Management of Dislocated Hip and Herniated Vertebral Disc
The management of a patient with a dislocated hip and herniated vertebral disc requires prompt surgical intervention for the hip dislocation followed by appropriate treatment of the disc herniation, which may be conservative or surgical depending on neurological symptoms. 1, 2
Hip Dislocation Management
Initial Management
- Immediate pain control with appropriate analgesics, considering renal function before administering opioids or NSAIDs 1
- Femoral or fascia iliaca nerve blocks can provide effective analgesia while awaiting definitive treatment 1
- Intravenous fluid therapy to maintain adequate hydration 1
Reduction of Hip Dislocation
- Closed reduction should be attempted promptly in the emergency department under procedural sedation 2
- For posterior hip dislocations (most common type): apply longitudinal traction with internal rotation 2, 3
- For anterior hip dislocations: use inline traction with external rotation, with an assistant pushing on the femoral head 2
- Post-reduction radiographs are essential to confirm successful reduction 1
Definitive Treatment
- Surgical intervention is typically required after reduction, with the approach depending on fracture type and patient factors 1
- For displaced femoral neck fractures in active, independent patients: total hip replacement is recommended 1
- For frail patients: hemiarthroplasty may be preferred due to shorter operative time and lower dislocation risk 1
- Careful selection of fixation devices and techniques is crucial in these often elderly patients with fragile bones 1
Herniated Vertebral Disc Management
Conservative Treatment
- Initial management is typically conservative for 6-12 weeks in the absence of significant neurological deficits 4
- Pain management with appropriate analgesics, including regular paracetamol and cautious use of opioids 1
- Activity modification and possibly bracing for symptomatic vertebral disc herniation 1
- Physical therapy interventions, though evidence for their effectiveness is inconclusive 1
Indications for Surgical Intervention
- Cauda equina syndrome (bladder/bowel dysfunction) requires emergency decompression within 24-48 hours 4
- Severe motor deficits (MRC ≤3/5) benefit from early intervention within three days 4
- Worsening pain or new onset of neurological deficits during conservative treatment 4
- Persistent symptoms after 6-12 weeks of conservative management 4, 5
Post-operative Care
Hip Dislocation
- Appropriate pain management following reduction 1
- Early mobilization to prevent complications 1
- Regular assessment of cognitive function, pressure sores, nutritional status, and renal function 1
- Wound assessment and care 1
Disc Herniation
- Long-term outcomes after standard surgical procedures for lumbar disc herniation show good results at 10-15 year follow-up 6
- Monitor for potential vertebral instability, though symptomatic instability is relatively uncommon 6
Special Considerations
Thromboprophylaxis
- All patients should receive appropriate thromboprophylaxis due to high risk of venous thromboembolism 1
Bone Health Management
- Assess for underlying osteoporosis, especially in older patients 1
- Consider calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
- Evaluate for pharmacological treatment to prevent future fractures 1
Rehabilitation
- The primary goal is to help patients regain their pre-injury level of mobility and independence 1
- Early identification of individual rehabilitation needs and goals is essential 1
- Structured rehabilitation program with appropriate weight-bearing instructions based on surgical procedure 1
Common Pitfalls to Avoid
- Delaying hip reduction increases risk of avascular necrosis and poor outcomes 2
- Overlooking neurological deficits that might indicate cauda equina syndrome requiring emergency intervention 4
- Inadequate pain management leading to delayed mobilization and increased complications 1
- Failure to assess for and treat underlying osteoporosis in fracture patients 1