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Time to initial hip relocation is considered an orthopedic emergency.
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Dislocations can be classified according to associated adjacent injuries, including acetabular, femoral head, and femoral neck fractures.
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Choice of open approach depends on visualization needed to treat associated hip injury.
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Complications include osteoarthritis, osteonecrosis, heterotopic ossification, and sciatic nerve palsy.
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Outcomes depend on the degree of initial trauma to the joint.
Treatment of Hip Dislocations and Associated Injuries: Current State of Care
Section snippets
Key points
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:
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The patient is placed in the supine position.
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The primary clinician provides an axial distraction force while an assistant applies a counterforce to the pelvis.
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The hip is then adducted,
Kocher-Langenbeck
Planning Positioning may be either lateral decubitus or prone, depending on surgeon preference. 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. 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°. 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
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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
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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:
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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
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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
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Cited by (29)
Musculoskeletal Trauma and Infection
2022, Magnetic Resonance Imaging Clinics of North AmericaCitation 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 ReportsCitation 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 MedicineCitation 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).
Neglected Dislocation in Adults: A New Therapeutic Strategy for an Uncommon Condition
2023, Geriatrics (Switzerland)
Disclosures: The authors received no funding and have no disclosures in relation to this current article.