TRAUMATIC HIP DISLOCATION IN CHILDHOOD

Actaortop. scand. 50,549-553,1979 TRAUMATIC HIP DISLOCATION IN CHILDHOOD A Report of 26 Cases and a Review of te Literature ANTONIO B ARQUET Institute and Department of Ortopaedics and Traumatology, Montevideo, Uruguay Twenty-six cases of traumatic ip dislocation in cildren are presented. Altoug closed reduction was acieved in most instances, open procedures ad to be employed in two cases of soft tissue interposition and in a patient wit ipsilateral fracture of te femoral saft. In 16 patients, wit a followup averaging 14 years, te incidence of complications (avascular necrosis, coxa magna and artrosis) was significant. Factors predisposing to abnormal results were delayed reduction and severe trauma. Neiter te metod of immobilization nor te interval witout weigt-bearing over 4 weeks were of influence. Principles of treatment are suggested. Key words: ip; ip dislocation; cildren Accepted 1O.iii.79 Traumatic ip dislocation (THD) in cildood is rare. As far as we could determine, no more tan 500 cases ave been reported. Te follow-up, a significant factor, is usually too brief (Funk 1962). Terefore, ip joint beaviour after traumatic dislocation in tis age group as not been adequately documented in order to provide defined terapeutic principles. Tis report, based on 26 cases collected in our country, and including a review of te world literature, is an attempt to face tese problems. PATIENTS AND METHODS occurred predominantly in younger cildren. Te severity of injuries increased wit age. Twenty-four dislocations were posterior and two were anterior. Among te posterior cases tere were six retroslcetabular dislocations; te femur ad only suffered a posterior rotatory displacement (Figure 1). Tere were no fracturedislocations. In one patient, severely injured, tere was a peroneal nerve palsy, and in anoter an obturator dislocation was associated wit an ipsilateral fracture of te femoral saft (Figure 2). Diagnosis was made witin te first 12 ours in 23 patients, wile in te oter 3 cases it was delayed over 40 ours. Of tese, only one was due to delayed consultation. Te interval before reduction was less tan 24 ours in 20 cases, and in te oter 6 cildren it ranged from 40 ours to 8 days. Twenty-six cases of THD in cildren under 16 years of age, from our Institute and from private records, were reviewed. Ages ranged from 4 to 15 years, averaging 10 years. Boys were involved tree times as often as girls. Injuries were grouped into sligt, suc as falls from te same level, moderate, suc as atletic traumas, and severe. Tey were sligt in 25 per cent of cases and tese Treatment Initial attempts at closed reduction, employing te Allis metod, were made in all cases. General anaestesia was used in all patients except two, in wom racianaestesia and analgesia were used. Tese attempts were effective in 23 patients. Te remaining tree cases underwent open reduction. Two of tem ad soft tissue interposition: 0001-6470/79/050549-05$02.50/0 0 1979 Munksgaard, Copenagen

550 ANTONIO BARQUET Figure 1. An example of retroacetabular dislocation. Te femur as only suffered a rotatory movement, wit neiter lateral nor altitudinal displacement. Note te concentric projection of te femoral ead and acetabulum. acetabular labrum in one and labrum and capsule in te oter. In bot cases, X-rays after manipulation sowed a greater gap between te femoral ead and te acetabulum tan on te contralateral side. In te remaining case te femoral fracture made closed manoeuvres inefficient. As to te post-reduction procedure, various metods were employed (bedrest, skin and skeletal traction, cast) from 10 days to 12 weeks, averaging 5 weeks. Except in one case, weigt-bearing was permitted witout an additional interval. Complications Sixteen patients ave been followed from 1.5 to 31 years, wit an average of 14.5 years, and complications were found in seven. Te peroneal nerve palsy remained uncanged 22 years after trauma. In tree cildren wose dislocations were reduced more tan 40 ours after injury, avascular necrosis was diagnosed 5, 19 and 20 monts later. Te injuries were classified as sligt, severe and Figure 2. An exceptional case of obturator dislocation of te ip associated wit ipsilateral fracture of te femoral saft in a girl of 6 years. moderate, respectively. Te first patient was found to ave an asymptomatic coxa plana 7 years post-reduction. In te second, artrosis was present after 5 years and severe after 18 (Figure 3). Te oter patient ad an asymptomatic deformed epipysis 31 years after injury (Figure 4). One patient developed coxa magna subluxans wit a sort and wide femoral neck. Tis was one of te cildren undergoing open and delayed reduction for soft tissue interposition. Artrosis was also present in anoter patient, X-rayed 18 years after is severe injury. Te patient wit peroneal nerve palsy also sowed ip pain and limp at te final evaluation; e refused to be X- rayed, but it may be assumed tat is ip is artrot ic. RESULTS Only ips followed to skeletal maturity were considered. Gartland s criteria were employed and a ip was judged abnormal if tere were pain, limited motion, sortening of te limb or

TRAUMATIC HIP DISLOCATION IN CHILDHOOD 55 1 Figure 4. Tirty-one years after dislocation. Tis was a case reduced by closed procedure 8 days after injury. Avascular necrosis was diagnosed 20 monts later. Note te deformed epipysis and te wide and sort femoral neck. limp, or if tere were radiograpic abnormalities (Pennsylvania Ortopaedic Society 1968). Ten patients, followed from 5 to 31 years, were in tis situation (Table 1). A normal result was obtained in six cases, Figure 3. End result of a dislocated ip, reduced in four it was Te factors 40 ours after te injuy. Avascular necrosis wic appear to ave favoured te abnormal occurred 19 monts later. Tis radiogram, taken results are delayed reduction and severe 18 years later, sows te deformed femoral ead trauma. Neiter initid post-reduction proand te degenerative joint canges. cedures nor te intervals witout weigtbearing over 4 weeks influenced te results. Table 1. Pertinent data Of 10 cildren wit THD Tere are no findings to indicate weter age followed to skeletal maturity or reduction procedure sould be considered. m v) L3 R Y * 0 Y '2 $ - 2 c 2 NA 4 M 192 C 5 31 A JP 12 Se 6 C 4 28 N JM 15 S1 7 C 4 25 N MT 6 M 6 C 6 20 N WA 15 Se 6 C 6 20 N JN 15 Se 8 C 6 22 A CP 13 Se 6 C 8 16 N ES 12 Se 8 C 4 18 A GG 14 Se 40 C 5 18 A GP 15 Se 12 C 5 S N M = Moderate Se = Severe S1 =Sligt C =Closed A =Abnormal N =Normal DISCUSSION THD in cildood occurs predominantly in older boys, wic is probably due to teir iger traumatic morbility (Morton 1959, Fiscer et al. 1971). Hip dislocation, especially in younger cildren, may result from sligt trauma (Finesci 1956, Sclonsky & Miller 1973), as in tis series, and tis migt be related to te anatomic caracteristics of tis age group (Bado, personal communication 1977). Giraud (1927) suggested tat anterior dislocations are proportionally more frequent tan in adults, but our findings do not confirm tis opinion. Tere were in tis series six retroacetabular dislocations: tis type, quoted by few autors (Trillat & Ringot

552 ANTONIO BARQUET 1951, Cavatte 1968, Fiscer & Imbert 1969), may cause diagnosis difficulties, as isolated frontal radiograms sowing a concentric projection of epipysis and acetabulum are not always demonstrative. As already mentioned by Piggot (1961) and Sclonsky & Miller (1973), our findings sow tat fracturedislocations are exceptional in cildren, peraps as a consequence of te particular plasticity of teir joints. Associated neurological injuries are rare, but tey may lead to poor results. Dislocations associated wit femoral saft fracture, toug rare, are remarkable as in more tan 50 per cent of previously reported cases dislocation was initially missed, te fracture providing an obvious injury and acting as a corrective osteotomy (Wadswort 1961, Helal & Skevis 1967). Closed reduction is usually effective in recent dislocations witout fracture. Irreducibility in tese cases is rare and it is caused by soft tissue interposition (acetabular labrum, capsule and muscles) as it as also been found by Funk (1962), Ferndez (1965), Fordyce (1971) and Pearson & Mann (1973). Only X-rays are definitive for te diagnosis in tese cases and open reduction is indicated. If tere is associated femoral saft fracture, closed reduction sould be attempted, including certain procedures suc as manipulation of te proximal fragment of te femur by means of screws or pins or even after its surgical exposure (Dene & Immerman 1951, Helal & Skevis 1971, M Bamalli 1975). Open reduction is required if tese measures fag. Post-reduction treatment as been very variable in tis series, as in oter reports. Avascular necrosis is a redoubtable complication. As it may be diagnosed until 24 monts after injury, te evaluation of its incidence sould be made on te basis of cases followed for at least tat interval. Necrosis appears to be te result of interference wit te extraosseous blood supply at te time of te injury (Cros 1959, Haliburton et al. 1961, Gula 1972). However, alternative mecanisms ave been mentioned (Epstein 1973). Te essential factor pre- disposing to necrosis in tis series was delayed reduction, and tis as also been found by Haliburton et al. (1961), Pennsylvania Ortopaedic Society (1968) and Hammelbo (1 976). Anoter accepted factor is severe trauma (Gula 1972, Epstein 1973). Open reduction as also been mentioned (Funk 1962), but if performed immediately can also be associated wit a good prognosis (Scoenecker et al. 1978). Coxa magna, found by few autors (Glass & Powell 1961, Hovelius 1974, Macfarlane & King 1976), may be caused by a pyseal disturbance, and can also be related to vascular impairment. Artrosis is te common end result of tese complications, toug it may also appear in teir absence, especially after severe trauma; its incidence seems iger tan usually considered. Te incidence of post-reduction treatment on complications and end-results is still under discussion. According to tis series, te non-weigt-bearing period need not be longer tan 4 weeks, and tis is also te opinion of Pearson & Mann (1973) and Hammelbo (1976). CONCLUSIONS Every cild wit ip or knee trauma (even sligt), wit multiple injuries or wit a femoral saft fracture sould be given a routine X-ray of te pelvis, including lateral ip views. If ip dislocation is present, immediate closed reduction, preferably by te Allis metod, is indicated. Manoeuvres sould be monitored radiograpically to avoid false reductions. Open reduction, altoug rarely required, is necessary in te case of soft tissue interposition and in dislocations associated wit femoral saft fracture in wic closed procedures ave failed. Postreduction treatment may include bedrest, skin traction or a cast for a period of 4 weeks, to allow ealing of soft tissue injuries, followed by free weigt-bearing. Clinical and radiological examinations sould be performed quarterly during te first 2 years and ten periodically until maturity to disclose eventual complications.

TRAUMATIC HIP DISLOCATION IN CHILDHOOD 553 ACKNOWLEDGEMENTS Te autor is indebted to Dr. N. Castiglioni and Dr. A. Silveri for elpful suggestions in te preparation of tis manuscript; to Miss R. Zabala and Mrs. I. Milano for secretarial elp, and to Mr. A. Corder0 for te potograps. REFERENCES Cavatte, J. (1968) Luxation traumatique de la ance cez l enfant. Tese, Lyon. Cros, A. (1959) Osteocondrosis of te upper femoral epipysis following traumatic dislocation of te ip joint. J. Bone Jt Surg. 41-A, 1335-1338. Dene, E. & Immermann, E. (1951) Dislocation of te ip combined wit fracture of te saft of te femur on te same side. J. Bone Jt Surg. 33-A, 731-745. Epstein, H. (1973) Traumatic dislocations of te ip. Clin. Ortop. 92, 116-142. Fernndez Herrera, E. (1965) Luxaci6n traumtica anterior de la cadera en la infancia. Bol. mbd. Hosp. infant. (Mkx.) 22, 95-99. Finesci, G. (1956) Die traumatisce Hiiftverrenkung bei kindem. Arc. ortop. Unfallcir. 48,225-236. Fiscer, L. & Imbert, J. (1969) Luxation traumatique de la ance rktro-cotyloidienne pure cez l enfant, sans dkplacement en auteur. Lyon mbd. 222, 825-826. Fiscer, L., Venouil, J., Baulieux, J. et al. (1971) Luxations traumatiques de la ance cez l enfant. Ca. Mbd. Lyon. 47, 3325-3331. Fordyce, A. (1971) Open reduction of traumatic dislocation of te ip in a cild. Brit. J. Surg. 58,705-707. Funk, F. (1962) Traumatic dislocation of te ip in cildren. J. Bone Jt Surg. 44-A, 1135-1 145. Giraud, D. (1927) Contribution a l ktude de la luxation traumatique de la ance cez l enfant. Tese, Bordeaux. Glass, A. & Powell, H. (1961) Traumatic disloca- tion of te ip in cildren. J. Bone Jt Surg. 43-B. 29-37. Gula, D. (1972) Recurrent traumatic dislocation of te ip in cildren. J. Amer. Osteopatol. Ass. 72, 32-39. Haliburton, R., Brockensire, F. & Barber, J. (1961) Avascular necrosis of te femoral capital epipysis after traumatic dislocation of te ip in cildren. J. Bone Jt Surg. 43-B, 43-46. Hammelbo, T. (1976) Traumatic ip dislocation in cildood. Acta ortop. scand. 47, 546549. Helal, B. & Skevis, X. (1967) Unrecognised dislocation of te ip in fractures of te femoral saft. J. Bone Jt Surg. 49-B, 293-300. Hovelius, L. (1974) Traumatic dislocation of te ip in cildren. Acta ortop. scand. 45, 746-75 1. Macfarlane, 1. & King, D. (1976) Traumatic dislocation of te ip joint in cildren. dust. N.Z. J. Surg. 46, 227-231. Morton, K. (1959) Traumatic dislocation of te ip in cildren. Brit. J. Surg. 47, 233-237. M Bamali, E. (1975) Unusual traumatic anterior dislocation of te ip. Znjury 6, 220-224. Pearson, D. & Mann, R. (1973) Traumatic ip dislocation in cildren. Clin. Ortop. 92, 189-1 94. Pennsylvania Ortopaedic Society (1968) Traumatic dislocation of te ip joint in cildren. J. Bone Jt Surg. SO-A, 79-88. Piggot, J. (1961) Traumatic dislocation of te ip in cildood. J. Bone Jt Surg. 43-B, 38-42. Sclonsky, J. & Miller, P. (1973) Traumatic ip dislocation in cildren. J. Bone Jt Surg. 55-A, 1057-1 063. Scoenecker, P., Manske, P. & Sertl, G. (1978) Traumatic ip dislocation wit ipsilateral femoral saft fractures. Clin. Ortop. 130, 233-23 8. Trillat, A. & Ringot, A. (19.51) Erreurs d interpretation radiograpique dans les fractures du cotyle avec luxation de la t&te fkmorale. Lyon cir. 46, 472-474. Wadswort, T. (1961) Traumatic dislocation of te ip wit fracture of te saft of te ipsilateral femur. J. Bone Jt Surg. 43-B, 47-49. Correspondence to: Antonio Barquet, M.D., Avda. Joaquin Surez 3132, Montevideo, Uruguay.