Closed Reduction of Posterior Hip Dislocation

- Discussion: - performed as soon a possible ( < 8-12 hrs) - either in OR under GEA (optimal) or in ER w/ sedation if delays are expected; - reduction may be performed w/ flouro, but orthopaedist may find that flouro interferes w/ hip flexion, which frequently is essential to performing an atraumatic reduction; - frequently all that is needed is one assistant to apply pressure to the ASIS, as the surgeon flexes the hip while applying traction; - reduction is felt as gentle clunk, at which point x-rays are obtained;
Methods of Reduction: - Rochester Method: - patient is placed supine with uninjured hip and knee flexed (this knee acts as a pivot point for the surgeon's hand); - one of the surgeon's hands is place underneath the injured knee and over top of the uninjured knee; - this manuever flexes both the patient's injured hip and knee; - the other hand grab's the ankle (injured side) and this can be used to generate traction (by pressing down on ankle) and at the same time the ankle can be used to control hip rotation; - reduction is obtained by traction, internal rotation, and then external rotation once the femoral hip clears the acetabular rim; - other reduction methods include: - Gravity Method of Stimson - Allis's maneuver - Bigelow's Maneuver - Post Reduction Management: - any widening of the join space after reduction suggests possibility of loose fragments or soft tissue in joint; - this requires open reduction & removal of osteochondral fragments (see hip arthroscopy); - always get post reduction CT scan: - if reduction is concentric but unstable and there are no assoc frx, traction should be maintained for 4-6 wks until soft-tissue healing occurs

Allis's maneuver: for Hip Dislocation

patient is placed in the supine position; - knee is flexed to relax the hamstrings; - assistant stabilizes the pelvis and applies a lateral traction force to the inside of the thigh; - longitudinal traction is applied in line w/ axis of femur, and the hip is slightly flexed; - essential feature is traction in direct line of deformity, followed by gentle felxion of the hip to 90 deg; - surgeon gently adducts & internal rotates the femur to get reduction; - hip is gently rotated internally & externally w/ continued longitudinal traction until reduction is achieved; The following is an illustration of a well-established reduction method (the Bigelow maneuver) that may be performed with minimal assistance with the patient in the supine position.

Place the patient supine on a stretcher that is elevated to the height of the waist of the practitioner performing the reduction. The injured hip is initially held in a position of adduction and internal rotation, with one practitioner applying longitudinal distraction and an assistant applying pressure on the patient's anterior superior iliac spines so as to stabilize the patient's pelvis.

pt lies supine, & assistant applies countertraction by downward pressure on the ASIS; - surgeon grasps affected limb at ankle w/ one hand, places opposite forearm behind the knee, and applies longitudinal traction in line of deformity; - adducted & internally rotated thigh is flexed > 90 deg on abdomen; - this relaxes the Y ligament and allows the surgeon to bring the femoral head near the posteroinferior rim of the acetabulum - while traction is maintained, femoral head is levered into acetabulum by abduction, external rotation, and extension of hip. - after reduction: - avoid: flexion, internal rotation, and adduction; - traction is maintained until pt. is pain free (2 wks) ------------------------------------------Reduction of posterior dislocation of the hip in the prone position. Herwig-Kempers A. Veraart BE. Journal of Bone & Joint Surgery - British Volume. 75(2):328,1993 Mar. - Reverse Bigelow's Maneuver: - position of hip is partial flexion and abduction;

- two methods of reduction: - first is lifting method, in which firm jerk is applied to flexed thigh; - this often results in reduction except in pubic dislocations; - if lifting method fails, traction is applied in the line of deformity; - hip is then adducted, sharply internally rotated, and extended; - one must be careful using this technique, since sharp internal rotation can result in frx of the femoral neck;

Gravity Method of Stimson

described primarily for acute posterior dislocations, but anterior dislocations can occassionally be reduced by this method; 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; -Contraindications: - superior dislocations of the pubic type in which the hip presents in extension are not amenable to a Stimson's maneuver because of the need for further extension to acheive reduction;

Radiographic Evaluation of Hip Dislocation

Pre Reduction Evaluation: frx-dislocation usually confirmed by a single AP x-ray; - rule out: assoc acetabular, femoral head, or femoral neck frx; these must be recognized prior to reduction; femoral head: for assoc frx; - acetabulum: presence, size, and location of fragments; - Judet View evaluate post. wall frx ( > 40% is Unstable) - injured side is elevated to 45 deg w/ pt supine, to demonstrate posterior acetabular rim in profile; - femoral neck: r/o non-displaced frx that might displace when Closed Reduction is attempted; - CT scan should be performed in all cases to identify intra articular fragments or associated fractures such as femoral head fractures; - CT would be indicated prior to reduction if radiographs show a posterior wall frx ( > 40% implies Unstable frx-dislocation); Post Reduction Evaluation:

- need to assess stability following either closed or open reduction; - CT can assist in assessment of stability after reduction of posterior dislocations of the hip; - stability is inversely proportional to the size of the posterior acetabular fragment; - fragments involving < 25% of acetabular wall do not affect hip stability, while those involving > 40% result in instability;