Hip dislocation

1. Hip
Dislocation

2. Introduction
Whatisthehip dislocation ?
Thehead of the femur displace inrelation tothe
acetabulum fromsevere trauma, causing
dislocation.

3. Introduction
Hip dislocations caused by significant force:
Association with otherfractures
Damage to vascular supply to femoral head
Thus, high chance ofcomplications

4. Incidence
Common in young population with high energy trauma.
Unrestrained motor vehicle accident occupants are at
significant higher risk for sustaining a hip dislocation than
passengerswearing a restraining device
AfterPrim THR 3.9 percent experience Hip dislocation in
first 6 months.
After Revised THRsurgery 15 percent experience
Dislocation in 6months.

5. Anatomy
Ball and socket typical synovial joint.
Femoral head: slightly asymmetric,forms 2/3 sphere.
Acetabulum: inverted “U” shaped articular surface.
Ligamentum teres, with artery to femoral head, passes
through middle ofinverted “U”.

6. Joint Contact Area
Throughout ROM:
40%of femoral head isin contactwith
acetabulum.
10%of femoral head isin contactwith
labrum.

7. Acetabular Labrum
Strong fibrous ring
Increases femoral head coverage
Contributes to hipjoint stability

8. Hip JointCapsule
Extends from intertrochanteric ridge of proximal femur to bony
perimeter of acetabulum.
Has several thick bands of fibrous tissue (3 lig)
=== Iliofemoral ligament , pubofemoral ligamentand
ischiofemoral ligament .

9. The ligaments of hipjoint
The primary capsular fibers run longitudinally and are
supplemented by much stronger ligamentous
condensations that run in a circular and spiral fashion.

10. …Cont

11. Hip Dislocation: Mechanismof
Injury
Almost always due to high-energy
trauma.
Most commonly involveunrestrained
occupants inRTAs.
Can also occur in pedestrian-RTAs, falls
from heights, industrial accidents and
sporting injuries.

12. According todirection of femoral head
displacement :
A- Posterior Dislocation
B-Anterior Dislocation
C- Central Dislocation

13. PosteriorDislocation
Generally results from axial load applied to femur, while
hip isflexed.
Most commonly caused by impact of dashboard on knee.

15. Types of PosteriorDislocation
Postero-superior (iliac)
ischial

16. PosteriorDislocation
POSTERIOR: - flexed, internally rotated, and adducted.

17. AnteriorDislocation
Femoral head situated anterior to
acetabulum
Hyperextension force against an
abducted leg that levers head out of
acetabulum.
Also force against posterior femoral
head or neck can produce dislocation
10 % to 15% of traumatic hip dislocation

18. ANTERIOR : The hip is minimally flexed, externally
rotated and markedly abducted

20. Mechanism of
Anterior
Dislocation
Extreme abduction with external rotation of hip.
Anterior hip capsuleistorn or avulsed.
Femoral headislevered out anteriorly.

21. Types of anteriordislocation
Pubic (superior)
Obturator (inferior)
Perineal

22. Central dislocation
Due to direct trauma to greater trochanter drive femoral
head inward fracture of floor of acetabulum.
ALWAYS fracture dislocation
Lateral force against an adducted femur

23. Effect of Dislocation on
Femoral Head Circulation
When capsule tears, ascending cervical branches are torn or
stretched.
Artery of ligamentum teresistorn.
Some ascending cervical branches may remain kinked or
compressed until the hipisreduced.
Thus, early reduction of the dislocated hip can improve blood
flow
to femoral head.

24. Associated Injuries
Mechanism: knee vs. dashboard injury
Contusions or fractures of distal femur
Patella fractures, knee injuries
Foot fractures, if knee extended
Sciatic nerve injuries occur in 10%ofhip
dislocations.

25. Irregular
:presentation/appearance if
femoral head or neck are fractured
femoral shaftfracture
obtunded patient, confused, shocked … …

26. ……Cont
Other associated injuries arecommon:
Head, neck and facial injuries
Chest injuries
Intra-abdominal injuries
Lower extremity fractures and dislocations

27. Management
History and Evaluation:
Significant trauma, usually RTA.
Awake, alert patients have severe pain in hip region.
lnability to stand or walk (disturbance of function).

28. Physical Examination (posterior
(dislocation
1)lnspection
Ecchymosis, bruises, swellings
Lower limb is flexed, adducted and internally
rotated.
Supratrochanteric shortening (shorteningwith
fixed greater trochanter-condyledistance).
2)Palpation
- Femoral head palpated post. empty femoral A.
-Narthes sign (i.e. Difficulty to palpate femoral
pulse due to backward migration of femoral
head).
3) Movement Painful limitation of all hip
movements.

29. Neurovascular examination
Signsofsciatic nerve injury include
thefollowing:
Loss of sensation in posterior leg and foot
Loss of dorsiflexion (peroneal branch)or
plantar flexion (tibialbranch)
Loss of deep tendon reflexes at the ankle S1,2
Signsoffemoral nerve injury include
thefollowing:
Loss of sensation over thethigh
Weakness of thequadriceps
Loss of deep tendon reflexes at knee L3, 4

31. Radiographs: AP PelvisX-Ray
Should allow diagnosis and show direction of dislocation.
Femoral head not centered in acetabulum (loss of
parallelism)
Femoral head appears larger (anterior) or smaller
(posterior).
Usually provides enough information to proceed with closed
reduction.

32. X-raysafter Hip
:Reduction
AP pelvis, Lateral Hipx-ray.
Judet views of pelvis.
CT scan with 2-3 mmcuts.

33. CTScan
Most helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.

34. MRIScan
Will reveal labral tear and soft-tissue
anatomy.
Has not been shown to be of benefit in
acute evaluation and treatment of hip
dislocations.

35. Clinical Management:
Emergent Treatment
Dislocated hip isan emergency.
The goal is to reduce risk of AVN and
Degenerative joint disease.

36. Benefits of earlyReduction
Allows restoration of flow through occluded or
compressed vessels.
Literature supports decreased AVN with earlier
reduction.
Requires proper anesthesia.
Requires “team” (i.e. more than one person).

37. The popular methods of achieving closed
reduction of the hip :
1.The Bigleow maneuver ,
2.Allis maneuver ,
3.Stimson gravity technique ,
4.Whistler technique and
5.Captain Morgan technique

38. AllisManeuver
Assistant: Stabilizes pelvis
Posterior-directed force on both ASIS’s
Surgeon: Stands on stretcher
Gently flexes hip to900
Applies progressively increasing traction to the
extremity
Adductionwith internal/external rotation
Reduction can often be seen and felt

41. StimpsonMethod
Described primarily for acuteposterior dislocations
Believed to beleast 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

43. How to know reduced Hip
The limb moves morefreely
Patient more comfortable
But……..
Requires testing of stability
Simply flexing hip to 900doesnot sufficiently test stability

44. Nonoperative Treatment
 analgesia
 Avoid Adduction, InternalRotation.
No flexion >60
o
.
 Earlymobilization usuallyfew days to 2weeks.
 Touch down weight-bearing may be delayed
Repeat x-raysbeforeallowing fullweight-bearing.
If hip stable after reduction, and reduction
congruent.
Maintain patient comfort skin traction ,

45. ?IrreducibleHip
Requires emergent reduction in theatre.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in
O.T. with anesthesia.
( Repeated efforts not likely to be successful and may create harm to
the neurovascular structures or the articular cartilage.)
Surgical approach from side of dislocation.

46. Indications for openReduction
Irreducible dislocation
Iatrogenic sciatic nerveinjury
Incongruent reduction with incarcerated fragments
Incongruent reduction with soft tissueinterposition
Incongruent reduction with Pipkin type Ifemoralhead
fracture (relative)

47. Complication OFHip
Dislocation
1-Sciatic NerveInjury
2-Vascularinjury :
Occasionallythe superior gluteal artery is torn and
bleeding may be profuse .
3-Associated fracturedfemoral shaft :
When this occurs at the same time as the
hip dislocation, the dislocation isoftenmissed.

48. :Late
1-Avascular Necrosis (AVN):
1-40%
Post-traumaticOsteoarthritis-2
Thromboembolism
Myositisossification

49. Conclusion
It is highly stable joint that needs high energy trauma to
dislocate,(so, don't missassociated injuries)
Early reduction of the dislocated hip (within 6 hrs) can
improve blood flow to femoral head.
Up to 5views of xrays/C-T may be needed for proper
evaluation( pre andpost reduction)

50. …..Cont
Minimize closed trialsto avoid the riskof vasculardamage
and AVN
Surgical approaches according to the direction of
dislocation
Surgeon experience is highly considered for treatment (as
revision surgeies caries a high risk of complications)

51. THANK YOU