HIP JOINT DISLOCATION

By: dr. Syafruddin, Sp.

B
Editor: Nurhayati, S.Ked

Introduction
Epidemiology
rare, buthigh incidence of associated
injuries
mechanism is usually young patients with
high energy trauma

Hip joint inherently stable due to

bony anatomy
soft tissue constraints including
labrum
Capsule
ligamentum teres

Classification
Simple vs. Complex
simple
pure dislocation without
associated fracture

complex
dislocation associated with
fracture of acetabulum or
proximal femur

 Anatomic
classification 1.
posterior
dislocation(90%)
occur with axial load
on femur, typically
with hip flexed and
adducted
axial load
through flexed
knee (dashboard
injury)

 position of hip determines

associated acetabular injury
increasing flexion and adduction
favors simple dislocation

associated with
osteonecrosis
posterior wall acetabular fracture
femoral head fractures
sciatic nerve injuries
ipsilateral knee injuries (up to 25%)

2. anterior dislocation
associated with femoral head
impaction or chondral injury
occurs with the hip in abduction and
external rotation
inferior vs. superior
hip extension results in a superior (pubic)
dislocation
flexion results in inferior (obturator)
dislocation

Presentation
Symptoms
acute pain, inability
to bear weight,
deformity

Physical exam
ATLS
95% of dislocations
with associated
injuries

 posterior
dislocation
(90%)
hip and leg in
slight flexion,
adduction,
andinternal
rotation
detailed
neurovascular
exam (10-20%
sciatic nerve
injury)
examine knee for
associated injury
or instability

internal rotation

 anterior
dislocation
hip and leg in
flexion,
abduction,
andexternal
rotation

external rotation

Imaging
Radiographs
can typically see
posterior dislocation on
AP pelvis
femoral head smaller then
contralateral side
Shenton's line broken
lesser trochanter shadow
reveals internally rotated
limb as compared to
contralateral side
scrutinize femoral neck to
rule out fracture prior to
attempting closed
reduction

 CT
a. helps to determine direction of
dislocation, loose bodies, and
associated fractures
anterior dislocation

 posterior dislocation

b. post reduction CTmust be performed for

all traumatic hip dislocations to look for
. femoral head fractures

 loose bodies

acetabular fractures

 MRI
controversial and routine use is not
currently supported
useful to evaluate labrum, cartilage and
femoral head vascularity

Treatment
1. Nonoperative
emergent closed reductionwithin 6 hours
indications
acute anterior and posterior dislocations

contraindications
ipsilateral displaced or non-displaced femoral neck fracture

2. Operative
open reduction and/or removal of
incarcerated fragments
indications

irreducible dislocation
radiographic evidence of incarcerated fragment
delayed presentation
non-concentric reduction
should be performed on urgent basis

3. ORIF

indications
associated fractures of
acetabulum
femoral head
femoral neck
should be stabilized prior to reduction

4. arthroscopy
indications
no current established indications
potential for removal of intra-articular fragments
evaluate intra-articular injuries to cartilage,
capsule, and labrum

Techniques
Closed reduction
perform with patient supine and apply traction in line
with deformity regardless of direction of dislocation
must have adequate sedation and muscular relaxation
to perform reduction
assess hip stability after reduction
post reduction CT scan requiredto rule out
femoral head fractures
intra-articular loose bodies/incarcerated fragments
may be present even with concentric reduction on plain films
acetabular fractures

post-reduction
for simple dislocation, follow withprotected weight bearing
for 4-6 weeks

 Open reduction
approach
posterior dislocation
posterior (Kocher-Langenbeck) approach

anterior dislocation
anterior (Smith-Petersen) approach

technique
may place patient in traction to reduce
forces on cartilage due to incarcerated
fragment or in setting of unstable dislocation
repair of labral or other injuries should be
done at the same time

Complications
Post-traumatic arthritis
up to 20% for simple dislocation, markedly
increased for complex dislocation

Femoral head osteonecrosis

5-40% incidence
Increased risk with increased time to reduction

Sciatic nerve injury

8-20% incidence
associated with longer time to reduction

Recurrent dislocations
less than 2%

Jazakallah..... ^_^