Treatment of fracture dislocation of the femoral head using safe
surgical hip dislocation: a case report.
Authors
Paa Kwesi Baidoo1, Kwasi Twumasi Baah
Jnr1, Abu Anning1, Alex Osei
Assim2, Emmanuel Kafui Ayodeji2,
Senyo Gudugbe1
1Directorate of Orthopedics and Trauma, Komfo Anokye
Teaching Hospital, Kumasi, Ghana
2Department of Surgery, Komfo Anokye Teaching
Hospital, Kumasi, Ghana
Corresponding author:
Paa Kwesi Baidoo
Directorate of Orthopedics and Trauma, Komfo Anokye Teaching Hospital,
Kumasi, Ghana
Email:
pakvandal@gmail.com
https://orcid.org/0000-0003-4028-1911
Abstract
We report the clinical and radiological outcomes of a 30-year-old female
with femoral head fracture following a posterior hip dislocation. The
patient was managed using safe surgical hip dislocation and reviewed the
literature on Pipkin type I fractures.
Keywords: Pipkin, femoral head, fracture, surgical hip dislocation,
outcome, complication
Funding: none
Introduction
Femoral head fractures are quite rare and may be associated with hip
dislocations, femoral neck, and acetabular
fractures1,2. The reported annual incidence is about 2
cases per million3. Since Birkett4first descriptions of these fractures in 1869, there have been many case
reports. Pipkin5 in 1957 recommended a classification
system for femoral head fractures and this is widely used to this day.
The classification divided these injuries into 4 types; type I. involves
the non-weight bearing part of the femoral head, type II affects the
weight-bearing part of the head of femur, type III may include either or
both types I or II with femoral neck fracture, and type IV involves type
I or II associated with acetabular fracture5.
Hip dislocations like any other joint dislocations are orthopedic
emergencies and usually result from high energy injuries. The classical
mechanism is from “dashboard injury” but may also result from sports
injuries or fall from heights6. Femoral head fractures
have traditionally been known to have poor functional outcomes and high
complication rates especially avascular necrosis (AVN) and
post-traumatic arthritis of the hip joint7-9. It is
well documented that early reduction should be done under anesthesia and
adequate muscle relaxation, stabilization, and rigid fixation to achieve
stable and congruent joint thereby reducing potential complication
rate1,6. The best surgical approach on whether to fix
or excise the femoral head fragment however remains
controversial2.
Many approaches have been proposed for the fixation of these fractures
but the drawback is the limited exposure of the femoral head in all
these approaches1,8. However, the current technique of
safe surgical hip dislocation (SHD) as proposed by Ganz et al10 allows for complete exposure of the femoral head
and acetabulum without interrupting the blood supply of the femoral
head. We report our management of a patient with pipkin using the
approach proposed by Ganz which conforms to the SCARE
Criteria11.
Case Report
Our patient is a 30-year-old Ghanaian female who was an unrestrained
backseat passenger in a saloon car that was involved in a head-on
collision. The patient lost consciousness that lasted for about an hour
after the accident. At presentation at the emergency department of the
hospital, she had a Glasgow coma score (GCS) of 15/15. The patient
sustained frontal scalp hematoma and multiple lacerations on the left
lower limb. Her left lower limb was shortened, flexed at the hip,
adducted, and internally rotated. There was no associated neurovascular
deficit. Computerized tomography (CT) scan of the brain was normal and a
pelvic x-ray showed posterior dislocation of the left hip associated
with femoral head fracture (Figure 1). A diagnosed of posterior
dislocation of the left hip (Pipkin type 1) was made.
An emergent closed reduction under general anesthesia was done at the
emergency department. Following the reduction, the hip was found to be
relatively unstable. Post reduction pelvic x-ray showed an incongruent
and widened hip joint (Figure 2). A CT scan of the pelvis with 3D
reconstruction showed a large femoral head fragment inferior to the
fovea centralis that was not anatomically reduced (Figures 3a and 3b).
An open anatomical reduction and internal fixation using safe surgical
hip dislocation as described by Ganz 10 was done 4
days after the initial. The delay was as a result of unavailability of
Herbert screws at the time of presentation. Intra-operatively, the
fragment was found to be viable (viability of the femoral head was
confirmed by observing bleeding from the fragment following perforation
using a 1.6mm Kirschner wire) hence anatomical reduction was done
followed by fixation of the fragment using two 2.7 mm subchondral
headless cannulated screws (Herbert screws) on the posterio-inferior
aspect of the head (Figure 4a and b). The labrum was found on inspection
to be torn and was repaired using Vicryl 2 suture. The capsule was
closed with Vicryl 2. The greater trochanter was fixed using two 3.5mm
cortical screws (Figure 4c).
Postoperatively, the patient was kept non-weight bearing on crutches for
8 weeks and was put on 25 mg indomethacin (trice daily for a month) as a
prophylaxis against heterotopic ossification. At one-year follow-up, she
had a painless hip with a full range of motion and there was no evidence
of AVN of the femoral head (Figure 5a and 5b) or heterotopic
ossification.
Discussion
The most important determinant of optimum outcome is the time between
the dislocation and reduction of the hip joint. Epstein et al7 recommended that all traumatic hip dislocations
should be managed as surgical emergencies and multiple attempts at
closed reduction should be avoided to minimize the risk of AVN which has
an incidence between 8% to 26% 2. According to
Epstein12 reduction within 24 hours lead to better
outcome compared to when done after 24 hours. McMurtry et al13 further indicated that the risk of AVN of the
femoral is small when reduction is done within 6 hours.
Pipkin I fractures can be managed either surgically or non-operatively
depending on the fragment size and surgical expertise. In general,
surgical management is recommended for types I and II fractures with
large fragments especially those located at the weight bearing region of
the head as well as all types III and IV14,15.
Achieving optimal results is dependent on obtaining an anatomic
reduction of the fragments, which is difficult with closed reduction.
Henle et al9 recommended surgical treatment to improve
the reduction if the gap between the fragments were more than 2 mm as
only 1 in 12 patients in their series had anatomic reduction following
closed manipulation.
The best surgical approach for Pipkin fractures remains
controversial1,9,10. The Kocher-Langenbeck,
Smith-Peterson, and Watson Jones approaches or percutaneous fixation
after a successful reduction have been used in managing these injuries
albeit with limited exposure of the femoral head and
acetabulum7,8,12. Safe SHD has been increasingly used
in addressing head of femur fractures despite its technical
challenges10,16. It enables full access to the whole
acetabulum and femoral head, facilitates the anatomic reduction of the
fragments, and also helps identify any chondral, subchondral, or labral
tears which may not be seen using the other
approaches1,2,10. Labral tears are found in up to 50%
of patients and are associated with poor outcome2. The
functional outcome (in terms of pain and range of motion of the hip
joint) of our patient was satisfactory probably because it was a Pipkin
type I fracture. However the choice of safe SHD may have contributed to
this outcome as the approach minimizes the risk of vascular injury to
the head and the already traumatized soft tissue.
Conclusion
This case demonstrates the efficacy of safe surgical hip dislocation in
managing femoral head fractures. The type of treatment and surgical
approach should be guided by the fracture type and the associated
injuries. Irrespective of the method or surgical approach however, we
should always aim for anatomical reduction of the fragments while
minimizing injury to the surrounding soft tissues.
Acknowledgements
None
Conflict of interest
None declared
Authors contribution
PKB, KTB, AA, AOA, EKA and SG performed the surgical procedure, followed
up on the patient and prepared the manuscript.
Ethical approval
Written informed consent was obtained from the patient for publication
of this case report and the associated images.
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Figure legends
Figure 1
Pre-operative pelvic x-ray, AP, showing fracture dislocation of the left
hip joint.
Figure 2
Post reduction pelvic x-rays showing widening of the left hip joint and
retained fragment of the femoral head.
Figure 3a and b
Post reduction axial C.T scan (3a) of the pelvis showing fracture of the
femoral head with a non-anatomical reduction of the fragment and 3D
reconstruction (3b) showing femoral head fracture inferior to the fovea
centralis (Pipkin I).
Figure 4a,b and c
Intra-operative image showing the large femoral head fragment (4a) and
reduced fragment (4b) fixed with two 2.7 mm Herbert screws subchondrally
and (4c)post-operative pelvic x-ray showing screw fixation of the
greater trochanter.
Figure 5a and b
Axial (5a) and sagittal C.T scans (5b) as well as AP pelvic x-ray at one
year post injury showing healed fracture with no evidence of avascular
necrosis.