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SHORT CASE
“HIP DISLOCATION”
Rini Riana Nenobesi
1408010062

Preceptor:
dr. Alders A. K. Nitbani, Sp.B

SURGERY DEPARTMENT - RSUD PROF. DR. W. Z. JOHANNES KUPANG

FACULTY OF MEDICINE – NUSA CENDANA UNIVERSITY
2019
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DISLOCATION
• Joint surfaces are completely displaced
CLINICAL FEATURES
• Pain
• Restriction of movements
• Limb held in characteristic position
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SIGNS
• Abnormal shape of joint
• Displaced bony landmarks
INVESTIGATION
• X-RAY, CT
TREATMENT
• Reduction
• Immobilization
• rehabilitation
• Complications
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 What is the hip dislocation ?

INTRODUCTION  The head of the femur displace in relation to the

acetabulum from severe trauma, causing
dislocation.
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 Common in young population with high energy trauma.

 Unrestrained motorcycle accident occupants are at
significant higher risk for sustaining a hip dislocation
than passengers wearing a restraining device
INCIDENCE  After Prim THR 3.9% experience Hip dislocation in first
6 months.
 After Revised THR surgery 15%experience Dislocation
in 6 months.
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HIP JOINT DISLOCATION

According to direction of
femoral head displacement

POSTERIOR

ANTERIOR

CENTRAL
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ANATOMY
 Hip is a modified ball and socket joint.
 Femoral head is deep in the acetabular socket –
enhanced by the cartilaginous labrum.
ANATOMY  Supported by fibrous joint capsule,
 Ileofemoral ligament, ischiofemoral ligament,
pubofemoral lig, muscles of upper thigh and gluteal
region.
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 Throughout ROM:
Joint Contact  40% of femoral head is in contact
with acetabulum.
Area  10% of femoral head is in contact
with labrum.
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Acetabular
Labrum
 Strong fibrous ring
 Increases femoral head coverage
 Contributes to hip joint stability
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 Extends from intertrochanteric ridge of proximal femur

to bony perimeter of acetabulum
 Has several thick bands of fibrous tissue (3 lig) 
Hip Joint Iliofemoral ligament
Capsule  Upside-down “Y”
 Blocks hip hyper-extension
 Allows muscle relaxation while standing
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 The primary capsular fibers run longitudinally and are supplemented

by much stronger ligamentous condensations that run in a circular
and spiral fashion.
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BLOOD SUPPLY
To Femoral
Head
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BLOOD SUPPLY
To Femoral
Head
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 Sciatic Nerve
Peroneal and tibial components differentiate
early, sometimes as proximal as in pelvis. \

SCIATIC NERVE

 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.
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 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.
Hip Dislocation:
Mechanism of
Injury
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 Type I :Pure dislocation with at most a small posterior

wall fragment.
Thomas and  Type II :Dislocation with large posterior wall fragment.
Epstein  Type III : Dislocation with comminuted posterior wall.
Classification of  Type IV : Dislocation with “acetabular floor” fracture
Hip Dislocations (probably transverse + post. wall acetabulum fracture-
dislocation).
Most well-known
 Type V :Dislocation with femoral head fracture.
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Posterior
Dislocation
 Generally results from axial load applied to femur, while hip
is flexed.
 Most commonly caused by impact of dashboard on knee.
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Mechanism of
Posterior
Dislocation

 Postero-superior (iliac)
 Posterior
 ischial
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 History and Evaluation :

 Significant trauma, usually RTA.
Management  Awake, alert patients have severe pain
in hip region.
 lnability to stand or walk
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 1) lnspection
 Lower limb is flexed, adducted and internally
rotated.
 Shortening +
Physical  2) Palpation
Examination (  - Femoral head palpated post.
posterior  - Narthes sign (i.e. Difficulty to palpate
dislocation ) femoral pulse due to backward migration of
femoral head).
 3) Movement Painful limitation of all hip
movements.
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 1. Inspection:
 Limb is slightly flexed, abducted & externally
rotated.
Physical
 May be lengthening.
Examination (
 2. Palpation:
anterior Head may be felt over pubic bone or in perineum.
dislocation )  3. Movement :
Painful limitation
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 Signs of sciatic nerve injury

 Loss of sensation in posterior leg and foot
 Loss of dorsiflexion (peroneal branch) or plantar
flexion (tibial branch)
Neurovascular
 Loss of deep tendon reflexes at the ankle S1,2
examination  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
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TREATMENT
All hip dislocations are emergencies
and need to be reduced

To prevent troublesome late

complications like AVN and
traumatic degenerative hip.
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 Allis method
 Bigelow method
Methods of
 Classical Watson Jones method
Closed
Reduction  Stimson’s gravity method
 Whistler’s technique(over-under)
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 Allis Method
 The patient is placed supine the surgeon standing above
the patient on the stretcher or table
 Initially, the surgeon applies inline traction while the
assistant applies counter traction by stabilizing the
patient’s pelvis.
 While increasing the traction force, the surgeon should
slowly increase the degree of flexion to approximately 70
degrees.
 Gentle rotational motions of hip as well as slight adduction
will often help the femoral head to clear the lip of the
acetabulum.
 A lateral force to the proximal thigh may assist in reduction.
An audible “clunk” is a sign of a successful closed
reduction.
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CASE
 Identity

Name : Mr. R K
Age: 42 years old
Sex: Male
 Anamnesis
Chief Complain : pain in right hip since 5 hours before admission
History :
Patient come with pain in right hip after had a traffic accident in Koenino
area. The patient was riding a motor cycle and hit by a car (bemo) from the front.
He also can’t move his right hip due to the pain. Helmet (-). The patient barely
known the mechanism of injury. Headache (-), nausea (-), vomit (-), blood from
nose and ear (-).
History of uncontrolled hypertension (+)
 Primary survey
A : clear and patent
B : RR: 22 times/minute, chest expansion simetrical,VBS L=R
C : Blood preasure : 140/100 mmHg , Pulse: 97 times/minute
reguler, CRT < 2 “,
D : GCS E4M6V5, neurological deficit (-)
E :Vulnus Excoriatum at left frontal regio
Hematoma at palpebra superior
hip flexion, knee flexion, posterior hip hematoma of the right hip
 SECONDARY SURVEY
GCS : E4M6V5
Head : Vulnus Excoriatum at left frontal regio, Hematoma at palpebra
superior
Eye : pupil isokor (+/+), Direct and Indirect Ligth Reflex
(+/+),conjungtive (-/-), icteric scelra (-/-)
Ear : otorrhea (-/-)
Nose : blood clot (-/-), rhinorrhea (-/-)
Thorax : chest expansion bilateral symmetric, crepitation (-), mass (-).
Vesicular (+/+), ; ronchi (-/-), whezing (-/-).
Abdomen
Inspection : flat, distended (-), lesion (-),
Palpation : tenderness (-), mass (-)
Percussion : timpanyc sound (+)
Auscultation : peristaltics (+) still normally

Extremity: edema -/-, CRT< 2”

localized Status: right hip
Look: hip flexion, knee flexion, posterior hip hematoma
Feel: tenderness (+)
Move: limited ROM due to pain
 Eosinofil : 0,21 10^3/uL
Hb : 14,2 g/dL
Basofil : 0,20 (H)
RBC : 6,20 (H) 10^3/uL
10^6/uL Neutrofil : 18,98 (H)
Hct : 47,4 (H) % 10^3/uL
Limfosit : 2,93 10^3/uL
MCV : 76,9 (L) fL Monosit : 1,51 (H)
MCH : 22,8 (L) pg 10^3/uL
PLT : 240 10^3/uL
MCHC : 29,7 (L)
Laboratory g/L GDS : 270 (H) mg/dL
Na : 140 mmol/L
(13-05-19) WBC : 23,83 (H)
10^3/uL K : 3, 6 mmol/L
Cl : 107 mmol/L
Ca Ion : 1.330 (H)
mmol/L
X -RAY PHOTO
 Assesment
Vulnus Excoriatum at left frontal regio
Hematoma at palpebra superior
right hip joint Posterior dislocation
Hyperglycemic
 Planning
IVFD RL 20 tpm
Inj. Ketorolac 3x30 mg
Pro close reduction hip under anesthesia
GDP, GD2PP co interna
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X-Ray Post
Reduction Hip