Hip Dislocation Treatment & Management

Rehabilitation Program

Physical Therapy

Acutely after successful reduction, resting and icing the hip and taking anti-inflammatory and/or narcotic medications to reduce pain are helpful.

• For type 1 posterior dislocations, athletes may return to weight bearing as pain allows.

  • Reviews of the literature do not show an increased risk of avascular necrosis with early weight bearing.

  • Athletes with type 2-5 posterior dislocations and anterior dislocations may require longer times to achieve weight bearing.

• Hip joints with associated fractures and/or instability are placed in a hip abduction brace postoperatively, which keeps the hip in abduction and slight external rotation for optimal healing, while allowing controlled (limited) flexion and extension. Within 5-7 days of the injury, patients can perform passive range-of-motion exercises with or without assistance in order to maintain normal flexibility (pendulum exercises).

Medical Issues/Complications

Serious complications include sciatic nerve damage, inability to perform closed reduction, and recurring dislocation.

• The sciatic nerve sits just inferoposterior to the hip joint and is injured in approximately 20% of all hip dislocations. These injuries range from nerve contusion to full laceration. The physician must perform a careful neurologic examination at the time of injury to assess sciatic nerve function. Most sciatic nerve injuries do not warrant acute intervention. Neurologic deficits that occur postreduction warrant immediate surgical intervention to decompress or reconstruct the damaged nerve.

• Reduction should be attempted as expediently as possible, as prolonged times to reduction are associated with more severe and frequent nerve injuries. ^[19]

• Closed reduction should be attempted under conscious sedation, general anesthesia, or spinal anesthesia immediately after the injury. The inability to perform closed reduction provides evidence for bony fragment involvement in the joint space and/or soft-tissue damage. CT scanning is warranted, followed by excision of loose bodies and open reduction. ^[20]

• The early phase of rehabilitation, involving traction of the injured leg, has been associated with recurring hip dislocation. A successful closed reduction that appears clinically and radiographically stable may redislocate during the first few weeks of the healing process. This dislocation may be caused by a bony fragment or soft-tissue damage that is preventing normal articulation. Perform a CT scan of the hip and discuss surgical intervention.

• Traumatic subluxation also carries a risk of complications and can be easily missed. Suspect this injury in patients who have an injury mechanism that is consistent with posterior hip dislocation and painful, limited hip motion. An MRI can be helpful in the diagnosis of this injury. ^[14]

• Anterior dislocations, although less common, have less risk of poor outcomes based on the available data. ^[21]

• Adolescents may be predisposed to epiphysiolysis during the reduction of a hip dislocation. A case was reported of a teenage football player in whom attempted closed reduction of a posterior hip dislocation resulted in complete separation of the epiphysis from the femoral neck metaphysis, with associated femoral head fracture and posterior dislocation of the femoral head. ^[22]

Surgical Intervention

Surgical intervention should be performed if closed reduction is unsuccessful, bony fragments or soft tissue remains in the joint space, or the joint remains unstable. Open reduction is typically performed using a posterior approach, owing to the decreased rate of avascular necrosis relative to the anterior approach.

Thoroughly irrigate the joint to assure adequate cleansing of any loose bone fragments or soft tissue that would prevent proper articulation. Internal fixation of large fracture fragments using screw and plate fixation should be performed by surgeons with experience in managing pelvic fractures.

Hip arthroscopy can be used to remove intraarticular fragments, evaluate intraarticular fractures and chondral injuries, and repair labral tears. When appropriate, hip arthroscopy is preferred to open surgery by those surgeons who are experienced in its use due to its minimally invasive nature, lower morbidity, and quicker recovery.

Consultations

Consult an orthopedic surgeon for any dislocated hip joint. Orthopedic surgeons should be present when attempting a closed reduction. If the closed reduction is unsuccessful, the patient will need to go to the operating room for an open reduction. Usually, keeping an unstable hip reduced with traction while awaiting surgical intervention is helpful (a postreduction hip should be held in traction for 6-8 weeks or until the leg is pain free). A CT scan is typically obtained before proceeding to the operating room.

Rehabilitation Program

Physical Therapy

• Dislocation of the hip joint is an extremely serious injury. The hip joint is crucial for weight bearing and ambulation. Proper rehabilitation must be performed to retain normal musculoskeletal function. Weight bearing with the help of crutches should begin immediately after the patient is pain free and transitioned to full weight bearing as pain allows.

• Rehabilitation may progress based on the athlete's clinical symptoms, and by 4 weeks, most type 1 hip dislocations can progress to functional weight-bearing exercises, such as shallow squats.

• An MRI should be considered at week 6 to assess for any signs of femoral head ischemia.

  • If any evidence of ischemia is present, the athlete should be made partial weight bearing and return to range-of-motion exercises only.

  • If no evidence of femoral head abnormalities is present, the athlete may continue his or her progression.

• Most athletes with type 1 hip dislocations can return to full activity in 3-4 months. Those with other injuries may require longer time periods to return to sports activity.

• Cardiovascular activities and stretching exercises are important early in the rehabilitation process to maintain full range of motion about the hip joint. Examples of these activities include upper-extremity cycling, weight training, and floor exercises such as push-ups.

Medical Issues/Complications

A number of chronic complications of hip dislocations can be very severe in nature. These include avascular necrosis, arthritis, chondrolysis, and myositis ossificans.

• Avascular necrosis is reported in up to 40% of patients because of the disruption of blood supply to the femoral head and from the mechanical force applied to the femoral head during the injury. The risk factor most associated with avascular necrosis is delayed reduction.

  • Generally, the consensus is that reduction should be performed as soon as possible (within 6 hours of injury), and certainly no later than 24 hours after the injury when no appropriate facilities are immediately available. ^{[6, 16, 17]} One study found that the risk of avascular necrosis further decreased when reduction was performed within 6 hours of injury. ^[17]

  • Avascular necrosis has been diagnosed radiographically from a few months to a few years post injury. Scheduling close follow-up visits every few months is imperative after hip dislocation. Serial radiographs should be taken to evaluate for evidence of avascular necrosis.

  • An MRI of the hip should be considered at 6 weeks after dislocation to assess for the possibility of avascular necrosis of the femoral head.

  • Case reports of late avascular necrosis have been rarely reported; therefore, hip pain in an athlete with a history of dislocation should be investigated regardless of the time interval that has passed. ^[23]

• Arthritis is the most common long-term complication after hip dislocation, affecting up to 50% of all patients. Arthritis is thought to occur from damage to the articular cartilage from traumatic injury. Open reduction has been said to decrease the incidence of postdislocation arthritis, although this is not widely accepted. Radiographs are important for diagnosing arthritis and nonsteroidal anti-inflammatory drugs (NSAIDs) should be prescribed to decrease pain and inflammation in the arthritic hip joint.

• Myositis ossificans occurs because of muscle and soft-tissue damage after hip dislocation. The rate of this complication is about 2% and is higher in patients who have undergone open reduction. Early closed reduction appears to be the most effective way of preventing myositis ossificans.

• Another possible complication is a labral tear, which is diagnosed by MRI in the acute setting or MRI arthrogram in the subacute setting. Labral tears are typically treated by hip arthroscopy.

Rehabilitation Program

Physical Therapy

Leg muscle strengthening exercises may begin once the patient is pain free and ambulating without crutches. Patients may work to strengthen the hip flexors, hip extensors, and the muscles nearest the hip, including the quadriceps and hamstrings. Over the next few months, gradually increasing the patient's level of cardiovascular training may be attempted, which should include brisk walking and swimming. Jogging or running may begin at 6-8 weeks but will differ by individual athlete and injury. Full return to sports is generally within 3-4 months.

Other Treatment

Imaging

X-rays should be repeated at 3 weeks, 6 weeks, 3 months, and 6 months to follow the healing of fractures.

An MRI arthrogram should be considered if the athlete develops symptoms with rehabilitation and has negative radiographic findings.

Athletes recovering from hip dislocations must follow a strict physical therapy regimen to ensure complete recovery of function. Stretching and range-of-motion exercises are important early in the recovery process, advancing to walking on crutches when the patient's pain fully resolves. Strengthening exercises of the muscles around the hip are important during the rehabilitation to take stress off the injured joint. The athlete should advance his or her rehabilitation regimen over time as tolerated, with light jogging by 6-8 weeks post injury, and regain full function in high-performance athletes by 3-4 months post injury.

No literature on the prevention of hip dislocations exists.

As these injuries are generally high-velocity injuries, the success of any prevention program, other than high-risk activity avoidance, would be unlikely.