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Hip Dislocation

Categories
  • Hip
  • Joint/Tendon
Tags
  • Hip injuries
Hip

Hip Dislocation

Female Pelvis: Anterior view
Female Pelvis: Top view
Hip
Sacrum: Posterior view
Sacrum: Anterior view

Blood Supply of Proximal Femur

Blood supply of proximal femur
Blood supply of proximal femur
Resisted hip flexion (hip flexor muscles)
Anatomy: Muscles around the knee joint
Sciatic nerve
The Lumbar Plexus

Hip Dislocation

The hip joint consists of the acetabulum and the femoral head. The hip joint bony and the supporting ligaments provides stability. Injury and fractures of the hip joint implies breakage of these related structures. Hip dislocations, especially with associated fractures, are high energy fractures with significant soft tissue injury and require patient stabilization management according the the ATLS principles. Posterior hip dislocation is the commonest type.

Anatomic classification:

  • Anterior
  • Inferior (obturator)
  • Superior (pubic)
  • Posterior
Hip dislocation
Dislocation after Total Hip Replacement Surgery

Causes:

High impact axial loading to the hip joint ± intra-articular fracture:

  • Falling on hip joint from elevated position
  • Motor vehicle accidents

Presentation:

  • Pain
  • Swelling
  • Deformity
  • Inability to walk

Clinical Assessment:

  • Bone tenderness
  • Deformity
  • Assess entire limb for ipsilateral limb injuries
  • Exclude neurovascular limb injury and compartment syndrome
  • Leg position with posterior dislocation: flexion, adduction and internal rotation
  • Leg position with anterior dislocation: abduction and external rotation

Associated Injuries:

  • Posterior acetabulum wall fractures
  • Femoral head fractures
  • Sciatic nerve injury
  • Knee injuries
Posterior hip dislocation with associated femoral head fracture

Posterior hip dislocation with associated femoral head fracture

Hip position with anterior and posterior dislocations

Hip position with anterior and posterior dislocations

Thompson and Epstein Posterior Hip Dislocation Classification

Thompson and Epstein posterior hip dislocation classification

Type Ⅰ: dislocation with no or minor fracture

Type Ⅱ: dislocation with single large fragment of posterior wall

Type Ⅲ: dislocation with comminuted posterior wall

Type Ⅳ:  dislocation with fracture through acetabular floor

Type Ⅴ: dislocation with fracture through acetabular floor and femoral head

Epstein Anterior Hip Dislocation Classification

Epstein anterior hip dislocation classification

Type ⅠA: Superior dislocation, no associated fracture

Type ⅠB: Superior dislocation, associated fracture or impaction of femoral head

Type ⅠC: Superior dislocation, associated acetabulum fracture

Type ⅡA : Inferior dislocation, including obturator and perineal

Type ⅡB: Inferior dislocation, associated fracture or impaction of femoral head

Type ⅡC: Inferior dislocation, associated acetabulum fracture

Investigations

X-rays:

    • AP pelvis
    • Hip X-rays
    • Additional: pelvis inlet/outlet and Judet views
    • X-ray additional anatomical areas where clinically indicated

CT: useful to assess hip position and associated hip fractures and for preoperative planning

Treatment Principles

Non-operative:

  • Closed Hip reduction
  • Post reduction X-rays and CT scan

Surgery:

Surgery indications:
  • Irreducible hip dislocation
  • Incongruent hip after closed reduction
  • Associated femur/ acetabulum fractures
Surgery Approach for irreducible hip dislocation:
  • Posterior: Kocher-Langenbeck
  • Anterior: Smith-Petersen

Surgery Options:

  • ORIF for acetabulum fracture: Plate & screw fixation
  • Screw fixation for femoral head/neck fractures
  • Arthroscopic hip surgery management in selected cases
  • Post hip arthroplasty dislocation: manage abnormal implant position with revision hip arthroplasty surgery

Physiotherapy modality principles:

  • Reduce pain and inflammation
  • Regain ROM
  • Gait re-education

Technique for Reducing Hip Dislocation

Technique for reducing hip dislocation

Left hip dislocation reduction technique:

  • Assistant stabilize hip at Anterior Superior Iliac Spine
  • Gently flex hip to 90° and apply progressive increasing leg traction to leg with gentle adduction and hip internal rotation
  • Reduction often felt
  • Post reduction pelvic X-rays

Post Hip Reduction Management for Isolated Hip Dislocation

  • No hip flexion > 60°
  • Early mobilization with partial weight bearing for 4-6 weeks
  • Follow up after 3 months and assess for femoral head AVN

Outcome Post Hip Dislocation

  • Recurrent dislocation
  • Sciatic nerve injury
  • AVN of femur head
  • Post traumatic arthritis

Surgery Technique

Surgery

Surgery Approach for Posterior Hip Dislocation

Surgery approach for posterior hip dislocation

Kocher-Langenbeck approach

  • Subcutaneous incision gluteus maximus and iliotibial band
  • Deep dissection: expose short external rotators by removing overlying fat covering (Sciatic nerve lies posterior to the gemelli & internal obturator muscles)
  • Detach gluteus maximus 1cm from the greater tuberosity insertion
  • Detach the external rotators and apply a stay suture in the piriformis tendon 1cm lateral to its insertion attachment point

Surgical Fixation of Associated Acetabulum Posterior Wall Fracture

Surgical fixation of associated acetabulum posterior wall fracture

Kocher-Langenbeck approach

Reduce fracture

ORIF plate and screw fixation

Surgical Hip Arthroscopy

Hip arthroscopy to manage associated hip dislocation injuries including labral tears

References

  1. Hip dislocation: evaluation and management. DM Foulk, BH Mullis. J Am Acad Orthop Surg. 2010 Apr;18(4): 199-209.
  2. Arthroscopic treatment of traumatic hip dislocation. JP Begly, B Robins, T Youm. J Am Acad Orthop Surg. 2016 May;24(5): 309-17.
  3. Management of acute hip fracture. Bhandari M, Swiontkowski M. N Engl J Med. 2017 Nov 23;377(21): 2053-2062.
  4. Hip fracture: diagnosis, treatment, and secondary prevention. LeBlanc KE, Muncie HL Jr, LeBlanc LL. Am Fam Physician. 2014 Jun 15;89(12): 945-51.

Contributor:

Prof S Maqungo

Learn More

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