A review of types of hip dislocations, causes, and management

1. Hip Dislocations
Topic Presentation
Surgery Block 4 2018
Akuila MBBS 4

2. Background
• Dislocation - loss of contact between normally articulating surfaces of
a joint.
• Hip joint – ball and socket joint. Surrounded by cartilaginous
labrum+joint capsule AND overlayed with multiple ligaments and
muscles of the upper thigh and gluteal region. Ie. Fairly strong joint.
Therefore a large force (mechanism of injury) is needed to dislocate
the hip.
• Large force = other life threatening injuries+fractures, making hip
dislocations, a true orthopedic emergency.

3. Anatomy
BONES

4. Anatomy
Ligaments

5. Anatomy muscles

6. Anatomy
Blood Supply

7. Anatomy – Nerve Supply

8. • CAUSES
- MVA's 2/3 of hip dislocations
- falls from height
- sports injuries (rugby, football, skiing)
- Congenital (spectrum of DDH)
• TYPES OF HIP DISLOCATION
- (1) Anterior
- (2) Posterior: most common 80-90%
- (3) Central
* position of femoral head to
acetabulum
*simple or complex based on associated
fracture (complex)

9. Posterior Hip Dislocation
• Femoral head is behind acetabulum
• Mechanism of Injury: "dashboard
injury" during MVA.
• Limb Position: during MVA, force
transmitted to flexed hip in one of
two ways: (1) car decelerates---knee
strikes dashboard---force
transmitted through femur to hip---
dislocation (2) car deccelerates---
extended knee strikes floor---force
transmitted through entire L.L to hip
joint---dislocation
• Common in both MVA's and
contact+collision sports (rugby,
football)

10. PHD (classification systems)
(1) Thompson-Epstein Classification (x-ray findings)
- Type1: with/without minor fracture
- Type2: with large, single fracture of acetabular rim
- Type3: with comminution of acetabulum, with/without major
fragments
- Type4: with fracture of acetabular floor
- Type5: with fracture of femoral head

11. PHD (classification systems)
(2) Steward-Milford system (functional hip stability)
- Type1: No fracture/insignificant fracture
-Type2: Associated with single or comminnuted posterior wall fragment
but hip remains stable through functional ROM
- Type3: Associated with gross intability of hip joint due to loss of
structural support
- Type4: Associated with femoral head fracture

12. X-ray (PHD)

13. Anterior Hip Dislocation
• 5-10% of all hip dislocations
• Mechanism of injury: most commonly from a
direct blow to the abducted hip. most often an
MVA during which the occupant has the hip
abducted and externally rotated at the time of
impact or a fall or sports injury causing forced
hyperextension. Anterior dislocations are classified
as (1)obturator, (2) iliac, (3) and pubic.
• Also common in sports involving high
speed+rotational forces (basketball, skiing)

14. X-Ray (AHD)

15. Central Hip
Dislocation
Always a fracture dislocation
Femoral head lies medial to a
fractured acetabulum.
Mechanism of Injury: side-impact
MVA's, where there is a lateral
force against an adducted femur.

16. Management
(1) Clinical Assessment
A.Primary Survey – DRS ABCDE. Very important for hip dislocations
because their main MOI (MVA) assoociated with other life threatening
injuries. Prompt treatment may reduce mortality rate and stabilizes
patient for further management and investigation.
B. Secondary Survey – done after patient is stabilized. It is a thorough
history and physical examination from head-to-toe, including the
reassessment of all vital signs.
C. AMPLE History – Allergies, Medications, Past medical Hx, Last Meal,
Events surrounding Injury

17. Management(Cont'd)
• (2) Pain Relief – give appropriate analgesia. If hemodynamically
stable, give IV opioids.
• Patient allowed to b in position he/she is most comfortable in.

18. Management
(cont'd)
• (3) Imaging
- X-ray: AP + L views initial
radiographic studies for all
suspected hip and femur
fractures. When analyzing AP
view, use Shenton + Klein lines to
help identify femoral fractures
and SCFE.
- Failure to detect these injuries
results in increased mortality, risk
of subsequent displacement, and
a higher incidence of
complications such as AVN.

19. • (3)Imaging – cont'd
Approx. 2-10% of all hip fractures are radiographically “occult” on
plain film. Therefore, if clinical suspicion remains and plain
radiographs are negative, magnetic resonance imaging (MRI) is
indicated. Although computed tomography (CT) scan can be used,
small studies suggest that it is inferior to MRI. CT does seem to have
merit when the patient does not have significant osteoporosis or in
the setting of significant trauma. MRI is the imaging modality of
choice with a sensitivity and specificity approaching 100%. In studies
of patients with suspicion of hip fracture and normal plain
radiographs, MRI showed occult fracture in 37% to 55% of patients
(4).

20. Management (cont'd)
• (4) Reduction – Open vs Closed
• All hip dislocations are emergencies and need to be reduced.
• Indications for Open reduction: NO CAST (Non union, Open fracture,
Compromise neurovascular structures, Articular fracture, Salter-Harris III-V,
Trauma. Done in- OT with patient sedated and monitored.
• Closed reduction is a set of maneuvers that can be done in ED. Involves 3 person
team minimum. Patient given appropriate sedation and analgesia and monitored
as per protocol.
• Reduction is optimally done within 6 hours of hospital presentation, to reduce
complications from occurring (AVN, traumatic degenerative hip).
• Methods for Closed Reduction: (1) Allis Method (2) Bigelow Method (3) Classic
Watson -Jones Method (4) Stimsons gravity method (5) Whistlers technique
(over-under) (6) Captain Morgan technigue

21. Allis Maneuver (for PHD)
• Assistant stabilizes pelvis, posteriorly directing
force onto both ASIS's.
• Surgeon stands on bed.
• Gently flexes knee to 90 degrees.
• Applies progressively increasing traction to the
limb.
• Applies adduction with internal rotation.
• Reduction can often be seen and felt (dull click)

22. Bigelows maneuver (PHD)
• pt lies supine, & assistant applies countertraction by
downward pressure on the ASIS;
- surgeon grasps affected limb at ankle w/ one hand,
places opposite forearm behind the knee, and applies
longitudinal traction in line of deformity;
- adducted & internally rotated thigh is flexed > 90 deg
on abdomen;
- this relaxes the Y ligament and allows the surgeon to
bring the femoral head near the posteroinferior rim of
the acetabulum
- while traction is maintained, femoral head is levered
into acetabulum by abduction, external rotation, and
extension of hip.
- after reduction:
- avoid: flexion, internal rotation, and adduction; -
traction is maintained until pt. is pain free (2 wks)

23. Reverse
Bigelow's
Maneuver
(AHD):

25. Stimson's Gravity
Method
• Reduction for both Ant.+Post. Hip Dislocation
- believed to be least traumatic;
- pt is in prone position w/ lower limbs hanging from end of
table;
- assistant immobilizes the pelvis by applying pressure on the
sacrum;
- hold knee and ankle flexed to 90 deg & apply downward
pressure to leg just distal to the knee;
- gentle rotatory motion of the limb may assist in reduction;
- Contraindications:
- superior dislocations of the pubic type in which the hip
presents in extension are not amenable to a Stimson's
maneuver because of the need for further extension to
acheive reduction

28. After Reduction...
Repeat x-ray to confirm joint placement
Repeat neurovascular exam
Repeat CT/MRI to guide further management
If relocation of hip is successful, immobilize legs in slight abduction by using pad
between legs, until skeletal traction can be applied.
Reduction---Patients bed-ridden+in pain---require supportive care---esp. Pain
relief
After either open or closed reduction of a hip dislocation, the patient is
instructed to remain on bed rest with his or her legs abducted and with skeletal
traction designed to keep the hip from displacing posteriorly.
The duration of traction is approximately 2 weeks, but the recommended period
with no weight bearing is controversial and varies from 9 days to 3 months.

29. Physical Therapy
• Acutely after successful reduction, resting and icing the hip and taking
anti-inflammatory and/or narcotic medications to reduce pain are helpful.
• For type 1 posterior dislocations, athletes may return to weight bearing as
pain allows.
• Reviews of the literature do not show an increased risk of avascular necrosis with early
weight bearing.
• Athletes with type 2-5 posterior dislocations and anterior dislocations may require
longer times to achieve weight bearing.
• Hip joints with associated fractures and/or instability are placed in a hip
abduction brace postoperatively, which keeps the hip in abduction and
slight external rotation for optimal healing, while allowing controlled
(limited) flexion and extension. Within 5-7 days of the injury, patients can
perform passive range-of-motion exercises with or without assistance in
order to maintain normal flexibility (pendulum exercises).

30. Physical Therapy (follow-up)
• Leg muscle strengthening exercises may begin once the patient is
pain free and ambulating without crutches. Patients may work to
strengthen the hip flexors, hip extensors, and the muscles nearest the
hip, including the quadriceps and hamstrings. Over the next few
months, gradually increasing the patient's level of cardiovascular
training may be attempted, which should include brisk walking and
swimming. Jogging or running may begin at 6-8 weeks but will differ
by individual athlete and injury. Full return to sports is generally
within 3-4 months.

31. Complications Of Hip Dislocation
• AVN
- Early diagnosis and treatment of dislocations decreases the incidence of AVN
- The incidence of AVN is increased with delayed reduction, repeated attempts at
reduction, and open reduction (40% vs 15.5% with closed reduction).
• Sciatic Nerve Injury (PHD)
- Function of the sciatic nerve 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.
• Femoral Nerve+Artery Injury
• Osteoarthritis
• Recurrent Dislocation
• Complications of immobilization (DVT, pulmonary embolus, bed sores,
pneumonia)

32. References
• Medscape
• Wheeless' Textbook of Orthopedics
• Toronto Clinical Notes 2016
• Slideshare
• Google Images