Category Archive Fracture of Bone A-Z

Phalangeal fractures of the hand are a common injury that presents to the emergency department and clinic. Injuries can occur at the proximal, middle, or distal phalanx. For the vast majority of phalanx fractures, an acceptable reduction is manageable with non-operative treatment. Early intervention is vital to allow healing and return of function.

The phalanges are the bones that make up the fingers of the hand and the toes of the foot. There are 56 phalanges in the human body, with fourteen on each hand and foot. Three phalanges are present on each finger and toe, with the exception of the thumb and large toe, which possess only two. The middle and far phalanges of the fourth and fifth toes are often fused together (symphalangism).^[rx] The phalanges of the hand are commonly known as the finger bones. The phalanges of the foot differ from the hand in that they are often shorter and more compressed, especially in the proximal phalanges, those closest to the torso.

Anatomy

The proximal and middle phalanges of the hand all possess a head, neck, shaft, and base. The distal phalanx divides into the tuft, shaft, and base. The proximal phalanx receives stabilization from the surrounding anatomy, including proper and accessory collateral ligaments, volar plate, and extensor/flexor tendons. The middle phalanx has two main insertions: the central slip (extensor mechanism) and the flexor digitorum superficialis (FDS). The distal phalanx anatomy includes distal interphalangeal joint (DIPJ), which is enveloped by the extensor and flexor tendons along with the volar plate and collateral ligaments. The flexor digitorum profundus (FDP) inserts at the volar metaphysis of the distal phalanx. At proximal interphalangeal joint (PIPJ), the flexor digitorum profundus and the flexor digitorum superficialis are within one sheath. The flexor digitorum superficialis is volar, and the flexor digitorum profundus is dorsal. As the tendons transverse the PIPJ the flexor digitorum superficialis bifurcates into two slips that form the Camper’s chiasm which inserts on the volar aspect of the middle phalanx. This important anatomic relationship that can lead to a swan neck deformity (a hyperextended PIPJ and flexed DIPJ).[rx]

Pathophysiology

Phalanx fractures displace according to the level at which the fracture occurs due to the eloquent soft tissue and tendon involvement of the phalanx.

Distal Phalanx

Distal phalanx fractures are usually nondisplaced or comminuted fractures. They classify into tuft (tip), shaft, or articular injuries.

• Tuft fractures usually result from a crushing mechanism such as hitting the tip of a finger with a hammer. A tuft fracture is frequently an open fracture due to its common association with injury to the surrounding soft tissues or nail bed. Even without surrounding soft tissue injury, the fracture is considered open in the presence of a nail bed injury.
• Shaft fractures
• Intra-articular fractures are associated with extensor tendon avulsion (Mallet’s finger) or flexor digitorum profundus tendon avulsion (Jersey’s finger).[rx]

  • Mallet finger

    • The traumatic loss of the terminal extension at the level of the DIPJ
  • Jersey Finger

    • Hyperextension injury with avulsion of flexor digitorum profundus[rx]

Middle Phalanx

Middle phalanx fractures occur in an apex dorsal or volar angulation depending on location. Apex dorsal angulation results from the fracture occurring proximal to the flexor digitorum superficialis (FDS) insertion so that the fragment becomes displaced by the pull of the central slip. Apex volar angulation occurs if the fracture is distal to the flexor digitorum superficialis insertion. A fracture through the middle third may angulate in either direction or not at all as a result of the inherent stability provided by an intact and prolonged flexor digitorum superficialis insertion. 

Proximal Phalanx

Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip.

Causes Of Phalangeal Fractures

• Injury to the phalanges – occurs with direct, blunt trauma, penetrating trauma, and crush injuries.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of broken and fractures.
• Sports injuries – Many fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Phalangeal Fractures

Common symptoms of radial and phalangeal fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent  wrist
• Pain
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.
• Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness and tingling in the arm/hand.

Diagnosis of Phalangeal Fractures

History and Physical

The main component to focus on assessment are:

• History – handedness, occupation, time of injury, place of injury (work-related)
• Mechanism of injury – magnitude, direction, point of contact, and type of force that caused the trauma
• Soft tissue damage
• Finger alignment – cascade, digit scissoring, rotational defect
• Open vs. Closed
• Tendon/nerve/vessel damage – tendon ruptures may accompany dislocations such as the terminal extensor tendon rupture in the distal interphalangeal joint dislocation or a central slip rupture in a proximal interphalangeal joint dislocation. Tendon damage otherwise only usually occurs with associated lacerations or open combined injuries. Nerves and vessels are rarely injured as part of a simple fracture or dislocation but often suffer injury in major open hand trauma.

Radiographs

Diagnostic tests to consider include:

• Radiographs – PA and lateral and oblique
• CT – rarely needed. May occasionally be helpful in operative planning with complex peri-articular fractures such as pilon fractures at the base of middle phalanx fractures. It can be used to detect foreign bodies like plastic, glass, and wood.
• Ultrasound – detect objects that lack radiopacity
• MRI – unclear diagnosis, foreign material, or tumor

Mostly phalangeal fractures are described by location (head, neck, shaft, base) and pattern (transverse, spiral, oblique, comminuted).[rx]

Treatment of Phalangeal Fractures

Non-Surgical

Treatment available can be broadly

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health.

Proximal Phalanx Fractures

• Extraarticular with less than 10 degrees angulation or under 2 mm shortening and no rotational deformity Stable, transverse fracture
  • Dorsal splinting in intrinsic plus position for 3 weeks
  • Buddy taping

Operative

• Reducible but unstable isolated fractures
  • Closed reduction internal fixation (CRIF)
• Intra-articular fractures with displacement
  • Open reduction internal fixation (ORIF)

Closed reduction and internal fixation of proximal phalanx shaft fractures can be accomplished longitudinally through the metacarpal phalangeal joint but not the metacarpal head, or just through the metacarpal head. The wires for either of these options are run in a parallel fashion, cross, or run transversely into the phalanx.

Middle Phalanx Fractures

Proximal intra-articular fractures may be comminuted with axial load and considered “pilon” fractures. If the volar portion of the proximal base fracture constitutes approximately 40% of the articular surface, then it carries the majority of the proper collateral ligament insertion. Also, the accessory ligament and volar plate insertions, which make the fracture unstable. Dorsal proximal base fractures may be considered central slip avulsions.

Non-operative

• Non-displaced
  • Dynamic splinting for 2to 3 weeks

Operative

• Transverse fractures with greater than 10 degrees angulation or 2 mm shortening or rotationally deformed
  • Closed reduction percutaneous pinning (CRPP) vs. ORIF
• Irreducible and unstable fractures
  • CRPP vs. ORIF

Distal Phalanx Fractures

• Open fractures – Tuft fracture is considered open in the presence of a nail bed injury. When the seal of the nail plate with the hyponychium has been broken, and the tuft fracture is displaced. This injury represents an open fracture that should receive treatment on the day of injury with debridement, followed by direct nail matrix repair. Stenting of the nail fold may be required to allow for the nail to grow [rx]
• Volar subluxed mallet finger fractures involving 30% of the articular surface
• Jersey finger injuries

References

Nasotracheal intubation (NTI) involves passing an endotracheal tube through the naris into the nasopharynx and the trachea; most commonly after induction of general anesthesia in the operating room. The use of NTI permits the administration of anesthetic gases without obfuscation of intraoral anatomy and is commonly used for procedures including dental, oropharyngeal, and maxillofacial operations. [rx][rx][rx]NTI am an essential skill for anesthesia providers.  Due to the potential complications in performing NTI, it is recommended that NTI not be attempted by anyone who is not skilled at orotracheal intubation as well.[rx][rx]

Anatomy and Physiology

Being able to perform NTI properly requires knowledge of the anatomy of the nasal vestibule, nasopharynx, oropharynx, and hypopharynx.

The nasal cavity begins at the anterior nares and ends at the posterior end of the nasal septum where it channels into the nasopharynx via the posterior nasal apertures (choanae). The nasal cavity sits above the oral cavity and hard palate and rests below the skull base.

The hard palate provides the base of the cavity that runs horizontally and directly behind the anterior nares. The ceiling of the nasal cavity is formed from the narrow cribriform plate of the ethmoid bone. Lastly, both left and right lateral walls are established by the medial wall of the respected orbit superiorly and the maxillary sinus inferiorly.

The lateral nasal walls incorporate three structures, the turbinates, which project into the nasal passages as ridges of tissue and are responsible for maintaining moisture and warmth in the nasal cavity as air flows through.

The inferior turbinate is the largest of the 3 and projects along the complete lateral nasal wall. The inferior turbinates are often responsible for blocking nasal airflow when they are enlarged or inflamed. The middle turbinate projects into the central nasal cavity adjacent to the nasal septum. Finally, the superior turbinate, the smallest of the three, attaches to the skull base superiorly and the nasal wall laterally.

The nasal cavity is separated by a nasal septum consisting of both a cartilaginous part that sits anteriorly and a bony portion that rests more posteriorly. This septum separates the anterior nasal pathway into a left and a right side, where these 2 cavities eventually coalesce to form a single continuous cavity in the back of the nose (the nasopharynx).

The nasal cavity is lined by respiratory mucosa (histologically described as ciliated pseudostratified columnar epithelium) lying on an extremely vascular stroma. These cells produce serous secretions that aid in humidification of inspired air. The cilia help to trap unwanted debris from entering the lungs.

Due to the high vascularity of the nasal cavity, minor trauma to any part of the tissue can cause bleeding to occur (epistaxis). The anterior nasal septum is particularly susceptible to developing epistaxis owing to the superficial location of the arterial plexus. This plexus is known as Kiesselbach’s area and is supplied by branches of the anterior and posterior ethmoid, superior labial, sphenopalatine and greater palatine arteries.

While considering normal nasal cavity anatomy, it is also important to understand that anomalies do often exist. Septal deviation is perhaps the most common anomaly which usually involves the cartilaginous aspect of the nasal septum. The deviation is most often due to trauma but can also be caused by continuous nasal congestion from recurrent sinus infections. Other variations to normal anatomy include conditions that result in unilateral obstruction such as nasal polyps, concha bullosa, and spurs. It is important to consider these anomalies during pre-anesthetic evaluation to minimize any complications as most of these variations will result in changes to airflow dynamics inside the nasal cavity. Nasal polyps or spurs may be unilateral which may dictate which side of the nose is more amenable to NTI.[rx][rx][rx]

Indications of Nasotracheal Intubation

Indications for NTI include, but are not limited to the following:

• Intraoral and oropharyngeal surgery
• Complex intra-oral procedures involving mandibular reconstructive procedures
• Rigid laryngoscopy
• Dental surgery
• Maxillofacial or orthognathic surgery
• Intraoral and oropharyngeal surgery.
• Oral route of intubation not possible due to trismus
• In ICU as an alternative to tracheostomy for longer ventilation periods
• Surgery of maxillofacial cases needing better surgical access
• Tonsillectomies
• Rigid laryngoscopy and microlaryngeal surgery

Contraindications of Nasotracheal Intubation

Absolute contraindications include:

• Suspected epiglottis
• Midface instability
• Previous history of old or recent skull base fractures
• Any known bleeding disorder that could predispose the patient to severe epistaxis
• Choanal atresia
• Patients that have experienced high-speed trauma or isolated facial trauma may have undiagnosed skull fractures that may result in nasotracheal tube placement into the brain.  It is best to avoid NTI in these patients.

Relative contraindications include:

• Anything that could compromise the nasal air passage (large nasal polyps, foreign bodies)
• Recent nasal surgery
• History of frequent episodes of epistaxis

METHOD

Blind nasal intubation as described by Rich Levitan: ‘Spray-Trumpet-Spray-Tube-Spray’

• Anaesthetic spray into naris (5-10cc of 4% topical lidocaine with oxymetazoline, either via disposable single patient bottle or via disposable spray pump atomizer or syringe)
• Insert nasal trumpet lubricated with 2% lidocaine jelly (leave in place for 1 min)
• Spray anesthetic spray through trumpet and remove trumpet
• Insert “trigger” tracheal tube (as large as will be tolerated, at least 7.0) to approximately 14–16 cm, keeping the proximal end of the tube directed toward the patient’s contralateral nipple (this helps to direct the tip of the tube toward the midline). There should be loud breath sounds audible through the tube. This verifies location above the laryngeal inlet.
• Spray anesthetic once through tube again. The patient will cough and buck
• Pass tracheal tube through cords during inhalation
• Confirm placement, sedate, and administer muscle relaxants as needed

OTHER INFORMATION

• deliver oxygen using a nasal cannula through the contralateral naris or through the mouth
• In the patient who is too agitated to permit the procedure consider using small aliquots of ketamine (10 mg IV, repeated up to 40-50 mg total, although more can be given if needed)
• when passing a nasal trumpet or ETT ensure the bevel faces the turbinates (laterally) and that the tube is advanced along the septum (medially) and the floor of the nasal cavity (which is perpendicular to the plane of the face)
• adjustment of head positioning, tube twisting, or laryngeal manipulation may assist in directing the tube forward into the trachea
• patient may need restraint once he ETT passes the cords
• typically 26cm at the nose for women and 28cm at the nose for men

Equipment of Nasotracheal Intubation

Some of the necessary equipment needed to perform a nasotracheal intubation includes the following:

• Endotracheal tube (Nasal RAE or standard endotracheal tube)
• Lidocaine jelly or a water-soluble lubricant
• Magill forceps
• Laryngoscope
• Vasoconstricting nasal spray (oxymetazoline 0.05% or phenylephrine nose drops 0.25% to 1%)
• Syringe to inflate cuff

Preparation of Nasotracheal Intubation

A pre-anesthetic evaluation must be performed for each patient undergoing a procedure requiring anesthesia with a particular focus on identifying any potential risks or complications related to the upcoming procedure and composing an individualized plan for patient care. Often, the patient can relay important information regarding unilateral restriction or congestion and give some direction as to which side should be used for the NTI. If the patient interview does not yield information related to relative patency of one side versus the other, then either side of the nose may be used.

An anterior rhinoscopy may be performed (this is not a common practice) which gives the provider the ability to visualize the anterior portion of each nasal cavity. The main limitation of anterior rhinoscopy is the inability to provide any information regarding the posterior nasal cavity. To fully assess the pathway, a flexible fiber-optic bronchoscope may be passed into the nasopharynx.[rx][rx]

Preparation for insertion of an NPA involves 2 steps. First, the healthcare provider gets the correct size NPA, and second, the provider coats the NPA with lubricant, anesthetic jelly, or any water-soluble lubricant.

In the ideal setting preparation for NT intubation can include all of the below-mentioned steps, but if the procedure if needed to be done immediately, the healthcare provider may be unable to prepare anything and may have to blindly place the NT tube when that is the indicated route of securing the airway.

Preparatory steps, not necessarily in the below order, include:

• Positioning the patient in the sniffing position, attaching the patient to the monitor, pulse oximetry, blood pressure monitor and cardiac monitor. If available, set up end-tidal carbon dioxide monitor (capnography)
• Placing 2 peripheral intravenous (IV) accesses and starting 1 liter of crystalloid fluid (if the patient is not fluid overloaded or at risk of overload)
• Preoxygenation via nasal cannula, non-rebreather, BVM, BIPAP increases the oxygen reserve and the time to desaturation after a sedative and/or paralytic medications have been given.
• Having a BVM ready bedside
• Turning on wall suction, setting up the suction tubing and a yanker
• Having a respiratory therapist or other personnel prepared with a ventilator
• Preparing sedative and paralytic medications if plan on sedating and/or paralyzing
• Having a CO2 detector, EtCO2
• Setting up the backup airway
• Setting aside 6 to 7.5 cm NT tubes and checking the cuff of the tubes for an air leak
• If using flexible bronchoscopy, having the bronchoscope turned on and placed bedside
• Placing the NT tube in warm sterile saline to allow the tube to soften and allow for a smoother insertion; this can decrease the risk for trauma to the nasal passageways.
• Assessing for the more patent nostril, which can be done by asking the patient to hold one nostril and take in a deep breath, identifying which naris allows for more air movement. It can also be assessed by placing an NPA and judging which naris allows for easier insertion. If the provider will be utilizing a flexible bronchoscopy, then the scope can be used to visualize which nostril is more patent.
• Lubricating the tube and bronchoscope with lubricant or lidocaine jelly/ointment. Care should be used to avoid smudging the camera of the bronchoscope.
• Spraying a topical vasoconstrictor in bilateral nares to reduce bleeding risk
• Placing an NPA coated with lidocaine jelly/ointment to provide anesthesia and lubrication
•  Spraying aerosolized lidocaine in the oropharynx
• Performing serial dilations of the bilateral nares or more patent nares with increasing larger diameter NPAs coated with lidocaine or lubricant

Nasal Intubation Techniques

Once beyond the nasal cavity, there are various techniques available to advance the ETT into the trachea.

• The method of picking up ETT and catheters in the oropharynx with the help of a forceps and guiding them into the trachea under direct vision by laryngoscopy was first described by Magill in 1920[rx]
• Various aids to blind nasal intubation have been employed including:

  1. Listening to breath sounds directly through the ETT or using an extension tube and earpiece[rx]

  2. Inflating the tracheal cuff (the cuff of the ETT is inflated in the oropharynx to help guide the tip of the tube into the trachea)[rx,rx]

  3. Monitoring the end-tidal carbon dioxide levels[rx]

  4. The technique of gently identifying the right pyriform fossa. With the tip of the ETT, the right pyriform fossa is identified as a bulge in the skin. Pulling the ETT back slightly and rotating it counterclockwise through 90° and then advancing toward the midline give access to the trachea. Depending on the curvature of the ETT, a minor adjustment in the degree of the atlantooccipital joint extension has to be made. Sometimes, the tube is abutting the anterior commissure, in such conditions flexion of the head helps. If the tube enters the esophagus, withdrawing the tube and reinserting it with head in hyperextended state achieves intubation

• Stylet-facilitated nasotracheal intubation. In this technique, the curved stylet is used to flex the tip of the ETT anteriorly and is removed immediately once the tube is in the nasal cavity. This helps in the smoother insertion of the tube through the nasal cavity, and the chances of bleeding are minimal
• With the use of a light wand The more commonly used technique describes the use of a light wand alone. After adequately preparing the patient with topical anesthesia, the patient is counseled and prepared psychologically. An appropriate-sized ETT is inserted till it is in the oral cavity (appreciated by a loss of resistance). The theater lighting is dimmed, and the light wand is inserted in the ETT till the fixer touches the top of the ETT
• Technique of using the Endotrol ETT and a light wand – This is a different method that uses the Trachlight and Endotrol tube (Mallinckrodt, Athlone, Ireland). The inner metal stylet is removed from the Trachlight, and the light wand is placed in the Endotrol tube till the tip of the light wand and the tip of the ETT are aligned. The Endotrol tube has a wire hook with which the curve of the tube can be controlled
• A modified nasal trumpet (MNT) to facilitate fiber-optic intubation – The MNT is a functionally similar device to both the laryngeal mask airway (LMA)[rx] and the cuffed oropharyngeal airway (COPA).[rx] The MNT establishes a patent airway and may substitute for mask ventilation in the unintubated patient. It permits positive pressure ventilation. It is placed blindly. Evidence suggests that when used as a tool for facilitating intubation, MNT is most likely more efficient and safer as compared to both the LMA and the COPA. The MNT may be inserted in a spontaneously breathing patient, who can either be awake or anesthetized. The MNT permits fiber-optic intubation, both oral and nasal, while it is in place
• Nasotracheal intubation with the Bonfils retromolar fiberscope. The Bonfils retromolar fiberscope usually referred to as the “Bonfils,” is one of the devices developed for managing the difficult airway.[rx] It was initially used for the management of patients with an anticipated difficult airway around the 1990s and as of today, it continues to be a very useful device for the management of the unexpected difficult airway[rx,rx,rx]
• With the patient under general anesthesia and under the appropriate level of anesthesia, relaxed as for any intubation procedure, the tube is introduced into the selected and prepared nasal cavity; the ETT is advanced till it reaches the oropharynx. Then, an assistant is required to perform upward mandibular traction, and the Bonfils retromolar fiberscope is inserted from the right lip commissure and a “retromolar gonioscopy” is performed. The Bonfils is advanced until the epiglottis and the vocal cords are identified. Then, the Bonfils is slightly withdrawn, and a panoramic view of the oropharynx is sought and the tracheal tube is identified. The person doing the intubation maneuvers the Bonfils and the ETT, and a skilled and trained person maintains the upward mandibular traction, which helps improve the visibility of the vocal cords. The tube is advanced up to the field of observation of the Bonfils and immediately the tube is guided up to the trachea under direct vision with the Bonfils
• Fiber-optic nasal intubation – The frequency of difficult intubation due to the inability of passing an ETT over an orally inserted fiberscope varies between studies, ranging from 0% to 90%.[rx] Fiber-optic intubation when performed nasally can be as difficult as oral fiber-optic intubation. The primary cause of the difficulty, while the ETT is being advanced over the fiber-optic bronchoscope, is considered to be due to the deviation in the course of the ETT from that of the fiberscope. This is because of a gap present between the two. The ETT usually deviates toward the epiglottis, arytenoids cartilage, pyriform fossa, or esophagus.[rx,rx] Showed that the sites of impingement of the ETT during fiber-optic nasal intubation are usually the posterior structures of the laryngeal inlet and suggested rotating the tube counterclockwise as a solution[rx]
• Single-hand maneuver for flexible fiber-optic bronchoscope-guided nasotracheal intubation (FNI)[rx] The single-hand maneuver is applied to maintain airway patency during the process of performing FNI in anesthetized patients. The little finger is placed below the angle of the mandible; the ring finger is placed below the body of the mandible, and the middle finger under the mentum. With the fingers in this position, manipulation of the degree of chin lift can be adjusted according to the quality of the bronchoscopic view. The bronchoscope is held by the thumb and index finger of the same hand
• Nasal intubation in the sitting position sitting endotracheal intubation has been proven to be more successful when compared to conventional intubation[rx]
• Using a dual bougie for nasotracheal intubation[rx] When it is anticipated that the nasotracheal intubation would be difficult, but at the same time conventional orotracheal intubation could be done through conventional laryngoscopy, this technique is used. A cuffed tracheal tube is placed into the trachea. The position of the tube is confirmed as usual through auscultation and capnography. This is followed by inserting an appropriate size cuffed tracheal tube nasally which is then guided into the oropharynx. An Eschmann bougie is passed through this nasal tube to the glottic aperture guided with the aid of a Magill forceps by direct laryngoscopy

Complications

The most common complication of nasotracheal intubation is epistaxis, which occurs with nearly every NTI. Other complications include bacteremia (by introducing bacteria from the nasal cavity into the body due to trauma from the tube) and risk of perforation (retropharyngeal perforation or perforation of a piriform fossa). As mentioned previously, it is best to avoid NTI in patients who have sustained high-speed trauma or isolated facial trauma due to the risk of inadvertent placement of the ETT into the brain.

• Septal hematoma
• Septal abscess
• Avascular necrosis of nasal septal cartilage leading to saddle deformity
• Nasal obstruction
• Blowout fractures: Extraocular muscle entrapment and diplopia
• Nasolacrimal duct injury: Due to the close relationship of the duct to the nasal bones
• Fracture of cribriform plate and cerebrospinal fluid (CSF) rhinorrhoea
• Inability to reduce: Fractures that cannot be reduced by closed techniques are candidates for open reduction.[rx]
• Airway compromise and hemorrhage.[rx]
• Nasofrontal duct and or lacrimal duct disruption as a result of direct damage or due to displaced fracture segments.[rx]
• Facial deformity, as full correction of telecanthus or nasal depression can be difficult to achieve, and some patients will retain a degree of asymmetry. Depending on the surgical approach, patients may experience temporary or permanent paralysis and or anesthesia of the forehead. Scars that cannot be hidden in the hairy scalp or skin folds may be prominent.[rx]
• Infection of the incision site, soft tissues, and meninges are recognized complications from these injuries.[rx]
• Mucocele formation is a complication of sinus or lacrimal drainage disruption and can become infected.[rx]
• Mental health, as patients with facial injuries are at greater risk of developing post-traumatic stress disorder or anxiety-related disorders. Particularly those who were victims of assault.[rx]

References

Fractures of the naso-orbital-ethmoid (NOE) complex involve the bones that form the NOE confluence, which includes the anterior cranial fossa, frontal bone, bones of the ethmoid and frontal sinuses, nasal bones, and orbits.[rx] They often occur alongside injuries to other parts of the face and body but can occur in isolation. Road traffic accidents and physical violence are the leading causes of these injuries, but this picture is changing with improved vehicle and road safety.[rx]

Knowledge of regional anatomy is fundamental in understanding assessment and management. The approach to these injuries starts with the advanced trauma life support approach, as these patients can have injuries to critical structures such as the airway. Further assessment relies on thorough clinical assessment aided by radiological imaging. The operative intervention depends on the classification of the NOE complex fracture, which is based on the status of the medial canthal tendon.[rx] Meticulous primary surgical correction is key in restoring aesthetic features and preventing future complications of trauma. Operative approach and exposure is carefully considered to balance the need to correct the deformities but also to prevent further aesthetic disruption and complications.[rx]

Pathophysiology

The naso-orbital-ethmoid complex is a confluence of structures made up of the nasal bones, nasal process of the frontal bone, frontal process of the maxilla, lacrimal bone, lamina papyracea of the ethmoid bone, and sphenoid bone.[1] The medial canthal tendon (MCT), also called medial palpebral tendon, is a band of fibrous tissue originating from the medial palpebral part of the orbicularis oculi muscle as well as the superior and inferior tarsus of the eyelids. The MCT splits and surrounds the lacrimal fossa, which includes the lacrimal duct before inserting into the lacrimal crest of the maxilla anteriorly and the lacrimal bone posteriorly.[rx] The facial skeleton is formed of four paired vertical and four horizontal buttresses, which are columns of bone that provide structure to surrounding tissues and help provide a form to the face. The NOE complex incorporates the medial vertical and inferior and superior transverse buttresses. These become the focus during surgical fixation. It has been suggested that NOE fractures are the result of facial bone design. The nasal bones transmit a force posteriorly to thinner bones, which crumple to transmit the force to the ethmoid sinuses, thus sparing the contents of the cranial vault and orbital contents.[rx] However, there is disagreement on whether facial bone fractures provide any protection to the brain itself.[rx]

Sensory innervation to the NOE region is by the ophthalmic and maxillary branches of the trigeminal nerve. Motor innervation is by the zygomatic branches of the facial nerve. Autonomic supply consisting of sympathetic and parasympathetic fibers innervate both intraocular and external structures. The lacrimal nerve transmits both fiber types to the lacrimal gland. Sympathetic fibers also provide innervation to the smooth muscle of the lids widening the palpebral fissure when stimulated.

Arterial supply to the region originates from the internal and external carotid arteries. The facial and maxillary arteries are given off by the external carotid artery and supply the majority of the face. The ophthalmic artery originating from the internal carotid supplies the orbital structures. The ophthalmic artery also gives rise to the anterior and posterior ethmoidal arteries which supply the ethmoid sinus and terminate in the nasal cavity where they anastomose with the sphenopalatine artery to form Little’s area which is prone to bleeding. Venous drainage follows a similar pattern to the arterial supply. The venous blood drains into the cavernous sinus, which can produce complications from thrombosis secondary to trauma or infection.[rx]

Classification of Fractures of the naso-orbital-ethmoid

The Markowitz and Manson system is the most widely used classification system of NOE complex fractures and has replaced other systems by making the integrity of the MCT a key feature of fracture severity.[3] This classification system relies on both CT scan and clinical examination which outline the status of NOE complex bony structures and MCT integrity, respectively:

• Type 1: The MCT is attached to a central fracture segment.
• Type 2: The MCT is attached to a comminuted central fracture segment.
• Type 3: The MCT is detached from a comminuted central fracture segment.

Causes of Fractures of the naso-orbital-ethmoid

• The NOE fracture pattern is caused by forceful, direct trauma to the central midface. Due to the high energy involved, these fractures often occur in combination with injuries to other parts of the face and body.
• The road traffic collision is the most common cause of NOE fractures, especially with motorcycles.[rx]. Fortunately, it appears to have reduced in frequency.
• The introduction of seatbelts and airbags has helped to decrease the incidence of facial fractures.[rx] Physical assault, sport, and horse kicks have also been associated with this fracture pattern.

Symptoms Of Fractures of the naso-orbital-ethmoid

Symptoms bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.

• Pain or tenderness, especially when touching your nose
• Swelling of your nose and surrounding areas
• Bleeding from your nose
• Bruising around your nose or eyes
• Bruising, swelling and tenderness around the nose
• A deformed, twisted or crooked nose
• Blockage of one or both nostrils
• A deviated septum
• A bruise-like discoloration under the eyes
• Crooked or misshapen nose
• Difficulty breathing through your nose
• Discharge of mucus from your nose
• Feeling that one or both of your nasal passages are blocked
• Gross facial edema may show firstly in the early stage of fracture, which will result in distortion of soft tissue landmarks.
• Ophthalmic symptoms include diplopia, telecanthus, enophthalmos, epiphora, and shortened palpebral fissure, which result from orbit wall or medal canthal tendon malformation.
• Moreover, the nasal symptoms include retrusion of the nasal bridge, anosmia caused by damage to the cribriform plate, and nasal congestion secondary to septal hematoma or bony/cartilaginous deformity. Cerebrospinal fluid leak (CSF) may also present, which needs to be highly valued.

Diagnosis of Fractures of the naso-orbital-ethmoid

History and Physical

An advanced trauma life support approach should be adopted when assessing patients with suspected facial trauma. Airway patency and stability are a key priority alongside cervical spine immobilization and hemorrhage control, as 10% of complicated facial fractures are associated with significant bleeding.[rx] Full neurological and ophthalmic examinations are indicated as two-thirds of facial fractures are associated with some form of ocular injury.[rx]

Examination of the NOE complex begins with a visual and manual inspection, which often will reveal severe swelling and periorbital ecchymosis, which sometimes make examination challenge. Excessive tear overflow in the eye and face (epiphora) can be associated with lacrimal duct damage or obstruction. A more reliable assessment of lacrimal duct function is using dye tests or dacryocystography (radiological contrast assessment of the lacrimal apparatus) if epiphora is persistent following surgery.[rx] Nasal bone fracture and depression can result in a decreased nasal dorsal projection with an associated upturn of the nasal tip.[rx] Epistaxis with associated mucosal nasal tearing may be present with or without cerebral spinal fluid (CSF) rhinorrhoea, as a result of anterior cranial fossa fracture. CSF presence can be confirmed with a beta-transferrin test, which is more accurate than the halo sign (CSF fluid on filter paper forming a halo pattern). Nasal patency can be crudely assessed with a metal object placed under each nostril.

Assessment of the MCT is a fundamental aspect of discerning the severity of an NOE complex injury. Telecanthus (increased distance between to the two medical canthi) with equal interpupillary distance is a sign of MCT rupture. Intercanthal distance is on average 30 to 31 mm, and the interpupillary distance is 60 to 61 mm. An intercanthal distance greater than 40 mm is noticeable, and an indication for surgical correction.[rx] The bow-string test involves palpating the nasal root whilst retracting the eyelid inferior-laterally, the eyelid will have greater laxity, and a fractured segment may be palpable if the MCT is compromised.

Evaluation

Investigations

The examination may be initially limited by severe pain and gross swelling of facial structures. Computed tomography (CT) scan of the head provides definitive details of soft tissue and bony injuries. The use of both 2D and 3D images on coronal and axial views aids the diagnosis and staging of NOE complex fractures and assists the operating team in planning corrective operations.[rx] The approach, degree of exposure, and equipment required are highly dependent on the CT scan. The study also outlines injuries of other structures in the head. In a trauma setting, it is likely to be performed early once the patient is stabilized with an advanced trauma life support approach.

Preoperative blood work should include CBC, electrolytes, coagulation profile, and a pregnancy test.

Imaging should provide useful information to differentiate orbital floor fractures from any of the following:

• Medial or lateral wall fractures
• Orbito-zygomatic fractures
• LeFort I, II, and III fractures
• Naso-orbital ethmoidal fractures (Markowitz fractures)

Clinical examination has to eliminate the need for acute intervention under the following conditions:

• Large fractures with a high risk of enophthalmos
• Entrapment of infra-orbital structures
• Optical neuropathy

Computed tomography scan

Computed tomography (CT) is the imaging modality of choice if a blowout fracture is suspected after blunt orbital trauma. Some symptoms include double vision, pain with eye movements, and restriction of extraocular muscle movements. A CT scan often reveals herniation of orbital fat or the inferior rectus muscle, into the maxillary sinus. Such a scan can also detect occult tears and retained foreign bodies if any are present.

Plain Radiograph

Can help suspect an orbital floor fracture in the presence of the following:

• Subcutaneous emphysema
• Soft-tissue teardrop along the roof of the maxillary sinus
• Air-fluid level in the maxillary sinus

Treatment of Fractures of the naso-orbital-ethmoid

NOE fractures require surgical fixation and/or reduction to restore the aesthetic features of the face. If the medial canthal tendon is avulsed, then this will need to be reduced. The approach will depend on the severity and distribution of fractures, and an effort is made to use the smallest incision to provide the greatest exposure of tissue and bone.[rx] The consideration of the incision site is very important as it can have a great aesthetic impact. Sometimes facial lacerations or pre-existing scars can be utilized. Pre-injury photographs can be of assistance to surgeons in planning reduction and fixation as so to return, as close as possible, the face back to its original form.

The coronal incision provides good exposure of the mid-upper face and is the gold standard approach to NOE fractures involving the frontal sinus. The midface degloving approach provides greater exposure of the midface. This technique, however, is associated with a number of complications, such as anesthesia and nasal deformity. Reduction and fixation of bony segments are sought before soft tissues are corrected.[rx] In type 1 NOE fractures, closed reduction can be achieved. Type 2 and type 3 fractures will require exposure of the fractured segments with open reduction and internal fixation. A titanium mesh is used to stabilize the medial orbital wall, however, absorbable meshes can be used.[rx] Microplates and screws are used to fix and stabilize bones and ensure the stabilization of the horizontal and vertical buttresses. Frontal sinus involvement requires additional repair of fractured walls and repair of open meninges if present. The sinuses are obliterated to avoid future mucocele formation with a variety of techniques. Pedicled flaps, autologous grafts (adipose tissue, bones, and muscles), xenografts, and biomaterial can be used for this purpose. Alternatively, in more severe sinus injuries, cranialization can be utilized – this is the removal of the posterior frontal sinus wall allowing brian tissue to fill the space.[rx]

In type 3 NOE complex fractures reduction of the MCT (canthopexy) is achieved by transnasal wiring, which is performed by drilling a small hole into the medial orbital wall and tethering the MCT with a wire. The use of a needle to secure the MCT in lieu of a drill is sometimes required for unstable comminuted fractures of the medial orbital wall.[23]

Disruption to the lacrimal pathways is a common complication of midfacial trauma, with epiphora reported in nearly half of cases immediately postoperatively. However, permanent epiphora is relatively uncommon.[24] As such, secondary correction with dacryocystorhinostomy is preferred six months after fracture fixation.[16] The aim is to correct tear drainage and prevent future mucocele formation.

• https://www.ncbi.nlm.nih.gov/books/NBK555912/
• https://www.ncbi.nlm.nih.gov/books/NBK557468/
• https://www.ncbi.nlm.nih.gov/books/NBK557519/
• https://www.ncbi.nlm.nih.gov/books/NBK557455/
• https://www.ncbi.nlm.nih.gov/books/NBK526060/
• https://www.ncbi.nlm.nih.gov/books/NBK538299/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052653/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052655/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379265/
• https://www.ncbi.nlm.nih.gov/books/NBK555912/
• https://www.sciencedirect.com/topics/medicine-and-dentistry/nose-fracture
• https://www.aafp.org/afp/2004/1001/p1315.html
• https://en.wikipedia.org/wiki/Nasal_fracture
• https://www.sciencedirect.com/science/article/pii/S1008127515000516

Nasal Septal Fractures have been associated with nasal bone fractures in 42% to 96% of patients. Nasal bone and septal fractures have an impact not only on cosmetic appearance but also on functional nasal breathing as well.[rx][rx]

The structural support of the nose is comprised mainly of cartilage, bone, and skin. The paired nasal bones are attached to the frontal bone superiorly and the frontal process of the maxilla on either side laterally. They are attached to the nasofrontal and nasomaxillary suture lines, respectively. The nasal bones tend to be thicker above the level of the medial canthus.[rx]

The nasal septum is comprised posteriorly of bone and anteriorly of cartilage. The perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly, make up the bony septum. These fuse with the quadrangular cartilage, which makes up the anterior portion of the nasal septum. The quadrangular cartilage provides support for the nasal dorsum from the keystone area to the supratip of the nose.[rx] This keystone area is a major structural support of the middle one-third of the nose. The upper lateral cartilages fuse to the cartilaginous septum, which is firmly attached to the perpendicular plate of the ethmoid bone. The final element of the keystone area is the attachment of the upper lateral cartilages to the nasal bony vault. The septum is attached to the nasal floor anteriorly at the nasal spine and posteriorly at the nasal crest of the maxilla and palatine bones.

Causes of Nasal Septal Fractures

Nasal bones are fractured with a variety of trauma to the maxillofacial skeleton.

• The most common causes of nasal bone fractures globally are interpersonal violence, motor vehicle accidents, sporting accidents, and falls. In North America, traffic accidents account for more nasal bone fractures than interpersonal violence.[rx]
• In children, the most common cause tends to be sporting accidents or motor vehicle accidents, depending on the source.[rx][rx] Interestingly, ball-related sports such as soccer, basketball, baseball, and rugby have a higher incidence of nasal bone fractures compared to fighting-related sports.[rx]

Symptoms Of Nasal Septal Fractures

Symptoms of a broken nose septum fracture include bruising, swelling, tenderness, pain, deformity, and/or bleeding of the nose and nasal region of the face.

• Pain or tenderness, especially when touching your nose
• Swelling of your nose and surrounding areas
• Bleeding from your nose
• Bruising around your nose or eyes
• Bruising, swelling and tenderness around the nose
• A deformed, twisted or crooked nose
• Blockage of one or both nostrils
• A deviated septum
• A bruise-like discoloration under the eyes
• Crooked or misshapen nose
• Difficulty breathing through your nose
• Discharge of mucus from your nose
• Feeling that one or both of your nasal passages are blocked

Diagnosis of Nasal Septal Fractures

History and Physical

Patients who have undergone trauma to the maxillofacial region should first have a primary trauma survey performed, addressing Airway, Breathing, and Circulation, and Disability. After life-threatening issues have been addressed, a thorough history and secondary physical examination may be performed.

It is important first to delineate the mechanism of trauma to the maxillofacial region. Higher impact injuries, as seen in motor vehicle accidents, are prone to more severe injuries and may be associated with multiple facial fractures. The direction of impact may be important to understand the underlying fracture pattern better. Lateral blows tend to cause a fracture on the impacted side and out fracture on the opposite side, while impact directed straight onto the nasal dorsum tends to cause splaying out fractures of the bilateral nasal bones.[rx] It is also essential to get a sense of premorbid appearance. Patients should be asked if they notice an obvious deviation or deformity compared to before the injury. Difficulty breathing through either side of the nose should be explored, as this can signify injury to the nasal septum.[rx] The patient should also be questioned on any prior nasal trauma or surgeries. Symptoms that may indicate more extensive injuries include diplopia, loss of vision, clear rhinorrhea, malocclusion, facial weakness, or numbness.

Physical examination should include a thorough examination of the entire head and neck region to include skin, ocular examination, otoscopic exam, intraoral, and intranasal examination. A complete examination of the nasal dorsum and nasal cavity should be performed with the aid of a headlamp as well as a nasal speculum or rigid endoscope. The external noise should be closely evaluated for the presence of lacerations and exposed bone or cartilage. Any deviation of the bony nasal pyramid should be documented. Increased intercanthal distance suggests a nasoorbitoethmoid fracture.[rx] The nasal tip should be palpated to assess for adequate support, and the nasal dorsum should be evaluated for a saddle-nose deformity, which indicates significant septal fracture or dislocation.[rx] An intranasal examination should first rule out a septal hematoma, which is seen as a fluctuant red or blue discoloration along the nasal septum.[rx] This submucoperi chondrial collection of blood needs an urgent incision and drainage to prevent septal cartilaginous necrosis, which may occur within 24 hours. Over time, the resulting cartilage necrosis leads to septal perforation or saddle nose deformity.[rx] Significant dislocations of the septum should be noted, and any intranasal lacerations or mucosal disruptions should be noted as well. Care should be taken to inspect for clear rhinorrhea, which may suggest a cerebrospinal fluid (CSF) leak.[11]

Evaluation

Imaging is generally not warranted for simple nasal bone fractures. Plain film X-rays are not typically useful. A computed tomography (CT) scan without intravenous contrast of the facial bones is the gold standard for evaluation of bony trauma of the maxillofacial area if there is a concern for more extensive facial injuries.[rx] Concerning symptoms, as previously noted, should prompt providers to order imaging. More recently, ultrasonography has been explored to help aid in the diagnosis of nasal bone fractures but proved inferior to CT.[rx]

Laboratory evaluation is generally not required in a simple nasal bone fracture or septal hematoma. A complete blood count and coagulation studies may be considered in patients with epistaxis who have lost a considerable amount of blood or who take anticoagulant medication. Patients with persistent clear rhinorrhea can have this collected and sent for beta-2-transferrin, which can be used to help confirm a CSF leak.

Treatment of Nasal Septal Fractures

Initial management should include control of epistaxis and closure of any lacerations of the external skin or internal nasal lining whenever possible. Epistaxis may be conservatively controlled with digital pressure, pushing the nasal alae against the septum. More serious epistaxis may require cauterization or nasal packing.

Observation without surgical intervention is recommended in patients who do not have an obvious cosmetic deformity or nasal obstruction. Conservative measures such as elevating the head and icing the area are recommended until local edema subsides. Patients should be closely followed within three to five days for reexamination, as nasal deviation can be unmasked with the resolution of edema.[rx]

Closed reduction of the nasal bone and septal fractures is generally recommended for fractures that cause nasal deviation or airway obstruction. It may be performed under local anesthetic or minimal sedation, but general anesthesia is most often preferred due to improved airway protection and overall patient comfort.[rx] Timing of closed reduction is varied in the literature, with some sources advocating early intervention within five to seven days, while others state that edema should completely resolve, and closed reduction should be performed within one to two weeks of injury.[rx][rx] After two weeks, patient satisfaction with cosmetic outcomes significantly decrease.[rx] Later intervention risks callus formation and difficulty reducing nasal bones into their premorbid location. In this case, an endonasal or percutaneous open reduction can be performed using osteotomies.[rx] In a typically closed reduction, a flat, broad instrument such as a Boies elevator is used endonasal to reduce fractures with a postoperative splint applied to the nasal dorsum.

Closed reduction may also be performed on the nasal septum using a Boies elevator or Asch forceps. If adequate reduction of the nasal septum cannot be performed in a closed fashion, some have advocated for an open septoplasty in the acute setting, showing that patients have significant improvement in nasal obstruction postoperatively.[rx] Intranasal splints or packing may also be used to help keep the septum reduced, but this is typically not used unless a septoplasty has been performed. Septoplasty is avoided if there is significant mucosal disruption along the septum due to the risk of postoperative septal perforation.[rx]

An open septorhinoplasty is generally avoided in the acute setting as there are frequently nasal lacerations or cartilage disruptions. Further dissecting these cartilage structures can revascularize them in the acute setting, and any cartilage grafts may be more susceptible to infection and rejection. It is therefore often recommended septorhinoplasty be delayed 3 to 6 months post-injury.[rx]

• https://www.ncbi.nlm.nih.gov/books/NBK555912/
• https://www.ncbi.nlm.nih.gov/books/NBK557468/
• https://www.ncbi.nlm.nih.gov/books/NBK557519/
• https://www.ncbi.nlm.nih.gov/books/NBK557455/
• https://www.ncbi.nlm.nih.gov/books/NBK526060/
• https://www.ncbi.nlm.nih.gov/books/NBK538299/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052653/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052655/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4379265/
• https://www.ncbi.nlm.nih.gov/books/NBK555912/
• https://www.sciencedirect.com/topics/medicine-and-dentistry/nose-fracture
• https://www.aafp.org/afp/2004/1001/p1315.html
• https://en.wikipedia.org/wiki/Nasal_fracture

Le Fort Fracture are complex fractures of the midface, named after Rene Le Fort who studied cadaver skulls that were subjected to blunt force trauma. His experiments determined the areas of structural weakness of the maxilla designated as “lines of weakness” where fractures occurred. These fractures are classified into 3 distinct groups based on the direction of the fracture: horizontal, pyramidal or transverse. The pterygoid plate is involved in all types of Le Fort fractures. This may result in a pterygomaxillary separation. The absence of a pterygoid fracture rules out a Le Fort fracture. However, the presence of a pterygoid fracture does not specifically indicate whether a Le Fort fracture exists. Up to one-third of pterygoid plate fractures do not result from a Le Fort fracture pattern.[rx][rx][rx]

Type of Fractures of Le Fort Fracture

Le Fort Type I

These fractures (trans-maxillary fracture) result from a force directed low on the maxillary rim in a downward direction. This occurs in the horizontal plane at the level of the base of the nose. A direct blow to the lower face causes fractures that involve all 3 walls of the maxillary sinus and pterygoid processes. The fracture extends around both maxillary antra, through the nasal septum and the pterygoid plates. This causes palate-facial separation. However, this fracture does not involve the glabella or zygoma.

Le Fort Type II

This pyramidal fracture occurs due to trauma to the midface. The fracture line begins in the region of the bridge of the nose (nasion) and extends obliquely through the medial aspect of the orbits and inferior orbital rims. It then continues posteriorly in a horizontal fashion above the hard palate to involve the pterygomaxillary buttresses, resulting in a disarticulation of the pyramid-shaped facial skeleton from the remainder of the skull. Note that the zygoma remains attached to the cranium.

Le Fort Type III

Also called cranial-facial separation, the fracture line in this injury passes from the nasofrontal area across the medial, posterior, and lateral orbital walls, the zygomatic arch, and through the upper portion of pterygoid plates.

Anatomic Level Classification

Le Fort Type I

Transverse fracture through the maxilla above the roots of the teeth, separating teeth from the upper face. These can be unilateral or bilateral.

Le Fort Type II

These fractures extend superiorly in the midface to include the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim. They are pyramidal fractures with teeth at the base and nasal bone at the apex. These fractures are typically bilateral.

Le Fort Type III

This type of fracture starts at the bridge of the nose and extends posteriorly along the medial wall of the orbit and the floor of the orbit, and then through the lateral orbital wall and the zygomatic arch. The fractures run parallel with the base of the skull, separating the entire midfacial skeleton from the cranial base. This discontinuity between the skull and the face is termed craniofacial dissociation. This may be associated with a cerebrospinal fluid (CSF) leak.

Causes of Le Fort Fracture

A high percentage of facial injuries occur secondary to injuries, from sports such as football, baseball, and hockey. Le Fort fractures can also occur secondary to motor vehicle collisions, assault, and fall from a substantial height. Patients with Le Fort fractures often have associated head and cervical spine injuries.[rx][rx][rx]

• Le Fort type I fractures may result from a force directed in a downward direction against the upper teeth.
• Le Fort type II fractures result from a force to lower or mid maxilla.
• Le Fort type III fractures are caused by impact to the nasal bridge and upper part of the maxilla

Le Fort Type I

These fractures result from a force directed low on the maxillary rim in a downward direction. Fractures extend from the nasal septum to lateral pyriform rims, and extend horizontally above the teeth, crossing below the zygomaxillary junction, then traversing the pterygomaxillary junction interrupting the pterygoid plates.

Le Fort Type II

These fractures result from a force to the lower or mid maxilla. This fracture has a pyramidal shape and extends from the nasal bridge at the nasofrontal suture through the maxilla. Inferolaterally, the fracture extends through the lacrimal bone and inferior orbital floor near the inferior orbital foramen and inferiorly through the anterior wall of the maxillary sinus. On the lateral aspect, it travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plate.

Le Fort Type III

These fractures result from an impact to the nasal bridge or upper maxilla. This results in complete craniofacial dysjunction.

Symptoms of Le Le Fort Fracture

• Le Fort I — Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin’s sign is present characterised by ecchymosis in the region of greater palatine vessels.
• Le Fort II and Le Fort III (common) — Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound.
• Le Fort II — Step deformity at the infraorbital margin, mobile mid-face, anesthesia or paresthesia of cheek.
• Le Fort III — Tenderness and separation at the frontozygomatic suture, lengthening of face, depression of ocular levels (enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.

Diagnosis of Le Fort Fracture

History and Physical

Le Fort Type I

Le Fort type I presents as a swollen upper lip, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and mobility of the maxilla.

Le Fort Type II

With a Le Fort type II fracture, there is significant deformity and swelling, widening of the intercanthal space (nasal septum fracture), mobility of the maxilla and nose as a combined segment, as well as bilateral periorbital edema and ecchymosis (raccoon eyes), epistaxis, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and possible CSF rhinorrhea. Since the fracture involves the inferior orbital rim and floor, there may be sensory deficits in the infraorbital region extending inferiorly to the upper lip.

Le Fort Type III

The most significant clinical findings are demonstrated by bilateral periorbital edema and ecchymosis (raccoon eyes), ecchymosis of the maxillary buccal vestibule and palate, lengthening of facial height- elongation and flattening of the face (dish-face deformity), orbital hooding, enophthalmos, ecchymosis over the mastoid region (Battle’s sign), CSF rhinorrhea, CSF otorrhea, and hemotympanum.

Evaluation

The initial evaluation of patients with maxillofacial trauma should follow advanced trauma life Support (ATLS) protocols. The primary survey includes airway and cervical spine stabilization, breathing and ventilatory support, attention to circulation and hemorrhage control, disability and neurologic evaluation, and exposure and environment control.

Airway obstruction associated with fractures of the midfacial skeleton can be life-threatening if not recognized promptly and treated appropriately. Orotracheal intubation is required when intranasal damage is a possibility. Airway obstruction in Le Fort injuries mainly occurs due to multiple sources bleeding into the upper airway, as well as midface altered airway anatomy. Beware that the risk of life-threatening hemorrhage in Le Fort II and III injuries is higher than that associated with other facial injuries.

Maxillofacial trauma is an obvious threat to the patient’s airway; therefore, a rapid evaluation must be performed to determine the need for a definitive airway. The concept of the definitive airway in cases of maxillofacial trauma is probably much more critical as compared to trauma to other body parts; therefore, an emergency airway may be required.

In a patient with complex maxillofacial trauma, cervical spine fracture should always be considered unless proven otherwise. Therefore, the cervical spine must be protected while providing airway management.

During the secondary survey, the assessment of maxillofacial fractures is performed after initial stabilization and resuscitation of the multisystem trauma patient. An ophthalmologic evaluation is required in Le Fort II and III fractures with orbital involvement. This should be completed before surgery to ensure there is no globe injury.

The mobility of the face should be tested on both sides as well as in the midline. The type of Le Fort fracture is determined by which regions are mobile.

• Le Fort I: Mobility of the maxilla; maxilla is free from the rest of the facial bones (floating palate)
• Le Fort II: Mobility of the maxilla and nose as a combined segment
• Le Fort III: Mobilized segment to include the maxilla, nose, and zygomas

A CT scan of facial bones is required to fully and adequately assess the extent of bone and soft tissue involvement. Plain radiographs are not sufficient for evaluation. Beware that penetrating trauma to the midface may involve injury to the brain and major vascular structures. Therefore, a CT scan of the head and diagnostic angiography should also be considered.

Treatment of Le Le Fort Fracture

The initial evaluation and stabilization should be performed in conjunction with a trauma surgeon. Definitive surgery should be performed after stabilization when life-threatening injuries are addressed. Le Fort fractures require fixation of unstable fracture segments to stable structures. [rx][rx][rx]The goals of fracture management are to:

• Restore the facial projection and the involved sinus cavities
• Reestablish proper occlusion of teeth; note that proper repair cannot be performed without good occlusion
• Restore the integrity of the nose and orbit

Le Fort fractures may be associated with other injuries such as dental or alveolar ridge fractures (alveolar and palatal fractures are commonly associated with all types of Le Fort fractures and make the repair more difficult and complex), cerebrospinal fluid leaks, and severe epistaxis.

In type III, significant facial swelling, deformity, and orbital ecchymosis are almost always present.

Antibiotic prophylaxis in patients with CSF leak remains controversial and should be considered at the discretion of the treating neurosurgeon.

References

Le Fort injuries are complex fractures of the midface, named after Rene Le Fort who studied cadaver skulls that were subjected to blunt force trauma. His experiments determined the areas of structural weakness of the maxilla designated as “lines of weakness” where fractures occurred. These fractures are classified into 3 distinct groups based on the direction of the fracture: horizontal, pyramidal or transverse. The pterygoid plate is involved in all types of Le Fort fractures. This may result in a pterygomaxillary separation. The absence of a pterygoid fracture rules out a Le Fort fracture. However, the presence of a pterygoid fracture does not specifically indicate whether a Le Fort fracture exists. Up to one-third of pterygoid plate fractures do not result from a Le Fort fracture pattern.[rx][rx][rx]

Type of Fractures of Le Fort injuries

Le Fort Type I

These fractures (trans-maxillary fracture) result from a force directed low on the maxillary rim in a downward direction. This occurs in the horizontal plane at the level of the base of the nose. A direct blow to the lower face causes fractures that involve all 3 walls of the maxillary sinus and pterygoid processes. The fracture extends around both maxillary antra, through the nasal septum and the pterygoid plates. This causes palate-facial separation. However, this fracture does not involve the glabella or zygoma.

Le Fort Type II

This pyramidal fracture occurs due to trauma to the midface. The fracture line begins in the region of the bridge of the nose (nasion) and extends obliquely through the medial aspect of the orbits and inferior orbital rims. It then continues posteriorly in a horizontal fashion above the hard palate to involve the pterygomaxillary buttresses, resulting in a disarticulation of the pyramid-shaped facial skeleton from the remainder of the skull. Note that the zygoma remains attached to the cranium.

Le Fort Type III

Also called cranial-facial separation, the fracture line in this injury passes from the nasofrontal area across the medial, posterior, and lateral orbital walls, the zygomatic arch, and through the upper portion of pterygoid plates.

Anatomic Level Classification

Le Fort Type I

Transverse fracture through the maxilla above the roots of the teeth, separating teeth from the upper face. These can be unilateral or bilateral.

Le Fort Type II

These fractures extend superiorly in the midface to include the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim. They are pyramidal fractures with teeth at the base and nasal bone at the apex. These fractures are typically bilateral.

Le Fort Type III

This type of fracture starts at the bridge of the nose and extends posteriorly along the medial wall of the orbit and the floor of the orbit, and then through the lateral orbital wall and the zygomatic arch. The fractures run parallel with the base of the skull, separating the entire midfacial skeleton from the cranial base. This discontinuity between the skull and the face is termed craniofacial dissociation. This may be associated with a cerebrospinal fluid (CSF) leak.

Causes of Le Fort injuries

A high percentage of facial injuries occur secondary to injuries, from sports such as football, baseball, and hockey. Le Fort fractures can also occur secondary to motor vehicle collisions, assault, and fall from a substantial height. Patients with Le Fort fractures often have associated head and cervical spine injuries.[rx][rx][rx]

• Le Fort type I fractures may result from a force directed in a downward direction against the upper teeth.
• Le Fort type II fractures result from a force to lower or mid maxilla.
• Le Fort type III fractures are caused by impact to the nasal bridge and upper part of the maxilla

Le Fort Type I

These fractures result from a force directed low on the maxillary rim in a downward direction. Fractures extend from the nasal septum to lateral pyriform rims, and extend horizontally above the teeth, crossing below the zygomaxillary junction, then traversing the pterygomaxillary junction interrupting the pterygoid plates.

Le Fort Type II

These fractures result from a force to the lower or mid maxilla. This fracture has a pyramidal shape and extends from the nasal bridge at the nasofrontal suture through the maxilla. Inferolaterally, the fracture extends through the lacrimal bone and inferior orbital floor near the inferior orbital foramen and inferiorly through the anterior wall of the maxillary sinus. On the lateral aspect, it travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plate.

Le Fort Type III

These fractures result from an impact to the nasal bridge or upper maxilla. This results in complete craniofacial dysjunction.

Symptoms of Le Fort injuries

• Le Fort I — Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin’s sign is present characterised by ecchymosis in the region of greater palatine vessels.
• Le Fort II and Le Fort III (common) — Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound.
• Le Fort II — Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek.
• Le Fort III — Tenderness and separation at frontozygomatic suture, lengthening of face, depression of ocular levels (enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.^[2]

Diagnosis of Le Fort injuries

History and Physical

Le Fort Type I

Le Fort type I presents as a swollen upper lip, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and mobility of the maxilla.

Le Fort Type II

With a Le Fort type II fracture, there is significant deformity and swelling, widening of the intercanthal space (nasal septum fracture), mobility of the maxilla and nose as a combined segment, as well as bilateral periorbital edema and ecchymosis (raccoon eyes), epistaxis, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and possible CSF rhinorrhea. Since the fracture involves the inferior orbital rim and floor, there may be sensory deficits in the infraorbital region extending inferiorly to the upper lip.

Le Fort Type III

The most significant clinical findings are demonstrated by bilateral periorbital edema and ecchymosis (raccoon eyes), ecchymosis of the maxillary buccal vestibule and palate, lengthening of facial height- elongation and flattening of the face (dish-face deformity), orbital hooding, enophthalmos, ecchymosis over the mastoid region (Battle’s sign), CSF rhinorrhea, CSF otorrhea, and hemotympanum.

Evaluation

The initial evaluation of patients with maxillofacial trauma should follow advanced trauma life Support (ATLS) protocols. The primary survey includes airway and cervical spine stabilization, breathing and ventilatory support, attention to circulation and hemorrhage control, disability and neurologic evaluation, and exposure and environment control.

Airway obstruction associated with fractures of the midfacial skeleton can be life-threatening if not recognized promptly and treated appropriately. Orotracheal intubation is required when intranasal damage is a possibility. Airway obstruction in Le Fort injuries mainly occurs due to multiple sources bleeding into the upper airway, as well as midface altered airway anatomy. Beware that the risk of life-threatening hemorrhage in Le Fort II and III injuries is higher than that associated with other facial injuries.

Maxillofacial trauma is an obvious threat to the patient’s airway; therefore, a rapid evaluation must be performed to determine the need for a definitive airway. The concept of the definitive airway in cases of maxillofacial trauma is probably much more critical as compared to trauma to other body parts; therefore, an emergency airway may be required.

In a patient with complex maxillofacial trauma, cervical spine fracture should always be considered unless proven otherwise. Therefore, the cervical spine must be protected while providing airway management.

During the secondary survey, the assessment of maxillofacial fractures is performed after initial stabilization and resuscitation of the multisystem trauma patient. An ophthalmologic evaluation is required in Le Fort II and III fractures with orbital involvement. This should be completed before surgery to ensure there is no globe injury.

The mobility of the face should be tested on both sides as well as in the midline. The type of Le Fort fracture is determined by which regions are mobile.

• Le Fort I: Mobility of the maxilla; maxilla is free from the rest of the facial bones (floating palate)
• Le Fort II: Mobility of the maxilla and nose as a combined segment
• Le Fort III: Mobilized segment to include the maxilla, nose, and zygomas

A CT scan of facial bones is required to fully and adequately assess the extent of bone and soft tissue involvement. Plain radiographs are not sufficient for evaluation. Beware that penetrating trauma to the midface may involve injury to the brain and major vascular structures. Therefore, a CT scan of the head and diagnostic angiography should also be considered.

Treatment of Le Fort injuries

The initial evaluation and stabilization should be performed in conjunction with a trauma surgeon. Definitive surgery should be performed after stabilization when life-threatening injuries are addressed. Le Fort fractures require fixation of unstable fracture segments to stable structures. [rx][rx][rx]The goals of fracture management are to:

• Restore the facial projection and the involved sinus cavities
• Reestablish proper occlusion of teeth; note that proper repair cannot be performed without good occlusion
• Restore the integrity of the nose and orbit

Le Fort fractures may be associated with other injuries such as dental or alveolar ridge fractures (alveolar and palatal fractures are commonly associated with all types of Le Fort fractures and make the repair more difficult and complex), cerebrospinal fluid leaks, and severe epistaxis.

In type III, significant facial swelling, deformity, and orbital ecchymosis are almost always present.

Antibiotic prophylaxis in patients with CSF leak remains controversial and should be considered at the discretion of the treating neurosurgeon.

References

Hematopoietic Stem Cell Transplant /Bone Marrow Transplant (hematopoietic stem cell transplant) (HPSCT) involves the administration of healthy hematopoietic stem cells in patients with dysfunctional or depleted bone marrow. This helps to augment bone marrow function and allows, depending on the disease being treated, to either destroy tumor cells with malignancy or to generate functional cells that can replace the dysfunctional ones in cases like immune deficiency syndromes, hemoglobinopathies, and other diseases.

Hematopoietic stem cell transplantation (HSCT) is the transplantation of multipotent hematopoietic stem cells, usually derived from bone marrow, peripheral blood, or umbilical cord blood. It may be autologous (the patient’s own stem cells are used), allogeneic (the stem cells come from a donor), or syngeneic (from an identical twin).^[rx][rx] It is most often performed for patients with certain cancers of the blood or bone marrow, such as multiple myeloma or leukemia.^[rx] In these cases, the recipient’s immune system is usually destroyed with radiation or chemotherapy before the transplantation. Infection and graft-versus-host disease are major complications of allogeneic HSCT.^[rx]

Types of Hematopoietic Stem Cell Transplant

There are two major types of bone marrow transplants. The type used will depend on the reason you need a transplant.

Autologous Transplants

• Autologous transplants involve the use of a person’s own stem cells. They typically involve harvesting your cells before beginning a damaging therapy to cells like chemotherapy or radiation. After the treatment is done, your own cells are returned to your body.
• Stem cells are removed from you before you receive high-dose chemotherapy or radiation treatment. The stem cells are stored in a freezer. After high-dose chemotherapy or radiation treatments, your stems cells are put back in your body to make normal blood cells. This is called a rescue transplant.
• This type of transplant isn’t always available. It can only be used if you have healthy bone marrow. However, it reduces the risk of some serious complications, including GVHD.

Allogeneic Transplants

• The term allo means other. Stem cells are removed from another person, called a donor. Most times, the donor’s genes must at least partly match your genes. Special tests are done to see if a donor is a good match for you. A brother or sister is most likely to be a good match. Sometimes parents, children, and other relatives are good matches. Donors who are not related to you, yet still match, may be found through national bone marrow registries.
• Allogeneic transplants are necessary if you have a condition that has damaged your bone marrow cells. However, they have a higher risk of certain complications, such as GVHD. You’ll also probably need to be put onmedications to suppress your immune system so that your body doesn’t attack the new cells. This can leave you susceptible to illness.
  • Related donor transplant — Typically patients begin by trying to identify a relative to be their donor. Siblings are most likely to be a close match (based on HLA typing).
  • Matched unrelated donor transplant — If you don’t have a relative available who is a match, doctors can search international donor registries for an unrelated donor.
  • Haploidentical transplant — If you have not been able to find a closely matched donor, you may be able to receive stem cells from a donor who is a half-match for you. This option broadens the pool of potential donors. Haploidentical, or half-matched, transplants rely on advances in drug therapies to prevent graft-versus-host disease.
  • Cord blood transplant — Stem cells from donated cord blood don’t need to match you as closely. The immune cells in cord blood are not yet trained to fight foreign invaders, like bacteria, so they’re less likely to interact adversely with your tissues. Normally, a unit of cord blood doesn’t have enough stem cells for a transplant in an adult. But doctors can combine units of cord blood and also greatly expand the number of cells per unit using specialized techniques in the lab.

Umbilical cord blood transplant

• This is a type of allogeneic transplant. Stem cells are removed from a newborn baby’s umbilical cord right after birth. The stem cells are frozen and stored until they are needed for a transplant. Umbilical cord blood cells are very immature so there is less of a need for perfect matching. Due to the smaller number of stem cells, blood counts take much longer to recover.

Syngeneic (identical twin transplant)

• Stem cells are donated by an identical twin, which is an ideal donor because of the matching genetic identity between donor and recipient.

Parent-child transplant and haplotype mismatched transplant

• Cells from a parent, child, brother, or sister are not always a perfect match for a patient’s HLA type, but they are a 50% match. Doctors are using these types of transplants more often, to expand the use of transplantation as an effective cancer treatment.

Before the transplant, chemotherapy, radiation, or both may be given. This may be done in two ways

• Ablative (myeloablative) treatment  – High-dose chemotherapy, radiation, or both are given to kill any cancer cells. This also kills all healthy bone marrow that remains and allows new stem cells to grow in the bone marrow.
• Reduced-intensity treatment also called a mini transplant – Lower doses of chemotherapy and radiation are given before a transplant. This allows older people, and those with other health problems to have a transplant.

Pre Procedure of Hematopoietic Stem Cell Transplant

• Major Histocompatibility Complex (MHC) – The group of genes on the short arm of chromosome 6 (p6) that encodes human leukocyte antigens (HLA) which are considered being highly polymorphic leading to a large difference in the resultant expressed proteins on human cells. They are divided into MHC I and MHC II
• Human Leukocyte Antigens (HLA) – These are the proteins expressed on the cellular surface and play an important role in alloimmunity. HLA can be divided into (HLA-A, B, and C) which are encoded by class I MHC and are expressed on all cell types and present peptides derived from the cytoplasm and are recognized by CD8+ T cells. The other HLA type is classified as (HLA- DP, DQ, and DR) which are encoded by MHC II and can be found on antigen-presenting cells (APCs) and this class is recognized by CD4+ T cells.
• Syngeneic Bone Marrow Transplantation – The donor and the recipient are identical twins. The advantages include no graft versus host disease (GVHD) and no graft failure. However, only a tiny number of transplant patients will have the ability to have an identical twin for transplantation.
• Autologous Bone Marrow Transplantation – The bone marrow products are collected from the patient and are reinfused after purification methods. The advantages include no GVHD. The disadvantage is that the bone marrow products may contain abnormal cells that can cause relapse in the case of malignancy hence; theoretically, this method cannot be used in all cases of abnormal bone marrow diseases.
• Allogenic Transplantation – The donor is an HLA matched family member, unrelated matched donor or mismatched family donors (haploidentical).
• Engraftment – The process of which infused transplanted hematopoietic stem cells produce mature progeny in the peripheral circulation
• Preparative Regimen – This is a regimen that comprises high-dose chemotherapy and/or total body irradiation (TBI) which are administered to the recipient prior to stem cell infusion to eliminate the largest number of malignant cells and to allow for immunosuppression in the recipient so that engraftment can occur.

Indications of Hematopoietic Stem Cell Transplant

Indications for stem cell transplantation are as follows:

Malignant (cancerous)

• Acute myeloid leukemia (AML)
• Chronic myeloid leukemia (CML)
• Acute lymphoblastic leukemia (ALL)
• Hodgkin lymphoma (HL) (relapsed, refractory)
• Non-Hodgkin lymphoma (NHL) (relapsed, refractory)
• Neuroblastoma
• Ewing sarcoma
• Multiple myeloma
• Myelodysplastic syndromes
• Gliomas, other solid tumors

Non-malignant (non-cancerous)

• Thalassemia
• Sickle cell anemia
• Aplastic anemia
• Fanconi anemia
• Malignant infantile osteopetrosis
• Mucopolysaccharidosis
• Pyruvate kinase deficiency
• Immune deficiency syndromes
• Autoimmune diseases^[rx]

Malignant Disease

• Multiple Myeloma – Autologous stem cell transplant accounts for most hematopoietic stem cell transplants according to CIBMTR in 2016 in the United States. Studies have shown increased overall survival and progression-free survival in patients younger than 65 years old when consolidation therapy with melphalan is initiated followed by autologous stem cell transplantation and lenalidomide maintenance therapy.[rx] The study showed a favorable outcome of high-dose melphalan plus stem-cell transplantation when compared with consolidation therapy with melphalan, prednisone, lenalidomide (MPR). It also showed a better outcome in patients who received maintenance therapy with lenalidomide.
• Hodgkin and Non-Hodgkin Lymphoma  – Studies have shown that chemotherapy followed by autologous stem cell transplantation in cases of recurrent lymphomas (HL and NHL) that do not respond to initial conventional chemotherapy have better outcomes. A randomized controlled trial by Schmitz N et al. showed a better 3-year outcome of high-dose chemotherapy with autologous stem cell transplant compared to aggressive conventional chemotherapy in relapsed chemosensitive Hodgkin lymphoma. However, the overall survival was not significantly different between the two groups.[rx] The number of hematopoietic stem cell transplant recipients comes second after multiple myeloma according to CIBMTR.
• Acute Myeloid Leukemia – Allogenic stem cell transplant has shown to improve outcomes in patients with AML who fail primary induction therapy and do not achieve a complete response and may prolong overall survival.[rx] The study recommended that early HLA typing for patients with AML can help if they fail induction therapy and are considered for bone marrow transplant.
• Acute Lymphocytic Leukemia – Allogenic stem cell transplant is indicated in refractory and resistant cases when induction therapy fails for the second time in inducing remission. Some studies suggest an increased benefit of allogeneic hematopoietic stem cell transplant in patients with high risk ALL including patients with Philadelphia chromosome and those with t(4, 11).[rx]
• Myelodysplastic Syndrome – Allogenic stem cell transplant is considered being curative in cases of disease progression and is only indicated in intermediate- or high-risk patients with MDS.
• Chronic Myeloid Leukemia/Chronic Lymphocytic Leukemia – Recipients with these two diseases come at the bottom of the list of patients who received allogeneic stem cell transplant in 2016. Hematopoietic stem cell transplantation has shown high cure rates but with available treatments like tyrosine kinase inhibitors and high success rates with the low adverse risk profile, HSCT is reserved for patients with the refractory disease to first-line agents in CML.
• Myelofibrosis, Essential Thrombocytosis, and Polycythemia Vera – Allogenic stem cell transplant has shown to improve outcomes in patients with myelofibrosis and those who had a diagnosis of myelofibrosis that was preceded by essential thrombocytosis and polycythemia vera.[rx]
• Solid Tumors – Autologous stem cell transplant is considered the standard of care in patients with germ cell tumors (testicular tumors) that are refractory to chemotherapy (after the third recurrence with chemotherapy).[rx] HSCT has also been studied in medulloblastoma, metastatic breast cancer, and other solid tumors.

Non-Malignant Diseases

• Aplastic Anemia – Systematic and retrospective studies have suggested an improved outcome with hematopoietic stem cell transplant in acquired aplastic anemia when compared with conventional immunosuppressive therapy.[rx] Allogenic stem cell transplant has shown better outcomes when it was collected from bone marrow compared to peripheral blood in a study that involved 1886 patients with acquired aplastic anemia.[rx] Patients with aplastic anemia need a preparative regimen given they still can develop immune rejection to the graft.
• Severe Combined Immune Deficiency Syndrome (SCID) – Large retrospective studies have shown increased overall survival in infants with SCID when they received the transplant early at birth before the onset of infections.[rx]
• Thalassemia – Allogenic stems transplant from a matched sibling donor is considered an option to treat Thalassemia and has shown 15-year survival reaching 80%. However, recent retrospective data showed similar overall survival compared with conventional treatment that consists of multiple transfusions in the case of thalassemia.[rx]
• Sickle Cell Anemia – Allogenic stem cell transplant is recommended for the treatment of sickle cell disease.[rx]
• Other Nonmalignant Diseases  – Stem cell transplant has been used in the treatment of chronic granulomatous disease, leukocyte adhesion deficiency, Chediak-Higashi syndrome, Kostman syndrome, Fanconi anemia, Blackfan-Diamond anemia, and enzymatic disorders. Moreover, the role of stem cell transplant is being explored in autoimmune diseases including systemic sclerosis, systemic lupus erythematosus, and has already shown promising results in cases like relapsing-remitting multiple sclerosis.[rx]

Contraindications of Hematopoietic Stem Cell Transplant

There are no absolute contraindications for hematopoietic stem cell transplant.

Rules for bone marrow transplant

These rules have been prepared as a guide for patients and their relatives.

• Stick to the physician’s prescription in using all medications.
• Make sure to come for regular check-ups. Please, arrive on an empty stomach and without having used any medication.
• Chemotherapy will inhibit the optimum functioning of the immune system for about a year. This is why it is very important to give extra care and attention to personal hygiene, nutrition, use of protective masks, accepting visitors, handshakes, and sexual relations throughout the entire year.
• Instructions for daily life after bone marrow transplant
• Your home should be especially clean following the transplant. Allocate a separate room for the patient. Remove dust magnet such as thick carpets and curtains from this room. Do not clean and air the patient’s room which he/she is still inside. If the room/home lacks central heating, make sure to light and clean the fire stove when the patient is outside the room. Adjust the room temperature carefully.
• The patient’s room must be away from any type of construction activity.
• All house plants and any kind of pet including cats, dogs, fish, and birds must be removed from the house for a year due to the risk of infection.
• Make sure to keep the rest of the house equally clean and tidy.
• Pay attention to land hygiene, take a wash at least two times a day, allocate a separate towel for the patient, and prevent its use by anyone else. Wash and iron the towel after each use. Take showers instead of baths, and use only moisturizing soaps.
• Use a paper towel for hand and face hygiene.
• Do not have guests for the first 100 days. Reduce the number of guests as much as possible in the subsequent period. Refrain from close contact including kissing, handshaking, and cuddling.
• Change the patient’s bed linen at least twice a week, frequently air the mattress.
• Do not use feather and wool-stuffed pillows.
• Make sure to wash all new clothes before use. Do not use corduroy or plush textiles.
• Make sure that the patient uses two masks whilst traveling or outdoors.
• Patients should not swim for a year (sea or pool) and should not use saunas.
• Prevent direct contact with sunlight for one year. Walks should be taken in the afternoon.
• Women should not get epilation for one year. Depilatory creams may be used if the physician approves.
• Give extra care to hygiene when getting the patient’s haircut.
• Brush teeth with a soft brush 3 times a day, try not to get gums bleeding.
• Do not use deodorants, perfumes, makeup, or hair dye for a year.
• Do not smoke or consume alcohol, steer clear of smoky, dusty, and dirty environments.
• Do not come in contact with people who have cold, flu, or infection.
• Immediately seek medical attention in case of bleeding, bruising, and swelling.
• Dress according to climate, avoid getting ill.
• Menstruation irregularities may develop in women following the transplant. Seek medical attention from the gynecology department in accordance with the physicians’ recommendations.
• Treatment will cause a loss in a sense of thirst, hunger, and taste for the first three months after the transplant. This is why patients have to drink three liters of water per day for a year. Drinking less can result in serious electrolyte disorder thus increasing the risk of getting sick. Liquid intake may also be supported by drinking milk, diluted yogurt, tea, fruit juice, or soup. Chew sugar-free chewing gum for building an appetite or suck on sweets for a sense of taste. Drink homemade lemonade 30 minutes before meals, if feeling nauseous.
• Do not drink spring water from unknown sources. Only drink bottled water.
• Use only pasteurized milk and cheese.
• Milk taken outside should be boiled for 15 minutes.
• Take single-use pasteurized and homemade yogurt.
• Thoroughly rinse all fruit and vegetables, leave them in water with vinegar for 30 minutes, and peel all skin before consuming.
• Eat seasonal fruit and vegetables. Avoid consuming processed foods and drinks with additives.
• Thoroughly cook all food. Strictly avoid eating salami, sausage, bacon, cured meat, spices, raw onions and garlic, tomato paste, animal fat, innards, legumes, pickles, creams, kebabs, pizzas, burgers and any sort of fast foods.
• Thoroughly cook all meats and eggs, make sure eggs are not cracked.
• Do not crack nuts with your teeth, use nutcrackers.
• Refrain from eating strawberries as they grow too close to the soil.
• Do not eat frozen, stale, or canned food. Food should be consumed in 24 hours.
• Store food in airtight containers.
• Use latex gloves to prepare food.
• Use mask whilst preparing food for the patient.
• Pay attention to expiration dates for all products and foods.
• Do not discuss distressing issues with the patient. Keep patient’s spirit high

Equipment

Special equipment exists for the collection, preservation, and administration of stem cell products. An interprofessional team approach is a mainstay of ensuring the high-quality collection and infusion of stem cell products.

Preparation

Preparation includes:

• Preparative regimen
• Collection of hematopoietic stem cells
• Instant infusion or cryopreservation followed by infusion

Technique

Mechanism of Action

The mechanism of action of stem cell transplant against malignancy in leukemia is based on the effect of the graft and donor immunity against malignant cells in recipients. These findings were demonstrated in a study that involved over 2000 patients with different leukemia. These patients received stem cell transplantation and showed that the lowest rate of relapses was in patients who received non-T-cell-depleted bone marrow cells and in those who developed GVHD compared to patients who received T-cell-depleted stem cells, those who did not develop GVHD, and patients who received syngeneic grafts. These findings support the notion that donor cellular immunity plays a central role in the engraftment’s efficacy against tumor cells.[rx]

The mechanism of action in autoimmune diseases is believed to be secondary to the increase in T-cell regulatory function which promotes immune tolerance. However, more studies are still needed to determine the exact pathophysiology.

In hemoglobinopathies, the transplanted stem cells produce functional cells after engraftment that replaces the diseased cells.

HLA Typing and Administration

HLA typing is an important step to determine the best donor suitable for stem cell collection. In theory, matched, related donors are the best candidates, followed by matched unrelated donors, cord blood, and then haploidentical donors. HLA typing is analyzed at either an intermediate-resolution level, which entails the detection of a small number of matched alleles between the donor serum and the recipient, or at a high-resolution level to determine the specific number of polymorphic alleles at a higher level. PCR and next-generation sequencing are used for HLA typing, and the results are reported as a score correlating with a match of two alleles for a specific HLA type. Different institutions use a different number of HLA subtypes for eligibility of donors but according to studies that showed matching for HLA-A, B, C, and DRB1 at a high-resolution level were associated with improved survival and outcomes.[rx] Recommendations about donor HLA assessment and matching have been proposed by the Blood and Marrow Transplant Clinical Trials Network (BM CTN).[rx]

The process may vary depending on the source of the stem cell site collection, whether it is bone marrow, peripheral blood, or cord blood. Moreover, there is a slight difference based on whether it is autologous, allogeneic, or syngeneic. For example, the procedure consists of initial mobilization of stem cells, in which peripheral blood stem cells are collected given the low number and the need for high levels of progeny cells, and then this is followed by a preparative regimen and finally, infusion.

Mobilization and collection involved the use of medication to increase the number of stem cells in the peripheral blood given that there are not enough stem cells in the peripheral blood. The agents used include granulocyte colony-stimulating factors (G-CSF) or chemokine receptor 4 (CXCR4) blockers like plerixafor. G-CSF is believed to enhance neutrophils to release serine proteases which lead to a break of vascular adhesion molecules and the release of hematopoietic stem cells from the bone marrow. Plerixafor blocks the binding of stromal cell-derived factor-1-alpha (SDF-1) to (CXCR4) which leads to the mobilization of stem cells to the peripheral blood.[rx] CD34+ is considered the marker for progenitor hematopoietic stem cells in the peripheral blood, and usually, a dose of 2 to 10 x 10/kg CD34+ cells/kg is needed for proper engraftment. Chemotherapy can be used in some instances for mobilization of hematopoietic stem cells; this process is termed chemoembolization.

The usual site of bone marrow collection is the anterior or posterior iliac crest. The procedure can be performed under local or general anesthesia. Complications include pain, fever, and serious iatrogenic complications can occur in less than 1% of cases. Multiple aspirations are done with each aspirate containing 15 mL. The goal is to collect up to 1 to 1.5 L of bone marrow product from the aspirations. The dose of nucleated cells from bone marrow should range between 2 to 4 x 10 cells/kg as studies showed that overall survival and long-term engraftment is strongly influenced by cell dose in allogeneic hematopoietic stem cell transplantation.[rx]

The preparative regimen consists of administration of chemotherapy with or without total body irradiation for the eradication of malignant cells and induction of immune tolerance for the transfused cells to engraft properly. This process is not only limited to patients with malignancies but also extends to cases like aplastic anemia and hemoglobinopathies given that these patients have an intact immune system that could cause graft failure if there is no conditioning.

The preparative regimen is divided into myeloablative conditioning and reduced-intensity conditioning. The preparative regimen depends on the disease being treated, existing comorbidities, and the source of the harvested hematopoietic stem cells. The preparative regimen consists of chemotherapy, total body irradiation, or both. There are different combination regimens used in the preparative period, and the choice of the regimen depends on the disease being treated, existing comorbidities, and previous exposure to radiation.

In the special case of SCID, there is no need for a preparative regimen in patients receiving from HLA-matched siblings given that there are no abnormal cells that are needed to be eliminated and because immunosuppression caused by SCID can prevent graft rejection. Reduced-intensity conditioning is preferred in patients with prior radiotherapy, older age, the presence of comorbidities, and history of extensive chemotherapy before BMT.[rx] The advantages of using reduced-intensity conditioning include less need for transfusion due to the transient post-transplant pancytopenia and less damage to the liver in cases of chemotherapy and lung due to radiation.[rx] However, the relapse rates are higher, but these regimens are more tolerated with a better safety profile in a specific patient population. Most of the chemotherapies used in preparative regimens consist of either potent immunosuppressive agents (high doses of cyclophosphamide 60 mg/kg IV), alkylating agents especially busulfan 130 mg/m2 IV, nucleoside analogs (fludarabine 40 mg/m2) and other agents like melphalan, antithymocyte globulin, rituximab, gemcitabine, and many others. Total body irradiation (TBI) is performed using fractionated doses because it has shown less pulmonary toxicity when compared with one dose regimen.[rx] The administration of the preparative regimen should immediately precede the bone marrow transplantation, and as a general rule, the effect of the regimen should produce bone marrow suppression within 1 to 3 weeks of administration.

Reinfusion of either fresh or cryopreserved stem cells can occur in an ambulatory setting and takes up to 2 hours. Before the infusion begins, quality measures are performed to ensure the number of CD34+ cells is sufficient.

Rehabilitation after stem cell transplant

The process of stem cell transplant doesn’t end when you go home. You’ll feel tired, and some people have physical or mental health problems in the rehabilitation period. You might still be taking a lot of medicines. These ongoing needs must now be managed at home, so caregiver and friend/family support is very important.

Transplant patients are followed closely during rehab. You might need daily or weekly exams along with things like blood tests, and maybe other tests, too. During early rehab, you also might need blood and platelet transfusions, antibiotics, or other treatments. At first you’ll need to see your transplant team often, maybe even every day, but you’ll progress to less frequent visits if things are going well. It can take 6 to 12 months, or even longer, for blood counts to get close to normal and your immune system to work well. During this time, your team will still be closely watching you.

Some problems might show up as much as a year or more after the stem cells were infused. They can include:

• Graft-versus-host disease (in allogeneic transplants)
• Infections
• Lung problems, such as pneumonia or inflammation that makes it hard to breathe
• Kidney, liver, or heart problems
• Low thyroid function
• Overwhelming tiredness (fatigue)
• Limited ability to exercise
• Slowed growth and development (in children)
• Cataracts
• Reproductive or sexual problems, like infertility, early menopause, pain or discomfort during sex, or loss of interest in sex
• New cancers caused by the transplant

Other problems can also come up, such as:

• Memory loss, trouble concentrating
• Emotional distress, depression, body image changes, anxiety
• Social isolation
• Changes in relationships
• Changes in how you view the meaning of life
• Feeling indebted to others
• Job and insurance concerns

What complications and side effects may happen following BMT?

Complications may vary, depending on the following:

• Type of marrow transplant
• Type of disease requiring a transplant
• Preparative regimen
• Age and overall health of the recipient
• The variance of tissue matching between donor and recipient
• Presence of severe complications

The following are complications that may happen with a bone marrow transplant. However, each individual may experience symptoms differently. These complications may also happen alone, or in combination:

• Infections – Infections are likely in the patient with severe bone marrow suppression. Bacterial infections are the most common. Viral and fungal infections can be life-threatening. Any infection can cause an extended hospital stay, prevent or delay engraftment, and/or cause permanent organ damage. Antibiotics, antifungal medicines, and antiviral medicines are often given to try to prevent serious infection in the immunosuppressed patient
• Low platelets and low red blood cells – Thrombocytopenia (low platelets) and anemia (low red blood cells), as a result of nonfunctioning bone marrow, can be dangerous and even life-threatening. Low platelets can cause dangerous bleeding in the lungs, gastrointestinal (GI) tract, and brain.
• Pain – Pain-related to mouth sores and gastrointestinal (GI) irritation is common. High doses of chemotherapy and radiation can cause severe mucositis (inflammation of the mouth and GI tract).
• Fluid overload – Fluid overload is a complication that can lead to pneumonia, liver damage, and high blood pressure. The main reason for fluid overload is because the kidneys cannot keep up with a large amount of fluid being given in the form of intravenous (IV) medicines, nutrition, and blood products. The kidneys may also be damaged from disease, infection, chemotherapy, radiation, or antibiotics.
• Respiratory distress – Respiratory status is an important function that may be compromised during transplant. Infection, inflammation of the airway, fluid overload, graft-versus-host disease, and bleeding are all potentially life-threatening complications that may happen in the lungs and pulmonary system.
• Organ damage – The liver and heart are important organs that may be damaged during the transplantation process. Temporary or permanent damage to the liver and heart may be caused by infection, graft-versus-host disease, high doses of chemotherapy and radiation, or fluid overload.
• Graft failure – Failure of the graft (transplant) taking hold in the marrow is a potential complication. Graft failure may happen as a result of infection, recurrent disease, or if the stem cell count of the donated marrow was insufficient to cause engraftment.
• Graft-versus-host disease – Graft-versus-host disease (GVHD) can be a serious and life-threatening complication of a bone marrow transplant. GVHD occurs when the donor’s immune system reacts against the recipient’s tissue. As opposed to an organ transplant where the patient’s immune system will attempt to reject only the transplanted organ, in GVHD the new or transplanted immune system can attack the entire patient and all of his or her organs. This is because the new cells do not recognize the tissues and organs of the recipient’s body as the self. Over time and with the help of medicines to suppress the new immune system, it will begin to accept its new body and stop attacking it. The most common sites for GVHD are the GI tract, liver, skin, and lungs.

• https://www.ncbi.nlm.nih.gov/books/NBK536951/
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• https://www.ncbi.nlm.nih.gov/books/NBK543669/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626005/
• https://www.ncbi.nlm.nih.gov/books/NBK538515/
• https://www.ncbi.nlm.nih.gov/books/NBK459249/
• https://www.ncbi.nlm.nih.gov/books/NBK441968/
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• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560153/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2694700/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071465/
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• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142500/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781735/
• https://medlineplus.gov/ency/article/003009.htm
• https://www.nhs.uk/conditions/stem-cell-transplant/risks/
• https://www.sciencedirect.com/topics/medicine-and-dentistry/bone-marrow-transplantation
• https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/bone-marrow-transplantation
• https://www.nhlbi.nih.gov/health-topics/blood-and-bone-marrow-transplant
• https://www.anadolumedicalcenter.com/en/bone-marrow-transplant
• https://www.health.harvard.edu/diseases-and-conditions/bone-marrow-transplant-a-to-z
• https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/stem-cell-transplant/process.html
• https://www.mayoclinic.org/tests-procedures/bone-marrow-transplant/about/pac-20384854
• https://en.wikipedia.org/wiki/Hematopoietic_stem_cell_transplantation
• https://www.stanfordchildrens.org/en/topic/default?id=bone-marrow-transplantation-in-children-90-P03062
• https://www.seattlecca.org/treatments/bone-marrow-transplant/how-bone-marrow-transplants-work
• https://www.britannica.com/science/bone-marrow-transplant
• https://www.ohsu.edu/knight-cancer-institute/understanding-bone-marrow-and-stem-cell-transplants
• https://www.medicalnewstoday.com/articles/327000#recovery
• https://www.childrensoncologygroup.org/index.php/treatmentoptions/bonemarrowtransplant
• https://winshipcancer.emory.edu/patient-care/clinics-and-centers/bone-marrow-transplant-center.html
• https://www.kucancercenter.org/cancer/cancer-treatments/blood-marrow-transplant
• https://www.ucsfbenioffchildrens.org/education/bone_marrow_transplant_glossary/
• https://www.westchestermedicalcenter.org/wmc-bone-marrow-transplant
• https://siteman.wustl.edu/treatment/specialized-programs/bone-marrow-and-stem-cell-transplant/

What Is Hip Dislocations?/Hip Dislocations after trauma are frequently encountered in the emergency setting. A significant force is generally required to dislocate a hip as this ball and socket joint is quite stable due to its bony structure and the associated muscular and ligamentous attachments. Due to the required force, hip dislocations often are associated with other significant injuries; for example, fractures are found in over 50% of these patients. The majority of all hip dislocations are due to motor vehicle accidents. Posterior hip dislocations are the most common type, with anterior occurring only about 10% of the time. These injuries are true orthopedic emergencies and should be reduced expediently. The majority will resolve with a closed reduction in the emergency department.[rx][rx][rx]

Hip instability is a loose or wobbly hip joint that’s usually caused by problems with the ligaments (the bands of connective tissue that hold bones or joints together).

Causes of Hip Dislocations

• Acquired – Acquired hip dislocation is normally associated with high-speed trauma, with motor vehicle collisions account half of the dislocation with other causes such as falls and sports injuries, less common. Hip dislocation is the second most common complication of hip joint replacements and occurs in ~5% (range 0.5-10%) of patients with ~60% of dislocations being recurrent.
• Congenital – Congenital hip dislocation is now considered part of the spectrum of developmental dysplasia of the hip (see the article for further information).
• Forceful thrust – Anterior hip dislocations are usually the result of a significant force, such as trauma, or from a poorly positioned total hip arthroplasty.
• In a traumatic setting – the hip is forced into abduction with external rotation of the thigh and often related to a motor vehicle accident or fall. [rx]
• Falls – Falling onto an outstretched hand is one of the most common causes of hip dislocation.
• Sports injuries – Many hip dislocation occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause dislocation of the hip.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey

Symptoms of Hip Dislocations

In an accident victim, a traumatic hip dislocation can cause the following symptoms

• There is severe hip pain, especially when the leg is moved.
• The injured leg is shorter than the uninjured leg.
• The injured leg lies in an abnormal position. In most cases, the leg is bent at the hip, turned inward and pulled toward the middle of the body.
• There can be swelling at the site of the injury. The surrounding skin is puffy.
• Hip immobility Patients can experience difficulty moving the affected hip and so the inability to walk because of the pain and swelling.
• Hear snapping, clicking or popping sounds or sensations (crepitus) in any part of the hip
• Experience hip pain or pain in the groin
• Can’t put weight on your hip
• Can no longer walk normally
• The affected limb is shortened, adducted, and internally rotated, with the hip and knee in slight flexion
• Pain in the hip, buttock, and posterior leg
• Loss of sensation in posterior leg and foot
• Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
• Loss of deep tendon reflexes (DTRs) at the ankle
• Local hematoma

Diagnosis of Hip Dislocations

History and Physical

Patients with hip dislocations generally arrive in severe pain in the hip area; however, reports of pain in the knee, lower back, thigh, or even lower abdomen or pelvis are not uncommon. It is important to note that additional bony leg injuries may alter this classic presentation.

• Neurovascular exam –  is also required. Injuries to the femoral artery, vein, or nerve may rarely occur with anterior dislocations and should also be sought out. Femoral nerve motor function may be difficult to assess fully due to pain and the nature of this injury; however, sensory deficits over the anteromedial aspect of the thigh and medial side of the leg and foot should raise suspicion. Sciatic nerve injuries occur more often with posterior dislocations; however, they should be ruled out in any hip dislocation or fracture. Due to the required mechanism of injury related to these dislocations, a full trauma evaluation for other associated injuries should be considered.

Imaging

• X-rays – Hip dislocations usually are obvious on standard AP (anteroposterior) images of the pelvis. However, complete imaging usually includes a cross-table lateral of the affected joint.  On a normal AP pelvis, the femoral heads should appear similar in size with symmetric joint spaces. The joint with an anterior dislocation will project a larger-appearing femoral head. A femoral neck fracture should be ruled out by this image prior to attempting reduction. Judet views (45 degree internal and external oblique views) may be of some help in evaluating for bone fragments and occult acetabular and femoral head and neck fractures.
• Arthrogram – An arthrogram uses dye injected into the hip joint before X-rays or other scans. This dye helps your doctor clearly see details of the joint’s condition.
• Computed tomography – CT (Computed tomography) is recommended after a successful, closed hip reduction to evaluate for occult fractures. It may also further elucidate the cause of postreduction joint space widening and find intra-articular bone fragments or soft tissue injury that may prevent appropriate joint articulation. Moreta et al. found loose bodies in 20% of the hips that underwent post-reduction CT.[rx]
• MRI – MRI may be indicated to evaluate for soft tissue injuries and cartilaginous bodies that continue to cause issues after the acute period. Osteonecrosis also may be seen in the subacute period (4 to 8 weeks), and some have suggested that MRI is superior to CT for children with hip injuries as CT may miss unossified labrum and acetabular fractures.
• Other Testing – Laboratory studies should be tailored to the individual patient; however, if significant blood loss is suspected due to femoral vessel injury, serial hemoglobin/hematocrit and a type and screen may be requested.

Treatment of Hip Dislocations

Non – Pharmacological

Immediately following the injury, the RICE method is recommended

• Rest – Activities that cause hip pain, such as running or walking for long periods of time, should be avoided until pain and swelling go away. The activity that caused the injury should be avoided until fully recovered.
• Ice – A person may wish to apply ice packs to the area to help reduce pain and swelling. Ice packs can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected hip.
• Elevation – Keeping the knee elevated and supported above the waist—for example, sitting in a recliner or lying down with the knee propped up on pillows—may help with swelling.
• Use crutches – to avoid weight-bearing. Crutches are not needed in all cases. Dispense crutches; allow weight-bearing as tolerated.

Medication

If pain is severe and intolerable following medicine may be considered to prescribe to control pain and healing.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Vitamin C – It essential to healing fracture and soft tissue infection.

Open Reduction

Indications for Open Reduction

• A nonconcentric reduction (indicating a retained loose body or significant soft tissue injury preventing proper reduction)
• An associated acetabular or femoral head fracture that will require an open repair
• Femoral neck fracture
• A dislocation that is not reducible by closed reduction techniques

Patients who do not warrant an open reduction should have an urgent closed reduction in the emergency department under procedural sedation.

Anterior Hip Dislocation Reduction Techniques

Allis Maneuver

The Allis Maneuver is the most common method performed and differs slightly from the Allis maneuver used for posterior hip reductions. The patient lies supine with the practitioner standing over them. An assistant stabilizes the pelvis by applying pressure over the bilateral anterior superior iliac spines. The practitioner holds the affected leg just below the knee and, while slightly flexing the hip, applies constant traction to the hip joint along the long axis. The hip may be internally rotated and adducted. A gentle lateral force to the thigh may be of some assistance. The reduction is performed until an audible click is heard, suggesting a successful reduction.

“Captain Morgan” Technique

The “Captain Morgan” Technique is a more novel approach named after the character on the spirit bottle. The patient lies supine with both the knee and hip flexed. The practitioner positioned their foot on the patient’s stretcher with their knee bent (hence the “Captain Morgan” moniker) and positioned behind the patient’s knee. The practitioner places a hand under the patient’s knee and the other on their ankle. With the first hand, the practitioner lifts the patient’s femur while plantar flexing their ankle to raise the patient’s femur. The practitioner then applies gentle downward pressure over the patient’s ankle. This “leverages” the hip back into place. Stabilization of the pelvis by a strap or an assistant may be helpful.

Reverse Bigelow Maneuver

The patient is positioned supine with the hip partially flexed and abducted. A firm jerk is then applied to the thigh. Another variation has the practitioner apply traction longitudinally with hip adducted and apply abrupt internal rotation and extension of the hip

Stimson Maneuver

This technique also is less frequently used due to difficult patient positioning; however, it is often suggested to be a less traumatic process. The patient is placed in the prone position with the affected leg allowed to hang from the side of the bed; the knee and hip are flexed while an assistant stabilizes the patient’s lower back. Traction is applied downward by the practitioner who is holding the leg just below the knee. This allows gravity to assist with the traction. Internal and external rotation are applied until a successful reduction is felt.

Open Reduction

• Multiple surgical approaches for reducing an anterior hip joint are possible; however, all require joint irrigation to remove any bony or soft tissue structures that would prevent a concentric reduction. Postoperatively reduced hips should be held in traction for 6 to 8 weeks, until definitive fixation, or until the pain has entirely resolved.

Rehabilitation

Hip dislocation rehabilitation can take anywhere from two to three months, depending on the person. Complications to nearby nerves and blood vessels can sometimes cause loss of blood supply to the bone, also known as osteonecrosis. The protective cartilage on the bone can also be disturbed by this type of injury. For this reason, it is important for people to contact a physician and get treatment immediately following injury.^[rx]

• The first step to recovering from a hip dislocation is a reduction. This refers to putting the bones back into their intended positions. Normally, this is done by a physician while the person is under a sedative. Other times, a surgical procedure is required to reduce the hip bones back into their natural state.^[rx]
• Next, rest, ice, and take anti-inflammatory medication to reduce swelling at the hip.
• Weight-bearing is allowed for the type one posterior dislocation, but should only be done as pain allows and the person is comfortable.^[rx]
• Within 5–7 days of the injury occurrence, people may perform passive range of motion exercises to increase flexibility.
• A walking aid should be used until the person is comfortable with both weight-bearing and range of motion.^[rx]

Exercises

Individuals suffering from hip dislocation should participate in physical therapy and receive professional prescriptive exercises based on their individual abilities, progress, and overall range of motion. The following are some typically recommended exercises used as rehabilitation for hip dislocation. It is important to understand that each individual has different capabilities that can best be assessed by a physical therapist or medical professional, and that these are simply recommendations.

• Bridge- Lie flat on the back. Place arms with palms down beside the body. Keep feet hip-distance apart and bend knees. Slowly lift hips upward. Hold the position for three to five seconds. This helps strengthen the glutes and increase the stability of the hip joint.^[rx]
• Supine leg abduction – Lie flat on the back. Slowly slide leg away from the body and then back in, keeping the knees straight. This exercises the gluteus medius and helps to maintain stability in the hip while walking.^[rx]
• Side-Lying Leg abduction – Lie on one side with one leg on top of the other. Slowly lift the top leg towards the ceiling and then lower it back down slowly.^[rx]
• Standing Hip abduction – Standing up and holding on to a nearby surface, slowly lift one leg away from the midline of the body and then lower it back to starting position. This is simply a more advanced way to do any of the lying hip abduction exercises and should be done as the person progresses in rehab.^[rx]
• Knee raises – While standing and holding onto a chair, slowly lift one leg off the ground and bring it closer to the body while bending the knee. Then lower the leg back down slowly. This helps to strengthen the hip flexor muscles and retain stability in the hip.^[rx]
• Hip flexion and extensions – Standing, hold on to a nearby chair or surface. Swing one leg forwards away from you, and hold the position for three to five seconds. Then swing the leg slowly backward and behind your body. Hold for three to five seconds. This exercise helps to increase range of motion, as well as strengthening the hip flexor and hip extensor muscles that control much of the hip joint.^[rx]
• Adding ankle weights – to any exercises can be done as progress is made in rehabilitation.

Complications

• Femoral head trauma – Anterior hip dislocations commonly are associated with femoral head trauma and therefore have a higher incidence of long-term decreased functional outcomes and post-traumatic arthritis. Moreta et al. found that 13.3% of patients that suffered a complex dislocation had radiographic signs of osteoarthritis.[rx] Approximately 50% of all anterior dislocations have femoral head indentation fractures; however, patients without these associated fractures often have an excellent, long-term outcome.
• Osteonecrosis – This complication ranges from 5% to 40% of all hip dislocations but is related to the time before the joint’s reduction, with over 6 hours increasing the risk. Up to 20% of all traumatic hip dislocations will suffer osteonecrosis of the hip. [rx]
• Thromboembolism – Patients are at an increased risk of thromboembolism due to both immobility post-injury and due to vascular intima injury related to traction. Rezaie et al. found a 0.5% risk of venous thromboembolism after a surgical hip dislocation. Prophylaxis should be the standard for this group. [rx]
• Recurrent dislocation – This occurs in approximately 2% of patients. Itokawa et al. found that 40% of patients who dislocated after total hip arthroplasty, suffered repeat hip dislocations. [rx]
• Neurovascular injury –  Although the injury to the femoral nerve or vasculature has been reported, it remains relatively rare. Cornwall et al. found 10% of adults and 5% of children will suffer neuropraxia following hip dislocation. Fortunately, 60-70% of patients had partial resolution of symptoms. [rx]

References

Hip Dislocations after trauma are frequently encountered in the emergency setting. A significant force is generally required to dislocate a hip as this ball and socket joint is quite stable due to its bony structure and the associated muscular and ligamentous attachments. Due to the required force, hip dislocations often are associated with other significant injuries; for example, fractures are found in over 50% of these patients. The majority of all hip dislocations are due to motor vehicle accidents. Posterior hip dislocations are the most common type, with anterior occurring only about 10% of the time. These injuries are true orthopedic emergencies and should be reduced expediently. The majority will resolve with a closed reduction in the emergency department.[rx][rx][rx]

Hip instability is a loose or wobbly hip joint that’s usually caused by problems with the ligaments (the bands of connective tissue that hold bones or joints together).

Causes of Hip Dislocations

• Acquired – Acquired hip dislocation is normally associated with high-speed trauma, with motor vehicle collisions account half of the dislocation with other causes such as falls and sports injuries, less common. Hip dislocation is the second most common complication of hip joint replacements and occurs in ~5% (range 0.5-10%) of patients with ~60% of dislocations being recurrent.
• Congenital – Congenital hip dislocation is now considered part of the spectrum of developmental dysplasia of the hip (see the article for further information).
• Forceful thrust – Anterior hip dislocations are usually the result of a significant force, such as trauma, or from a poorly positioned total hip arthroplasty.
• In a traumatic setting – the hip is forced into abduction with external rotation of the thigh and often related to a motor vehicle accident or fall. [rx]
• Falls – Falling onto an outstretched hand is one of the most common causes of hip dislocation.
• Sports injuries – Many hip dislocation occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause dislocation of the hip.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey

Symptoms of Hip Dislocations

In an accident victim, a traumatic hip dislocation can cause the following symptoms

• There is severe hip pain, especially when the leg is moved.
• The injured leg is shorter than the uninjured leg.
• The injured leg lies in an abnormal position. In most cases, the leg is bent at the hip, turned inward and pulled toward the middle of the body.
• There can be swelling at the site of the injury. The surrounding skin is puffy.
• Hip immobility Patients can experience difficulty moving the affected hip and so the inability to walk because of the pain and swelling.
• Hear snapping, clicking or popping sounds or sensations (crepitus) in any part of the hip
• Experience hip pain or pain in the groin
• Can’t put weight on your hip
• Can no longer walk normally
• The affected limb is shortened, adducted, and internally rotated, with the hip and knee in slight flexion
• Pain in the hip, buttock, and posterior leg
• Loss of sensation in posterior leg and foot
• Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
• Loss of deep tendon reflexes (DTRs) at the ankle
• Local hematoma

Diagnosis of Hip Dislocations

History and Physical

Patients with hip dislocations generally arrive in severe pain in the hip area; however, reports of pain in the knee, lower back, thigh, or even lower abdomen or pelvis are not uncommon. It is important to note that additional bony leg injuries may alter this classic presentation.

• Neurovascular exam –  is also required. Injuries to the femoral artery, vein, or nerve may rarely occur with anterior dislocations and should also be sought out. Femoral nerve motor function may be difficult to assess fully due to pain and the nature of this injury; however, sensory deficits over the anteromedial aspect of the thigh and medial side of the leg and foot should raise suspicion. Sciatic nerve injuries occur more often with posterior dislocations; however, they should be ruled out in any hip dislocation or fracture. Due to the required mechanism of injury related to these dislocations, a full trauma evaluation for other associated injuries should be considered.

Imaging

• X-rays – Hip dislocations usually are obvious on standard AP (anteroposterior) images of the pelvis. However, complete imaging usually includes a cross-table lateral of the affected joint.  On a normal AP pelvis, the femoral heads should appear similar in size with symmetric joint spaces. The joint with an anterior dislocation will project a larger-appearing femoral head. A femoral neck fracture should be ruled out by this image prior to attempting reduction. Judet views (45 degree internal and external oblique views) may be of some help in evaluating for bone fragments and occult acetabular and femoral head and neck fractures.
• Arthrogram – An arthrogram uses dye injected into the hip joint before X-rays or other scans. This dye helps your doctor clearly see details of the joint’s condition.
• Computed tomography – CT (Computed tomography) is recommended after a successful, closed hip reduction to evaluate for occult fractures. It may also further elucidate the cause of postreduction joint space widening and find intra-articular bone fragments or soft tissue injury that may prevent appropriate joint articulation. Moreta et al. found loose bodies in 20% of the hips that underwent post-reduction CT.[rx]
• MRI – MRI may be indicated to evaluate for soft tissue injuries and cartilaginous bodies that continue to cause issues after the acute period. Osteonecrosis also may be seen in the subacute period (4 to 8 weeks), and some have suggested that MRI is superior to CT for children with hip injuries as CT may miss unossified labrum and acetabular fractures.
• Other Testing – Laboratory studies should be tailored to the individual patient; however, if significant blood loss is suspected due to femoral vessel injury, serial hemoglobin/hematocrit and a type and screen may be requested.

Treatment of Hip Dislocations

Non – Pharmacological

Immediately following the injury, the RICE method is recommended

• Rest – Activities that cause hip pain, such as running or walking for long periods of time, should be avoided until pain and swelling go away. The activity that caused the injury should be avoided until fully recovered.
• Ice – A person may wish to apply ice packs to the area to help reduce pain and swelling. Ice packs can be applied several times throughout the day for about 10 to 20 minutes at a time.
• Compression – Swelling can be managed by wearing an elastic bandage around the affected hip.
• Elevation – Keeping the knee elevated and supported above the waist—for example, sitting in a recliner or lying down with the knee propped up on pillows—may help with swelling.
• Use crutches – to avoid weight-bearing. Crutches are not needed in all cases. Dispense crutches; allow weight-bearing as tolerated.

Medication

If pain is severe and intolerable following medicine may be considered to prescribe to control pain and healing.

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Dietary supplement-to remove general weakness & improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
• Vitamin C – It essential to healing fracture and soft tissue infection.

Open Reduction

Indications for Open Reduction

• A nonconcentric reduction (indicating a retained loose body or significant soft tissue injury preventing proper reduction)
• An associated acetabular or femoral head fracture that will require an open repair
• Femoral neck fracture
• A dislocation that is not reducible by closed reduction techniques

Patients who do not warrant an open reduction should have an urgent closed reduction in the emergency department under procedural sedation.

Anterior Hip Dislocation Reduction Techniques

Allis Maneuver

The Allis Maneuver is the most common method performed and differs slightly from the Allis maneuver used for posterior hip reductions. The patient lies supine with the practitioner standing over them. An assistant stabilizes the pelvis by applying pressure over the bilateral anterior superior iliac spines. The practitioner holds the affected leg just below the knee and, while slightly flexing the hip, applies constant traction to the hip joint along the long axis. The hip may be internally rotated and adducted. A gentle lateral force to the thigh may be of some assistance. The reduction is performed until an audible click is heard, suggesting a successful reduction.

“Captain Morgan” Technique

The “Captain Morgan” Technique is a more novel approach named after the character on the spirit bottle. The patient lies supine with both the knee and hip flexed. The practitioner positioned their foot on the patient’s stretcher with their knee bent (hence the “Captain Morgan” moniker) and positioned behind the patient’s knee. The practitioner places a hand under the patient’s knee and the other on their ankle. With the first hand, the practitioner lifts the patient’s femur while plantar flexing their ankle to raise the patient’s femur. The practitioner then applies gentle downward pressure over the patient’s ankle. This “leverages” the hip back into place. Stabilization of the pelvis by a strap or an assistant may be helpful.

Reverse Bigelow Maneuver

The patient is positioned supine with the hip partially flexed and abducted. A firm jerk is then applied to the thigh. Another variation has the practitioner apply traction longitudinally with hip adducted and apply abrupt internal rotation and extension of the hip

Stimson Maneuver

This technique also is less frequently used due to difficult patient positioning; however, it is often suggested to be a less traumatic process. The patient is placed in the prone position with the affected leg allowed to hang from the side of the bed; the knee and hip are flexed while an assistant stabilizes the patient’s lower back. Traction is applied downward by the practitioner who is holding the leg just below the knee. This allows gravity to assist with the traction. Internal and external rotation are applied until a successful reduction is felt.

Open Reduction

• Multiple surgical approaches for reducing an anterior hip joint are possible; however, all require joint irrigation to remove any bony or soft tissue structures that would prevent a concentric reduction. Postoperatively reduced hips should be held in traction for 6 to 8 weeks, until definitive fixation, or until the pain has entirely resolved.

Rehabilitation

Hip dislocation rehabilitation can take anywhere from two to three months, depending on the person. Complications to nearby nerves and blood vessels can sometimes cause loss of blood supply to the bone, also known as osteonecrosis. The protective cartilage on the bone can also be disturbed by this type of injury. For this reason, it is important for people to contact a physician and get treatment immediately following injury.^[rx]

• The first step to recovering from a hip dislocation is a reduction. This refers to putting the bones back into their intended positions. Normally, this is done by a physician while the person is under a sedative. Other times, a surgical procedure is required to reduce the hip bones back into their natural state.^[rx]
• Next, rest, ice, and take anti-inflammatory medication to reduce swelling at the hip.
• Weight-bearing is allowed for the type one posterior dislocation, but should only be done as pain allows and the person is comfortable.^[rx]
• Within 5–7 days of the injury occurrence, people may perform passive range of motion exercises to increase flexibility.
• A walking aid should be used until the person is comfortable with both weight-bearing and range of motion.^[rx]

Exercises

Individuals suffering from hip dislocation should participate in physical therapy and receive professional prescriptive exercises based on their individual abilities, progress, and overall range of motion. The following are some typically recommended exercises used as rehabilitation for hip dislocation. It is important to understand that each individual has different capabilities that can best be assessed by a physical therapist or medical professional, and that these are simply recommendations.

• Bridge- Lie flat on the back. Place arms with palms down beside the body. Keep feet hip-distance apart and bend knees. Slowly lift hips upward. Hold the position for three to five seconds. This helps strengthen the glutes and increase the stability of the hip joint.^[rx]
• Supine leg abduction – Lie flat on the back. Slowly slide leg away from the body and then back in, keeping the knees straight. This exercises the gluteus medius and helps to maintain stability in the hip while walking.^[rx]
• Side-Lying Leg abduction – Lie on one side with one leg on top of the other. Slowly lift the top leg towards the ceiling and then lower it back down slowly.^[rx]
• Standing Hip abduction – Standing up and holding on to a nearby surface, slowly lift one leg away from the midline of the body and then lower it back to starting position. This is simply a more advanced way to do any of the lying hip abduction exercises and should be done as the person progresses in rehab.^[rx]
• Knee raises – While standing and holding onto a chair, slowly lift one leg off the ground and bring it closer to the body while bending the knee. Then lower the leg back down slowly. This helps to strengthen the hip flexor muscles and retain stability in the hip.^[rx]
• Hip flexion and extensions – Standing, hold on to a nearby chair or surface. Swing one leg forwards away from you, and hold the position for three to five seconds. Then swing the leg slowly backward and behind your body. Hold for three to five seconds. This exercise helps to increase range of motion, as well as strengthening the hip flexor and hip extensor muscles that control much of the hip joint.^[rx]
• Adding ankle weights – to any exercises can be done as progress is made in rehabilitation.

Complications

• Femoral head trauma – Anterior hip dislocations commonly are associated with femoral head trauma and therefore have a higher incidence of long-term decreased functional outcomes and post-traumatic arthritis. Moreta et al. found that 13.3% of patients that suffered a complex dislocation had radiographic signs of osteoarthritis.[rx] Approximately 50% of all anterior dislocations have femoral head indentation fractures; however, patients without these associated fractures often have an excellent, long-term outcome.
• Osteonecrosis – This complication ranges from 5% to 40% of all hip dislocations but is related to the time before the joint’s reduction, with over 6 hours increasing the risk. Up to 20% of all traumatic hip dislocations will suffer osteonecrosis of the hip. [rx]
• Thromboembolism – Patients are at an increased risk of thromboembolism due to both immobility post-injury and due to vascular intima injury related to traction. Rezaie et al. found a 0.5% risk of venous thromboembolism after a surgical hip dislocation. Prophylaxis should be the standard for this group. [rx]
• Recurrent dislocation – This occurs in approximately 2% of patients. Itokawa et al. found that 40% of patients who dislocated after total hip arthroplasty, suffered repeat hip dislocations. [rx]
• Neurovascular injury –  Although the injury to the femoral nerve or vasculature has been reported, it remains relatively rare. Cornwall et al. found 10% of adults and 5% of children will suffer neuropraxia following hip dislocation. Fortunately, 60-70% of patients had partial resolution of symptoms. [rx]

References