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Hip Dislocations

Hip
• The hip is a ball and socket joint
• Reinforced by ligaments, the joint capsule, and
large muscle insertions. Consequently, a large
amount of force is required to dislocate the hip.
• A hip dislocation is a true orthopedic
emergency. The incidence of subsequent
avascular necrosis (AVN) of the femoral
head is a time-dependent phenomenon,
becoming more likely to occur if reduction
is delayed beyond 6 hours.
Hip Dislocation

• Posterior hip dislocation


• Anterior hip dislocation
• Central hip dislocation (fracture-
dislocation)
Posterior dislocation
• 90% of hip dislocation cases
• The head of femur pushed out of the
acetabulum posteriorly.
• Mechanism of injury
– Also known as dashboard injury
– Violence directed along the shaft of femur with the
hip flexed
– Most commonly in an MVA, when the knee strikes
against the dashboard
Posterior dislocation
• Clinical features
– history of great force applied to a flexed knee and
hip.
• The affected limb is
– shortened, adducted, and internally rotated
– the hip and knee held in slight flexion.
• Patient may be unable to walk or adduct the leg.
• Signs of vascular or sciatic nerve injury may be present.
– Pain in 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 at the ankle
Posterior dislocation

• X-rays
– Femoral head out of acetabulum.
– Thigh internally rotated, therefore the lesser
trochanter becomes less prominent
– Shenton line is broken
• Treatment
– Closed reduction
• 2 common manoeuvres – Allis & Stimsom
Posterior dislocation
– Preferably under GA /deep sedation
– Allis manoeuvre
– Patient placed supine on the floor
– Assistant holds the pelvis down firmly
– The other person, flexes the hip & knee at
right angles & exerts an axial pull
– Usually a ‘click’ will be heard once the hip is
reduced & the hip can moved in all directions
Posterior dislocation
2. Stimson manoeuvre
– With the patient placed prone, allow the dislocated leg 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, apply
force to the calf and gradually increase until relocation is
accomplished.
– Although this technique is often more successful than the Allis
technique, it has the disadvantages that the knee may be injured if
too great a force is applied to the popliteal area.

– The leg kept in light traction with hip abducted for 3


to 6 weeks.
Posterior dislocation

• Complications
1. Sciatic nerve injury
– Lies behind posterior wall acetabulum
– Pain in 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 at the ankle
• Recovers spontaneously
Posterior dislocation

2. Avascular necrosis
• Occurs in 15 – 20% of cases.
• The changes appear on X-ray generally 1 –
2 years post injury.
• Avascular head appears dense & gradually
collapses
• Patient c/o hip pain after a seemingly
painless period post treatment
Posterior dislocation
3. Osteoarthritis
• Late complication of hip dislocation
• Cause: sequelae of AVN or incongrous acetabulum
& femoral head
• Initial treament – conservative.
• THR may be required later
4. Myositis ossificans
• Occurs few weeks to months post injury.
• Patient c/o hip pain & stiffness
• X-ray: may show a mass of new bone around hip
• Treatment: rest & analgesia
Anterior dislocation

• Rare injury
• Mechanism of injury
– Anterior hip dislocations occur when force is
applied to an abducted leg that levers the hip
anteriorly out of its articulation.
– For e.g. fall from a tree when foot gets stuck
& the hip abducts excessively
Anterior dislocation
• Clinical features
– 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.
• Paresis of lower extremity
• Dull, aching pain in lower extremity
• Weak or absent reflexes at knee
• Lower extremity pale and/or cool to touch
• Paresthesias of lower extremity
Anterior dislocation
• X-ray
– The femur is abducted and externally rotated while
the head of the femur is medial and inferior to the
acetabulum.
• Treatment
– Similar technique of reduction of posterior hip
dislocation except that
• While the flexed thigh is pulled upwards, it should be
adducted
– The subsequent Rx is similar to posterior dislocation.
Central hip dislocation

• 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.
• Also known as a fracture/dislocation.
Central hip dislocation
• Clinical features
• 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 an associated femoral shaft
fracture is present.
• The leg distal to the fracture assumes 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.
Central hip dislocation
• X-ray
– The femoral head displaced medially and the
acetabular floor fractured

• Treatment
– The displacement of the head varies from
minimal to the whole head lying inside the
pelvis.
– Joint stiffness & OA are inevitable.
Central hip dislocation
– Therefore the main aim of RX is to get a congruous
articular surface as much as possible.
– For this to occur
• Skeletal traction is applied distally & laterally.
• If fragments fall into place and reasonably reconstitute the
articular margins, the traction is continued for 8-12 weeks.
– For some, reconstruction of acetabular floor may be
needed if the fragments do not fall back in place by
traction
Central hip dislocation

• Complications
1. Joint stiffness
2. OA
Open reduction
• Indications for open reduction
– Irreducible dislocation (approximately 10% of
all dislocations)
– Persistent instability of the joint following
reduction (eg, fracture/dislocation of the
posterior acetabulum)
– Fracture of the femoral head or shaft
– Neurovascular deficits that occur after closed
reduction