The hip joint connects the femoral head to the acetabulum and is stabilized by ligaments and muscles. A 34-year-old man presents with severe left hip pain and an externally rotated lower extremity after a motor vehicle accident. X-rays show a posterior hip dislocation, identified by the femoral head appearing smaller and the shaft in adduction. Treatment involves closed or open surgical reduction to place the femoral head back in the acetabulum, sometimes requiring stabilization procedures. Complications can include nerve injury, osteonecrosis, arthritis, and recurrent dislocations.

1. HIP DISLOCATION
Hip joint is the ball and socket joint between head of femur and
acetabulum of hip bone. The femoral head is covered with articular
cartilage except for the fovea for the ligament of head of femur. The joint
is supplied by circumflex femoral arteries, the foveal artery, the superior
and inferior gluteal arteries.

2. The hip joint is designed for stability as it bears the weight of the whole
upper body. It’s stability is ensure by the ligaments that enclose the hip
joint, and tje muscles whose counteracting contraction (during hip
extension) pulls the femur into the acetabulum.
Anterio-superiorly; illiofemoral ligament
Posteriorly; ischiofemoral ligament
Anterio-inferiorly; pubofemoral ligament
Medial rotators: Gluteus minimus and gluteus medius
Lateral rotators: Gluteus maximus, Obturator externus,
Quadratus femoris, Piriformis

3. A 34-year-old man presents to the emergency
department after a motor vehicle accident with severe
left hip pain and a lower extremity rotational deformity.
He was the driver when he lost control and hit a pole.
On examination, he has a shortened and externally
rotated left lower extremity.

4. • Complete primary survey of patient; ABCDE (exposure involves full body
assessment for any bleeding, open wounds, or other fractures/dislocation)
• Inspection – The typical presentation in a posterior dislocation is a shortened,
slightly flexed, internally rotated and adducted
If the patient can walk or stand up, check for Trendelenburg gait and
perform Trendelenburg test.
Palpation, ROM, NV examination
• Investigations - Xray pelvis
AP + lateral view
CT scan after reduction

5. Differentials include
1. Congenital hip dysplasia
2. Hip subluxation
3. Hip fracture or femoral neck fracture
4. Soft tissue injuries
Hip dislocation always occurs due to high energy trauma, and is divided into
anterior and posterior dislocation, which depends on the direction of the force
causing the dislocation. Posterior dislocation is more common, and occurs as a
result of trauma to a flexed knee position (dashboard injury).

6. In a posterior dislocation
the affected femoral head
will appear smaller than the
normal hip with the
femoral shaft in adduction,
while, in an anterior
dislocation, the femoral
head will appear slightly
larger than the normal with
the shaft in abduction.
Posterior
dislocation
Anterior
dislocation

7. The Kohler line (red A) is
normally tangential to the
pelvic inlet and the obturator
foramen. The acetabular fossa
should lie lateral to this line
The iliofemoral line (red B)
and the Shenton line (red C)
should appear in a normal AP
radiograph as smooth,
continuous lines that are
bilaterally symmetrical
In a dislocated hip, shenton
line is broken.

9. Treatment involves reduction of the dislocated hip in an emergency basis, leaving the
dislocation for more than 12 hours increases the risk of osteonecrosis.
In type 1 dislocation closed reduction under general anesthesia is performed. Upto two
attempts are made, failing which open reduction is indicated to prevent further damage to the
femoral head. Closed reduction is followed by immobilisation. Methods of closed reduction
include.
Allis method
1. Apply traction to the affected hip joint
2. Slowly flex the hip while providing traction upto
70° – 90°
3. Externally and internally rotate the joint

10. Bigelow manoeuvre
1. Longitudinal traction in the line of deformity is
applied and the hip is slowly flexed upto 90°
2. Abduction
3. External rotation
4. Extension

11. East Baltimore lift
The patient’s leg is flexed so that the hip and knee are at 90°. The surgeon places his or her arm that is closest to the
patient’s head under the proximal calf of the patient, cradling the leg in his or her elbow with his or her hand resting on the
shoulder of the assistant. The surgeon’s other hand grips the patient’s ankle. The assistant’s arm passes under the proximal
calf of the patient (similar to the surgeon’s) and rests on the surgeon’s shoulder. The surgeon and assistant squat slightly
with knees bent. They straighten up together to apply traction to the hip without straining their backs. The surgeon rotates
the leg at the ankle. A second assistant stabilizes the pelvis.

12. In type 2, closed reduction can be performed, but afterwards a stability check is done
while the patient is under anaesthesia. If stable, then fracture surgery can be
performed in the next few days.
In unstable type 2, type 3, and 4 open reduction is performed as an emergency
procedure and the fracture is corrected within the next few days. Open reduction of
posterior dislocations is usually performed through a Kocher–Langenbeck approach

13. Type 5 is divided into further 4 types according to pipkin
classification. Management after closed or open reduction
ranges from short periods of bed rest to various durations
of skeletal traction

14. Complications
Sciatic nerve injury
Osteonecrosis
Post-traumatic osteoarthritis
Recurrent dislocation
Associated fractures

15. Anterior dislocation
Anterior dislocation results from forced external rotation and abduction of the hip.
If the hip is in flexion during dislocation, it results in an inferior (obturator)
dislocation, and if in extension a superior (pubic) dislocation occurs.
It is classified into the following types

16. Clinically, the hip is in marked external rotation with mild flexion and abduction.
Injury to the femoral artery, vein or nerve may occur as a result of an anterior
dislocation and must be looked for.
Closed reduction is achieved by longitudinal traction on the thigh with a lateral
force on the proximal thigh while simultaneously pushing the femoral head to the
acetabulum.
The reverse Bigelow manoeuvre may also be used. Here the traction is applied in
the line of the deformity, the hip is then adducted, internally rotated and extended. If
closed reduction fails, open reduction is performed thorough a Smith-Petersen
approach.

17. Congenital hip dysplasia
Dislocation occurs when the femoral head is not properly located in the acetabulum.
Inability to abduct the thigh is characteristic of congenital dislocation. In addition,
the affected limb appears (and functions as if it is) shorter because the dislocated
femoral head is more superior than on the normal side, resulting in a positive
Trendelenburg sign (hip appears to drop on one side during walking).
Approximately 25% of all cases of arthritis of the hip in adults are the direct result
of residual defects from congenital dislocation of the hip.