Diferencia entre revisiones de «Hip dislocation»

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==Background==
==Background==
{{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


===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


Trauma is primary mechanism. In adults, requires substantial force vectors (MVC, fall from a height)
==Clinical Features==
===Posterior Dislocation===
*Extremity is shortened, internally rotated, adducted
*Neurovascular exam may review sciatic nerve compromise


Because of force required, 50% will have other fractures or significant injuries
===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>


==Differential Diagnosis==
{{Hip pain DDX}}


==Epidemiology==
==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)


===Diagnosis===
*Diagnosed typically via radiograph (see above)


90% posterior (10% central or anterior)
==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]]


Posterior = force applied to flexed knee and hip (e.g. dashboard)
===Posterior===
====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


Anterior = direct blow to posterior hip or posterior force to abducted leg
====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


Central = direct impact to lateral aspect.
====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>====
[[File:Waddell_Technique.jpg|thumb|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


Mortality primarily due to associated injuries
===Anterior===
*Reduction: traction, internal rotation, and then external rotation once the femoral hip clears the acetabular rim


Head, thorax & pelvis
==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


==Presentation==
==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==


Shortened, adducted & internally rotated. Hip and knee in slight flexion
==References==
<references/>


NB: not true if there is associated femoral fx
[[Category:Orthopedics]]
 
Look for:
 
-Loss of sensat posterior leg/foot (sciatic nerve)
 
-Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)
 
-LE pale / cool to touch (femoral art)
 
 
==W/U==
 
 
Usually obvious, but can be subtle on single AP view
 
Typically femoral head is seen lateral and superior to acetabulum
 
CT very accurate, and helps especially in delineating acetabular injury (where plain films are notoriously poor)
 
 
==Reduction==
 
 
Multiple techniques described (Allis/Stimson)
 
All involve longitudinal traction to unlock the femoral head, with gentle internal/external rotation to seat it in the acetabulum
 
ED success rate for native hip dislocation/reduction unclear
 
(10% reported, but not a pure series)
 
 
==Consequences==
 
 
Other injuries/life threats aside, the primary pathophysiology associated with hip dislocation is 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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