Hip dislocations are usually caused by traumatic injury and are most commonly posterior dislocations. Associated injuries should be screened for and prompt reduction of the dislocation is important. Closed reduction techniques include the Allis, Bigelow, Stimson, and Watson-Jones methods. Open reduction may be needed if closed reduction fails or if there are fractures of the acetabulum or femoral head. Rehabilitation focuses on early mobilization while avoiding positions that could cause redislocation. Complications may include avascular necrosis, traumatic arthritis, or nerve palsies.

1. DISLOCATION
OF HIP

2. INTRODUCTION
Hip dislocations are infrequent
Almost always after a traumatic injury
85% to 90% posterior dislocations
Associated injuries should be screened
Time to presentation and reduction of the hip dislocation is
essential
Sanders, S., Tejwani, N., & Egol, K. A. (2010). Traumatic Hip Dislocation. Bulletin of the NYU Hospital for joint Diseases, 68(2), 91-6.

3. ANATOMY
▶ The hip joint has a ball-and-
socket configuration;
synovial articulation between
the head of the femur and
the acetabulum of the pelvis
bone.
▶ Forty percent of the femoral
head is covered by the bony
acetabulum at any position
of hip motion. The effect of
the labrum is to deepen the
acetabulum and increase the
stability of the joint.

4. ▶ Main vascular supply is
from the lateral and
medial femoral
circumflex arteries,
branches of the
profunda femoral
artery.
▶ An extracapsular
vascular ring is formed
at the base of the
femoral neck with
ascending cervical
branches that pierce
the hip joint at the level

5. MECHANISM OF INJURY
Axial loading
Secondary to impact with
a dashboard in a motor
vehicle crash
The direction
of the
dislocation
Anterior
The hip is
abducted and
externally
rotated
Posterior
The knee
with the hip
in an
adducted
position
leads to a
posteriorly-
directed
force
Leiberman JR (2014) AAOS Comprehensive Orthopaedic Review. American Academy of Orthopaedic Surgeons

6. POSTERIOR DISLOCATION
▶ Also known as “dashboard injury”
▶ They result from trauma to the
flexed knee, with the hip in varying
degrees of flexion. The femur is
thrust upwards and the femoral
head is forced out of its socket.
▶ The scenario is usually when
someone seated in a truck or car,
during a road accident is thrown
forward striking the knee against the
dashboard.
▶ Seat-belt restraints can reduce the
number of posterior hip dislocation.

7. CLINICAL FEATURES
▶ There is usually history of trauma
▶ The patient has a flexion, adduction and
medial rotation deformity of the
affected limb
▶ There is marked shortening and gross
restriction of all hip movements.
▶ Head of the femur is felt as a hard mass
in the gluteal region and it moves along
with the femur.
▶ Vascular sign of Narath is negative.
▶ There could be features of sciatic nerve
palsy.

8. THOMPSON AND EPSTEIN
CLASSIFICATION
Type I: With or without minor fracture.
Type II: With a large single fracture of
the posterior acetabular rim.
Type III: With communition of the rim
of the acetabulum with or
without a major fragment.
Type IV: With fracture of the
acetabular floor.
Type V: With fracture of the femoral
head.

9. ANTERIOR
DISLOCATION
Hyperextension force against an abducted
leg that levers head out of acetabulum.
Femoral head dislocated anterior to
acetabulum
In RTA’s, when the knee strikes the
dashboard with the thigh abducted.
Violent fall from the height.
Forceful blow to the back of the patient in
a squatted position.

10. ▶ The hip is minimally flexed, externally rotated and
markedly abducted

11. EPSTIENS CLASSIFICATION
Type I: Superior dislocation (includes pubic and subspinous dislocation).
▶ Type IA : No associated fracture
▶ Type IB : Associated facture of the head and/or neck of the femur.
▶ Type IC : Associated fracture of the acetabulum.
Type II : Inferior dislocation (includes obturator, and perineal
dislocation).
▶ Type IIA : No associated fracture
▶ Type IIB : Associated fracture of the head and/or neck of the femur.
▶ Type IIC : Associated fracture of the acetabulum

12. DIAGNOSIS
History and Evaluation :
▶ Significant trauma, usually road traffic accident.
▶ Awake, alert patients have severe pain in hip region.
▶ lnability to stand or walk

13. PHYSICAL EXAMINATION (POSTERIOR DISLOCATION)
1) lnspection
▶ Lower limb is flexed, adducted
and internally rotated.
▶ Shortening +
2) Palpation
- Femoral head palpated post.
- Narthes sign (i.e. Difficulty to palpate femoral pulse
due to backward migration of femoral head).
3) Movement Painful limitation of all hip movements.

14. PHYSICAL EXAMINATION (ANTERIOR DISLOCATION
1. Inspection:
▶Limb is slightly flexed, abducted & externally rotated.
▶ May be lengthening.
2. Palpation:
Head may be felt over pubic bone or in perineum.
3. Movement :
Painful limitation

15. IMAGING EVALUATION
Standard AP radiographs show
dislocation of the femoral head
• Help diagnose the location of the dislocation
and identify associated transverse or
posterior wall fractures.
• The obturator oblique view  posterior
dislocation and the posterior wall
CT Scan  concentric reduction, bony or cartilaginous fragments
in the joint, associated fractures, marginal impaction of the
posterior wall, avulsion fractures, and femoral head or neck
fractures
MRI of the hip  labral injury and
cartilage damage to the femoral head,
and to predict head survival.
Leiberman JR (2014) AAOS Comprehensive Orthopaedic Review. American Academy of Orthopaedic Surgeons; Thompson J
(2010) Netter’s Concise Orthopaedic Anatomy, 2nd Ed. In: Elsevier Saunders.

16. POSTERIOR

17. ANTERIOR

18. NEUROVASCULAR
EXAMINATION
Signs of sciatic nerve injury:
🠶 Loss of sensation in posterior leg and foot
🠶 Loss of dorsiflexion (peroneal branch) orplantar flexion (tibial branch)
🠶 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

19. TREATMENT
•Abduction pillows  maintain post reduction stability while awaiting surgery.
•Skeletal traction  for patients with instability or dome involvement.
Preoperative care
•Allis Method
•Stimson Gravity Technique
•Bigelow and Reverse Bigelow Maneuvers
Closed reduction
•Indications: irreducible dislocation, a nonconcentric reduction, an unstable hip joint, and an
associated femoral or acetabular fracture.
•Open reduction and internal fixation
•Approach (Kocher-Langenbeck posterior, Smith-Petersen anterior)
Surgical treatment
Leiberman JR (2014) AAOS Comprehensive Orthopaedic Review. American Academy of Orthopaedic Surgeons; Thompson J (2010) Netter’s Concise Orthopaedic Anatomy, 2nd Ed. In: Elsevier Saunders. Sanders, S., Tejwani, N., & Egol, K. A. (2010). Traumatic
Hip Dislocation. Bulletin of the NYU Hospital for joint Diseases, 68(2), 91-6.

20. REHABILITATION
Early mobilization
Posterior dislocations hyperflexion is avoided for 4 to 6 weeks.
Immediate weight bearing for simple dislocations.
Delayed weight bearing for large posterior wall or dome fracture fixation.
Leiberman JR (2014) AAOS Comprehensive Orthopaedic Review. American Academy of Orthopaedic Surgeons; Thompson J (2010) Netter’s Concise Orthopaedic Anatomy, 2nd Ed. In: Elsevier Saunders. Sanders, S., Tejwani, N., & Egol, K. A. (2010). Traumatic
Hip Dislocation. Bulletin of the NYU Hospital for joint Diseases, 68(2), 91-6.

21. Allis method
Bigelow method
Classical Watson Jones method
Stimson’s gravity method
Whistler’s technique(over-under)
Methods of
Closed
Reduction

22. Allis Method
•The patient is placed supine
the surgeon standing above the
patient on the stretcher or table
•. Initially, the surgeon applies in- line
traction while the
assistant applies counter traction
by stabilizing the patient’s pelvis.
•While increasing the traction force,
the surgeon should slowly increase
the degree of flexion to
approximately 70 degrees.
•Gentle rotational motions of hip as
well as slight adduction will often
help the femoral head to clear the
lip of the acetabulum.
•A lateral force to the proximal
thigh may assist in reduction. An
audible “clunk” is a sign of a
successful closed reduction.

23. BIGELOW’S
METHOD
• Patient is supine.
•An assistant applies counter
traction on both the ASIS.
•Surgeon applies longitudinal
traction in the line of the
deformity.
•The hip is gently adducted,
internally rotated and bent on the
abdomen. This relaxes the Y-
ligament and brings the femoral
head near the poster inferior
aspect of the acetabulum.
•By adduction, external rotation
and extension of the hip, head is
levered back into the acetabulum.

24. WATSON – JONES METHOD
▶ This technique is useful in both
anterior and posterior
dislocation of the hip.
▶ Irrespective of the type of
dislocation the limb is first
brought to the neutral position.
▶ In this position the head of the
femur lies posterior to the
acetabulum even in anterior
dislocation.
▶ Now with an assistant steadying
the pelvis the head of the femur
is reduced into the acetabulum
by applying a longitudinal
traction in the long axis of the
femur.

25. STIMSONS GRAVITY METHOD
The steps are as follows:
• Patient is prone
• Patient is brought to the edge of the table.
•An assistant stabilizes the pelvis by
applying downward pressure over the
sacrum
• The affected hip and knees are flexed to
90 degrees.
•Downward pressure is applied on the
flexed knee.
•To facilitate the reduction, gentle rotations
needs to be done.

26. WHISTLER’S TECHNIQUE (OVER-UNDER)
▶
▶ 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.

27. NONOPERATIVE TREATMENT
If hip stable after reduction.
▶ Maintain patient comfort  skin traction , analgesia
▶ Avoid Adduction, Internal Rotation.
▶ No flexion > 60o
.
▶ Early mobilization usually few days to 2 weeks.
▶ Repeat x-rays before allowing full weight-bearing.

28. INDICATIONS
FOR OPEN
REDUCTION
• Failed closed reduction.
• Failed stability test.
• Big posterior lip fragment.
• Bone fragment within the acetabulum.
• Fracture of the femoral head.
• Sciatic nerve palsy.

29. COMPLICATIONS
Myositis ossificans
Traumatic osteoarthritis due to
avascular necrosis
Sciatic nerve injury
Irreducible dislocation

30. THANK YOU