HIP DISLOCATION & IT’S

MANAGEMENT

Presenter: Shameni Devi Vinodamaney

Mentor: Dr Faizal
Anatomy

 Hip joint is a ball-and-socket joint, formed by an articulation between the

pelvic acetabulum and head of femur
 Femur head is held in acetabulum by
 Bony structures
 Capsule
 Ligaments
 Acetabular labrum
Femur head

• The femoral head articulates with the cupshaped (cotyloid) acetabulum,

• its Centre lying a little below the middle third of the inguinal ligament.
• The femoral head is covered by articular cartilage, except over the rough pit
where the ligamentum teres is attached
ligament

 Capsule is reinforced by
• iliofemoral ligament-infront
 strongest and resists hyperextension
 Y-shaped ligament of Bigelow
• pubofemoral ligament- inferiorly
• ischiofemoral ligament- behind
• transverse acetabular ligament
• femoral head ligament
 Nerve supply

 The femoral nerve (L2-L4) supplies the quadriceps and pectineus muscles of
the anterior thigh
 The sciatic nerve (L4-S3) supplies the long head of biceps femoris, hamstring
muscles common, to supply the hip flexors and muscles of the lower
leg(peroneal and tibial nerves)
 superior gluteal nerve (L4,5)- gluteus medius, minimus and TFL.
 Inferior gluteal nerve (L5, S1) - gluteus maximus.
 The obturator nerve (L2-4)
-anterior division-- hip joint and adductor longus, brevis, and gracilis,
- posterior division obturator internus and adductor magnus.
 blood supply

 Largely by medial and lateral circumflex femoral arteries

 Branches of profunda femoris artery (deep femoral artery)
 Major blood supply to the head and neck of the femur is usually the medial
femoral circumflex artery, a branch of the common femoral artery
 Hip dislocation

 Complete disruption (loss of contact) of articular surfaces is called dislocation

 Etiology :
 Acquired:
 Trauma
 Pathological: infection, trauma, CP, poliomyelitis
 Congenital
 CLASSIFICATION

(i) posterior dislocation (the commonest)

(ii) anterior dislocation
(iii)Central dislocation
 Overall Classification of the Hip Dislocations
(Stewart and Milfort, based on the hip stability and
femoral head condition, both anterior and
posterior)
Comprehensive Classification (Both Anterior and
Posterior)
POSTERIOR DISLOCATION OF THE HIP

 More common
 The head of the femur is pushed out of the acetabulum posteriorly.
 associated with a chip fracture of the posterior lip of the acetabulum, in
which case it is called a fracture-dislocation.
THOMPSON AND EPSEIN
CLASSIFICATION
MECHANISM OF INJURY

 The injury is sustained by violence directed along the shaft of the femur, with
the hip flexed.
 requires a moderately severe force to dislocate a hip, eg. in motor accidents.
 also known as dashboard injury.
Clinical features

 The patient presents with a history of severe trauma followed by pain,

swelling and deformity (flexion, adduction and internal rotation).
 This is associated with a shortening of the leg.
 able to feel the head of the femur in the gluteal region.
Before Reduction

 Laboratory tests: Hb percent, BT, CT, Blood group, RBS, etc. needs to be done as for any
other major surgery.
 Plain X-ray of the hip: All high-energy trauma and multiple injury patients should have a
screening AP view of the pelvis.
 What to look for in the initial X-ray:
• Are the femoral heads symmetric in size?
• Is the joint space symmetric throughout?
• Is the head large (anterior dislocation) or small (posterior dislocation)?
• Is the Shenton’ line maintained or broken? broken
• Is the greater trochanter prominent (posterior) or inconspicuous (anterior) reverse
with lesser trochanter? thigh is internally rotated so that the lesser trochanter is not seen
• Is the femoral neck normal? Out of out of the acetabulum
 TREATMENT

 Reduction of a dislocated hip is an emergency, since longer the head remains out,
more the chances of it becoming avascular.
 Closed reduction within 6 hours
 In most cases it is possible to reduce the hip by manipulation under general
anaesthesia.
 Maintain reduction with immobilization
 Skin/ skeletal traction for 3-6 weeks
 Open reduction may be required in cases where:
 (i) closed reduction fails, usually in those presenting late;
 (ii) if there is intra-articular loose fragment not allowing accurate reduction
 (iii) if the acetabular fragment is large and is from the weight bearing part of the
acetabulum
Closed reduction techniques

The important methods are the ABC’S.

 A – Allis method
 B – Bigelow method
 C – Classical Watson Jones method
 S – Stimson’s gravity method
 Allis Method

• The patient is anaesthetised and placed supine on the floor.

• An assistant stabilizes the pelvis by applying pressure on both the ASIS.
• Traction is applied in the line of the deformity.
• The hip is gently flexed to 90 degrees.
• The hip is now gently rotated, internally and externally, with continued
longitudinal traction till reduction is achieved.
 maximum adduction as the longitudinal traction is applied in the axis of the
femur while an assistant stabilizes the pelvis.
 The leg is kept in light traction with the hip abducted, for 3 weeks.
 After this, hip mobilisation exercises are initiated.
Bigelow’s Method

• Patient is supine.
• An assistant applies counter traction on both the ASIS.
• Surgeon applies longitudinal traction in the line of the deformity.
• The hip is gently adducted, internally rotated and bent on the abdomen. This
relaxes the Y-ligament and brings the femoral head near the poster inferior
aspect of the acetabulum.
• By adduction, external rotation and extension of the hip, head is levered back
into the acetabulum.
 Stimson’s Gravity Method

the reverse Allis method of reduction. The steps are as follows:

• Patient is prone.
• Patient is brought to the edge of the table.
• An assistant stabilizes the pelvis by applying downward pressure over the
sacrum.
• The affected hip and knees are flexed to 90 degrees.
• Downward pressure is applied on the flexed knee.
• To facilitate the reduction, gentle rotations needs to be done.
After Reduction

 Plain X-ray of the hip

 • AP X-ray centered on the affected hip
 • Judet views with the affected hip in internal and external oblique views at
45 degrees.
 What to look for?
• Is there any incarcerated osteochondral fragment within the joint?
• Is the joint space asymmetric?
• Look for the anterior and posterior ace tabular wall.
• Look for any indentation on the femoral head
COMPLICATIONS

1. Injury to the sciatic nerve:

 The sciatic nerve lies behind the posterior wall of the acetabulum.
 Therefore, it may be damaged in a posterior dislocation of the hip; if the
dislocation is associated with a large bony fragment from the posterior lip of
the acetabulum.
 Treatment: Injury is a neurapraxia in most cases and recovers spontaneously.
 In cases where the fragment of the posterior lip is not reduced by closed
method, open reduction of the fracture, and nerve exploration may be
required.
2. Avascular necrosis of the femoral head:
 The changes of avascular necrosis appear on X-rays generally 1-2 years after
the injury.
 The avascular head appears dense, and gradually collapses
 The patient complains of pain in the hip after a seemingly painless period
following treatment for a dislocated hip.
 Over a period of a few years, changes of osteoarthritis become apparent,
clinically and radiologically.
 Such cases need hip replacement.
3. Osteoarthritis:
 late complication of hip dislocation
 The treatment is initially conservative.
 In some cases an operation may be necessary, a total hip replacement is required

4. Myositis ossificans:
 This occurs a few weeks to months after the injury.
 The patient complains of persistent pain and stiffness of the hip.
 X-rays shows a mass of fluffy new bone around the hip.
 It is particularly common in patients with head injury.
 Treatment is rest and analgesics
ANTERIOR DISLOCATION OF THE HIP

 a rare injury, usually sustained when the legs are forcibly abducted and
externally rotated.
 This may occur in a fall from a tree when the foot gets stuck and the hip
abducts excessively, or in a road accident.
 Clinical Features
• Position of the limb suggests the diagnosis:
– In the superior type (Iliac or Pubic): The hip is extended and externally rotated and the head is
felt near the anterosuperior iliac spine in the
 iliac type and in the groin in the pubic type.
 There may be true lengthening, with the head palpable in the groin.
 Treatment and complications are similar to that of posterior dislocation.
Investigations

• X-ray: Diagnosis can be easily made on a plain xray. Look for any associated
damage to the femoral head, neck
• CT Scan: This helps to detect intra-articular fragments if any and also helps to
evaluate the femoral head and acetabulum. CT is also indicated after closed
reduction or if closed reduction fails before doing the open reduction.
• MRI: This helps to evaluate the integrity of the labrum, vascularity of the
femoral head and osteochondral lesion if any. It has a definite role in these cases
of unstable hip after dislocation or in widened joint space after reduction.
CENTRAL DISLOCATION OF HIP

 This is the least common dislocation

 CF:
 there is no limb shortening
 no external rotation deformity
 head is not externally palpable
 The limb is in neutral position
 Pain
 severe restriction of hip movements
 huge bruise over the greater trochanter
 Head is felt easily by a per-rectal examination
Investigations

X-ray evaluation:
 AP view of the pelvis: helps in the demonstration of the femoral head
 acetabular relationship
 internal and external oblique views: helps in delineating fracture lines and
displacement.
CT scan: This helps to delineate the fracture lines better and with far more great
accuracy than plain X-rays.
MRI scan: This helps to study the vascularity of the femoral head and the bony
and cartilage architecture.
 Treatment

 Reduction is achieved through skeletal traction over the greater trochanter in

line of the neck of femur.
 The skeletal traction is maintained for 10-12 weeks if the acetabulum is
reasonably reconstructed.
 Open reduction is reserved for cases of failed closed reduction
 Primary arthroplasty or arthrodesis: This is recommended in extreme cases
where closed reduction fails and open reduction reveals severe articular
damage.
Complications

 Early complications: This includes sciatic nerve palsy, superior gluteal artery
injury, thrombophlebitis, bowel obstruction, aseptic necrosis, pin-tract
infection, recurrent central dislocations
 Delayed complications: Post-traumatic osteoarthritis, myositis, avascular
necrosis of the femoral head and a stiff and disabling hip.