summary Hip dislocations are traumatic hip injuries that result in femoral head dislocation from the acetabular socket. Diagnosis can be made with hip radiographs to determine the direction of dislocation and CT scan studies to assess for associated injuries. Treatment is urgent reduction to minimize risk of avascular necrosis followed by CT scan to assess for associated injuries that may require surgical treatment (loose bodies, femoral head fractures, acetabular fractures). Epidemiology Incidence rare, but high incidence of associated injuries Etiology Pathophysiology mechanism is usually young patients with high energy trauma Pathoanatomy Hip joint inherently stable due to bony anatomy soft tissue constraints including labrum capsule ligamentum teres Classification 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 Presentation 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 extension, abduction, and external rotation Imaging Radiographs recommended views AP cross-table lateral used to differentiate between anterior vs. posterior dislocation scrutinize femoral neck to rule out fracture prior to attempting closed reduction obtain AP, inlet/outlet, judet views after reduction findings loss of congruence of femoral head with acetabulum disruption of shenton's line arc along inferior femoral neck + superior obturator foramen anterior dislocation femoral head appears larger than contralateral femoral head femoral head is medial or inferior to acetabulum posterior dislocation femoral head appears smaller than contralateral femoral head femoral head superimposes roof of acetabulum decreased visualization of lesser trochanter due to internal rotation of femur 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 Treatment Nonoperative emergent closed reduction within 12 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 Techniques 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 Complications 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%
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next (OBQ20.112) Figure A is the radiograph of a 26-year-old male involved in a snow skiing accident. After a failed closed reduction attempt in the operating room, the patient is indicated for open reduction. The surgical approach chosen for this patient’s injury pattern has been shown to decrease blood loss while best reducing the risk of compromising femoral head blood flow. Which of the following correctly describes the muscular and nervous interval(s) for the approach used? QID: 215523 FIGURES: A B Type & Select Correct Answer 1 Sartorius (femoral nerve) and tensor fasciae latae (superior gluteal nerve) 80% (708/886) 2 Tensor fasciae latae (superior gluteal nerve) and gluteus medius (inferior gluteal nerve) 7% (61/886) 3 Rectus femoris (femoral nerve) and gluteus medius (inferior gluteal nerve) 4% (34/886) 4 Gluteus medius (superior gluteal nerve) and vastus lateralis (inferior gluteal nerve) 2% (16/886) 5 No true internervous plane, splits gluteus maximus 7% (61/886) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 586 FIGURES: A Type & Select Correct Answer 1 Femoral skeletal traction 3% (72/2218) 2 CT scan of hip and pelvis 88% (1942/2218) 3 Dynamic fluoroscopic examination under general anesthesia 6% (126/2218) 4 Hip spica dressing 0% (6/2218) 5 Touch down weight bearing mobilization 3% (66/2218) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 789 FIGURES: A Type & Select Correct Answer 1 Right knee meniscus tear 61% (2103/3475) 2 Left knee ACL tear 3% (117/3475) 3 Subdural hematoma 16% (542/3475) 4 Right ankle fracture-dislocation 13% (452/3475) 5 Lumbar burst fracture 7% (253/3475) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
All Videos (7) Podcasts (2) Login to View Community Videos Login to View Community Videos Posterior Hip Dislocation - Reduction Maneuver Kemal Gokkus Trauma - Hip Dislocation A 11/13/2021 435 views 3.5 (4) Login to View Community Videos Login to View Community Videos Inferior hip dislocation (Luxatio Erecta Femoris) Kemal Gokkus Trauma - Hip Dislocation C 9/7/2021 118 views 5.0 (1) Kocher Langenbeck Approach for Acetabular Fractures - Michael Githens, MD Trauma - Hip Dislocation C 4/14/2021 1231 views 0.0 (0) Trauma⎜Hip Dislocation (ft. Dr. Joaquin A. Castaneda) Team Orthobullets 4 Trauma - Hip Dislocation Listen Now 13:45 min 10/18/2019 194 plays 4.5 (2) Trauma⎪Hip Dislocation Orthobullets Team Trauma - Hip Dislocation Listen Now 15:55 min 1/14/2020 702 plays 4.7 (6) See More See Less
Posterior Hip Dislocation with Posterior Wall Acetabulum Fracture in 25M (C101735) Craig Forsthoefel Trauma - Hip Dislocation B 3/29/2021 209 11 0 Unique and Rare Presentation for a Floating Hip Injury (Fracture-Dislocation) (C101347) Ibrahim Hussein Trauma - Hip Dislocation E 12/27/2019 41 1 1 Chronic posterior dislocation of left hip joint (C2338) krishnaprasad nimmagadda Trauma - Hip Dislocation E 9/7/2015 240 0 2 See More See Less