DISLOCATION OF THE

HIP
 INTRODUCTION
• The magnitude of force needed to dislocate the hip, a joint
particularly well-contained by virtue of its bony and soft-tissue
anatomy, is so great that the dislocation is often associated with
fractures – either around the joint or elsewhere in the same limb.
• Small fragments of bone are often chipped off, usually from the
femoral head or from the wall of the acetabulum.
• If there is a major fragment, the injury is regarded as a fracture-
dislocation.

• Hip dislocations are classified according to the direction of the

femoral head displacement: posterior (by far the commonest variety),
anterior and central (a comminuted or displaced fracture of the
acetabulum).
 POSTERIOR DISLOCATION OF HIP
• A posterior dislocation, usually occurs in a road accident when
someone seated in a truck or car is thrown forward, striking the knee
against the dashboard. (DASHBOARD INJURY)

• The femur is thrust upwards and the femoral head is forced out of its
socket.

• Often a piece of bone at the back of the acetabulum (usually the

posterior wall) is sheared off, making it a fracture-dislocation.

• Seat-belt restraints can reduce the number of posterior hip

dislocations.
 CLINICAL FEATURES
• In a straightforward case the diagnosis is easy; the leg is short and lies
adducted, internally rotated and slightly flexed.

• However, if one of the long bones is fractured – usually the femur –

the injury can easily be missed as the limb can adopt almost any
position.

• The golden rule is to x-ray the pelvis in every case of severe injury
and, with femoral fractures, to insist on an x-ray that includes both
the hip and knee.

• The lower limb should be examined for signs of sciatic nerve injury
DEFORMITY IN POSTERIOR DISLOCATION OF HIP

This is the typical posture in a patient with posterior

dislocation: the left hip is slightly flexed, adducted and
internally rotated.
 X RAY
• In the anteroposterior film the femoral head is seen out of its socket
and above the acetabulum.

• A segment of acetabular rim or femoral head may have been broken

off and displaced; oblique films are useful in demonstrating the size of
the fragment.

• If any fracture is seen, other bony fragments (which may need

removal) must be suspected.

• A CT scan is the best way of demonstrating an acetabular fracture (or

any bony fragment) but detailed imaging at this stage should be
undertaken only if it does not delay reduction of the dislocation
unduly.
The x-ray in this case showed a simple Another patient with dislocation and an
dislocation, with the femoral head lying associated acetabular rim fracture
above and behind the acetabulum.
In some cases it may need a CT scan and three-dimensional image
reconstruction to appreciate the full extent of the associated acetabular injury
 RADIOLOGICAL CLASSIFICATION HELPFUL IN MANAGEMENT

TYPE THOMPSON AND EPSTEIN CLASSIFIATION OF POSTERIOR DISLOCATION HIP

I DISLOCATION WITH NO MORE THAN MINOR CHIP FRACTURES

II DISLOCATION WITH SINGLE LARGE FRAGMENT OF POSTERIOR ACETABULAR WALL

III DISLOCATION WITH COMMINUTED FRAGMENTS OF ACTABULAR WALL

IV DISLOCATION WITH FRACTURE THROUGH ACETABULAR FLOOR

V DISLOCATION WITH FRACTURE OF FEMORAL HEAD, (+/- # THROUGH ACETABULAR FLOOR)

 CLASSIFICATION BASED ON RADIOLOGY
• Thompson and Epstein (1951) suggested a classification which is
helpful in planning treatment.

• Types I and II are relatively simple dislocations; these are associated

with either minor chip fractures (small fragments of the acetabular
wall or fovea centralis) or a single large fragment from the posterior
acetabular wall.

• In Type III the posterior wall is comminuted.

• Type IV has an associated fracture of the acetabular floor.

• Type V an associated fracture of the femoral head

 TREATMENT
• The dislocation must be reduced as soon as possible under general
anaesthesia.
• In the vast majority of cases this is performed closed, but if this is not
achieved after two or three attempts an open reduction is required.
• An assistant steadies the pelvis; the surgeon starts by applying
traction in the line of the femur as it lies (usually in adduction and
internal rotation), and then gradually flexes the patient’s hip and knee
to 90 degrees, maintaining traction throughout.
• At 90 degrees of hip flexion, traction is steadily increased and
sometimes a little rotation (either internal or external) is required to
accomplish reduction.
• Another assistant can help by applying direct medial and anterior
pressure to the femoral head through the buttock.
 TREATMENT
• A ‘clunk’ sound terminates the manoeuvre.
• An important test follows, to assess the stability of the reduced hip.
• By flexing the hip to 90 degrees and applying a longitudinal and
posteriorly-directed force, the hip is screened on an image-intensifier
looking for signs of subluxation.
• Evidence of this should prompt a repair to the posterior wall of the
acetabulum.
• Reduction is usually stable in type I injuries, but the hip has been
severely injured and needs to be rested.
• The simplest way is to apply traction and maintain it for a few days.
• Movement and exercises are begun as soon as pain allows; continuous
passive movement machines are helpful.
• The terminal ranges of hip movements are avoided to allow healing of
the capsule and ligaments.
 TREATMENT
• As soon as active limb control is achieved, and this may take about 2
weeks, the patient is allowed to walk with crutches but without taking
weight on the affected side.

• The rationale for not bearing weight is to prevent collapse of femoral

head due to an unsuspected avascular change.

• The period of hip ‘protection’ varies according to the risk of avascular

necrosis: if the reduction was performed promptly (within 6 hours),
then no more than 6 weeks should suffice, but if there was a longer
delay then an extended period of 12 weeks may be wiser.

• Progression of weightbearing should be graduated and the hip joint

monitored by x-ray.
 TREATMENT
• If the post-reduction x-rays or CT scans show the presence of intra-
articular bone fragments or larger femoral head pieces that are
incompletely reduced, an open procedure should be planned.
• The approach is dictated by the location of the fragment on CT scan.
• However, the operation is not an emergency and can be done once
the patient’s condition has stabilized.
• The joint needs to be thoroughly washed out at the conclusion of the
procedure to remove bone ‘grit’.
• TYPE II DISLOCATIONS NEED OPEN REDUCTION AND FIXATION OF
POSTERIOR FRAGMENT as many cases the reduction of acetabular
posterior margin is not good.
• If patient is not fit for surgery then initially do the reduction and apply
traction, then do OR&IF of posterior fragment at second sitting.
 TREATMENT
• Type III injuries are treated closed, but there may be retained fragments and these
should be removed by open operation.
• Fixation of a comminuted posterior wall is sometimes impossible – if persistent
instability is present, referral to a specialist centre.
• There reconstruction using a segment of iliac crest could be undertaken, is
advisable.
• Types IV and V are treated initially by closed reduction.
• The indications for surgery follow the principles already outlined: instability,
retained fragments or joint incongruity.
• In type V injuries, a femoral head fragment may automatically fall into place, and
this can be confirmed by post-reduction CT.
• If the fragment remains unreduced, operative treatment is indicated: a small
fragment can simply be removed, but a large fragment should be replaced
• The joint is opened, the femoral head dislocated and the fragment fixed in position
with a countersunk screw.
• Postoperatively, traction is maintained for 2–4 weeks and full weightbearing is
 COMPLICATIONS
• EARLY
a. SCIATIC NERVE INJURY - The sciatic nerve is damaged in 10–20 per
cent of cases but it usually recovers. Nerve function must be tested
and documented before reduction is attempted.
b. VASCULAR INJURY - Occasionally the superior gluteal artery is torn
and bleeding may be profuse. If this is suspected, an arteriogram
should be performed. The torn vessel may need to be ligated.
c. ASSOCIATED FEMORAL SHAFT FRACTURE – often dislocation is
missed. As a rule image hip and knee in all fracture shaft femur.
Suspect dislocation if proximal fragment is adducted in transverse
fracture of femur in X ray.
Prompt Open Reduction of dislocation and simultaneous ORIF of
femoral shaft fracture is indicated.
 COMPLICATION
• LATE
a. AVASCULAR NECROSIS - Avascular necrosis of the femoral head has
been reported in about 10 per cent of traumatic hip dislocations; if
reduction is delayed by more than 12 hours, the figure rises to over
40 per cent.
b. MYOSITIS OSSIFICANS - This is an uncommon complication,
probably related to the severity of the injury. During recovery,
movements should never be forced and in severe injuries the period
of rest and non-weightbearing may need to be prolonged. Small
areas of ossification seen on x-ray usually bear no clinical
significance.
c. UNREDUCED DISLOCATION – when injury is missed
d. OSTEOARTHRITIS – not uncommon. Due to cartilage injury, retained
small fragments in joint and AVN femoral head.
 ANTERIOR DISLOCATION OF HIP
• Anterior dislocation is rare when compared with posterior.

• Dislocation of one or even both hips may occur when a weight falls
onto the back of a miner or building labourer who is working with his
legs wide apart, knees straight and back bent forwards.

• However, nowadays the usual cause is a road accident or air crash –

even a posteriorly directed force on an abducted and externally
rotated hip may cause the neck to impinge on the acetabular rim and
lever the femoral head out in front of its socket.

• The femoral head will then lie superiorly (type I - pubic) or inferiorly
(type II - obturator).
 CLINICAL FEATURES
• The leg lies externally rotated, abducted and slightly flexed.
• It is not short, because the attachment of rectus femoris prevents the
head from displacing upwards.
• Occasionally the leg is abducted almost to a right angle.

• Seen from the side, the anterior bulge of the dislocated head is
unmistakable, especially when the head has moved anteriorly and
superiorly.
• The prominent head is easy to feel, either anteriorly (superior type) or
in the groin (inferior type).
• Hip movements are impossible
The hip is only slightly abducted and the head shows
clinically as a prominent lump.
 X RAY PICTURE OF ANTERIOR
DISLOCATION
 X RAY
• In the anteroposterior view the dislocation is usually obvious, but
occasionally the head is almost directly in front of its normal position;
any doubt is resolved by a lateral film.

• TREATMENT – OPEN REDUCTION UNDER GENERAL ANAESTHESIA

• COMPLICATIONS – Avascular necrosis in 10% of cases.

 CENTRAL FRACTURE DISLOCATION
• Rare and always a # dislocation

• Severe trauma is involved and a blow on the lateral aspect of the hip
causes the floor of the acetabulum to give way and the head of the
femur is pushed into the pelvis.

• TWO MAJOR TYPES – are seen

1)Fracture-dislocation with an intact weight bearing articular surface
2)Comminuted displaced fracture of the floor of the acetabulum
 CENTRAL FRACTURE
DISLOCATION
 CLINICAL FEATURES
• Complains of – severe hip pain
• No marked deformity as in other types
• Flexion and extension are relatively free but abduction adduction are
markedly restricted
• If suspicious a per rectal examination will reveal a smooth hemispherical
bulge in the lateral wall of the rectum – diagnostic
• X – rays will reveal the condition
• TREATMENT – continuous heavy femoral pin skeletal traction with lateral
trochanteric traction with limb in 30 degrees of abduction
• This will reduce the dislocation
• Maintain for 4 -6 weeks
• After this non weight bearing exercises are encouraged
• For cases with wt. bearing articular surface involvement surgery is needed
 OLD UNREDUCED DISLOCATION HIP
• Common clinical entity in India

• Initial treatment by traditional bone setter

• Presents with painful stiff and deformed hip
• Difficult to treat

• X rays may show myositis ossificans complicating the problem

• If less than 3 months old then a open reduction may be tried after a
period of skeletal traction
• After this the results are not good and a sub-trochanteric osteotomy
is done to correct the deformity and relieve pain.
 OLD NEGLECTED HIP
DISLOCATION