Reduction of Posterior Hip Dislocation Periprocedural Care

History and physical examination

Obtain and document a thorough preprocedural history that includes the following:

• History of prior injuries and surgical procedures
• Mechanism of trauma
• Amount of time elapsed since the traumatic event
• Description of the presenting symptoms
• Any subjective loss of strength or sensation
• Patient’s age in reference to skeletal maturity

Perform and document a thorough physical examination, with special attention paid to the following:

• Ecchymoses
• Swelling
• Pallor
• Abrasions and lacerations
• Paresthesia
• Weakness
• Notable deformities of the hip
• Presence and character of femoral, popliteal, and pedal pulses

The exact position in which the hip and distal leg are held should be noted, and a comparison examination of the contralateral hip should be done (bilateral hip dislocations ^{[10, 11]} are a rare but well-described occurrence). Emphasis should be placed on assessing the neurovascular status of the distal limb, particularly in assessing the sciatic distribution.

Typically, the patient with a posterior traumatic hip dislocation presents with a notably shortened lower limb held in a position of hip flexion, adduction, and internal rotation. ^[8] The femoral head may sometimes be palpable at the ipsilateral buttock. Whereas this presentation is reliable in patients with simple hip dislocations, the presence of fractures in the ipsilateral femur or pelvis may dramatically alter the patient's presenting position. A high incidence of undetected hip dislocations in patients with ipsilateral fractures, as well as the marked increase in long-term morbidity when initial reduction is delayed, illustrates the need to be able to recognize atypical presentations of this injury.

Assess the patient for additional injuries, particularly life-threatening injuries that may have resulted from the same high-force trauma that caused the hip dislocation. Follow Advanced Trauma Life Support (ATLS) protocols when these are deemed appropriate. Continue management of the hip dislocation as soon as proper evaluation and resuscitation of the patient have insured hemodynamic stability.

Diagnostic imaging

Obtain diagnostic imaging of the patient's bilateral hips and pelvis, choosing the modality that can be performed and evaluated in the shortest duration of time and make the diagnosis. Choices include the following:

• A single anteroposterior (AP) pelvis view that shows both hips
• An AP pelvis and a lateral or oblique Judet view
• A computed tomography (CT) scan of the hip that includes the area from the iliac crest to the symphysis pubis

Plain film radiographs are usually the diagnostic modality of choice because they can be performed and evaluated in a very short amount of time. Because of the observance of ATLS protocols, an AP view of the pelvis, including adequate views of the bilateral hips, is commonly the only film acquired before the diagnosis is confirmed; if the patient is unstable in this setting, it may be the only option.

An additional lateral or oblique Judet view of the pelvis may yield more information about the presence and direction of the dislocation than a single AP pelvis view would. However, additional radiographs may be difficult to obtain secondary to the patient's pain, and the acquisition of the additional views should not delay patient care (eg, by interfering with acute resuscitation).

Posterior hip dislocations can be visualized well on an AP film ^[8]  by the presence of the femoral head outside and just superior to the acetabulum. They are commonly associated with ipsilateral acetabular fractrues (81% of posterior hip dislocations in adults have posterior acetabular fractures) or femoral fractures.

CT of the hip can also be performed to diagnose and describe the anatomy of the dislocation and identify small fracture fragments. Although this diagnostic modality provides excellent visualization of the injury, it should be done only if it can be both performed and evaluated in an extremely timely manner; the reduction attempt must not be delayed.

Equipment that may be used for reducting a posterior hip dislocation includes the following:

• Oxygen supply
• Bag-valve mask
• Oxygen saturation monitor
• Wall suction, suction tubing, and Yankauer suction catheter
• Intravenous catheter (≥20 gauge)
• Medications as needed for procedural sedation
• Normal saline (0.9% NaCl) flushes

Anesthesia

Procedural sedation is usually indicated. A dedicated clinician should be responsible only for the procedural sedation. For more information, see Procedural Sedation.

General anesthesia in the operating room is an alternative.

Positioning

Various techniques have been proposed to accomplish closed reduction of posterior hip dislocations, including maneuvers performed with the patient in supine or prone positions and maneuvers performed by one or several practitioners. ^[12]

The Bigelow maneuver is a well-established reduction method that may be performed with minimal assistance with the patient in the supine position. The patient is placed supine on a stretcher that is elevated to the height of the waist of the practitioner performing the reduction. The injured hip is initially held in a position of adduction and internal rotation, with one practitioner applying longitudinal distraction and an assistant applying pressure on the patient's anterior superior iliac spines so as to stabilize the patient's pelvis. (See the image below.)

Long-term orthopedic follow-up should be arranged in conjunction with the orthopedic specialist, who will continue to treat this patient. Many patients require inpatient management for this or other injuries. If outpatient management is deemed appropriate, the patient should have a follow-up appointment within a few days of the injury.

Outpatient instructions should include the following:

• The patient should not bear weight on the injured hip for several weeks or until the first follow-up appointment
• The hip should be splinted and maintained in a safe position that does not allow for any tension on the healing capsular structures
• The patient should return for emergency care immediately if he or she experiences an increase in pain, an onset of groin pain, or any numbness or weakness in the ipsilateral leg
• The patient should follow instructions for pain medicine, as deemed appropriate; narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), or both are usually warranted