创伤性髋关节脱位合并膝关节损伤的临床研究

目的探讨创伤性髋关节脱位中合并的膝关节损伤的发病情况.方法 2004年4月至2010年5月本组共收治创伤性髋关节脱位患者28例,通过同侧膝关节的病史、体格检查和MRI检查,研究所有创伤性髋关节脱位患者同侧膝关节的损伤情况.结果 28例髋关节脱位患者中有21例（75%）同侧膝关节疼痛.体格检查中25例（89%）发现软组织损伤的可见证据,2例（7%）交叉韧带或侧副韧带损伤,10例（36%）膝关节积液,4例（14%）半月板损伤的体征.28例膝关节MRI检查中1例产生伪影予排除,其余27例中有25例MRI上发现异常信号,其中膝关节积液（37%）、骨挫伤（33%）、半月板撕裂（30%）是最常见的异常.结论 该研究中发现创伤性髋关节脱位患者合并同侧膝关节损伤的发病率较高,骨挫伤可能为髋关节脱位后同侧膝关节持续性疼痛提供合理解释.本研究推荐常规应用MRI进行膝关节检查,以发现单靠病史和体格检查可能被遗漏的关节内病变.     

外伤性髋关节脱位与同侧膝关节损伤的研究

目的研究外伤性髋关节脱位患者中同侧膝关节损伤情况。方法观察2005年1月～2006年12月期间收治的31例外伤性髋关节脱位患者。对入选的患者系统询问同侧膝关节外伤史，摄X线片，手法复位的麻醉前、后各进行膝关节物理检查，复位后对怀疑病例进行膝关节MRI检查。MRI发现的骨挫伤按vellet方法进行评估分类，半月板损伤按Crues和Stoller分类系统分类以区分急、慢性损伤。结果31例髋关节脱位患者中，16例有同侧膝关节疼痛，11例有膝关节周围软组织伤，12例因疼痛不能接受完整膝关节物理检查，2例后抽屉试验阳性，1例侧方应力试验阳性，4例麦氏征或关节线压痛。X线片发现6例骨折。行MRI检查的21例中有16例损伤。结论对外伤性髋关节脱位患者应进行详尽的体格检查并对高度怀疑同侧膝关节损伤者进行MRI检查，以诊断同侧膝关节可能存在的损伤。     

Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography

BACKGROUND: Popliteal artery injury is frequently associated with knee dislocation following blunt trauma, an injury that is being seen with increasing frequency. The primary purpose of the present study was to evaluate the use of physical examination to determine the need for arteriography in a large series of patients with knee dislocation. The secondary purpose was to evaluate the correlation between physical examination findings and clinically important vascular injury in the subgroup of patients who underwent arteriography. METHODS: One hundred and thirty consecutive patients (138 knees) who had sustained an acute multiligamentous knee injury were evaluated at our level-1 trauma center between August 1996 and May 2002 and were included in a prospective outcome study. Four patients (four knees) were lost to follow-up, leaving 126 patients (134 knees) available for inclusion in the study. The results of the physical examination of the vascular status of the extremities were used to determine the need for arteriography. The mean duration of follow-up was nineteen months (range, eight to forty-eight months). Physical examination findings, magnetic resonance imaging findings, and surgical findings were combined to determine the extent of ligamentous damage. RESULTS: Nine patients had flow-limiting popliteal artery damage, for an overall prevalence of 7%. Ten patients had abnormal findings on physical examination, with one patient having a false-positive result and nine having a true-positive result. The knee dislocations in the nine patients with popliteal artery damage were classified, according to the Wascher modification of the Schenck system, as KD-III (one knee), KD-IV (seven knees), and KD-V (one knee). CONCLUSIONS: Selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. There is a strong correlation between the results of physical examination and the need for arteriography. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.     

Knee injuries in traumatic hip dislocation

Of 187 patients treated at the author's institutions for fracture and/or dislocation of the hip during a 10-year period (1985-1994), 46 patients (25%) with a knee injury on the same side as the hip injury were evaluated 6 months to 11 years after the initial accident (mean, 3.65 years). Thirty-nine patients (85%) had symptoms or clinical signs in the knee. Ligamentous injuries overlooked in the initial examination were found in seven patients. Knee injuries often accompany hip fracture and/or dislocation, and can be produced by direct or indirect trauma. A delayed diagnosis of such injuries may lead to their treatment in the sequela phase, which complicates the final outcome. Therefore, an exhaustive physical examination is recommended for patients with traumatic hip dislocation to detect potential injuries to the ipsilateral knee. Early diagnosis and treatment of such injuries greatly improve final outcome.     

Subchondral contusion of the knee caused by axial loading from dashboard impact: detection by magnetic resonance imaging

We studied the occurrence of "bone bruises" of the knee resulting from dashboard impaction and detected by magnetic resonance imaging (MRI). We chose 21 knees of 20 front seat occupants in head-on motor vehicle collisions. To ensure all knees had received a significant axial load, patients selected had ipsilateral posterior hip dislocations and/or posterior wall acetabular fractures. Anteroposterior and lateral knee radiographs were negative for fracture in all cases. T1-weighted axial and sagittal MRI of each knee with a 1.5-T magnetron scanner revealed signal changes consistent with subchondral microfracture or bone bruise in 8 of the 21 knees. Previous cadaveric, animal, and MRI studies have suggested that such changes may be precursors of posttraumatic osteoarthritis. With the increasing incidence of serious lower extremity injury as a result of motor vehicle accidents, these occult injuries may significantly affect individuals and society.     

Traumatic Bilateral Knee Dislocations, Unilateral Hip Dislocation, and Contralateral Humeral Amputation: A Case Report

Bilateral traumatic knee dislocations are a rarity. We report a case of bilateral traumatic knee dislocations with concomitant right hip dislocation and complete traumatic amputation of the left, nondominant upper extremity at the level of the proximal one-third of the humerus. Angiograms revealed no evidence of popliteal artery injury. Orthopedic treatment consisted of immediate reduction of the dislocations and urgent revision amputation of the upper extremity. Staged, bilateral knee ligamentous reconstructions were performed on hospital days 24 and 29, respectively. Despite this constellation of devastating injuries, the patient had a satisfactory outcome. In patients with high-energy hip or knee dislocations, the bilateral hips and knees should be carefully examined to check for associated fractures and/or dislocations.     

The role of arteriography in assessing popliteal artery injury in knee dislocations

BACKGROUND: This study aimed to review the need for angiography among patients with traumatic knee dislocations, and to evaluate any adverse consequences associated with the clinical decision to pursue or defer angiography. METHODS: A retrospective analysis was performed for 55 patients (57 knees) with traumatic knee dislocation during a 7-year period. The presence or absence of arterial injury was assessed via physical examination (to determine presence of foot pulses and ankle-brachial index > or = 0.80) and, in selected cases, via angiography. RESULTS: At the vascular examination, 32 knees (56%) were found to be normal and 25 (44%) to be abnormal. None of the 32 knees with normal examination results had substantial vascular injuries, as determined by angiography in 13 cases (41%) or by clinical follow-up assessment in 19 cases (59%). All 25 patients with abnormal vascular examination results underwent angiography, with 12 patients (48%) demonstrating vascular injury (7 major and 5 minor injury). Seven patients (6 with major and 1 with minor injury) underwent surgical repair with reverse saphenous vein grafting. CONCLUSIONS: No limb with initial normal vascular examination results was found to have a vascular injury that required treatment. Routine screening angiography may not be necessary for all patients with traumatic knee dislocations.     

Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report

IntroductionWe experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation.Presentation of caseWe report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient’s hip pain resolved and the low-intensity band was no longer observed on follow-up MRI.DiscussionAlthough the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head.ConclusionThis study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.     

Recurrent traumatic hip dislocation in a child

Recurrent traumatic hip dislocation is rarely seen in childhood. We presented a case of traumatic hip dislocation which was treated by conservative methods. A two-year-old girl was treated with closed reduction and a hip spica cast for posterior traumatic dislocation in the right hip. Two years later, a recurrent dislocation occurred following a minor trauma on the same side. She was again treated with closed reduction and immobilization with a hip spica cast for three weeks followed by a three-week load bearing restriction. Early follow-up examinations showed an increased internal rotation of the hip compared to the left side, suggesting increased posterior capsular laxity. It then disappeared on her final follow-up at age six and magnetic resonance imaging showed no evidence for avascular necrosis or capsular laxity. She was asymptomatic and her physical examination was within normal limits. Of note, several members in her family had developmental dysplasia of the hip.     

Traumatic posterior hip instability and femoroacetabular impingement in athletes

We describe 3 cases of posterior hip instability associated with femoroacetabular impingement. In each case, we obtained a detailed medical history, performed a physical examination, evaluated imaging, recorded intraoperative findings, and clinically followed the patient for 1 year. Two of the 3 patients sustained a traumatic posterior hip subluxation caused by noncontact injuries. All patients had decreased internal rotation on physical examination, radiographic evidence of acetabular retroversion, a cam lesion, an elevated α angle, and a posterior acetabular rim fracture with associated labral injury. All patients underwent hip arthroscopy and direct repair of the bony acetabular fragment using 3 to 5 suture anchors. One-year follow-up in all cases demonstrated good to excellent results and full return to activities without restriction. Patients with femoroacetabular impingement may be predisposed to traumatic posterior dislocation or subluxation and a concomitant posterior acetabular rim fracture with labral injury. We propose that FAI predisposed these athletes to posterior hip instability.     

Traumatic hip dislocation with spontaneous incomplete reduction: a diagnostic trap

We are reporting three children and adolescents who presented with incongruous reduction of the hip following injury. In each case, the diagnosis was initially missed. None of the patients presented with a hip dislocation, but two gave a history consistent with transient hip subluxation or dislocation. Low-energy trauma was the cause in two cases. Treatment consisted of arthrotomy to remove interposed capsule and labrum to obtain concentric reduction. When reduction of a hip dislocation occurs spontaneously, the condition may be misjudged. Any child or adolescent who complains of hip pain following injury should have radiographs scrutinized for asymmetric widening of the hip joints. Any asymmetry should be evaluated by appropriate imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI). Removal of any interposed tissue is recommended, even when the diagnosis is delayed by several months.     

Bilateral quadriceps tendon rupture and coexistent femoral neck fracture in a patient with chronic renal failure

Simultaneous bilateral quadriceps tendon rupture is a very rare injury mostly seen in patients with chronic renal failure or other systemic chronic diseases. Metabolic acidosis in chronic renal failure predisposes these patients to tendon degeneration. A 37-year-old woman who received hemodialysis for chronic renal failure for two years presented with complaints of severe pain in the left hip and inability to walk. She had a history of two consecutive falls in the past two months. On physical examination, there were joint spaces in both suprapatellar areas, active extension of both knees was inhibited, and movements of the left hip were quite painful. Knee ultrasonography and magnetic resonance imaging showed bilateral quadriceps tendon rupture from patellar attachment. At surgery, full-thickness quadriceps tendon tears were repaired with Tycron transpatellar suture anchors. Internal fixation was not considered for hip fracture due to the presence of chronic renal failure, so hemiarthroplasty with bipolar endoprosthesis was performed in the same session for femoral neck fracture. Six months after the operation, the patient was able to walk without support and almost regained her normal knee functions.     

Concomitant ipsilateral traumatic dislocation of the hip and knee following high-energy trauma: a case report

Traumatic dislocation of the hip or knee can occur after high-energy trauma and is often associated with concomitant injuries and secondary complications. Concomitant traumatic dislocation of both hip and knee is rare. We describe a case of combined ipsilateral posterior hip dislocation with a posterior acetabular fracture and a complete open knee dislocation with disruption of the popliteal artery that resulted in amputation.     

膝关节磁共振成像的类骨坏死68例分析

目的 回顾性研究不同疾病类型膝关节磁共振成像(MRI)的软骨下骨的信号改变特点,以进一步细化诊断为治疗提供依据.方法 研究2003～2006年间68膝成人膝关节MRI图像,并将较易诊断的剥脱性骨软骨炎排除,MRI有类骨坏死信号,T1为低信号,T2为中或低信号,在股骨端坏死灶的近侧或胫骨坏死灶的远侧如有一条低密度的线状影即为含线状影,若无即为无线状影.将坏死灶的分布,大小,T1和T2信号特点,有无合并骨髓水肿,有无合并表面软骨缺损,进行记录,并进行数据分析.结果 有隔离线的坏死灶面积大且伴有骨髓水肿急性病程,多为有不全骨折的骨坏死;有软骨缺损无隔离线的类坏死信号改变多为亚急性病程,多数为骨关节炎.结论 对膝关节的MRI进行详细的分析其类骨坏死信号的特点,有无隔离线及骨髓水肿的程度,以及关节软骨的特点可区分骨坏死及骨关节炎,作出诊断.     

Ipsilateral hip and knee dislocation: Case report and review of literature

Hip and knee dislocations are not uncommon but simultaneous ipsilateral dislocation of the hip and knee joint is rare; consequently, there is an inadequate amount of literature on the subject. We identified only 11 such cases reported in English literature. In the present report, we describe the case of a 23-year-old male patient who presented with ipsilateral hip and knee dislocation on the right side after being involved in a road traffic accident. The hip dislocation was associated with a posterior wall acetabular fracture. The hip as well as the knee joints was reduced in the emergency bay. The patient underwent an urgent fixation of the posterior wall acetabular fracture with delayed ligament reconstruction for the knee dislocation. At one-year follow-up, he had no pain in the hip or knee. There was grade 1 posterior sag but no symptoms of knee instability. Radiographs revealed no evidence of avascular necrosis or arthritis of the femoral head. The normal treatment protocol for individual injury is affected by the simultaneous occurrence of hip and knee dislocation.     

Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography

BACKGROUND: We prospectively describe the incidence, magnetic resonance-based diagnosis, and treatment of vertebral artery (VA) injury resulting from closed cervical spine trauma. METHODS: Patients with fracture or dislocation on plain radiographic studies underwent computed tomography. Among these patients, the subset with computed tomographic evidence of foramen transversarium (FT) fracture underwent magnetic resonance angiography as early as possible. RESULTS: During a 16-month period, 38 patients with closed cervical trauma were treated. Twelve patients demonstrated fracture extension through at least one FT by computed tomography. Among these patients, four showed unilateral VA injury by magnetic resonance angiography, all ipsilateral to the fractured FT. Three cases of VA occlusion and one of focal narrowing were demonstrated. All four patients were initially treated with aspirin, and two were systemically anticoagulated. None developed irreversible neurologic deficits from the VA compromise. CONCLUSION: Our data suggest that the incidence of VA injury in closed cervical spine trauma is significant and that FT fractures warrant flow-sensitive magnetic resonance imaging.     

Magnetic resonance imaging of the multiple-ligament injured knee

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in detecting soft tissue, neurovascular, and bony injury after multiple ligament knee injury, including knee dislocation. MATERIALS AND METHODS: A retrospective search was performed for patients presenting with reported knee dislocation from May 1993 through May 2000 who underwent both MRI and surgical reconstruction. Twenty-one patients met these criteria (15 men and six women; age range 14 to 75 years; mean 32.6 years). Magnetic resonance diagnoses of soft tissue and bony injury were compared with the patients' operative findings. MRA of the popliteal vessels was performed in seventeen of our twenty-one patients, and the results of these studies are described. RESULTS: Multiple ligamentous, tendinous, meniscal, chondral, osseous, and neural injuries were seen. There was excellent correlation (kappa > 0.8) between the magnetic resonance and operative findings with regard to the size and location of tears. Regarding meniscal tears, the type (e.g., bucket, radial split, meniscocapsular separation) and location correlated well with surgery. All ten nerve injuries noted on magnetic resonance were confirmed at surgery. Six of our patients had both conventional angiograms and MRAs with 100 percent agreement between the studies. In one patient an intimal flap in the popliteal artery was seen on MRA and confirmed on conventional angiographic images. CONCLUSION: MRI is an accurate method of assessing soft tissue, osseous, and neural damage after knee dislocation. Our early experience with popliteal fossa MRA is encouraging with complete agreement between the MRA and conventional angiography in patients who had both studies.     

Anterior shoulder dislocation in adolescents

Of 780 patients treated for primary anterior shoulder dislocations, 33 (4.2%) were aged 12 to 17 years at the time of the dislocation. We clinically evaluated 28 of these patients a mean of 7.1 years after the initial dislocation. All patients were radiographed, and 15 underwent magnetic resonance imaging or computed arthrotomography of the shoulder. The primary dislocation had been traumatic in 21 patients (75%) and atraumatic in 7 patients (25%). Recurrent dislocations had occurred in 24 cases (86%), the number of recurrences ranging from 1 to 30. In the group with traumatic primary dislocations, the rate of recurrences was 92% and the mean number of redislocations was 7 in the patients who had been 14 to 17 years of age at the time of the initial injury, whereas the corresponding figures were 33% and 0.3 in the patients who had been 13 years of age or less at the time of the initial injury. Imaging studies showed a Bankart lesion in 80% of cases; each of these patients had had a traumatic primary dislocation and was 14 to 17 years old at the time of injury. During the follow-up period, operative stabilizing procedures had been performed in 7 cases. At follow-up evaluations, all nonoperated patients showed clinical evidence of anterior or multidirectional instability of the involved shoulder; of the operated patients, each of those with traumatic primary dislocations reported no recurrences and had a satisfactory result, whereas both of the patients with atraumatic primary dislocations continued to have subluxation and/or dislocations of the operated shoulder. In the 14- to 17-year-old adolescents with traumatic primary dislocations in whom imaging studies show Bankart lesions, there is an indication for prophylactic stabilizing surgery at the time of the initial injury.     

髋关节骨折--后脱位合并坐骨神经损伤的创伤机制及漏诊分析

目的探讨髋关节骨折-后脱位合并坐骨神经损伤的创伤机制及漏诊原因.方法统计分析1986年1月～1997年6月髋关节骨折-后脱位并坐骨神经损伤36例临床资料.结果此类损伤发病率占同期收治髋关节后脱位的69.3%,明显高于以往的报道,且首诊漏诊率高达58.2%,其中15例病人疗效不满意.结论特定环境下屈髋、屈膝位时,经股骨轴向的暴力打击是髋关节骨折-后脱位合并坐骨神经损伤的主要创伤机制,细致的临床检查,特别是CT扫描是早期确诊、提高疗效的关键.     

The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury?

OBJECTIVES: To map by magnetic resonance imaging (MRI) and quantitative MRI (qMRI) concomitant fractures and meniscal injuries, and location and volume of traumatic bone marrow lesions (BMLs) in the acutely anterior cruciate ligament (ACL) injured knee. To relate BML location and volume to cortical depression fractures, meniscal injuries and patient characteristics. METHODS: One hundred and twenty-one subjects (26% women, mean age 26 years) with an ACL rupture to a previously un-injured knee were studied using a 1.5T MR imager within 3 weeks from trauma. Meniscal injuries and fractures were classified by type, size and location. BML location and volume were quantified using a multi-spectral image data set analyzed by computer software, edited by an expert radiologist. RESULTS: Fractures were found in 73 (60%) knees. In 67 (92%) of these knees at least one cortical depression fracture was found. Uni-compartmental meniscal tears were found in 44 (36%) subjects and bi-compartmental in 24 (20%). One hundred and nineteen (98%) knees had at least one BML, all but four (97%) located in the lateral compartment. Knees with a cortical depression fracture had larger BML volumes (P<0.001) than knees without a cortical depression fracture, but no associations were found between meniscal tears and BML volume or fractures. Older age at injury was associated with smaller BML volumes (P<0.01). CONCLUSION: A majority of the ACL injured knees had a cortical depression fracture, which was associated with larger BML volumes. This indicates strong compressive forces to the articular surface and cartilage at the time of injury, which may constitute an additional risk factor for later knee osteoarthritis development.