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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
Coxa magna deformity
Recurrent post-traumatic dislocation of the hip
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Delayed reduction of posterior dislocation of the hip has been shown to increase the risk of AVN.
Pediatric hip dislocations are uncommon. Posterior dislocations are most common. The incidence of AVN ranges from 0-43%. In younger children (<6yrs), minimal force is required to dislocate the hip because of general ligamentous laxity and a mostly cartilaginous acetabulum. As a result, associated acetabular fractures are uncommon in the pediatric population. As the child's age increases, greater force is required as these structures become more rigid. Other complications include femoral head deformity, premature physeal fusion, sciatic nerve injury, recurrent hip instability, degenerative arthritis, chondrolysis, coxa magna deformity and missed ipsilateral femoral shaft fractures
Kutty et al. discuss traumatic posterior hip dislocations in children. They comment that AVN rates are 6%,
13% and 66% if reduction occurs within 4h, between 5-24h, and >24h respectively.
Hamilton et al. examined 18 cases of traumatic hip dislocation in childhood. Mean time to reduction was 6h (range, 3-22h). Mean time to follow-up was 70 months (range, 17-132 months). There were no cases of AVN or early degenerative changes.
Figure A is an AP radiograph of the pelvis showing a posterior dislocation of the right hip in a skeletally-immature individual.
Answers 1,2,3,4: Time to reduction has not been shown to affect the incidence of coxa magna deformity, recurrent dislocation, chondrolysis or heterotopic ossification.
Kutty S, Thornes B, Curtin WA, Gilmore MF.
Pediatr Emerg Care. 2001 Feb;17(1):32-5. PMID: 11265904 (Link to Abstract)
Hamilton PR, Broughton NS.
J Pediatr Orthop. 1998 Sep-Oct;18(5):691-4. PMID: 9746428 (Link to Abstract)
Hamilton, JPO 1998
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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?
Repeat closed reduction
Skeletal traction for 1 month
Hip arthrotomy via posterior approach
Hip arthrotomy via anterior approach
Weight-bearing as tolerated with close follow-up and serial radiographs
After a posterior hip dislocation, post-reduction radiographs must be assessed for joint congruity and articular widening. Persistent joint incongruity is likely to be caused by soft tissue interposition consisting of a torn labrum including the lateral acetabular apophysis. A post-reduction CT can be performed to look for interposed bone/osteochondral elements located within the hip joint. Surgical extirpation of osteochondral fragments is warranted. Since the patient had a posterior dislocation, the posterior structures have already been disrupted, and further disruption of the anterior structures through an anterior approach is not the best choice.
Vialle et al reviewed 35 patients that were seen with a hip dislocation over a 22 year period. Eight patients were found to have post-reduction joint asymmetry and underwent arthrotomy with excision of the osteochondral fragment. Thirty-four of 35 had good or excellent results with one patient suffering poor results and total head AVN after dislocation that was reduced 24 hours later.
Quick and Eastwood state that pediatric pelvic injuries are rare and "there is no substantial evidence base for the surgical treatment of most injuries". In contrast, "there is increasing evidence to support an appropriately prompt and aggressive operative approach to the treatment of femoral neck fractures and other injuries to the hip joint to reduce the incidence of major complications and their accompanying disabilities". The inherent complication of AVN has been found only to be statistically linked to a delay between dislocation and reduction.
Vialle R, Odent T, Pannier S, Pauthier F, Laumonier F, Glorion C
J Pediatr Orthop. 2005 Mar-Apr;25(2):138-44. PMID: 15718889 (Link to Abstract)
Vialle, JPO 2005
Quick TJ, Eastwood DM
Clin. Orthop. Relat. Res.. 2005 Mar;(432):87-96. PMID: 15738808 (Link to Abstract)
Quick, CORR 2005
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