Posttraumatic Anterior Hip Dislocation with Ipsilateral Comminuted Intertrochanteric Fracture: A Rare Case Report

Abstract

Hip joint is a ball and socket type of joint and its anatomic features makes it very stable. However, Incidence of hip dislocation has increased recently due to high energy trauma like road traffic accident, fall from height etc. It is usually associated with fracture of femoral head, neck, shaft and acetabular wall. Association of ipsilateral intertrochantric fracture is exceedingly rare and only a few case reports are available in the literature. We are presenting a rare case report of neglected anterior hip dislocation with ipsilateral comminuted intertrochanteric fracture managed with hemiarthroplasty using long cemented distal press-fit revision stem. A 66-year-old male presented to our outpatient department with history of fall from a tree 22 days back with pain in right hip and inability to bear weight on right lower limb. Radiographs were suggestive of anterior hip dislocation with fracture of ipsilateral comminuted intertrochanteric fracture of right side. Anterior hip dislocation with ipsilateral intertrochanteric fracture is a very rare entity, and only a few case reports are available in the literature. Management includes early open reduction and fixation to achieve optimal outcomes, but doing primary arthroplasty is also a viable option especially in neglected cases as there is high chances of avascular necrosis and secondary osteoarthritis of the hip joint later on.

INTRODUCTION

The hip joint is a ball and socket type of joint and its anatomic features make it very stable. However, Incidence of hip dislocation has increased recently due to high energy trauma like road traffic accident. It is frequently associated with fractures of the femoral head, neck, shaft, and acetabular wall. Traumatic hip dislocation with ipsilateral intertrochanteric fracture is a relatively rare entity, and very few case reports are available in literature. Posterior hip dislocation is nine times more common than anterior hip dislocation.[1,2] Anterior hip dislocation with ipsilateral comminuted intertrochanteric and neck fractures is a very rare pattern, and it possesses a great challenge to the orthopedicians.[3,4,5,6]

We are presenting a rare case of neglected anterior hip dislocation with ipsilateral intertrochanteric fracture managed by primary hip arthroplasty.

CASE REPORT

A 66-year-old male came to our outpatient department with a chief complaint of pain, swelling, and tenderness over the right hip with an inability to bear weight on the right lower limb. On examination, there is a globular swelling and tenderness over the right groin and the lateral aspect of the hip joint. His right lower limb was abducted, shortened, and externally rotated. There was no sign of neurovascular injury with intact distal movement and pulsations. On further inquiry, he gave a history of fall from a tree 22 days back. He fell from a tree and was unable to bear weight at the same time.

A radiograph of the pelvis, including both hip joints anteroposterior view and lateral view done which was suggestive of a comminuted intertrochanteric fracture with the fractured neck with ipsilateral anterior hip dislocation of the right hip joint [Figure 1]. Computed tomography scan with three-dimensional reconstruction was also advised to assess the proper extent of the fracture pattern [Figure 2]. Clinical and other radiological investigations were also done to exclude thoracic, abdominal, and other musculoskeletal injuries. In taking account of old age, neglected dislocation, avascular necrosis, and avoidance of the second surgery, primary hemiarthroplasty was planned with the consent of the patient and his attendants.

Figure 1.

Radiograph of the pelvis, including both hip joints, showing comminuted intertrochanteric fracture with anterior dislocation of the right hip

Figure 2.

Three-dimensional computed tomography scan showing comminuted intertrochanteric fracture with anterior dislocation of the hip joint

Under regional anesthesia, the patient was positioned on the table in a lateral position. The lateral approach of the hip joint was used and the femoral head was removed carefully [Figure 3]. A greater trochanter was apposed and fixed with SS wire, and hemiarthroplasty using cemented distal fit long modular revision femoral stem prosthesis was done [Figure 4]. Part of the abductors was secured using nonabsorabable suture with the fenestrations over the lateral aspect of the implant. Intraoperative length and stability were checked and found to be satisfactory. The patient was walking comfortably with the help of a walker from the 2^nd day of the postoperative period.

Figure 3.

Intraoperative photograph showing anteriorly displaced femoral head with comminution of neck and intertrochanteric region

Figure 4.

Postoperative photograph showing hemiarthroplasty using cemented distal fit long modular revision femoral stem prosthesis with SS wire

DISCUSSION

Incidence of hip dislocation has raised recently due to high-energy trauma, particularly during road traffic accidents; however, other modes of injuries are fall from height, industrial accidents, sports injuries (e.g. soccer, rugby, and wrestling), etc.[7] It is usually associated with a fracture of the acetabular wall or fracture of the femoral head, neck, and shaft. The association of intertrochanteric fracture with dislocation is suggestive of very high-energy trauma. Hip dislocation with associated ipsilateral intertrochanteric fracture has been very infrequently described in the literature. Anterior hip dislocation with ipsilateral intertrochanteric fracture is a very rare entity and the literature on it is also very scarce.

Anterior hip dislocations usually result after a high-energy trauma, which determines forced abduction and external rotation of the hip. Depending on the position of the hip at the time of the impact, dislocations may be anterior inferior (if the hip is in flexion) or anterior superior (If the hip is in extension). As the patient fell from a tree while climbing down, his limbs were in the position of flexion, abduction, and external rotation, which may lead to the anterior type of hip dislocation [Figure 5]. Simultaneously, direct trauma during fall may cause intertrochanteric fracture ipsilaterally in our case. Hip dislocation is an emergency and must be urgently addressed to avoid avascular necrosis, heterotopic ossification around joint, and damage to the adjacent neurovascular structure. Associated intertrochanteric fracture possesses a great challenge to orthopedicians to achieve close reduction. Normally, it requires open reduction, but sometimes, it can be achieved percutaneously using Schanz pin under C-arm guidance with manual manipulation, particularly in acute cases.

Figure 5.

An image depicting a man climbing down tree with the attitude of the lower limb in flexion, abduction, and external rotation of the hip joint

A few case reports of attempting closed reduction with axial traction in emergency are mentioned in literature but failed. Chotai et al. reported a case of hip dislocation with ipsilateral intertrochanteric fracture in which they tried closed reduction with axial traction under anesthesia but failed and later did open reduction through a lateral approach.[8] Agarwal et al. reported a similar case of hip dislocation with ipsilateral intertrochanteric fracture in which he tried closed reduction using Schanz pin as a joystick but did not get reduced, and later, open reduction and fixation through lateral approach was done.[9] Ul Haq et al. also reported two cases of hip dislocation with an ipsilateral intertrochanteric fracture where open reduction and internal fixation were done in both cases after failed attempted closed reduction.[10] Fracture should be fixed early.

The osteonecrosis rate has been reported to be 4.8% if the reduction was done within 6 h of injury compared with 53% if the reduction was delayed for more than 6 h.[11] Displaced femoral intertrochanteric fractures, along with dislocation of the hip, have a higher risk of avascular necrosis of the femoral head due to damage to the retinacular vessels at the time of injury. McClelland et al. did collarless press-fit bipolar prosthesis to a case of obturator hip dislocation associated with femoral fractures of the head and neck.[5] Bonnevialle et al. noted a better functional outcome of cemented compared to uncemented stems and, thus, recommended cementing femoral stems in the absence of contraindication.[12] In older patients with poor bone quality and very thin diaphyseal cortices, cement improves stem fixation by providing immediate stability and additionally decreases the risk of intraoperative periprosthetic fracture.[13] Adequate reduction and fixation of greater trochanter are necessary to improve the function of the hip joint and prosthesis and restore sufficient tension. The choice of the fixation depends on fracture pattern, bone quality, and surgeon’s preference. Tension band wiring using K-wire and SS wire, cerclage are viable options for greater trochanter reconstruction. Nonabsorbable sutures are preferred if fragments are very small, comminuted, and if bone quality is poor. Sometimes, trochanteric plates are also used. Despite all efforts to repair the fractured greater trochanter, its secondary displacement is a common complication regardless of the repair technique; yet, in older patients with low functional demands, it is well tolerated and often asymptomatic.[14]

In taking account of patients age (66 years), neglected dislocation (more than 3 weeks), comminuted fracture of the intertrochanteric region extending to the neck, high chances of avascular necrosis of femoral head, and avoidance of the 2^nd surgery, we manage the case by hemiarthroplasty using cemented distal fit long modular revision femoral stem prosthesis, with fixation of greater trochanter using SS wire and securing fixation of rest of abductors with the femoral stem with nonabsorbable suture through lateral approach.

CONCLUSION

Posttraumatic anterior hip dislocation with ipsilateral intertrochanteric fracture is a very rare entity, and only very few case reports are available in the literature. Management of this type of fracture dislocation possesses a great challenge to the orthopedician as close reduction usually fails. Management includes early open reduction and fixation to achieve optimal outcomes, but doing primary arthroplasty is also a viable option especially in neglected cases as there is high chances of avascular necrosis and secondary osteoarthritis of the hip joint later on.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.