FRACTURE-DISLOCATION

OF THE HIP IN ADULTS

Dr.E.Kaizar Ennis
 Definition
 A dislocation is a separation of two bones
where they meet at a joint. A dislocated bone
is no longer in its normal position. A
dislocation may also cause ligament or nerve
damage. Dislocations may be associated with a
periarticular fracture
 Introduction
 Hip joint injuries commonly are complicated
by injuries to other organ systems or to the
pelvis, which can result in hemorrhage and
shock. Displacement of the femoral head or
acetabulum may injure the sciatic, femoral, or
obturator nerve.
 Anatomy: Hip Joint
Ball and socket joint.
Femoral head: slightly
asymmetric, forms 2/3
sphere.
Acetabulum: inverted “U”
shaped articular surface.
Ligamentum teres, with
artery to femoral head,
passes through middle of
inverted “U”.
 Joint Contact Area
Throughout ROM:
 40% of femoral
head is in contact
with acetabular articular
cartilage.
 10% of femoral
head is in contact
with labrum.
 Acetabular Labrum
Strong fibrous ring
Increases femoral head
coverage
Contributes to hip joint
stability
 Hip Joint Capsule
 Extends from intertrochanteric ridge of
proximal femur to bony perimeter of
acetabulum
 Has several thick bands of fibrous tissue
 Femoral Neck Anteversion
 Males and Females have been noted to have
anteversion of 140 and 160 respectively.
 Slightly higher in females
Blood Supply to Femoral Head

Blood supply to the

femoral head

1 - artery of ligamentum teres

2 - retinacular vessels

3 - metaphyseal blood supply

Cont…
 Sciatic Nerve
Composed from roots of L4 to S3.
Peroneal and tibial components
differentiate early, sometimes
as proximal as in pelvis.
Passes posterior to posterior wall
of acetabulum.
Generally passes inferior to
piriformis muscle, but
occasionally the piriformis will
split the peroneal and tibial
components
 Mechanism of Injury
Almost always due to high-energy trauma.

Most commonly involve unrestrained occupants

in MVAs.

Can also occur in pedestrian-MVAs, falls from

heights, industrial accidents and sporting
injuries
 Clinical Evaluation-History
ABC s
Evaluation of hip dislocation

Associated injuries are common:

Head and facial injuries
• Chest injuries
• Intra-abdominal injuries
• Extremity fractures and dislocations
 Associated Injuries
 “Dashboard” injury
Contusions of distal femur
Patella fractures
Foot fractures, if knee extended
 Associated Injuries
Sciatic nerve injuries occur in 10% of hip
dislocations.
Most commonly, these resolve with reduction of
hip and passage of time.
Stretching or contusion most common.
Piercing or transection of nerve by bone can
occur.
 Physical Examination
 Classical Appearance

Posterior Dislocation:
Hip flexed, internally
rotated, adducted.
 Physical Examination
Anterior Dislocation:
Extreme external
rotation, less-
pronounced abduction
and flexion.
 Unclassical presentation (posture)
 femoral head or neck fracture
 femoral shaft fracture
 obtunded patient
 Physical Examination
 Pain to palpation of hip.
 Pain with attempted motion of hip.
 Possible neurological impairment:
Thorough exam essential!
 Investigations-X-rays
 AP pelvis, Lateral Hip
x-ray.
 Judet views of pelvis.
 CT scan with 2-3 mm
cuts
AP view of normal pelvis
 CT Scan
Most helpful after hip
reduction.
Reveals:
Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.
 MRI Scan
 Will reveal labral tear
and soft-tissue anatomy.
 Has not been shown to
be of benefit in acute
evaluation and treatment
of hip dislocations.
 Effect of Dislocation on Femoral
Head Circulation
When capsule tears, ascending cervical branches
are torn or stretched.
Artery of ligamentum teres is torn.
Some ascending cervical branches may remain
kinked or compressed until the hip is reduced.
Thus, early reduction of the dislocated hip can
improve blood flow to femoral head.
 Clinical Management:
Emergent Treatment
 These injuries are orthopaedic emergencies;
the dislocation of the hip should be reduced as
quickly as possible.
 Operative reduction is indicated if satisfactory
closed reduction cannot be obtained promptly.

 Goal is to reduce risk of AVN and DJD.

 Emergent Reduction
 Allows restoration of flow through occluded or
compressed vessels.
 Literature supports decreased AVN with
earlier reduction.
 Requires proper anesthesia.
 Requires “team” (i.e. more than one person).
 Older classification systems described hip
dislocations as posterior, anterior, obturator, or
central. True central fracture-dislocation is rare. In a
few patients with significant metabolic bone disease,
a true central dislocation may occur through the floor
of the acetabulum without fracture of the anterior or
posterior columns. More commonly, a central
fracture-dislocation actually is a transverse fracture of
the acetabulum, a both-column acetabular fracture.
 Posterior Dislocation

 90% of all hip dislocations.

 Patients with a posterior dislocation of the hip
generally present with a shortened, internally rotated,
adducted limb in slight flexion. This position can be
altered if the femoral head is impaled on a fractured
posterior acetabular wall
 If the hip is adducted at the time of injury, a pure
dislocation occurs, whereas a neutral position or
abduction leads to dislocation associated with a
fracture of the femoral head or acetabulum.
 Radiographic features
 Femoral head lateral and
superior to the acetabulum.
 Fracture of the posterior rim
of the acetabulum in most
cases.
 Femur in internal rotation
and adduction.
 Affected femoral head may
appear smaller secondary to
magnification.
 Thompson and Epstein classified
posterior dislocations of the hip
 Type I: Dislocation with or without minor fracture

 Type II: Dislocation with a large single fracture of the

posterior acetabular rim

 Type III: Dislocation with comminution of the posterior

acetabular rim with or without a major fragment

 Type IV: Dislocation with fracture of the acetabular floor

 Type V: Dislocation with fracture of the femoral head

 The proper treatment of a dislocation or fracture-
dislocation of the hip depends primarily on the type
of injury, but regardless of the type of dislocation,
some general guidelines apply: (1) long-term results
are directly related to the severity of the initial
trauma; (2) reduction, open or closed, should be
performed within 12 hours; and (3) only one or two
attempts at closed reduction should be made; if these
fail, open reduction is indicated to prevent further
damage to the femoral head.
 Type I Posterior Dislocation
 General anesthesia
 A type I dislocation is treated by closed reduction, if
possible, followed by immobilization in Buck
traction, an abduction pillow, knee immobilizer
(preventing hip flexion), or Thomas splint.
 If reduction cannot be performed under these
conditions, repeated attempts are not advisable
because of the risk of additional damage to the
femoral head.
 Closed reduction may be prevented by
multiple sources: (1) buttonholing of the
femoral head through the posterior capsule; (2)
interposition of the piriformis, obturator, and
gemelli muscles; (3) a torn acetabular labrum;
and (4) osteochondral acetabular fragments
and fracture fragments from the femoral head.
 Before open or closed reduction, the patient should be
examined carefully for injury to the sciatic nerve. A
complete or partial palsy of this nerve occurs in
approximately 10% to 15% of patients with posterior
dislocations
 Direct nerve trauma from the force of the dislocation,
bone fragments, or nerve ischemia from pressure on it
by the head
 partial recovery occurred in 60% to 70% of patients.
Sciatic nerve function should be documented after
reduction.
 After closed reduction of the hip is performed,
another anteroposterior pelvic radiograph is
obtained to ensure that the reduction of the hip
is concentric
 nonconcentric reduction can be shown as a
persistent widening of the distance between
the radiographic teardrop and the femoral head
compared with the normal hip
 Bone fragments that are interposed between
the articular surfaces of the femoral head and
the acetabulum require operative débridement
 Closed Reduction
 Gravity Method of
Stimson
 Allis Maneuver
With the patient supine, the
pelvis is stabilized by an assistant
applying pressure to the anterior
superior iliac spines. The surgeon
applies longitudinal traction in the
direct line of the deformity
followed by flexion of the hip to
90 degrees while continuing
traction. Internal and external
rotations of the hip are performed
until reduction is achieved.
 Bigelow Maneuver
The femoral head is
levered into the
acetabulum by the
combination of
abduction, external
rotation, and extension
of the hip.
 East Baltimore Lift .
 Open Reduction
 Anterior and posterior approaches have been
described for reduction of posterior
dislocations of the hip.
 Most of the offending structures in an
irreducible posterior dislocation are reached
more easily through a posterior approach
 After Treatment for CR
 Mobilizing patients after they have regained
the ability to perform a straight leg raise,. They
are mobilized with crutches initially with
touch-down weight bearing and resumption of
weight bearing to tolerance as pain subsides.
Patients observe these precautions for 6 weeks
Type II, III, or IV Posterior Dislocation
 reduced by the same closed techniques used for
uncomplicated dislocations
 The dislocation should be reduced as soon as possible
because delay of more than 12 hours makes
subsequent osteonecrosis of the femoral head much
more likely. When the femoral head has been reduced
accurately within the intact part of the acetabulum,
open reduction of the acetabular fragments, if
indicated, can be delayed for 5 to 10 days.
 In type II fracture-dislocations involving
smaller posterior wall fragments, stability must
be evaluated after reduction of the dislocation.
 Test of stability : the hip is flexed to 90
degrees with neutral rotation and abduction. If
the hip is stable with this test, initially
advocated by Gregory, no surgery is indicated
 This test of stability is not done in patients who have
a posterior wall fracture that involves more than half
of the articular surface of the posterior wall. These
hips are assumed to be inherently unstable because of
the extent of the posterior wall fracture, and repeat
dislocation is avoided to prevent further injury to the
femoral head. These fractures, fractures that fail the
stability test, and fractures with nonconcentric
reductions because of retained fragments are treated
operatively
 If a dislocation or fracture-dislocation of the
hip has been treated by closed reduction, and a
progressive sciatic nerve deficit appears,
exploration of the hip is indicated to ensure
that the sciatic nerve is not entrapped within
the joint or being compressed by a displaced
posterior wall fragment .When open reduction
of a dislocation is performed, an injured sciatic
nerve should routinely be explored and its
condition documented.
Type V Posterior Fracture-Dislocation
with Femoral Head Fracture
 Fractures of the femoral head associated with
posterior dislocation of the hip are uncommon.
They occur as a shearing injury as the flexed
hip is driven across the posterior wall of the
acetabulum during dislocation.
 Pipkin classification
 Pipkin subclassified Epstein-Thomas type V fracture-dislocations into four
additional subtypes

 Type I: Posterior dislocation of the hip with fracture of the femoral head
caudad to the fovea capitis

  Type II: Posterior dislocation of the hip with fracture of the femoral head
cephalad to the fovea capitis

 Type III: Type I or II posterior dislocation with associated fracture of the

femoral neck

 Type IV: Type I, II, or III posterior dislocation with associated fracture of
the acetabulum
 Brumback classification
 Brumback et al.
further classified
femoral head fractures
emphasizing hip
stability, with type
“B” injuries being
unstable
 Closed reduction of the hip dislocation usually is
successful in Pipkin types I and II injuries.
Occasionally, the femoral head fragment
spontaneously reduces to an anatomical position as
well.
 The Pipkin classification scheme was a useful
predictor of outcomes. Patients with less severe
Pipkin type I or II injuries had significantly better
outcomes than patients with type III or IV injuries.
 If the hip dislocation is irreducible, immediate CT
scanning of the pelvis is indicated to determine the
size of the femoral head fracture fragment and to
evaluate the impediments to reduction. Open
reduction is performed immediately, with fixation or
excision of the fracture fragment as indicated by
Pipkin type.
 Arthroscopic treatment of these injuries, removing
small fragments or torn sections of the acetabular
labrum, has been reported with encouraging results
 Pipkin Type I Dislocation with
Femoral Head Fracture
 Closed reduction of Pipkin type I fracture-
dislocations should be performed . It should be done
as gently and quickly as the patient's general
condition permits
 Four factors are crucial: (1) the concentricity of the
reduced femoral head in the acetabulum, (2) the
accuracy of the reduction of the displaced femoral
head fragment, (3) the size of the femoral head
fragment, and (4) the stability of the reduction.
 If the reduction is concentric, and the dislocation is
stable, the size of the head fragment in Pipkin type I
fractures is unimportant, and results have been
excellent with small and large head fragments.
 If closed reduction is impossible or if the reduction is
not concentric, open reduction with excision of small
fragments should be done immediately. Large
fragments also are removed, provided that they do not
alter the postreduction stability.
 Pipkin Type II Dislocation with
Femoral Head Fracture
 In Pipkin type II fracture-dislocations, closed
reduction is attempted immediately. Anatomical
reduction of these superior head fragments is more
crucial than reduction of type I inferior head
fragments
 If the reduction is nonanatomical and nonconcentric,
open reduction should be done. (Countersunk lag
screws /Herbert screws)
 Any soft-tissue attachments to the fragment,
including the ligamentum teres, should be preserved
if possible
 After internal fixation, the patient is mobilized
with touch-down weight bearing for 3 months.
“Hip precautions,” or avoiding the positions of
potential redislocation, are crucial. The
insertion of a femoral head prosthesis instead
of internal fixation should be considered in
older patients because of the high rate of
osteonecrosis of the fracture fragment and
posttraumatic arthritis after internal fixation in
these patients
 Pipkin Type III Dislocation with
Femoral Neck Fracture
 The treatment of Pipkin type III fracture-
dislocations is controversial. In younger
patients, open reduction of the dislocation,
fixation of the femoral neck fracture, and use
of some type of vascularized graft have been
attempted
 Hemiarthroplasty usually is recommended for
older patients.
 Pipkin Type IV Dislocation with
Acetabular Fracture
 In Pipkin type IV injuries, treatment usually is
determined by the type of acetabular fracture .Open
reduction and reconstruction of the acetabulum
usually are recommended, but late problems may be
encountered. In young patients, if concentric
reduction with reasonable joint congruity cannot be
obtained by closed means, open reduction and
internal fixation of all major fragments are justified.
In older patients or in patients with significant
preexisting disease within the joint, some type of
replacement arthroplasty may be considered,
depending on the type of fracture and the extent of
acetabular involvement
 Siebenrock et al. and Ganz et al. described a
surgical hip dislocation technique for femoral
head fractures with posterior hip dislocation.
Inspection of the entire femoral head and full
circumference of the acetabulum is possible,
and the risk of osteonecrosis is minimized
 Anterior Dislocation of the Hip
 10-15% of traumatic dislocations of hip
 They occur with the hip externally rotated and
abducted.
 Anterior dislocations are classified according
to the position assumed by the femoral head:
pubic, obturator, or perineal .
 Presentation
 At presentation in the emergency department, the
lower extremity is externally rotated, and the hip is
extended (pubic dislocation) or flexed and abducted
(obturator dislocation).
 Because of their anterior relationship to the hip, the
femoral vessels and nerve may be injured, especially
with pubic dislocations. An anterior dislocation
usually can be reduced without surgery by pulling
longitudinally on the thigh with appropriate traction
and applying lateral force on the proximal thigh while
pushing the femoral head toward the acetabulum.
 If the dislocation cannot be reduced by these
maneuvers, open reduction is performed
through a Smith-Petersen approach.
Interposition of soft tissues, including the
rectus femoris and iliopsoas muscles and the
torn hip capsule, and a “buttonhole”
entrapment of the femoral head by the capsule
are potential obstructions to reduction.
 In obturator dislocations, the femoral head
rests against the sharp anterolateral margin of
the obturator foramen, causing an indentation
fracture on the anterosuperior aspect of the
femoral head.
 Central Dislocations

 Central frx/dislocation is crippling injury with a poor

prognosis
 Extensive degree of concomitant articular injury
occurs
 22% incidence of sciatic nerve injury
 Distal and occassionally, lateral traction of proximal
femur may be necessary to effect and maintain
reduction of the femoral head
 Total hip arthroplasty may be the treatment of choice;
 Once the head/acetabular relationship is
restored, pt is maintained in longitudinal
traction for 10-12 weeks
 Lateral traction thru a trochanteric pin is used
to reduce the joint and if necessary can be
maintained for 8-10 weeks if necessary
Complications of Hip Dislocation
 Avascular Necrosis (AVN): 1-20%
 Post-traumatic Osteoarthritis
 Recurrent Dislocation
 Recurrent Dislocation Caused by
Defect in Posterior Wall and/or Femoral Head
 Delayed Diagnosis of Hip Dislocation
 Sciatic Nerve Injury (20%)
 Foot Drop
 Infection
 Iatrogenic Sciatic Nerve Injury
 Thromboembolism
 Posterior vs Anterior Approach
 Support for Posterior Approach
 Sarmiento, CORR 1973
 Epstein, JBJS 1974 (0 good results with ant. approach)

 Support for Anterior Approach

 Swiontkowski, Thorpe, Seiler, Hansen, J Orthop Trauma 1992:
 12 anterior, 12 posterior.
 Less blood loss and operative time with anterior approach.
 Improved visualization anteriorly.

 67% good and excellent in each group.

 Nork, Routt et al, OTA 2001: 21 cases, ? one AVN

 Reconstruct Head Whenever
Possible
THANK YOU