CASE REPORT

POSTERIOR HIP DISLOCATION

Disusun untuk memenuhi sebagian tugas kepaniteraan klinik
bagian Ilmu Bedah di RSUD Soewondo Kendal

Disusun oleh:
Bhethari Ayu Kusuma Wardani
30101206814
Pembimbing:
dr. Wisnu Murti., Sp.OT
FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2016
HALAMAN PENGESAHAN

Nama

: Bhethari Ayu Kusuma Wardani

NIM

: 30101206814

Fakultas

: Kedokteran

Universitas

: Universitas Islam Sultan Agung ( UNISSULA )

Tingkat

: Program Pendidikan Profesi Dokter

Bagian

: Ilmu Bedah

Judul

: POSTERIOR HIP DISLOCATION

Kendal,

Juli 2016

Mengetahui dan Menyetujui

Pembimbing Kepaniteraan Klinik
Bagian Ilmu Bedah RSUD Soewondo Kendal

Pembimbing,

dr. Wisnu Murti Sp.OT

CHAPTER I
INTRODUCTION
Hip dislocations, regardless of their etiology, are orthopedic emergencies that require
immediate diagnosis, evaluation, and treatment. The adult hip joint is remarkably stable. It is
reinforced with thick capsular and labral structures. The presence of a dislocation injury
indicates a large force from a traumatic mechanism (a traction force 90 lb) or the presence
of underlying pathology leading to inherent instability of the joint. Posterior dislocations

make up 80-95% of traumatic hip dislocations. In the presence of a large force injury,
Advanced Trauma Life Support (ATLS) measures may need to be initiated in the initial
assessment of the patient. Pediatric hip dislocations may occur with smaller amounts of force
and have been documented after gymnastic maneuvers and falls from standing. Elderly
patients or those with Ehlers-Danlos Syndrome or Down Syndrome are also more likely to
dislocate a hip with smaller amounts of traumatic force.
Posterior traumatic hip dislocations occur when the force acts with adduction, internal
rotation, and some degree of flexion of the hip. The incidence of this injury has increased as a
consequence of high-velocity motor vehicle use. Injuries in which the front-seat passengers
are involved in a head-on collision that drives the dashboard into their lower extremities
(known as dashboard injuries) have become a notorious cause of posterior traumatic hip
displacement. This mechanism of injury is associated with an incidence of simultaneous
severe knee injury in 26% of patients, including patellar fractures in 4% of patients. The
increasing popularity of extreme sports has also led to an increase in hip dislocations. One
study showed that snowboarders are more likely than skiers to experience hip dislocations.
The difficulty in detecting a knee injury in a patient who has a dislocated hip underscores the
need for the clinician to maintain a high index of suspicion for multiple lower extremity
injuries (eg, acetabular and femoral head, neck, or shaft fractures) as well as occult visceral
damage. A review by Onche et al highlighted the high rate of other extremity injuries
associated with hip dislocations.
Often accompanied by a pelvic injury serious injury that requires immediate
management of. Pelvic injury should be reduced because the longer caput femoral is outside
the acetabulum, the higher the incidence of avascular necrosis. Just a little caput femoral
which

can

survive

if

it

remains

dislocated

for

more

than

24

hours.

Reduction can be done in closed and open. Before doing the reduction is worth remembering
that neurovascular examination should be done first. Closed reduction should be done under
general anesthesia, done gently, and muscle relaxation are necessary to achieve atraumatic
reduction. If closed reduction does not work, then do the open reduction.
Posterior hip dislocations are also seen following total hip arthroplasty. Relatively
minor forces, such as flexing the hip to pick an item up from the floor, can result in postoperative hip dislocation. Several studies indicate that slight alterations in surgical technique
(slightly larger femoral head and slightly less acetabular component anteversion) may
decrease postoperative dislocation rates. Multiple studies have demonstrated that the ultimate
morbidity for the patient increases as the time interval from injury to reduction increases.
Complications such as osteonecrosis of the femoral head, arthritic degeneration of the hip
joint, and long-term neurologic sequelae become more likely as reduction is delayed.
Whereas the goal is to perform an adequate reduction as quickly as possible, careful
prereduction evaluation must be performed to properly diagnose the injury. If adequate closed
reduction cannot be attained or if a nerve palsy becomes apparent after closed reduction is
achieved, emergency operative reduction is required.

CHAPTER II
CONTENTS REVIEW
1.ANATOMI
The hip joint is a ball and socket synovial type joint between the head of the femur and
acetabulum of the pelvis. It joins the lower limb to the pelvic girdle. The hip joint is designed
to be a stable weight bearing joint. To achieve this, a large range of movement is sacrificed
for stability.

Structures of the Hip Joint

Fig 1.0 The femoral head and acetabulum of the hip joint.
The hip joint consists of an articulation between the head of femur and acetabulum of the
pelvis.
The acetabulum is a cup-like depression in the lateral side of the pelvis (much like the
glenoid fossa of the scapula). The head of femur is hemispherical, and fits completely into the
concavity of the acetabulum.
Both the acetabulum and head of femur are covered in articular cartilage, which is thicker at
the places of weight bearing.
Ligaments

The ligaments of the hip joint act to increase stability. They can be divided into two groups
intracapsular and extracapsular.
Intracapsular
The only intracapsular ligament is the ligament of head of femur. It is a relatively small
ligament that runs from the acetabular fossa to the fovea of the femur. It encloses a branch of
the obturator artery, which comprises a small proportion of the hip joint blood.
Extracapsular
There are three extracapsular ligaments. They are continuous with the outer surface of the hip
joint capsule.

Iliofemoral: Located anteriorly. It originates from the ilium, immediately inferior to the
anterior inferior iliac spine. The ligament attaches to the intertrochanteric line in two places,
giving the ligament a Y shaped appearance. It prevents hyperextension of the hip joint.

a.

Pubofemoral: Located anteriorly and inferiorly. It attaches at the pelvis to the iliopubic
eminence and obturator membrane, and then blends with the articular capsule. It prevents
excessive abduction and extension.

Ischiofemoral: Located posteriorly. It originates from the ischium of the pelvis and attaches
to the greater trochanter of the femur. It prevents excessive extension of the femur at the hip
joint.

Fig 1.1 The extracapsular ligaments of the hip joint.

Fig 1.2 The medial and lateral circumflex arteries.

Vascular supply to the hip joint is achieved via the medial and lateral circumflex femoral
arteries, and the artery to head of femur.
The circumflex arteries are branches of the profunda femoris artery. They anastomose at the
base of the femoral neck to form a ring, from which smaller arteries arise to the supply the
joint itself.
The medial circumflex femoral artery is responsible for the majority of the arterial
supply (the lateral circumflex femoral artery has to penetrate through the thick iliofemoral
ligament to reach the hip joint). Damage to the medial circumflex femoral artery can result
in avascular necrosis of the femoral head.

The hip joint is innervated by the femoral nerve, obturator nerve, superior gluteal nerve, and
nerve to quadratus femoris.

Stabilising Factors
The primary function of the hip joint is to bear weight. There are various structures present
that increase its stability.
The first structure is the acetabulum. It is deep, and encompasses nearly all of the head of
the femur. This decreases the probability of the head slipping out of the acetabulum, and
causing a dislocation.
There is a fibrocartilaginous collar around the acetabulum which increases its depth. It is
known as the acetabular labrum. The increase is depth provides a large articular surface,
thus improving the stability of the joint.
The iliofemoral, pubofemoral and ischiofemoral ligaments are very strong, and along with the
thickened joint capsule, they stabilise the joint greatly. These ligaments have a unique spiral
orientation; this causes them to become tighter when the joint is extended, which adds
stability to the joint, and also means less energy is needed to maintain a standing position.
Muscles and ligaments work in a reciprocal fashion at the hip joint:

Anteriorly, where the ligaments are strongest, the medial flexors (located anteriorly) are
fewer and weaker.

Posteriorly, where the ligaments are weakest, the medial rotators are greater in number and
stronger they effectively pull the head of the femur into the acetabulum.

Bones and osteology

Femur
The femur is the longest and heaviest bone in the human body. It consists of a superior or
proximal end, a shaft, and an inferior or distal end (see the image below).

Parts of femur.

The superior end of the bone is the articulating side of the femur to the acetabulum. The
upper femoral epiphysis closes by 16 years of age. The trabecular bone configuration in the
proximal femur obeys Wolff's Law, which states that bony structures orient themselves in
form and mass so as to best resist extrinsic forces. The principal compressive group, the
principal tensile group, the greater trochanteric group, the secondary tensile group, the
secondary compressive group, and, finally, Ward's triangle can be found. The superior end of
the femur consists of a head, a neck, and greater and lesser trochanters. The head of the femur
is angled superomedially and slightly anteriorly when articulating with the acetabulum. The
head is attached to the femoral body or shaft by the neck of the femur.
The superior border of the neck begins just lateral to the femoral head and ends distally at the
greater trochanter. The inferior border of the neck begins lateral to the femoral head and
extends to the inferior trochanter. The superior border is shorter and thicker than the inferior
border. The anterior surface of the neck is rough in comparison to the smooth femoral head.
The necks posterior surface has a concave appearance. The head and neck are at an angle of
130 ( 7) to the shaft. The angle is larger at birth and decreases with age. The greater
trochanter is a bony prominence on the anterolateral surface of the proximal shaft of the
femur, distal to the femoral neck. It serves as the insertion site for the gluteus medius and
gluteus minimus. The lesser trochanter is a bony prominence on the proximal medial aspect
of the femoral shaft, just distal to the femoral neck. It serves as the iliopsoas insertion site.
The intertrochanteric line is a raised area that extends from the greater to the lesser trochanter
anteriorly. This connection posteriorly is called the intertrochanteric crest, which contains the
calcar femorale, another anatomic location on the femoral neck. The calcar femorale is a

vertically oriented plate of dense cancellous bone from the posteromedial portion of the
femoral shaft radiating superiorly toward the greater trochanter.
Pelvis
At birth, each pelvic half consists of 3 separate primary bones: the ilium, the ischium, and the
pubis (see the images below). These bones are joined by hyaline cartilage.

Parts of pelvis.

Pelvis and acetabulum, with muscle

attachment sites.

In infants and children, these large parts of the hip bones are incompletely ossified. At
puberty, the 3 primary bones are still separated by a Y-shaped triradiate cartilage centered in
the acetabulum. The primary bones begin to fuse at 15-17 years. Fusion is complete between
20-25 years of age. The fact that these bones were originally separate is fairly undetectable in
adult bones on imaging. Although the parts of the hip bone are fused in adulthood, they are
still referred to by their separate origins.
Ilium
The ilium is the largest part of the hip bone and makes up the superior part of the acetabulum.
The ala provides an insertion point for the gluteal muscles laterally and the iliacus muscle
medially. Anteriorly, the ilium has an anterior superior iliac spine (ASIS); inferior to this is
an anterior inferior iliac spine. From the ASIS, anteriorly, the iliac crest comes around
laterally and continues posterior to the posterior superior iliac spine (PSIS). The PSIS marks
the superior point of the greater sciatic notch. The lateral surface of the ilium has 3 rough
curved lines: the posterior, anterior, and inferior gluteal lines. Medially, the ilium has an iliac
fossa. Posteriorly, the medial aspect of the ilium has an auricular surface.
Ischium
The ischium is the inferior aspect of the pelvis. The superior part of the body of the ischium
fuses with the pubis and ilium, forming the posteroinferior aspect of the acetabulum. The
ramus of the ischium joins the inferior ramus of the pubis to form a bar of bone called the
ischiopubic ramus, which constitutes the inferomedial boundary of the obturator foramen.

The posterior border of the ischium forms the lower margin of a deep indentation the greater
sciatic notch. The large triangular ischial spine at the inferior margin of this notch is a sharp
demarcation separating the greater sciatic notch from a smaller rounded inferior indentation
called the lesser sciatic notch. The bony projection at the inferior end of the body of the
ischium and its ramus is the ischial tuberosity.
Pubis
The pubis makes up the anteromedial part of the hip bone and contributes the anterior part of
the acetabulum. The pubis has a flat body and 2 rami: superior and inferior. Medially, the
symphyseal surface of the body of the pubis articulates at the pubic symphysis with the
surface of the body of the contralateral pubis. The anterosuperior border of the united bodies
and symphysis forms the pubic crest. The pubic tubercles, small projections at the lateral ends
of this crest where the inguinal ligaments attach medially, are extremely important landmarks
of the inguinal regions. The posterosuperior aspect of the superior ramus of the pubis is called
the pectin pubis. The obturator foramen is an oval opening formed by the rami of the pubis
and the ischium. The obturator canal houses the obturator nerve and vessels.
Acetabulum
As indicated above, the acetabulum is formed from parts of the ilium, ischium, and pubis.
The acetabulum is the cup-shaped socket on the lateral aspect of the pelvis, which articulates
with the head of the femur to form the hip joint. The margin of the acetabulum is deficient
inferiorly. An additional fibrocartilaginous margin of the acetabulum is referred to as the
acetabular labrum. The labrum functions to deepen the acetabulum, thus holding the femoral
head more securely. The lunate is the articular surface of the acetabulum to the femoral head.
The rough depression in the floor of the acetabulum is the acetabular fossa, which is
continuous with the acetabular notch. The transverse acetabular ligament is located along the
inferior aspect of the acetabulum; it prevents the femoral head from moving inferiorly by
deepening the acetabulum inferiorly.
Ligaments

The hip joint contains a strong fibrous capsule that attaches proximally to the acetabulum and
transverse acetabular ligament and distally to the neck of the femur anteriorly at the greater
trochanter (see the image below). Posteriorly, the fibrous capsule crosses to the neck 1-1.5 cm
proximal to the intertrochanteric crest.

Hip ligaments.

Most of the fibers go from the hip bone to the intertrochanteric line, but some deeper fibers
go around the neck, forming the orbicular zone, which holds the femoral neck in the
acetabulum. The anterior capsule of the hip is the strongest and thickest part.
This capsule is composed of 3 ligaments. The iliofemoral ligament, sometimes referred to as
the Y ligament of Bigelow, attaches to the anterior inferior iliac spine and the acetabular rim
proximally and takes an inferolateral direction to insert on the intertrochanteric line distally. It
is the strongest part of the capsule. The iliofemoral ligament prevents hyperextension of the
hip joint during standing by holding the femoral head within the acetabulum.
The ischiofemoral ligament reinforces the capsule posteriorly. It originates on the ischial part
of the acetabular rim and spirals superolaterally to the neck of the femur, medial to the greater
trochanter. This ligament, like the iliofemoral, also prevents hyperextension and holds the
femoral head within the acetabulum.
The pubofemoral ligament reinforces the capsule anteriorly and inferiorly. It begins from the
obturator crest of the pubic bone and passes inferolaterally to join the fibrous capsule of the
hip joint. This ligament prevents overabduction of the hip joint.
An iliopectineal bursa lies anteriorly over the gap in the ligaments, beneath the iliopsoas
tendon.
There are several additional structures of importance related to the fibrous capsule. Lining the
fibrous capsule is the synovial membrane. It covers the neck of the femur between the
attachment of the fibrous capsule and the edge of the articular cartilage of the head; it also

covers the nonarticular area of the acetabulum, providing a covering for the ligament of the
femoral head.
Retinacula, which contain blood vessels, are deep longitudinal fibers of the capsule that go
superiorly from the femoral neck and blend with the periosteum. The bursa is considered the
synovial extension beyond the free margin of the fibrous capsule onto the posterior aspect of
the femoral neck.
The ligament of the femoral head is weak. It attaches to the margins of the acetabular notch
and the transverse acetabular ligament; its narrow end attaches to the pit in the head of the
femur. Usually the ligament contains a small artery to the head of the femur.
A fat pad in the acetabular fossa is covered with synovial membrane. It fills the acetabular
area that is not filled by the femoral head.

Hip nerves, anterior view.

Vasculature

2. HIP DISLOCATION
2.1 DEFINITION
Hip dislocation is a state where the displacement of the touch surface caput femoris of
the acetabulum. Dislocation occurs when the head of femur out of the acetabulum. This
condition may be congenital or acquired.

2.2 HIP DISLOCATION traumatic (acquired)

2.2.1 Epidemiology
With the increasing number of traffic accidents, traumatic hip dislocation increasingly
common. Hip dislocation can occur in all age groups. Posterior hip dislocation is the most
frequent dislocations. Posterior hip dislocation occurs as much as 90% of cases, whereas the
anterior hip dislocation occurs as much as 10% of all cases of hip dislocation traumatik.

2.2.2 Classification
Under the direction of dislocation, hip dislocation is divided into three, namely dislocation
posterior, anterior dislocation, and dislocation of the center (central) .
A. Posterior dislocation
a. Mechanism of Injury
Four out of five traumatic hip dislocation is a posterior dislocation. Usually
these dislocations occurred in a traffic accident when someone is sitting in the
car was thrown forward so your knees hit the dashboard. Pushed to the top of
the femur and femoral caput out of the acetabulum, the acetabulum fracture
often occurs (fracture-dislocation) .

Figure 1. Mecanism of Injury in Posterior Hip Dislocation

b. Clinical and Physical Examination
Femoral caput can be in a high position (iliac) or low (ischiatic), depending
on the position of flexi thigh when there dislocation.
Dislocation iliac type:
- Pelvic flexi, adduction, endorotation.
- Affected extremity seem shorter.
- Trochanter major and buttocks in an area that suffered a dislocated
stand out.

- Knee extremities were dislocated looked gone in the thigh next to it.
Dislocation ischiatic type:
- Pelvic flexi.
- The pelvis is adduction so knees in extremities were dislocated seemed
-

to rest on in the thigh next to it.

Lower extremity appears in extreme endorotation position.
- Trochanter major and buttocks in an area that suffered a dislocated
stand out.

Figure 2. Joint position on the posterior hip dislocation

If one suffered fracture of long bones (usually the femur), hip dislocation often
undiagnosed. A good guideline is to a pelvic examination with radiological
examination. Lower leg should also be examined to find whether there is
nerve injury ischiadicus.
Neurovascular injury on the posterior hip dislocation can give you an idea as
follows:
Pain in the pelvis, buttocks and lower limbs posterior part.
Loss of sensation in the lower legs and feet.
Loss of ability dorsoflexi (peroneal branch) or plantarflexi (tibial branch).
The loss of deep tendon reflexes in the ankle.
Local Hematoma.
c. Classification
Epstein and Thompson (1951) suggested a classification that can help
planning governance. This classification was made before the discovery of
CT-scan. Here is the classification of posterior hip dislocation by Epstein and
Thompson:
Type I: Dislocation simple, with or without fragments in the posterior wall of
the acetabulum.
Type II: Dislocation with large fragments in the posterior wall of the
acetabulum.
Type: Dislocation with comminution of the posterior wall of the acetabulum.
Type IV: The dislocations with fracture the base (floor) acetabulum.
Type V: dislocations with fracture femoral caput, which are classified
according to Pipkin (1957).

Figure 3. Classification of Fractures Caput femoris According Pipkin

A) Type I: fracture lines are under the fovea, B) fracture fragment includes the fovea, C)
Same as type I and II, but accompanied by a femoral neck fracture, D) Fracture caput femoris
and acetabulum in any form.

d. Radiological examination
In the photo anteroposterior (AP), femoral caput seen coming out of the
acetabulum and is above the acetabulum. Segment acetabulum roof or femoral
caput has broken and shifted. Oblique photos can be used to determine the size
of the fragment. CT scan is the best way to see the fracture of the acetabulum
or any bone fragment.

Figure 4. Overview radiology posterior hip dislocation

e. Therapy
Dislocations should be reduced as soon as possible under general
anesthesia. Reductions must be made within 12 hours from the onset of
dislokasi. In most cases performed closed reduction, but if closed reduction
fails 2 times open reduction should be performed to prevent damage femoral
caput futhermore. Prior to reduction, neurovascular examination should be
performed ,
Indications closed reduction:
- Dislocation with or without neurological deficits if there is no fracture.
- Dislocations with fracture if there are no neurological deficits.
Contraindications closed reduction:
- Dislocation pelvis open.
Here are some techniques that can be used to reduce simple posterior hip dislocation (type I
Epstein) .
- Maneuver Allis
1. The patient lies in a supine position.
2. An assistant pressing spina iliaca anterior superior.

3. The operator holds the limbs dislocated ankle in one hand.

4. Forearm operator placed below the knee, and then do the parallel longitudinal traction
deformity.
5. Thighs in adduction and endorotation position, then flexed 90. This action relaxes the
iliofemoral ligament.
6. After traction is maintained, caput prying into the acetabulum with abduction, external
rotation and hip extension.

- Maneuver Stimson
This maneuver heavy use of lower limbs and gravity to reduce dislocation.
1. The patient is placed on a table in prone position.
2. The legs were dislocated hung down and the knee flexed.
3. An assistant holds a healthy leg horizontally.
4. The operator gave a steady downward pressure on knee flexion.
5. This position was maintained until muscle relaxation and caput femoris down to the

acetabulum.
Sometimes with a little swinging thigh can accelerate the reduction.

- Maneuver Bigelow
1. The patient was laid on the floor in a supine position.
2. An assistant pressing spina iliaca anterior superior.
3. Lift the leg dislocated and flex the hip and knee joints.
4. Rotate the legs to a neutral position.
5. Create a steady traction on the lower leg upward, lift the caput femoris into the
acetabulum.

6. After traction upwards finished, place the thighs down the extension position.

- Mechanical Whistler
Who suffered a dislocated pelvis relocated using operator arm to lift and maneuver when the
limbs dislocated shoulder appointed operator. The operator's hand rests on the contralateral
thigh. An assistant or other hand the operator does kontratraksi on the tibia or fibula.

- Longitudinal traction
Patients were placed in the supine position, then an assistant to perform lateral traction, while

the operator performs longitudinal traction

- Leg-crossing maneuvers
Sometimes dislocation can be reduced by persuading the patient to slowly crossed his legs are
dislocated toward the adjacent legs (adduction) and then apply gentle traction when an
assistant guide caput femoris back to its original position by exerting pressure on the anterior
side.
X-Ray examination is needed to ensure the reduction and to rule out fracture. When there is a
bit of a suspicion that the bone fragments have been trapped inside the joint, then needed a
CT-scan. Reduction is usually stable, pelvic who has suffered an injury should be rested. The
simplest way to rest the pelvis is to install and maintain traction during 3 weeks. Movement
and exercise begins as soon as the pain subsides. At the end of three weeks the patient is
allowed

to

walk

with

crutches

for

support.

If the X-ray or CT-scan showed a reduction after intra-articular fragments, fragments must be
removed and rinsed joints through the posterior approach. It is usually delayed until the
patient's

condition

is

stable.

Fracture-dislocation type II Epstein is often treated with open reduction and fixation
immediately anatomically loose fragments. However, if the patient's general condition

dubious or not available skilled surgeons in this field, reduced pelvic closed as described
above. If the joint is unstable or large fragments remain unreduced, then open reduction and
internal fixation is still required. In the case of Type II, traction is maintained for 6 weeks.
Fracture-dislocation type III treated in a closed, but there may be fragments that survive and
these fragments must be removed by open surgery. Traction is maintained for 6 weeks.
Fracture-dislocation type IV and V were originally treated with closed reduction. Fragments
can be automatically caput femoris is in place, and this can be confirmed by CT-scan after the
reduction. If the fragment remains unreduced, surgical treatment is indicated: a small
fragment discarded, but the larger fragments had to be replaced; open joints, dislocated
femoral caput and fragments fastened in position with countersunk screw. Postoperatively, the
traction is maintained for 4 weeks and full loading was delayed for 12 weeks.
Posterior approach the hip joint (Kocher-Langenbeck)
Patients were placed in the lateral position.
Start with a skin incision at the trochanter major regions and expand in the direction of 6 cm
proximal from the spina iliaca posterior. The incision can be extended distally along the
lateral surface of the thigh 10 cm or as needed.
Separate fasciae latae parallel to the skin incision and separate the gluteus maximus is blunt
parallel to the fiber direction . Protect branch of inferior gluteal nerve anterosuperior direction
of the gluteus maximus.
Identify and protect nerve ischiadicus which is above Quadratus femoris .
Separate M. piriformis tendon, gemellus, and obturator internus parallel to the insertion in
the trochanter major and then the muscles exorotasi pulled medially to protect nerve
ischiadicus. M. qudratus femoris be left intact to protect the medial femoral arterial branches
circumflexa . The place of attachment of the tendon Gluteus maximus on the femur can be

incised to expand the exposure area.

Figure 7. Posterior Approach of Hip

 Identification of the capsule surrounding the femoral neck and if necessary view rips toward
the proximal and distal to liberate and caput collum femoris.
Reduction:
Traction thigh along its longitudinal axis.
Flexed 90 and adduksi pelvic.
Dislocated femoral caput posterior thigh with endorotated.
Create a longitudinal traction on the femur firmly.
Find a picture of the labrum cartilage in the acetabulum.
Pull out the labrum of the acetabulum with a blunt hook.
Cut inherent part of the labrum.
Tighten the caput femoris by making a longitudinal traction on the femur and aduction
flexed.
After open reduction, was installed in the lower limbs skin traction. Pelvis in a position of
extension and extremities slightly abduksi. Traction is maintained for 3 weeks. A few days
after the reduction, active and passive movements of the hip joint can begin. At the end of
three weeks, the patient is allowed the use crutches for support. Patients were allowed to
sustain weight loss at the end of the week to 12-14 and allowed back on the move as usual 610 months after surgery. Follow the progress of patients for 2 years (every 3 months), each
inspection record growth range of motion of the hip joint and do X-ray examination to
determine the presence or absence of avascular necrosis of the head femoris.

f. Complication

Early
- Ischiadic nerve injury. This nerve is sometimes injured, but usually improves

again. If after reducing dislocations, nerve lesions ischiadic and acetabulum

fracture is not reducible diagnosed, then the nerve must be explored and fragments
corrected to its original place (screwed into position). Healing often takes several
months, and while the legs should be avoided from the ankle injury and should be
wrapped to avoid drooping foot (foot drop).
- Vascular injury. Sometimes the superior gluteal artery was torn and there may be
a lot of bleeding. If this condition is suspected, it should be arteriogram. Torn blood
vessels may need to be ligated.
- Fracture corpus femoris. When this occurs simultaneously with hip dislocation,
dislocation is usually overlooked. Guidelines that should be used on every corpus
femoris fracture, buttocks and trochanter per palpation, and pelvis should do X-ray
examination. Even if this precaution is not done, a dislocation should be suspected
when proximal fragment in transverse fracture in the trunk looks adducted.
- Reduction of dislocation is much harder, but slowly closed manipulation should
still try. If this fails, then open reduction should be attempted, and at the same time,

the femur can be fixed with intramedullary nail.

Late
- Avascular necrosis. The blood supply in the caput femoris very disturbed at least
10% of traumatic hip dislocation. If the reduction was delayed more than a few
hours, the figure had risen to 40%. Avascular necrosis seen on X-ray examination
as caput femoris increased density, but these changes can not be found for at least 6
weeks, and sometimes much longer (up to 2 years), depending on the speed of
bone repair. If caput femoris shows signs of fragmentation, surgery may be
required. If there is a small necrotic segment, osteotomy bone alignment
(realigment) is the method of choice. By contrast, in younger patients, the choice is
between the replacement of the head of the femoral prosthesis artrodesis bipolar or

pelvis. In patients aged over 50 years, total hip replacement is a better option.
- Osifikans myositis. Complication is rare, may be associated with the severity of
the injury. Because it is difficult to predict, it is difficult to prevent complication.
Movement should not be forced and the severe injury, rest periods and loading may
need to be extended.
- Irreducible dislocation. After several weeks, the dislocation is not treated can
rarely be reduced by closed manipulation and required open reduction. The
incidence of avascular necrosis stiffness or greatly improved and later the patient
may need surgery rekonstruktif.33
- Osteoarthritis. Secondary osteoarthritis is common and caused by (1) cartilage
damage at the time of dislocation, (2) the presence of fragments that survive in the
joints, or (3) in the caput femoris ischemic necrosis.

CHAPTER III
PATIENTS STATUS

I.

IDENTITY
a. Name
: Mr. Hartoyo
b. Age
: 21 years old
c. Sex
: Male
d. Job
: Student
e. Address
: Juwiring
f. Room
: Kenanga
g. Register Number : 480664
h. Date of in patient : June 3rd 2016
II. ANAMNESA
Chief complaint
Pain in dislocation hip posterior and locking movement of the left lower extremity.
Present status
The man came to the clinic orthopedic that his left cant move. He just had complained
that he feel decreasing of sensation of the left foot and cant move his feet like before. He
had already done ORIF operation on January in Baitul Hikmah before because he had an
accident about september last year when riding motorcycle. Patient said he was coma and
did not remember the mecanism of trauma.
Primary Survey
Airway and cervical spine stabilisation : Cleared
Breathing : adequate breathing ( respiration rate : 20x/minutes ) nothing abnormality
Circulation : adequate circulation
Disability : E4M5V6, pupil refleks +/+ isokor
Exposure : abnormality on lower left extremity
Medical condition history
- History of similar injury
- History of asthma and allergies
- History of heart disease
- History of hypertension
- History of diabetes

: denied
: denied
: denied
: denied
: denied

Family history
-

History of asthma and allergies : denied

History of heart disease
: denied
History of hypertension
: denied
History of diabetes
: denied

Socioeconomic status
The cost of treatment using BPJS

III.

PHYSICAL EXAMINATION
GCS
: 15
Vital sign
HR : 80 x/m
RR : 20 x/m
to
: 36,5o
BP : 120/80
Status Generalis
1.
2.
3.
4.
5.
6.
7.
8.

Skin
Head
Eyes
Ear
Nose
Mouth
Neck
Thorax

: Turgor (N)
: Mesocephal, Wound (-)
: Anemis -/-, Icteric -/: Discharge -/: Deviation septum -/-, discharge -/: Bleeding (-)
: Simetris, Trachea deviation (-)
: Normochest, simetris

COR
Inspeksi
Palpasi

: Ictus cordis (-)

: Ictus cordis palpable at SIC V, 2 cm medial to the linea mid

clavicularis sinistra, pulsus the sternal (-), pulsus epigastrium (-)

Percussion : heart border
Bottom left: SIC V, 2 cm medial linea mid clavicularis sinistra
Top left : SIC II linea sternalis sinistra
Top right : SIC II linea sternalis dextra
Waist heart: SIC III linea parasternalis sinistra
Impression: configuration of the heart normal

 Auscultation : heart sound I-II regular, gallop (-), murmur (-)

Pulmo :
Anterior
Posterior
I: Statis: normochest(+/+), simetris (+/ I: Statis: normochest(+/+), simetris (+/
+), retraction (-/-). Dinamis: simetris

+), retraction (-/-).Dinamis: simetris

Pa:

Pa:

statis:

simetris

(+),

nothing

statis:

simetris

(+),

nothing

widening between the ribs, retraction

widening between the ribs, retraction

(-/-), sterm fremitus dx=sin

(-/-), sterm fremitus dx=sin

Pe: Sonor (+/+)

Pe: Sonor (+/+)

Aus: vesicular (+/+), ronchi (-/-),

Aus: vesicular (+/+), ronchi (-/-),

wheezing (-/-)

wheezing (-/-)

9. Abdomen
Inspection : normal, massa (-)
Palpation
: Supel, pain (-), hepar and lien are not papble
Percussion : tympani (+)
Auscultation : bowel (+) Normal
10. Back : kifosis and lordosis (-)
11. Extremity:

IV.

Akral

Superior
-/-

Inferior
-/-

Oedem

-/-

+/-

Capillary refill

<2

<2

Lession

-/-

-/-

Hematom

-/-

+/-

LOCALIS STATUS
Left lower extremity
Look
: endorotated (+), adducted (+), knee slight flexion (+), hip slight flexion (+)
drop foot (+)
Feel
: pain (+) and
Move
:
o Active movement:

- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension, endorotasi,
eksorotasi upper extremities.
- Limitation (+) and pain (+) in supination, pronation of the ankle joint.
- Limitation (+) and pain (+) in flexion, extension, abduction, extension of the fingers.
o Passive Movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension, endorotasi,
eksorotasi upper extremities.
- Limitation (+) and pain (+) in supination, pronation of the ankle joint.
- Limitation (+) and pain (+) in flexion, extension, abduction, extension of the fingers.
Measurement :
Dextra
True Lenght
86 cm
Apparent Lenght
89 cm
Anatomical Lenght
36 cm
Limb Length Discrepancy (LLD) : 3 cm

Sinistra
88 cm
91 cm
39 cm

V. LABORATORY RESULT
June 1st 2016
Hematologi
Hemoglobin
Leukosit
Trombosit
Hematokrit
Protombin Time (PT)
APTT
Ureum
Creatinin
SGPT
SGOT

VI.

RADIOLOGY
Before:
X foto rontgen Pelvis AP

Hasil
13,3 gr/dL
7,2 10^3/uL
273 10^3/uL
42,7 %
12,7 s
33,0 s
19 mg/dL
0,65 mg/dL
30 U/L
16 U/L

Reference value
13-18
4,0-10,0
150-500
39,0-54,0
11,3-14,7
27,4-39,3
10-50
0.50 1.10
12 37
12 - 41

After Open Reduction :

X photo rontgen Pelvis AP :

After Total Hip Replacement:

X photo rontgen Pelvis AP

VII.

DIAGNOSE
Posterior Hip Dislocation
VIII. INITIAL PLAN
a. Ip Terapeutik
Medical treatment
- Infus RL 20 tpm
- Inj. Cefazolin 2x1 g
- Inj. Hypobax 2x1 g
- Inj. Dexketoprofen 2x50mg
- Inj. Ranitidine 3x1
b. Ip. Operatif
Total Hip Replacement
c. Ip. Monitoring
General situation, Vital sign, the result of supporting examination
IX.

PROGNOSIS
Quo ad vitam
: ad bonam
Quo ad sanam
: ad bonam
Quo ad fungsionam : ad bonam

CHAPTER IV
DISCUSSION

Anamnesis :
The man came to the clinic orthopedic that his left cant move. He just had complained
that he feel decreasing of sensation of the left foot and cant move his feet like before. He
had already done ORIF operation on January in Baitul Hikmah before because he had an
accident about september last year when riding motorcycle. Patient said he was coma and
did not remember the mecanism of trauma.
X. LOCALIS STATUS
Left lower extremity
Look
: endorotated (+), adducted (+), knee slight flexion (+), hip slight flexion (+)
drop foot (+)
Feel
: pain (+)
Move
:
o Active movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension, endorotasi,
eksorotasi upper extremities.
- Limitation (+) and pain (+) in supination, pronation of the ankle joint.
- Limitation (+) and pain (+) in flexion, extension, abduction, extension of the fingers.
o Passive Movement:
- Limitation (+) and pain (+) in the abduction, adduction, flexion, extension, endorotasi,
eksorotasi upper extremities.
- Limitation (+) and pain (+) in supination, pronation of the ankle joint.
- Limitation (+) and pain (+) in flexion, extension, abduction, extension of the fingers.
Measurement :
Dextra
True Lenght
86 cm
Apparent Lenght
89 cm
Anatomical Lenght
36 cm
Limb Length Discrepancy (LLD) : 3 cm
Medical treatment
- Infus RL 20 tpm

Sinistra
88 cm
91 cm
39 cm

Inj. Cefazolin 2x1 g

Inj. Hypobax 2x1 g
Inj. Dexketoprofen 2x50mg
Inj. Ranitidine 3x1

The patient with posterior hip dislocation have specific apperiance like edorotation,
abduction of leg, knee slight flexion, hip slight flexion .The leg loses its usual roundness.
Check the distal artery like a. Poplitea or a. Dorsalis pedis. Neurovascular injury on the
posterior hip dislocation can give complain pain in the pelvis, buttocks and lower limbs
posterior part, loss of sensation in the lower legs and feet, loss of ability dorsoflexi (peroneal
branch) or plantarflexi (tibial branch), the loss of deep tendon reflexes in the ankle, local
Hematoma.
Dislocations should be reduced as soon as possible under general anesthesia.
Reductions must be made within 12 hours from the onset of dislocation. In most cases
performed closed reduction, but if closed reduction fails 2 times open reduction should be
performed to prevent damage femoral caput futhermore. Prior to reduction, neurovascular
examination should be performed. Fracture-dislocation type II Epstein is often treated with
open reduction and fixation immediately anatomically loose fragments. However, if the
patient's general condition dubious or not available skilled surgeons in this field, reduced
pelvic closed as described above. If the joint is unstable or large fragments remain unreduced,
then open reduction and internal fixation is still required. In the case of Type II, traction is
maintained for 6 weeks.
In this patient, he do not want to move because of pain so after 3 months, he had
complication, it was avascular necrosis. The blood supply in the caput femoris very disturbed
at least 10% of traumatic hip dislocation. If the reduction was delayed more than a few hours,
the figure had risen to 40%. Avascular necrosis seen on X-ray examination as caput femoris

increased density, but these changes can not be found for at least 6 weeks, and sometimes
much longer (up to 2 years), depending on the speed of bone repair. If caput femoris shows
signs of fragmentation, surgery may be required. If there is a small necrotic segment,
osteotomy bone alignment (realigment) is the method of choice. By contrast, in younger
patients, the choice is between the replacement of the head of the femoral prosthesis
artrodesis bipolar or pelvis. In patients aged over 50 years, total hip replacement is a better
option.

CHAPTER V
CONCLUSSION
Hip dislocations, regardless of their etiology, are orthopedic emergencies that require
immediate diagnosis, evaluation, and treatment. The adult hip joint is remarkably stable. It is
reinforced with thick capsular and labral structures. The presence of a dislocation injury
indicates a large force from a traumatic mechanism (a traction force 90 lb) or the presence
of underlying pathology leading to inherent instability of the joint. Posterior dislocations
make up 80-95% of traumatic hip dislocations..
Posterior traumatic hip dislocations occur when the force acts with adduction, internal
rotation, and some degree of flexion of the hip. The incidence of this injury has increased as a
consequence of high-velocity motor vehicle use. Injuries in which the front-seat passengers
are involved in a head-on collision that drives the dashboard into their lower extremities
(known as dashboard injuries) have become a notorious cause of posterior traumatic hip

displacement. Hip dislocations are classified according to the direction of the femoral head
displacement: posterior by far the commonest variety, anterior and central, a comminuted or
displaced fracture of the acetabulum.
Dislocations should be reduced as soon as possible under general anesthesia. Reductions
must be made within 12 hours from the onset of dislocation. In most cases performed closed
reduction, but if closed reduction fails 2 times open reduction should be performed to prevent
damage femoral caput futhermore. Prior to reduction, neurovascular examination should be
performed. If caput femoris shows signs of fragmentation, total hip replacement is a better
option.

CHAPTER VI
REFRENCES
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Management. emedicine.medscape.com/article/86930-treatment
2. Matthew Gammons, MD; Sherwin SW Ho, MD. Hip Dislocation Clinical
Presentation. emedicine.medscape.com/article/86930-clinical
3. Stephen R McMillan, MD;: Barry E Brenner, MD, PhD, FACEP Hip Dislocation in
Emergency Medicine. http://emedicine.medscape.com/article/823471-overview
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