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Chinese Journal of Traumatology 2011;14(6):367-370
Case reports
Irreducible traumatic posterior hip dislocation with entrapment and a buttonhole effect
André-Pierre Uzel*, Ricardo Bertino, Guy Daculsi and George Yves Laflamme
【Abstract】The authors reported the case of a 27year-old man who sustained an irreducible postero-lateral
traumatic dislocation of the hip with capsular and labral
entrapment. Initial X-rays showed only a small acetabular
fragment. After two attempts to reduce the hip with muscle
paralysis under general anaesthesia failed, the patient was
treated by immediate open reduction through a posterolateral approach. Surgical exploration of the hip revealed a
small osteochondral fragment attached to a large piece of
labrum and capsule, clogging the acetabulum. The femoral
head crossed over the torn capsule with a buttonhole effect.
These elements were relieved, the bone fragment was fixed
with a 2 mm screw and the capsule was repaired. At the 10year follow-up, the functional outcome was excellent with a
Harris score of 100 points and no signs of necrosis or
osteoarthritis. The authors propose a literature review of
this uncommon lesion.
Key words: Hip dislocation; Tears; Acetabulum; Necrosis
T
which the femoral head does not cross the acetabular
rim. We report a case of actual irreducibility, where the
femoral head crossed over a buttonhole through the capsule and did not cross the edge of the acetabulum, due
to a bucket-handle tear in the acetabular labrum.
raumatic dislocation of the hip is a surgical
emergency. The incidence of aseptic necrosis
varies from 4.8%, if the hip is reduced within 6
hours after injury, to as high as 52.9%, if the hip is
reduced in more than 6 hours after injury. 1 Most
commonly, in more than 85% of cases, the dislocation
occurs in a posterior direction.2 Thompson-Epstein’s
classification3 distinguishes 5 types of posterior hip dislocation based on size, comminution of the posterior
wall fragment or the presence of a femoral head fracture.
Irreducible hip dislocation is a rare condition: only 3%
of cases in Canale and Manugian’s4 report. We must
distinguish the non-concentric reduction, which results
from a failure to fully seat the femoral head secondary to
interposed soft tissues4-7 and/or an incarcerated osseous
fragment7, from an actual irreducible dislocation4,8-10, in
DOI: 10.3760/cma.j.issn.1008-1275.2011.06.009
Department of Trauma and Orthopaedic Surgery,
C H R U de P o in t e-A -P it re, 9 7 1 59 P o in t e-A -P it re,
Guadeloupe, France (Uzel AP and Bertino R).
CHU Bordeaux, CIC-IT INSERM, Hospital Xavier
Arnozan, 33000 Bordeaux, France (Daculsi G).
Division of Orthopaedic Surgery, Hospital du Sacré
Coeur, 5400 GouinOuest, Local J-3245, Montreal, Quebec H4J 1C5, Canada (Laflamme GY)
*Corresponding author: Tel: 33-0690575564, Fax: 330590891744, Email: andre-pierre.uzel@wanadoo.fr
Chin J Traumatol 2011;14(6):367-370
CASE REPORT
On December 25, 1999, a 27-year-old male victim
of a car accident was admitted to the emergency department with isolated trauma to the right hip. A
dermoabrasion of the front of the knee indicated a dashboard injury. X-rays showed a posterior dislocation and
a small acetabular rim fracture (Figure 1). The patient
was taken to the operating theater for emergency
reduction. Under general anaesthesia, a Bigelow manoeuvre (closed reduction) with curare was attempted
without success. A second attempt under C-arm
fluoroscan control failed to reduce the femoral head into
the acetabulum. During the postero-lateral approach,
shredding was identified in the perior wall of the
acetabulum. We found an osteochondral fragment measuring 2 cmx1 cm attached to the labrum with a 3-cm
capsular tear incarcerated in the acetabulum. The cartilage in the femoral head was explored, and abrasions
were identified on the femoral head adjacent to the fovea
capitis over a surface of 1.5 cm².
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A femoral head extractor was introduced along the
femoral neck through the greater trochanter in order to
disengage the femoral head, as well as to access the
osteochondral fragment and the interposed soft tissues
deep in the acetabulum. The labrum was sewed up to
the soft tissues, the capsule was repaired using absorbable sutures and the osteochondral fragment was
fixed with a 2 mm cortical screw. We did not use suture anchors on these soft tissues because the peripheral elements were still intact. The trochanteric pelvis
muscles were repaired. Fluoroscan imaging and postoperative X-rays confirmed the concentric reduction with
symmetrical widening of the joint space. The rehabilitative regimen consisted of longitudinal traction with bed
rest for one month, followed by weight-bearing as
tolerated, ambulation with crutches and an active range
of motion protocol. At the 3rd month of follow-up, the
patient could walk without pain or limp and his hip mobility had returned to normal. He was able to resume
his work as an agricultural worker three months after
surgery and CT scan showed a good reduction (Figure
2). Unfortunately, the same patient was involved in another car accident on January 1, 2001 and sustained a
second posterior dislocation of the right hip with no associated fractures. Closed reduction under general anaesthesia was successful and physical examination confirmed inherent stability of the hip. The same postoperative regimen was applied with traction for 1 month.
He returned to work after one and a half months. At the
latest follow-up in December 2010, the patient was asymptomatic and had a Harris score of 100. Only Brooker’s
stage 1 heterotopic ossification was seen on the Xrays, with no signs of osteonecrosis or degenerative
arthritis (Figure 3).
Figure 1. X-rays showing posterior hip dislocation with a small
piece of acetabular rim.
Chinese Journal of Traumatology 2011;14(6):367-370
Figure 2. CT s c an s howing s uc c es s f ul reduc tion of the
osteosynthesis.
Figure 3. Anteroposterior view of the pelvis after 2 times of hip
dislocations showing the integrity of the joint.
DISCUSSION
For Slatis and Latvala9, in more than half of their
cases, posterior dislocation is complicated by fracture
of the hip joint. As a complication of hip dislocation,
sciatic nerve palsy is reported in 10%-15% of cases.11
Bilateral traumatic hip dislocation rarely occurs and few
cases associated with acetabular fractures have been
reported.12 An association with bilateral sciatic nerve
palsy is rarer.13 Posterior dislocations of the hip are
often the result of motor vehicle accidents in which the
passenger’s knee hits the dashboard. Depending on
the degree of hip adduction and flexion, the lesion may
vary from pure dislocation to acetabular lip or femoral
head fractures.4 For Paterson5, the size of the fractured
fragment of the posterior wall increases as flexion and
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Chinese Journal of Traumatology 2011;14(6):367-370
adduction lessen. When faced with a dislocation of the
hip, to determine how isolated it is by appropriate X-ray
assessment is important. The irreducibility of isolated
dislocations may be due to an acetabular or femoral
head fragment. The irreducibility of femoral head fractures occurring during posterior dislocation has been
noted by several authors with the risk of transforming
Pipkins’ type 2 into type 3 during reduction. 14,15 In
addition, the irreducibility of a pure dislocation can be
related to the incarceration of soft tissues of various
origin: buttonholed through the capsule, 2 cases for
Canale and Manugian4, 1 case for El-Andaloussi et al10;
piriformis muscle wrapped around the femoral neck, 1
case for Proctor8, Slatis and Latvala9 and Canale and
Manugian4 respectively; obstruction of the acetabulum
by obturator internus, gemellus superior and inferior
muscles, 1 case for Slatis and Latvala9. Buchholz and
Wheeless16 found an anatomical variant of the typical
acetabular rim fracture represented by a posterosuperior and superior fragment which may occur when the
capsule, ileofemoral ligament and rectus femoris muscle
attachments are wrenched.
The case presented is reminiscent of the two previous explanations of irreducibility reported by Paterson5,
also Buchholz and Wheeless16. When the classic clunk
is not heard during the reduction of a dislocated hip, an
intervening torn acetabular labrum should be suspected
and investigated appropriately. According to Chun et
al17, the presence of a radiopaque body in the articular
spaces is indicative of the incarceration of a femoral or
acetabular bone fragment. Thus, after reducing the
dislocation, a CT-scan is needed to detect any osteochondral lesions, such as impaction of the femoral head,
which may compromise the long-term functional prognosis of the hip.18 On the other hand, Kim et al7 carried
out an arthro-CT or MRI in order to detect the interposition of soft parts and/or capsule and labrum damage. In
our case, open surgical reduction offered the best opportunity to visualize the acetabulum by decoaptation of
the hip. The hip joint can be distracted with the AO/
ASIF distractor from the iliac crest to the proximal femur or with traction placed by an assistant. On
occasion, dislocation of the hip must be performed to
allow for removal of the fragments. A forceful pulsatile
lavage system may also help flush out the debris.
duction should be performed immediately by a posterior approach to the hip, in preference to anterior or
anterolateral approaches, if torn tissues and fractures
need repair.
It is important to carry out fluoroscan imaging to
assess the full reintegration of the femoral head during
the intervention. Osteosynthesis of the small bone fragments attached to the labrum and capsule should be
repaired if possible. The importance of the capsule and
labrum in the posterior stability of the hip has effectively been noted by several authors.6,20-22
During the postsurgical period, we mounted the patient with traction for the healing of the soft tissues,
although Schlickewei et al23 preclude the need for it.
Functional results may in fact be better with early mobilization and weight-bearing. In our case, we preferred
traction in order to allow the soft tissues to heal.
Our patient presented two episodes of dislocation
and we studied the femoral anteversion on CT scan:
10° on the right side and 11° on the left. These results
were physiological. Upadhyay et al24 found that reduced
femoral anteversion predisposes an individual to traumatic posterior dislocation of the hip.
In conclusion, good quality X-rays and careful interpretation of them are important before any closed reduction of a dislocated hip. It is essential that the type
of dislocation be determined, and whether or not it is
isolated. In cases of irreducible posterior dislocations,
the surgical posterior approach must be adopted immediately in order to remove the interposition. Associated injuries to the capsule, labrum and muscles should
be repaired.
Conflict of interest statement
The authors declare that they have no conflict of interest related to the publication of this manuscript.
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Edited by LIU Gui-e