1. A 9-year-old boy presented to the emergency room with a dislocated right hip after falling from a height of about 2 meters while trying to jump onto a basketball hoop. 2. Physical examination revealed an anterior dislocation of the right hip with external rotation, abduction and flexion. 3. The patient underwent closed reduction of the right hip dislocation under general anesthesia using traction and counter-traction maneuvers. Post-reduction x-rays confirmed an acceptable reduction with no fractures seen.

1. By.
Tharinee Thanaprakobkorn
Phramongkutklao College Of Medicine
EXTERN
CONFERENCE

2. Chief complaint
ผู้ป่วยเด็กชายไทย อายุ 9 ปี
ภูมิลาเนา จ.นครราชสีมา
ขาผิดรูป 4 ชั่วโมงก่อนมาโรงพยาบาล
ประวัติ กระโดดโหนแป้นบาสแล้วตกจากแป้นบาส
สูงประมาณ 2 เมตร

3. • A : Can speak, c-spine not tender, full ROM
• B : Clear breath sound equal both lungs, trachea in midline, CCT
negative
• C : BP 103/69mmHg, Pulse 100 bpm, capillary refill time < 2 sec, no
active bleeding
• D : E4V5M6, pupils 3 mm RTLBE
• E : No external wound
Primary Survey

4. • A : No history of food and drug allergy
• M : No current medications
• P : No underlying disease
• L : 14:00 (3 hr PTA)
• E : 4 hr PTA ผู้ป่วยกระโดดพยายามจะโหนแป้นบาส สูงประมาณ 2 เมตร จากนั้นตกลงมาที่พื้น สะโพกข้างขวากระแทก
กับพื้น ปวดสะโพกด้านขวา ขาขวาผิดรูป งอขาขวาเข้าไม่ได้ขยับสะโพกขวาไม่ได้เดินไม่ได้ ไม่มีอาการชา ไม่มีบาดแผลเลือดออก
• ปฏิเสธประวัติดื่มสุรา ปฎิเสธประวัติศีรษะกระแทก จาเหตุการณ์ได้ไม่สลบ ไม่มีปวดศีรษะ ปฎิเสธอก/ท้องกระแทก
Secondary Survey

5. • GA : A boy, good consciousness, well co-operative, no
dyspnea
• Vital signs: Temp 36.8 C, BP 110/70 mmHg, PR 86/min, RR
16/min
• HEENT : no pale conjunctivae, anicteric sclera
• CVS : full regular pulses all extremities, normal S1 S2, no
murmur
• Respiratory : No dyspnea, normal breath sound, no
adventitious sound
Physical examination

6. • Fixed position of the right hip
–External rotation, Abduction and
Flexion
• tender at right groin
• no external wound
• unable to move the right hip, limited
ROM due to pain
• motor power grade 5
• Pulses: right PA 2+, PTA 2+, DPA 2+
Affected part

7. Film Pelvis AP view
• hip abduction
• Femoral head inferior to the
acetabulum
• Shenton's line broken
• Lesser trochanter is more visible
due to external rotation
• No fracture seen

8. Anterior dislocation
of right hip
RARE
Most commonly dislocated joint of the lower extremity
 Male : Female = 4 : 1
 Mechanism : usually young patients with high energy trauma

9. Emergency
condition
Multiple trauma
Avascular necrosis
Goal: reduce risk of AVN and Degenerative joint disease

10. Film LS Spine AP Lat

11. Film Knee AP Lat

12. • Admit
• Monitor V/S, I/O
• NPO
• 5% DN/2 (1000) IV drip rate 40 ml/h
• CBC, anti-HIV
• Pethidine (1 mg/kg) 35 mg IV prn q6h
• Cefazolin 1 g IV to OR
• Set OR emergency for close reduction of the right hip under GA
Management at ER

13. Closed reduction
under GA
• Traction and counter
traction
• Adduction
• Internal rotation

14. Anatomy of hip joint

15.  Simple
: dislocation without associated fracture
• Complex
: dislocation associated with fracture of acetabulum or proximal
femur

16. Posterior dislocation (90%)
• occur with axial load on
femur, typically with hip
flexed and adducted
• axial load through flexed
knee (dashboard injury)
• sciatic n. injury
Anterior dislocation (10%)
• Femoral head situated
anterior to acetabulum
• Hyperextension force
against an abducted leg
that levers head out of
acetabulum.
• force against posterior
femoral head or neck can
produce dislocation

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

18. Posterior Dislocation
 POSTERIOR: - flexed, internally rotated, and adducted.

19. Neurovascular examination
• Femoral vessels injury :
• Femoral nerve injury :
– Loss of sensation over the thigh
– Weakness of the quadriceps
– Loss of deep tendon reflexes at knee L3, 4

20. Hip dislocation
Associated injuries
– Multiple trauma, sometimes life threatening
– Ipsilateral femoral neck, femoral shaft fracture
– Ipsilateral patella fracture
– Ipsilateral knee injuries (cruciate, collateral
ligaments and periarticular fracture)
– Sciatic nerve

21. Hip dislocation
Management
• orthopedic emergency
• Reduction within 6 hours – preventing avascular
necrosis of the femoral head
• Reduction under general anesthesia
• Allis maneuver for hip dislocation
• Test for stability of the hip after reduction : 90 °
• Re-evaluate associated fracture of acetabulum and
femoral head
• Re-evaluate vascular status and sciatic nerve

22. Non-operative :
Emergent closed reduction within 6 hr
 Allis maneuver
 Stimson maneuver
 Bigelow maneuver

23. Hip dislocation
Indication for surgery
• Hip dislocation with femoral
neck or acetabular fracture
• Incarcerated fragment in the
hip joint
• Irreducible reduction
• Incongruent reduction
• Unstable hip after reduction

24. X-rays after Hip Reduction:
• AP pelvis, Lateral Hip x-ray.
• CT scan :
Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
bony fragments.

25. Film Pelvis Post reduction

26. Complications
• Post-traumatic arthritis
– up to 20% for simple dislocation, markedly increased for complex dislocation
– If an associated acetabular fracture is present, the incidence of traumatic arthritis is as high as 80%.
• Femoral head osteonecrosis
– 5-40% incidence
– Increased risk with increased time to reduction
• Sciatic nerve injury
– 8-20% incidence
– associated with longer time to reduction
• Recurrent dislocations
– less than 2%
– Risk factors for recurrent dislocation are large capsular defects, intra-articular fragments, or a prosthetic hip.