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CASE REPORT

Bilateral Traumatic ‘Windswept’ Hip Dislocation: A Case With A Delayed Presentation

Irshad Tabasum , Mohammed Umar Mumtaz, Shabir Ahmed Dhar *, Mohammed Ramzan,Mohammed Farooq Butt

* Government Hospital for Bone and Joint Surgery, Barzallah, Srinagar , Kashmir, INDIA

Address for Correspondence:

Dr.Shabir Ahmed Dhar MS
Government Hospital for Bone and Joint
Surgery, Barzallah, Srinagar , Kashmir , INDIA , 190005. 
E-mail : shabirdhar@yahoo.co.in

Abstract:

Bilateral traumatic dislocation of the hip joint is a rare combination. Simultaneous asymmetric dislocation of the hip joints is even rarer. Early diagnosis and treatment of traumatic hip dislocation is essential to reduce morbidities that are commonly associated with delayed reduction. We report a two year followup of a case who presented to our hospital 3 days after sustaining the injury. Closed reduction was successful. Two years after sustaining the trauma the patient has mild pain in one hip and no sign of avascular necrosis.  

J.Orthopaedics 2008;5(1)e1

 
Introduction:

Dislocation of the hip was once thought to be a rare injury. Due to the increasing incidence and severity of road traffic accidents the injury has become more common.[1,2]A hip dislocation is a major injury in view of the large forces required to cause the dislocation. Posterior dislocation of the hip is a commoner than the anterior type with the anterior type constituting 10% of the presentations.[2]. Simultaneous anterior and posterior traumatic dislocation of both hips is even more unusual.[3]. Early diagnosis and treatment of traumatic hip dislocation is essential to reduce morbidities that are commonly associated with a delay in reduction.[4]           

We report a case with bilateral asymmetric [ windswept] dislocation of the hip joints presenting 3 days after the injury. 2 years after the reduction, the hips did not show any signs of avascular necrosis.

Case Report:

A 27 year old labourer fell from a tree while cutting its branches. While falling he recalled that his right limb had snagged in one branch breaking his fall to an extent. He had fallen to the ground on the lateral side of his left leg. As the area where he had sustained the injury is remote it took him three days to report to our hospital. On admission, his right leg was externally rotated, abducted and slight flexed, while the left was held in fixed flexion, internal rotation and adduction. A radiograph of the pelvis showed that the patient had a bilateral traumatic assymmetrical [ windswept] dislocation of the hips. The right hip had an anterior dislocation with an indentation fracture of the femoral head and the left side had a posterior dislocation. There was no associated fracture of the acetabulum or femur.  Both hips were reduced within two hours of presentation by closed manipulation under general anaesthesia. A radiograph after reduction confirmed concentric reduction and excluded any intra-articular fragmentsHe was kept on bed rest for two weeks with skin traction followed by a further six weeks of non-weightbearing. The patient reportedmonthly to our hospital in view of the indentation of the right femoral head. At 2 years the patient had mild pain of the right hip which did not interfere with his routine activity. The radiographs did not show any sign of avascular necrosis.   

Discussion :

Dislocation of the hip is an uncommon injury with every hip dislocation being classified as an emergency.[5] Bilateral hip dislocation occurring as a result of trauma is a rare condition. Simultaneous anterior and posterior traumatic dislocation of both hips is even more unusual. Traumatic dislocation of the normal hip joint is rare because of its deep acetabular cavity and strong surrounding ligamentous structures. Ninety per cent of dislocations are posterior, occurring as a result of high energy transfer mostly in car and motorcycle accidents (46% and 18% respectively). This results when a sufficient force is applied in the long axis of the femoral shaft while the hip is flexed and adducted. In contrast, anterior dislocations are caused by rotation and may be classified as superior and inferior. Superior ones occur attributable to abduction and external rotation in extension and inferior ones occur when the hip is adducted and external rotated in flexion.[2].

Bilateral hip dislocation in our case occurred due to the fall with the anterior hip dislocation being caused by the branch forcing the right hip into abduction and the ground reaction force being transmitted through the adducted left limb. This "windswept" mechanism is inconsistent with the commonly accepted road traffic accident theory that an off centre passenger cell intrusion directs longitudinal force along both femora, yet has a vector in the coronal plane. Our case had two separate trauma incidents in a single fall.

Figure 1:  Showing Assymmetric Dislocation Of The Hip Joints.

Figure 2: 2 Years After The Trauma There Is No Sign Of Avascular Necrosis.

Several studies have shown that the risk of osteonecrosis occurring after a hip dislocation is related to the length of time the hip remains dislocated. The risk rises after a delay of six hours, or after repeated attempts at closed reduction. Overall, the risk of developing osteonecrosis of the femoral head after an anterior or posterior hip dislocation ranges from between 8% and 15%, to as high as 40% after operative treatment. [7,8]

Our case demonstrates the fact that injury mechanisms might vary in such complex presentations. Also delayed presentation in spite of being a risk factor for increased complications does not always preclude a good result.

Reference :

  1. Armstrong JR; Traumatic Dislocation of the hip joint. JBJS. 30-B; 430-445. 1948  

  2. Epstein HC. Traumatic dislocation of the hip. Baltimore . Williams and Wilkins, 1980.  

  3. Hill RJ, Chmell S. Contralateral anterior/posterior traumatic hip dislocations. Orthopedics 1990;13:87–8  

  4. Alonge TO, Ogunlade SO, Idowu OE. Traumatic dislocation of the hip joint--pattern and management in a tropical African population. West Afr J Med. 2002 Oct-Dec;21(4):288-90.  

  5. Vécsei V, Schwendenwein E, Berger G. Hip dislocation without bone injuries. Orthopade. 1997 Apr;26(4):317-26.

  6. Upadhyay S, Moulton A. The long term results of traumatic posterior dislocation of the hip. J Bone Joint Surg 1981;63B:548–51.

  7. Upadhyay S, Moulton A, Burwell R. Biological factors predisposing to traumatic posterior dislocation of the hip. J Bone Joint Surg 1985;67B:232–6.

  8. Epstein HC. Posterior fracture-dislocations of the hip: long term follow up. J Bone Joint Surg 1974;56A:1103–27

 

This is a peer reviewed paper 

Please cite as : Shabir Ahmed Dhar: Bilateral Traumatic ‘Windswept’ Hip Dislocation: A Case With A Delayed Presentation

J.Orthopaedics 2008;5(1)e1

URL: http://www.jortho.org/2008/5/1/e1

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