Rare Combination of Ipsilateral Acetabular Fracture-Dislocation and Pertrochanteric Fracture

A Case Report & Literature Review Rare Combination of Ipsilateral Acetabular Fracture-Dislocation and Pertrochanteric Fracture Kevin M. Kuhn, CDR, MC, USN, John A. Boudreau, MD, and J. Tracy Watson, MD oral fractures. Other case reports have described acetabular Abstract fracture-dislocations associated with femoral neck fractures.1-3 Acetabular fracture-dislocations are severe This case report describes an acetabular fracture-dislocation injuries that require urgent closed reduction associated with an ipsilateral pertrochanteric fracture and sub- of the hip and often require surgery to restore trochanteric extension. hip stability. Other authors have described We propose a staged treatment strategy consisting of early acetabular fracture-dislocations associated minimally invasive reduction of the hip and delayed reduction with femoral neck fractures, but to our knowl- and fixation of the fractures. This strategy may be useful in edge, this case report is the first to describe an managing a polytraumatized patient who may not be stable acetabular fracture-dislocation in association enough to undergo early definitive management, or a patient with an ipsilateral pertrochanteric fracture and who requires prolonged transfer to receive definitive care. subtrochanteric extension. The patient provided written informed consent for print The polytraumatized patient initially was not and electronic publication of this case report. stable enough for prolonged surgery. Through a 3-cm anterolateral hip incision, a 5-mmAJO Schanz Case Report screw was introduced percutaneously into the A 44-year-old man was involved in a head-on motor vehicle femoral head through the primary fracture site collision at highway speed. He was taken to a local hospital, under fluoroscopic guidance. With inline traction stabilized, and transferred to our facility for definitive man- on the leg, the Schanz screw was used to ma- agement. He had a history of diabetes mellitus and hyper- nipulate the femoral head back into the acetabu- tension, both managed with oral medications. He denied any lar fossa. The Schanz screw was removed, the significant surgical history. On arrival, he was graded 15 on DOhead remained reduced, andNOT a skeletal traction the Glasgow COPY Coma Scale and reported chest and left hip pain. pin was placed to maintain length and alignment Trauma workup revealed multiple rib fractures bilaterally and of the pertrochanteric fracture until definitive associated pulmonary contusions, left-sided pneumothorax, stabilization was possible. and elevated serum creatinine consistent with acute renal fail- We propose a staged treatment strategy con- ure. Radiographs showed a left posterior hip dislocation with sisting of early closed reduction of the hip, and associated posterior wall acetabular fracture and an ipsilateral after the patient has been stabilized, reduction pertrochanteric fracture with subtrochanteric extension (Fig- and fixation of the fractures. This strategy may ure 1). In addition, he had a traumatic arthrotomy of the left be useful in managing an unstable polytrauma- wrist, a triquetral fracture, and a right-hand phalanx fracture. tized patient or a patient who requires prolonged After initial resuscitation and stabilization, the patient was transfer to receive definitive care. urgently taken to the operating room for reduction of the left hip dislocation 4 hours after arrival at our facility and 8 hours after the initial injury. Considering his physiologic condition, he was only stable enough to attempt reduction. Through a cetabular fracture-dislocations are severe injuries 3-cm anterolateral hip incision, a 5-mm Schanz screw was that require urgent closed reduction of the hip and introduced percutaneously into the femoral head through the A often surgery to restore hip stability. These injuries primary fracture site under fluoroscopic guidance. With inline are seldom seen in conjunction with ipsilateral proximal fem- traction on the leg, the Schanz screw was used to manipulate Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, the US Department of Defense, or the US Government. 372 The American Journal of Orthopedics® August 2013 www.amjorthopedics.com A Case Report & Literature Review the femoral head back into the acetabular fossa (Figure 2). The reduction was con- firmed by fluoroscopy. We then removed the Schanz pin, and the head remained reduced. The incision was lavaged and closed, and a distal femoral skeletal traction pin was placed to maintain length and alignment of the pertrochanteric fracture until definitive stabilization. The traumatic wrist arthrotomy was de- brided, irrigated, and closed. The patient was taken to the intensive care unit (ICU) Figure 2. Intraoperative fluoroscopy and underwent continued resuscitation. shows Schanz pin in reduced femoral Computed tomography of the pelvis and head with posterior wall acetabular the proximal femur, obtained in the in- fracture. terim for surgical planning, showed a posterior column with associated posterior wall fracture and marginal impaction Figure 1. Injury radiograph shows left (Figure 3). posterior hip dislocation with associated By hospital day 4, the patient’s physi- posterior wall acetabular fracture and ologic condition had stabilized enough ipsilateral pertrochanteric fracture with for him to return to the operating room subtrochanteric extension. for definitive fracture treatment. An extended Kocher-Langenbeck incision was used to address his injuries. Of note, the hip-reduction inci- in good condition sion was 4 cm anterior to the Kocher-LangenbeckAJO incision. and non–weight- We addressed the proximal femur first. There was extensive bearing on the left soft-tissue stripping, including stripping of the entire anterior lower extremity capsule, which was detached from the proximal femur. There (Figure 5). was a comminuted fracture of the greater trochanter with Figure 3. Postreduction axial computed fracture lines extending down below the lesser trochanter. Discussion tomography of left hip shows posterior The fracture was reduced and stabilized with lag screws and a Multiple cases of wall fracture with marginal impaction. lockingDO proximal femoral plate construct.NOT After reduction and concomitant COPY ac- fixation, there was a large void resulting from intertrochanteric etabular fracture- bone loss, which we filled with a moldable composite allograft dislocations and femoral neck fractures have been reported in bone void substitute. the literature,1-3 but to our knowledge this case report is the first Our attention then turned to the acetabular fracture. The to describe a posterior acetabular fracture-dislocation with an fracture was exposed and examined through the same ex- associated pertrochanteric fracture. Posterior hip dislocations tended incision. There was a large posterior wall fracture, are severe injuries that require urgent reduction to minimize which was divided into superior and inferior fragments. The the chances of long-term sequelae, including posttraumatic os- inferior fracture line extended into the posterior column and teoarthritis and osteonecrosis. Sequelae are related to injury or into the ischium. There was marginal impaction superiorly tensioning of the medial femoral circumflex artery, which is and posteriorly. The impaction was elevated, backfilled with the primary blood supply to the femoral head.4 Several authors allograft, and stabilized with 1.5-mm bioabsorbable pins. The have shown the rate of osteonecrosis of the femoral head to be wall piece was then reduced and stabilized with 3 lag screws, related to duration of dislocation, though whether the critical a spring plate, and a buttress plate. Another plate was used to period is 6, 12, or 24 hours is controversial.5,6 stabilize the posterior column (Figure 4). The avulsed anterior In the presence of a proximal femoral fracture, closed reduc- capsule was repaired back to bone through drill holes, as were tion may be impossible as traction cannot be applied through the external rotators. The wound was closed over drains. the injured extremity. In this situation, urgent open reduction Postoperatively, the patient remained intubated and re- is usually required. However, reduction cannot always be done turned to the ICU. He was extubated on postoperative day 3. in a timely manner. This is due to multiple factors, including On postoperative day 7, duplex scan showed a popliteal deep polytrauma that prevents the patient from undergoing poten- vein thrombosis, and he was started on an anticoagulant. He tially prolonged definitive surgery, and initial presentation was mobilized with physical therapy using a walker and on to an orthopedic surgeon who is not comfortable offering hospital day 18 was discharged to an acute rehabilitation center definitive treatment for this complex injury. www.amjorthopedics.com August 2013 The American Journal of Orthopedics® 373 Rare Combination of Ipsilateral Acetabular Fracture-Dislocation and Pertrochanteric Fracture K. M. Kuhn et al authors have not found a cor- Caudad Anterior relation between time to reduction and outcome.8,9 How- ever, most would agree that reduction of the traumatically dislocated hip should be done as soon as possible. Anterior dislocations have a better long- term prognosis than posterior

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