Review Question - QID 217513

Acetabular Fractures Treatment Operative QID: 217513 (OBQ21.194)

QID 217513 (Type "217513" in App Search)

A 21-year-old male presents to the emergency department after a motor vehicle collision. His left leg is flexed and internally rotated with decreased sensation in the sciatic nerve distribution. His radiograph in the emergency department is shown in Figure A. The orthopaedic resident on call performs a closed reduction under conscious sedation, with the post-reduction radiographs shown in Figure B. The numbness gradually improves afterward. Which of the following would be an absolute indication for surgical intervention for this patient?

Type & Select Correct Answer

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Sciatic nerve palsy

28/1180

Large posterior labral tear

3/1180

Fracture of the posterior wall of the acetabulum

27/1180

1 cm osseous loose body in the weight bearing surface of the joint

94%

1110/1180

Chondral defect to the femoral head

3/1180

Select Answer to see Preferred Response

An osseous loose body in the weight-bearing aspect of the hip is an absolute indication for surgical intervention to avoid progressive joint destruction.

Hip dislocations are typically a high-energy injury in young patients. Posterior dislocations make up 90% of hip dislocations. There are several associated injuries including acetabular fractures, proximal femur fractures, sciatic nerve injuries, labral injuries, and knee injuries. An emergent closed reduction is indicated to avoid complications such as avascular necrosis. Surgical intervention is indicated in irreducible dislocations, non-concentric reductions, incarcerated fragments, proximal femur fractures, and acetabular fractures that result in instability.

Foulk et al. reviewed the evaluation and management of hip dislocations. They state that a hip dislocation should be reduced emergently with deep procedural sedation. Indications for surgery include nonconcentric reductions, proximal femur fracture, and acetabular fractures producing instability. They note that arthroscopy is rising in popularity to address intra-articular injuries after dislocations that may not be evident on a CT scan.

Upadhyay et al. reported their results of 81 patients with posterior hip dislocation. They found that 24% of patients had a poor result. Patients who were deemed to have more severe injuries had a 73% rate of poor to fair outcomes.

Figure A is an AP radiograph demonstrating a left hip dislocation without obvious evidence of fracture. Figure B is an AP radiograph showing a concentric reduction of the left hip.

Incorrect Answers:
Answer 1: Sciatic nerve palsies are associated with 10-15% of posterior hip dislocations but are often a stretch neuropraxia that resolve with time and not an absolute indication for surgery, particularly in this patient who is already having resolution.
Answer 2: Labral tears are common after hip dislocations, but whether or not they require surgery is still debated, as they may have the potential to heal.
Answer 3: Posterior wall fractures only require surgery if they produce instability. Fractures involving less than 20% of the acetabulum should undergo an exam of stability under anesthesia.
Answer 5: Chondral defects of the femoral head are common after hip dislocations, but surgical intervention has not proven to be of benefit to address them.