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Hip Dislocation

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Other Names

  • Hip Fracture-Dislocation
  • Hip Subluxation
  • Posterior Hip Dislocation

Background

  • This page refers to dislocations of the Hip Joint

History

Epidemiology

Pathophysiology

  • General
    • Hip dislocations may be classified into two groups based on the direction of movement of the femoral head: anterior or posterior
    • Posterior hip dislocations is the most frequent direction of dislocation [1] [2]

Mechanism

  • General
    • Most common mechanism is during a motor vehicle accident when an individual's flexed knee strikes the dashboard
    • Traumatic hip dislocations are rare in sports
    • Athletic-related hip dislocations are often trauma-related due to a collision
    • Common sports with hip dislocations include snowboarding, skiing, rugby, basketball and American football [3]
  • Posterior hip dislocation
    • may occur one of two ways
    • With a flexed, adducted hip when there is a forward fall on a knee
    • Blow from posterior to anterior while the athlete is on his or her hands and knees [3]
  • Anterior hip dislocation
    • Flexed hip is forced into excessive abduction and external rotation (ie, splits-related injury) [4]

Risk Factors

Differential Diagnosis

Clinical Features

  • History
    • Inquire about the mechanism of injury: trauma to the area during contact sports, high-speed accident in racing sports, or awkward jumping, landing or twisting of
    • Severe hip and upper leg pain
    • Inability to bear weight
    • Limb deformity
    • Possible paresthesias
  • Physical Exam: Physical Exam Hip
    • Posterior hip dislocation
      • Hip is shortened, adducted, flexed, and internally (medially) rotated
      • Sciatic and common peroneal nerve are frequently injured
    • Anterior hip dislocation
      • hip is flexed, abducted, and externally (laterally) rotated.[8]

Evaluation

  • Posterior Hip Dislocation

  • Inferior Hip Dislocation

  • Arthroplasty Dislocation

  • Posterior Hip Dislocation (CT)

Radiographs

  • Should be done before closed reduction and after apparent successful closed reduction[4]
  • A/P and lateral films of the hip and A/P pelvic radiographs are recommended
  • A/P view of the pelvis
    • Posteriorly dislocated femoral head will appear smaller than the uninjured side
    • Anteriorly dislocated femoral head will appear larger than the normal side
    • May reveal concurrent femoral neck fracture
  • X-rays should be obtained at 2 weeks, 6 week, 3 months and 6 months after injury to ensure no avascular necrosis or arthritis development [4]

CT

  • Useful if there is a need to remove interposed tissue or associated fracture(s)

MRI

  • Obtained after successful closed reduction to ensure there is no damage to soft tissue
  • May provide baseline comparison to follow the development of avascular necrosis
  • Recommended with persistent or new-onset pain in the setting of normal X-rays [4]

Classification

  • Hip dislocation may be initially classified as anterior or posterior depending on the direction of femoral head movement
  • Posterior dislocation may be further characterized using the following schemes
    • Thompson and Epstein Classification (based on radiographic findings) [9]
      • Type 1 – With or without minor fracture
      • Type 2 – Large, single fracture of posterior acetabular rim
      • Type 3 – Comminution of rim of acetabulum, with or without major fragments
      • Type 4 – Presence of a fracture of the acetabular floor
      • Type 5 – Presence of a fracture of the femoral head
    • Steward and Milford Classification (based on hip stability) [10]
      • Type 1 – No fracture or insignificant fracture
      • Type 2 – Associated with a single or comminuted posterior wall fragment, but the hip remains stable through a functional range of motion
      • Type 3 – Associated with an unstable hip joint due to loss of structural support
      • Type 4 – Associated with femoral head fracture

Management

  • Operative and non-operative techniques should be done to reduce the dislocation as long as possible with a goal of less than six hours [11]

Nonoperative

  • First line if possible
  • Other Treatment
    • NSAIDs
    • Ice
    • Rest
    • Physical therapy [8]
      • Focused on strengthening the quadriceps, hamstrings, hip flexors, and hip extensors
      • Maintenance and improvement of hip range of motion

Operative

  • Open reduction with internal fixation is the preferred method if closed reduction fails
  • Indications [11]
    • Failure of closed reduction
    • Presence of bony fragments or soft tissue in the joint space
    • Hips that have been dislocated for a long period of time
    • Joint instability
    • Redislocation
  • Technique [11]
    • Posterior dislocations
      • Treated with the Kocher-Langenbeck Approach
        • Posterior structures are accessed by demarcation of the posterior superior iliac spine, greater trochanter, and femoral shaft
    • Anterior dislocations
      • Smith-Petersen or Watson-Jones approach
        • Anterior structures are accessed by demarcation of the anterior superior iliac spine, greater trochanter, and femoral shaft
    • Arthroscopy can be used to remove bone fragments and repair labral tears

Rehab and Return to Play

Rehabilitation

  • Functional weight-bearing exercises (ie, bodyweight squats) may begin at around 4 weeks
  • Jogging or running may begin at 6-8 weeks

Return to Play

  • Most athletes may return to full activity in 3-4 months

Complications and Prognosis

Prognosis

Complications

  • General
    • 71% of traumatic hip dislocations have other associated injuries[12]
  • Avascular necrosis (<6% in Type I and II dislocations, ~50% in type III and IV) [13]
  • Osteoarthritis (25%) [13]
  • Need for Total Hip Arthroplasty
  • Myositis ossificans
  • Labral tear
  • Sciatic Nerve Injury (10% in adults, 5% in children) [14]

See Also

References

  1. ↑ Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242–252. doi:10.31486/toj.17.0079
  2. ↑ Sahin V, Karakaş ES, Aksu S, Atlihan D, Turk CY, Halici M J Trauma. 2003 Mar; 54(3):520-9.
  3. ↑ 3.0 3.1 Giza E, Mithöfer K, Matthews H, Vrahas M. Hip fracture-dislocation in football: a report of two cases and review of the literature. Br J Sports Med. 2004;38(4):E17. doi:10.1136/bjsm.2003.005736
  4. ↑ 4.0 4.1 4.2 4.3 Pallia CS, Scott RE, Chao DJ. Traumatic hip dislocation in athletes. Curr Sports Med Rep. 2002 Dec;1(6):338-45.
  5. ↑ Woo RY, Morrey BF J Bone Joint Surg Am. 1982 Dec; 64(9):1295-306.
  6. ↑ Dargel J, Oppermann J, Brüggemann GP, Eysel P Dtsch Arztebl Int. 2014 Dec 22; 111(51-52):884-90.
  7. ↑ Bozic K, Kurtz S, Lau E, et al. The epidemiology of revision total hip arthroplasty in the United StatesJ Bone Joint Surg. [Am] 2009;91-A:128–133.
  8. ↑ 8.0 8.1 Yates, C., Bandy, W. D., & Blasier, R. D. (2008). Traumatic dislocation of the hip in a high school football player. Physical therapy, 88(6), 780–788. doi:10.2522/ptj.20070298
  9. ↑ Thompson VP, Epstein HC. 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;33:746–778
  10. ↑ Stewart MJ, Milford LW. Fracture-dislocation of the hip: an end-result study. J Bone Joint Surg Am. 1954;36:315–342.
  11. ↑ 11.0 11.1 11.2 Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242–252. doi:10.31486/toj.17.0079
  12. ↑ Sahin, Vedat, et al. "Traumatic dislocation and fracture-dislocation of the hip: a long-term follow-up study." Journal of Trauma and Acute Care Surgery 54.3 (2003): 520-529.
  13. ↑ 13.0 13.1 Dwyer AJ, John B, Singh SA, Mam MK. Complications after posterior dislocation of the hip. Int Orthop. 2006;30(4):224–227. doi:10.1007/s00264-005-0056-9
  14. ↑ Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91.
Created by:
John Kiel on 5 July 2019 08:31:08
Last edited:
5 October 2022 13:04:41
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