Open Journal of Orthopedics, 2011, 1, 1-4
doi:10.4236/ojo.2011.11001 Published Online September 2011 (
Copyright © 2011 SciRes. OJO
Trochanteric Fracture of a Congenital/
Developmental Dislocation of the Hip
in an Elderly Woman: A Case Report
Kazuhiro Imai
Department of Orthopaedic Surgery, Mishuku Hospital, Tokyo, Japan.
Received July 22nd, 2011; revised August 25th, 2011; accepted September 4th, 2011.
An 87-year-old woman with a residual dislocated hip suffered a trochanteric fracture on the ipsilateral side. The frac-
ture was treated by open reductio n and intern al fixation surgery with good results. To treat a proxima l femoral fracture
of the residual dislocated hip in an elderly patient, the patient’s overall sta tus, pre-fracture ability, hip joint configura-
tion, and fracture pattern should be considered.
Keywords: Congenital/Developmental Dislocation of the Hip, Trochanteric Fracture, Elderly Woman
1. Introduction
Managing congenital/developmental dislocation of the
hip (CDH) in adults presents many challenges. It is also
difficult to manage a trochanteric fracture in a patient
with CDH. We present an elderly woman with a tro-
chanteric fracture of a CDH who underwent open reduc-
tion and internal fixation surgery. We also describe the
treatment options that allowed for restoration of the pa-
tient’s pre-fracture status.
2. Case Report
An 87-year-old woman slipped and fell to the floor at
home and was admitted urgently to our hospital with left
hip pain and an inability to walk. The patient had a his-
tory of CDH and her pre-fracture activity level was dou-
ble-crutch walking. She had used crutches since she was
42 years old. She had hypertension and was diagnosed
with congestive heart failure when she was 86 years old.
Her height was 147 cm and her weight was 46 kg.
Radiographs showed a fracture at the left proximal
femur (AO classification of trochanteric fractures type
A3) and a residual dislocated hip on the ipsilateral side
(Figure 1). The residual femoral neck was located in the
gluteal muscles above the original acetabulum. The
amount of subluxation was more than 100% (Crowe type
IV [1]). The left femoral head and the lesser trochanter
were absent. The left femoral neck was short and the
proximal femoral shaft was narrow. The right hip formed
the secondary acetabulum above the original acetabulum.
The right femoral neck was extremely short and the right
femoral head was severely deformed.
At first, a nonsurgical approach was taken. The patient
remained on bed rest for 3 weeks without traction. At 3
weeks, radiographs showed the displaced fracture and no
bone format ion (Figure 2).
The fracture was treated by open reduction and inter-
nal fixation surgery. A traction table and X-ray fluoros-
copy were used. The displaced fracture was reduced with
the left hip 10 degrees adducted. The proximal femur
Figure 1. Radiograph of the pelvis on admission showing
fracture at the proximal left femur and residual dislocated
hip on the ipsilateral side.
Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report
was explored through a lateral incision. A 50 mm lag
screw was inserted into the proximal fragment and a 95-
degree DCS® plate (Synthes, West Ch ester, Pennsylvan ia,
USA), stabilized by four cancellous screws and three
cortical screws, was used (Figure 3).
Figure 2. Radiograph 3 weeks after admission, showing the
displaced fracture without bone formation.
Figure 3. Postoperative radiograph of the left hip.
The patient remained on bed rest for 2 weeks without
an extern a l f ixatio n and 2 week s af ter sur g er y, sh e st ar ted
sitting in a wheelchair. At 4 weeks, bone formation at the
fracture site was noted and partial weight bearing was
started. Full weight bearing was started 6 weeks post-
operatively. She was able to walk 50 meters with double-
crutches 3 months postoperatively. She was able to walk
indoors with double crutches 2 years postoperatively at
the age of 89. Radiographs showed healed fracture (Fig-
ure 4). Consent for publication has been obtained from
the patient and her daughter.
3. Discussion
Newborn and infant screening and prevention of CDH
has been in place since the 1970s in Japan, and the pres-
ence of residual dislocated hips has markedly decreased
[2]. Howev er, before th e 1970s, CDH prev ention was no t
available and the prevalence of CDH was more than 3%.
Therefore, residual dislocated hips are not rare in elderly
people in present-day Japan.
Conservatively treated CDH might be a major risk
factor for low bone mineral density at the hip and osteo-
porotic hip fracture [3]. In elderly people, and especially
in elderly women, minor trauma like falling can cause a
fracture at the proximal femur because of skeletal fragil-
ity due to osteoporosis. Therefore, elderly patients with
residual dislocated hips may suffer a proximal femoral
fracture, althoug h few reports have been pub lishe d.
We found only one case in previous reports that had
suffered the combination of proximal femoral fracture
and residual dislocated hip. The case was a 20-year-old
active male with a high congenital dislocation of the hip
who sustained a displaced subcapital fracture in a traffic
accident [4]. He underwent Girdlestone resection arthro-
plasty [5] and 2 years after surgery, he had almost full
range of motion at the hip and was able to resume his
preoperative hobbies, including jogging, swimming, and
contact sports.
Figure 4. Radiograph 2 years postoperatively.
Copyright © 2011 SciRes. OJO
Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report
Copyright © 2011 SciRes. OJO
The English literature does not cite any reports de-
scribing a proximal femoral fracture with residual dislo-
cated hip in an elderly person. Several options are avail-
able to treat this combination in an elderly patient, as
described below.
3.1. Total Hip Arthroplasty (THA)
In patients with a residual dislocated hip undergoing
THA, the acetabular component should be placed in the
anatomical position and the femur should be shortened to
prevent excessive limb lengthening or sciatic nerve in-
jury [6]. In these patients, the original acetabulum is
shallow with a short anteroposterior diameter, and this
limits the size of the cup and therefore the thickness of
the polyethylene insert. Excessive polyethylene wear
results in cup revisions. The surv ival rate in patients with
high congenital hip dislocation was reported to be 68% -
78% at 10 - 20 years [7-12] (Table 1).
In this case, THA could have been considered because
the patient was old and long-term survival was not a ma-
jor goal. However, we did not choose THA because of
the invasiveness of this procedure considering our pa-
tient’s age and cardiopulmonary status.
3.2. Open Reduction and Internal Fixation
Our patient had a long h istory of a left dislocated hip and
had not complained of hip pain before the fracture.
Therefore, the most appropriate treatment option to con-
sider would be one that best restores her pre-fracture
status, that is, provide a good reduction and a secure in-
ternal fixation, disregarding the fact that the hip was dis-
In terms of fixation devices, compression hip screws
or trochanteric nails are generally used for trochanteric
fractures in elderly patients. However, in this case, there
were no properly sized lag screws because the femoral
head was absent and the femoral neck was short. Nail
fixation might be another option, but again in this case,
there were no properly sized nails because the proximal
femoral shaft was narrow.
We used a 95-degree DCS® plate because of the
availability of the shortest lag screw fitted for proximal
fragment and suf fi c i ent fi xat i on and st ren gth (ie, 50 mm ).
3.3. Arthrodesis
The ideal patient for hip arthrodesis is a young adult with
an active lifestyle. Previous studies have indicated that
most young patients who undergo arthrodesis for severe
osteoarthritis are very satisfied despite the functional
disadvantages of a fusion [13,14]. In our case, the patient
was old and might incur nonunion and complications
associated with prolonged cast immobilization.
3.4. Proximal Femoral Neck Resection
Girdlestone resection arthroplasty or femoral head resec-
tion has been reported to achieve good pain relief, mobil-
ity, and function in older patients with osteoarthritis or
ankylosing spondylitis. Th e Girdlestone procedure for an
unreduced fracture-dislocation has been shown to have
good results 6 years postoperatively [15]. In our case, we
considered resection of the proximal femoral neck frag-
ment as the second choice because of the lack of the
femoral head. Our first choice was open reduction and
internal fixation to restore the pr e-fracture status. If open
reduction and internal fixation was technically unf easible,
proximal femoral neck resection might be a better option
than THA or arthrodesis in this patient.
3.5. Conservative Treatment
Conservative treatment based on traction method and bed
rest is one of the options for a proximal femoral fracture
in an elderly patient. Compared to conservative treatment,
operative treatment with internal fixation devices is more
likely to result in the fracture healing without leg short-
ening, a shorter hospital stay and a statistically non-sig-
nificant increase in the return of patients back to their
original residence [16]. We took conservative treatment
of bed rest without traction method at first because the
fracture was not displaced. However, the fracture was
displaced without bone formation at 3 weeks. Traction
method might be more appropriate for conservative treat-
Table 1. Summary of reported results of total hip arthroplasty in high c ong enital hip disloc ations.
Reference No. of hips Average age at surgery
(years) Revised rateSurvival rate
[follow-up period]
Fredin H [7] 21 46.5 43% -
Numair J [8] 46 41.5 17% 68% [15 years]
Kerboull M [9] 118 52.0 13% 78% [20 years]
Hartofilakidis G [10] 83 49.5 22% 76% [15 years]
Lai KA [11] 56 35.4 16% 77% [12 years]
Eskelinen A [12] 68 54.0 43% 73% [10 years]
Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report
4. Conclusions
Although there are few reports about the combination of
proximal femoral fracture and residual dislocated hip in
elderly people, more and more patients will suffer this
combination because the elderly population continues to
increase. To treat proximal femoral fracture of residual
dislocated hip in an elderly patient, the patient’s overall
status, pre-fracture ability, hip joint configuration, and
fracture pattern should be considered.
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