DMMC Institute of Health Sciences

A CLIENT WITH TAUMATIC, CHRONIC, POSTERIOR HIP DISLOCATION

PRESENTED BY:

SALDUA,Ma Shiela S. DMMC- HIS

I. INTRODUCTION

Person with a hip dislocation has a bone in the hip that has come out of place. In adults, hip dislocations are caused by injuries. The dislocation may occur with a hip fracture. Congenital hip dislocations are present at birth.Hip dislocations are relatively uncommon during athletic events. Injuries to small joints (eg, finger, wrist, ankle, knee) are much more common. However, serious morbidity can be associated with hip dislocations, making careful and expedient diagnosis and treatment important for the sports medicine physician.Large-force trauma (eg, motor vehicle accidents, pedestrians struck by automobiles) are the most common causes of hip dislocations. This type of injury is also associated with high-energy impact athletic events (eg, American football, rugby, water skiing, alpine skiing/snowboarding, gymnastics, running, basketball, race car driving, equestrian sports). Diagnosing and correctly treating these injuries to avoid long-term sequelae of avascular necrosis and osteoarthritis is imperative.Hip dislocations are either anterior or posterior, with posterior hip dislocations comprising the majority of traumatic dislocations.

ALTERNATIVE NAMES

Developmental dislocation of the hip joint; Developmental hip dysplasia; DDH; Congenital dysplasia of the hip; Congenital dislocation of the hip; CDH; Pavlik harness Epidemiology

Posterior hip dislocations account for 90% of hip dislocations.

Incidence has decreased with the development of passenger air bags and use of seat belts in cars. The incidence is higher in young males because of risk-associated behaviour. Long-term disability after hip dislocations is very common with half of patients experiencing pain or reduced mobility.

Posterior dislocation of the hip This is caused by major force to a flexed knee and hip, e.g. when knees strike the dashboard in a road traffic accident. Other serious injuries are also often present, including fractures of the posterior acetabular or femoral shaft. Account for the majority of hip dislocations. The frequency has decreased with the increased use of belts and air bags. The affected leg is shortened and internally rotated with flexion and adduction at the hip. This appearance may not occur if there is also a femoral shaft fracture. Diagnosis is usually obvious on AP X-ray. Lateral views may be needed to exclude a hip dislocation with certainty. Initial treatment: o Resuscitation and deal with ABC priorities first o Analgesia: pain is severe o Refer for reduction under general anaesthetic o "Allis' technique" for reduction:2 Probably easiest and safest to place the anaesthetised patient on the floor An assistant holds the pelvis down Flex the hip and knee both to 90 and correct adduction and internal rotation deformities Grip the patient's lower leg between your knees and grasp the patient's knee with both hands Lean back and then lever the knee up, pulling the patient's hip upwards A clunk confirms successful reduction X-ray to confirm reduction Complications include: o Sciatic nerve injury: pain in the distribution of the sciatic nerve, loss of sensation in the posterior leg and foot and loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch) of the foot o Vascular injury: not as frequent as with anterior dislocations o Avascular necrosis of the femoral head: risk increases the longer the hip is dislocated3 o Secondary osteoarthritis

CAUSES Hip dislocations are relatively rare and severe injuries. They are often associated with pelvic fractures. A normal hip joint is stable and strong. A hip dislocation can only occur when a strong force is applied to the hip joint, such as:

Severe falls, especially from heights Motor vehicle accidents Sports injuries Risk Factors

These factors increase your chance of developing this condition. Tell your doctor if you have any of these:

Prior hip replacement surgery Abnormal hip joint Alcohol use Poor muscle control or weakness leading to falls Symptoms:

Severe pain in the hip, especially when attempting to move the leg Leg on the affected side appears shorter than the other leg Hip joint appears deformed Pain or numbness along the sciatic nerve area (back of thighs) if injury presses on this nerve Diagnosis

Tests may include: X-RAY - a test that uses radiation to take a picture of structures inside the body, especially bones CT- SCAN - a type of x-ray that uses a computer to make pictures of structures inside the body, used to view fractures of the pelvis

Treatment Treatments include: Closed Reduction

Pain medication Sedation Muscle relaxants General or spinal anesthesia

Open Reduction In some cases, surgery is needed. Open reduction is often done if the thigh or pelvic bones are also broken. Hip arthroscopy can be used to remove intraarticular fragments, evaluate intraarticular fractures and chondral injuries, and repair labral tears. When appropriate, hip arthroscopy is preferred to open surgery by those surgeons who are experienced in its use due to its minimally invasive nature, lower morbidity, and quicker recovery. Medication Patients who have experienced hip dislocation are usually in severe pain. The pain should be evaluated on a scale (0-10) and the patient provided with sufficient analgesia. While in the hospital, intravenous narcotics are the best choice for pain relief. Intravenous morphine (0.1 mg/kg q2-4h) is recommended for optimal analgesia. Postdischarge oral narcotics should be prescribed to keep the patient comfortable at home and during their rehabilitation period. Decreasing the inflammation near the site of injury by giving NSAIDs (eg, ibuprofen, naproxen) every 6 hours is also important. This enables the patient to be as comfortable as possible, while aiding in the healing process. Rehabilitation It takes timesometimes 2 to 3 monthsfor the hip to heal after a dislocation. The rehabilitation time may be longer if there are additional fractures. An orthopaedic surgeon may recommend traction for a short period of time, followed by controlled exercises using a continuous passive motion machine. Patients can probably begin walking with crutches when free of pain. A walking aid, such as a cane, should be used until the limp disappears.

A hip dislocation can have long-term consequences, particularly if there are associated fractures. As the thighbone is pushed out of its socket, it can disrupt blood vessels and nerves. When blood supply to the bone is lost, the bone can die, resulting in avascular necrosis or osteonecrosis. The protective cartilage covering the bone may also be damaged, which increases the risk of developing arthritis in the joint.

II. BIOLOGIOCAL DATA

Name: Ms. R

Address: Carmen Planas Binondo Manila

Birthday: Novenber 14,2006

Age: 5 years old

Gender: Female

Religious affiliation: Roman Catholic

Marital Status: Single

Chief Complaint: Pain on the Right Hip

Provisional Diagnosis: Traumatic, Chronic, Right Posterior hip dislocation

Attending Physician: Dr. Jonathan Flordelis

Date of Admission:October 29,2011

III. History of present illness

2 weeks prior to admission patient stumbled and fell and was unable to walk. Patient was left seated for two weeks resolution of swelling. They consulted Mary Johnston hospital where x- rays of leg and knee showed no abnormality. (+) manipulated was done by hilot and application of illness. Patient consulted our institution due to presence of symptoms hence admission.

IV. Anatomy and Physiology

Bone Structures of the Hip The bones comprising your hip joint are your femur and pelvis.

Femur Your femur is the largest, heaviest and longest bone in your body. It has two bone ends: the head of the femur that connects with your pelvis forming the hip joint and the distal end called the femoral condyles that connects with your leg bones forming your knee joint. The head of the femur, also called femoral head, is shaped like a sphere that fits almost perfectly on its corresponding socket formed by your pelvis.

Pelvis (Pelvic bones) You have two pelvic bones connected by the symphysis pubis in the front and the sacrum at the back. There are three bones comprising each of your pelvises: the ilium, ischium and pubis. These three bones fuse to form a deep depression called the acetabulum where your femoral head fits to form a joint.

Role of the Joint Cartilage A joint cartilage is a smooth and slippery tissue covering bone ends of all your moving joints. Also called articular cartilage, joint cartilages allow smooth movements of your joints and prevent friction between the two bone ends. As you age, this smooth joint cartilage may become damaged resulting from normal wear and tear of everyday use. Once damaged, your bone ends can rub against each other, causingosteoarthritis. The condition can cause pain, swelling and stiffness in your hip joint. Over time, constant rubbing of your bones can lead to permanent damage and cause disability. Physical therapy can help with most cases of hip osteoarthritis. In some, hipreplacementsurgery may be necessary. Supporting Structures of the Hip The strength of your hip also depends on the supporting structures surrounding your joint. These surrounding hip joint structures contribute to the stability of the joint. Your hip is supported by a capsule, ligaments and muscles. Hip Joint Capsule The hip joint capsule is a strong fibrous tissue that surrounds your hip joint. Along with the surrounding ligaments, the capsule provides added stability to your joint. Ligaments A ligament is a strong cord of tissue that connects a bone to another at a joint. The ligaments surrounding your hip joint work to keep your hip stable; limit certain hip movements; and prevent dislocation of your joint.

Your hip ligaments can become irritated, stretched or torn resulting in sprain. Hip ligament sprain can cause pain and swelling in your joint. Muscles Your hip muscles are one of the strongest muscles of your body. This is especially true because of its functions of: maintaining stability in your hip joint, moving your lower limbs and keeping your posture.

Pathophysiology The hip is a ball and socket joint and has theinherent stability associated with such joints. In addition,the hip has tremendous reinforcement by ligaments, the jointcapsule and large muscle insertions that provide additionalstability. Consequently, it requires a large amount of force todislocate the hip. A hip dislocation is a true orthopedicemergency in that the incidence of subsequent avascular necrosisof the femoral head is a time-dependent phenomenon becomingincreasingly common if relocation is delayed beyond 6 hours. The hip may dislocate posteriorly, which is the most commontype, anteriorly or centrally through the acetabulum into thepelvis. It may be a simple dislocation or a fracture/dislocation involving the acetabulum or the head,surgical neck or shaft of the femur.Posterior hip dislocations occur most typically during MVAs inwhich the knees of the front seat occupants strike the dashboardduring a head-on collision. Energy is transmitted along thefemoral shaft to the hip joint.If the leg is struck while in anadducted position, a posterior dislocation may result. If theleg is in neutral or an abducted position when struck, ananterior dislocation or fracture/dislocation may occur. In thelatter case, the posterior wall of the acetabulum is fracturedmaking subsequent reduction less stable. Anterior dislocationof the hip occurs either from a direct blow to the posterioraspect of the hip or, more commonly, to a force applied to anabducted leg that levers the hip anteriorly out of theacetabulum. The third type of hip dislocation is a centraldislocation in which a direct impact to the lateral aspect ofthe hip forces the hip centrally through the acetabulum into thepelvis. This is by definition a fracture/dislocation.

V. Nursing Care Plan

ASSESSMENT

NURSING DIAGNOSIS - Acute pain and immobility , related to diagnosis of fracture.

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

- Assess for history of the injury, presence of factors that may cause pathologic fractures (osteoporosis, osteomyelitis, neoplastic diseases, etc.). - Assess presence of signs of fracture (edema, pain, loss of motion, crepitus, extremity disproportion or abnormal positioning). - Assess presence of signs and symptoms of soft tissues involvement (swelling, hemorrhage, impaired sensation in the extremity). - Assess extremity for presence of open fracture and severe external hemorrhage. - Assess vital signs, fluid balance and urine output. - Assess diagnostic tests and procedures for abnormal values. - Assess routine preoperative history

- Increase comfort, decrease pain. - Prevent avoidable injury. - Prevent complications of immobility. - Provide optimal bone and wound healing. - Then surgical intervention prescribed, prevent postoperative complications. - Decreased anxiety with increased knowledge.

- Provide emergency care if requires (hemostasis, respiratory care, prevention of shock).

- Reports increased comfort, decreased pain. - No evidence of respiratory, vascular or skin complications of - Provide fracture immobility. fixation to prevent - Individual with - Maintains stable vital following injury of external locus of signs, fluid and tissues. control may take little metabolic balance, or no responsibility for nutritional state. - Observe signs of fat pain management. - Has sufficient fracture embolism (especially healing rate. during first 48 hours - Observations may - Laboratory tests after the fracture). or may not be results shows no congruent with verbal abnormalities. reports indicating - No postoperative - Monitor clients vital need for further complications, or signs. evaluation. treatment - Monitor fluids input complications. and output - Vital signs usually - Learned of crutchcontinuously, insert IV altered in acute pain. walking, taking care of catheter, urinary himself then possible. catheter. - Demonstration of understanding of fracture healing process, diagnostic and treatment procedures, trauma prevention, and need for follow-up.

- To rule out worsening of underlying condition or development of complications.