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Neglected subluxation of the hip after trauma: A case report
Shohei Matsubayashi1, Eri Kanzaki1, Ritsu Tsujimoto1
1Department of Orthopedic Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Japan.
Insights
Delayed detection of hip dislocation in children can occur due to cartilage. This case highlights the importance of clinical signs and advanced imaging for diagnosing hip subluxation and avascular necrosis in pediatric trauma patients.
Area of Science:
- Pediatric Orthopedics
- Trauma Surgery
- Radiology
Background:
- Children's pelves have significant cartilage, complicating X-ray and CT detection of spontaneous hip dislocation after trauma.
- Delayed diagnosis of hip dislocation in pediatric patients can lead to significant complications.
Observation:
- A 10-year-old boy presented with limping 7 months after a car accident and pelvic ring fracture.
- Clinical examination revealed limited left hip range of motion, and imaging showed joint space narrowing, femoral head deformity, and a broken Shenton line.
Findings:
- Computed tomography (CT) revealed posterior acetabular wall dislocation and femoral head subluxation.
- Magnetic resonance imaging (MRI) confirmed avascular necrosis of the femoral head.
- Surgical intervention included femoral and pelvic osteotomies, followed by temporary sciatic nerve paralysis.
Implications:
- Prompt recognition of hip subluxation is crucial, even with negative initial imaging, especially when hip extension, abduction, and internal rotation are limited and the Shenton line is disrupted.
- Successful surgical management can improve range of motion and resolve femoral head necrosis and nerve deficits.
- This case underscores the need for high clinical suspicion and advanced imaging in pediatric hip trauma.
Introduction:
In children, the pelvis contains a large amount of cartilage components; therefore, when traumatic hip dislocation spontaneously reduces, it can be impossible to see on X-ray or computed tomography (CT) images in some cases, which can delay its detection.
Case Presentation:
We report the case of a 10-year-old boy who was injured by being hit by a car while walking. Upon diagnosis of pelvic ring fracture, the patient received conservative treatment. Seven months after injury, the patient was referred to our department with the chief complaint of limping.
Diagnosis:
Marked limitation was observed in the left hip with extension of -40°, abduction of 10°, and internal rotation of 20°. X-ray revealed narrowing of the left hip joint space, with deformity of the femoral head, obturator foramen narrowing, and the break in the Shenton line. CT revealed proximal dislocation of the posterior acetabular wall and posterior subluxation of the femoral head. Magnetic resonance imaging (MRI) revealed necrosis of the femoral head.
Intervention:
Operation was performed with soft tissue dissection, varus-extension-internal rotation femoral osteotomy, greater trochanteric epiphysiodesis, and pelvic osteotomy (incomplete periacetabular osteotomy: IPO). After operation, complete paralysis of the sciatic nerve was observed.
Outcomes:
At 1 year after operation, the patient's limited range of motion (ROM) and femoral head necrosis had improved. The sciatic nerve paralysis had fully recovered.
Conclusion:
If hip extension, abduction, and internal rotation are limited and X-ray reveals a break in the Shenton line., subluxation of the hip should be suspected.
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