Our Patient Today
Isabelle is 23 years old female BIBA , was involved in MVA about
an hour ago. She was driver of the car, going at 90km/hour, had
head on collision with another car. Air bag deployed, hit her head to
wind screen, smashed her knees to the dash board, brief LOC and
could not move out of the car. SJA called, and brought to ED.
On arrival: HR 110, stable BP.
Complaining of neck pain, knee and hip pain.
Focus: This patient can have many serious injuries , but i am going
to talk about one of these injuries that can happen in high energy
What To Cover Today
Brief anatomy of Hip Joint
Mechanism and types of Hip Dislocations
Role Of Procedural sedation
Techniques of Closed Reduction
Post Reduction disposition and investigations
Developmental : overall frequency 1 in 1000 individuals
Acquired: Highest incidence rate after hip replacement surgery.
After Prim THR 3.9 percent experience Hip dislocation in first 6
After Revised THR surgery 15 percent experience Dislocation in 6
Also common in young population involved in high energy trauma.
Hip is a modified ball and socket joint.
Femoral head is deep in the acetabular socket – enhanced by
the cartilaginous labrum.
Supported by fibrous joint capsule,
Ileofemoral ligament, ischiofemoral ligament, pubofemoral lig,
muscles of upper thigh and gluteal region.
Simple vs complex
Complex associated with fractures.
3 main patterns in relation to acetabulum
Posterior, Anterior, Central.
Mostly posterior dislocation (80-90% of dislocations in MVA)
Occurs with axial load on femur, typically with hip flexed and
adducted. Dashboard Injury is an example of axial load on
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
ANTERIOR: The hip is minimally flexed,
externally rotated and markedly abducted
ALWAYS fracture dislocation
Lateral force against an adducted femur – side impact MVA.
Signs of sciatic nerve injury include the following:
Loss of sensation in posterior leg and foot
Loss of dorsiflexion (peroneal branch) or plantar flexion
Loss of deep tendon reflexes at the ankle S1,2
Signs of femoral nerve injury include the following:
Loss of sensation over the thigh
Weakness of the quadriceps
Loss of deep tendon reflexes at knee L3, 4
Good sedation and muscle relaxation is the key
Propofol and fentanyl
The patient lies supine on the gurney.
Unaffected leg is flexed with an assistant stabilizing the leg.
The assistant can also help stabilize the pelvis.
Provider's other hand grasps the lower leg of the affected leg,
usually around the ankle.
The dislocated hip should be flexed to 90 degrees.
The provider's forearm is the fulcrum and the affected lower leg
is the lever.
When pulling down on the lower leg, it flexes the knee thus
pulling traction along the femur.
Described primarily for acute posterior dislocations, but anterior
dislocations can occasionally be reduced by this method
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
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
Indications Of open reduction
Irreducible dislocation (approximately 10% of all
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
If relocation of the hip is successful, immobilize the legs in
slight abduction by using a pad between the legs to
prevent adduction until skeletal traction can be instituted. ?
CT scan for all traumatic dislocations after closed
After reduction, patients with hip dislocation should be
admitted to the hospital.
The duration of traction and non–weight-bearing
immobilization is controversial. Evidence suggests that
early weight bearing (eg, 2 wk after relocation) may
increase the severity of aseptic necrosis when it occurs.
Sciatic nerve injury (posterior dislocation)
Fractures of head and neck
Femoral-artery injury (in anterior dislocations)
AVN of the hip incidence of AVN increases with multiple
Ligamentous injury of the knee, other fractures
Complications of immobilization (DVT, pulmonary embolus,