What is the management of hip dislocation?

Management of Hip Dislocation

Hip dislocations require urgent reduction to prevent avascular necrosis of the femoral head, with most cases (over 90%) being successfully reduced in the emergency department setting. 1, 2

Initial Assessment and Management

Clinical Recognition

• Identify key signs: hip pain, inability to weight-bear, shortened and externally rotated leg (in posterior dislocations) 3
• Determine dislocation type:
  • Posterior (most common): limb appears shortened, adducted, and internally rotated
  • Anterior: limb appears externally rotated and abducted

Immediate Actions

• Provide adequate analgesia:
  • Paracetamol regularly unless contraindicated
  • Opioids with caution (40% of hip fracture patients have renal dysfunction)
  • Avoid NSAIDs (relatively contraindicated) 3
• Consider nerve blocks (femoral/fascia iliaca) for pain control 3
• Initiate IV fluid therapy and patient warming strategies 3

Reduction Techniques

Posterior Hip Dislocations

• Apply longitudinal traction with internal rotation 1
• Success rates for most reduction maneuvers range from 60-90% 4

Anterior Hip Dislocations

• Perform inline traction with external rotation
• An assistant may push on the femoral head or pull the femur laterally to assist reduction 1

Important Considerations

• Closed reduction should be the first choice of treatment for any dislocation 5
• Reduction should be performed urgently to reduce risk of avascular necrosis 2
• If initial reduction attempt fails, try an alternative technique 4
• Sedation and muscle relaxation are typically required for successful reduction

Post-Reduction Management

Immediate Post-Reduction

• Obtain post-reduction imaging to confirm proper reduction
• Assess neurovascular status
• Examine hip stability under anesthesia - if unstable after closed reduction, consider immediate reoperation 5

Continued Care

• Provide appropriate pain management
• Consider antibiotic prophylaxis
• Correct postoperative anemia if present
• Perform regular systems examinations
• Assess cognitive function, pressure sores, nutritional status, and renal function
• Monitor bowel and bladder function
• Provide wound assessment and care
• Initiate early mobilization 3

Special Considerations

Hip Dislocations After Total Hip Replacement

• Classify according to:
  1. Positional (no radiographic abnormality)
  2. Component malposition (inadequate version/position of acetabular or femoral component)
  3. Soft tissue imbalance (change in muscle functional length)
  4. Combined component malposition and soft tissue imbalance 5
• Patients with soft tissue imbalance and weak abductor muscles (with or without component malposition) have highest risk for requiring multiple operations 5

Imaging Evaluation

• Radiographs: AP pelvis and lateral hip views to confirm diagnosis and rule out associated fractures
• CT: for detailed assessment of bony structures and associated injuries
• MRI: to evaluate soft tissue injuries, particularly labral tears and cartilage damage 6

Complications to Monitor

• Avascular necrosis of the femoral head (most serious complication)
• Associated fractures (acetabular rim, femoral head)
• Sciatic nerve injury (especially with posterior dislocations)
• Recurrent dislocations
• Post-traumatic arthritis

Remember that timely reduction is the most critical factor in preventing avascular necrosis of the femoral head, which can occur if reduction is delayed beyond 6 hours after injury.