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Management of Simultaneous Ipsilateral Dislocation of Hip, Knee, and Ankle CPT Brian R

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Management of Simultaneous Ipsilateral Dislocation of Hip, Knee, and Ankle CPT Brian R (aspects of trauma) Management of Simultaneous Ipsilateral Dislocation of Hip, Knee, and Ankle 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 joint. 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 shoulder.” 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 femur 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 foot 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 tibia 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 arteries. Initial Department of Orthopaedic Surgery, trauma radiographs showed a right University of Texas Southwestern Medical posterior hip dislocation (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 ligament, 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 artery 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 thigh. Schierz and colleagues5 dislocation of the tarsometatarsal ticular must be promptly recognized obtained closed reduction of an joints. 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 neck. Most recently,
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