Hip dislocation Taiz University , faculty of medicine and health sciences By Dr : Monther Alkhawlany

1. Hip
Dislocation
GROUP D
2015

2. What To Cover Today:
 Introduction
 Incidence
 Brief anatomy of Hip Joint
 Mechanism and types of Hip Dislocations
 Techniques of Closed Reduction
 Post Reduction disposition and investigations

3. Introduction
 What is the hip dislocation ?
The head of the femur displace in relation to the
acetabulum from severe trauma, causing
dislocation.

4. Introduction
Hip dislocations caused by significant force:
 Association with other fractures
 Damage to vascular supply to femoral head
Thus, high chance of complications

5. Incidence
 Common in young population with high energy trauma.
 Unrestrained motor vehicle accident occupants are at
significant higher risk for sustaining a hip dislocation than
passengers wearing a restraining device
 After Prim THR 3.9 percent experience Hip dislocation in
first 6 months.
 After Revised THR surgery 15 percent experience
Dislocation in 6 months.

6. Anatomy
Ball and socket typical synovial joint.
 Femoral head: slightly asymmetric, forms 2/3 sphere.
 Acetabulum: inverted “U” shaped articular surface.
 Ligamentum teres, with artery to femoral head, passes
through middle of inverted “U”.

8. Joint Contact Area
Throughout ROM:
 40% of femoral head is in contact with
acetabulum.
 10% of femoral head is in contact with
labrum.

9. Acetabular Labrum
Strong fibrous ring
Increases femoral head coverage
Contributes to hip joint stability

10. Hip Joint Capsule
 Extends from intertrochanteric ridge of proximal femur to bony
perimeter of acetabulum.
 Has several thick bands of fibrous tissue (3 lig)
=== Iliofemoral ligament , pubofemoral ligament and
ischiofemoral ligament .

11. The ligaments of hip joint
 The primary capsular fibers run longitudinally and are
supplemented by much stronger ligamentous
condensations that run in a circular and spiral fashion.

12. Cont…

13. Blood Supply to Femoral Head

15. Sciatic Nerve
 Peroneal and tibial components differentiate
early, sometimes as proximal as in pelvis.
 Passes posterior to posterior wall of acetabulum.
 Generally passes inferior to piriformis muscle, but
occasionally the piriformis may split the peroneal
and tibial components
 Composed from roots of L4 to S3.
Nerve supply

16. Hip Dislocation: Mechanism of
Injury
 Almost always due to high-energy
trauma.
 Most commonly involve unrestrained
occupants in RTAs.
 Can also occur in pedestrian-RTAs, falls
from heights, industrial accidents and
sporting injuries.

17. Classification:
 1-According to direction of femoral head
displacement :
A- Posterior Dislocation
B- Anterior Dislocation
C- Central Dislocation
2- Multiple systems exist :
 Thompson and epstein
 Stewart and milford
 AO/OTA Classification

18. Thompson and epstein
classification

19. Posterior Dislocation
 Generally results from axial load applied to femur, while
hip is flexed.
 Most commonly caused by impact of dashboard on knee.

21. Types of Posterior Dislocation
 Postero-superior (iliac)
 ischial

22. Posterior Dislocation
 POSTERIOR: - flexed, internally rotated, and adducted.

23. Thomas and Epstein Classification
of Posterior Hip Dislocations
Most well-known
Type I pure dislocation with or without insignificant
Posterior wall fragment
Type II Dislocation with large posterior wall fragment.
Type III Dislocation with comminuted posterior wall.
Type IV Dislocation with “acetabular floor” fracture
(probably transverse + post. wall acetabulum
fracture-dislocation
Type V Dislocation with femoral head fracture.

24. Anterior Dislocation
 Femoral head situated anterior to
acetabulum
 Hyperextension force against an
abducted leg that levers head out of
acetabulum.
 Also force against posterior femoral
head or neck can produce dislocation
 10 % to 15% of traumatic hip dislocation

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

27. Mechanism of
Anterior
Dislocation
 Extreme abduction with external rotation of hip.
 Anterior hip capsule is torn or avulsed.
 Femoral head is levered out anteriorly.

28. Types of anterior dislocation
 Pubic (superior)
 Obturator (inferior)
 Perineal

30. Central dislocation
 Due to direct trauma to greater trochanter drive femoral
head inward fracture of floor of acetabulum.
 ALWAYS fracture dislocation
 Lateral force against an adducted femur

31. Effect of Dislocation on
Femoral Head Circulation
 When capsule tears, ascending cervical branches are torn or
stretched.
 Artery of ligamentum teres is torn.
 Some ascending cervical branches may remain kinked or
compressed until the hip is reduced.
Thus, early reduction of the dislocated hip can improve blood
flow
to femoral head.

32. Associated Injuries
Mechanism: knee vs. dashboard injury
 Contusions or fractures of distal femur
 Patella fractures, knee injuries
 Foot fractures, if knee extended

33. Cont…
 Sciatic nerve injuries occur in 10% of hip
dislocations.
*Most commonly, these resolve with reduction of
hip and passage of time.
* Stretching or contusion most common.
*Piercing or transection of nerve by bone can
occur.

34. Irregular
presentation/appearance if:
 femoral head or neck are fractured
 femoral shaft fracture
 obtunded patient, confused, shocked ……

35. Cont……
Other associated injuries are common:
 Head, neck and facial injuries
 Chest injuries
 Intra-abdominal injuries
 Lower extremity fractures and dislocations

36. Management
History and Evaluation :
 Significant trauma, usually RTA.
 Awake, alert patients have severe pain in hip region.
 lnability to stand or walk (disturbance of function).

37. Physical Examination ( posterior
dislocation(
 1) lnspection
 Ecchymosis, bruises, swellings
 Lower limb is flexed, adducted and internally
rotated.
 Supratrochanteric shortening (shortening with
fixed greater trochanter-condyle distance).
 2) Palpation
 - Femoral head palpated post. empty femoral A.
 - Narthes sign (i.e. Difficulty to palpate femoral
pulse due to backward migration of femoral
head).
 3) Movement Painful limitation of all hip
movements.

38. Physical Examination:
Classical Appearance
Posterior Dislocation: Hip flexed, internally
rotated, adducted.

39. 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:
-impaired.

40. Physical Examination:
Classical Appearance
Anterior Dislocation: Extreme external rotation,
less-pronounced abduction
and flexion.

41. Irregular
presentation/appearance if:
 femoral head or neck are fractured
 femoral shaft fracture
 obtunded patient, confused, shocked ……

42. Neurovascular examination
 Signs of sciatic nerve injury include
the following:
 Loss of sensation in posterior leg and foot

Loss of dorsiflexion (peroneal branch) or
plantar 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

45. Radiographs: AP Pelvis X-Ray
 In primary survey as per ATLS Protocol.
 Should allow diagnosis and show direction of dislocation.
 Femoral head not centered in acetabulum (loss of
parallelism)
 Femoral head appears larger (anterior) or smaller
(posterior).
 Usually provides enough information to proceed with closed
reduction.

46. Reasons to Obtain More
X-Rays Before Hip Reduction
 View of femoral neck inadequate to rule out fracture.
 Patient requires CT scan of abdomen/pelvis to rule out associated
injuries.

47. X-rays after Hip
Reduction:
 AP pelvis, Lateral Hip x-ray.
 Judet views of pelvis.
 CT scan with 2-3 mm cuts.

48. CT Scan
Most helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.

49. MRI Scan
 Will reveal labral tear and soft-tissue
anatomy.
 Has not been shown to be of benefit in
acute evaluation and treatment of hip
dislocations.

50. Clinical Management:
Emergent Treatment
 Dislocated hip is an emergency.
 The goal is to reduce risk of AVN and
Degenerative joint disease.

51. Benefits of early Reduction
 Allows restoration of flow through occluded or
compressed vessels.
 Literature supports decreased AVN with earlier
reduction.
 Requires proper anesthesia.
 Requires “team” (i.e. more than one person).

52. Patterns Treated Non
operatively
 No associated fracture and congruent reduction
 Posterior wall fracture that is clinically stable with
congruent reduction
 Pipkin type I fracture with congruent reduction.
 Pipkin type II fracture with anatomic reduction
and congruent joint

53. Anesthesia
 General anesthesia with muscle
relaxation facilitates reduction, but is
not necessary, but……
 Conscious sedation is acceptable.
 Attempts at reduction with inadequate
analgesia/ sedation will cause unnecessary
pain, muscle spasm and make subsequent
attempts at reduction more difficult.

54. The popular methods of achieving closedThe popular methods of achieving closed
reduction of the hip :reduction of the hip :
1.1.TheThe BigleowBigleow maneuver ,maneuver ,
2.2.AllisAllis maneuver ,maneuver ,
3.Stimson3.Stimson gravity technique ,gravity technique ,
4.Whistler technique and4.Whistler technique and
5.Captain Morgan technique5.Captain Morgan technique

55. Allis Maneuver
 Assistant: Stabilizes pelvis
 Posterior-directed force on both ASIS’s
 Surgeon: Stands on stretcher
 Gently flexes hip to 900
 Applies progressively increasing traction to the
extremity
 Applies adduction with internal/external rotation
 Reduction can often be seen and felt

58. Reverse Bigelow reduction Maneuver
for anterior hip dislocation
 The position of the hip in the
reverse Bigelow maneuver is
partial flexion and abduction.
Bigelow suggests two
methods of reduction. First is
the lifting method, in which a
firm "jerk" is applied to the
flexed thigh. This method
often results in reduction
except in pubic dislocations.
 If this "lifting method" fails,
traction is applied in the line
of deformity. The hip then is
adducted, sharply internally
rotated, and extended

59. Reduction of
posterior
dislocation
Bigelow maneuver
East Baltimore lift technique

60. East Baltimore lift

62. Bigelow maneuver

63. Stimpson Method
 Described primarily for acute posterior dislocations
 Believed to be least traumatic
 Pt. is in prone position w/ lower limbs hanging from
end of table
 Assistant immobilizes the pelvis by applying pressure
on
the sacrum
 Hold knee and ankle flexed to 90 deg & apply
downward pressure to leg just distal to the knee
 Gentle rotatory motion of the limb may assist in
reduction

65. 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.

67. Captain Morgan technique

68. How to know reduced Hip
 The limb moves more freely
 Patient more comfortable
But……..
 Requires testing of stability
 Simply flexing hip to 900
does not sufficiently test stability

69. Nonoperative Treatment
 If hip stable after reduction, and reduction
congruent.
 Maintain patient comfort  skin traction ,
analgesia
 Avoid Adduction, Internal Rotation.
 No flexion > 60
o
.
 Early mobilization usually few days to 2 weeks.
 Touch down weight-bearing may be delayed
 Repeat x-rays before allowing full weight-bearing.

70. Irreducible Hip?
 Requires emergent reduction in theatre.
 Pre-op CT obtained if it will not cause delay.
 One more attempt at closed reduction in
O.T. with anesthesia.
( Repeated efforts not likely to be successful and may create harm to
the neurovascular structures or the articular cartilage.)
Surgical approach from side of dislocation.

71. Causes of Irreducible
dislocation
 Anterior:
Buttonholing through the capsule
Rectus femoris
Capsule
Labrum
Psoas tendon
 Posterior:
Piriformis tendon
Gluteus maximus
Capsule, Ligamentum teres
Posterior wall, Bony fragment
Iliofemoral ligament
Labrum

72. Irreducible anterior hip dislocation
 Smith-Peterson approach ,Watson-Jones
approach, Extended iliofemoral,
ilioinguinal approach.
 Allows visualization and retraction of
interposed tissue.
 Placement of Schanz pin in
intertrochanteric region of femur will assist
in manipulation of the proximal femur.
 Repair capsule, if this can be
accomplished without further dissection.

74. Irreducible Hip Dislocation:
Posterior

75. 1.Irreducible Posterior Dislocation with
Large Femoral Head Fracture
Fortunately, these are rare.
Difficult to fix femoral head fracture from posterior
approach without transecting ligamentum teres.

76. Three Options
 1- Detach femoral head from ligamentum

teres repair femoral head fracture with hip
 dislocated reduce hip.
 2- Close posterior wound, fix femoral head
 fracture from anterior approach (either now or
 later).
 3- Ganz trochanteric flip osteotomy.
Best option is not known: Damage to blood supply
 from anterior capsulotomy vs. damage to blood
 supply from transecting ligamentum teres. Mm

77. 2.Hip Dislocation with Femoral
Neck Fracture
 Attempts at closed reduction potentiate chance
of fracture displacement with consequent
increased risk of AVN.
 If femoral head is dislocated with neck fracture,
then the ability to reduce the head by closed
means is markedly compromised.
Thus, closed reduction should not be attempted.

78. Cont…..
 Usually the dislocation is posterior.
 If fracture is non-displaced, stabilize fracture with
parallel lag screws first.
 If fracture is displaced, open reduction of femoral
head into acetabulum, reduction of femoral
neck fracture, and stabilization of femoral neck
fracture.

79. 3.Incarcerated
Fragment
 Can be detected on x-ray or CT scan.
 Surgical removal necessary to prevent abrasive
wear of the articular cartilage.
 Posterior approach allows best visualization of
acetabulum (with distraction or intra-op dislocation).
 Anterior approach only if:
dislocation was anterior and,
fragment is readily accessible anteriorly.

80. 4.Incongruent Reduction
 Acetabulum Fracture (weight-bearing portion).
 Femoral Head Fracture (any portion).
 Interposed tissue.
 Achieve congruence by removing interposed tissue and/or
reducing and stabilizing fracture.

81. 5.Unstable Hip after Reduction
 Due to posterior wall and/or femoral head
fracture.
 Requires reduction and stabilization fracture.
 Labral detachment or tear
 Highly uncommon cause of instability.
 Its presence in the unstable hip would justify surgical
repair.
 MRI may be helpful in establishing diagnosis.

82. Indications for open Reduction
 Irreducible dislocation
 Iatrogenic sciatic nerve injury
 Incongruent reduction with incarcerated fragments
 Incongruent reduction with soft tissue interposition
 Incongruent reduction with Pipkin type I femoral head
fracture (relative)

83. Results of Treatment
 Pain : normal to severe pain and degeneration.
 In general, dislocations with associated femoral head
or acetabulum fractures fare worse.
 Dislocations with fractures of both the femoral head
and the acetabulum have a strong association with
poor results.
 Irreducible hip dislocations have a strong association
with poor results.
 13/23 (61%) poor and 3/23 (13%) fair results.

84. Complication OF Hip
Dislocation
Early ;
1- Sciatic Nerve Injury
 Occurs in up to 20% of patients with hip dislocation.
 Nerve stretched, compressed or transected.
 With reduction: 40% complete resolution
 25-35% partial resolution

85. Sciatic Nerve Palsy:
If No Improvement after 3–4 Weeks
 EMG and Nerve Conduction Studies for baseline
information and for prognosis.
Allows localization of injury in the event that surgery
is required.

86. 2-Vascular injury :
Occasionally the superior gluteal artery is
torn and bleeding may be profuse .
3- Associated fractured femoral
shaft :
When this occurs at the same time as the hip
dislocation, the dislocation is often missed.

87. Late:
1- Avascular Necrosis (AVN):
1-40%
 Several authors have shown a positive correlation
between duration of dislocation and rate of AVN.
 Results are best if hip reduced within six hours.

88. 2-Post-traumaticOsteoarthritis
 Can occur with or without AVN.
 May be unavoidable in cases with
severe cartilaginous injury.
 Incidence increases with associated
femoral head or acetabulum
fractures.
 Efforts to minimize osteoarthritis are
best directed at achieving anatomic
reduction of injury and preventing
abrasive wear between articular
carrtilage and sharp bone edges.

89. 3- Unreduced dislocation :
After a few weeks an untreated dislocation can seldom be
reduced by closed manipulation and open reduction is
needed.

90. 4-Thromboembolism
 Hip dislocation = high risk patient.
 Prophylactic treatment with:
low molecular weight heparin
 Early postoperative mobilization.
 Discontinue prophylaxis after 2-6 weeks (if patient
mobile).

91. 5.Myositis ossification
 Higher incidence after open reduction with
internal fixation via an anterior approach than a
posterior approach
 The use of indomethacin may diminish the rate of
clinically significant heterotrophic ossification.
 The other choice is to use radiation therapy,
usually 700 Gy in one dose. This method is very
effective in decreasing the rate of heterotopic
ossification, but is not favored in young patients

92. Conclusion
 It is highly stable joint that needs high energy trauma to
dislocate,(so, don't miss associated injuries)
 Early reduction of the dislocated hip (within 6 hrs) can
improve blood flow to femoral head.
 Up to 5 views of xrays/C-T may be needed for proper
evaluation( pre and post reduction)

93. Cont…..
 Minimize closed trials to avoid the risk of vascular damage
and AVN
 Surgical approaches according to the direction of
dislocation
 Surgeon experience is highly considered for treatment (as
revision surgeies caries a high risk of complications)

94. Thanks
BY :
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