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Hip Dislocation
GROUP D 2015
What To Cover Today :
Introduction
Incidence
Brief anatomy of Hip Joint
Mechanism and types of Hip Dislocations
Techniques of Closed Reduction
Post Reduction disposition and investigations
Introduction
What is the hip dislocation ? The head of the femur displace in relation to the acetabulum from severe trauma, causing dislocation.
Introduction
Hip dislocations caused by significant force: Association with other fractures Damage to vascular supply to femoral head
Thus, high chance of complications
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.
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”.
Joint Contact Area
Throughout ROM: 40% of femoral head is in contact with
acetabulum. 10% of femoral head is in contact with
labrum.
Acetabular Labrum
Strong fibrous ring
Increases femoral head coverage
Contributes to hip joint stability
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 , pubofemoral ligament and
ischiofemoral ligament .
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.
Cont…
Blood Supply to Femoral Head
Sciatic Nerve Peroneal and tibial components differentiate
early, sometimes as proximal as in pelvis.
Passes posterior to posterior wall of acetabulum.
Generally passes inferior to piriformis muscle, but occasionally the piriformis may split the peroneal and tibial components
Composed from roots of L4 to S3.
Nerve supply
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.
Classification : 1-According to direction of femoral head
displacement : A- Posterior Dislocation B- Anterior Dislocation C- Central Dislocation
2- Multiple systems exist : Thompson and epstein Stewart and milford AO/OTA Classification
Thompson and epsteinclassification
Posterior Dislocation
Generally results from axial load applied to femur, while hip is flexed.
Most commonly caused by impact of dashboard on knee.
Types of Posterior Dislocation
Postero-superior (iliac)
ischial
Posterior Dislocation POSTERIOR: - flexed, internally rotated, and adducted.
Thomas and Epstein Classificationof 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.
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
ANTERIOR : The hip is minimally flexed, externally rotated and markedly abducted
Mechanism of AnteriorDislocation
Extreme abduction with external rotation of hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.
Types of anterior dislocation
Pubic (superior)
Obturator (inferior)
Perineal
Central dislocation
Due to direct trauma to greater trochanter drive femoral
head inward fracture of floor of acetabulum.
ALWAYS fracture dislocation
Lateral force against an adducted femur
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.
Associated Injuries
Mechanism: knee vs. dashboard injury Contusions or fractures of distal femur
Patella fractures, knee injuries
Foot fractures, if knee extended
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.
Irregular presentation/appearance if:
femoral head or neck are fractured
femoral shaft fracture
obtunded patient, confused, shocked ……
Cont……
Other associated injuries are common:
Head, neck and facial injuries Chest injuries Intra-abdominal injuries Lower extremity fractures and dislocations
Management
History and Evaluation :
Significant trauma, usually RTA.
Awake, alert patients have severe pain in hip region.
lnability to stand or walk (disturbance of function).
Physical Examination ( posterior dislocation ( 1) lnspection
Ecchymosis, bruises, swellings
Lower limb is flexed, adducted and internally rotated.
Supratrochanteric shortening (shortening with fixed greater trochanter-condyle distance).
2) Palpation
- Femoral head palpated post. empty femoral A.
- 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: Classical Appearance
Posterior Dislocation: Hip flexed, internally rotated, adducted.
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 :
- impaired.
Physical Examination: Classical Appearance
Anterior Dislocation: Extreme external rotation, less-pronounced abduction and flexion.
Irregular presentation/appearance if:
femoral head or neck are fractured
femoral shaft fracture
obtunded patient, confused, shocked ……
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
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.
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.
X-rays after Hip Reduction:
AP pelvis, Lateral Hip x-ray.
Judet views of pelvis.
CT scan with 2-3 mm cuts.
CT ScanMost helpful after hip reduction.
Reveals: Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.
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.
Clinical Management: Emergent Treatment
Dislocated hip is an emergency.
The goal is to reduce risk of AVN and Degenerative joint disease.
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).
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
Anesthesia
General anesthesia with muscle
relaxation facilitates reduction, but is
not necessary, but…… Conscious sedation is acceptable.
Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, muscle spasm and make subsequent attempts at reduction more difficult.
The popular methods of achieving closed The popular methods of achieving closed reduction of the hip :reduction of the hip : 1.1.The The BigleowBigleow maneuver , maneuver ,
2.2.AllisAllis maneuver , maneuver ,
3.Stimson3.Stimson gravity technique , gravity technique ,
4.Whistler technique and4.Whistler technique and
5.Captain Morgan technique5.Captain Morgan technique
Allis Maneuver
Assistant: Stabilizes pelvis Posterior-directed force on both ASIS’s
Surgeon: Stands on stretcher Gently flexes hip to 900
Applies progressively increasing traction to the extremity
Applies adduction with internal/external rotation Reduction can often be seen and felt
Reverse Bigelow reduction Maneuver for anterior hip dislocation The position of the hip in the
reverse Bigelow maneuver is partial flexion and abduction. Bigelow suggests two methods of reduction. First is the lifting method, in which a firm "jerk" is applied to the flexed thigh. This method often results in reduction except in pubic dislocations.
If this "lifting method" fails, traction is applied in the line of deformity. The hip then is adducted, sharply internally rotated, and extended
Reduction of posterior dislocation
Bigelow maneuver
East Baltimore lift technique
East Baltimore lift
Bigelow maneuver
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
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.
Captain Morgan technique
How to know reduced Hip
The limb moves more freely
Patient more comfortable
But……..
Requires testing of stability
Simply flexing hip to 900 does not sufficiently test stability
Nonoperative Treatment If hip stable after reduction, and reduction
congruent.
Maintain patient comfort skin traction , analgesia
Avoid Adduction, Internal Rotation.
No flexion > 60o.
Early mobilization usually few days to 2 weeks.
Touch down weight-bearing may be delayed
Repeat x-rays before allowing full weight-bearing.
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.
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
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.
Irreducible Hip Dislocation: Posterior
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.
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
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.
Cont…..
Usually the dislocation is posterior.
If fracture is non-displaced, stabilize fracture with parallel lag screws first.
If fracture is displaced, open reduction of femoral head into acetabulum, reduction of femoral neck fracture, and stabilization of femoral neck fracture.
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.
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.
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.
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)
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.
Complication OF Hip Dislocation
Early ;1- Sciatic Nerve Injury
Occurs in up to 20% of patients with hip dislocation.
Nerve stretched, compressed or transected.
With reduction: 40% complete resolution
25-35% partial resolution
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.
2-Vascular injury : Occasionally the superior gluteal artery is torn and bleeding may be profuse .
3- Associated fractured femoral shaft : When this occurs at the same time as the hip dislocation, the dislocation is often missed.
Late :
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.
2-Post-traumaticOsteoarthritis
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.
3- Unreduced dislocation : After a few weeks an untreated dislocation can seldom be
reduced by closed manipulation and open reduction is
needed.
4- 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).
5. Myositis ossification
Higher incidence after open reduction with internal fixation via an anterior approach than a posterior approach
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
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)
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)
Thanks
BY :Mὄᾗȶђἔ Ałʀ ќђᾄᾧłᾄᾗƳ
