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HIPHIP
DISLOCATIONDISLOCATION
Fahad zakwanFahad zakwan
MD5MD5
DefinitionDefinition
• A dislocationA dislocation is an injury in which a bone isis an injury in which a bone is
displaced from its proper positiondisplaced from its proper position
Traumatic hip dislocationTraumatic hip dislocation
• This usually follows a serious violence. TheThis usually follows a serious violence. The
following are the clinical types of dislocation.following are the clinical types of dislocation.
                               i)i) AcuteAcute dislocationdislocation
            ii)            ii) Old unreducedOld unreduced dislocationdislocation
           iii)           iii) RecurrentRecurrent dislocationdislocation
Dislocations Of TheDislocations Of The
HipHip
• Complete loss of contact between the articularComplete loss of contact between the articular
surfaces forming the joint.surfaces forming the joint.
Classified according to the directionClassified according to the direction
of the femoral head to:of the femoral head to:
• PosteriorPosterior ((commonestcommonest).).
• AnteriorAnterior..
• CentralCentral (comminuted or displaced(comminuted or displaced
fracture of acetabulumfracture of acetabulum).).
1.1. POSTERIOR DISLOCATIONPOSTERIOR DISLOCATION
• Mechanism of injury:Mechanism of injury:
Road traffic accidentRoad traffic accident when thewhen the
victim thrown forwardvictim thrown forward strikingstriking
the knee against thethe knee against the
dashboard with the hip anddashboard with the hip and
knee flexedknee flexed forcing the headforcing the head
out of the acetabulum, someout of the acetabulum, some
time posterior wall fracturetime posterior wall fracture
happen (fracture dislocation).happen (fracture dislocation).
.Signs & Symptoms of Posterior HipSigns & Symptoms of Posterior Hip
Dislocation :Dislocation :
1.1. painpain in the hip and buttock area.in the hip and buttock area.
2. The affected limb is2. The affected limb is shortenedshortened,, adductedadducted, and, and
internally rotatedinternally rotated, with the hip and knee held in, with the hip and knee held in slightslight
flexionflexion..
3. Patient may be3. Patient may be unable to walkunable to walk oror adduct the legadduct the leg..
4. Signs of4. Signs of vascular or sciatic nerve injuryvascular or sciatic nerve injury may be presentmay be present
::
- Pain in hip, buttock, and posterior leg- Pain in hip, buttock, and posterior leg
- Loss of sensation in posterior leg and foot- Loss of sensation in posterior leg and foot
- Loss of dorsiflexion- Loss of dorsiflexion (peroneal branch)(peroneal branch) or plantar flexionor plantar flexion (tibial(tibial
branch)branch)
Clinical FeaturesClinical Features
• The leg isThe leg is shortenedshortened,,
adductedadducted,, internallyinternally
rotatedrotated andand flexedflexed atat
the hip joint.the hip joint.
• Be careful if associatedBe careful if associated
with fracture femurwith fracture femur
(rule).(rule).
• Always examine forAlways examine for
signs of sciatic nervesigns of sciatic nerve
injury.injury.
Radiographic evaluationRadiographic evaluation
• AnAn anteroposterior (APanteroposterior (AP)) radiograph of the pelvis isradiograph of the pelvis is
essential, as well asessential, as well as lateral viewlateral view of the affected hip.of the affected hip.
• On theOn the AP viewAP view of the pelvisof the pelvis::
• The femoral heads should appear similar in size, and the joint spacesThe femoral heads should appear similar in size, and the joint spaces
should be symmetric throughout. In posterior dislocations, theshould be symmetric throughout. In posterior dislocations, the affectedaffected
femoral head will appear smaller than the normal femoral headfemoral head will appear smaller than the normal femoral head. In. In
anterior dislocation, theanterior dislocation, the femoral head will appear slightly larger thanfemoral head will appear slightly larger than
the normal hipthe normal hip because of magnification of the femoral head to the x-because of magnification of the femoral head to the x-
ray cassette.ray cassette.
• AA lateral viewlateral view of the affected hip may helpof the affected hip may help distinguish adistinguish a
posterior from an anterior dislocation.posterior from an anterior dislocation.
• Use of 45-degree oblique (Judet) viewsUse of 45-degree oblique (Judet) views of the hip may be helpful toof the hip may be helpful to
ascertain the presence of osteochondral fragments, the integrity of theascertain the presence of osteochondral fragments, the integrity of the
acetabulum, and the congruence of the joint spaces. Femoral headacetabulum, and the congruence of the joint spaces. Femoral head
depressions and fractures may also be seen.depressions and fractures may also be seen.
• Computed tomography (CT) scansComputed tomography (CT) scans are usually obtained followingare usually obtained following
closed reduction of a dislocated hip. If closed reduction is not possible andclosed reduction of a dislocated hip. If closed reduction is not possible and
an open reduction is planned, a computed tomography scan should bean open reduction is planned, a computed tomography scan should be
obtained to detect the presence of intra-articular fragments and to rule outobtained to detect the presence of intra-articular fragments and to rule out
associated femoral head and acetabular fracturesassociated femoral head and acetabular fractures
• The role of magnetic resonance imaging(MRI)The role of magnetic resonance imaging(MRI) in the evaluation of hipin the evaluation of hip
dislocations has not been established; it may prove useful in the evaluationdislocations has not been established; it may prove useful in the evaluation
of the integrity of the labrum and the vascularity of the femoral head.of the integrity of the labrum and the vascularity of the femoral head.
ClassificationClassification
•Hip dislocations are classifiedHip dislocations are classified
based on:based on:
1.1.the relationship of the femoralthe relationship of the femoral
head to the acetabulumhead to the acetabulum
2.2.whether or not associatedwhether or not associated
fractures are present.fractures are present.
Thomson and EpsteinThomson and Epstein
ClassificationClassification
of Posterior Hip Dislocationsof Posterior Hip Dislocations
Type IType I Pure dislocation with/without a small posteriorPure dislocation with/without a small posterior
wall fragment.wall fragment.
Type IIType II Dislocation with large posterior wall fragment.Dislocation with large posterior wall fragment.
Type IIIType III Dislocation with comminuted posterior wall.Dislocation with comminuted posterior wall.
Type IVType IV Dislocation with “acetabular floor” fractureDislocation with “acetabular floor” fracture
Type VType V Dislocation with femoral head fracture.Dislocation with femoral head fracture.
ManagementManagement
•Dislocated hip is anDislocated hip is an emergencyemergency..
•Goal is to reduce risk ofGoal is to reduce risk of
•AVASCULAR NECROSISAVASCULAR NECROSIS
•DJDDJD..
•Evaluation and treatment must beEvaluation and treatment must be
streamlinedstreamlined
Closed ReductionClosed Reduction
• Regardless of the direction ofRegardless of the direction of
the dislocation, the reductionthe dislocation, the reduction
can be attempted with in-linecan be attempted with in-line
traction with the patient lyingtraction with the patient lying
supine.supine.
• The preferred method is toThe preferred method is to
perform a closed reduction usingperform a closed reduction using
general anesthesiageneral anesthesia, but if this is, but if this is
not feasible, reduction undernot feasible, reduction under
intravenous sedationintravenous sedation is possible.is possible.
There are threeThere are three
popular methods ofpopular methods of
achieving closedachieving closed
reduction of the hip:reduction of the hip:
1.1.TheThe BigelowBigelow
maneuver ,maneuver ,
2.2.AllisAllis maneuvermaneuver
andand
3.3.StimsonStimson gravitygravity
Management of Posterior HipManagement of Posterior Hip
Dislocation :Dislocation :
The Bigelow maneuverThe Bigelow maneuver
and reverse Bigelowand reverse Bigelow
maneuversmaneuvers
May be performed with minimalMay be performed with minimal
assistance with the patient in theassistance with the patient in the supinesupine
position . Place the patient supine on aposition . Place the patient supine on a
stretcher that is elevated to the height ofstretcher that is elevated to the height of
the waist of the practitioner performingthe waist of the practitioner performing
thethe reductionreduction..
The injured hip is initially held in a position ofThe injured hip is initially held in a position of adduction and internaladduction and internal
rotationrotation, with one practitioner applying, with one practitioner applying longitudinal distraction andlongitudinal distraction and
an assistant applying pressure on the patient's anterioran assistant applying pressure on the patient's anterior
superior iliac spinessuperior iliac spines so as to stabilize the patient's pelvis.so as to stabilize the patient's pelvis.
These have beenThese have been
associated with iatrogenicassociated with iatrogenic
femoral neck fracturesfemoral neck fractures
and are not as frequentlyand are not as frequently
used as reductionused as reduction
techniques.techniques.
.
This is most commonThis is most common
used.used.
Under GA, place theUnder GA, place the
patient in supine position.patient in supine position.
WhileWhile an assistantan assistant
stabilizes the pelvis withstabilizes the pelvis with
direct pressuredirect pressure, Flex the, Flex the
hip and knee to 90° andhip and knee to 90° and
pulls the thigh verticallypulls the thigh vertically
upward.upward.
Allis maneuverAllis maneuver
• The patient is placed prone onThe patient is placed prone on
the stretcher with the affectedthe stretcher with the affected
leg hanging off the side of theleg hanging off the side of the
stretcher.stretcher.
• This brings the extremity into aThis brings the extremity into a
position of hip flexion and kneeposition of hip flexion and knee
flexion of 90 degrees each. Inflexion of 90 degrees each. In
this position, the assistantthis position, the assistant
immobilizes the pelvis, and theimmobilizes the pelvis, and the
surgeon applies an anteriorlysurgeon applies an anteriorly
directed force on the proximaldirected force on the proximal
calf. Gentle rotation of the limbcalf. Gentle rotation of the limb
may assist in reductionmay assist in reduction
Stimson gravityStimson gravity
techniquetechnique
After TreatmentAfter Treatment
• Type IType I: Traction for 3 weeks then partial wt. bearing.: Traction for 3 weeks then partial wt. bearing.
• Type IIType II:: Open reduction and rigid fixation ofOpen reduction and rigid fixation of
posterior wall followed by traction for 6 weeks.posterior wall followed by traction for 6 weeks.
• Type IIIType III:: Traction for 6 weeks.Traction for 6 weeks.
• Type IV&VType IV&V:: closed reduction may lead to automaticclosed reduction may lead to automatic
reduction of the fractures, if not open reduction andreduction of the fractures, if not open reduction and
internal fixation followed by traction for 6 weeks.internal fixation followed by traction for 6 weeks.
• Full weight bearing allowed only after 12 weeks.Full weight bearing allowed only after 12 weeks.
Complications of PosteriorComplications of Posterior
Hip DislocationHip Dislocation
1. Sciatic nerve injury.1. Sciatic nerve injury.
2. Vascular injury2. Vascular injury (hematoma).(hematoma).
3. Avascular necrosis.3. Avascular necrosis.
4. Osteoarthritis.4. Osteoarthritis.
5. Myositis ossificans5. Myositis ossificans
.
2. Anterior Hip2. Anterior Hip
Dislocation :Dislocation :•These comprise 10% to 15% ofThese comprise 10% to 15% of
traumatic hip dislocations.traumatic hip dislocations.
•They result from external rotation andThey result from external rotation and
abduction of the hip.abduction of the hip.
•Anterior dislocation of the hip occursAnterior dislocation of the hip occurs
from a directfrom a direct blow to the posteriorblow to the posterior
aspectaspect of the hip or, more commonly,of the hip or, more commonly,
from afrom a force applied to anforce applied to an
abducted legabducted leg that displace the hipthat displace the hip
anteriorly out of the acetabulum.anteriorly out of the acetabulum.
Signs & Symptoms of Anterior HipSigns & Symptoms of Anterior Hip
Dislocation :Dislocation :
1.1. PainPain in the hip area andin the hip area and inabilityinability to walk or adduct the legto walk or adduct the leg
2. The leg is2. The leg is externally rotatedexternally rotated,, abductedabducted, and, and extended atextended at
the hip.the hip.
3. The3. The femoral headfemoral head may be palpated anterior to the pelvis.may be palpated anterior to the pelvis.
 Signs of injury to theSigns of injury to the femoral nerve or arteryfemoral nerve or artery may bemay be
present:present:
femoral nerve :femoral nerve :
Paresis of lower extremityParesis of lower extremity
Weak or absent DTR at kneeWeak or absent DTR at knee
Paresthesias of lower extremityParesthesias of lower extremity
femoral artery:femoral artery:
Anterior Dislocation: Extreme external rotation, less-
pronounced abduction and flexion
Unclassical presentation (posture) ifUnclassical presentation (posture) if
1.1. Femoral head or neckFemoral head or neck
fracturefracture
2.2. Femoral shaft fractureFemoral shaft fracture
3.3. Obtunded patientObtunded patient
ClassificationClassification
Management of Anterior HipManagement of Anterior Hip
Dislocation :Dislocation :
• ReductionReduction : almost identical: almost identical
to posterior dislocation, exceptto posterior dislocation, except
while the thigh is pulledwhile the thigh is pulled
upward it should be adductedupward it should be adducted
then an assistant helps bythen an assistant helps by
applying lateral tractionapplying lateral traction to theto the
Complications of Anterior HipComplications of Anterior Hip
Dislocation :Dislocation :
1.1. Avascular necrosis.Avascular necrosis.
2.2. femoral nerve injury.femoral nerve injury.
3.3. femoral artery injury.femoral artery injury.
3. Central Hip3. Central Hip
Dislocation :Dislocation :
The third type of hip dislocationThe third type of hip dislocation
is a central dislocation in whichis a central dislocation in which
aa direct impact to thedirect impact to the
lateral aspectlateral aspect of the hipof the hip
forces the hip centrallyforces the hip centrally
through the acetabulumthrough the acetabulum
into the pelvis. This is ainto the pelvis. This is a
fracture -dislocationfracture -dislocation..
Indications for OpenIndications for Open
Reduction :Reduction :
1.1. IrreducibleIrreducible dislocation by closed meansdislocation by closed means
2.2. PersistentPersistent instability of the joint following reductioninstability of the joint following reduction
(e.g fracture-dislocation of the posterior acetabulum)(e.g fracture-dislocation of the posterior acetabulum)
3.3. FractureFracture of the femoral head or shaftof the femoral head or shaft
4.4.NeurovascularNeurovascular deficits that occur after closeddeficits that occur after closed
reductionreduction
5.5.Non concentric reductionNon concentric reduction
6.6.Fracture of the acetabulum or femoral head requiringFracture of the acetabulum or femoral head requiring
excision or open reduction and internal fixation.excision or open reduction and internal fixation.
7.7.Ipsilateral femoral neck fractureIpsilateral femoral neck fracture..
• Management after closed or open reduction rangesManagement after closed or open reduction ranges
from short periods of bed rest to various durations offrom short periods of bed rest to various durations of
skeletal traction. No correlation exists between earlyskeletal traction. No correlation exists between early
weight bearing and osteonecrosis. Therefore, partialweight bearing and osteonecrosis. Therefore, partial
weight bearing is advised.weight bearing is advised.
• If reduction is concentric and stable:If reduction is concentric and stable: A shortA short
period of bed rest is followed by protected weightperiod of bed rest is followed by protected weight
bearing for 4 to 6 weeks.bearing for 4 to 6 weeks.
• If reduction is concentric but unstable:If reduction is concentric but unstable: SkeletalSkeletal
traction for 4 to 6 weeks is followed by protective weighttraction for 4 to 6 weeks is followed by protective weight
bearing.bearing.
PrognosisPrognosis
• The outcome following hip dislocation ranges from an essentially normalThe outcome following hip dislocation ranges from an essentially normal
hip to a severely painful and degenerated joint.hip to a severely painful and degenerated joint.
• Most patients 70% to 80% have good or excellent outcome in simpleMost patients 70% to 80% have good or excellent outcome in simple
posterior dislocations. When posterior dislocations are associated withposterior dislocations. When posterior dislocations are associated with
a femoral head or acetabular fracture, however, the associateda femoral head or acetabular fracture, however, the associated
fractures generally dictate the outcome.fractures generally dictate the outcome.
• Anterior dislocations of the hip are noted to have a higher incidence ofAnterior dislocations of the hip are noted to have a higher incidence of
associated femoral head injuries (transchondral or indentation types).associated femoral head injuries (transchondral or indentation types).
The only patients with excellent results in most cases are those withoutThe only patients with excellent results in most cases are those without
an associated femoral head injury.an associated femoral head injury.
ComplicationsComplications
Osteonecrosis:Osteonecrosis:
•This is observed in 5% to 40% of injuries, with increased risk associatedThis is observed in 5% to 40% of injuries, with increased risk associated
with increased duration of dislocation (>6 to 24 hours); however, somewith increased duration of dislocation (>6 to 24 hours); however, some
authors suggest that osteonecrosis may result from the initial injury and notauthors suggest that osteonecrosis may result from the initial injury and not
from prolonged dislocation. Osteonecrosis may become clinically apparentfrom prolonged dislocation. Osteonecrosis may become clinically apparent
up to 5 years after injury. Repeated reduction attempts may also increaseup to 5 years after injury. Repeated reduction attempts may also increase
its incidence.its incidence.
Posttraumatic osteoarthritis:Posttraumatic osteoarthritis:
•This is the most frequent long-term complication of hip dislocations; theThis is the most frequent long-term complication of hip dislocations; the
incidence is dramatically higher when dislocations are associated withincidence is dramatically higher when dislocations are associated with
acetabular fractures or transchondral fractures of the femoral headacetabular fractures or transchondral fractures of the femoral head
Recurrent dislocation:Recurrent dislocation:
• This is rare (<2%), although patients with decreased femoralThis is rare (<2%), although patients with decreased femoral
anteversion may sustain a recurrent posterior dislocation, whereasanteversion may sustain a recurrent posterior dislocation, whereas
those with increased femoral anteversion may be prone to recurrentthose with increased femoral anteversion may be prone to recurrent
anterior dislocations.anterior dislocations.
Neurovascular injury:Neurovascular injury:
• Sciatic nerve injury occurs in 10% to 20% of hip dislocations. It isSciatic nerve injury occurs in 10% to 20% of hip dislocations. It is
usually caused by a stretching of the nerve from a posteriorlyusually caused by a stretching of the nerve from a posteriorly
dislocated head or from a displaced fracture fragment. Prognosis isdislocated head or from a displaced fracture fragment. Prognosis is
unpredictable, but most patients 40% to 50% full recoveryunpredictable, but most patients 40% to 50% full recovery
• Injury to the femoral nerve and femoral vascular structures has beenInjury to the femoral nerve and femoral vascular structures has been
reported with anterior dislocations.reported with anterior dislocations.
Femoral head fracturesFemoral head fractures ::
• These occur in 10% of posterior dislocations (shear fractures) and inThese occur in 10% of posterior dislocations (shear fractures) and in
25% to 75% of anterior dislocations (indentation fractures).25% to 75% of anterior dislocations (indentation fractures).
Heterotopic ossification:Heterotopic ossification:
• This occurs in 2% of patients and is related to the initial muscularThis occurs in 2% of patients and is related to the initial muscular
damage and hematoma formation. Surgery increases its incidence.damage and hematoma formation. Surgery increases its incidence.
Prophylaxis choices include indomethacin for 6 weeks or use ofProphylaxis choices include indomethacin for 6 weeks or use of
radiation.radiation.
Thromboembolism:Thromboembolism:
• This may occur after hip dislocation owing to traction-induced intimalThis may occur after hip dislocation owing to traction-induced intimal
injury to the vasculature. Patients should be given adequate prophylaxisinjury to the vasculature. Patients should be given adequate prophylaxis
consisting of compression stockings, sequential compression devices,consisting of compression stockings, sequential compression devices,
and chemoprophylaxis, particularly if they are placed in traction.and chemoprophylaxis, particularly if they are placed in traction.

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3. hip dislocations

  • 2. DefinitionDefinition • A dislocationA dislocation is an injury in which a bone isis an injury in which a bone is displaced from its proper positiondisplaced from its proper position Traumatic hip dislocationTraumatic hip dislocation • This usually follows a serious violence. TheThis usually follows a serious violence. The following are the clinical types of dislocation.following are the clinical types of dislocation.                                i)i) AcuteAcute dislocationdislocation             ii)            ii) Old unreducedOld unreduced dislocationdislocation            iii)           iii) RecurrentRecurrent dislocationdislocation
  • 3.
  • 4. Dislocations Of TheDislocations Of The HipHip • Complete loss of contact between the articularComplete loss of contact between the articular surfaces forming the joint.surfaces forming the joint. Classified according to the directionClassified according to the direction of the femoral head to:of the femoral head to: • PosteriorPosterior ((commonestcommonest).). • AnteriorAnterior..
  • 5. • CentralCentral (comminuted or displaced(comminuted or displaced fracture of acetabulumfracture of acetabulum).).
  • 6. 1.1. POSTERIOR DISLOCATIONPOSTERIOR DISLOCATION • Mechanism of injury:Mechanism of injury: Road traffic accidentRoad traffic accident when thewhen the victim thrown forwardvictim thrown forward strikingstriking the knee against thethe knee against the dashboard with the hip anddashboard with the hip and knee flexedknee flexed forcing the headforcing the head out of the acetabulum, someout of the acetabulum, some time posterior wall fracturetime posterior wall fracture happen (fracture dislocation).happen (fracture dislocation).
  • 7. .Signs & Symptoms of Posterior HipSigns & Symptoms of Posterior Hip Dislocation :Dislocation : 1.1. painpain in the hip and buttock area.in the hip and buttock area. 2. The affected limb is2. The affected limb is shortenedshortened,, adductedadducted, and, and internally rotatedinternally rotated, with the hip and knee held in, with the hip and knee held in slightslight flexionflexion.. 3. Patient may be3. Patient may be unable to walkunable to walk oror adduct the legadduct the leg.. 4. Signs of4. Signs of vascular or sciatic nerve injuryvascular or sciatic nerve injury may be presentmay be present :: - Pain in hip, buttock, and posterior leg- Pain in hip, buttock, and posterior leg - Loss of sensation in posterior leg and foot- Loss of sensation in posterior leg and foot - Loss of dorsiflexion- Loss of dorsiflexion (peroneal branch)(peroneal branch) or plantar flexionor plantar flexion (tibial(tibial branch)branch)
  • 8. Clinical FeaturesClinical Features • The leg isThe leg is shortenedshortened,, adductedadducted,, internallyinternally rotatedrotated andand flexedflexed atat the hip joint.the hip joint. • Be careful if associatedBe careful if associated with fracture femurwith fracture femur (rule).(rule). • Always examine forAlways examine for signs of sciatic nervesigns of sciatic nerve injury.injury.
  • 9. Radiographic evaluationRadiographic evaluation • AnAn anteroposterior (APanteroposterior (AP)) radiograph of the pelvis isradiograph of the pelvis is essential, as well asessential, as well as lateral viewlateral view of the affected hip.of the affected hip. • On theOn the AP viewAP view of the pelvisof the pelvis:: • The femoral heads should appear similar in size, and the joint spacesThe femoral heads should appear similar in size, and the joint spaces should be symmetric throughout. In posterior dislocations, theshould be symmetric throughout. In posterior dislocations, the affectedaffected femoral head will appear smaller than the normal femoral headfemoral head will appear smaller than the normal femoral head. In. In anterior dislocation, theanterior dislocation, the femoral head will appear slightly larger thanfemoral head will appear slightly larger than the normal hipthe normal hip because of magnification of the femoral head to the x-because of magnification of the femoral head to the x- ray cassette.ray cassette. • AA lateral viewlateral view of the affected hip may helpof the affected hip may help distinguish adistinguish a posterior from an anterior dislocation.posterior from an anterior dislocation.
  • 10. • Use of 45-degree oblique (Judet) viewsUse of 45-degree oblique (Judet) views of the hip may be helpful toof the hip may be helpful to ascertain the presence of osteochondral fragments, the integrity of theascertain the presence of osteochondral fragments, the integrity of the acetabulum, and the congruence of the joint spaces. Femoral headacetabulum, and the congruence of the joint spaces. Femoral head depressions and fractures may also be seen.depressions and fractures may also be seen. • Computed tomography (CT) scansComputed tomography (CT) scans are usually obtained followingare usually obtained following closed reduction of a dislocated hip. If closed reduction is not possible andclosed reduction of a dislocated hip. If closed reduction is not possible and an open reduction is planned, a computed tomography scan should bean open reduction is planned, a computed tomography scan should be obtained to detect the presence of intra-articular fragments and to rule outobtained to detect the presence of intra-articular fragments and to rule out associated femoral head and acetabular fracturesassociated femoral head and acetabular fractures • The role of magnetic resonance imaging(MRI)The role of magnetic resonance imaging(MRI) in the evaluation of hipin the evaluation of hip dislocations has not been established; it may prove useful in the evaluationdislocations has not been established; it may prove useful in the evaluation of the integrity of the labrum and the vascularity of the femoral head.of the integrity of the labrum and the vascularity of the femoral head.
  • 11. ClassificationClassification •Hip dislocations are classifiedHip dislocations are classified based on:based on: 1.1.the relationship of the femoralthe relationship of the femoral head to the acetabulumhead to the acetabulum 2.2.whether or not associatedwhether or not associated fractures are present.fractures are present.
  • 12. Thomson and EpsteinThomson and Epstein ClassificationClassification of Posterior Hip Dislocationsof Posterior Hip Dislocations Type IType I Pure dislocation with/without a small posteriorPure dislocation with/without a small posterior wall fragment.wall fragment. Type IIType II Dislocation with large posterior wall fragment.Dislocation with large posterior wall fragment. Type IIIType III Dislocation with comminuted posterior wall.Dislocation with comminuted posterior wall. Type IVType IV Dislocation with “acetabular floor” fractureDislocation with “acetabular floor” fracture Type VType V Dislocation with femoral head fracture.Dislocation with femoral head fracture.
  • 13. ManagementManagement •Dislocated hip is anDislocated hip is an emergencyemergency.. •Goal is to reduce risk ofGoal is to reduce risk of •AVASCULAR NECROSISAVASCULAR NECROSIS •DJDDJD.. •Evaluation and treatment must beEvaluation and treatment must be streamlinedstreamlined
  • 14. Closed ReductionClosed Reduction • Regardless of the direction ofRegardless of the direction of the dislocation, the reductionthe dislocation, the reduction can be attempted with in-linecan be attempted with in-line traction with the patient lyingtraction with the patient lying supine.supine. • The preferred method is toThe preferred method is to perform a closed reduction usingperform a closed reduction using general anesthesiageneral anesthesia, but if this is, but if this is not feasible, reduction undernot feasible, reduction under intravenous sedationintravenous sedation is possible.is possible. There are threeThere are three popular methods ofpopular methods of achieving closedachieving closed reduction of the hip:reduction of the hip: 1.1.TheThe BigelowBigelow maneuver ,maneuver , 2.2.AllisAllis maneuvermaneuver andand 3.3.StimsonStimson gravitygravity
  • 15. Management of Posterior HipManagement of Posterior Hip Dislocation :Dislocation : The Bigelow maneuverThe Bigelow maneuver and reverse Bigelowand reverse Bigelow maneuversmaneuvers May be performed with minimalMay be performed with minimal assistance with the patient in theassistance with the patient in the supinesupine position . Place the patient supine on aposition . Place the patient supine on a stretcher that is elevated to the height ofstretcher that is elevated to the height of the waist of the practitioner performingthe waist of the practitioner performing thethe reductionreduction.. The injured hip is initially held in a position ofThe injured hip is initially held in a position of adduction and internaladduction and internal rotationrotation, with one practitioner applying, with one practitioner applying longitudinal distraction andlongitudinal distraction and an assistant applying pressure on the patient's anterioran assistant applying pressure on the patient's anterior superior iliac spinessuperior iliac spines so as to stabilize the patient's pelvis.so as to stabilize the patient's pelvis. These have beenThese have been associated with iatrogenicassociated with iatrogenic femoral neck fracturesfemoral neck fractures and are not as frequentlyand are not as frequently used as reductionused as reduction techniques.techniques.
  • 16. . This is most commonThis is most common used.used. Under GA, place theUnder GA, place the patient in supine position.patient in supine position. WhileWhile an assistantan assistant stabilizes the pelvis withstabilizes the pelvis with direct pressuredirect pressure, Flex the, Flex the hip and knee to 90° andhip and knee to 90° and pulls the thigh verticallypulls the thigh vertically upward.upward. Allis maneuverAllis maneuver
  • 17. • The patient is placed prone onThe patient is placed prone on the stretcher with the affectedthe stretcher with the affected leg hanging off the side of theleg hanging off the side of the stretcher.stretcher. • This brings the extremity into aThis brings the extremity into a position of hip flexion and kneeposition of hip flexion and knee flexion of 90 degrees each. Inflexion of 90 degrees each. In this position, the assistantthis position, the assistant immobilizes the pelvis, and theimmobilizes the pelvis, and the surgeon applies an anteriorlysurgeon applies an anteriorly directed force on the proximaldirected force on the proximal calf. Gentle rotation of the limbcalf. Gentle rotation of the limb may assist in reductionmay assist in reduction Stimson gravityStimson gravity techniquetechnique
  • 18. After TreatmentAfter Treatment • Type IType I: Traction for 3 weeks then partial wt. bearing.: Traction for 3 weeks then partial wt. bearing. • Type IIType II:: Open reduction and rigid fixation ofOpen reduction and rigid fixation of posterior wall followed by traction for 6 weeks.posterior wall followed by traction for 6 weeks. • Type IIIType III:: Traction for 6 weeks.Traction for 6 weeks. • Type IV&VType IV&V:: closed reduction may lead to automaticclosed reduction may lead to automatic reduction of the fractures, if not open reduction andreduction of the fractures, if not open reduction and internal fixation followed by traction for 6 weeks.internal fixation followed by traction for 6 weeks. • Full weight bearing allowed only after 12 weeks.Full weight bearing allowed only after 12 weeks.
  • 19. Complications of PosteriorComplications of Posterior Hip DislocationHip Dislocation 1. Sciatic nerve injury.1. Sciatic nerve injury. 2. Vascular injury2. Vascular injury (hematoma).(hematoma). 3. Avascular necrosis.3. Avascular necrosis. 4. Osteoarthritis.4. Osteoarthritis. 5. Myositis ossificans5. Myositis ossificans
  • 20. . 2. Anterior Hip2. Anterior Hip Dislocation :Dislocation :•These comprise 10% to 15% ofThese comprise 10% to 15% of traumatic hip dislocations.traumatic hip dislocations. •They result from external rotation andThey result from external rotation and abduction of the hip.abduction of the hip. •Anterior dislocation of the hip occursAnterior dislocation of the hip occurs from a directfrom a direct blow to the posteriorblow to the posterior aspectaspect of the hip or, more commonly,of the hip or, more commonly, from afrom a force applied to anforce applied to an abducted legabducted leg that displace the hipthat displace the hip anteriorly out of the acetabulum.anteriorly out of the acetabulum.
  • 21. Signs & Symptoms of Anterior HipSigns & Symptoms of Anterior Hip Dislocation :Dislocation : 1.1. PainPain in the hip area andin the hip area and inabilityinability to walk or adduct the legto walk or adduct the leg 2. The leg is2. The leg is externally rotatedexternally rotated,, abductedabducted, and, and extended atextended at the hip.the hip. 3. The3. The femoral headfemoral head may be palpated anterior to the pelvis.may be palpated anterior to the pelvis.  Signs of injury to theSigns of injury to the femoral nerve or arteryfemoral nerve or artery may bemay be present:present: femoral nerve :femoral nerve : Paresis of lower extremityParesis of lower extremity Weak or absent DTR at kneeWeak or absent DTR at knee Paresthesias of lower extremityParesthesias of lower extremity femoral artery:femoral artery:
  • 22. Anterior Dislocation: Extreme external rotation, less- pronounced abduction and flexion
  • 23. Unclassical presentation (posture) ifUnclassical presentation (posture) if 1.1. Femoral head or neckFemoral head or neck fracturefracture 2.2. Femoral shaft fractureFemoral shaft fracture 3.3. Obtunded patientObtunded patient
  • 25. Management of Anterior HipManagement of Anterior Hip Dislocation :Dislocation : • ReductionReduction : almost identical: almost identical to posterior dislocation, exceptto posterior dislocation, except while the thigh is pulledwhile the thigh is pulled upward it should be adductedupward it should be adducted then an assistant helps bythen an assistant helps by applying lateral tractionapplying lateral traction to theto the
  • 26. Complications of Anterior HipComplications of Anterior Hip Dislocation :Dislocation : 1.1. Avascular necrosis.Avascular necrosis. 2.2. femoral nerve injury.femoral nerve injury. 3.3. femoral artery injury.femoral artery injury.
  • 27. 3. Central Hip3. Central Hip Dislocation :Dislocation : The third type of hip dislocationThe third type of hip dislocation is a central dislocation in whichis a central dislocation in which aa direct impact to thedirect impact to the lateral aspectlateral aspect of the hipof the hip forces the hip centrallyforces the hip centrally through the acetabulumthrough the acetabulum into the pelvis. This is ainto the pelvis. This is a fracture -dislocationfracture -dislocation..
  • 28. Indications for OpenIndications for Open Reduction :Reduction : 1.1. IrreducibleIrreducible dislocation by closed meansdislocation by closed means 2.2. PersistentPersistent instability of the joint following reductioninstability of the joint following reduction (e.g fracture-dislocation of the posterior acetabulum)(e.g fracture-dislocation of the posterior acetabulum) 3.3. FractureFracture of the femoral head or shaftof the femoral head or shaft 4.4.NeurovascularNeurovascular deficits that occur after closeddeficits that occur after closed reductionreduction 5.5.Non concentric reductionNon concentric reduction 6.6.Fracture of the acetabulum or femoral head requiringFracture of the acetabulum or femoral head requiring excision or open reduction and internal fixation.excision or open reduction and internal fixation. 7.7.Ipsilateral femoral neck fractureIpsilateral femoral neck fracture..
  • 29. • Management after closed or open reduction rangesManagement after closed or open reduction ranges from short periods of bed rest to various durations offrom short periods of bed rest to various durations of skeletal traction. No correlation exists between earlyskeletal traction. No correlation exists between early weight bearing and osteonecrosis. Therefore, partialweight bearing and osteonecrosis. Therefore, partial weight bearing is advised.weight bearing is advised. • If reduction is concentric and stable:If reduction is concentric and stable: A shortA short period of bed rest is followed by protected weightperiod of bed rest is followed by protected weight bearing for 4 to 6 weeks.bearing for 4 to 6 weeks. • If reduction is concentric but unstable:If reduction is concentric but unstable: SkeletalSkeletal traction for 4 to 6 weeks is followed by protective weighttraction for 4 to 6 weeks is followed by protective weight bearing.bearing.
  • 30. PrognosisPrognosis • The outcome following hip dislocation ranges from an essentially normalThe outcome following hip dislocation ranges from an essentially normal hip to a severely painful and degenerated joint.hip to a severely painful and degenerated joint. • Most patients 70% to 80% have good or excellent outcome in simpleMost patients 70% to 80% have good or excellent outcome in simple posterior dislocations. When posterior dislocations are associated withposterior dislocations. When posterior dislocations are associated with a femoral head or acetabular fracture, however, the associateda femoral head or acetabular fracture, however, the associated fractures generally dictate the outcome.fractures generally dictate the outcome. • Anterior dislocations of the hip are noted to have a higher incidence ofAnterior dislocations of the hip are noted to have a higher incidence of associated femoral head injuries (transchondral or indentation types).associated femoral head injuries (transchondral or indentation types). The only patients with excellent results in most cases are those withoutThe only patients with excellent results in most cases are those without an associated femoral head injury.an associated femoral head injury.
  • 31. ComplicationsComplications Osteonecrosis:Osteonecrosis: •This is observed in 5% to 40% of injuries, with increased risk associatedThis is observed in 5% to 40% of injuries, with increased risk associated with increased duration of dislocation (>6 to 24 hours); however, somewith increased duration of dislocation (>6 to 24 hours); however, some authors suggest that osteonecrosis may result from the initial injury and notauthors suggest that osteonecrosis may result from the initial injury and not from prolonged dislocation. Osteonecrosis may become clinically apparentfrom prolonged dislocation. Osteonecrosis may become clinically apparent up to 5 years after injury. Repeated reduction attempts may also increaseup to 5 years after injury. Repeated reduction attempts may also increase its incidence.its incidence. Posttraumatic osteoarthritis:Posttraumatic osteoarthritis: •This is the most frequent long-term complication of hip dislocations; theThis is the most frequent long-term complication of hip dislocations; the incidence is dramatically higher when dislocations are associated withincidence is dramatically higher when dislocations are associated with acetabular fractures or transchondral fractures of the femoral headacetabular fractures or transchondral fractures of the femoral head
  • 32. Recurrent dislocation:Recurrent dislocation: • This is rare (<2%), although patients with decreased femoralThis is rare (<2%), although patients with decreased femoral anteversion may sustain a recurrent posterior dislocation, whereasanteversion may sustain a recurrent posterior dislocation, whereas those with increased femoral anteversion may be prone to recurrentthose with increased femoral anteversion may be prone to recurrent anterior dislocations.anterior dislocations. Neurovascular injury:Neurovascular injury: • Sciatic nerve injury occurs in 10% to 20% of hip dislocations. It isSciatic nerve injury occurs in 10% to 20% of hip dislocations. It is usually caused by a stretching of the nerve from a posteriorlyusually caused by a stretching of the nerve from a posteriorly dislocated head or from a displaced fracture fragment. Prognosis isdislocated head or from a displaced fracture fragment. Prognosis is unpredictable, but most patients 40% to 50% full recoveryunpredictable, but most patients 40% to 50% full recovery • Injury to the femoral nerve and femoral vascular structures has beenInjury to the femoral nerve and femoral vascular structures has been reported with anterior dislocations.reported with anterior dislocations.
  • 33. Femoral head fracturesFemoral head fractures :: • These occur in 10% of posterior dislocations (shear fractures) and inThese occur in 10% of posterior dislocations (shear fractures) and in 25% to 75% of anterior dislocations (indentation fractures).25% to 75% of anterior dislocations (indentation fractures). Heterotopic ossification:Heterotopic ossification: • This occurs in 2% of patients and is related to the initial muscularThis occurs in 2% of patients and is related to the initial muscular damage and hematoma formation. Surgery increases its incidence.damage and hematoma formation. Surgery increases its incidence. Prophylaxis choices include indomethacin for 6 weeks or use ofProphylaxis choices include indomethacin for 6 weeks or use of radiation.radiation. Thromboembolism:Thromboembolism: • This may occur after hip dislocation owing to traction-induced intimalThis may occur after hip dislocation owing to traction-induced intimal injury to the vasculature. Patients should be given adequate prophylaxisinjury to the vasculature. Patients should be given adequate prophylaxis consisting of compression stockings, sequential compression devices,consisting of compression stockings, sequential compression devices, and chemoprophylaxis, particularly if they are placed in traction.and chemoprophylaxis, particularly if they are placed in traction.