Diferencia entre revisiones de «Hip dislocation»

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==Background==
==Background==
Trauma is primary mechanism. In adults, requires substantial force vectors (MVC, fall from a height)
{{Hip anatomy background images}}
*Orthopedic emergency
**Reduction of native hip should occur within 6hr due to high risk of avascular necrosis
**Hip prosthetic dislocation is more common and less emergent
*High-energy trauma is primary mechanism for native hip dislocation
**Dashboard impact, fall from height, sports injury
*Low-energy trauma can cause hip prosthetic dislocation
**Tying shoes, sitting on toilet or low seat


Because of force required, 50% will have other fractures or significant injuries
===Types===
*Posterior
**90% of hip dislocations
**Often associated with acetabular fracture
*Anterior
**10% of hip dislocations<ref>Holt GE and McCarty EC. Anterior hip dislocation with an associated vascular injury requiring amputation. J Trauma. 2003; 55(1):135-138.</ref>
**Can be superior (pelvic) or inferior (obturator)
**Neurovascular compromise is unusual


===Epidemiology===
==Clinical Features==
90% posterior (10% central or anterior)
===Posterior Dislocation===
*Extremity is shortened, internally rotated, adducted
*Neurovascular exam may review sciatic nerve compromise


Posterior = force applied to flexed knee and hip (e.g. dashboard)
===Anterior Dislocation===
*Extremity is extended (superior) or flexed (inferior), externally rotated, abducted<ref>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.</ref>


Anterior = direct blow to posterior hip or posterior force to abducted leg
==Differential Diagnosis==
{{Hip pain DDX}}


Central = direct impact to lateral aspect.
==Evaluation==
===Workup===
[[File:HipdisX.png|thumb]]
[[File:Posthipdislocation.jpg|thumb|Post-surgical hip dislocation]]
*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)


Mortality primarily due to associated injuries
===Diagnosis===
*Diagnosed typically via radiograph (see above)


Head, thorax & pelvis
==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>
*'''Femoral neck fracture is a contraindication to closed reduction'''
*[[Procedural sedation]]


==Diagnosis==
===Posterior===
Shortened, adducted & internally rotated. Hip and knee in slight flexion
====Allis Maneuver====
[[File:Hip_Reduction.jpg|thumb|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


NB: not true if there is associated femoral fx
====Captain Morgan Hip Reduction<ref>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.</ref>====
*See figure [http://67.media.tumblr.com/tumblr_lriey37Dpa1qafl51o1_500.png here]
*See video [https://www.youtube.com/watch?v=iCxRMj6h3So 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


Look for:
====The Waddell Technique<ref>Waddell BS, Mohamed S, Glomset JT, Meyer MS. A Detailed Review of Hip Reduction Maneuvers: A Focus on Physician Safety and Introduction of the Waddell Technique. Orthop Rev (Pavia). 2016;8(1):6253.</ref>====
#Loss of sensat posterior leg/foot (sciatic nerve)
[[File:Waddell_Technique.jpg|thumb|The Waddell technique]]
#Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
*A modified Allis Maneuver that allows the provider to follow back safety recommendations provided by OSHA
#LE pale / cool to touch (femoral art)
*Provider hovers over patient on the bed and places their forearm under the patient's knee
*The provider squats down, draping their forearm over their knees with the elbow on one knee and wrist/hand over the other knee
*Provider then leans back, pivoting on feet and holding the patient's leg close to their chest, while an assistant stabilizes the pelvis


==Workup==
===Anterior===
Usually obvious, but can be subtle on single AP view
*Reduction: traction, internal rotation, and then external rotation once the femoral hip clears the acetabular rim


Typically femoral head is seen lateral and superior to acetabulum
==Disposition==
*If reduced, outpatient with ortho follow up


CT very accurate, and helps especially in delineating acetabular injury (where plain films are notoriously poor)
===Post Reduction Care===
*Maintain dislocation precautions:
**Do not bend the operated hip past 90 degrees
***Zimmer splint or other knee immobilizer can help with this as most individuals cannot flex hip without flexing knee
**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 or feather weight-bearing


==Treatment==
==Complications==
===Reduction===
*Post-traumatic arthritis
Multiple techniques described (Allis/Stimson)
**20% in simple dislocations
**Common in complex dislocations
*Femoral head osteonecrosis
**5-40%
**Delay in reduction >6 hours increases risk
*Sciatic nerve injury (check EHL function - toe extension)
**8-20% incidence
**Delay in reduction increases risk
*Recurrent dislocations: <2%


All involve longitudinal traction to unlock the femoral head, with gentle internal/external rotation to seat it in the acetabulum
==External Links==


ED success rate for native hip dislocation/reduction unclear
==References==
<references/>


(10% reported, but not a pure series)
[[Category:Orthopedics]]
 
==Prognosis==
#Other injuries/life threats
#Avascular necrosis (AVN)
##Occurs in 10-20% of cases
##Time-dependant phenomenon
##6-hours is the cut-off
#Sciatic Nerve injury: 10-15%
##Usually neuropraxia with eventual recovery expected
##Incidence of this 2.5X with delay > 6 hours for reduction
##Osteoarthritis: 10%-35%  30-70% after open-reduction
 
==Source==
ACEP ('09)
 
[[Category:Ortho]]

Revisión actual - 20:25 26 feb 2025

Background

Hip anatomy.
Extracapsular ligaments (anterior right hip).
Extracapsular ligaments (posterior right hip).
  • Orthopedic emergency
    • Reduction of native hip should occur within 6hr due to high risk of avascular necrosis
    • Hip prosthetic dislocation is more common and less emergent
  • High-energy trauma is primary mechanism for native hip dislocation
    • Dashboard impact, fall from height, sports injury
  • Low-energy trauma can cause hip prosthetic dislocation
    • Tying shoes, sitting on toilet or low seat

Types

  • Posterior
    • 90% of hip dislocations
    • Often associated with acetabular fracture
  • 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
  • Neurovascular exam may review sciatic nerve compromise

Anterior Dislocation

  • Extremity is extended (superior) or flexed (inferior), externally rotated, abducted[2]

Differential Diagnosis

Hip pain

Acute Trauma

Chronic/Atraumatic

Evaluation

Workup

HipdisX.png
Post-surgical hip dislocation
  • 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)

Diagnosis

  • Diagnosed typically via radiograph (see above)

Management

  • Reduction recommended within 6 hours to prevent avascular necrosis of the femoral head[3]
  • Femoral neck fracture is a contraindication to closed reduction
  • Procedural sedation

Posterior

Allis Maneuver

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

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

The Waddell Technique[5]

The Waddell technique
  • A modified Allis Maneuver that allows the provider to follow back safety recommendations provided by OSHA
  • Provider hovers over patient on the bed and places their forearm under the patient's knee
  • The provider squats down, draping their forearm over their knees with the elbow on one knee and wrist/hand over the other knee
  • Provider then leans back, pivoting on feet and holding the patient's leg close to their chest, while an assistant stabilizes the pelvis

Anterior

  • Reduction: traction, internal rotation, and then external rotation once the femoral hip clears the acetabular rim

Disposition

  • If reduced, outpatient with ortho follow up

Post Reduction Care

  • Maintain dislocation precautions:
    • Do not bend the operated hip past 90 degrees
      • Zimmer splint or other knee immobilizer can help with this as most individuals cannot flex hip without flexing knee
    • 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 or feather weight-bearing

Complications

  • Post-traumatic arthritis
    • 20% in simple dislocations
    • Common in complex dislocations
  • Femoral head osteonecrosis
    • 5-40%
    • Delay in reduction >6 hours increases risk
  • Sciatic nerve injury (check EHL function - toe extension)
    • 8-20% incidence
    • Delay in reduction increases risk
  • Recurrent dislocations: <2%

External Links

References

  1. ↑ Holt GE and McCarty EC. Anterior hip dislocation with an associated vascular injury requiring amputation. J Trauma. 2003; 55(1):135-138.
  2. ↑ 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.
  3. ↑ Jaskulka RA, et al. Dislocation and fracture-dislocation of the hip. J Bone Joint Surg Br. 1991; 73(3):465-469.
  4. ↑ 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.
  5. ↑ Waddell BS, Mohamed S, Glomset JT, Meyer MS. A Detailed Review of Hip Reduction Maneuvers: A Focus on Physician Safety and Introduction of the Waddell Technique. Orthop Rev (Pavia). 2016;8(1):6253.
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