CLASSIFICATION

Hip dislocations are classified based on (1) the relationship of the

femoral head to the acetabulum and (2) whether or not associated
fractures are present.
Thompson and Epstein Classification of
Posterior Hip Dislocations (Fig. 27.4)
1. Type I:
Simple dislocation with or without an insignificant posterior wall
fragment
2. Type II:
Dislocation associated with a single large posterior wall fragment
3. Type III:
Dislocation with a comminuted posterior wall fragment
4. Type IV:
Dislocation with fracture of the acetabular floor
5. Type V:
Dislocation with fracture of the femoral head (Pipkin classification)
Figure 27.4 Thompson and Epstein classification of posterior hip…
 Tipe I:
Dislokasi sederhana dengan atau tanpa dinding fragmen posterior yang signifikan

Tipe II:
Dislokasi terkait dengan dinding besar tunggal fragmen posterior

Tipe III:
Dislokasi dengan kominuted dinding fragmen posterior

Tipe IV:
Dislokasi dengan fraktur lantai acetabular

Tipe V:
Dislokasi dengan fraktur kepala femur (klasifikasi Pipkin)

Epstein Classification of Anterior Hip

Dislocations (Fig. 27.5)
Figure 27.5 Epstein classification of anterior hip dislocations. (From Rockwood…
1. Type I:
Superior dislocations, including pubic and subspinous
2. IA:
No associated fractures
3. IB:
Associated fracture or impaction of the femoral head
4. IC:
Associated fracture of the acetabulum
5. Type II:
Inferior dislocations, including obturator, and perineal
6. IIA:
No associated fractures
7. IIB:
Associated fracture or impaction of the femoral head
8. IIC:
Associated fracture of the acetabulum

OTA Classification of Hip Dislocations

See Fracture and Dislocation Classification Compendium
athttp://www.ota.org/compendium/compendium.html.

TREATMENT
 One should reduce the hip on an urgent basis to minimize the risk of
osteonecrosis of the femoral head; it remains controversial whether this
should be accomplished by closed or open methods. Most authors
recommend an immediate attempt at a closed reduction, although some
believe that all fracture–dislocations should have immediate open
surgery to remove fragments from the joint and to reconstruct fractures.
 The long-term prognosis worsens if reduction (closed or open) is
delayed more than 12 hours. Associated acetabular or femoral head
fractures can be treated in the subacute phase.

• Reduksi pinggul harus dilakukan secara mendesak untuk

meminimalkan risiko osteonekrosis kepala femoral; masih
menjadi kontroversial apakah ini harus dilakukan dengan
metode tertutup atau terbuka. Kebanyakan penulis
merekomendasikan upaya langsung pada reduksi tertutup,
meskipun beberapa percaya bahwa semua fraktur-dislokasi
harus memiliki operasi terbuka langsung untuk menghilangkan
fragmen dari sendi dan untuk merekonstruksi patah tulang.
• Prognosis jangka panjang memburuk jika reduksi (tertutup
atau terbuka) tertunda lebih dari 12 jam. Acetabular atau
patah tulang kepala femoral dapat diobati dalam fase subakut.

Closed Reduction
 Regardless of the direction of the dislocation, the reduction can be
attempted with in-line traction with the patient lying supine. The
preferred method is to perform a closed reduction using general
anesthesia, but if this is not feasible, reduction under conscious sedation
is possible. There are three popular methods of achieving closed
reduction of the hip:
Terlepas dari arah dislokasi, reduksi dapat dicoba dengan in-line traksi
dengan pasien berbaring terlentang. Metode yang dipilih adalah dengan
melakukan reduksi tertutup menggunakan general anestesi, tetapi jika
hal ini tidak layak, reduksi di bawah sedasi sadar mungkinkan. Ada tiga
metode populer untuk mencapai reduksi tertutup pinggul:

1. Figure 27.6 The Allis reduction technique for posterior hip

dislocations…ALLIS METHOD. This consists of traction applied in line
with the deformity. The patient is placed supine with the surgeon
standing above the patient on the stretcher or table. Initially, the surgeon
applies in-line traction while the assistant applies countertraction by
stabilizing the patient’s pelvis. While increasing the traction force, the
surgeon should slowly increase the degree of flexion to approximately 70
degrees. Gentle rotational motions of the hip as well as slight adduction
will often help the femoral head to clear the lip of the acetabulum. A
lateral force to the proximal thigh may assist in reduction. An audible
“clunk” is a sign of a successful closed reduction (Fig. 27.6).

Teknik reduksi Allis untuk dislokasi posterior hip ... METODE

ALLIS. Ini terdiri dari traksi diterapkan sesuai dengan
deformitas. Pasien ditempatkan terlentang dengan dokter
bedah berdiri di atas pasien di tandu atau meja. Awalnya, ahli
bedah melakukan in-line traksi, sementara asisten melakukan
countertraction dengan menstabilkan panggul pasien.
Sementara meningkatkan kekuatan traksi, ahli bedah harus
perlahan-lahan meningkatkan tingkat fleksi ke sekitar 70
 derajat. Gerakan rotasi lembut pada pinggul serta sedikit
adduksi sering akan membantu kepala femoral untuk
membersihkan bibir acetabulum. Gaya lateral paha proksimal
dapat membantu dalam reduksi. Sebuah "bunyi" yang
terdengar adalah tanda reduksi tertutup sukses

2. STIMSON GRAVITY TECHNIQUE. The patient is placed prone on

the stretcher with the affected leg hanging off the side of the stretcher.
This brings the extremity into a position of hip flexion and knee flexion
of 90 degrees each. In this position, the assistant immobilizes the pelvis,
and the surgeon applies an anteriorly directed force on the proximal calf.
Gentle rotation of the limb may assist in reduction (Fig. 27.7). This
technique is difficult to perform in the emergency department.
Stimson GRAVITASI TEKNIK. Pasien ditempatkan tengkurap di
tandu dengan kaki yang menggantung pada sisi tandu. Hal ini
membawa ekstremitas pada posisi fleksi panggul dan fleksi
lutut masing-masing 90 derajat. Dalam posisi ini, asisten
mengimobilisasikan panggul, dan ahli bedah memberikan
kekuatan yang diarahkan secara anterior pada betis proksimal.
Rotasi lembut dari kaki dapat membantu dalam reduksi
(Gambar. 27,7). Teknik ini sulit untuk dilakukan di gawat
darurat.

Figure 27.7 The Stimson gravity method of…

3. BIGELOW AND REVERSE BIGELOW MANEUVERS. These have
been associated with iatrogenic femoral neck fractures and are not as
frequently used as reduction techniques. In the Bigelow maneuver, the
patient is supine, and the surgeon applies longitudinal traction on the
limb. The adducted and internally rotated thigh is then flexed at least 90
degrees. The femoral head is then levered into the acetabulum by
abduction, external rotation, and extension of the hip. In the reverse
Bigelow maneuver, used for anterior dislocations, traction is again
 applied in the line of the deformity. The hip is then adducted, sharply
internally rotated, and extended.
o Following closed reduction, AP pelvis radiographs should be obtained to
confirm the adequacy of reduction. The hip should be examined for
stability while the patient is still sedated or under anesthesia. If there is
an obvious large displaced acetabular fracture, the stability examination
need not be performed.
 Stability is checked by flexing the hip to 90 degrees in neutral position. A
posteriorly directed force is then applied. If any sensation of subluxation
is detected, the patient will require additional diagnostic studies and
possibly surgical exploration or traction.
 Following successful closed reduction and completion of the stability
examination, the patient should undergo CT evaluation.

3 Bigelow dan reverse Bigelow manuver. Ini dikaitkan dengan

patah tulang leher femur iatrogenik dan tidak sering digunakan
sebagai teknik reduksi. Dalam manuver Bigelow, pasien
terlentang, dan ahli bedah memberikan traksi memanjang pada
anggota badan. Adduksi dan rotasi internal paha tersebut
kemudian dilipat setidaknya 90 derajat. Kepala femoral
kemudian dijadikan pengungkit ke dalam acetabulum dengan
abduksi, rotasi eksternal, dan ekstensi pinggul. Dalam reverse
Bigelow manuver, digunakan untuk dislokasi anterior, traksi
diterapkan lagi di garis deformitas. Pinggul tersebut kemudian
menjadi dalam posisi adduksi, rotasi internal, dan memanjang.
o Setelah reduksi tertutup, foto AP pelvis harus diperoleh untuk
mengkonfirmasi kecukupan reduksi. Pinggul harus diperiksa
untuk stabilitas saat pasien masih dibius atau di bawah
anestesi. Jika ada perpindahan fraktur acetabular besar yang
jelas, pemeriksaan stabilitas tidak perlu dilakukan.
Stabilitas diperiksa dengan meregangkan pinggul sampai 90
derajat pada posisi netral. Sebuah gaya diarahkan posterior
 kemudian diterapkan. Jika ada sensasi subluksasi terdeteksi,
pasien akan memerlukan studi diagnostik tambahan dan
eksplorasi bedah atau traksi.
Setelah reduksi tertutup sukses dan penyelesaian
pemeriksaan stabilitas, pasien harus menjalani CT evaluasi.

Open Reduction
 Indications for open reduction of a dislocated hip include
o Dislocation irreducible by closed means.
o Nonconcentric reduction.
o Fracture of the acetabulum or femoral head requiring excision or open
reduction and internal fixation.
o Ipsilateral femoral neck fracture.
 A standard posterior approach (Kocher–Langenbeck) will allow
exploration of the sciatic nerve, removal of posteriorly incarcerated
fragments, treatment of major posterior labral disruptions or instability,
and repair of posterior acetabular fractures.
 An anterior (Smith-Peterson) approach is recommended for isolated
femoral head fractures. A concern when using an anterior approach for
a posterior dislocation is the possibility of complete vascular disruption.
By avoiding removal of the capsule from the femoral neck and
trochanters (i.e., taking down the capsule from the acetabular side), the
lateral circumflex artery be preserved.
 An anterolateral (Watson-Jones) approach is useful for most anterior
dislocations and combined fracture of both femoral head and neck.
 A direct lateral (Hardinge) approach will allow exposure anteriorly and
posteriorly through the same incision.
 In the case of an ipsilateral displaced or nondisplaced femoral neck
fracture, closed reduction of the hip should not be attempted. The hip
fracture should be provisionally stabilized through a lateral approach. A
gentle reduction is then performed, followed by definitive fixation of the
femoral neck.
 Management after closed or open reduction ranges from short periods
of bed rest to various durations of skeletal traction. No correlation exists
between early weight bearing and osteonecrosis. Therefore, partial
weight bearing is advised.
o If reduction is concentric and stable: A short period of bed
rest is followed by protected weight bearing for 4 to 6 weeks.
o If reduction is concentric but unstable: Skeletal traction for
4 to 6 weeks is followed by protective weight bearing.

Indikasi untuk reduksi terbuka dari dislokasi pinggul:

 Dislokasi yang tidak tereduksi dengan cara tertutup
 Pengurangan non-konsentrik
 Fraktur acetabulum atau kepala femoral membutuhkan eksisi
atau reduksi terbuka dan fiksasi internal
 Fraktur ipsilateral leher femoralis
 Pendekatan posterior standar (Kocher-Langenbeck) akan
memungkinkan eksplorasi dari saraf sciatic, penghilangan
fragmen posterior yang terkurung, pengobatan dari gangguan
mayor posterior labral atau ketidakstabilan, dan perbaikan patah
tulang acetabular posterior.
 Pendekatan anterior (Smith-Peterson) direkomendasikan untuk
patah tulang kepala femoral yang terisolasi. Perhatian saat
menggunakan pendekatan anterior untuk dislokasi posterior
adalah kemungkinan gangguan vaskular yang komplit, dengan
menghindari pemindahan kapsul dari leher femoralis dan
trochanter, arteri sirkumfleksa lateralis dipertahankan.
 Pendekatan anterolateral (Watson-Jones) ini berguna untuk
sebagian besar dislokasi anterior dan fraktur gabungan dari
kedua kepala femoral dan leher.
 Pendekatan lateral (Hardinge) langsung akan memungkinkan
paparan anterior dan posterior melalui sayatan yang sama.
  Dalam kasus ipsilateral displaced atau fraktur leher femoralis
non-displaced, reduksi tertutup pinggul tidak harus dicoba.
Fraktur pinggul harus sementara distabilkan melalui pendekatan
lateral. Reduksi yang lebut kemudian dilakukan, diikuti dengan
fiksasi yang definitif pada leher femoralis.
 Penatalaksanaan setelah reduksi tertutup atau terbuka berkisar
dari istirahat periode singkat sampai dengan berbagai jangka
waktu traksi skeletal. Tidak ada korelasi antara aktifitas
menopang berat awal dan osteonecrosis. Oleh karena itu,
aktifitas menopang berat partial disarankan.
 Jika reduksi konsentrik dan stabil: periode istirahat singkat
diikuti penopang berat dengan proteksi selama 4-6 minggu.
 Jika reduksi konsentrik terapi tidak stabil: traksi skeletal selama
4-6 minggu diikuti dengan penopangan berat dengan proteksi.

PROGNOSIS
 The outcome following hip dislocation ranges from an essentially
normal hip to a severely painful and degenerated joint.
 Most authors report a 70% to 80% good or excellent outcome in simple
posterior dislocations. When posterior dislocations are associated with a
femoral head or acetabular fracture, however, the associated fractures
generally dictate the outcome.
 Anterior dislocations of the hip are noted to have a higher incidence of
associated femoral head injuries (transchondral or indentation types).
The only patients with excellent results in most authors’ series are those
without an associated femoral head injury.

• Hasil berikut dislokasi pinggul berkisar dari pinggul dasarnya

normal bersama sangat menyakitkan dan merosot.
• Sebagian besar penulis melaporkan 70% sampai 80% baik
atau hasil yang sangat baik dalam dislokasi posterior
sederhana. Ketika dislokasi posterior berhubungan dengan
 kepala femoral atau fraktur acetabular, bagaimanapun, patah
tulang yang terkait umumnya mendikte hasilnya.
• dislokasi anterior pinggul tercatat memiliki insiden yang lebih
tinggi terkait cedera kepala femoral (transchondral atau
lekukan jenis). Satu-satunya pasien dengan hasil yang sangat
baik di seri yang paling penulis adalah mereka tanpa cedera
kepala femoral terkait.

COMPLICATIONS
 Osteonecrosis: This is observed in 5% to 40% of injuries, with
increased risk associated with increased time until reduction (>6 to 24
hours); however, some authors suggest that osteonecrosis may result
from the initial injury and not from prolonged dislocation.
Osteonecrosis may become clinically apparent several years after injury.
Repeated reduction attempts may also increase its incidence.
 Posttraumatic osteoarthritis: This is the most frequent long-
term complication of hip dislocations; the incidence is dramatically
higher when dislocations are associated with acetabular fractures or
transchondral fractures of the femoral head.
 Recurrent dislocation: This is rare (<2%), although patients with
decreased femoral anteversion may sustain a recurrent posterior
dislocation, whereas those with increased femoral anteversion may be
prone to recurrent anterior dislocations.
 Neurovascular injury: Sciatic nerve injury occurs in 10% to 20% of
hip dislocations. It is usually caused by a stretching of the nerve from a
posteriorly dislocated head or from a displaced fracture fragment.
Prognosis is unpredictable, but most authors report 40% to 50% full
recovery. Electromyographic studies are indicated at 3 to 4 weeks for
baseline information and prognostic guidance. If no clinical or electrical
improvement is seen by 1 year, surgical intervention may be considered.
If a sciatic nerve injury occurs after closed reduction is performed, then
entrapment of the nerve is likely and surgical exploration is indicated.
 Injury to the femoral nerve and femoral vascular structures has been
reported with anterior dislocations.
 Femoral head fractures: These occur in 10% of posterior
dislocations (shear fractures) and in 25% to 75% of anterior dislocations
(indentation fractures).
• Osteonekrosis: ini diamati pada 5% sampai 40% dari cedera, dengan peningkatan risiko yang terkait
dengan peningkatan waktu sampai reduksi (> 6 sampai 24 jam); Namun, beberapa penulis menyarankan
bahwa osteonekrosis mungkin timbul dari cedera awal, bukan dari dislokasi berkepanjangan.
Osteonekrosis dapat menjadi klinis jelas setelah beberapa tahun cedera. Upaya reduksi berulang juga
dapat meningkatkan insiden..

• Osteoarthritis Post-traumatik: ini adalah komplikasi jangka panjang yang paling sering pada dislokasi
pinggul; kejadian ini jauh lebih tinggi ketika dislokasi berhubungan dengan fraktur atau patah tulang
acetabular transchondral dari kepala femoral.

• Dislokasi rekuren: Ini jarang terjadi (<2%), meskipun pasien dengan reduksi anteversion femoralis
mungkin akan mengalami dislokasi posterior berulang, sedangkan mereka dengan peningkatan
anteversion femoralis mungkin rentan terhadap dislokasi anterior berulang.

• Cedera neurovaskular: cedera saraf siatik terjadi pada 10% sampai 20% dari dislokasi pinggul. Hal ini
biasanya disebabkan oleh peregangan saraf dari kepala dislokasi posterior atau dari fraktur fragmen
yang terpindah. Prognosis tidak dapat diprediksi, tetapi kebanyakan penulis melaporkan 40% sampai
50% pemulihan penuh. Studi elektromiografi ditunjukkan pada 3 sampai 4 minggu untuk informasi dasar
dan bimbingan prognostik. Jika tidak ada perbaikan klinis atau elektrik terlihat setelah 1 tahun,
intervensi bedah dapat dipertimbangkan. Jika cedera saraf siatik terjadi setelah reduksi tertutup
dilakukan, maka penjeratan saraf mungkin dan eksplorasi bedah diindikasikan. Cedera pada struktur
pembuluh darah dan saraf dan femoralis telah dilaporkan dengan dislokasi anterior.

• Patah tulang kepala femoralis: ini terjadi pada 10% dari dislokasi posterior (fraktur geser) dan di 25%
sampai 75% dari dislokasi anterior (lekukan patah tulang).

Classification Based on Fracture Classifications

The four common classifications of femoral neck fractures are those
based on (a) anatomic location of the fracture ( 66), (b) direction of the
fracture angle (67), and (c) displacement of the fracture fragments ( 68).

Anatomic Location
Some authors classify intracapsular fractures of the neck of the femur
anatomically into subcapital and transcervical types ( 66). The so-called
base of the neck fracture (basicervical) is extracapsular and, therefore,
not included in this discussion. The term subcapital is used to describe
fractures that occur immediately beneath the ar ticular surface of the
femoral head along the old epiphyseal plate ( 69). Transcervical fractures
pass across the femoral neck between the femoral head and the greater
trochanter (69). Klenerman and Marcuson ( 69) and Garden (68)
suggested that the exact location of the fracture in the femoral neck
cannot be determined precisely by radiography. Bayliss and Davidson
(70) reported that there was no functional difference between subcapital
and transcervical fractures. Askin and Bryan ( 67) agreed that subcapital
and transcervical fractures are essentially the same and that any
identified difference is artifactual secondary to x-ray parallax. In
addition, Klenerman and Marcuson ( 65) were unable to find a true
transverse cervical fe moral neck fracture in their series, the fractures all
being of the subcapital type. Banks ( 68,69), on the other hand, divided
his patients’ injuries anatomically into four types: classic subcapital
fracture, wedge subcapital fracture, inferior beak fracture, and midneck
fracture. In essence, his first three types were all of the subcapital
variety. He, too, found the transcervical type to be extremely rare.
Because of the relative infrequency of true transcervical fractures and
the difficulty of describing the fractures by radiograph y, as noted in the
preceding series, this classification has not been used extensively.

Fracture Angle (Pauwels Classification)

Pauwels (63) divided femoral neck fractures into three types based on
the direction of the fracture line across the femoral neck. Type I is a
fracture 30 degrees from the horizontal; type II, 50 degrees from the
horizontal; and type III, 70 degrees from the horizontal ( Fig. 44-4). Type
I fractures are much more horizontal than type III fractures, which are
almost vertical. Pauwels attributed nonunion in type III to the increased
shearing force of this vertical fracture. However, Boyd and Salvatore
(70) were unable to demonstrate a direct relationsh ip between the angle
of the fracture and the incidence of aseptic necrosis or nonunion. Type II
fractures had 12% nonunion and 33% aseptic necrosis rates compared
with type III fractures, which had only 8% nonunion 30% aseptic
necrosis rates. In addition, Cassebaum and Nugent (71) and Ohman et al
(72) could find no relation between end results and the Pauwels fracture
type.

The Pauwels classification is based on the x -ray shadow of the fracture

line. Garden (73) stated that because the femoral neck is spiral, it is the
x-ray projection of the fracture line and not the fracture line itself that
varies in obliquity with rotation of the distal fragment ( 73). Garden (73)
found the fracture line to be rema rkably constant at 50 degree from the
horizontal on the frontal x-ray.

Garden (73,74,75) believed that any change in obliquity was the result of
a misinterpretation of the x-ray examination. Therefore, he thought that
the Pauwels classification was a better measure of reduction than an
indication of the angle at which the femoral neck was broken. Linton ( 58)
stressed that the direction of the fracture line on the x -ray could be
altered by changing the direction of the beam or the position of the limb.
To be accurate, the x-ray must be made with the femoral neck parallel to
the film. This is rarely possible because of pain. Linton ( 58) also found
that the inclination of the fracture surface did not var y greatly, with
more than 85% being between 45 and 60 degrees. He proposed that
various types of femoral neck fractures represented different stages of
the same displacing movement. Because of the findings of Garden
(73,74,75) and Linton (58), and the fact that Boyd and Salvatore found
little difference between the nonunion and aseptic necrosis rates of type
II and III, the Pauwels classification system is used today to diagnose
and treat femoral neck delayed and nonunions.

Pearls and Pitfalls

The Pauwels classification should not be used to treat an acute femoral
neck fracture. However, a high -grade Pauwels,postreduction, may be
predictive of outcome. Some feel it may indicate the quality of the
reduction, but this has not been shown conclusively to date.

Fracture Displacement (Garden Classification)

Garden proposed a classification system based on the degree of
displacement of the fracture noted on prereduction anteroposterior (AP)
x-rays (Fig. 44-5) (73,74,75). This measurement is taken in the AP view
only, in the classic paper by Garden. Obviously the lateral can be used to
confirm the AP measurements regarding partial or complete displacement
versus angulation of the fragments. Garden agreed with Linton, who
suggested that the various types of subcapital fractures actually were
different degrees of displacement of a single fracture type ( 58).

The Garden I fracture is an incomplete or impacted fracture. In this

fracture, the trabeculae of the inferior neck are still intact. This group
includes the “abducted impaction fracture.” A Garden II fracture is a
complete fracture without displacement. The x -ray demonstrates that the
weight-bearing trabeculae are interrupted by a fracture line across the
entire neck of the femur. A Garden III fracture is a compl ete fracture
with partial displacement. In this fracture, there frequently is shortening
and external rotation of the distal fragment. The retinaculum of
Weitbrecht remains attached to, and maintains continuity between, the
proximal and distal fragments ( 20). In the Garden III fracture, the
trabecular pattern of the femoral head does not line up with that of the
acetabulum, demonstrating incomplete displacement between the femoral
fracture fragments. A Garden IV fracture is a complete fracture with total
displacement of the fracture fragments. In this fracture, all continuity
between the proximal and distal fragments is disrupted. The femoral
head assumes its normal relationship in the acetabulum. Therefore, the
trabecular pattern of the femoral head lines up with the trabecular
pattern of the acetabulum. Frandsen et al ( 76) evaluated the Garden
classification of femoral neck fractures. They report ed that only 22% of
100 femoral neck fractures were classified the same by eight trained
observers. In addition, in 33% of the fractures, the observers disagreed
as to whether the fractures were even displaced. The authors concluded
that their observers had a poor ability to delineate the varied stages of
the Garden classification.

Finally, Eliasson-Eiskjaer and Ostgard ( 77) and, recently, Kreder (78)

demonstrated that classification and neck displacement does not alter
treatment or outcome in Garden stage I compared with stage II fractures
nor in Garden stage III fractures as compared with stage IV fractures
(77,78). Because of these findings, they recommended simply
distinguishing between undisplaced (Garden I and II) and displaced
(Garden III and IV) femoral neck fractures.
The Garden classification of femoral neck fractures. Type I fractures can
be incomplete, but much more typically they are impacted into valgus,
and retroversion (A). Type II fractures are complete, but undisplaced.
These rare fractures have a break in the trabeculations, but no shift in
alignment (B). Type III fractures have marked angulation, but usually
minimal to no proximal translation of the shaft (C). In the Garden type
IV fracture, there is complete displacement between fragments and the
shaft translates proximally (D). The head is free to realign itself within
the acetabulum, and the primary compressive trabeculae of the head and
acetabulum realign (white lines).

Orthopaedic Trauma Association (OTA) Classification

In the Orthopaedic Trauma Association (OTA) alphanumeric fractu re
classification, femoral neck fractures are designated type 31B, in which
31 is the proximal femur group and B the femoral neck subgroup ( Fig 44-
6). B1 fractures are subcapital fractures with slight displacement, B2
fractures are transcervical fractures, and B3 fractures are displaced
subcapital fractures. Subcategorical codes further describe the fracture
pattern and amount of fracture displac ement. This schema is mainly used
for research purposes.

The OTA classification of femoral neck fractures. The B1 group fracture is

nondisplaced to minimally displaced subcapital fracture. The B2 group
includes transcervical fractures through the middle or base of the neck,
and the B3 group includes all displaced nonimpacted subcapital fractures.
Subgroups further specify fracture geometry. The diagrams represent
common examples of the defined fracture pattern.
Dislocation of hip –Traumatic

Characteristics

-Mechanism of injury usually involves massive force transmitted along the femoral shaft, e.g. a
dashboard injury in a road traffic accidents or a back injury in someone kneeling.

-Posterior dislocation (commonest by far) tends to occur with the hip flexed and adducted at time of
impact. With abduction, anterior dislocation can occur. Central dislocation occurs with medial
displacement of the femoral head through or partially through a fragmented acetabulum.

-Often associated with other injuries, such as a patellar fracture or posterior acetabular hip fracture.

Clinical features

-classically with a posterior dislocation the hip is flexed, shortened, adducted and internally rotated
(compare to a femoral neck fracture).

-pain tends to be excruciating. May spontaneously reduce if associated with an acetabular fracture.

- an associated femoral shaft fracture may mask the classical deformity.

-sciatic nerve injuries are common (traction and compression)

Radiological features

-Abnormality usually obvious on the AP view. Lateral view recommended in all cases to aid in
determining posterior or anterior dislocation and to visualize difficult dislocations.

-with posterior dislocations the femoral head appears smaller than the unaffected side on the AP view
and conversely with anterior it appears larger (related to magnification in the same way the heart
appears larger on an AP film).

-Look for the lesser trochanter – overlies the femoral shaft in posterior dislocations whereas seen in
profile with anterior (relates to internal/external rotation).

-Look for acetabular involvement as this affects likelihood of sciatic nerve damage, stability and long-
term functional outcome.

-Always assess the pelvic ring fully as associated fractures/disruption are common.
Femoral neck fracture

Characteristics

-Increasing incidence with age is thought to be secondary to bone density loss.

-Commoner in elderly females; below the age of 60, men are affected more frequently (usually
extracapsular fractures).

-Seen more commonly in patient taking a variety of medications, such as corticosteroids, thyroxine,
phenytoin and furosemide.

-Most related to only minor trauma.

-Divide neck of femur (NOF) fracture into intra-(blood supply to femoral head damaged) and extra-
capsular (blood supply intact). They are further classified by anatomical level. Intracapsular
subdivided into subcapital, transcervical and basicervical. Extracapsular relates to pertrochanteric (or
intertrochanteric) fractures.

-Intracapsular fractures are classified according to Garden- Grades 1-4:

1. Incomplete: Inferior cortex is not completely broken

2. Complete: Inferior cortex also clearly broken. Trabecula pattern interrupted but not angulated.

3. Slightly displaced: Angulated trabecular pattern

4. Fully displaced: Severest grade. Often no bony continuity.

Clinical features

-Inability to weight-bear. Beware as occasionally the patient can mobilise.

-Clasically the leg is shortened and externally rotated.

-Pain on rotation and tenderness over the femoral neck.

Radiological features

-AP and lateral radiographs will usually visualize the fracture line.

-Look for asymmetry. Compare Shenton’s lines on the AP view. On the lateral view check for
angulation of the head in respect to the neck.

-Subtle fractures may only be recognized by trabecular pattern disruption.

-If suspicious, but no fracture is seen, a bone scan at 48 hours or delayed repeat film can be of benefit.
Dislokasi pinggul –traumatik

Karakteristik

Mekanisme cedera biasanya melibatkan kekuatan besar yang ditransmisikan sepanjang poros femoralis,
misalnya cedera dashboard dalam kecelakaan lalu lintas jalan atau cedera punggung pada seseorang
yang sedang berlutut.

Dislokasi -Posterior (paling umum) cenderung terjadi dengan pinggul tertekuk dan adduksi pada waktu
cedera. Dengan abduksi, dislokasi anterior dapat terjadi. Dislokasi sentral terjadi dengan perpindahan
medial caput femoral melalui atau sebagian melalui asetabulum yang terfragmentasi.

-Sering berhubungan dengan luka lain, seperti fraktur patella atau patah tulang pinggul asetabulum
posterior.

Gambaran klinis

 Secara klasik dislokasi pinggul posterior dalam posisi fleksi, memendek, adduksi dan rotasi
internal (dibandingkan dengan patah tulang leher femur).
 Nyeri cenderung menyiksa. Mungkin secara spontan berkurang jika dihubungkan dengan fraktur
acetabulum.
 Jika ada asosiasi fraktur pada batang femur maka dapat menutupi deformitas klasik.
 Cedera saraf umunya saraf siatik (traksi dan kompresi)
Fitur Radiologi

 Abnormalitas biasanya jelas pada tampilan AP. Tampilan lateral direkomendasikan dalam semua
kasus untuk membantu dalam menentukan dislokasi posterior atau anterior dan untuk
mengvisualisasikan dislokasi yang sulit.
 Pada dislokasi posterior, caput femoral muncul lebih kecil dari sisi yang terpengaruh pada
tampilan AP dan sebaliknya dengan anterior tampak lebih besar (yang berhubungan dengan
pembesaran dengan cara yang sama jantung tampak lebih besar pada film AP).
 Lihat trochanter minor – terletak di atas batang femur di dislokasi posterior sedangkan terlihat
sesuai pada dislokasi anterior (berkaitan dengan rotasi internal / eksternal).
 Lihat keterlibatan asetabulum karena ini akan mempengaruhi kemungkinan kerusakan saraf
siatik, stabilitas dan hasil fungsional jangka panjang.
 Selalu nilai cincin panggul sepenuhnya sebagai patah tulang yang terkait / gangguan yang
umum.