Hip dislocations caused by significant

force:
◦ Association with other fractures
◦ Damage to vascular supply to femoral head
Thus, high chance of complications
1 Femoral nerve. N. femoralis.
2. Muscular branches. Rami
musculares. Branches to the
sartorius, pectineus and
quadriceps femoris muscles
3. Lumbosacral trunk. Truncus
lumbosacralis. Connection to the
lumbar plexus formed by L5 and
a part of L4.
4 SACRAL PLEXUS. Plexus sacralis.
Plexus arising from L5−S3 and a
part of L4 and S4, lying anterior
to and beneath the fascia of the
piriformis muscle beneath its
fascia.
 Generally results from axial load applied to
femur, while hip is flexed.
 Most commonly caused by impact of
dashboard on knee.
1. Direction of applied force.

2. Position of hip.

3. Strength of patient’s
bone.
Extreme abduction with external rotation of hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.
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.
 Posterior Dislocation Anterior Dislocation
Hip flexed, Extreme external
internally rotated, rotation, less-
adducted. pronounced abduction
and flexion.
 Pain to palpation of hip.
 Pain with attempted motion of hip.
 Possible neurological impairment:
 In primary survey of ATLS Protocol.
 Should allow diagnosis and show direction of dislocation.
◦ Femoral head not centered in acetabulum.
◦ Femoral head appears larger (anterior) or smaller (posterior).
 Usually provides enough information to proceed with
closed 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).
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).
 Assistant: Stabilizes pelvis
 Surgeon: Stands on stretcher
 Gently flexes hip to 900
 Applies progressively increasing traction to
the extremity
 Applies adduction with internal rotation
 Reduction can often be seen and felt
 Moves more freely
 Patient more comfortable

 Requires testing of stability

 Simply flexing hip to 900 does not
sufficiently test stability
 o
1. Hip flexed to 90
2. If hip remains stable, apply internal
rotation, adduction and posterior force.
3. The amount of flexion, adduction and
internal rotation that is necessary to
cause hip dislocation should be
documented.
4. Caution!: Large posterior wall fractures
may make appreciation of dislocation
difficult.
Requires emergent reduction in O.R.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in O.R.
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.

 If hip stable after reduction, and reduction
congruent.
 Maintain patient comfort.
 ROM precautions (No Adduction, Internal
Rotation).
o
 No flexion > 60 .
 Early mobilization.
 Touch down weight-bearing for 4-6 weeks.
 Repeat x-rays before allowing weight-bearing.
1. Irreducible hip dislocation
2. Hip dislocation with femoral neck fracture
3. Incarcerated fragment in joint
4. Incongruent reduction
5. Unstable hip after reduction
 Avascular Necrosis (AVN): 1-20%

◦ Several authors have shown a positive correlation

between duration of dislocation and rate of AVN.

◦ Results are best if hip reduced within six hours.

 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.
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 (rare).
Can occur from detached labrum, which
would benefit from repair (rare).
 Shoulder dislocation

Anterior shoulder dislocation is a condition in

which the humeral head out from the shallow
cavity shoulder joint artikulare
Anatomy
 95% of all cases of joint instability
 Often occurs at a young age
often caused by excessive movement, especially
during exercise or direct trauma
 Dislocation occurs due to forces that cause
the movement of external rotation and
extension of the shoulder joint.
 Humeral head pushed forward and caused
avulsion of joint capsule and cartilage and
anterior glenoid labrum periosteum.
 On recurrent dislocation labrum and capsule
are often separated from the anterior glenoid
circumference.
 In some cases the intact labrum and capsule
and ligaments glenohumerus apart or
stretched towards both the anterior and
inferior.
 Anterior shoulder dislocation can be a
dislocation sub-korakoid (most often), sub-
glenoid, sub-klavikular, and dislocation
intrathorasik.
dislocation sub-korakoid
 Diagnosis :
 anamnesis,
 physical examination
 investigation.

 Physical examination  pain, a lump on the

front of the shoulders, abduction of the arm
position - exorotation, the edge of the
shoulder looked angular, tender, and the
disruption of the shoulder joint motion
 Two distinctive mark :
 the axis of the humerus is not pointing to
the shoulder
 shoulder contours change as an empty area
below the acromion on palpation.
 X-Ray : anteroposterior X-ray photo (AP) and
lateral
the abnormal right shoulder contour
(white arrow)
Limited movement due to shoulder
dislocation
Primary differential diagnosis of anterior
dislocation is a fracture and dislocation neck
fracture of the humerus.
Normal Dislocation anterior
Subglenoid dislocation with
greater tuberosity
fracture.
 Management : conservative and operative.
 Reduction of the dislocation must be done
immediately.
 Immediate reduction can be done with two
metode:
1. Stimson method

2. Hippocrates method
 Indications of operative therapy is an old case
 Complications that can be occur are recurrent
dislocation, brachial plexus lesion and the
axillary nerve, and interposition of head of
the biceps tendon longum.