http://upload.orthobullets.com/topic/1035/images/r hip fracture dislocation.jpg
http://upload.orthobullets.com/topic/1035/images/anterior hip dislocation.jpg
http://upload.orthobullets.com/topic/1035/images/AP exray hip dislocation_moved.gif
  • Epidemiology
    • rare, but high incidence of associated injuries 
    • mechanism is usually young patients with high energy trauma
  • Hip joint inherently stable due to
    • bony anatomy
    • soft tissue constraints including
      • labrum
      • capsule 
      • ligamentum teres
  • Simple vs. Complex
    • simple
      • pure dislocation without associated fracture
    • complex
      • dislocation associated with fracture of acetabulum or proximal femur
  • Anatomic classification
    • posterior dislocation (90%)
      • occur with axial load on femur, typically with hip flexed and adducted
        • axial load through flexed knee (dashboard injury
      • position of hip determines associated acetabular injury
        • increasing flexion and adduction favors simple dislocation
      • associated with
        • osteonecrosis
        • posterior wall acetabular fracture
        • femoral head fractures
        • sciatic nerve injuries 
        • ipsilateral knee injuries (up to 25%) 
    • anterior dislocation 
      • associated with femoral head impaction or chondral injury
      • occurs with the hip in abduction and external rotation
      • inferior ("obturator") vs. superior ("pubic")
        • hip extension results in a superior (pubic) dislocation
          • Clinically hip appears in extension and external rotation
        • flexion results in inferior (obturator) dislocation
          • Clinically hip appears in flexion, abduction, and external rotation 
  • Symptoms
    • acute pain, inability to bear weight, deformity
  • Physical exam
    • ATLS
      • 95% of dislocations with associated injuries 
    • posterior dislocation (90%) 
      • most common
      • associated with posterior wall and anterior femoral head fracture
      • hip and leg in slight flexion, adduction, and internal rotation 
      • detailed neurovascular exam (10-20% sciatic nerve injury)
      • examine knee for associated injury or instability
      • chest X-ray ATLS workup for aortic injury 
    • anterior dislocation
      • hip and leg in flexion, abduction, and external rotation 
  • Radiographs
    • can typically see posterior dislocation on AP pelvis 
      • femoral head smaller then contralateral side
      • Shenton's line broken
      • lesser trochanter shadow reveals internally rotated limb as compared to contralateral side
      • scrutinize femoral neck to rule out fracture prior to attempting closed reduction
      • AP pelvis and Judet views after reduction to evaluate associated acetabular fractures
  • CT
    • helps to determine direction of dislocation, loose bodies, and associated fractures
      • anterior dislocation 
      • posterior dislocation 
    • post reduction CT must be performed for all traumatic hip dislocations to look for  
      • femoral head fractures 
      • loose bodies 
      • acetabular fractures 
  • MRI
    • controversial and routine use is not currently supported 
    • useful to evaluate labrum, cartilage and femoral head vascularity
  • Nonoperative
    • emergent closed reduction within 6 hours 
      • indications
        • acute anterior and posterior dislocations
      • contraindications
        • ipsilateral displaced or non-displaced femoral neck fracture
  • Operative
    • open reduction and/or removal of incarcerated fragments
      • indications
        • irreducible dislocation
        • radiographic evidence of incarcerated fragment 
        • delayed presentation 
        • non-concentric reduction
        • should be performed on urgent basis
    • ORIF
      • indications
        • associated fractures of
          • acetabulum 
          • femoral head
          • femoral neck 
            • should be stabilized prior to reduction
    • arthroscopy
      • indications
        • no current established indications
        • potential for removal of intra-articular fragments
        • evaluate intra-articular injuries to cartilage, capsule, and labrum
  • Closed reduction 
    • perform with patient supine and apply traction in line with deformity regardless of direction of dislocation
    • must have adequate sedation and muscular relaxation to perform reduction 
    • assess hip stability after reduction
    • post reduction CT scan required to rule out
      • femoral head fractures 
      • intra-articular loose bodies/incarcerated fragments
        • may be present even with concentric reduction on plain films
        • acetabular fractures
    • post-reduction 
      • for simple dislocation, follow with protected weight bearing for 4-6 weeks
  • Open reduction
    • approach
      • posterior dislocation
        • posterior (Kocher-Langenbeck) approach
      • anterior dislocation
        • anterior (Smith-Petersen) approach
    • technique
      • may place patient in traction to reduce forces on cartilage due to incarcerated fragment or in setting of unstable dislocation
      • repair of labral or other injuries should be done at the same time
  • Post-traumatic arthritis 
    • up to 20% for simple dislocation, markedly increased for complex dislocation
  • 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%

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Questions (2)

(OBQ08.200) A 41-year-old female sustains the injury shown in Figure A as a result of a high-speed motor vehicle collision. After a successful attempt at closed reduction in the emergency room using conscious sedation, repeat radiographs show a reduced hip joint. What is the next most appropriate step in treatment? Review Topic


Femoral skeletal traction




CT scan of hip and pelvis




Dynamic fluoroscopic examination under general anesthesia




Hip spica dressing




Touch down weight bearing mobilization



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The radiograph shown in Figure A reveals a left hip dislocation, with some obscuring of detail secondary to the trauma backboard. CT scans should be obtained following a hip dislocation to evaluate for fractures or impacted areas of the femoral head or acetabulum, as well as noncongruent reductions and free intraarticular joint fragments.

The referenced study by Brumback et al comments on the importance of post-reduction CT scans and found that 23% of their posterior wall fractures had associated marginal impaction, with 94% of these discovered via preoperative CT scan.

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(OBQ07.128) A 30-year-old driver is involved in a motor vehicle collision and sustains the injury shown in Figure A. What is the most likely concomitant injury? Review Topic


Right knee meniscus tear




Left knee ACL tear




Subdural hematoma




Right ankle fracture-dislocation




Lumbar burst fracture



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Traumatic hip dislocation results from the dissipation of a large amount of energy about the hip joint. Clinically, these forces often are first transmitted through the knee en route to the hip. It is therefore logical to look for coexistent ipsilateral knee injury in patients with a traumatic hip dislocation.

Schmidt, et al, prospectively evaluated the ipsilateral knee of all patients who had a traumatic hip dislocation and found that 93% had abnormalities on MRI of the knee, with effusion (37%), bone bruise (33%), and meniscal tear (30%) being the most common findings. They suggest liberal use of MRI to the ipsilateral knee if injury is suspected.

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