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Hip Dislocation in Emergency Medicine Treatment & Management

  • Author: Stephen R McMillan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Apr 11, 2016
 

Prehospital Care

Patients with hip dislocation often have associated injuries that may take precedence during stabilization, both in the field and in the ED. Attempts to reduce the dislocation in the field are ill advised.

Establish the ABCs with appropriate spinal immobilization.

If hip dislocation is detected in the field, the patient should be placed on a backboard and allowed to assume the leg position that is most comfortable (ie, hip slightly flexed, leg adducted).

The patient should be transported to a level of trauma center appropriate for his or her overall clinical status.

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Emergency Department Care

Patients with hip dislocations often have life-threatening injuries that take precedence. Once life-threatening injuries have been stabilized or ruled out, the hip dislocation can be addressed. A proper neurovascular examination should be performed. If a neurovascular deficit exists, there is even more urgency to reduce the dislocation.

Appropriate analgesia should be provided. If hemodynamic status permits, intravenous narcotics are usually indicated.

Radiographs to detect hip pathology should be obtained.

Reduction is greatly facilitated by the use of procedural sedation. Unless sufficient sedation and muscle relaxation is achieved, attempts at relocation are futile. A variety of medications may be used for this purpose depending on physician preference and hospital protocol. A combination of agents with muscle relaxant and analgesic properties is optimal. The patient should be appropriately monitored during procedural sedation according to institutional protocol.

Simple hip dislocations without associated fracture are within the practice scope of most emergency physicians. Consider orthopedic consultation if it will not delay relocation beyond a reasonable amount of time, usually within 6 hours.

Once procedural sedation has been achieved, the hip may be reduced by one of the preceding methods. Reducing a hip usually takes a significant amount of space and resources. Usually, one person applies traction and one or two people supply counter traction. A nurse or other physician provides sedation. More than 3 attempts at closed reduction in the ED is not recommended. The incidence of AVN increases with multiple attempts. If the dislocation cannot be reduced, an emergent CT scan is indicated to visualize any bony or soft tissue fragments that may hinder reduction. Closed reduction may be attempted in the operating room under general anesthesia. However, a majority of these patients may require open reduction.

Fracture-dislocations or concomitant fractures of the femoral neck usually require the expertise of an orthopedic specialist. Practice styles vary widely. Some orthopedists make an attempt at closed reduction, whereas others immediately perform an open reduction if a fracture-dislocation exists.

After closed reduction, confirm placement with a repeat radiograph. A repeat neurovascular examination should be performed and documented as well. A CT scan or MRI of the hip can provide valuable information about further treatment and prognosis.

If relocation of the hip is successful, immobilize the legs in slight abduction by using a pad between the legs to prevent adduction until skeletal traction can be instituted.

After reduction, patients with hip dislocation should be admitted to the hospital. Patients will be nonambulatory and require a great deal of supportive care. Pain will be significant, even after reduction, and patients may require parenteral narcotics.

The duration of traction and non–weight-bearing immobilization is controversial. Evidence suggests that early weight bearing (eg, 2 wk after relocation) may increase the severity of aseptic necrosis when it occurs. Early weight bearing decreases the incidence of other complications (eg, venous thromboembolism, decubiti), and some studies have found equivalent outcomes with early and delayed weight bearing.

Once stabilized, patients with multiple trauma may be transferred. A patient with an isolated hip dislocation may be transferred if no neurovascular deficit is suspected and if the transfer time does not extend the dislocation time by longer than 6 hours. In general, hip dislocations are reduced at the receiving facility and, if necessary, the patient is transferred for ongoing inpatient care with appropriate immobilization en route.

Indications for open reduction

Indications for open reduction include the following:

  • Irreducible dislocation (approximately 10% of all dislocations)
  • Persistent instability of the joint following reduction (eg, fracture-dislocation of the posterior acetabulum)
  • Fracture of the femoral head or shaft
  • Neurovascular deficits that occur after closed reduction

Follow-up

Various techniques can be used to accomplish open reduction, acetabular repair, and fixation of associated fractures; these techniques are beyond the scope of this article.

After reduction of the hip dislocation, obtain repeat AP and lateral radiographs of the hip to verify proper reduction.

After either open or closed reduction of a hip dislocation, the patient is instructed to remain on bed rest with his or her legs abducted and with skeletal traction designed to keep the hip from displacing posteriorly.

The duration of traction is approximately 2 weeks, but the recommended period with no weight bearing is controversial and varies from 9 days to 3 months.

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Consultations

And orthopedic surgeon and/or trauma surgeon should be consulted.

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Complications

AVN of the hip

AVN is common, occurring in 8-13% of patients.

Early diagnosis and treatment of dislocations decreases the incidence of AVN.

The effect of early weight bearing on the occurrence of AVN is controversial. Most studies have shown that early weight bearing after reduction is associated with more severe AVN, but it does not appear to increase the incidence.

The incidence of AVN is increased with delayed reduction, repeated attempts at reduction, and open reduction (40% vs 15.5% with closed reduction). This finding may be due to operative trauma or because those dislocations requiring surgery are inherently more severe.

AVN may not become apparent on plain radiographs for several months. Early diagnosis can be made with MRI or nuclear scanning, and these modalities should be considered in a patient who develops late and persistent pain after a dislocation.

Sciatic nerve injury (posterior dislocation)

Injury to the sciatic nerve occurs in 10-14% of posterior dislocations during the initial trauma or during relocation.

Function of the sciatic nerve should be verified before and after relocation to detect this complication. The finding of sciatic nerve dysfunction mandates surgical exploration to release or repair the nerve.

Femoral-nerve injury

Anterior dislocations are occasionally associated with injury to the femoral artery or nerve.

Dislocations in children can occur with relatively minor trauma (eg, sports activities), and reduction must be gentle to avoid iatrogenic injury to the femoral epiphysis (eg, slipped capital femoral epiphysis).

Other complications

Other complications of hip dislocation are the following:

  • Osteoarthritis
  • Heterotopic calcification
  • Recurrent dislocation
  • Ligamentous injury of the knee, other fractures
  • Complications of immobilization (DVT, pulmonary embolus, decubiti, pneumonia)
  • Femoral-artery injury (in anterior dislocations)
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Contributor Information and Disclosures
Author

Stephen R McMillan, MD Resident Physician, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Stephen R McMillan, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, FACEP Associate Professor of Emergency Medicine, Residency Program Director, Vice-Chair for Education, Department of Emergency Medicine, University of Kentucky-Chandler Medical Center

Christopher I Doty, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edward T Tham, MD Fellow in Emergency Ultrasound, Clinical Instructor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine

Edward T Tham, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, Paul Carter, MD, and Edward Newton, MD, to the development and writing of this article.

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A normal anteroposterior (AP) pelvis radiograph.
Right posterior hip dislocation in a young woman following a high-speed motor vehicle collision (MVC).
Fracture-dislocation of the right hip. The bony fragments are likely part of the acetabulum.
Posterior dislocation of right hip with acetabular fracture.
Portable AP pelvis with subtle presentation of right posterior hip dislocation. Abnormal rotation is present, and the right femoral head appears smaller, indicating that it is further away.
 
 
 
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