What is the proper procedure for relocating a dislocated hip?

Hip Dislocation Reduction: Immediate Closed Reduction Under Sedation

Closed reduction under procedural sedation should be performed immediately in the emergency department for traumatic hip dislocations, as this approach reduces door-to-relocation time by nearly 6 hours compared to operating room-based general anesthesia and minimizes the risk of avascular necrosis. 1, 2

Classification and Initial Assessment

Hip dislocations are classified by the direction of femoral head displacement:

• Posterior dislocations (most common): The femoral head displaces posteriorly, and the affected limb appears shortened, adducted, and internally rotated 1
• Anterior dislocations (less common): The femoral head displaces anteriorly, and the limb appears externally rotated and may be slightly abducted 1, 3

Critical caveat: Immediate neurovascular assessment is mandatory before any reduction attempt, specifically evaluating sciatic nerve function (posterior dislocations) and femoral nerve/vessel integrity (anterior dislocations) 1

Timing of Reduction

Reduction should occur within 2 hours of injury whenever possible to minimize complications, particularly avascular necrosis of the femoral head 4. Emergency department procedural sedation achieves significantly faster reduction times (average 2 hours 21 minutes) compared to operating room general anesthesia (average 8 hours 32 minutes) 2.

Reduction Techniques

For Posterior Hip Dislocations (Most Common)

The Allis maneuver is the standard technique:

• Position the patient supine on the floor or stretcher 1
• Flex the hip and knee to 90 degrees 1
• Apply longitudinal traction along the axis of the femur with internal rotation 1
• An assistant should stabilize the pelvis by applying downward pressure on the anterior superior iliac spines 1
• A palpable "clunk" indicates successful reduction 1

For Anterior Hip Dislocations

Inline traction with external rotation:

• Apply inline traction along the femoral axis 1
• Gently externally rotate the hip 1
• An assistant should push posteriorly on the femoral head or pull the femur laterally to assist reduction 1

Post-Reduction Management

Immediate Post-Reduction Care

• Obtain post-reduction radiographs (AP pelvis and lateral hip) to confirm concentric reduction and rule out associated fractures 1
• Repeat neurovascular examination to document any changes 1
• Consider CT scan if there is concern for intra-articular fragments or acetabular fracture 1

Immobilization Protocol

Early mobilization is superior to prolonged traction:

• For traumatic native hip dislocations: Begin mobilization within 9 days after reduction with partial weight-bearing, progressing to full weight-bearing at 3 months 4
• This approach shows comparable long-term outcomes to 2 weeks of skeletal traction but allows earlier return to work and improved patient comfort 4

For prosthetic hip dislocations (anterior): Immobilize in the "deck chair position" (45° hip flexion, 10-20° abduction, neutral rotation) for 2 weeks 3. This conservative approach prevents recurrence without requiring revision surgery in most cases 3.

Critical Complications to Monitor

Avascular Necrosis

• Risk increases significantly with delays beyond 6 hours 1
• No cases occurred in patients reduced within 2 hours and mobilized early 4

Failed Closed Reduction

• If closed reduction fails after appropriate sedation and technique, proceed to open reduction in the operating room 1
• Do not make more than 2-3 attempts at closed reduction, as this increases soft tissue damage 1

Recurrent Dislocation

• More common with prosthetic hips, particularly with excessive component anteversion (>25°) 3
• Even recurrent anterior prosthetic dislocations can be managed conservatively with repeat deck chair immobilization 3

Common Pitfalls

• Delaying reduction for operating room availability: ED procedural sedation is both faster and equally effective 2
• Excessive force during reduction: Gentle, controlled traction is key; forceful manipulation increases fracture risk 1
• Prolonged immobilization: Extended traction (>2 weeks) provides no benefit over early mobilization for native hip dislocations 4
• Missing associated fractures: Always obtain post-reduction imaging before mobilization 1