(aspects of trauma)

Management of Simultaneous Ipsilateral Dislocation of , , and CPT Brian R. Waterman, MD, MC, USA, and Rahul Banerjee, MD

osterior hip dislocations Case Report terior dislocation of the tibiotalar frequently result from A 25-year-old man was struck by a . The ankle was also immedi- forces applied at the knee car while he was changing a tire on ately treated with closed reduction. Pjoint and are associ- the side of a highway. The patient Because of the multiple ipsilat- ated with high rates of concomi- was brought emergently to a level I eral injuries, closed reduction of tant intra-articular knee injury.1,2 trauma facility. On arrival, pulse was the hip was performed with a modi- Simultaneous ipsilateral hip and 140 beats per minute, respirations fication of the techniques described knee dislocations present a challeng- were 30 breaths per minute, systolic by Allis8 and Marya and Samuel.9 ing problem because of the need for blood pressure was 120 mm Hg, and With 2 assistants stabilizing the urgent reduction, which is balanced Glasgow Coma Scale score was 14. patient’s pelvis, the surgeon flexed by the need to avoid iatrogenic inju- On secondary survey, the right hip the right hip past 90° and gen- ry that may be caused by reduction was flexed, adducted, and internally tly stabilized the ipsilateral knee attempts.2-7 Additional ipsilateral rotated. In addition, there were gross and ankle by flexing it over his injuries to the extremity increase the complexity of the early manage- ment of these dislocation injuries. “With 2 assistants stabilizing the patient’s We present the case of a 25-year- old man who sustained simultane- pelvis, the surgeon flexed the right hip past ous ipsilateral dislocations of the hip, 90°and gently stabilized the ipsilateral knee knee, and ankle after being struck and ankle by flexing it over his right .” by a car. The patient underwent suc- cessful closed reduction of the hip through use of a novel reduction valgus deformity and swelling of the right shoulder. With assistants in technique. Additional injury to the right knee. The right ankle dem- position, manual axial traction was ipsilateral knee and the ankle was pre- onstrated gross swelling and valgus applied to the distal with vented. The patient provided written deformity with anterior tenting of gentle, alternating internal and informed consent for print and elec- the skin and a plantarflexed external rotation at the hip. Unlike tronic publication of this case report. position. The patient also had an the technique described by Marya open left fracture. Results of and Samuel,9 the tibia was not used CPT Waterman is Orthopaedic Surgery neurologic examination of the lower as a fulcrum because of the ipsilat- Resident, Department of Orthopaedic extremities were normal. Vascular eral knee and ankle dislocations. Surgery and Rehabilitation, William examination revealed weakly audi- Beaumont Army Medical Center, El Paso, ble Doppler signals at dorsalis pedis Texas. Dr. Banerjee is Assistant Professor, and posterior tibial . Initial Department of Orthopaedic Surgery, trauma radiographs showed a right University of Texas Southwestern Medical posterior (Figure 1) Center, Dallas, Texas. and multiple rib fractures. The patient underwent rapid- Address correspondence to: CPT Brian R. Waterman, MD, Orthopaedic Surgery sequence intubation in the trauma Service, William Beaumont Army Medical bay. Examination of the right knee Center, 5005 N Piedras St, El Paso, confirmed the presence of a knee TX 79920-5001 (tel, 915-569-2288; fax, dislocation with gross anteroposteri- 915-569-1931; e-mail, brian.r.waterman@ or and valgus instability of the knee. gmail.com). The knee was immediately reduced Am J Orthop. 2011;40(6):301-304. Copyright after identification of the disloca- Figure 1. Anteroposterior radiograph of Quadrant HealthCom Inc. 2011. All rights tion on examination. Examination pelvis shows right posterior hip disloca- reserved. of the right ankle revealed a pos- tion. www.amjorthopedics.com June 2011 301 Simultaneous Ipsilateral Dislocation

Figure 2. Postreduction radiograph of Figure 3. Postreduction radiographs of right knee. right hip without evident fracture.

The closed reduction was suc- stability. Subsequent MRI of the The patient noted mild difficul- cessfully performed with use of right knee showed medial cruciate ties in climbing stairs, bending or this method and postreduction , anterior cruciate ligament, kneeling, pivoting, and participat- radiographs (Figure 2). Computed and posterior cruciate ligament inju- ing in recreational activities. tomography confirmed concentric ries with an associated medial menis- hip reduction without associated cal tear (Figure 5). The right knee Discussion acetabular fracture. Postreduction was maintained in a knee immobiliz- To our knowledge, this is the only radiographs of the knee (Figure 3) er. The patient was able to ambulate report of a patient with closed showed no fractures. Postreduction with full weight on the left leg, and he simultaneous ipsilateral disloca- radiographs of the ipsilateral leg remained non–weight-bearing on the tions of the hip, knee, and ankle and ankle showed tibia-fibular dias- right leg. The patient was discharged without associated fractures. tasis and a fracture of the proximal on postoperative day 10. Besides dislocating the ankle, the fibula (Figure 4). The patient remained in a knee patient sustained a Maisonneuve- Repeat vascular examination after immobilizer for 3 weeks. Knee liga- type ankle injury, which also had closed reduction of the hip, knee, ment reconstruction was discussed not been reported in conjunction and ankle revealed weakly audible with the patient, and recommend- Doppler signals at the posterior tibial ed, but he refused further surgery. and dorsalis pedis arteries. Femoral The patient was placed into a phys- angiography demonstrated common ical therapy program consisting of femoral and popliteal injury. hip and knee range of motion and The patient was taken urgently to gradual strengthening starting 6 the operating room and underwent weeks after injury. arterial repair with interpositional At 8-month follow-up, the grafting. The right lower extremity patient was ambulating with full was immobilized in a plaster splint, weight-bearing on both lower and the left open tibia fracture was extremities without assistive devic- debrided and treated with an intra- es. Right knee range of motion was medullary nail. At the end of the 0° to 105°, and there were no symp- procedure, the left lower extremity toms of instability. Radiographs of had palpable pulses in the dorsalis the hip, knee, and ankle showed pedis and posterior tibial arteries. maintenance of joint reduction, The patient was extubated on no evidence of avascular necrosis postoperative day 1. On postopera- of the hip, and no evidence of tive day 7, the right ankle was sta- arthrosis in any joint. At 6 months, bilized with syndesmotic screw fixa- the patient’s Short Musculoskeletal Figure 4. Anteroposterior radiograph of tion. Examination of the ankle after Function Assessment scores were right leg shows tibiofibular diastasis and syndesmotic fixation demonstrated 42 (Dysfunction) and 12 (Bother). fracture of proximal fibula.

302 The American Journal of Orthopedics® www.amjorthopedics.com B. R. Waterman and R. Banerjee

A B

Figure 5. Sagittal (A) and coronal (B) magnetic resonance imaging shows a medial meniscal tear and medial cruciate ligament, ante- rior cruciate ligament, and posterior cruciate ligament injuries. with an ankle dislocation. In 1984, of hip dislocations, Gillespie15 found posterior hip and knee dislocations, Malimson10 reported a case of that 11% of associated knee injuries Freedman and colleagues6 reduced ipsilateral fracture-dislocations of were missed on initial evaluation. the hip with manual traction on the hip and knee and a fracture- Associated knee dislocations in par- the . Schierz and colleagues5 dislocation of the tarsometatarsal ticular must be promptly recognized obtained closed reduction of an . In 1991, Millea and col- and reduced, as up to 45% of poste- ipsilateral hip (with a posterior wall leagues11 described a case of ipsi- rior knee dislocations may have asso- acetabular fracture) and knee dis- lateral fracture-dislocations of the ciated vascular injuries.17,18 Similarly, location by maintaining the hip hip and knee and an open fracture- ankle dislocations may compromise and knee in a 90°/90° flexed posi- dislocation of the ankle. The 3 the surrounding skin or neurovas- tion. DuBois and colleagues4 used dislocations described in these 2 cular structures until reduction is Schanz pins to maneuver the closed

“In a series of hip dislocations, Gillespie15 found that 11% of associated knee injuries were missed on initial evaluation.” reports had associated fractures. obtained. Simultaneous ipsilateral reduction in a hip dislocation with Pure tibiotalar dislocations, with- dislocations of the hip, knee, and an ipsilateral knee dislocation. The out associated malleolar fractures, ankle therefore present a challenging Schanz pins were inserted in the are rare,12-14 and this combination problem. The potential for develop- femoral condyles and in the lateral of dislocations without fractures ment of avascular necrosis of the aspect of the femur at the level of was not previously reported. femoral head warrants urgent reduc- the femoral . Most recently, Hip, knee, and ankle dislocations tion, but the potential for neurovas- Motsis and colleagues3 reported all require urgent reduction. Ninety cular injury exists with the instability on a patient with a concomitant percent of hip dislocations are pos- of the knee and the ankle. ipsilateral hip dislocation and open terior, and they often result from an Previous reports of simultaneous knee dislocation in which the hip axial force transmitted through the ipsilateral hip and knee dislocations was successfully treated with closed flexed knee.15 Longer duration of hip have described different methods reduction, but they did not describe dislocation has been associated with of reducing the hip while maintain- their reduction technique. development of avascular necrosis ing knee reduction. Kreibich and In the case of concomitant ipsi- of the femoral head, and therefore, colleagues7 reported a case of ipsi- lateral dislocations of the hip, knee, early reduction is warranted.16 The lateral posterior hip and knee frac- and ankle, additional consider- incidence of ipsilateral bony and ture-dislocations in which the hip ation must be given to stabiliza- soft-tissue extremity injuries with hip dislocation was reduced through tion of the ankle while the more dislocation can be as high as 33% an open posterior approach. In proximal reductions are obtained. and 93%, respectively.1 In a series a case of simultaneous ipsilateral Malimson10 obtained closed reduc- www.amjorthopedics.com June 2011 303 Simultaneous Ipsilateral Dislocation tion of the hip, knee, and tarsometa- pins. Although these techniques The opinions or assertions con- tarsal joint fracture-dislocations, but are efficacious, the additional time tained herein are the private views of they did not describe their reduction required to transport the patient the authors and are not to be con- techniques or the method for stabi- to the operating room and prepare strued as official or reflecting the views lizing the other joints. Millea and for a surgical case prolongs the of the US Department of Defense or colleagues11 reported using open duration of the hip dislocation. the US Government. The authors are reduction for all ipsilateral hip, knee, DuBois and colleagues noted that employees of the US Government. and ankle fracture-dislocations. their patient arrived in the oper- With our patient, we used a novel ating room 3 hours after injury. References modification of the hip reduction Although this time frame is ideal, 1. Schmidt GL, Sciulli R, Altman GT. Knee injury in patients experiencing a high-energy trau- 8 techniques of Allis and Marya and our level I trauma center is in a matic ipsilateral hip dislocation. J Bone Joint Samuel.9 Allis described a technique remote location, and often patients Surg Am. 2005;87(6):1200-1204. 2. Tabuenca J, Truan JR. Knee injuries in traumatic in which longitudinal traction is with hip dislocations are transport- hip dislocation. Clin Orthop. 2000;(377):78-83. applied to the leg with gentle inter- ed to us over great distances and 3. Motsis EK, Pakos EE, Zaharis K, Korompilias AV, Xenakis TA. Concomitant ipsilateral trau- nal and external rotation and grad- long time frames. Therefore, tech- matic dislocation of the hip and knee following ual flexion of the hip. In the “piggy- niques such as ours, which allowed high-energy trauma: a case report. J Orthop Surg (Hong Kong). 2006;14(3):322-324. back” reduction technique described for immediate closed reduction of 4. DuBois B, Montgomery WH Jr, Dunbar RP, by Marya and Samuel, the surgeon all 3 dislocations in the trauma bay, Chapman J. Simultaneous ipsilateral posterior places his or her back to the patient, are advantageous. knee and hip dislocations: case report, includ- ing a technique for closed reduction of the hip. and the patient’s knee is placed over Our patient’s case also illustrates J Orthop Trauma. 2006;20(3):216-219. the surgeon’s shoulder, which is used the practice and the importance 5. Schierz A, Hotz T, Käch K. Ipsilateral knee and hip [in German]. Unfallchirurg. as a fulcrum. The patient’s tibia is of reducing dislocations immedi- 2002;105(7):660-663. levered against the fulcrum to facili- ately, as soon as they are recog- 6. Freedman DM, Freedman EL, Shapiro MS. Ipsilateral hip and knee dislocation. J Orthop tate reduction. nized during secondary survey. We Trauma. 1994;8(2):177-180. In our patient’s case, the treating recommend that knee and ankle 7. Kreibich DN, Moran CG, Pinder IM. Ipsilateral surgeon faced the patient, and the dislocations be reduced promptly, hip and knee dislocation. A case report. Acta Orthop Scand. 1990;61(1):90-91. patient’s knee was flexed over the before radiographs are obtained, to 8. Allis O. An Inquiry Into the Difficulties surgeon’s shoulder (as described by restore vascular flow and prevent Encountered in the Reduction of Dislocations 9 of the Hip. Philadelphia, PA: Dornan; 1986. Marya and Samuel ), but the shoulder neurovascular compromise. 9. Marya SK, Samuel AW. Piggy back technique was not used as a fulcrum. Instead, for relocation of posterior dislocation of the hip. Injury. 1994;25(7):483-484. gently placing the knee in this posi- Conclusion 10. Malimson PD. Triple fracture-dislocation of the tion allowed the knee dislocation to be Simultaneous ipsilateral hip, lower limb. Injury. 1984;16(1):11-12. 11. Millea TP, Romanelli RR, Segal LS, Lynch stabilized while the hip was reduced. knee, and ankle dislocations CJ. Ipsilateral fracture-dislocation of the hip, Furthermore, the reduced posterior without associated fracture are a knee, and ankle: case report. J Trauma. ankle dislocation was stabilized by rare injury pattern that was not 1991;31(3):416-419. 12. Hatori M, Kotajima S, Smith RA, Kokubun S. allowing the ankle to rest against the described until now. The combi- Ankle dislocation without accompanying mal- surgeon’s back. Traction was applied nation of these injuries illustrates leolar fracture. A case report. Ups J Med Sci. 2006;111(2):263-268. through the distal femur to prevent the importance of careful second- 13. Rivera F, Bertone C, De Martino M, Pietrobono further injury to the knee disloca- ary survey in patients with hip D, Ghisellini F. Pure dislocation of the ankle: three case reports and literature review. Clin tion. The tibia was not used as a ful- dislocations. Prompt reduction of Orthop. 2001;(382):179-184. crum because of the knee injury and all 3 joints is mandatory. The 14. Soyer AD, Nestor BJ, Friedman SJ. Closed the associated tibiotalar dislocation. technique of hip reduction, such posteromedial dislocation of the tibiotalar joint without fracture or diastasis: a case report. Flexion of the hip and gentle internal as the one we used, must maintain Foot Ankle Int. 1994;15(11):622-624. and external rotation, as described by knee and ankle reduction to pre- 15. Gillespie WJ. The incidence and pattern of 8 knee injury associated with dislocation of the Allis, completed the maneuver and vent further injury. hip. J Bone Joint Surg Br. 1975;57(3):376-378. facilitated reduction. 16. Moed BR, WillsonCarr SE, Watson JT. Results of operative treatment of fractures of the Many of the previously reported Authors’ Disclosure posterior wall of the acetabulum. J Bone Joint reduction techniques require trans- Statement and Surg Am. 2002;84(5):752-758. cknowledgments 17. Jones RE, Smith EC, Bone GE. Vascular and porting the patient to the operating A orthopedic complications of knee dislocation. 7,11 room for open procedures or, The authors report no actual or Surg Gynecol Obstet. 1979;149(4):554-558. in the case of DuBois and col- potential conflict of interest in rela- 18. Green NE, Allen BL. Vascular injuries associ- ated with dislocation of the knee. J Bone Joint 4 leagues, for placement of Schanz tion to this article. Surg Am. 1977;59(2):236-239.

This paper will be judged for the Resident Writer’s Award

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