Updated: 10/29/2018

Traumatic Hip Dislocation - Pediatric

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Questions
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https://upload.orthobullets.com/topic/4017/images/hip_disloc_xr_3_yo.jpg
https://upload.orthobullets.com/topic/4017/images/nonconcentric.jpg
https://upload.orthobullets.com/topic/4017/images/osteochondral_fragment.jpg
 
Introduction
  • Overview
    • pediatric traumatic hip dislocation are usually posterior and may occur due to low injury sports injuries in children less than 10 years of age
      • treatment is urgent closed reduction under general anesthesia or sedation
      • open reduction may be required if there is an intraarticular fragment following reduction
  • Epidemiology
    • location
      • 80% are traumatic posterior dislocations
      • more common than hip fracture in pediatric patients
  • Pathophysiology
    • mechanism of injury
      • age <10
        • may have low energy sports injury, or trip and fall
      • age >10
        • mostly high energy (e.g. MVA)
  • Associated conditions
    • fractures
      • acetabular fractures
        • lower incidence of acetabular fractures compared with adults
        • due to cartilaginous acetabulum and ligamentous laxity
        • posterior wall fractures are most common
      • femoral head fracture
      • femoral neck fracture 
      • proximal femoral physis
    • avascular necrosis of femoral head
      • increased rate if not reduced within 6 hours
  • Prognosis
    • typically associated with good long-term outcomes when treated promptly
      • most have mild or no pain
      • most return to high-demand activities
Presentation
  • Symptoms
    • pain, inability to bear weight
  • Physical exam
    • posterior dislocation (most common)
      • slight flexion, adduction, and internal rotation of the limb
      • clinical limb length discrepancy
      • if large posterior wall acetabular fracture, can appear shortened without malalignment
    • anterior dislocation
      • slight flexion, abduction, and external rotation
    • inferior dislocation
      • External rotation and extension
    • neurovascular exam
      • check for sciatic or gluteal nerve palsy (rare)
Imaging
  • Radiographs
    • recommended views
      • AP
        • most can be diagnosed on AP pelvis films
      • lateral
        • used to differentiate between anterior vs. posterior dislocation
        • scrutinize femoral neck to rule out fracture prior to attempting closed reduction
      • post reduction films
        • necessary to inspect for joint incongruity or nonconcentric reduction   
    • findings
      • loss of congruence of femoral head with acetabulum   
  • CT
    • indications
      • second choice behind MRI for any abnormal findings on post-reduction radiographs such as joint widening
        • radiation exposure should be considered
    • findings
      • inspect for joint incongruity or nonconcentric reduction
      • osteochondral fragments can be seen in older children and are easily detected by CT 
      • interposed soft-tissue can be difficult to appreciate on CT scan  
  • MRI
    • indications
      • study of choice for any abnormal findings on post-reduction radiographs such as joint widening
        • decreased radiation exposure than a CT scan
    • findings
      • inspect for joint incongruity or nonconcentric reduction
      • osteochondral fragments can be seen in older children and are easily detected by CT 
      • interposed soft-tissue is best evaluated with MRI 
      • entrapped labrum or capsule is best evaluated via MRI  
Treatment
  • Nonoperative
    • closed reduction under general anesthesia or sedation within 6 hours
      • indications
        • urgent attempt at closed reduction is first line treatment
        • most are successful reduced with closed means (85%)
      • outcomes
        • increased risk of AVN if not performed within 6 hours
  • Operative
    • open reduction
      • indications
        • nonconcentric reduction 
        • intra-articular fragment
        • unstable acetabular rim fracture, associated femoral head or neck fracture
        • irreducible by closed means
      • technique
        • surgical approach is typically performed in direction of dislocation (most commonly posterior) 
Techniques
  • Closed reduction technique
    • reduction
      • adequate anesthesia or sedation during reduction is mandatory in order to decrease the risk of displacing an unrecognized fracture of the proximal femoral epiphysis 
      • reduction under fluoroscopy has been recommended to decrease risk of displacement due to possibility of epiphyseolysis
      • mainly traction in flexion with gentle rotation maneuver
    • post-reduction
      • test hip stability before weaning sedation
      • obtain post-reduction imaging
      • some advocate spica cast or bed rest with abduction splint for 4 weeks in patients < 10 years old or bracing in older children with 6-12 weeks protected weight-bearing on crutches
Complications
  • Osteonecrosis
    • reported in 3-15%
    • decreased incidence under age 5
    • less frequent than in adults if there is an absence of an associated femoral neck fracture
    • if present, thought to be related to delayed reduction  
  • Coxa magna
    • common radiographic finding (20%)
    • not associated with functional limitation
  • Redislocation
    • rare sequela
    • treatment
      • prolonged immobilization
      • if recurrent and recalcitrant to immobilization: address with capsulorrhaphy
  • Nerve injury
    • sciatic or gluteal nerve injury can occur, usually resolves after reduction
 

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Questions (2)

(OBQ13.56) A 3-year-old male is an unrestrained backseat passenger in a car involved in a head-on collision. An injury radiograph is seen in Figure A. A delay in achieving a concentric reduction has been shown to increase the risk of Tested Concept

QID: 4691
FIGURES:
1

Coxa magna deformity

1%

(51/4608)

2

Recurrent post-traumatic dislocation of the hip

2%

(76/4608)

3

Chondrolysis

6%

(277/4608)

4

Heterotopic ossification

0%

(13/4608)

5

Avascular necrosis

90%

(4168/4608)

L 1 B

Select Answer to see Preferred Response

(OBQ06.152) A 10-year-old boy sustained an isolated injury shown in Figure A. Immediate closed reduction was performed in the emergency room with conscious sedation. Post-reduction radiographs are shown in Figure B and post-reduction CT scan in Figure C. What is the next appropriate step in management? Tested Concept

QID: 338
FIGURES:
1

Repeat closed reduction

1%

(19/1413)

2

Skeletal traction for 1 month

3%

(42/1413)

3

Hip arthrotomy via posterior approach

48%

(684/1413)

4

Hip arthrotomy via anterior approach

30%

(422/1413)

5

Weight-bearing as tolerated with close follow-up and serial radiographs

15%

(216/1413)

L 4 D

Select Answer to see Preferred Response

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