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Reduction
of Neglected
Traumatic
of the Hip by Heavy
BY
R.
AND
Fro,n
Heavy
ABSTRACT:
to seven
patients
tile
old
GUPTA,
B.
P.
Department
traction
with
C.
SHRAVAT,
was
posterior
by reducing
results
were
the
good
traction
and
to excellent.
there
was no evidence
of avascular
arthritis
during
a follow-up
period
to
three
years.
The
centric.
The
the dislocation
whom
method
was
femoral
heads
failed
of nine
in one
months’
a comminuted
other
fractures
fracture
of the
or osteosix months
were
fully
patient
duration
of the
pelvis
abducting
the
In six patients
became
in
con-
and
present.
management
of neglected
location
of the hip becomes
the passing
of time after
surgery
have
been
encountered
very
the
cases
of traumatic
in reducing
the
Great
femonal
head
is
it is bound
Injury
Age
(Yr.s. )
3
M
4
4
M
22
Accident
described
been successful
present
paper,
intervals
of about
the patient
under
drugs
skeletal
regimens
to accomplish
reduction
or by closed
maby a period
of light traction
only in exceptional
we describe
the
cases.
treatment
of
one month
following
the injury.
sedation
and with muscle-relaxant
administered
intravenously,
traction
for five days and
we applied
heavy
reduced
the disloca-
then
tion by abducting
the leg. This method
proved
successful
in all but one of our patients.
In that instance,
the patient’s
hip had been dislocated
for nine months
before
treatment
begun.
Case
Reports
I . A twenty-eight-year-old
to admission
to our hospital.
CASE
days
prior
and
manipulated
on
man
fell
from
During
that
occasions
several
a tree
twenty-six
interval,
but
his hip was
he was
not
hos-
I
Interval from
Sex
all previously
massaged
TABLE
Case
A Ilahahad
dis-
difficulty
when
College.
three cases of posterior
dislocation
of the hip and tabulate
data on four others
(Table
I). In two of the cases described
treatment
was successful.
The dislocations
were reduced
more and more difficult
with
injury.
The results
of late
disappointing.
Medical
or not, had
In the
was
The
INDIA
the reduction,
either
by open
nipulation,
whether
preceded
after
With
whom
and in
acetabulum
also
M. L . N.
However,
applied
dislocation
necrosis
of from
F.I.C.S.*,
ALLAHABAD,
Surgery.
of the hip. Traction
of seven
to eighteen
kilograms
applied under
sedation
for five to seventeen
days allowed
over-reduction
of the dislocation.
Then gradual
reduction of the femoral
head into the acetabulum
was accomplished
limb.
The
Traction
M.S.(ORTH.),
D.ORTH.*,
Orthopaedie
of
treatment
isolated
M.S.(SURG.),
Dislocation
Traction
to
Over-
to
Hospitalization
Reduction*
(Days)
(Days)
FaIl
75
3 (6.8
Sports
45
7
Traction
in
Follow-up
Abductiont
(Days)
kg)
Results
(Yrs.)
S
10
2#{189}
Excellent
2#{189}
Redislocated
when traction
was relaxed;
eventually
excellent
5
M
22
Sports
40
10
10
6
F
25
FaIl
55
10
10
*
Traction
t
Diminishing
of up to eighteen
traction
in an abnormal
acetabulum
head.
open
Others
off
tempt
made
hip.
this,
the
which
supply
stages.
simple
on
operative
normal
femoral
also
to the
the
instances
pitalized.
*
VOL.
M.L.N.
Medical
of Allahabad,
59-A,
NO.
College,
Allahabad,
2.
MARCH
Department
India.
977
examination,
he had
centimeters
with
a marked
mity.
The femoral
head
was palpable
posterior
dislocation
adduction
shortening
and
in the gluteal
of the right
of
internal
hip
limb
made
of
defordiagnosis
The
region.
was
the
rotation
(Figs.
I -A and
1-B).
displacement
anatomical
has
of
physical
On
eight
of isolated
regimens
head
fills
femonal
osis an at-
features
to be reduced.
of
Manipulation
and
reduction
The
was
then
failed.
traction
with
Orthopaedics,
Univer-
patient
through
meperidine
Roentgenograms
adequate
sity
Excellent
begun.
in such
or two
of these
the
abduction
anthrodesis
advised
to restore
tissue
blood
in one
in none
To do
the
advised
have
but
before
Excellent
#{189}
abduction.
by scan
cuts
reduction
teotomy,
the
position
and
Watson-Jones
after
kilograms
during
2
was being
tion.
Again
a pin
in the
and skeletal
were
lengthening
changed,
eighteen
made
of the
the
head
kilograms
under
subjected
tibial
anesthesia
tubercle.
relaxation
on
alternate
limb,
then
of the
was
to eighteen
He was
kept
with
days.
fifth
femur
went
of traction
was
On
the
position.
back
applied
to
and
it
of skeletal
under
was obtained
in neutral
tried,
kilograms
sedation
mephenesin.
day
there
As the
its original
and
this
was
splint
posi-
brought
249
R.
250
and
below
the
the acetabulum
lowed
by
of
time
discharge
The
I-C).
the
hip
FIG.
view
The
limb
was
hip
were
had
the
At
in all respects,
of 90
hip
the
for three
another
five
was
stable,
but
a three-year
Roentgenograms
fol-
2-B).
the
follow-up
The
incon-
(Fig.
2-C).
a nor-
cises
were
from
the
2. A twenty-seven-year-old
of an injury
interval.
On
physical
examination,
with
and
internal
rotation
tion
of all
movements.
lated
posterior
The
eighteen
Fig.
Fig.
Fig.
was
kilograms
2-A:
2-B:
Case
Same
2-C:
Same
was
were
the left
centimeters
given
early
was
hip
of true
myositis
through
ossificans
slow
on the seventeenth
day,
a
had
given
hip
follow-up,
grees.
knee
showed
crosis
four
normal.
of hip
or degenerative
was
gradually
in the
acetabulum
found
maintained
The
patient
fiexion
allowed
after
was short
next
two
exer-
was
of
discharged
the
three
of the full
after
with
for the
day.
non-weight-bearing
active
Follow-up
movement
limb
was
and
was
fifth
(Fig.
fourth
was
of
the
every
weeks.
hip flexion
was
range
a full
next
60 degrees
On
kilograms
head
removed,
Weight-bearing
three-month
The
the
with
The
3.6
by
days.
of the acetabulum
overcorrected.
kilograms
was
alternate
the level
femoral
of seven
traction
for
joint.
been
the
on
below
relaxed
day
hospital
made
found
margins.
range
and
two
hip
no evidence
and
months.
a
At
by 15 de-
a half
years
of avascular
ne-
arthritis.
and restricshowed
drip
Skeletal
traction
tibial
tuberosity.
head
reduced
iso-
of
hip
the
traction
CASE
admission
2-A).
of the left
The
in the
adduction,
intravenous
in the
with
a
(Fig.
saline.
traction.
with
fall from
provided
shortening
a pin
of
a
in flexion,
roentgenogram
day
hospital
in
examination
per day in normal
2. Anteroposterior
hip on the fifth
hip
before
the treatments
a continuous,
applied
to our
days
roentgenographic
with
300 milligrams
meperidine,
6.4
The
dislocation
patient
came
thirty-seven
and manipulation
Massage
tractor.
man
sustained
the
dislocation.
acetabular
were
hip
traction
Traction
Then
stable
CASE
the
posterior
normal
was
deformities
and
weeks.
affected
hip.
history
head
After the seventeenth
other
showed
of the
the femoral
abducted
the
1-C
FIG.
day,
At
the
1-B
into
slight
follow-up
SHRAVAT
abducted
weeks
and
P.
head
weeks.
degrees
three-month
and
gradually
reduced
continued
for
flexion
normal;
remained.
then
This
exercises
joint
was
kilograms.
Traction
patient
B.
of the right hip showing
isolated
isolated
posterior
dislocation
with
incongruity
of the articular
surfaces.
roentgenogram
of the same
hip showing
is reduced
with slight
dislocation
to seven
the
the
of
of
mal
Oblique
1 -C:
(Fig.
was normal
hip
1 -B:
Fig.
non-weight-bearing
movements
gruity
1 -A:
reduced
AND
1 . Anteroposterior
Case
Fig.
Fig.
the acetabulum.
traction
GUPTA
1-A
FIG.
the head
C.
of
manipulated
of
right
hip
centimeters
showing
femur
and
is
posterior
partially
the
limb
A thirty-year-old
7.
to our hospital.
several
was
times.
in flexion,
of
in abduction.
On
fell
that
and
head
THE
internal
restriction
nine
hip
was
of all
at
rotation.
months
before
massaged
and
admission,
There
movements
the
was
6.4
of the
hip.
ossificans.
is in the
JOURNAL
a tree
his
examination
and
with
myositis
acetabulum.
The
from
period
physical
adduction,
shortening
dislocation
below
the
man
During
acetabulum
OF
BONE
but
AND
incongruous.
JOINT
SURGERY
REDUCTION
Roentgenographic
with
examination
a comminuted
pubis.
There
patient
was
femur
down
not
be
was
put
of
disruption
the
skeletal
traction
but we could
accomplished
probably
dislocation
TRAUMATIC
myositis
ossificans.
that
brought
the
the
it. The
was
of the
could
filled
Cases
of neglected
traumatic
while
not common,
have
been
However,
even the largest
series
of
which
Thompson
long
and
intervals
Epstein,
had
elapsed
dislocation
collected
of cases,
did not
between
jury and the time when the dislocation
of this type cannot
be rare, especially
of the hip,
and studied.
those
of Bray
the average
include
many
in
the time of in-
was reduced.
in areas where
has
not
Cases
medi-
produces
compared
we have not been able to find in
of traction
treatment
such as we
were
They
reduction.
Bray
excluding
central
the chief
complications
emphasized
reviewed
the
of reduction
and
incidence
of
262
dislocations
fracture-dislocation
of
and
found
for avascular
necrosis
to become
injury is seventeen
months
and
not supervene
after two years
become
manifest.
Our
the
femoral
significantly
less
with
immediate
patients
have
that
if it
been
trauma
closed
the soft-tissue
is exerted
on
and
femoral
Consequently
or
the
be decreased.
patients,
and
a rela-
or
osteoarthnitis.
to the
reduction.
structures
the articular
head,
The
professions
possible
that
are
pa-
without
traction
femoral
With
more
cartilage
head
ade-
relaxed,
of the
and no manipulative
neduc-
is required.
of early
hip
head,
returned
to their original
symptoms.
It may be
acetabulum
tion
in unsatis-
importance
of
quate
traction
less pressure
described.
arthritis
required
after
does
already
tients
have
any residual
Thompson
and Epstein,
and Epstein
in a later study,
reviewed
a series
of dislocations
and fracture-dislocations
of the hip and concluded
that avascular
necrosis
and
cases.
time
251
followed
for a minimum
period
of two years
and the results were good in those for whom
the reduction
was successful.
There
was no evidence
of avascular
necrosis,
in-
that need treatment.
Yet
the literature
any account
factory
time
evident
clinically
this complication
regularity
traumatic
the
HIP
in 57 pen cent.
cal care
is not adequately
available
on where
multiplyinjured
patients
cannot
have a satisfactory
course
of treatment provided
for the dislocation,
given the other injuries
have
THE
Stewart
and Milford
found that in no instance
was a
good
result
obtained
when
the reduction
was not done
within
the first twenty-four
hours.
Stewart
showed
that
Discussion
and
between
veloped
with
scar tissue.
uncompressible
OF
avascular
necrosis.
Of 204 hips
reduced
within
twelve
hours
of injury,
avascular
necrosis
developed
in 18 per
cent, while in fifty-eight
reduced
after twelve
hours it de-
The
head
reduction
acetabulum
the
of
DISLOCATION
tionship
of the hip
rami
both
and
not reduce
because
NEGLECTED
and
acetabulum
of the pelvis
on heavy
adequately,
a posterior
showed
fracture
OF
later
the danger
degenerative
changes
Myositis
it preceded
of recurrence
of dislocation
in the
head
femoral
ossificans
was seen in two
the traction
treatment.
may
of our
References
1.
BRAy,
E.
A.:
Traumatic
Dislocation
2.
Sept. 1962.
EPSTEIN,
H. C.: Posterior
3.
STEWART,
of the
Hip.
Army
Experience
and
Results
over
a Twelve-Year
Period.
J. Bone
and
Joint
Surg.
,
44-A:
11 15-
1134,
Mosby,
4.
MARCUS:
Fracture-Dislocations
In Campbell’s
Dislocations.
of the
Operative
Hip.
Long-Term
Follow-up.
Orthopaedics,
edited
by
J. Bone and Joint
A. H. Crenshaw.
Surg.,
56-A:
Ed. 5, vol.
1103-1127,
1, p. 422.
St.
Sept.
1974.
Louis,
C.
V.
1971.
M.
STEWART,
J.,
and
MILFORD,
L.
W.:
Fracture-Dislocation
ofthe
Hip.
An
End-Result
Study.
J. Bone
of Two
Hundred
and JointSurg.,
36-A:
315-342,
April
1954.
5.
P.,
Years.
THOMPSON,
V.
Twenty-one
6.
VOL.
WATSON-JONES,
59-A,
NO.
and EPSTEIN,
H. C.: Traumatic
Dislocations
of the Hip.
J. Bone
and Joint Surg.,
33-A:
746-778,
July 1951.
REGINALD:
Fractures
and Joint Injuries.
Ed. 4, vol. 2, pp.
2. MARCH
1977
A Survey
674-676.
Edinburgh,
E. and
and
Four
Cases
S. Livingstone,
Covering
1955.
a Period
of
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