Hip dislocation: Difference between revisions
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==Background== | ==Background== | ||
*Orthopedic emergency; reduction should occur within 6hr due to high risk of avascular necrosis | *Orthopedic emergency; reduction of native hips should occur within 6hr due to high risk of avascular necrosis | ||
*High-energy trauma is primary mechanism | *High-energy trauma is primary mechanism | ||
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**Posterior Dislocation: AP view femoral head posterior and superior to acetabulum | **Posterior Dislocation: AP view femoral head posterior and superior to acetabulum | ||
**Anterior Dislocation: AP view shows femoral head in obturator foramen (inferior to acetabulum) | **Anterior Dislocation: AP view shows femoral head in obturator foramen (inferior to acetabulum) | ||
**If associated femoral neck fracture, will likely need orthopedics | |||
*Consider Judet views | *Consider Judet views | ||
*Consider knee xray | *Consider knee xray | ||
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==Management== | ==Management== | ||
Reduction recommended within 6 hours to prevent avascular necrosis of the femoral head<ref>Jaskulka RA, et al. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991; 73(3):465-469.</ref> | *Reduction recommended within 6 hours to prevent avascular necrosis of the femoral head<ref>Jaskulka RA, et al. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991; 73(3):465-469.</ref> | ||
*[[Procedural sedation]] | |||
===Posterior=== | ===Posterior=== | ||
*Allis Maneuver: supine patient on table: deeper sedation (propofol helps with tissue relaxation); firm distal traction at flexed knee to pull head back into acetabulum; assistant stabilizes pelvis by pushing on ASISs | *Allis Maneuver: supine patient on table: deeper sedation (propofol helps with tissue relaxation); firm distal traction at flexed knee to pull head back into acetabulum; assistant stabilizes pelvis by pushing on ASISs | ||
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*See figure [http://67.media.tumblr.com/tumblr_lriey37Dpa1qafl51o1_500.png here] | *See figure [http://67.media.tumblr.com/tumblr_lriey37Dpa1qafl51o1_500.png here] | ||
*See video [https://www.youtube.com/watch?v=iCxRMj6h3So here] | *See video [https://www.youtube.com/watch?v=iCxRMj6h3So here] | ||
*Provider's knee behind supine patients flexed knee with anterior force lifting and rotation as needed | *Provider's knee behind supine patients flexed knee with anterior force lifting (via provider plantar flexing foot) and rotation as needed | ||
*Successful in patients with prosthetic hips as well | *Successful in patients with prosthetic hips as well | ||
*Poses less risk of knee injury since most force is applied by lifting leg rather than applying leverage at knee | *Poses less risk of knee injury since most force is applied by lifting leg rather than applying leverage at knee | ||
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==Post Reduction Care== | ==Post Reduction Care== | ||
*Maintain dislocation precautions: | *Maintain dislocation precautions: | ||
**Do not bend the operated hip past 90 degrees | **Do not bend the operated hip past 90 degrees (use knee immobilizer as needed) | ||
**Do not cross the midline of the body with operated leg | **Do not cross the midline of the body with operated leg (use hip abduction pillow) | ||
**Do not rotate the operated leg inward | **Do not rotate the operated leg inward | ||
**In bed, toes and knee cap should point toward ceiling | **In bed, toes and knee cap should point toward ceiling | ||
*Toe touch weight bearing | *Toe touch weight bearing | ||
Revision as of 15:47, 18 April 2017
Background
- Orthopedic emergency; reduction of native hips should occur within 6hr due to high risk of avascular necrosis
- High-energy trauma is primary mechanism
Types
- Posterior
- 90% of hip dislocations
- Acetabular fractures may result as well
- Anterior
- 10% of hip dislocations[1]
- Can be superior (pelvic) or inferior (obturator)
- Neurovascular compromise is unusual
Clinical Features
- Posterior Dislocation
- Extremity is shortened, internally rotated, adducted
- Often Knee-to-Dashboard
- Assess neurovascular exam
- Sciatic nerve is most common compromised
- Anterior Dislocation
- Extremity is extended (superior) or flexed (inferior), externally rotated, abducted[2]
- Similar to hip fracture
Differential Diagnosis
Hip pain
Acute Trauma
- Femur fracture
- Proximal
- Intracapsular
- Extracapsular
- Shaft
- Mid-shaft femur fracture (all subtrochanteric)
- Proximal
- Hip dislocation
- Pelvic fractures
Chronic/Atraumatic
- Hip bursitis
- Psoas abscess
- Piriformis syndrome
- Meralgia paresthetica
- Septic arthritis
- Obturator nerve entrapment
- Avascular necrosis of hip
Evaluation
- Hip AP and lateral views
- Posterior Dislocation: AP view femoral head posterior and superior to acetabulum
- Anterior Dislocation: AP view shows femoral head in obturator foramen (inferior to acetabulum)
- If associated femoral neck fracture, will likely need orthopedics
- Consider Judet views
- Consider knee xray
- Consider CT to evaluate acetabulum for subtle fractures (esp for posterior dislocation)
Management
- Reduction recommended within 6 hours to prevent avascular necrosis of the femoral head[3]
- Procedural sedation
Posterior
- Allis Maneuver: supine patient on table: deeper sedation (propofol helps with tissue relaxation); firm distal traction at flexed knee to pull head back into acetabulum; assistant stabilizes pelvis by pushing on ASISs
Anterior
- Reduction: traction, internal rotation, and then external rotation once the femoral hip clears the acetabular rim
Captain Morgan Hip Reduction[4]
- See figure here
- See video here
- Provider's knee behind supine patients flexed knee with anterior force lifting (via provider plantar flexing foot) and rotation as needed
- Successful in patients with prosthetic hips as well
- Poses less risk of knee injury since most force is applied by lifting leg rather than applying leverage at knee
- Less risk to provider who does not have to stand on top of gurney, and requires only one provider
Post Reduction Care
- Maintain dislocation precautions:
- Do not bend the operated hip past 90 degrees (use knee immobilizer as needed)
- Do not cross the midline of the body with operated leg (use hip abduction pillow)
- Do not rotate the operated leg inward
- In bed, toes and knee cap should point toward ceiling
- Toe touch weight bearing
Complications
- Post-traumatic arthritis
- 20% in simple dislocations
- high in complex dislocations
- Femoral head osteonecrosis
- 5-40% incidence
- Delay in treatment >6 hours can lead to avascular necrosis of the femoral head => osteonecrosis
- Sciatic nerve injury
- 8-20% incidence
- associated with longer time to reduction
- Recurrent dislocations: <2%
Video
{{#widget:YouTube|id=BLZXlVnqLs0}}
References
- ↑ Holt GE and McCarty EC. Anterior hip dislocation with an associated vascular injury requiring amputation. J Trauma. 2003; 55(1):135-138.
- ↑ Alonso JE, et al. A review of the treatment of hip dislocations associated with acetabular fractures. Clin Orthop Relat Res. 2000; 377(8):32-43.
- ↑ Jaskulka RA, et al. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991; 73(3):465-469.
- ↑ Hendey GW and Avila AA. The Captain Morgan Technique for the Reduction of the Dislocated Hip. Annals of Emergency Medicine, Volume 60, Issue 1, July 2012, Pages 135-136.