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Saturday, 14 July 2012

HIP JOINT DISLOCATION DIAGNOSIS AND TREATMENT / DISLOKASI SENDI PANGGUL DIAGNOSA DAN PENATALAKSANAAN


HIP joint dislocation DIAGNOSIS AND TREATMENT


Pelvis is a bone to protect the tools in the pelvic space. Hip fracture is rare in children compared with adults. Most of the cause was traffic accident trauma in children aged 1-8 years due to a lack of awareness of traffic. Hip fractures in children is generally a part of a multiple trauma to other organs such as the head, thorax and limbs.




BIRTH-dislocation of the hip

Or congenital hip dislocation Congenital Dislocation of the Hip (CDH) is the phase spectrum of the instability of the hip joint in infants. Under normal circumstances, the newborn pelvis in a stable and slightly flexed.
Pelvic instability range 5-20% of 1,000 live births, and most will be stable after 3 weeks and only 1-2% that remained unstable. Congenital hip dislocation seven times more in women than in men, the left hip joint is more often affected and only 15% are bilateral. The disorder is more common in Americans and Japanese and is rarely found in people of Indonesia.





Etiology and pathogenesis
A. Genetic factors
2. Hormonal factors
3. Intrauterine malposition
4. Post-natal factors
5. Environmental factors



Diagnosis
Diagnosis of congenital dislocation of hip based on clinical and radiological examination.
The clinical
Clinical picture of congenital hip dislocation is asymmetry in the folds of skin between the thighs.
Clinical examination to determine the congenital hip dislocation in newborn babies are:
• Test Ortolani
• Test Barlow
• A Galeazzi

Radiological examination
Examination is usually quite difficult because of the new joint ossification centers appear in infants aged 3 months or more so this is only useful examination at the age of 6 months or more



.
Ultrasound
Ultrasound examination performed on the babies to replace the X-ray imaging of the pelvis. In newborns, the head of the acetabulum and femoral connected by cartilage, so that the ordinary plain sight. By ultrasound examination, although patients under the age of 3 months, the relationship between the head and the acetabulum femoris can be observed.
Diagnosis of congenital hip dislocation by Barlow based on:
A. Physical examination
2. Certain tests
3. Radiological examination
Diagnosis can be established if there is a picture:
• Asymmetry groin
• Test Ortolani, Barlow and positive Galeazzi
• Asetabuler index 40 0 ​​or greater
• Disposition caput femoris on the lateral radiogram
• Limitation of settling of the hip joint movement with or without abnormal radiological picture.
Treatment
In the congenital dislocation of the hip joint is necessary for handling the early diagnosis of diseases that need to be as early as possible, so that a complete orthopedic examination and meticulous in the newborn needs to be done.
Treatment generally is only by putting splint to maintain the position of the hip joint.
As many as 80-90% of the hip joint in newborns is not stable until the age of 3 months and usually within a period of 23 weeks will be a stable pelvis spontaneously. When the hip joint remains unstable after that time period, you should be monitoring further (follow up). Dislocation of the hip in patients aged 3-18 months, can be attempted closed reduction and reduction actions should be considered when surgery is not successful. If the patient is aged 18 months to 5 years then it has to be an irreversible disorder that Brazilians is surgery the only alternative treatment to correct abnormalities.

Dislocation of the hip
With the ever increasing road traffic accidents resulting in dislocation of the hip joint are common. Dislocation of the hip joint is a great trauma.
Definition
Shifting caput femur from the hip joint, located in the acetabulum and the posterior (posterior dislocation), the anterior acetabulum (anterior dislocation), and the caput of the femur through the acetabulum (central dislocation)






Traumatic dislocation and fracture of the hip joint is divided into three types:
A. Posterior dislocation or a fracture with posterior dislocation
2. Anterior dislocation
3. Central dislocation
Posterior type: This type is most common iliac; head of the femur was
 diposterior and superior along the lateral aspect of the ileum
Anterior Type: The head of the femur was in the obturator membrane
Pubic; the head of the femur to shift along the antero superior pubic bone ramus superior.
Central type: in these circumstances was found fractured acetabulum komunitif central part
where there is transfer of the head of the femur and acetabulum into the pelvic fragments.

Posterior dislocation

Mechanism of trauma
Four of the five-traumatic hip dislocations are posterior. This fracture usually occurs in a traffic accident when someone is sitting in a truck or car was thrown forward, so that your knees knock at dashboard.femur caput femoris pushed upward and out of the bowl, often a piece of bone at the back of the acetabulum is truncated (fracture dislocation)
The head of the femur fitted out to the back of the acetabulum through a trauma that delivered on diafisis femur in a position where the hip joint flexion and semifleksi.
Trauma usually occurs because of an accident in which the cross lalul knee flexion and a passenger in a state that was hit hard in front of the knee. Fifty percent of fracture dislocation at the edge of the acetabulum with a small or large fragments





Classification
Classification is important to plan treatment, which according to Thompson Epstein (1973):
A. Type I: no fracture or dislocation with a small bone fragment
2. Type II: dislocation with a single large fragment in the posterior acetabulum
3. Type III: fracture dislocation of the acetabulum is komunitif lips
4. Type IV: fracture dislocation of the acetabulum base
5. Type V: radial head dislocation with fracture of the femur.

Clinical features:
Patients come after experiencing trauma: eg fall from a tree, bike or because kecelakaaan traffic.
In type 1 (Posterior Dislocation) visible above the limb flexion, internal rotation, and adduction.
In type 2 (anterior dislocation) the upper limbs in a state of abduction, external rotation and slightly flexed.
In type 3 (central dislocation) fracture of the acetabulum accompanied the picture is not visible deformity of the lower limbs, there is only movement disorders in the hip joint due to muscle spasm.
X-ray examination will determine the type of dislocation.

Treatment:
Dislocation should be repositioned as soon as possible with general anesthesia with adequate relaxation. Patients lay on the floor and the maid holding the pelvis. The hip joint flexed and the knee flexed 90 degrees and then do the pull of the thigh is vertical. Once repositioned, the stability of the hip joint can be examined whether seendi didislokasi by moving vertically on the hip joint.
repositioning should be done as soon as possible within 6 hours, if not will cause difficulties and complications in the future avaskuler necrosis.
Closed reduction performed with general anesthesia in several ways:

A. method of Bigelow
the patient is placed in a supine position on the floor, an assistant to do the opposite traction and resistance to the anterior superior iliac spine and the ileum. Surgeon holding the affected limb at the ankle with one hand, and other hands behind the knee. Difleksi 90o or more legs on the abdomen and performed longitudinal traction. In this way the Y ligament will experience relaxation and the head of the femur is located in the posterior acetabulum. Then the head of the femur with the release of muscular rotator to rotate and move the leg forward and back. Furthermore, in a state of traction, the head of the femur is moved into the acetabulum by manipulation of abduction, external rotation, and extension at the hip.
2. Stimson method
patients in keaadaan stomach and lower leg trauma left dangling on the edge of the table. Pelvis were mobilized by the assistant by pressing the sacrum. With his left hand holding the ankle surgeons and perform at 90o flexion of the knee with his right hand pressing down on the lower leg below the knee. With a rocking motion and rotation of the legs as well as direct pressure on the repositioning of the head of the femur can be done.
3. Allis methods
patient in a supine position on the floor, an assistant to hold the pelvis and press it, surgeons perform knee flexion of 90 ° and legs in adduction and medial rotation of the light. The forearm is placed under the knees and made the head of the femur traction and lifted vertically from the posterior acetabulum. Hip and knee diekstensikan carefully. 3 this method to an easier method. The most important requirement is the repositioned as soon as possible and be done with general anesthesia with adequate relaxation.
treatment after repositioning
skin traction for 4-6 weeks, after it did not set foot in the street to use crutches for three months.

Complications:
Dini:
A. Skiatikus nerve damage, nerve is sometimes injured, but can be improved again. In the event it is necessary to reposition the lesion after nerve exploration.
2. Damage to the head of the femur during a radial head dislocation is often hit the acetabulum until the femur broke.
3. Damage to blood vessels that normally experienced tearing of the artery glutea superior.
4. Diafisis femur fracture is often found diafisis femur fracture with dislocation of the hip. Suspicion that there is dislocation of the hip, when in a position of femoral fracture proximal femur was found in a state of adduction. Radiological examination should be performed on the joints above and below the fracture area.
Information:
A. Avaskuler necrosis as much as 10% of all hip dislocations were damaged blood vessels. If repositioning was delayed for several hours then insidensnya will increase to 40% of these abnormalities are usually detected during the 6 months to 2 years, and radiological examination found fragmentation, sclerosis and formation of cysts.
2. Dislocations that can not be reduced. If the reduction is usually delayed for several days to reposition manipulation difficult.
3. Osteoarthritis is due to cartilage damage, there is a fracture fragment in the joint space or the presence of ischemic necrosis of the head of the femur.

Anterior dislocation
Anterior dislocations are less common than posterior dislocations.

Mechanism of trauma:
Anterior dislocation caused by traffic accidents, falls from a height or trauma from back when squatting and positioning the patient in a forced abduction keaadaan.
Neck of femur or acetabulum and trokanter crashing headlong out through a tear in the anterior capsule. When the hip joint in flexion, there will be a type of obturator dislocation of the hip joint and in a state where the position of the extension there will be a dislocation of the pubic or iliac type.



Clinical features:
Lower leg in an external rotation, abduction and flexion slightly. Limbs do not have shortening of the femur for the attachment of the rectus muscle to prevent the head of the proximal femur shift.
There are bumps in front of the inguinal region, where the head of the femur can be palpated easily. Difficult to move the hip joint

Radiological examination:
AP X-ray examination of the position of the anterior dislocation is often less clear, it is also necessary for lateral photographs

Treatment
Performed posterior repositioning of such dislocations except during flexion and traction on the dislocated posterior limb adduction performed in anterior dislocation.
Repositioning of anterior dislocation is recommended to use the method of Allis. If not managed by the Bigelow method upside down. After reposisim, followed by skin traction circuitry extension to Buck. For several days after it is installed spika pelvis for 4-6 weeks.

Complications:
The most frequent complication is necrosis avaskuler.


Central dislocation

Mechanism of trauma
Central dislocation occurs when the head of the femur is pushed to the dindiing medial acetabulum in the pelvis. Here capsule remains intact. Acetabulum fracture occurs due to the strong encouragement of the lateral or falling from a height on one side or the pressure through the hip where the femur in an abducted

Clinical features:
It was found bleeding and swelling in the area of ​​the proximal limb but still normal position. Trokanter tenderness in the area. Very limited movement of the hip joint.



Radiological examination:
Radiological examination can be known by the shift of the head of the femur through the pelvis.

Treatment:
Attempted to reposition the fracture and restore the normal form of the acetabulum to form. In the acetabulum without the protrusion of the radial head fracture of the femur into the pelvis, the conservative therapy with bone traction for 4-6 weeks. At the head of the femur which penetrates into the acetabulum, traction should be two components, namely the longitudinal and lateral components for 6 weeks and after 8 weeks is allowed to run circuitry using body weight support
Reduction of central dislocation of the bone by means of traction requires a K-wire for a few weeks since the central dislocation of the acetabulum with an invoice.


Complications:
a. Damage to equipment in the pelvis that can occur with pelvic fractures.
b. Stiff joints are further complications
c. osteoarthritis











REFERENCES



1.     Apley, A. Graham. Cedera tungkai bawah dalam Buku ajar ortopedi fraktur sistem Apley, edisi 7. hal 364-367
2.     Rasjad, chairuddin. Dislokasi panggul dalam Pengantar ilmu bedah ortopedi. Hal 401-403. 2003. Bintang Lamumpatue.

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