Introduction

Posterior dislocation of the hip with fracture of the ipsilateral shaft of femur occurs very rarely. Ipsilateral fractures and dislocation occur due to high-energy trauma, and reduction of hip dislocation is considered an orthopaedic emergency. Frequent concerns regarding this injury include delayed diagnosis and treatment of the hip dislocation, difficulty in reduction of the hip dislocation, avascular necrosis of the head of femur and sciatic nerve palsy. Early closed reduction of the hip joint is difficult because the long lever of the femoral shaft is affected due to loss of continuity and classical methods of reduction cannot be used. The nuances of hip joint reduction in case of associated ipsilateral fracture, and the need for emergent intervention is emphasized in this case report.

Case report

A 23-year-old female presented to the emergency department with an alleged history of road traffic accident and sustained injury to both her hips. After initial stabilisation and clinical evaluation, radiological assessment showed segmental fracture of right femur shaft with ipsilateral posterior hip dislocation and sciatic nerve palsy and left femur shaft fracture (figure 1). Reduction of hip dislocation was planned as an emergency procedure. After optimisation, the patient was shifted to the operation theatre, where closed reduction was attempted under general anaesthesia. Following failure of closed reduction, an external fixator (Figure 2) was applied to stabilise the fracture and dislocation was reduced by longitudinal traction, flexion and adduction.

The patient was shifted to ICU for observation and planned for bilateral femoral shaft nailing the next day since the vitals were stable. Under general anaesthesia, we proceeded with left femoral intramedullary nailing first after achieving closed reduction on a traction table. Following that, right femur nailing was done similarly with some difficulty since the fracture was segmental in nature (figure 3). After the procedure, the patient was shifted back to ICU for observation, since femur fractures could cause fat embolism and sudden deterioration of vital parameters owing to massive blood loss. 2 units of packed red cells were transfused to compensate for the blood loss.

Since post-operative day 1, bedside physiotherapy and chest spirometry was started. Skin traction for the right lower limb was maintained in view of hip dislocation. Oral antibiotics, analgesics, anti-inflammatory drugs and other supportive drugs were advised. For foot drop, nerve conduction study was done which revealed sciatic nerve injury at hip level. The patient was discharged on day 5 with foot drop splint and was advised to continue skin traction for three weeks to prevent recurrent dislocation. Antiplatelet drugs were continued for two weeks post-operatively and mobilisation with support was initiated after one month from surgery.

Figure 1: showing posterior dislocation of right hip with fracture of shaft of both femur

Figure 2: Post reduction of hip after external fixator application

Figure 3: post-operative x-ray

Discussion

Incidence: Dislocation of hip with ipsilateral shaft fracture is relatively rare and that with segmental fracture is rarely reported. This case report hence highlights the need for radiograph covering the entire bone including the joint above and below to avoid missing the diagnosis.

Treatment considerations:

Definitive fixation versus Damage control orthopaedics: Considering the severity of the injury involving bilateral femur, there is enough evidence in the literature to suggest that minimal essential orthopaedic intervention should be done at first stage and then definitive fixation as a second stage once the patient’s general condition improves. Hence external fixator was applied to right femoral shaft to aid in hip reduction and left femur was effectively splinted with plaster slabs.

Mode of fixation: Reamed nailing was done on left femur and unreamed nailing in right femur. This was to address two concerns, one to reduce the risk of fat embolism, and other being avoidance of devascularisation of the fractured segment.

Intensive care stay: Although the patient was stabilised in the emergency department itself and the vitals were stable throughout, ICU stay was warranted in view of potential life threatening complications including fat embolism and SIRS which typically occurs on 2nd or 3rd POD.

Prophylaxis: Early mobilisation is important to prevent VTE, joint stiffness and complex regional pain syndromes. However, mechanical and chemoprophylaxis against VTE should be initiated in these patients due to added risk from prolonged immobilisation of both lower limbs.

Conclusion

Ipsilateral fracture of the femur shaft and hip dislocation are rare injuries and demands early diagnosis and prompt management. Early intervention incorporating the principles of damage control orthopaedics is prudent to prevent limb-threatening complications.

References

⦁ Rajesh Rana, Saroj K. Patra, Susanta Khuntia, Mantu jain, Bishnu P. Patro. Traumatic posterior dislocation of hip with ipsilateral femur shaft fracture: Temporary Fixator assisted reduction and final fixation with interlocking nail. DOI: 10.7759/cureus.5488

⦁ SMA Ethhisham et al. Traumatic dislocation of hip joint with fracture of shaft of femur on the same side.

Dr Mirunaalini Thangavelan
First Year DNB Resident in Orthopaedics
Kauvery Hospital Chennai