Adolescent Hip Dislocation Combined With Proximal Femoral Physeal Fractures and Epiphysiolysis

The risks and long-term effects of acute hip dislocation combined with proximal femoral physeal fractures and epiphysiolysis have been minimally addressed in the literature. This infrequent combination must be understood to avoid the major complications of complete separation of proximal femoral components during attempted reduction and to predict the probable outcome of surgical treatment.

Medical records and imaging were retrospectively reviewed to identify patients with a diagnosis of severe to complete slipped capital femoral epiphysis (CFE) or proximal femoral epiphysiolysis in association with hip dislocation. The focus included possible anatomic/vascular disruption and their consequences.

Twelve patients were identified. Nine dislocations were posterior; 3 were anterior. In 4 patients, the intact proximal femur was dislocated posteriorly. In 3 patients only the femoral neck was reduced, whereas the CFE remained dislocated. In 1 patient percutaneous pinning was done in the dislocated position before closed reduction. The reduction was successful. In 7 patients only the CFE (4 patients) or femoral neck (3 patients) was displaced at the initial presentation in the emergency room. One patient presented with posterior dislocation associated with complete separation of both components. Ten patients underwent open reduction and internal fixation. Two patients had closed reduction. Nine patients developed complete avascular necrosis, progressive collapse of the femoral head, and degenerative arthritis. Three subsequently had a total hip arthroplasty. One patient developed ischemic change limited to the femoral neck and a nonunion through the epiphysis. One patient had incomplete ischemic necrosis. Only 1 patient had no evidence of ischemic necrosis.

This combination of injuries has several anatomic variations. Leaving the CFE dislocated while reducing only the femoral neck must be avoided. Reduction should be done in the operating room with muscle relaxation. The emergency room is not the venue for reduction. The risk of avascular necrosis is extremely high, whether the separation occurs during the acute dislocation or attempted reduction.

Level IV-case series (retrospective review).