Purpose: Traumatic hip dislocations (THD) are rarely reported from developing countries. The aim of the current study is to describe the trauma, the presentation, the treatment and the outcome patterns of THD received in the trauma unit of an emergency department (ED) in west Africa. Patients and Methods: A retrospective ongoing study from 2008 to 2014 was performed at the ED. All patients over 15 years with an unreduced THD and an anteroposterior pelvic radiograph were studied. Data were collected and analyzed by means of a statistical software. Results: A total of 50 THD were included in the study. We found an average of seven dislocations per year with a mean age of 36 years mainly males (n = 37). Road traffic accidents by motorcycle (n = 20) were the common circumstance of trauma. Forty-five extra-pelvic THD were diagnosed. According to the Bigelow classification, THD were classified posterior (n = 33), anterior (n = 10) and irregular (n = 2). Associated acetabular fractures (n = 36), ipsilateral lower limb fractures (n = 10) and sciatic nerve palsy (n = 2) were also found. The THD cases were treated by closed reduction (n = 34), open reduction (n = 6) and Girdlestone procedure (n = 1). The outcome after 16 months showed 21 good and excellent functional results and one death. The short term complications were post traumatic arthritis (n = 10) and osteonecrosis (n = 2). Conclusion: The THD occurrences are important in our emergency department. They are characterized by the place of motorcycle accidents and by the delayed reduction due to hospital’s locations and numbers and beliefs. A reduction before four hours, an earlier rehabilitation, a non-use of traction and a short hospitalization time below 14 days gave better results.
The traumatic hip dislocations (THD) are rare occurrence [
The aim of our study is to describe socio-demographic, etiologic, anatomo- pathologic, the therapeutic features, and the outcome features of the THD received in a trauma center of a West African country.
Our hospital is the second university teaching hospital of the country. The Orthopedic and Trauma department was created in 2008. The hospital is the only facility offering twenty-four hour specialized trauma care and rehabilitation for the patients from the western part of the country (around five billions inhabitants) and the surrounding countries. In 2015, the Department had four senior orthopedic surgeons, four junior surgeons, six wards, 30 beds and, one operating room.
A retrospective study spanning 81 months from January 2008 to September 2014 was carried in our trauma emergency department (ED). All cases of unreduced THD in adults over 15 years old were included in the study. The socio-demographic features, the circumstances of trauma, the mechanisms of injury, the clinical findings, the treatment and the follow-up variables were identified (
Fifty-two cases of THD were found among 17,192 surgical emergency patients. Two cases with incomplete medical records were removed from the sample.
The number of THD cases had increased from 2008 to 2014 with an average of seven cases per year (6.51 - 7.57 CI 95%). The majority of cases (n = 27) came from 100 to 200 km. The mean age was 36 years old (32.00 - 40.03). Thirty-two
Socio-demographic features Age Sex Occupation Provenance |
---|
Trauma features Trauma circumstances Mechanisms of injury |
Clinical features Time of admission Dislocation type Associated complications |
Treatment features Time of reduction Reduction method Associated treatments Hospitalization time |
Follow-up features Follow-up time Functional outcome (the Harris Hip Score) Late complications |
cases were aged between twenty and forty years old (
The male: female ratio was 2.85. Mean ages at the trauma time was 37 years for men and 32 years for women. Sixty percent of injured patients are farmers and informal sector workers (
Trauma circumstances | Mechanisms of injury | Cases (n) |
---|---|---|
Aggressions/Violences | Fall from height | 1 |
Everyday accidents | Fall from height | 2 |
Work accident | Fall from height | 1 |
Road Traffic accident | Hit | 45 |
Railway Traffic accident | Hit | 1 |
Five patients had an associated condition to their THD such as a pregnancy (n = 1), a hip osteoarthritis (n = 1), a chronic epiphysiolysis (n = 1), a peri-articular calcification (n = 1) and an osteoporosis (n = 1). The main circumstance of trauma was road traffic accident (n = 45) (
A collision with an environmental object was commonly found in motorcycle accidents (n = 22) (
We used Pelvic AP and oblique views to describe the dislocations forms and the associated bony lesions. Fifteen cases of THD occurred in polytrauma patients. It was 25 right injured hips and 25 left injured hips. We found five intra-pelvic dislocations with acetabular fractures and 45 extra-pelvic dislocations. Extra- pelvic dislocations were classified according to the Bigelow Classification 7 to irregular type (n = 2) (
Three fourth of Three fourth of regular dislocations were posterior (
An associated periarticular fracture was frequent (n = 48), mainly an acetabular fracture (n = 36) (
Type | Cases (n) | ||
---|---|---|---|
Extra-pelvic | 45 | ||
Regular | 43 | ||
Posterior | 33 | ||
Posterosuperior (Iliac) | 32 | ||
Posteroinferior (Ischiatic) | 1 | ||
Anterior | 10 | ||
Anterosuperior (Pubic) | 5 | ||
Anteroinferior (Thyroid) | 5 | ||
Irregular (sus-acetabular) | 2 | ||
Intra-pelvic | 5 |
Closed reduction (n = 34), open reduction (n = 6) and Girdlestone procedure (n = 1) were performed. Girdlestone procedure was performed on a patient with a neglected, 8-month-old obturator dislocation.
In five cases, the reduction was unstable. Eight patients refused the reduction and one patient died before reduction. Only half of THD cases were reduced in first six hours (
The delayed care and the distance to travel were statistically significant (corr. = 0.36, p = 0.018). The mean hospitalization time was 25 days (18.52 - 31.91). Twenty-three days’ average trans-condylar traction was applied for 35 patients. No traction was applied was in the 15 other cases. The antithrombotic prophylaxis rate increased from zero in 2008 to nine tenth in 2013 and 2014. Twenty-two
Site | |||
---|---|---|---|
Peri-articular associated fractures | 48 | ||
Acetabulum | 36 | ||
Posterior wall fracture | 23 | ||
Anterior wall fracture | 4 | ||
Both anterior and posterior walls | 8 | ||
Transverse fracture | 1 | ||
Femoral Head | 2 | ||
Femoral Neck | 3 | ||
Trochanteric region | 7 | ||
Other associated fractures | 20 | ||
Ipsilateral fractures | 12 | ||
Pelvic ring | 3 | ||
Femur | 3 | ||
Patella | 1 | ||
Tibia | 3 | ||
Ulna | 1 | ||
Costal bones | 1 | ||
Controlateral fractures | 8 | ||
Pelvic ring | 1 | ||
Femur | 1 | ||
Tibia | 1 | ||
Humerus | 1 | ||
Ulna | 2 | ||
Costal bones | 1 | ||
Tarsal bones | 1 |
patients had got physical rehabilitation. Weight bearing was authorized in the first week in simple THD (n = 16) and after one to two months in complicated THD (n = 34).
Thirty-one patients were monitored, 17 others refused medical follow-up and left the hospital immediately or few days after their hip reduction. One patient with posterior fracture-dislocation of the hip associated with a contralateral diaphyseal femur fracture died after a massive post-reduction embolus.
The mean follow-up time for the followed patients was 16.23 months (11.36 - 21.08 IC95%). The pregnant case of THD sustained an abortion after a retro placental hematoma. The functional evaluation by the Harris Hip Score (HHS) showed 21 good and excellent results. These results are better in the first year (
The coxo-femoral joint is a deep spheroid type joint that needs a strong femoral neck and a high energy trauma to dislocate [
Follow-up time | 3 months | 3 - 6 months | 6 - 12 months | 12 - 18 months | Total |
---|---|---|---|---|---|
HHS Grading | |||||
Poor | 1 | 0 | 0 | 2 | 3 |
Fair | 0 | 0 | 0 | 1 | 1 |
Good | 0 | 3 | 5 | 1 | 9 |
Excellent | 1 | 3 | 4 | 0 | 8 |
Total | 2 | 6 | 9 | 4 | 21 |
road traffic injuries in developing countries due to motor vehicles, roads conditions and pedestrians’ habits. Men around the third decade of life are more exposed [
The mean MOI of Hip dislocations are described as a car dashboard accident. Although the majority of our patients are drivers or passengers of two-wheelers, the concept of dashboard accident is still applicable, the collision is still making on a bent knee and a flexed hip. We called this mechanism of injury: “the motorcycle hip accident” (
Posterior regular THD is the more common dislocation [
As associated peri-articular fractures, we found an important rate of acetabular fractures, mainly posterior wall fractures (n = 23). These fractures are common in posterior directed dislocations [
In one half of cases, early reduction was performed as recommended [
Some authors recommend a temporary traction after the reduction [
short-term complications. We think that this might be explained the migration of osteochondral fragments and by the distraction effect on contused vessels.
Stuck and Vaughan stated that osteonecrosis might be reduced if weight bearing is delayed [
Our study showed better functional outcome in the first year in a THD reduced before four hours with an earlier rehabilitation program. Earlier rehabilitation keeps muscular strength and remodeling joint surfaces. Osteonecrosis of the femoral head and osteoarthritis of the hip joint are the main complications after a THD [
Our study has some limitations. Indeed, having no computed tomography and MRI, the morphological description of the osteo-articular lesions was certainly not optimal. Moreover, the small decline is also a limit when it is known that some complications (osteonecrosis and osteoarthritis) sometimes take place after two years of evolution. We believe that a study with longer follow-up and using MRI and CT for lesion diagnosis will yield even more relevant results.
The THD occurrences are important in our emergency department. They are characterized by the place of motorcycle accidents and by the delayed reduction due to hospital’s locations and numbers and beliefs. The current study showed the advantage of an earlier reduction before four hours, an earlier physical rehabilitation and a short hospitalization time below 14 days and the disadvantage of tractions. However, functional outcome is good in the first year and complications such as osteonecrosis and osteoarthritis appear in the second year.
Dakouré, P.W.H., Diallo, M., Guigma, T.A.W., Soulama, M. and Gandéma, S. (2017) Profile of Traumatic Hip Dislocations in a West African Teaching Hospital. Open Journal of Orthopedics, 7, 345-355. https://doi.org/10.4236/ojo.2017.711035