five cases only in the literature relating to fracture-dislocation of the hip associated with fracture of the femoral neck and intrapelvic intrusion of the femoral head [1, 4, 5]. Fracture of the anterior column of the acetabulum due to external force on the lateral greater trochanter has
104
been reported at hip flexion of 90° and external rotation of 25° [3]. Although details of our case are uncertain, it is likely that the patient’s hip joint at the time of impact was in a flexed and externally rotated position. Therefore, force on the outside of the lateral greater trochanter drove the femoral head into the acetabulum, fracturing the anterior column. The femoral head became impaled in the anterior column and the femoral neck fracture occurred because the greater trochanter acted as a fulcrum as the automobile overturned. Our therapeutic indication for femoral neck fracture is internal fixation rather than prosthesis. This also is the indication for pelvic fractures, unless the state is unstable due to multiple injuries. Then external fixation is indicated. However, because we had no previous experience with a case such as this, we felt it inappropriate to apply our usual indications, as the state of pelvic fracture was not stable and there were too few pieces of bone to apply internal fixation. We therefore chose external fixation to gain stability. As for the femoral neck fracture, because the femoral head intruded into the pelvis, we strongly suspected severance of the feeding artery. We therefore chose the Judet-Meyers muscle-pedicle grafting procedure, taking into consideration future risk of femoral head necrosis. A similar case treated by Meinhard [4] with the same method resulted in full range
of motion and a good result – which is normality of gait despite deformity of femoral head – 2 years after operation. In our case the patient has not complained of pain, although ectopic ossification around the femoral head caused arthrokleisis, and femoral head necrosis developed.
References 1. Arthur H, Michel D (1985) Anterior dislocation of the hip with ipsilateral basicervical fracture. J Bone Joint Surg [Am] 67:326– 329 2. Judet R (1962) Traitement des fractures du col du fe´mur par greffe pe´dicule´e. Acta Orthop Scand 32:421–427 3. Judet R, Judet J, Letournel E (1964) Fracture of the acetabulum. Classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg [Am] 461615–1646 4. Meinhard BP, Misoul C, Joy D, Ghillani R (1987) Central acetabular fracture with ipsilateral neck fracture and intrapelvic dislocation of the femoral head without major pelvic column disruption. J Bone Joint Surg [Am] 69:612–615 5. Mestdagh H, Butruille Y, Vigier PH (1991) Central fracturedislocation of the hip with ipsilateral femoral neck fracture: case report. J Trauma 31:1445–1447 6. Meyers MH, Havey JP, Moore TM (1973) Treatment of displaced subcapital and transcervical fractures of the femoral neck by muscle-pedicle-bone graft and internal fixation. J Bone Joint Surg [Am] 55:257–273
