Hip dislocation class

hip dislocation

1. Hip Dislocations
Dr. Harpreet Singh Bhatia
DMC Ludhiana
2015

2. Introduction
Hip dislocations caused by significant force:
–Association with other fractures
–Damage to vascular supply to femoral head
Thus, high chance of complications

3. What To Cover Today
Incidence
Brief anatomy of Hip Joint
Mechanism and types of Hip Dislocations
Techniques of Closed Reduction
Post Reduction disposition and investigations

4. Incidence
Common in young population with high energy trauma.
Unrestrained motor vehicle accident occupants are at
significant higher risk for sustaining a hip dislocation
than passengers wearing a restraining device
After Prim THR 3.9 percent experience Hip dislocation
in first 6 months.
After Revised THR surgery 15 percent experience
Dislocation in 6 months.

5. Anatomy
Ball and socket typical synovial joint.
•Femoral head: slightly asymmetric, forms 2/3 sphere.
•Acetabulum: inverted “U” shaped articular surface.
•Ligamentum teres, with artery to femoral head, passes through
middle of inverted “U”.

8. Joint Contact Area
Throughout ROM:
• 40% of femoral head is in contact with
acetabulum.
• 10% of femoral head is in contact with
labrum.

9. Acetabular Labrum
Strong fibrous ring
Increases femoral head coverage
Contributes to hip joint stability

10. Hip Joint Capsule
•Extends from intertrochanteric ridge of
proximal femur to bony perimeter of
acetabulum
•Has several thick bands of fibrous tissue (3
lig) ===Iliofemoral ligament
•Upside-down “Y”
•Blocks hip hyper-extension
•Allows muscle relaxation while standing

11. The ligaments of hip joint
•The primary capsular fibers run longitudinally and are
supplemented by much stronger ligamentous condensations that
run in a circular and spiral fashion.

12. Blood Supply to Femoral Head
2. Ascending Cervical Branches
•Arise from ring at base of neck.
•Ring is formed by branches of medial and lateral
circumflex femoral arteries.
•Penetrate capsule near its femoral attachment and
ascend along neck.
•Perforate bone just distal to articular cartilage.
•Highly susceptible to injury with hip dislocation.

15. Sciatic Nerve
•Composed from roots of L4 to S3.
•Passes posterior to posterior wall of acetabulum.
•Generally passes inferior to piriformis muscle, but
occasionally the piriformis may split the peroneal and
tibial components.

16. Hip Dislocation: Mechanism of Injury
•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.

18. Classification
Multiple systems exist:
•Thompson and epstein
•Stewart and milford
•AO/OTA Classification

19. Posterior Dislocation
•Generally results from axial load applied to
femur, while hip is flexed.
•Most commonly caused by impact of
dashboard on knee.

21. Types of Posterior Dislocation
•Postero-superior (iliac)
•Posterior
•ischial

24. Posterior Dislocation
POSTERIOR: - flexed, internally rotated, and adducted.

25. Thomas and Epstein Classification
of Posterior Hip Dislocations
Most well-known
Type I Pure dislocation with or without insignificant
posterior wall fragment
Type II Dislocation with large posterior wall fragment.
Type III Dislocation with comminuted posterior wall.
Type IV Dislocation with “acetabular floor” fracture
(probably transverse + post. wall acetabulum
fracture-dislocation).
Type V Dislocation with femoral head fracture.

26. Anterior Dislocation
Femoral head situated anterior to acetabulum
Hyperextension force against an abducted leg that levers
head out of acetabulum.
Also force against posterior femoral head or neck can
produce dislocation
10 % to 15% of traumatic hip dislocation

27. ANTERIOR: The hip is minimally flexed, externally
rotated and markedly abducted

29. Mechanism of
Anterior
Dislocation
•Extreme abduction with external rotation of
hip.
•Anterior hip capsule is torn or avulsed.
•Femoral head is levered out anteriorly.

30. Types of anterior dislocation
• Pubic
• Obturator
• Perineal

32. Central dislocation
ALWAYS fracture dislocation
Lateral force against an adducted femur

33. Effect of Dislocation on Femoral Head
Circulation
•When capsule tears, ascending cervical
branches are torn or stretched.
•Artery of ligamentum teres is torn.
•Some ascending cervical branches may remain
kinked or compressed until the hip is reduced.
Thus, early reduction of the dislocated hip can
improve blood flow to femoral head.

34. Associated Injuries
Mechanism: knee vs. dashboard injury
–Contusions or fractures of distal femur
–Patella fractures, knee injuries
–Foot fractures, if knee extended

35. Cont…
•Sciatic nerve injuries occur in 10% of hip
dislocations.
*Most commonly, these resolve with
reduction of hip and passage of time.
* Stretching or contusion most common.
*Piercing or transection of nerve by bone
can occur.

36. Irregular presentation/appearance if:
•femoral head or neck are fractured
•femoral shaft fracture
•obtunded patient, confused, shocked ……

37. Neurovascular examination
•Signs of sciatic nerve injury include the
following:
–Loss of sensation in posterior leg and foot
–Loss of dorsiflexion (peroneal branch) or plantar
flexion (tibial branch)
–Loss of deep tendon reflexes at the ankle S1,2
•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

40. Radiographs: AP Pelvis X-Ray
•In primary survey as per ATLS Protocol.
•Should allow diagnosis and show direction of dislocation.
–Femoral head not centered in acetabulum (loss of parallelism)
–Femoral head appears larger (anterior) or smaller (posterior).
•Usually provides enough information to proceed with closed
reduction.

41. Reasons to Obtain More
X-Rays Before Hip Reduction
•View of femoral neck inadequate to rule out
fracture.
•Patient requires CT scan of abdomen/pelvis to rule
out associated injuries.

42. X-rays after Hip Reduction:
•AP pelvis, Lateral Hip x-ray.
•Judet views of pelvis.
•CT scan with 2-3 mm cuts.

43. CT Scan
Most helpful after hip reduction.
Reveals:Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.

44. MRI Scan
•Will reveal labral tear and soft-tissue anatomy.
•Has not been shown to be of benefit in acute
evaluation and treatment of hip dislocations.

45. Clinical Management:
Emergent Treatment
•Dislocated hip is an emergency.
•The goal is to reduce risk of AVN and Degenerative
joint disease.

46. Benefits of early Reduction
•Allows restoration of flow through occluded or
compressed vessels.
•Literature supports decreased AVN with earlier
reduction.
•Requires proper anesthesia.
•Requires “team” (i.e. more than one person).

47. Patterns Treated Non operatively
•No associated fracture and congruent
reduction
•Posterior wall fracture that is clinically
stable with congruent reduction
•Pipkin type I fracture with congruent
reduction.
•Pipkin type II fracture with anatomic
reduction and congruent joint

48. Nonoperative Treatment
•If hip stable after reduction, and reduction congruent.
•Maintain patient comfort  skin traction , analgesia
•Avoid Adduction, Internal Rotation.
•No flexion > 60
o
.
•Early mobilization usually few days to 2 weeks.
•Touch down weight-bearing may be delayed
•Repeat x-rays before allowing full weight-bearing.

49. Reduction Maneuvers
Allis: Patient supine.
Requires at least two people.
Stimson:Patient prone, hip flexed and
leg off stretcher.
Requires one person.
Impractical in trauma (i.e. most
patients).

50. The popular methods of achieving closed reduction of The popular methods of achieving closed reduction of
the hip:the hip:

1.1.The The BigleowBigleow maneuver , maneuver ,
2.2.AllisAllis maneuver maneuver

3.Stimson3.Stimson gravity technique gravity technique
4.Whistler technique4.Whistler technique
5.Captain Morgan technique5.Captain Morgan technique

51. Allis Maneuver
•Assistant: Stabilizes pelvis
•Posterior-directed force on both ASIS’s
•Surgeon: Stands on stretcher
•Applies progressively increasing traction to
the extremity
•With continues traction slowly increase the
degree of flexion to 70 degree
•Genral rotational motions with slight
adduction help the femoral head to clear lip
of acetabulum
•Reduction can often be seen and felt as
audible chunk.

54. Bigelow maneuver

56. Stimpson Method
Described primarily for acute posterior dislocations
Believed to be least traumatic
Pt is in prone position w/ lower limbs hanging from end
of table
Assistant immobilizes the pelvis by applying pressure on
the sacrum
Hold knee and ankle flexed to 90 deg & apply downward
pressure to leg just distal to the knee
Gentle rotatory motion of the limb may assist in
reduction

58. Whistler’s technique
The patient lies supine on the gurney.

Unaffected leg is flexed with an assistant stabilizing the leg. The
assistant can also help stabilize the pelvis.
Provider's other hand grasps the lower leg of the affected leg, usually
around the ankle.
The dislocated hip should be flexed to 90 degrees.
The provider's forearm is the fulcrum and the affected lower leg is
the lever.
When pulling down on the lower leg, it flexes the knee thus pulling
traction along the femur.

60. East Baltimore lift

63. Irreducible Hip ?
•Requires emergent reduction in theatre.
•Pre-op CT obtained if it will not cause delay.
•One more attempt at closed reduction in O.T. with
anesthesia.
( Repeated efforts not likely to be successful and may
create harm to the neurovascular structures or the
articular cartilage.)
Surgical approach from side of dislocation.

64. Causes of Irreducible dislocation
•Anterior:
Buttonholing through the capsule
Rectus femoris
Capsule
Labrum
Psoas tendon
•Posterior:
Piriformis tendon
Gluteus maximus
Capsule, Ligamentum teres
Posterior wall, Bony fragment
Iliofemoral ligament
Labrum

65. Indications for open Reduction
•Irreducible dislocation
•Iatrogenic sciatic nerve injury
•Incongruent reduction with incarcerated
fragments
•Incongruent reduction with soft tissue
interposition
•Incongruent reduction with Pipkin type I
femoral head fracture (relative)

67. Irreducible anterior hip dislocation
•Smith-Peterson approach ,Watson-Jones approach,
Extended iliofemoral, ilioinguinal approach.
•Allows visualization and retraction of interposed
tissue.
•Placement of Schanz pin in intertrochanteric
region of femur will assist in manipulation of the
proximal femur.
•Repair capsule, if this can be accomplished
without further dissection.

68. • Kocher-Langenbeck approach.
•Remove interposed tissue, or
release buttonhole.
•Repair posterior wall of acetabulum if
fractured and amenable to fixation.
Irreducible Hip Dislocation: Posterior

69. Complications of Hip Dislocation
1- Avascular Necrosis (AVN): 1-40%
–Several authors have shown a positive
correlation between duration of dislocation and
rate of AVN.
–Results are best if hip reduced within six hours.

70. 2- Post-traumatic Osteoarthritis
•Can occur with or without AVN.
•May be unavoidable in cases with severe
cartilaginous injury.
•Incidence increases with associated femoral head
or acetabulum fractures.
•Efforts to minimize osteoarthritis are best directed
at achieving anatomic reduction of injury and
preventing abrasive wear between articular
carrtilage and sharp bone edges.

71. 3- Sciatic Nerve Injury
Occurs in up to 20% of patients with hip
dislocation.
Nerve stretched, compressed or transected.
EMG studies at 3-4 wks for baseline information
and prognostic guidance
With reduction: 40% complete resolution
25-35% partial resolution

72. 4- Recurrent Dislocation
•Rare, unless an underlying bony instability has not
been surgically corrected (e.g. excision of large
posterior wall fragment instead of ORIF).
•Some cases involve pure dislocation with
inadequate soft-tissue healing – may benefit from
surgical imbrication .
•Can occur from detached labrum, which would
benefit from repair (rare).

73. 5. Heterotrophic ossification
• Higher incidence after open reduction with internal fixation
via an anterior approach than a posterior approach
•Ocuurs in 2% of patients and is related to muscular
damage and hematoma formation.
•The use of indomethacin may diminish the rate of clinically
significant heterotrophic ossification.
•The other choice is to use radiation therapy, usually 700 Gy
in one dose. This method is very effective in decreasing the
rate of heterotopic ossification, but is not favored in young
patients

74. 6- Thromboembolism
•Hip dislocation = high risk patient.
•Prophylactic treatment with:
low molecular weight heparin
•Early postoperative mobilization.
•Discontinue prophylaxis after 2-6 weeks (if
patient mobile).

75. Thank you

76. 1. Irreducible Posterior Dislocation with Large
Femoral Head Fracture
Fortunately, these are rare.
Difficult to fix femoral head fracture from
posterior approach without transecting
ligamentum teres.

77. Three Options
1.Detach femoral head from ligamentum teres
repair femoral head fracture with hip dislocated
reduce hip.
2.Close posterior wound, fix femoral head fracture
from anterior approach (either now or later).
3.Ganz trochanteric flip osteotomy.
Best option is not known: Damage to blood supply from
anterior capsulotomy vs. damage to blood supply from
transecting ligamentum teres. Mm

78. 2. Hip Dislocation with Femoral Neck
Fracture
• Attempts at closed reduction potentiate chance of
fracture displacement with consequent increased risk of
AVN.
• If femoral head is dislocated with neck fracture, then
the ability to reduce the head by closed means is
markedly compromised.
Thus, closed reduction should not be attempted.

79. 3. Incarcerated
Fragment
• Can be detected on x-ray or CT scan.
• Surgical removal necessary to prevent abrasive wear of
the articular cartilage.
• Posterior approach allows best visualization of
acetabulum (with distraction or intra-op dislocation).
• Anterior approach only if:
dislocation was anterior and,
fragment is readily accessible anteriorly.

80. 4. Incongruent Reduction
• Acetabulum Fracture (weight-bearing
portion).
• Femoral Head Fracture (any portion).
• Interposed tissue.
• Achieve congruence by removing interposed
tissue and/or reducing and stabilizing fracture.

81. 5. Unstable Hip after Reduction
•Due to posterior wall and/or femoral head fracture.
•Requires reduction and stabilization fracture.
•Labral detachment or tear
–Highly uncommon cause of instability.
–Its presence in the unstable hip would justify surgical repair.
–MRI may be helpful in establishing diagnosis.

82. Results of Treatment
•Pain : normal to severe pain and degeneration.
•In general, dislocations with associated femoral head or
acetabulum fractures fare worse.
•Dislocations with fractures of both the femoral head and the
acetabulum have a strong association with poor results.
•Irreducible hip dislocations have a strong association with poor
results.
–13/23 (61%) poor and 3/23 (13%) fair results.
McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of
the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.

83. Recurrent Dislocation
Caused by Defect in
Posterior Wall and/or
Femoral Head
•Can occur after excision of fractured fragment.
•Pelvic or intertrochanteric osteotomy could alter the
alignment of the hip to improve stability.
•Bony block could also provide stability.

84. 4- Delayed Diagnosis of Hip Dislocation
•Increased incidence in multiple trauma patients.
•Higher if patient has altered sensorium.
•Results in more difficult closed reduction, higher
incidence of AVN.
In NO Case should a hip dislocation be treated
without reduction.

85. Sciatic Nerve Palsy:
If No Improvement after 3–4 Weeks
•EMG and Nerve Conduction Studies for
baseline information and for prognosis.
Allows localization of injury in the event that
surgery is required.

86. 6- Foot Drop
Splinting (i.e. ankle-foot-orthosis):
•Improves gait
•Prevents contracture

87. 7- Infection
Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches

88. 8- Iatrogenic Sciatic Nerve Injury
Most common with posterior approach to hip.
Results from prolonged retraction on nerve.

89. Iatrogenic Sciatic Nerve Injury
Prevention:
Maintain hip in full extension
Maintain knee in flexion
Avoid retractors in greater sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)

90. Conclusion
•It is highly stable joint that needs high
energy trauma to dislocate,(so, don't miss
associated injuries)
•Early reduction of the dislocated hip (within
6 hrs) can improve blood flow to femoral
head.
• Up to 5 views of xrays/C-T may be needed
for proper evaluation( pre and post
reduction)

91. Cont…..
•Minimize closed trials to avoid the risk of
vascular damage and AVN
•Surgical approaches according to the
direction of dislocation
•Surgeon experience is highly considered for
treatment (as revision surgeies caries a high
risk of complications)