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Chinese Journal of Traumatology 2011; 14(3):183-187 .  .

Ipsilateral fracture dislocations of the and with contralateral open fracture of the leg: a rare case and its management principles

Ramesh Kumar Sen*, Sujit Kumar Tripathy, Vibhu Krishnan, Tarun Goyal and Vanyambadi Jagadeesh

AbstractThis paper discussed the injury mecha- bility in both joints after fixation when he was examined nism and management of a patient who had concomitant under anesthesia. The fractures united after 3 months and ipsilateral hip and knee dislocations and contralateral open the patient had no residual instability of hip and knee. There leg fracture. was no clinical or radiological evidence of osteonecrosis in A 32-year-old man presented with ipsilateral fracture- the hip after 6 months. At one-year follow-up, he had dislocations of the left hip (Pipkin’s type IV) and knee satisfactory functional outcome with almost normal range (Moore II) joints and contralateral open fracture of the leg of motion at both joints. bones after a car accident. After emergency resuscitative Ipsilateral hip and knee dislocations are rare injuries and measures, the hip joint was reduced and Pipkin’s fracture more caution is needed for early diagnosis. A timely appro- was fixed using Ganz approach with lag screws; knee joint priate intervention can provide good functional outcome to was reduced closely and tibial plateau fracture was stabi- the patient in this situation. lized with lateral buttress plate and a transarticular span- Key words: ; Knee dislocation; ning fixator. The open fracture on the other leg was de- Fractures, bone brided and fixed with an external fixator. There was no insta- Chin J Traumatol 2011; 14(3):183-187

ashboard injury is a common mode of trauma in such injuries, possible complications that the sur- following high velocity road traffic accidentsand geons should be aware of and the prognoses and Dresults in a variety of serious lower limb outcomes. injuries. Severe disruption of osseous and soft tissue framework around hip and knee occurs. Such injuries CASE REPORT pose a great challenge to the specialists and the after- maths of these injuries can be terrible and morbid. 1,2 A 32-year-old man was referred to our emergency services after sustaining injury to his left hip and knee Concomitant fracture dislocation of the hip and knee joints following a road accident. The patient was a car is rare and only about 4 cases have been reported in driver by profession and sustained the injury when his the literature so far.3-6 The rarity and complexity of this car underwent an end-on collision against a tree. The injury poses a unique challenge for surgeons. We dis- injury mechanism described was typical of dashboard cussed a case with similar injury mechanism, result- injury. The patient simultaneously got thrown off his ing in concomitant fracture-dislocations of the hip and seat (the patient was unrestrained and was not wear- knee joints and contralateral open fracture of the leg ing his seat belt during the impact). He was urgently bones. We also discussed the management aspects referred to our trauma centre with suspicion of an asso- ciated vascular compromise of the affected limb.

DOI: 10.3760/cma.j.issn.1008-1275.2011.03.012 The patient’s vital signs were stable at admission. Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, On examination, his left lower limb was in an attitude of India (Sen RK, Tripathy SK , Krishnan V, Goyal T and flexion, adduction and internal rotation with painful re- Jagadeesh V) striction of all active and passive movements of the hip *Corresponding author: Tel: 91-9914209744, Email: joint. A globular bony mass was palpable in the gluteal [email protected] area. The left knee joint was grossly deformed and .  . Chinese Journal of Traumatology 2011; 14(3):183-187 was dislocated posteriorly. Movements around the knee ing raft screws and the stabilization was further supple- joint were restricted. There was an open fracture of both mented using a laterally placed buttress plate (MRI com- bones of leg on the right side. No other significant sys- patible titanium implants, Figure 4). This was followed temic or associated musculoskeletal injuries were by an intraoperative examination of the joint to rule out noted. The limb was splinted appropriately and the pa- any residual instability. The knee joint was supported with tient was adequately resuscitated. The distal pulses a spanning external fixator (Figure 5). The open fracture were present (though feeble) on both legs and capillary of the contralateral leg was also thoroughly debrided flow was adequate. Regular monitoring of the capillary and fixed using an external fixator. blood flow using continuous pulse-oximetry was car- ried out. Postoperative period was uneventful. Bedside mobilization, pumps and isometric quadriceps ex- After emergency stabilization, urgent X-rays of the ercises were initiated on the second postoperative day. affected limbs (radiographs of the pelvis with bilateral hip Three weeks after operation, external fixators were re- joints and left knee joint, chest, entire spine and skull) moved from both limbs and patellar tendon bearing cast and other routine blood investigations were performed. was applied on the right leg. Knee flexion and extension The radiographs showed a dislocated hip joint with as- exercises were started on both the limbs. The patient sociated fractures of the femoral head and posterior-su- was followed up at 6, 12, 24 and 48 weeks after operation. perior acetabular wall (type IV Pipkin’s fracture1). The Gradual hip abductor strengthening, hamstring and quad- knee X-rays showed a posterior dislocation of the joint riceps strengthening exercises were initiated. Weight with associated tibial plateau fracture (Hohl and Moore7 bearing was delayed for 6 weeks as both the limbs were type II fracture-dislocation with comminution of the inter- injured. Subsequently, the patient was allowed to ambu- condylar fragment, Figure 1). A closed reduction of the late with partial weight bearing using axillary crutches. hip joint was attempted, but it was unsuccessful. The Unrestricted weight bearing was allowed 3 months after knee joint was reducible, but unstable. An emergent CT operation when radiological signs of union were present. scan of the hip and knee joints and CT angiography of Complete clinical and radiological examinations were per- the affected limb were carried out (Figures 2, 3). The CT formed at each postoperative visit. The MRI scan was scan of hip showed a dislocated hip joint with fracture of also carried out at 3 and 6 months after operation to look posterior wall of acetabulum and fracture of the femoral for any evidence of avascular necrosis. The clinical as- head. CT scan of knee showed a sagittal split and dis- sessments of the hip and knee joints were carried out placed lateral tibial condyle fragment (Figure 3). CT an- using the Harris hip scale (HHS) and International Knee giogram of the affected limb showed normal patency of Documentation Committee (IKDC) scores, while the hip the lower limb vessels (Figure 4). joint was radiologically assessed using Matta scores at the last follow-up. There was no demonstrable knee lax- An urgent open reduction and internal fixation of the ity in either plane in the postoperative period or at follow- fracture-dislocation were planned and the patient was up, rulling out any associated ligamentous injury. evaluated for surgical fitness. The surgery was performed 12 hours after injury (the patient was brought to our At the last follow-up, the patient had no clinical or hospital only 4 hours after injury). The hip was ap- radiological features suggestive of avascular necrosis proached using Ganz’s surgical dislocation of the hip.8 of the hip joint (Figure 6). The patient was broadly symp- The displaced femoral head fragment was reduced and tom-free. The range of motion achieved by the hip joint fixed with a lag screw. The acetabular fragments were at one year follow-up was almost full except for a 15 small and not amenable to plate fixation and were sta- degrees restriction of abduction and 10 degrees restric- bilized using lag screws. Hip joint was subsequently tion of flexion and extension. The knee joint fell short of reduced and checked for stability and congruency. The complete flexion by 10 degrees (Figure 7). Clinical evalu- knee joint was reduced closely by forward traction of ation of the hip joint by HHS (HHS = 90) revealed ex- the tibia over . The tibial plateau fracture was cellent outcome and radiological grading (Matta score) opened through the anterolateral approach. The de- was good. Subjective evaluation of the knee by IKDC pressed articular surface was raised and supported us- score was also good at the last follow-up. Chinese Journal of Traumatology 2011; 14(3):183-187 .  .

Figure 1. Preoperative radiographs of the hip (A)andknee (B) show ipsilateral fracture dislocations of the left hip joint and knee joint. Figure 2. Preoperative CT of the hip in coronal (A) and trans-axial (B) sections shows type IV Pipkin’s fracture dislocation (superior rim of acetabular fracture with femur head fracture) of left hip joint.

Figure 3. CT of knee joint shows the fracture dislocation of left knee joint (Hohl and Moore type II). Figure 4. CT-angiographic image of lower limb shows complete patency of lower limb vessels.

Figure 5. Postoperative anteroposterior views of left hip (A) and knee joints (B), and lateral view of left knee joint (C) show a good reduction with fixation of femur head and acetabular rim with partially threaded cancellous screws. It is also demonstrated the knee fracture dislocation after reduction and internal fixation with buttress plate. Figure 6. At one-year follow-up, X-ray reveals that the fractures have completely united.

DISCUSSION

In the literature, 8 case reports on concomitant dis- locations9-16, 4 reports on fracture-dislocations3-6 and 4 case series on concomitant knee injuries2,17-19 in cases of hip dislocations were identified. The combination of simultaneous hip and knee dislocations is one of the Figure 7. The functional outcome of the patient one year after most challenging conditions encountered by the ortho- surgery. He was able to squat (A) and sit cross leg (B). .  . Chinese Journal of Traumatology 2011; 14(3):183-187 pedic surgeons, with higher instances of early mortal- coxarthritis, stiffness, heterotopic ossification, recur- ity and an increase of early, intermediate and late rent instability, chronic pain and degenerative arthritis complications. Many authors have reported arthrofibrosis in the knee is well-known. Clinical examinations to rule of knee joint, popliteal injury leading to limb am- out associated vascular or neurological injuries or com- putation and osteonecrosis of the hip despite an partment syndrome and other investigations including aggressive management of such injury.4,10,12 CT scans of the hip and knee joints (in addition to X- rays) to assess the joint and fracture morphologies and Considering the high velocity of the trauma and se- CT-angiography of the limb before and after the reduc- verity of the impact involved, it is not surprising to note tion are necessary in these situations. MRI scan may the high risk of hemodynamic instability and other seri- also be necessary at follow up to diagnose avascular ous and life-threatening injuries associated with these necrosis of the hip joint or associated meniscal or cru- fracture-dislocations. The significance of timely inter- ciate injuries in the knee joint. vention (early and adequate resuscitation to stabilize the general condition of the patient, complete primary The urgency, that the treating surgeon shows in survey to look for other life-threatening conditions and managing these injuries, significantly affects the prog- a secondary survey to rule out other associated inju- nosis and outcome finally achieved by these patients ries and complications) in managing these situations (golden period in reducing the hip joint has been de- cannot be understated. A high degree of clinical suspi- scribed to be 6 hours)12. The usual management proto- cion is essential so that one injury is not overlooked in col includes an immediate attempt at closed reduction the shadow of graveness of the other injury. of the joints (knee followed by hip joint). However, fac- tors like soft tissue impingement, capsular button-holing, The typical mechanism for posterior hip dislocations or associated fractures may preclude any possibility of involves a deceleration accident that follows an axial closed reduction, if so, an emergent open reduction impact on the knee, usually against the dashboard should be appropriately planned. (following road traffic accident) or fall from height with the hip and knee joints in flexed position. Position of We had planned a single staged surgery (as both the hip, direction of the force vector and the anatomy of the injuries were orthopedic emergencies) with a deci- the proximal femur determine whether the patient suf- sion to operate upon the hip joint first. In a dislocated fers from isolated dislocation or fracture-dislocation. A knee joint, especially associated with neurovascular or longitudinally-directed, severe, axial impact on a more other complications, the knee injury deserves emer- anteverted hip, applied across the through the gent care. In our case, an uncomplicated, knee dislo- knee, with the limb in a relatively less adducted and cation was reducible with proper splintage and the ap- internal rotated position, forces the joint to undergo frac- prehension of greater insult to the vascularity of femo- ture-dislocation rather than isolated dislocation.1 Such ral head with delay in hip reduction prompted us to con- posteriorly directed impact along with associated varus/ sider managing this injury foremost. The surgical ap- valgus or rotational forces displace the knee joint with/ proach to the hip in these injuries for arthrotomy has without associated tibial or femoral fractures.7 Our pa- been controversial until recent studies have confirmed tient had a similar mode of injury with the resultant type the advantages of Smith Peterson approach or poste- IV Pipkin’s fracture and Hohl and Moore type II knee rior approach with trochanteric flip osteotomy (surgical fracture-dislocation. The type II fracture-dislocation of dislocation of hip described by Ganz et al8)inpreserv- the knee joint involves the medial or lateral plateau and ing the major blood supply to femoral head via medial the fracture line extends into the opposite compartment circumflex femoral artery (over the traditional Kocher beneath the intercondylar eminence. It results in an langenbach approach). In a posteriorly dislocated hip instability equivalent to the loss of the cruciates and joint along with an associated posterior wall acetabular corresponding collateral . fracture (as in our case), the posterior approach along with flip trochanteric osteotomy provides the more con- As discussed earlier, a high association of these venient exposure. We, however, ensured a judicious injuries with diverse complications, such as neurovas- handling of the knee joint during the hip procedure so cular injuries, avascular necrosis of femoral head, as to avoid inflicting any further soft tissue disruption. Chinese Journal of Traumatology 2011; 14(3):183-187 .  .

The tibial fixation was then performed, as described, 5. Millea TP, Romanelli RR, Segal LS, et al. Ipsilateral frac- using a laterally placed buttress plate (in the locking ture-dislocation of the hip, knee and ankle: case report. J Trauma mode). The joint stability was then re-assessed under 1991;31(3):416-419. anesthesia and ascertained. As discussed in the 6. Schierz A, Hotz T, Kach K. Ipsilateral knee and hip joint literature, any further instability needs to be addressed dislocation. Unfallchirurg 2002;105(7):660-663. with appropriate management although, the time and 7. Moore TM. Fracture-dislocation of the knee. Clin Orthop type of repair or reconstruction performed in different Relat Res 1981;(156):128-140. soft tissue injuries are still controversial and the issue 8. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the needsto be individualized based on the surgeon’sknowl- adult hip: a technique with full access to the femoral head and edge of the concepts and understanding of the patient’s acetabulum without the risk of vascular necrosis. J Bone Joint need. The index case had no signs of knee instability Surg Br 2001;83(8):1119-1124. at the latest follow-up. The fractures of lateral tibial 9. Magistroni A. Hip and knee homolateral traumatic plateau, fibular head and inter-condylar eminence had dislocation. Minerva Orthop 1968;19(4):187-191. actually resulted in avulsion of the collateral and cruci- 10. Freedman DM, Freedman EL, Shapiro MS. Ipsilateral hip ate and they got united after the fixation. Had and knee dislocation. J Orthop Trauma 1994;8(2):177-180. there been any intrasubstance tear of these ligaments, 11. Vasali AS, Seara JL. Ipsilateral dislocation of knee, the patient might have manifested at a later stage and and ankle. Arch Orthop Trauma Surg 2004;124(6):418-420. a ligament reconstruction procedure had to be 12. Motsis EK, Pakos EE, Zaharis K, et al. Concomitant performed. Again the knee support with spanning fixator ipsilateral traumatic dislocation of the hip and knee following high- for 3 weeks provided adequate time for periarticular soft energy trauma: a case report. J Orthop Surg (Hong Kong) 2006;14 tissue healing and avoided the possibility of instability. (3):322-324. 13. DuBois B, Montgomery WH Jr, Dunbar RP, et al. Simul- The rarity of these injuries and the complications taneous ipsilateral posterior knee and hip dislocations: case report, associated has been elaborately described. A high de- including a technique for closed reduction of the hip. J Orthop gree of suspicion is needed to ensure an early diagno- Trauma 2006;20(3):216-219. sis of this uncommon combination of injuries. This 14. Voos JE, Heyworth BE, Piasecki DP, et al. Traumatic paper, thus, aimed to stress upon the importance of bilateral knee dislocations, unilateral hip dislocation, and contralat- timely, appropriate interventions by technically experi- eral humeral : a case report. HSS J 2009;5(1):40-44. enced surgeons in such complicated situations in or- 15. Ali C, Malkus T, Podskubka A. Ipsilateral traumatic dis- der to provide a good, final, functional outcome . location of hip and knee joints. Case report. Acta Chir Orthop Traumatol Cech 2009;76(4):329-34. REFERENCES 16. Vaseenon T, Wongtriratanachai P, Laohapoonrungsee A. Ipsilateral anterior hip dislocation and posterior knee : 1. Sahin V, Karakas ES, Aksu S, et al. Traumatic dislocation a case report. J Med Assoc Thai 2010;93(1):128-131. and fracture-dislocation of the hip: a long-term follow-up study. J 17 Hunter GA. Posterior dislocation and fracture-dislocation Trauma 2003;54(3):520-529. of the hip. A review of fifty-seven patients. J Bone Joint Surg Br 2. Schmidt GL, Sciulli R, Altman GT. Knee injury in patients 1969;51(1):38-44. experiencing a high-energy traumatic ipsilateral hip dislocations. J 18. Gillespie WJ. The incidence and pattern of knee injury Bone Joint Surg Am 2005;87(6):1200-1204. associated with dislocation of the hip. J Bone Joint Surg Br 1975; 3. Malimson PD. Triple fracture-dislocation of the lower limb. 57(3):376-378. Injury 1984;16(1):11-12. 19. Tabuenca J, Truan JR. Knee injuries in traumatic hip 4. Kreibich DN, Moran CG, Pinder IM. Ipsilateral hip and dislocation. Clin Orthop Relat Res 2000;(377):78-83. knee dislocation. A case report. Acta Orthop Scand 1990;61(1): 90-91. (Received February 12, 2011) Edited by LIU Jun-lan