Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report

doi:10.4236/ojo.2011.11001

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Open Journal of Orthopedics, 2011, 1, 1-4

doi:10.4236/ojo.2011.11001 Published Online September 2011 (http://www.SciRP.org/journal/ojo)

Trochanteric Fracture of a Congenital/

Developmental Dislocation of the Hip

in an Elderly Woman: A Case Report

Kazuhiro Imai

Department of Orthopaedic Surgery, Mishuku Hospital, Tokyo, Japan.

Email: [email protected]

Received July 22nd, 2011; revised August 25th, 2011; accepted September 4th, 2011.

ABSTRACT

An 87-year-old woman with a residual dislocated hip suffered a trochanteric fracture on the ipsilateral side. The frac-

ture was treated by open reductio n and intern al fixation surgery with good results. To treat a proxima l femoral fracture

of the residual dislocated hip in an elderly patient, the patient’s overall sta tus, pre-fracture ability, hip joint configura-

tion, and fracture pattern should be considered.

Keywords: Congenital/Developmental Dislocation of the Hip, Trochanteric Fracture, Elderly Woman

1. Introduction

Managing congenital/developmental dislocation of the

hip (CDH) in adults presents many challenges. It is also

difficult to manage a trochanteric fracture in a patient

with CDH. We present an elderly woman with a tro-

chanteric fracture of a CDH who underwent open reduc-

tion and internal fixation surgery. We also describe the

treatment options that allowed for restoration of the pa-

tient’s pre-fracture status.

2. Case Report

An 87-year-old woman slipped and fell to the floor at

home and was admitted urgently to our hospital with left

hip pain and an inability to walk. The patient had a his-

tory of CDH and her pre-fracture activity level was dou-

ble-crutch walking. She had used crutches since she was

42 years old. She had hypertension and was diagnosed

with congestive heart failure when she was 86 years old.

Her height was 147 cm and her weight was 46 kg.

Radiographs showed a fracture at the left proximal

femur (AO classification of trochanteric fractures type

A3) and a residual dislocated hip on the ipsilateral side

(Figure 1). The residual femoral neck was located in the

gluteal muscles above the original acetabulum. The

amount of subluxation was more than 100% (Crowe type

IV [1]). The left femoral head and the lesser trochanter

were absent. The left femoral neck was short and the

proximal femoral shaft was narrow. The right hip formed

the secondary acetabulum above the original acetabulum.

The right femoral neck was extremely short and the right

femoral head was severely deformed.

At first, a nonsurgical approach was taken. The patient

remained on bed rest for 3 weeks without traction. At 3

weeks, radiographs showed the displaced fracture and no

bone format ion (Figure 2).

The fracture was treated by open reduction and inter-

nal fixation surgery. A traction table and X-ray fluoros-

copy were used. The displaced fracture was reduced with

the left hip 10 degrees adducted. The proximal femur

Figure 1. Radiograph of the pelvis on admission showing

fracture at the proximal left femur and residual dislocated

hip on the ipsilateral side.

Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report

was explored through a lateral incision. A 50 mm lag

screw was inserted into the proximal fragment and a 95-

degree DCS® plate (Synthes, West Ch ester, Pennsylvan ia,

USA), stabilized by four cancellous screws and three

cortical screws, was used (Figure 3).

Figure 2. Radiograph 3 weeks after admission, showing the

displaced fracture without bone formation.

Figure 3. Postoperative radiograph of the left hip.

The patient remained on bed rest for 2 weeks without

an extern a l f ixatio n and 2 week s af ter sur g er y, sh e st ar ted

sitting in a wheelchair. At 4 weeks, bone formation at the

fracture site was noted and partial weight bearing was

started. Full weight bearing was started 6 weeks post-

operatively. She was able to walk 50 meters with double-

crutches 3 months postoperatively. She was able to walk

indoors with double crutches 2 years postoperatively at

the age of 89. Radiographs showed healed fracture (Fig-

ure 4). Consent for publication has been obtained from

the patient and her daughter.

3. Discussion

Newborn and infant screening and prevention of CDH

has been in place since the 1970s in Japan, and the pres-

ence of residual dislocated hips has markedly decreased

[2]. Howev er, before th e 1970s, CDH prev ention was no t

available and the prevalence of CDH was more than 3%.

Therefore, residual dislocated hips are not rare in elderly

people in present-day Japan.

Conservatively treated CDH might be a major risk

factor for low bone mineral density at the hip and osteo-

porotic hip fracture [3]. In elderly people, and especially

in elderly women, minor trauma like falling can cause a

fracture at the proximal femur because of skeletal fragil-

ity due to osteoporosis. Therefore, elderly patients with

residual dislocated hips may suffer a proximal femoral

fracture, althoug h few reports have been pub lishe d.

We found only one case in previous reports that had

suffered the combination of proximal femoral fracture

and residual dislocated hip. The case was a 20-year-old

active male with a high congenital dislocation of the hip

who sustained a displaced subcapital fracture in a traffic

accident [4]. He underwent Girdlestone resection arthro-

plasty [5] and 2 years after surgery, he had almost full

range of motion at the hip and was able to resume his

preoperative hobbies, including jogging, swimming, and

contact sports.

Figure 4. Radiograph 2 years postoperatively.

Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report

The English literature does not cite any reports de-

scribing a proximal femoral fracture with residual dislo-

cated hip in an elderly person. Several options are avail-

able to treat this combination in an elderly patient, as

described below.

3.1. Total Hip Arthroplasty (THA)

In patients with a residual dislocated hip undergoing

THA, the acetabular component should be placed in the

anatomical position and the femur should be shortened to

prevent excessive limb lengthening or sciatic nerve in-

jury [6]. In these patients, the original acetabulum is

shallow with a short anteroposterior diameter, and this

limits the size of the cup and therefore the thickness of

the polyethylene insert. Excessive polyethylene wear

results in cup revisions. The surv ival rate in patients with

high congenital hip dislocation was reported to be 68% -

78% at 10 - 20 years [7-12] (Table 1).

In this case, THA could have been considered because

the patient was old and long-term survival was not a ma-

jor goal. However, we did not choose THA because of

the invasiveness of this procedure considering our pa-

tient’s age and cardiopulmonary status.

3.2. Open Reduction and Internal Fixation

Our patient had a long h istory of a left dislocated hip and

had not complained of hip pain before the fracture.

Therefore, the most appropriate treatment option to con-

sider would be one that best restores her pre-fracture

status, that is, provide a good reduction and a secure in-

ternal fixation, disregarding the fact that the hip was dis-

located.

In terms of fixation devices, compression hip screws

or trochanteric nails are generally used for trochanteric

fractures in elderly patients. However, in this case, there

were no properly sized lag screws because the femoral

head was absent and the femoral neck was short. Nail

fixation might be another option, but again in this case,

there were no properly sized nails because the proximal

femoral shaft was narrow.

We used a 95-degree DCS® plate because of the

availability of the shortest lag screw fitted for proximal

fragment and suf fi c i ent fi xat i on and st ren gth (ie, 50 mm ).

3.3. Arthrodesis

The ideal patient for hip arthrodesis is a young adult with

an active lifestyle. Previous studies have indicated that

most young patients who undergo arthrodesis for severe

osteoarthritis are very satisfied despite the functional

disadvantages of a fusion [13,14]. In our case, the patient

was old and might incur nonunion and complications

associated with prolonged cast immobilization.

3.4. Proximal Femoral Neck Resection

Girdlestone resection arthroplasty or femoral head resec-

tion has been reported to achieve good pain relief, mobil-

ity, and function in older patients with osteoarthritis or

ankylosing spondylitis. Th e Girdlestone procedure for an

unreduced fracture-dislocation has been shown to have

good results 6 years postoperatively [15]. In our case, we

considered resection of the proximal femoral neck frag-

ment as the second choice because of the lack of the

femoral head. Our first choice was open reduction and

internal fixation to restore the pr e-fracture status. If open

reduction and internal fixation was technically unf easible,

proximal femoral neck resection might be a better option

than THA or arthrodesis in this patient.

3.5. Conservative Treatment

Conservative treatment based on traction method and bed

rest is one of the options for a proximal femoral fracture

in an elderly patient. Compared to conservative treatment,

operative treatment with internal fixation devices is more

likely to result in the fracture healing without leg short-

ening, a shorter hospital stay and a statistically non-sig-

nificant increase in the return of patients back to their

original residence [16]. We took conservative treatment

of bed rest without traction method at first because the

fracture was not displaced. However, the fracture was

displaced without bone formation at 3 weeks. Traction

method might be more appropriate for conservative treat-

ment.

Table 1. Summary of reported results of total hip arthroplasty in high c ong enital hip disloc ations.

Reference No. of hips Average age at surgery

(years) Revised rateSurvival rate

[follow-up period]

Fredin H [7] 21 46.5 43% -

Numair J [8] 46 41.5 17% 68% [15 years]

Kerboull M [9] 118 52.0 13% 78% [20 years]

Hartofilakidis G [10] 83 49.5 22% 76% [15 years]

Lai KA [11] 56 35.4 16% 77% [12 years]

Eskelinen A [12] 68 54.0 43% 73% [10 years]

Trochanteric Fracture of a Congenital/Developmental Dislocation of the Hip in an Elderly Woman: A Case Report

4. Conclusions

Although there are few reports about the combination of

proximal femoral fracture and residual dislocated hip in

elderly people, more and more patients will suffer this

combination because the elderly population continues to

increase. To treat proximal femoral fracture of residual

dislocated hip in an elderly patient, the patient’s overall

status, pre-fracture ability, hip joint configuration, and

fracture pattern should be considered.

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