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Hip Dislocation Workup

  • Author: Matthew Gammons, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Mar 27, 2014
 

Laboratory Studies

See the list below:

  • Laboratory studies should be based on the individual patient, mechanism of injury, and concern about other injuries.
  • Hemoglobin/hematocrit: Evaluate the amount of blood loss if a patient has any significant trauma to the hip or if vessel injury is suspected. Observation of serial hemoglobin/hematocrit is important in case of disruption or intimal tear of the femoral vessels.
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Imaging Studies

See the list below:

  • Radiographs (anteroposterior [AP], lateral, and internal and external oblique views)
    • A full series of prereduction radiographs should be obtained expeditiously, including the AP pelvis view, which shows most hip dislocations and provides evidence for the type of dislocation. Include other views, such as a cross-table lateral, and Judet (oblique) views. Exceptions would include expedient on-field reduction and not having timely access to a facility with radiographic capability, such as backcountry skiing/snowboarding areas.
    • In the AP pelvis view, the femoral head will appear small when compared with the uninjured side in a posterior dislocation and large in an anterior dislocation.
    • Evaluate where the femoral head lies in comparison to the acetabulum (eg, anterior vs posterior, superior vs inferior), if surgery is required to reduce the joint.
    • Lateral and oblique views are very important to evaluate for fractures of the femoral head, neck, and acetabulum.
    • Two oblique views are taken.
      • The first oblique view is taken with the patient placed on the injured side and angled anteriorly approximately 15°.
      • The second view is taken with the patient supine and angled upward about 60°.
    • A full series of postreduction films must be obtained to assess the adequacy of the reduction maneuver.
    • Although loose bony fragments or fractures may be difficult to see on a post-reduction x-ray, evaluating the hip joint for these fragments and fractures is imperative, as they may prevent complete reduction and cause further postreduction damage to the joint.
  • Computed tomography (CT) scanning
    • Indications for CT scanning of hip dislocations are debatable, although the fact that failure of closed reduction indicates a CT scan or an asymmetric joint space is widely agreed, as discussed below. CT scanning is helpful to the physician for diagnosing loose bodies and fragments that impede closed reduction and to evaluate acetabular fractures as well.
    • Bony fragments or damaged soft tissues that prevent closed reduction may be present, and the patient would need to be taken to the operating room for open reduction.
    • The presence of postreduction joint-space widening is a second widely accepted indication for a CT scan. This finding may also be evidence for bony fragment involvement that cannot be seen on x-ray or soft-tissue damage that prevents normal articulation.
    • Most physicians recommend obtaining a CT scan of the hip in every patient after closed reduction to evaluate for occult fractures and soft-tissue damage.
  • Magnetic resonance imaging (MRI)
    • MRI is indicated subacutely in certain cases of acute hip dislocations to evaluate labral tears, chondral injuries and cartilaginous loose bodies, particularly in the elite athlete and other patients who are likely to sustain high stresses to the hip, and in whom surgical repair of labrum and capsular ligaments would be considered.
    • MRIs should be done in 4-6 weeks to look for signs of osteonecrosis. This is repeated at about 3 months.
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Procedures

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  • Closed reduction
    • Numerous studies have shown that closed reduction should be attempted as soon as possible after a hip dislocation and certainly within the first 6 hours after injury to minimize long-term joint damage.[6, 14, 15] These techniques should be performed using conscious sedation in the emergency department or under general or spinal anesthesia in the operating room. All of the methods are 2-person closed reduction.
    • The following are methods of closed reduction of a dislocated hip:
      • The Allis maneuver, the most widely performed method, involves having an assistant bilaterally stabilize the anterior superior iliac spines while the patient is supine. First, the knee of the affected side is flexed, and then the hip is flexed, with traction being placed below the knee pulling upward. The leg is internally and externally rotated until the femoral head is rearticulated with the acetabulum.
      • The Stimson maneuver places the patient in the prone position and is the least traumatic of the closed reduction methods. An assistant provides pressure on the patient's lower back for stability, while the injured leg is allowed to hang from the side of the bed with the knee and hip fully flexed. Traction is applied along with the force of gravity behind the knee, while internal and external rotation is applied to pop the femoral head back into place. Note: This technique is contraindicated in the setting of thoracoabdominal trauma or a difficult airway.
      • The Bigelow maneuver is the final method of closed reduction. As in the Allis maneuver, an assistant applies pressure to the anterior spines of the patient's pelvis for stability. One hand is used to apply traction on the affected leg by pulling on the ankle, while the other forearm is placed under the knee. The knee and hip are flexed on the injured leg, and abduction, external rotation, and extension of the hip are performed until the femoral head is in the acetabulum.
      • Another novel technique for the reduction of a hip dislocation realized high success rates with no reported neurovascular complications or injuries to the knee. The “Captain Morgan” technique involves placing the physician's knee behind the supine patient's flexed knee and lifting with anterior force, with rotation as needed.[16]
    • Reports of on-field reduction of posterior hip dislocations exist.[6, 8] Although this leads to expedient reduction and may theoretically decrease complication rates from the reduction, caution should be used. Only those with experience in hip reductions should even consider attempting an on-field reduction. However, early reduction within the first 5-10 minutes can often be much easier before the onset of muscle spasm. Also consider early out-of-hospital reduction, if significant transport time will occur, such as in wilderness or backcountry situations.
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Contributor Information and Disclosures
Author

Matthew Gammons, MD Assistant Clinical Professor, Department of Family and Community Medicine, Medical College of Wisconsin; Medical Director, Castleton State College; Consulting Staff, Vermont Orthopaedic Clinic and Killington Medical Clinic

Matthew Gammons, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Society of Mechanical Engineers

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.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Alexander Zlidenny, MD, and Federico E Vaca, MD, FACEP, to the development and writing of this article.

References
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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.
 
 
 
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