Treatment of Hip Dislocations and Associated Injuries: Current State of Care

https://doi.org/10.1016/j.ocl.2016.02.002Get rights and content

Section snippets

Key points

  • Time to initial hip relocation is considered an orthopedic emergency.

  • Dislocations can be classified according to associated adjacent injuries, including acetabular, femoral head, and femoral neck fractures.

  • Choice of open approach depends on visualization needed to treat associated hip injury.

  • Complications include osteoarthritis, osteonecrosis, heterotopic ossification, and sciatic nerve palsy.

  • Outcomes depend on the degree of initial trauma to the joint.

Relevant anatomy

Overall stability of the hip joint is reliant on the bony architecture and the joint’s soft tissue constraints. As one of the most stable joints in the body, around 82% of the articular surface of the femoral head is enclosed by the bony acetabulum at neutral position.13 This coverage is further extended by the labrum attached to the perimeter of the acetabulum. The labrum ensures that at least 50% of the femoral head is covered by the labral-acetabular complex in any position of hip motion.14

A

History

Patients with hip dislocations generally present after high-energy trauma. For this reason, patients often have distracting injuries or present in an obtunded state. It is imperative for physicians to recognize the signs and symptoms of a dislocation because delayed diagnosis in unconscious or obtunded patients can have serious results. Patients who are able to participate in an examination often complain of inability to move the lower extremity because of the semiconstrained position of the

Classification

Several classification systems have been developed for hip dislocations and their associated injuries. The first division in classification of hip dislocations is based on the direction of displacement of the femoral head in relation to the acetabulum.

Closed reduction

Closed reduction is generally performed through disengagement of the femoral head from the acetabulum and recreation of the injury pattern with inline traction. Several reduction techniques, for the more common posterior dislocation, have been described.

The Bigelow37 maneuver was initially described in 1870:

  • 1.

    The patient is placed in the supine position.

  • 2.

    The primary clinician provides an axial distraction force while an assistant applies a counterforce to the pelvis.

  • 3.

    The hip is then adducted,

Kocher-Langenbeck

Planning

  1. Positioning may be either lateral decubitus or prone, depending on surgeon preference.

  2. If in the lateral position, the injured leg may be draped free. An advantage of lateral positioning is the ability to test for hip stability following posterior repair and before wound closure.

  3. If in the prone position, distal femoral traction is generally placed and the leg is positioned into a traction table with the hip in extension and the knee flexed to slightly less than 90°.

  4. The use of a traction table

Postoperative care

Many clinicians currently allow weight bearing as tolerated with crutches for comfort and to instate posterior or anterior hip precautions for 6 to 8 weeks, depending on the direction of dislocation.14 The preference of the senior author is to allow touchdown (foot flat) weight bearing with 2-arm support for 6 weeks and to use posterior hip precautions for 3 months. Previously, investigators have recommended bed rest, spica casting, or even temporary traction, despite a stable hip, in an

Complications and management

  • Because of modern imaging and standardization of trauma management, modern cohorts do not report on missed or late-diagnosed hip dislocations.4, 5, 7, 8

  • Surgical infection is not reported as an outlier specific in hip fracture-dislocations; however, several complications and morbidities affect both closed-treated and open-treated hips:

    • Posttraumatic arthritis: overall rates have been reported in 16% to 24% of all hip dislocations,4, 6, 7, 32, 35 and in as many as 89% of those with femoral neck or

Outcomes

Long-term results in the literature are often reported on a subjective functional score range of very good to poor, although some investigators do report on radiographic findings or use validated tests such as the Merle d’Aubigne7, 109 functional score. Because several different classifications have been used, as discussed earlier, and several different scoring systems, this article simplifies the reported classification scheme and outcomes where possible into binary results. The studies listed

First page preview

First page preview
Click to open first page preview

References (109)

  • S.J. Svoboda et al.

    Hip arthroscopy for osteochondral loose body removal after a posterior hip dislocation

    Arthroscopy

    (2003)
  • J. Fowler et al.

    Abdominal compartment syndrome after hip arthroscopy

    Arthroscopy

    (2010)
  • M.J.B. Keel et al.

    Clinical results of acetabular fracture management with the pararectus approach

    Injury

    (2014)
  • P. Slätis et al.

    Irreducible traumatic posterior dislocation of the hip

    Injury

    (1974)
  • H. Proctor

    Dislocations of the hip joint (excluding “central” dislocations) and their complications

    Injury

    (1973)
  • A. Lang-Stevenson et al.

    The Pipkin fracture-dislocation of the hip

    Injury

    (1987)
  • K.-S. Park et al.

    Clinical and radiographic outcomes of femoral head fractures: excision vs. fixation of fragment in Pipkin type I: what is the optimal choice for femoral head fracture?

    J Orthop Sci

    (2015)
  • K.J. Fairbairn et al.

    Gas bubbles in the hip joint on CT: an indication of recent dislocation

    AJR Am J Roentgenol

    (1995)
  • R.V. Funsten et al.

    Dashboard dislocation of the hip: a report of twenty cases of traumatic dislocations

    J Bone Joint Surg Am

    (1938)
  • D.J. Hak et al.

    Severity of injuries associated with traumatic hip dislocation as a result of motor vehicle collisions

    J Trauma

    (1999)
  • S.S. Upadhyay et al.

    The long-term results of traumatic posterior dislocation of the hip

    J Bone Joint Surg Br

    (1981)
  • K.E. Dreinhofer et al.

    Isolated traumatic dislocation of the hip. Long-term results in 50 patients

    J Bone Joint Surg Br

    (1994)
  • S.S. Upadhyay et al.

    An analysis of the late effects of traumatic posterior dislocation of the hip without fractures

    J Bone Joint Surg Br

    (1983)
  • V. Sahin et al.

    Traumatic dislocation and fracture-dislocation of the hip: a long-term follow-up study

    J Trauma

    (2003)
  • R.S. Yang et al.

    Traumatic dislocation of the hip

    Clin Orthop Relat Res

    (1991)
  • G.A. Hunter

    Posterior dislocation and fracture-dislocation of the hip. A review of fifty-seven patients

    J Bone Joint Surg Br

    (1969)
  • M.J. Stewart et al.

    Fracture-dislocation of the hip; an end-result study

    J Bone Joint Surg Am

    (1954)
  • V.H. Frankel

    Biomechanics of the hip joint

    Instr Course Lect

    (1986)
  • H.C. Epstein et al.

    Traumatic anterior dislocation of the hip

    Orthopedics

    (1985)
  • J.A. Goulet

    Hip Dislocations

  • E. Gautier et al.

    Anatomy of the medial femoral circumflex artery and its surgical implications

    J Bone Joint Surg Br

    (2000)
  • N.R. Smoll

    Variations of the piriformis and sciatic nerve with clinical consequence: a review

    Clin Anat

    (2010)
  • J. Nerubay

    Traumatic anterior dislocation of hip joint with vascular damage

    Clin Orthop Relat Res

    (1976)
  • K.S. Eisenberg et al.

    Posterior dislocation of the hip producing lumbosacral nerve-root avulsion. A case report

    J Bone Joint Surg Am

    (1972)
  • M.F. Bonnemaison et al.

    Traumatic anterior dislocation of the hip with acute common femoral occlusion in a child

    J Bone Joint Surg Am

    (1968)
  • W.J. Gillespie

    The incidence and pattern of knee injury associated with dislocation of the hip

    J Bone Joint Surg Br

    (1975)
  • G.L. Schmidt et al.

    Knee injury in patients experiencing a high-energy traumatic ipsilateral hip dislocation

    J Bone Joint Surg Am

    (2005)
  • J. Tabuenca et al.

    Knee injuries in traumatic hip dislocation

    Clin Orthop Relat Res

    (2000)
  • P. Tornetta et al.

    Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol

    J Bone Joint Surg Am

    (2007)
  • R.A. Baird et al.

    Radiographic identification of loose bodies in the traumatized hip joint

    Radiology

    (1982)
  • N.A. Ebraheim et al.

    Soft-tissue window to enhance visualization of entrapped osteocartilaginous fragments in the hip joint

    Orthop Rev

    (1993)
  • S.W. Mayer et al.

    MRI as a reliable and accurate method for assessment of posterior hip dislocation in children and adolescents without the risk of radiation exposure

    Pediatr Radiol

    (2015)
  • V.P. Thompson et al.

    Traumatic dislocation of the hip; a survey of two hundred and four cases covering a period of twenty-one years

    J Bone Joint Surg Am

    (1951)
  • H.C. Epstein

    Traumatic dislocations of the hip

    Clin Orthop Relat Res

    (1973)
  • J.H. Pringle et al.

    Traumatic dislocation of the hip joint: an experimental study on the cadaver

    Glasgow Med J

    (1943)
  • J.R. Armstrong

    Traumatic dislocation of the hip joint; review of 101 dislocations

    J Bone Joint Surg Br

    (1948)
  • J.L. Marsh et al.

    Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee

    J Orthop Trauma

    (2007)
  • H.J. Bigelow

    Luxations of the hip-joint

    Boston Med Surg J

    (1870)
  • O.H. Allis

    An inquiry into the difficulties encountered in the reduction of dislocation of the hip

    Boston Med Surg J

    (1896)
  • L.A. Stimson

    A treatise on fractures

    (1883)
  • Cited by (29)

    • Musculoskeletal Trauma and Infection

      2022, Magnetic Resonance Imaging Clinics of North America
      Citation Excerpt :

      MR plays a key role in guiding clinical management of suspected musculoskeletal processes, with this article focusing on septic arthritis, soft tissue infection, and osteomyelitis. The hip is a highly stable articulation, with greater than 80% of the femoral head cartilage articulating with the acetabulum.4 Several strong ligaments coalesce into a fibrous capsule to provide additional support and increase the passive stability of the hip.

    • Posterior hip fracture-dislocation associated with posterior wall fracture of the acetabulum and ipsilateral comminuted trochanteric fracture of the femur: A case report

      2022, International Journal of Surgery Case Reports
      Citation Excerpt :

      Although an IMN is less invasive for soft tissues and the patient's hemodynamic condition as compared to DHS fixation with a trochanteric stabilizing plate, the risk factors for IMN fixation failure in unstable femoral trochanteric fractures have also been reported [10]. Loss of the anteromedial cortical support on the anteroposterior and lateral views during intraoperative fluoroscopy worsened the clinical outcomes and increased the complications (loss of reduction, cutout, excessive sliding of the cephalic nail, and implant breakage) [10,11]. The order of facture fixation in the treatment of acetabular fractures associated with ipsilateral femoral fractures is controversial.

    • Hip Dislocations in the Emergency Department: A Review of Reduction Techniques

      2018, Journal of Emergency Medicine
      Citation Excerpt :

      Hip dislocations are a common emergency department (ED) presentation, with studies suggesting an increasing incidence in North America (1–3). The hip joint is a ball-and-socket joint that is supported by multiple strong capsular ligaments (4–6). However, these ligaments may get disrupted when a strong force is applied to the femur, most commonly after motor vehicle collisions (4).

    View all citing articles on Scopus

    Disclosures: The authors received no funding and have no disclosures in relation to this current article.

    View full text