Journal of Orthopaedic Surgery 2015;23(1):123-6
Inferior dislocation of the hip: a case report and literature review Sameer Jain, Benjamin A Haughton, Richard J Grogan
Bradford, West Yorkshire, West Yorkshire, United Kingdom
ABSTRACT We report on a 17-year-old man who underwent open reduction and internal fixation for an inferior dislocation of the right hip and displaced fractures of the right femoral head and neck, and antegrade intramedullary nailing for a displaced fracture of the left femoral shaft. In addition, 13 men and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed from the literature. Key words: fracture fixation, internal; hip dislocation
INTRODUCTION Inferior dislocation of the hip, also known as luxatio erecta femoris or infracotyloid dislocation, is a rare injury. It is characterised by forceful and extreme flexion of the hip, with caudal displacement of the femur and dislocation of the femoral head. There
are 2 types of injury mechanism. The obturator type involves a force applied to an abducted hip, which is then flexed and externally rotated to dislocate the femoral head to lie anteriorly and inferiorly to the obturator foramen; the thigh can be in varying degrees of flexion and abduction. The ischial type involves a force applied to the flexed hip and knee, with the femur in extreme flexion (i.e. parallel to the long axis of the body but with little or no abduction or external rotation of the thigh); the femoral head dislocates inferiorly and lies next to the ischium. The ischial type is more common than the obturator type. Treatment consists of closed reduction under sedation or general anaesthesia with axial traction while gradually extending the thigh with additional internal rotation manoeuvres, followed by immobilisation for 2 to 6 weeks and then gradual return to normal weightbearing. This study reports on a 17-year-old man who underwent open reduction and internal fixation for an inferior dislocation of the right hip and displaced fractures of the right femoral head and neck, and antegrade intramedullary nailing for a displaced fracture of the left femoral shaft. In addition, 13 men
Address correspondence and reprint requests to: Mr Sameer Jain, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, United Kingdom. Email: [email protected]
Journal of Orthopaedic Surgery
124 S Jain et al.
and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed from the literature.1–14 CASE REPORT In October 2009, a 17-year-old man presented to the emergency department with pain in the right hip and left thigh after a motor vehicle collision. His right leg was held in a frog-leg position, and the left thigh was deformed, with a weak dorsalis pedis pulse palpable. The patient was haemodynamically stable, with no neurological impairment. Radiography and computed tomography showed inferior dislocation of the right hip, displaced fractures of the right femoral head and neck (Fig. a), and a displaced fracture of the left femoral shaft. Angiography showed a site of short occlusion in the left superficial femoral artery, which was stented. The patient was given antibiotic prophylaxis (gentamicin and teicoplanin) at anaesthetic induction. The left femoral shaft fracture was treated first with an antegrade intramedullary nail (T2 nailing system, Stryker, Germany), as it was the most severe injury owing to vascular compromise. The right hip was then accessed through the anterolateral modified Hardinge approach. The femoral head was dislocated inferiorly, with the posterior capsule attached and preserved. An osteochondral fragment from the femoral head was reduced and fixed using a headless variable-pitch compression screw (Newdeal, France). The femoral neck fracture was stabilised with a 135º 2-hole compression hip screw and a neutralisation plate (Omega 2, Stryker, Germany). Low-molecular-weight heparin (5000 units of dalteparin) was given and continued until the patient was discharged. There were no immediate
(a)
postoperative complications; satisfactory reduction and fixation was achieved (Fig. b). The patient was discharged 13 days later and was advised on active hip movements and non-weightbearing on the right side for 6 weeks. Weightbearing as tolerated was allowed after 6 weeks. At 3 months, the right femoral neck fracture and left femoral shaft fracture had united. At 6 months, the patient was walking without aids and achieved a full range of flexion of both hips. At 13 months, the patient had no evidence of avascular necrosis, and the compression hip screw was removed at his request. At 4 years, the patient had a full range of motion of the right hip, with no evidence of degenerative hip arthropathy, despite mild symptoms of moderate heterotopic ossification (Fig. c). He was walking unaided and had returned to employment. DISCUSSION MEDLINE, PubMed, and Google Scholar were searched using the key words: ‘hip’ and ‘inferior dislocation’ or ‘luxatio erecta’ or ‘infracotyloid dislocation’. A total of 14 articles reporting on 13 men and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed (Table).1–14 One patient had a concurrent displaced fracture of the ipsilateral proximal femur.10 Six patients were children,1–4,6,13 of whom 2 were injured when another child fell onto their back as they fell.4,6 Dislocation in children is usually secondary to low-energy trauma, owing to increased joint laxity and a shallow acetabulum.6 The mechanism of injury included road traffic accidents (n=5), falling while running (n=4), sports related (n=4), falling from a height (n=2), falling from a bicycle (n=1), and falling from a tree branch onto a leg
(b)
(c)
Figure Radiological examination (a) before and (b) immediately after surgery, and (c) at the 4-year follow-up showing inferior dislocation of the right hip and displaced fractures of the right femoral head and neck treated with a dynamic hip screw, and a displaced fracture of the left femoral shaft treated with and an antegrade intramedullary nail.
Vol. 23 No. 1, April 2015
Inferior dislocation of the hip 125 Table Review of the literature regarding inferior dislocation of the hip
Study
Year
Sex/age (years)
Injury mechanism
Dislocation Treatment type
Mauck and 1935 Anderson1 Sankarankutty2 1967
F/6
Fall from a height
Ischial
Closed reduction, bed rest 2 weeks
M/7
Fall from a bicycle
Ischial
Closed reduction, traction 6 weeks, non-weightbearing 3 months Closed reduction, traction 4 days, spica casting 4 weeks Closed reduction, traction 2 weeks, spica casting 3 weeks Closed reduction, bed rest 4 days
3
Rao and Read
1975
F/5
Fall while running
Ischial
Abad Rico and Barquet4 Eddy and Connell5 Beauchesne et al.6 Bartley and Dimon7 Brogdon and Woolridge8 Ferguson and Harris9 Singh et al.10
1982
M/10
Fall while running
Ischial
1988
F/28
Fall while running
Ischial
1994
M/7
Fall while running
Ischial
1995
F/23
Sports related
1997
M/15
Sports related
2000
M/ adult
Sports related
2006
M/35
Road traffic accident
Kolar et al.11
2011
M/37
Sports related
Pankaj et al.12
2011
M/33
Aggarwal et al.13
2012
M/40, M/56, M/10, M/29
Bhagwat et al.14 2012
M/30
Road traffic accident 6 months earlier Road traffic accident (n=2), fall from a height, tree branch falling on a leg Road traffic accident
Present study
M/17
Road traffic accident
2015
Closed reduction, traction 3 days, toe-touch weightbearing 4 weeks Ischial Closed reduction, traction 2 days, protected weightbearing 6 weeks Ischial Closed reduction, traction 2 weeks, toe-touch weightbearing Obturator Closed reduction, traction 3 days, toe-touch weightbearing Obturator Open reduction, dynamic hip screw for concurrent intertrochanteric fracture, traction 2 weeks, protected weightbearing 2 months Ischial Closed reduction Obturator Uncemented total hip arthroplasty owing to chronic dislocation Closed reduction, traction 6 weeks
Bilateral closed reduction, traction 6 weeks Obturator Open reduction and internal fixation, antegrade intramedullary nailing for a displaced fracture of the left femoral shaft, nonweightbearing 6 weeks
(n=1). Most patients presented with an ischial-type dislocation, with extreme hip flexion, prominence of the greater trochanter, and the thigh touching the anterior abdominal wall,1–8,11 whereas some presented with varying degrees of flexion, abduction, and external rotation, indicating an associated fracture, a chronic injury, or an obturator-type dislocation.9,10,12 All dislocations were treated with closed reduction under sedation or general anaesthesia, followed by varying regimens of traction and restricted weightbearing. One patient with a chronic, neglected inferior dislocation of the hip underwent total hip arthroplasty and regained normal activity by 3 months.12 One patient with a concurrent intertrochanteric proximal femoral fracture underwent open reduction (with the aid of a Schanz pin) and internal fixation (with a compression hip screw).10
-
Outcome Recurrent dislocation at 1 year Full recovery at 6 months Full recovery at 5 months Lost to follow-up Lost to follow-up Full recovery at 18 months Slight discomfort at 6 years, no avascular necrosis Lost to follow-up Full recovery at 2.5 years
Full recovery at 1 year, no participation in sports Full recovery at 3 months Full recovery at a mean of 6 months Full recovery Moderate heterotopic ossification at 4 years, no avascular necrosis
One patient had a recurrent dislocation after a fall from a standing height one year later. All patients eventually achieved a full and pain-free range of hip motion, with no evidence of avascular necrosis of the femoral head. All children achieved normal hip development. Four patients were lost to followup.4,5,8,9 A limitation of this study was that meta-analysis was not performed and that only case reports and case series were reviewed. Nonetheless, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to minimise publication bias. DISCLOSURE No conflicts of interest were declared by the authors.
126 S Jain et al.
Journal of Orthopaedic Surgery
REFERENCES 1. 2. 3. 4.
Mauck HP, Anderson RL. Infracotyloid dislocation of the hip. J Bone Joint Surg 1935;17:1011–3. Sankarankutty M. Traumatic interior dislocation of the hip (luxatio erecta) in a child. J Bone Joint Surg Br 1967;49:145. Rao JP, Read RB. Luxatio erecta of the hip. An interesting case report. Clin Orthop Relat Res 1975;110:137–8. Abad Rico JI, Barquet A. Luxatio erecta of the hip. A case report and review of the literature. Arch Orthop Trauma Surg 1982;99:277–9. 5. Eddy RJ, Connell DG. Luxatio erecta of the hip. AJR Am J Roentgenol 1988;151:412. 6. Beauchesne R, Kruse R, Stanton RP. Inferior dislocation (luxatio erecta) of the hip. Orthopedics 1994;17:72–5. 7. Bartley RE 3rd, Dimon JH 3rd. Traumatic inferior hip dislocation in an adult (luxatio erecta). Orthopedics 1995;18:1173–4. 8. Brogdon BG, Woolridge DA. Luxatio erecta of the hip: a critical retrospective. Skeletal Radiol 1997;26:548–52. 9. Ferguson KL, Harris VV. Inferior hip dislocation in an adult: does a rare injury now have a common mechanism? Am J Emerg Med 2000;18:117–8. 10. Singh R, Sharma SC, Goel T. Traumatic inferior hip dislocation in an adult with ipsilateral trochanteric fracture. J Orthop Trauma 2006;20:220–2. 11. Kolar MK, Joseph S, McLaren A. Luxatio erecta of the hip. J Bone Joint Surg Br 2011;93:273. 12. Pankaj A, Sharma M, Kochar V, Naik VA. Neglected, locked, obturator type of inferior hip dislocation treated by total hip arthroplasty. Arch Orthop Trauma Surg 2011;131:443–6. 13. Aggarwal S, Kumar V, Bhagwat KR, Shashikanth VS, Ravikumar HS. Inferior dislocation of the hip: a case series and literature review. Chin J Traumatol 2012;15:317–20. 14. Bhagwat KR, Garg B, Aggarwal S, Dhillon MS. Bilateral inferior dislocation of the hip—a case report. Chin J Traumatol 2012;15:121–3.
Inferior dislocation of the hip: a case report and literature review Sameer Jain, Benjamin A Haughton, Richard J Grogan
Bradford, West Yorkshire, West Yorkshire, United Kingdom
ABSTRACT We report on a 17-year-old man who underwent open reduction and internal fixation for an inferior dislocation of the right hip and displaced fractures of the right femoral head and neck, and antegrade intramedullary nailing for a displaced fracture of the left femoral shaft. In addition, 13 men and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed from the literature. Key words: fracture fixation, internal; hip dislocation
INTRODUCTION Inferior dislocation of the hip, also known as luxatio erecta femoris or infracotyloid dislocation, is a rare injury. It is characterised by forceful and extreme flexion of the hip, with caudal displacement of the femur and dislocation of the femoral head. There
are 2 types of injury mechanism. The obturator type involves a force applied to an abducted hip, which is then flexed and externally rotated to dislocate the femoral head to lie anteriorly and inferiorly to the obturator foramen; the thigh can be in varying degrees of flexion and abduction. The ischial type involves a force applied to the flexed hip and knee, with the femur in extreme flexion (i.e. parallel to the long axis of the body but with little or no abduction or external rotation of the thigh); the femoral head dislocates inferiorly and lies next to the ischium. The ischial type is more common than the obturator type. Treatment consists of closed reduction under sedation or general anaesthesia with axial traction while gradually extending the thigh with additional internal rotation manoeuvres, followed by immobilisation for 2 to 6 weeks and then gradual return to normal weightbearing. This study reports on a 17-year-old man who underwent open reduction and internal fixation for an inferior dislocation of the right hip and displaced fractures of the right femoral head and neck, and antegrade intramedullary nailing for a displaced fracture of the left femoral shaft. In addition, 13 men
Address correspondence and reprint requests to: Mr Sameer Jain, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, United Kingdom. Email: [email protected]
Journal of Orthopaedic Surgery
124 S Jain et al.
and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed from the literature.1–14 CASE REPORT In October 2009, a 17-year-old man presented to the emergency department with pain in the right hip and left thigh after a motor vehicle collision. His right leg was held in a frog-leg position, and the left thigh was deformed, with a weak dorsalis pedis pulse palpable. The patient was haemodynamically stable, with no neurological impairment. Radiography and computed tomography showed inferior dislocation of the right hip, displaced fractures of the right femoral head and neck (Fig. a), and a displaced fracture of the left femoral shaft. Angiography showed a site of short occlusion in the left superficial femoral artery, which was stented. The patient was given antibiotic prophylaxis (gentamicin and teicoplanin) at anaesthetic induction. The left femoral shaft fracture was treated first with an antegrade intramedullary nail (T2 nailing system, Stryker, Germany), as it was the most severe injury owing to vascular compromise. The right hip was then accessed through the anterolateral modified Hardinge approach. The femoral head was dislocated inferiorly, with the posterior capsule attached and preserved. An osteochondral fragment from the femoral head was reduced and fixed using a headless variable-pitch compression screw (Newdeal, France). The femoral neck fracture was stabilised with a 135º 2-hole compression hip screw and a neutralisation plate (Omega 2, Stryker, Germany). Low-molecular-weight heparin (5000 units of dalteparin) was given and continued until the patient was discharged. There were no immediate
(a)
postoperative complications; satisfactory reduction and fixation was achieved (Fig. b). The patient was discharged 13 days later and was advised on active hip movements and non-weightbearing on the right side for 6 weeks. Weightbearing as tolerated was allowed after 6 weeks. At 3 months, the right femoral neck fracture and left femoral shaft fracture had united. At 6 months, the patient was walking without aids and achieved a full range of flexion of both hips. At 13 months, the patient had no evidence of avascular necrosis, and the compression hip screw was removed at his request. At 4 years, the patient had a full range of motion of the right hip, with no evidence of degenerative hip arthropathy, despite mild symptoms of moderate heterotopic ossification (Fig. c). He was walking unaided and had returned to employment. DISCUSSION MEDLINE, PubMed, and Google Scholar were searched using the key words: ‘hip’ and ‘inferior dislocation’ or ‘luxatio erecta’ or ‘infracotyloid dislocation’. A total of 14 articles reporting on 13 men and 4 women aged 5 to 56 (mean, 23) years with 16 unilateral and one bilateral inferior dislocation of the hip were reviewed (Table).1–14 One patient had a concurrent displaced fracture of the ipsilateral proximal femur.10 Six patients were children,1–4,6,13 of whom 2 were injured when another child fell onto their back as they fell.4,6 Dislocation in children is usually secondary to low-energy trauma, owing to increased joint laxity and a shallow acetabulum.6 The mechanism of injury included road traffic accidents (n=5), falling while running (n=4), sports related (n=4), falling from a height (n=2), falling from a bicycle (n=1), and falling from a tree branch onto a leg
(b)
(c)
Figure Radiological examination (a) before and (b) immediately after surgery, and (c) at the 4-year follow-up showing inferior dislocation of the right hip and displaced fractures of the right femoral head and neck treated with a dynamic hip screw, and a displaced fracture of the left femoral shaft treated with and an antegrade intramedullary nail.
Vol. 23 No. 1, April 2015
Inferior dislocation of the hip 125 Table Review of the literature regarding inferior dislocation of the hip
Study
Year
Sex/age (years)
Injury mechanism
Dislocation Treatment type
Mauck and 1935 Anderson1 Sankarankutty2 1967
F/6
Fall from a height
Ischial
Closed reduction, bed rest 2 weeks
M/7
Fall from a bicycle
Ischial
Closed reduction, traction 6 weeks, non-weightbearing 3 months Closed reduction, traction 4 days, spica casting 4 weeks Closed reduction, traction 2 weeks, spica casting 3 weeks Closed reduction, bed rest 4 days
3
Rao and Read
1975
F/5
Fall while running
Ischial
Abad Rico and Barquet4 Eddy and Connell5 Beauchesne et al.6 Bartley and Dimon7 Brogdon and Woolridge8 Ferguson and Harris9 Singh et al.10
1982
M/10
Fall while running
Ischial
1988
F/28
Fall while running
Ischial
1994
M/7
Fall while running
Ischial
1995
F/23
Sports related
1997
M/15
Sports related
2000
M/ adult
Sports related
2006
M/35
Road traffic accident
Kolar et al.11
2011
M/37
Sports related
Pankaj et al.12
2011
M/33
Aggarwal et al.13
2012
M/40, M/56, M/10, M/29
Bhagwat et al.14 2012
M/30
Road traffic accident 6 months earlier Road traffic accident (n=2), fall from a height, tree branch falling on a leg Road traffic accident
Present study
M/17
Road traffic accident
2015
Closed reduction, traction 3 days, toe-touch weightbearing 4 weeks Ischial Closed reduction, traction 2 days, protected weightbearing 6 weeks Ischial Closed reduction, traction 2 weeks, toe-touch weightbearing Obturator Closed reduction, traction 3 days, toe-touch weightbearing Obturator Open reduction, dynamic hip screw for concurrent intertrochanteric fracture, traction 2 weeks, protected weightbearing 2 months Ischial Closed reduction Obturator Uncemented total hip arthroplasty owing to chronic dislocation Closed reduction, traction 6 weeks
Bilateral closed reduction, traction 6 weeks Obturator Open reduction and internal fixation, antegrade intramedullary nailing for a displaced fracture of the left femoral shaft, nonweightbearing 6 weeks
(n=1). Most patients presented with an ischial-type dislocation, with extreme hip flexion, prominence of the greater trochanter, and the thigh touching the anterior abdominal wall,1–8,11 whereas some presented with varying degrees of flexion, abduction, and external rotation, indicating an associated fracture, a chronic injury, or an obturator-type dislocation.9,10,12 All dislocations were treated with closed reduction under sedation or general anaesthesia, followed by varying regimens of traction and restricted weightbearing. One patient with a chronic, neglected inferior dislocation of the hip underwent total hip arthroplasty and regained normal activity by 3 months.12 One patient with a concurrent intertrochanteric proximal femoral fracture underwent open reduction (with the aid of a Schanz pin) and internal fixation (with a compression hip screw).10
-
Outcome Recurrent dislocation at 1 year Full recovery at 6 months Full recovery at 5 months Lost to follow-up Lost to follow-up Full recovery at 18 months Slight discomfort at 6 years, no avascular necrosis Lost to follow-up Full recovery at 2.5 years
Full recovery at 1 year, no participation in sports Full recovery at 3 months Full recovery at a mean of 6 months Full recovery Moderate heterotopic ossification at 4 years, no avascular necrosis
One patient had a recurrent dislocation after a fall from a standing height one year later. All patients eventually achieved a full and pain-free range of hip motion, with no evidence of avascular necrosis of the femoral head. All children achieved normal hip development. Four patients were lost to followup.4,5,8,9 A limitation of this study was that meta-analysis was not performed and that only case reports and case series were reviewed. Nonetheless, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to minimise publication bias. DISCLOSURE No conflicts of interest were declared by the authors.
126 S Jain et al.
Journal of Orthopaedic Surgery
REFERENCES 1. 2. 3. 4.
Mauck HP, Anderson RL. Infracotyloid dislocation of the hip. J Bone Joint Surg 1935;17:1011–3. Sankarankutty M. Traumatic interior dislocation of the hip (luxatio erecta) in a child. J Bone Joint Surg Br 1967;49:145. Rao JP, Read RB. Luxatio erecta of the hip. An interesting case report. Clin Orthop Relat Res 1975;110:137–8. Abad Rico JI, Barquet A. Luxatio erecta of the hip. A case report and review of the literature. Arch Orthop Trauma Surg 1982;99:277–9. 5. Eddy RJ, Connell DG. Luxatio erecta of the hip. AJR Am J Roentgenol 1988;151:412. 6. Beauchesne R, Kruse R, Stanton RP. Inferior dislocation (luxatio erecta) of the hip. Orthopedics 1994;17:72–5. 7. Bartley RE 3rd, Dimon JH 3rd. Traumatic inferior hip dislocation in an adult (luxatio erecta). Orthopedics 1995;18:1173–4. 8. Brogdon BG, Woolridge DA. Luxatio erecta of the hip: a critical retrospective. Skeletal Radiol 1997;26:548–52. 9. Ferguson KL, Harris VV. Inferior hip dislocation in an adult: does a rare injury now have a common mechanism? Am J Emerg Med 2000;18:117–8. 10. Singh R, Sharma SC, Goel T. Traumatic inferior hip dislocation in an adult with ipsilateral trochanteric fracture. J Orthop Trauma 2006;20:220–2. 11. Kolar MK, Joseph S, McLaren A. Luxatio erecta of the hip. J Bone Joint Surg Br 2011;93:273. 12. Pankaj A, Sharma M, Kochar V, Naik VA. Neglected, locked, obturator type of inferior hip dislocation treated by total hip arthroplasty. Arch Orthop Trauma Surg 2011;131:443–6. 13. Aggarwal S, Kumar V, Bhagwat KR, Shashikanth VS, Ravikumar HS. Inferior dislocation of the hip: a case series and literature review. Chin J Traumatol 2012;15:317–20. 14. Bhagwat KR, Garg B, Aggarwal S, Dhillon MS. Bilateral inferior dislocation of the hip—a case report. Chin J Traumatol 2012;15:121–3.
