Hip dislocation

Hip Dislocation

1. Anatomy:
   • The hip joint is a synovial, ball-and-socket joint.
   • Stabilizing Factors:
     • Bony: Spherical femoral head well-fitted in the deep acetabulum, with 70% coverage.
     • Labrum: Deepens the acetabulum and contributes to stability.
     • Static:
       • Capsule: Very strong.
       • Ligaments: Iliofemoral, pubofemoral, and ischiofemoral ligaments.
     • Dynamic: Joint surrounded by strong muscles for additional support.
   • Sciatic Nerve: Leaves the pelvis at the greater sciatic notch below the piriformis.
2. Types of Hip Dislocation:
   • Posterior Dislocation (Sciatic): Most common (85-90%). الاشهر
     • Mechanism: Often due to a dashboard injury (flexed knee, flexed adducted hip).
   • Anterior Dislocation (Pubic): Occurs less frequently (10-15%).
     • Mechanism: Trauma to a flexed, adducted hip (e.g., trauma to a flexed knee).
   • Superior (Iliac) Dislocation: Occurs when the hip is extended.
   • Inferior (Obturator) Dislocation: Occurs with a flexed hip.
   • Complex: associated with other injury.
3. Classification:
   • Thompson Classification:
     • Simple Dislocation: No associated fractures.
     • Complex Dislocation: Associated femoral head or acetabular fractures.
   • Epstein Classification:
     • Superior dome acetabular fracture.
     • Posterior wall fractures.
     • Comminuted posterior wall fractures.
     • Femoral head impaction.
4. Clinical Presentation:
   • Pain deformity instability LROM or wt bear.
   • Posterior Dislocation:
     • Flexion, adduction, internal rotation, shortening. Mcq ❓️
   • Anterior Dislocation:
     • Flexion, abduction, external rotation.
5. Imaging:
   • X-ray: AP, cross-table lateral, and oblique views.
   • CT: if you suspect confirm,  Used post-reduction to check for associated fractures. Incarcerated fragments.  Mcq ❓️
   • MRI: Follow-up to detect avascular necrosis (AVN).bearing. later on.
6. Treatment:
   • Initial Management:
     • Closed Reduction under anesthesia/sedation:
       • emergent closed reduction within 12 hours. Mcq ❓️
       • Allis Method: Traction in line with deformity, flexion of the hip and knee to 90° while maintaining traction اكتم نفسك, and gentle rotational movement.
       • Bigelow-Keverse manipulation Method: Traction in line with deformity, abduction and external rotation (for posterior dislocation), adduction and internal rotation ( for anterior dislocation) to lever the femoral head into the acetabulum.
       • Stimson Gravity Method: Patient prone with leg hanging off the stretcher, vertical traction, and gentle rotation.
   • Post-reduction:
     • Test for stability and perform a neurovascular (NV) assessment.
     • CT: To confirm reduction and check for associated fractures or incarcerated fragments. مهم جدا
     • Traction:
       • Concentric, stable: Bed rest with protected weight-bearing (WB) for 4-6 weeks.
       • Concentric, unstable: Traction for 4-6 weeks.
       • Non-concentric reduction: Open reduction required.
     • Contraindication for Closed Reduction: Ipsilateral femoral neck fracture.
7. Operative Treatment:
   • Indications: Mcq ❓️
     • Irreducibility, non-concentric reduction (e.g., incarcerated fragments), associated femoral neck fractures, post reduction sciatic injury entrapped in the reduction. شفوى
   • Approaches:
     • Posterior Dislocation: Kocher-Langenbeck or lateral (Hardinge) approach.
     • Anterior Dislocation: Smith-Peterson or anterolateral (Watson-Jones) approach.
     • For Associated Fractures: Open reduction and internal fixation (RIF) for fractures of the femoral head or acetabulum.
     • Arthroscopy: To remove intraarticular fragments or evaluate labral/cartilage injury.
8. Central Dislocation:
   • Mechanism: Occurs when the femoral head is forced through the acetabular floor, often caused by a fall on the side or direct blow to the greater trochanter (GT).
9. Complications:
   • AVN: Avascular necrosis due to delayed reduction (>12 hours).
   • Sciatic Nerve Injury: Affects 10-20% of cases.
   • Myositis Ossificans.
   • Recurrence: Rare.
   • Irreducibility: Due to incarcerated fragments, buttonholing of the femoral head through the posterior capsule, interposition of external rotators, or torn labrum.

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