anterior and posterior knee dislocation

1. Extern Noon
Conference
ณัฐพล ภาณุพินธุ
11/11/59

2. Case ชายไทย อายุ 15 ปี
• นักเรียนชั้นมัธยมศึกษาชั้นปี ที่ 3 โรงเรียนนิคมพิมาย
ศึกษา
• ภูมิลาเนา อาเภอพิมาย จังหวัดนครราชสีมา
• นาส่ง emergency department โดย ambulance จาก
โรงพยาบาลพิมาย (21:00)
• ประวัติ MC ล้ม 30 นาทีก่อนมาโรงพยาบาล (17:00)
• จาเหตุการณ์ตอนเกิดเหตุไม่ได้ ตื่นขึ้นมามีบาดแผล
ถลอกตามตัว สะโพกขวาผิดรูป ปวด และขยับไม่ได้

3. Acute hospital
management at ER
Advanced trauma life support protocol
• Airway maintenance with cervical spine
control
• Breathing and ventilation
• Circulation with hemorrhagic control
• Disability evaluation
• Exposure and environmental control
ในเบื้องต้นต้อง R/O head and c-spine injury?,
shock?, severe skeletal and soft tissue injury?
เพราะมี mechanism ที่รุนแรง
พิจารณาส่ง films C-spine (lateral), CXR, pelvis

4. Primary survey and adjuncts to
primary survey
•Airway maintenance with cervical spine
control – รู ้ตัวดี พูดคุยได้ ไม่เจ็บบริเวณใบหน้า ศีรษะ และ
คอ
•Breathing and ventilation – RR 18/min, regular,
good air entry, clear, equal breath sounds,
compression tests negative
•Circulation with hemorrhagic control – BP
110/70 mmHg, PR 86/min full, regular, symmetrical
•Disability evaluation – GCS = 15, pupils 3 mm
RTLBE
•Exposure and environmental control – no
external bleeding, no hypothermia

5. Secondary survey: AMPLE
•Allergy – none
•Medication – none
•Past medical history – none
•Last meal – 11:30
•Events – as described

6. Physical examination
• GA : A young man, good consciousness, well co-
operative, no dyspnea
• Vital signs: Temp 36.8 C, BP 110/70 mmHg, PR 86/min,
RR 16/min
• HEENT : no pale conjunctivae, anicteric sclera
• CVS : full regular pulses all extremities, normal S1 S2,
no murmur
• Respiratory : No dyspnea, normal breath sound, no
adventitious sound
• GI : Soft, mild tender at RUQ and epigastrium, no
distension, normoactive bowel sound

7. Physical examination: right hip,
thigh and leg
• Fixed position of the right
hip
1. External rotation
2. Abduction
3. Flexion
• Fullness and tender at right
groin
• Few lacerated wounds on
the right thigh and leg
• Unable to move the right
hip, limited ROM of the right
knee due to pain

8. Film X-ray of Pelvis
(AP view)
• The lesser trochanter is
more visible due to
external rotation
• The hip is abducted
• The femur head is
usually inferior to the
acetabulum
• Shenton's line is also

9. Pertinent findings
• Mild tenderness at RUQ and epigastrium
• Deformity of the right hip with painful sensation
and limited ROM
Problem list
• Blunt abdominal trauma (hemodynamic stable)
• Anterior dislocation of the right hip

10. Management at ER
(trauma + ortho)
• Admit
• Monitor V/S, I/O
• NPO
• 5% DN/2 (1000) IV drip rate 80 ml/h
• CBC, anti-HIV
• Films: skull AP lateral, chest, pelvis AP, film right leg
AP including knee
• Retained NG and lavage with NSS 500 ml
• FAST, CT whole abdomen
• Pethidine (1 mg/kg) 45 mg IV prn q6h
• Cefazolin 1 g IV to OR
• Set OR emergency for close reduction of the right

11. CT whole abdomen
• Small laceration at hepatic segment 6, suspecting
grade II liver injury
• Small left pneumothorax
• Right anterior hip dislocation

12. Closed reduction
under GA
• Traction and counter
traction
• Adduction
• Internal rotation

13. Results and further
management
• Successful reduction with
stable and intact femoral
bone and pelvis
• No disruption of Shenton’s
line
• No leg length discrepancy
• Intact neuro-vascular status
• Partial weight bearing with
axillary clutch, ROM
exercise, strengthening

14. Hip dislocation
Indication for surgery
• Hip dislocation with femoral
neck or acetabular fracture
• Incarcerated fragment in the
hip joint
• Irreducible reduction
• Incongruent reduction (does
not fit properly)
• Unstable hip after reduction

15. Anatomy of hip joint
Ball-and-socket joint surrounded by
ligaments

16. Hip dislocation
Summary
• Typically caused by high-
energy trauma, frequently
in young patients
• Types of dislocations
- Anterior dislocation
- Central acetabular fracture
dislocations
- Posterior hip dislocation
usually with posterior

17. Posterior hip dislocation
(90%)
•A posterior dislocation leaves the lower leg
in a fixed position, with the knee and foot
rotated internally

18. Hip dislocation
Associated injuries
• Multiple trauma, sometimes life threatening
• Ipsilateral femoral neck, femoral shaft fracture
• Ipsilateral patella fracture
• Ipsilateral knee injuries (cruciate, collateral ligaments
and periarticular fracture)
• Sciatic nerve

19. Hip dislocation
Management
• True orthopedic emergency
• Reduction within 6 hours – preventing avascular
necrosis of the femoral head
• Reduction under general anesthesia or spinal
anesthesia
• Allis maneuver for hip dislocation
• Test for stability of the hip after reduction
• Re-evaluate associated fracture of acetabulum and
femoral head