DISLOCATION

OF HIP JOINT
DR.PONNILAVAN
ANATAOMY
 The hip joint has a ball-and-
socket configuration;
synovial articulation between
the head of the femur and
the acetabulum of the pelvis
bone.
 Forty percent of the femoral
head is covered by the bony
acetabulum at any position
of hip motion. The effect of
the labrum is to deepen the
acetabulum and increase the
stability of the joint.
 The joint is supplemented
by much stronger
ligamentous condensations
iliofemoral
Illiopubic
pubofemoral and eminence
ischiofemoral ligaments that
run in a spiral fashion,
preventing excessive hip
extension.

Pubofemoral
ligament
 Main vascular supply is
from the lateral and
medial femoral
circumflex arteries,
branches of the
profunda femoral
artery.

 An extracapsular
vascular ring is formed
at the base of the
femoral neck with
ascending cervical
branches that pierce
the hip joint at the level
CLASSIFICATION

Depending upon the position of the head with respect to the

acetabulum, hip dislocations are classified as:

• Posterior dislocations: Commonest and is seen in 80-90

percent of the cases.
• Anterior dislocations: Seen in 10-15 percent.
• Central dislocations: Relatively rare
 Posterior Dislocation
 Also known as “dashboard injury”
 They result from trauma to the
flexed knee, with the hip in varying
degrees of flexion. The femur is
thrust upwards and the femoral
head is forced out of its socket.
 The scenario is usually when
someone seated in a truck or car,
during a road accident is thrown
forward striking the knee against the
dashboard.
 Seat-belt restraints can reduce the
number of posterior hip dislocation.
Clinical features
 There is usually history of trauma
 The patient has a flexion, adduction and
medial rotation deformity of the
affected limb
 There is marked shortening and gross
restriction of all hip movements.
 Head of the femur is felt as a hard mass
in the gluteal region and it moves along
with the femur.
 Vascular sign of Narath is negative.
 There could be features of sciatic nerve
palsy.
 THOMPSON AND EPSTEIN
CLASSIFICATION
Type I: With or without minor fracture.

Type II: With a large single fracture of

the posterior acetabular rim.

Type III: With communition of the rim

of the acetabulum with or
without a major fragment.

Type IV: With fracture of the

acetabular floor.

Type V: With fracture of the femoral

head.
ANTERIOR DISLOCATION

•Hyperextension force against an abducted leg that levers

head out of acetabulum.

Femoral head dislocated anterior to acetabulum

In RTA’s, when the knee strikes the dashboard with the

thigh abducted.
• Violent fall from the height.
• Forceful blow to the back of the patient in a squatted
position
 The hip is minimally flexed, externally rotated and
markedly abducted
 EPSTIENS CLASSIFICATION
Type I: Superior dislocation (includes pubic and subspinous dislocation).
 Type IA : No associated fracture
 Type IB : Associated facture of the head and/or neck of the femur.
 Type IC : Associated fracture of the acetabulum.

Type II : Inferior dislocation (includes obturator, and perineal

dislocation).
 Type IIA : No associated fracture
 Type IIB : Associated fracture of the head and/or neck of the femur.
 Type IIC : Associated fracture of the acetabulum
CENTRAL DISLOCATION
 This is the least common and
most difficult of all dislocations
of the hip joint.
 Mechanism of Injury- It could
be due to direct blow on the
greater trochanter as in the
case of RTA or fall on the sides
 It is invariably associated with
the fractures of the
acetabulum and this is what
makes it a very difficult
problem to treat
 Management

History and Evaluation :

 Significant trauma, usually RTA.

 Awake, alert patients have severe pain in hip region.

 lnability to stand or walk

Physical Examination ( posterior
dislocation )
1) lnspection
 Lower limb is flexed, adducted
and internally rotated.
 Shortening +

2) Palpation
- Femoral head palpated post.
- Narthes sign (i.e. Difficulty to palpate femoral pulse
due to backward migration of femoral head).
3) Movement Painful limitation of all hip movements.
Physical Examination ( anterior dislocation
)
1. Inspection:
Limb is slightly flexed, abducted & externally
rotated.
 May be lengthening.
2. Palpation:
Head may be felt over pubic bone or in
perineum.
3. Movement :
Painful limitation
XRAY
POSTERIOR
ANTERIOR
CENTRAL
Neurovascular examination
 Signs of sciatic nerve injury

 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

TREATMENT

 All hip dislocations are emergencies and need to be

reduced

 To prevent troublesome late complications like AVN

and traumatic degenerative hip.
Methods of Closed Reduction
Allis method
Bigelow method
Classical Watson Jones method
Stimson’s gravity method
Whistler’s technique(over-under)
Allis Method
•The patient is placed supine
the surgeon standing above the
patient on the stretcher or table
•. Initially, the surgeon applies in-
line 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.
 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.
• REVERSE Bigelow’s method
Here the hip is in partial flexion and abduction. He has
described two methods: –
The traction method: Here the traction is applied
in the line of the deformity and the hip is adducted,
internally rotated and extended. –
The lifting method: Here a flexed thigh is lifted
with a sudden jerk. However, this method is not
successful in pubic dislocations.
WATSON – JONES METHOD
 This technique is useful in both
anterior and posterior
dislocation of the hip.
 Irrespective of the type of
dislocation the limb is first
brought to the neutral position.
 In this position the head of the
femur lies posterior to the
acetabulum even in anterior
dislocation.
 Now with an assistant steadying
the pelvis the head of the femur
is reduced into the acetabulum
by applying a longitudinal
traction in the long axis of the
femur.
 STIMSONS GRAVITY
METHOD
This is 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.
Whistler’s technique(over-under)
 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.
 Nonoperative Treatment
If hip stable after reduction.

 Maintain patient comfort  skin traction , analgesia

 Avoid Adduction, Internal Rotation.

o
 No flexion > 60 .
 Early mobilization usually few days to 2 weeks.

 Repeat x-rays before allowing full weight-bearing.

Indications for Open Reduction

Indications for Open Reduction

• Failed closed reduction.
• Failed stability test.
• Big posterior lip fragment.
• Bone fragment within the acetabulum.
• Fracture of the femoral head.
• Sciatic nerve palsy.
Technique of Open
Reduction
• Approach: Posterior approach is favoured
• Debridement: Joint is thoroughly irrigated to remove all pieces of
bone and cartilage.
• Reduction of the hip, if it has not been done previously.
• Reposition of the fracture fragments carefully and reconstruct the
acetabulum.
• In Type II injury with the large Acetabular chunk can be fixed by a
single cancellous screws.
• In Type III with several fragments - reconstruction is
attempted as accurately as possible and fixation is done
with cancellous screws or small malleable plate, etc.
In severe comminution- reconstruction is done
through a full thickness iliac graft/auto graft
 In type IV fractures are fixed based on the location
Postoperative Treatment

• Skeletal traction (10-15 lbs) with the hip in slight

abduction and extension.
• Within 3-5 days, gentle active and passive exercises in
traction are begun.
• Traction to be maintained for 6-8 weeks.
• Later protected weight bearing is allowed
Complications
Myositis ossificans (2%):
 It is seen commonly in posterior dislocation with head injury and is
unknown in simple posterior dislocation.
 It may be seen after reduction also.
 It can be prevented by avoiding repeated manipulation, early
immobilization and by immobilizing for 6 weeks in hip spica.
Traumatic osteoarthritis due to avascular necrosis (35%):
 For head of the femur major blood supply enters from the capsule
and to a lesser extent through the ligamentum teres.
 If both these sources are damaged, it gradually leads to AVN
followed by osteoarthritis of the hip joint. Incidence is about 10
percent.
Sciatic nerve injury:
 Incidence of this injury is 10 to 13 percent

 It is 3 times more common in fracture dislocation

simple dislocation.
 Usually, it is a neuropraxia and the peroneal division is
commonly affected.
 It may be due to stretch of the nerve or may be due
impalement between the fracture fragments.
 If it is associated with acetabular fracture the nerve
should be explored. Prognosis is variable.
Irreducible dislocation (31%):
This may be due to bony (acetabular fragments, femoral head, etc.) or
soft tissue (acetabular labrum, etc.) obstruction. It may also be due to
coma, ipsilateral fracture femur or dislocation of opposite hip. It may
require exploration and open reduction.
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