Unusual Combination of Posterior Femoral Head Dislocation and Ipsilateral Intertrochanteric Open Fracture : Case Report

1 Department of Orthopedics, Clinical Emergency Hospital of Bucharest, Romania 2 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3 Department of Plastic Surgery and Reconstructive Microsurgery, Clinical Emergency Hospital of Bucharest, Romania 4 „C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania 5 Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, Romania 6 Department of Urology, „Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania 7 Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital of Bucharest, Romania Corresponding author: Tiberiu Paul Neagu, Department of Plastic Surgery and Reconstruction Microsurgery, Emergency Clinical Hospital, 8th Floreasca Avenue, 1st District, Bucharest, Romania. E-mail: dr.neagupaul@gmail.com Abstract


INTRODUCTION
Th e combination of posterior femoral head dislocation with ipsilateral intertrochanteric fracture is an extremely rare occurrence, therefore, few reports exist.Th e posterior femoral head dislocation is an injury most common encountered in road traffi c accident (dashboard) and may associate various types of acetabular, femoral head or femoral neck fractures 1-3 but almost never an intertrochanteric fracture.Th e intertrochanteric fracture in young people is also the result of a high energy trauma unlike in elderly patients, for whom this type of fracture occurs in ninety percent from a simple fall 2 .Operative management, which allows early rehabilitation and off ers the patient the best chance for functional recovery, is the treatment of choice for the vast majority of intertrochanteric fractures 4,5 .Th e implant choice may vary depending on the fracture severity (stable or unstable according to Evans classifi cation), the implant availability and the surgeons prefered technique 2,4,6,7 .We chose a DHS-plate fi xation of the fracture.Th e main goal was to obtain a stable limb in order to allow early mobilization and to reduce blood loss in a polytraumatized patient.

CASE REPORT
A 49-year-old patient presented at our emergency department after he was hit by tram.Th e patient was rushed to the hospital and upon presentation the state of consciousness was unaltered.He stated that he cannot feel his left leg and further examination revealed a pathological position of the inferior limb, a small puncture wound on the posteroinferior aspect of the buttock, respiratory diffi culty and pain in the left hand.Th e patient underwent plain X-rays and a full body computed tomography scan (CT-scan) that revealed posterior femoral head dislocation (Figure 1-3) with ipsilateral intertrochanteric open fracture, fl ail chest, fracture of the fourth and fi fth left metacarpals.We admitted him for surgery and we proceeded to reduce the dislocated femoral head on a traction table and afterwards reduce fracture and fi x it with a DHS-plate type implant.Post-op X-rays were showing good reduction and stable fi xation.Due to the fl ail chest and subsequent lung concussion the patient was transferred to the Intensive Care Unit (ICU).During his stay in the ICU, he developed an infection with Accinetobacter spp.Th is resulted in a diffi cult mobilization which led to an abnormal position of the lower limb.During his stay in our hospital the nervous status of the lower   check-up no progress on the mobilization of the hip was shown -at this time it was fi xed in external rotation with limited fl exion and some degrees of extension.Th e check-up X-rays were inconclusive and it has been stated that this appearance may be the result of implant failure (Figure 4).We decided to admit the patient and to proceed with surgery in order to obtain better reduction and better internal fi xation.Upon positioning on the traction table we observed that the previous X-rays were faulty so after the anesthesia we switched our plan to mobilization.We obtained and excellent result (Figure 5-6) only with the plain mobilization of the limb, the patient being later discharged with fully rotational movement at the hip level.Th e three months follow-up was good, the patient maintained the range of motion previously gained, but still with a small degree defi cit on sensory and motor function of the left foot.

DISCUSSION
Due to the fact that the combination of posterior femoral head dislocation with ipsilateral intertrochanteric fracture is an extremely rare occurrence and few reports exist, the right approach for this lesion is debatable.We opted for reduction on a traction table, lateral approach and a DHS-plate fi xation.In the process of pre-ope-ratory planning we also considered prone position and posterior Kocher-Langenbeck aproach that in our case would have presented some advantages such as a better visualisation of the displaced femoral head and direct visualization of the sciathic nerve 8,9 .Th e down-fall of this aproach would be that the fi xation would have been troublesome; furthermore, the fl ail chest prevented the prone position.For fi xation of the fracture we could have gone for the centromedulary implant.In this way, the periosteum would have been preserved [10][11][12][13] .Apart from this two methods, there are cases where a good fi xation of the fracture site is diffi cult to achieve [10][11][12][13] , so the best option for the patient is a prosthetic replacement, aspect that should be considered with the patient   zation time, have a better functional and vital outcome and for the socio-economical reinsertion of the patient is to perform emergency surgery on the traction table and fi xation with DHS-plate or centromedulary implant.

Compliance with ethics requirements:
Th e authors declare no confl ict of interest regarding this article.
Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008( 5), as well as the national law.Informed consent was obtained from all the patients included in the study.
1. Raja JA, Valsalan BP.A Case of Anterior Dislocation of Hip before entering surgery 4 .Th e mobilization during the pacient's stay could have improved the short term outcome and it might have spared him from the second anesthesia, but the associated injuries prevented the reabilitation program.Th e patient should be followed up at least two years.

CONCLUSION
Due to high energy trauma in which this type of lession may occur, the surgical management is complex and it must be individualized to every patient acording to the associated lessions to ensure the lowering of the specifi c mortality and morbidity.We apreciate that the right aproach for this case in order to reduce hospitali-