Hip Dislocation in Emergency Medicine Treatment & Management
- Author: Edward T Tham, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
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.
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.
Indications for open reduction
- 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
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