anterior-hip-dislocation

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.