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HIP DISLOCATION Background: There are three main types of hip dislocation: traumatic dislocation of a previously normal hip,

dislocation of a prosthetic hip and developmental dysplasia of the hip resulting in spontaneous, and often chronic, dislocation. The most common etiology dealt with in the ED is traumatic hip dislocation. Although children may sustain a hip dislocation from relatively minor trauma such as athletic activities, adult hip dislocations are generally associated with more severe mechanisms of injury. Because the energy required to dislocate an adult's hip is significant, the most common etiologies are motor vehicle accidents (MVAs) and falls from a significant height. Consequently, many patients with hip dislocation have multiple injuries that may take precedence in the resuscitation sequence. Conversely, the physical findings of a hip dislocation may be overlooked on the initial resuscitation of a trauma patient, especially an unconscious one. Part of the secondary trauma survey should include an assessment of the hips and other large joints. Pathophysiology: The hip is a ball and socket joint and has the inherent stability associated with such joints. In addition, the hip has tremendous reinforcement by ligaments, the joint capsule and large muscle insertions that provide additional stability. Consequently, it requires a large amount of force to dislocate the hip. A hip dislocation is a true orthopedic emergency in that the incidence of subsequent avascular necrosis of the femoral head is a time-dependent phenomenon becoming increasingly common if relocation is delayed beyond 6 hours. The hip may dislocate posteriorly, which is the most common

type, anteriorly or centrally through the acetabulum into the pelvis. It may be a simple dislocation or a fracture/dislocation involving the acetabulum or the head, surgical neck or shaft of the femur. Posterior hip dislocations occur most typically during MVAs in which the knees of the front seat occupants strike the dashboard during a head-on collision. Energy is transmitted along the femoral shaft to the hip joint.If the leg is struck while in an adducted position, a posterior dislocation may result. If the leg is in neutral or an abducted position when struck, an anterior dislocation or fracture/dislocation may occur. In the latter case, the posterior wall of the acetabulum is fractured making subsequent reduction less stable. Anterior dislocation of the hip occurs either from a direct blow to the posterior aspect of the hip or, more commonly, to a force applied to an abducted leg that levers the hip anteriorly out of the acetabulum. The third type of hip dislocation is a central dislocation in which a direct impact to the lateral aspect of the hip forces the hip centrally through the acetabulum into the pelvis. This is by definition a fracture/dislocation. Frequency: In the U.S.: Posterior hip dislocations are more common than anterior and account for almost 90% of dislocations. The frequency has decreased in the U.S. with the increased use of safety belts and air bags. Anterior dislocations and central fracture/dislocations account for less than 10% of hip dislocations. Mortality/Morbidity: The mortality associated with hip dislocation is primarily assignable to associated injuries of the pelvis, head or thorax.

Approximately 50% of patients with hip dislocation have other fractures as well. There is a significant incidence of deep venous thrombosis (DVT) and potentially lethal pulmonary embolus associated with hip dislocations caused by local venous injury and prolonged immobilization. Osteoarthritis is a common and potentially disabling complication, occuring in 23-50% of cases. Avascular necrosis is common, occuring in 8-13% of cases. Early diagnosis and treatment of dislocations decreases the incidence. There is a controversy regarding the effect of early weight bearing on the occurence of avascular necrosis. Most studies have found that early weight bearing following reduction is associated with more severe avascular necrosis but does not appear to increase the incidence. The incidence of avascular necrosis is increased with delayed reduction, repeated attempts at reduction and open reduction (40% vs. 15.5% with closed reduction). It is unclear whether this is due to operative trauma or because those dislocations requiring surgery are inherently more severe. Adults develop avascular necrosis more commonly than children. Avascular necrosis may not become apparent on plain radiographs for several months. Earlier diagnosis can be made with MRI or nuclear scanning and these modalities should be considered in a patient who develops pain following a dislocation. Injury to the sciatic nerve occurs in 10-14% of posterior dislocations during the initial trauma or during relocation. Sciatic nerve function should be verified before and after relocation to detect this complication. The finding of sciatic nerve dysfunction mandates surgical exploration to release or repair the nerve. Anterior dislocations are occasionally associated with injury to the femoral artery or nerve.

Dislocations in children can occur with relatively minor trauma (e.g., sports activities) and reduction must be gentle to avoid iatrogenic injury to the femoral epiphysis (e.g., slipped capital femoral epiphysis). Race: Hip dislocations are more commonly seen in whites in the U.S. Sex: Hip dislocations are more commonly seen in young males, often associated with MVAs and sports injuries. Age: Hip dislocations are more common in traumatic injuries (especially MVAs) under the age of 35. They are more common in falls over the age of 65. CLINICAL History: An anterior or posterior hip dislocation may occur. Each presents with its own unique history of force application. Posterior hip dislocations: Usually, there is a history of great force applied to a flexed knee and hip. The patient, if conscious, will complain of pain in the hip and buttock area. There may be an associated injury of the sciatic nerve due to compression or laceration by bony fragments. The resultant neurologic deficit ranges from pain in the sciatic nerve distribution, to loss of sensation in the posterior leg and foot, loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch) of the foot and loss of deep tendon reflexes (DTRs) at the ankle. Vascular injury is relatively rare with posterior dislocations compared to anterior, but it may result in hematoma formation locally. The soft tissues tend to tamponade bleeding

short of producing hemorrhagic shock, so that the presence of shock should lead to a search for other injuries. Anterior dislocation: The patient will complain of pain in the hip area and inability to walk or adduct the leg. Injury to the femoral nerve can occur, resulting in lower extremity paresis, weak or absent DTR at the knee and numbness in the femoral nerve distribution. Injury to the femoral artery can produce vascular deficiency in the lower extremity with dull aching pain, pallor, paresthesias and coolness of the lower extremity. Physical: Posterior hip dislocations: The affected limb is shortened, adducted and internally rotated, with the hip and knee held in slight flexion. Signs of vascular or sciatic nerve injury may be present. Anterior hip dislocation: The leg is externally rotated, abducted and extended at the hip. The femoral head may be palpated anterior to the pelvis. Signs of injury to the femoral nerve or artery may be present. Central dislocation: The leg is shortened, abducted or adducted and internally or externally rotated depending on the type and extent of penetration into the pelvis. The typical posture of the leg with anterior or posterior

hip dislocation may not be seen if there is an associated femoral shaft fracture. The leg distal to the fracture will assume a neutral position, masking the usual rotation seen with a dislocation. The incidence of missed hip dislocation is much higher in the presence of a femoral shaft fracture. Causes: Anterior dislocations: Anterior hip dislocations occur when force is applied to an abducted leg, which levers the hip anteriorly out of its articulation. Central dislocations: Central dislocation occurs when force is transmitted axially along the shaft of the femur, causing the hip to fracture through the acetabulum. This occurs mainly in falls from a significant height or from lateral impact on the hip. General causes: The most common cause of a hip dislocation is a MVA in which a front seat occupant strikes the flexed knee against the dashboard during a head-on impact. Transmitted forces displace the hip posteriorly out of the acetabulum. Patients with hip prostheses may undergo hip dislocation with relatively little trauma as the ligaments supporting the joint are no longer functioning. Paients with Down's syndrome are prone to hip dislocations. DIFFERENTIALS Abdominal Trauma, Blunt Dislocations, Hip Fractures, Femur Fractures, Hip Fractures, Pelvic

Legg-Calve-Perthes Disease Pediatrics, Limp WORKUP Lab Studies: There are no laboratory tests specific for diagnosing hip dislocation. A variety of tests may be indicated in the overall trauma work-up, depending on the mechanism of injury and the patient's clinical presentation. These tests commonly include the following: Complete blood count (CBC) Serial spun hematocrits Urinalysis Type and cross match for blood Additional tests are appropriate in certain circumstances such as pregnancy test, toxicology screen, coagulation profile and serum chemistry panel. Plain radiographs of the pelvis should be obtained routinely in patients with a severe mechanism of injury, such as an MVA or fall from significant height. Pelvic fractures may occur in up to 10% of these patients. The appearance of a hip dislocation may be very subtle on a single AP pelvis view because the femoral head may come to lie in an apparently normal position on this view even though it is dislocated. Central dislocations will usually be easily seen on this view. Associated acetabular fractures may be seen as well. Hip radiographs will often reveal the dislocated position of the femoral head, whether anterior or posterior. Although not a routine part of the trauma work-up, this view is useful if a hip dislocation is suspected. Oblique (Judet) views of the pelvis are more specifically designed to examine the posterior elements of the pelvis. The angulated view may also

reveal a hip dislocation that was was inapparent on the AP view. Although the patient may not be able to position her/his leg appropriately, plain radiographs of the hip will reveal the dislocation as well as associated fractures of the hip. CT scan: A CT scan of the hip is very accurate in delineating the extent and nature of acetabular and hip fractures and dislocations. If the patient is sufficiently stable and operative repair is contemplated, CT scanning provides essential information to the orthopedist. Plain radiographs tend to underestimate the severity of acetabular fractures and are less useful in this situation. Magnetic resonance imaging (MRI): MRI of the hip is usually impractical in the intial evaluation of a trauma patient. It is, however, the best imaging modality in detecting and assessing avascular necrosis of the hip and in detecting undisplaced stress fractures of the femoral neck. MRI is also useful in the diagnosis of bone tumors, osteomyelitis, osteoarthritis and congenital abnormalities of the hip joint. Other Tests: Radionucleotide scanning: Radionucleotide scanning is a sensitive method for detecting early avascular necrosis. This is increasingly being replaced by MRI, which demonstrates greater anatomic detail and appears to be equally sensitive. Procedures: General guidelines:

Reduction of a hip dislocation should be deferred to an orthopedic specialist, if possible. Emergency physicians should be familiar with reduction techniques and should perform the reduction if a specialist is unavailable within a 6-hour window from the time of injury or if there is a neurovascular deficit present. Even if an orthopedist attempts a closed reduction, the emergency physician can often provide assistance, such as countertraction, during the procedure and will often be responsible for the conscious sedation that is required in performing a closed reduction. Attempts at closed reduction can be made even with central dislocations. Urgent indications are the presence of neurovascular deficits or delays in care approaching 6 hours. The particular approach to reduction should be based on the exact nature of the dislocation and the position of the femoral head in relation to the acetabulum. For example, a pure superior dislocation may best be treated by simple longitudinal traction. There are two main techniques for reducing a simple posterior hip dislocation: Allis maneuver: Under deep conscious sedation (e.g., methohexital infusion), the patient is placed in a supine position. Vital signs, cardiac rhythm and pulse oximetry are monitored. While an assistant stabilizes the pelvis with direct pressure, the operator stands on the bed over the patient. The hip and knee are flexed to 90 degrees, and axial traction is applied with gradually increasing force and a rocking motion until the hip relocates. Additional lateral traction to the proximal femur may help disengage the femoral head and facilitate reduction.

Stimson maneuver: With the patient placed prone on a gurney, under deep conscious sedation, the dislocated leg is allowed to hang over the edge of the bed with the hip and knee at 90 degrees of flexion. With an assistant providing stabilizing pressure to the pelvis, force is applied to the calf and gradually increased until relocation is accomplished. Although this technique is often more successful thean the Allis technique, it has the disadvantages that the knee may be injured if too great a force is applied to the popliteal area. It is also difficult to monitor the patient's respiration and provide ventilation to a patient in the prone position. Other techniques: Reverse Bigelow maneuver: This technique is seldom used in the ED and involves the application of a firm jerk to a partially flexed thigh while holding the proximal tibia/knee area. Leg crossing maneuver: Occasionally, a dislocation can be gently reduced by gradually coaxing the patient to cross the affected leg over the other (adduction) and then applying gentle traction to the leg while an assistant guides the femoral head back into position by direct pressure in an anterior direction. Longitudinal traction: This may be adequate to reduce a purely superior dislocation. Indications for open reduction: Irreducible dislocation (approximately 10%) Persistent instability of the joint following reduction (fracture/dislocation of the posterior acetabulum) Fracture of the femoral head or shaft

Neurovascular deficits that occur after closed reduction TREATMENT Prehospital Care: Patients with hip dislocation often have associated injuries that may take precedence for stabilization, both in the field and in the ED. Consequently, the standard ABCDE approach with appropriate spinal immobilization is indicated. If detected in the field, the patient with a hip dislocation should be placed on a backboard and allowed to assume the leg position that is most comfortable (i.e., hip slightly flexed, leg adducted). Attempts to reduce the dislocation in the field are ill-advised. The patient should be transported to the level of trauma center appropriate for the overall clinical status. Emergency Department Care: Similarily, the patient with a hip dislocation will often have other injuries that require immediate stabilization or emergent investigation in the ED, and reduction of the dislocation may have to await the treatment of these more severe injuries. IV access is indicated to provide for fluid resuscitation and administration of analgesia, as well as other medications as needed. Once life-threatening injuries have been stabilized or ruled out, evaluation of the hip dislocation can proceed. Orthopedic consultation should be obtained whenever possible. An attempt at emergency closed reduction should be made if the patient has a neurovascular deficit or if a specialist is unavailable within a 6-hour time frame from the time of injury. Additional radiographs or a CT scan may be useful in delineating the extent and exact nature of the dislocation and

the presence of associated fractures, which may complicate the reduction or the stability of the joint following reduction. If the patient's vital signs and overall clinical condition permit, adequate analgesia is indicated. Reduction is greatly facilitated by the use of conscious sedation and a variety of medications may be used for this purpose. A combination of agents with muscle relaxation and analgesic effects is optimal. The patient should be monitored appropriately during conscious sedation. Once sufficient relaxation has been achieved, attempts at closed reduction using one of the techniques described above can be initiated. No more than 3 attempts at closed reduction should be made as the incidence of avascular necrosis increases with multiple attempts. If relocation of the hip is successful, the legs are immobilized in slight abduction using a pad between the legs to prevent adduction until skeletal traction can be instituted. The duration of traction and non-weightbearing immobilization is controversial. There is some evidence that early weight-bearing (e.g., two weeks post relocation) can result in increased severity of aseptic necrosis when it occurs. Early weight-bearing decreases the incidence of other complications (e.g., venous thromboembolism, decubiti) and some studies have found an equivalent outcome with early and delayed weight-bearing. Consultations: Orthopedic consultation is indicated for all hip dislocations. MEDICATION Adequate analgesia is indicated if the patient's clinical status

allows. Conscious sedation with agents that provide muscle relaxation, amnesia and analgesia are indicated for ED reductions. General anesthesia may be required for patients with dislocations that are irreducible by closed means as well as those with significant associated fractures, central dislocations or associated neurovascular injury. FOLLOW-UP

replacement of the hip with a prosthetic joint. In/Out Patient Meds: Appropriate analgesia and sedation are required during hospitalization. Anti-inflammatory medications (NSAIDs) may be required on an outpatient basis. Transfer: Once stabilized, patients with multiple trauma may be transferred. A patient with an isolated hip dislocation may be transferred providing there is no neurovascular deficit and the transfer will not extend the dislocation time beyond a 6-hour window. Generally, hip dislocations are reduced at the receiving facility and, if necessary, the patient is transferred for ongoing inpatient care with appropriate immobilization in route. Complications: Complications of hip dislocation are discussed above. The following is a listing of the potential complications: Avascular necrosis of the hip Osteoarthritis Heterotopic calcification Recurrent dislocation Complications of immobilization (DVT, pulmonary embolus, decubiti, pneumonia) Sciatic nerve injury (posterior dislocation) Femoral nerve injury (anterior dislocation) Femoral artery injury (anterior dislocation) Ligamentous injury of the knee, other fractures Prognosis:

Further Inpatient Care: There are a variety of techniques for accomplishing open reduction, acetabular repair and fixation of associated fractures that are beyond the scope of this text. Following reduction, a repeat AP and lateral x-ray of the hip as well as repeat CT scan or MRI of the hip is indicated to verify proper reduction. After either open or closed reduction of a hip dislocation, the patient is placed at bed rest with the legs abducted and with skeletal traction designed to keep the hip from displacing posteriorly. The duration of traction is usually approximately two weeks, but the period of non-weight bearing is controversial and varies from nine days to three months. Further Outpatient Care: Repeat CT or MRI scans are useful to obtain at 2-3 months after reduction to verify proper location and to screen for complications such as avascular necrosis, osteoarthritis and heterotopic calcification at an early stage. The development of avascular necrosis or severe osteoarthritis following a hip dislocation may require

The prognosis of a hip dislocation varies with the type of dislocation, associated fractures of the femoral head or acetabulum and the presence of other injuries. Overall, good to excellent results are obtained in 76-93% of patients. The principal determinants of a poor prognosis are as follows: The incidence of avascular necrosis (AVN) occurs in 421.8% in some reviews and 8-13% in others. The incidence is increased with delays in reduction beyond 6 hours and open reduction. The severity of AVN is increased in patients who undergo early weight bearing. AVN is a severe complication, which usually requires replacement by a prosthetic hip. Severe osteoarthritis occurs in at least 10% of cases and is more common in older patients. There appears to be an increased incidence compared to populations of a similar age and some authors have found the incidence to range from 30-71% after open reduction. Injury to either the femoral or sciatic nerve usually consists of a neuropraxia and eventual recovery of function can be expected in these cases. Permanent injury to these nerves can occur and the resulting deficits can be disabling. Recurrent dislocation is a common complication because supporting ligaments have been disrupted. Special Concerns: Dislocation of a prosthetic hip: Hip prostheses frequently deteriorate over time and may dislocate with minimal trauma, such as crossing one's legs. There is much less urgency in reducing such dislocations, as the concern regarding avascular necrosis and osteoarthritis is non-existent.

Reduction is accomplished in identical fashion and the treatment is the same as for nonprosthetic hips, but these patients can be mobilized to bear weight sooner than those with non-prosthetic hip dislocation. Neonates: Developmental dysplasia of the hip is a common problem that can result in dislocation or severe deformity of the hip joint. Screening for this condition is routine during the initial newborn examination by means of the Ortolani test (eliciting a click on passive abduction of the flexed hip). Although this situation rarely arises in the ED, this test should be part of the normal newborn examination. Patients with Down's syndrome are more susceptible to hip dislocation. Pediatrics: Children may dislocate a hip more easily and with a lesser mechanism of injury than adults. Interpretation of radiographs is complicated by the presence of open epiphyses and Salter fractures may occur. Reduction should be accomplished in very gentle fashion, under general anesthesia or deep conscious sedation, to avoid producing iatrogenic fractures, slipped capital femoral epiphysis or other epiphyseal injury.

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