What is the management plan for a dislocated hip in a paraplegic individual?

Management of Hip Dislocation in Paraplegic Patients

For a paraplegic patient with a dislocated hip, immediate closed reduction should be performed urgently (ideally within 3 hours) to prevent avascular necrosis and relieve autonomic dysreflexia, followed by imaging to assess for associated fractures and consideration of surgical stabilization if recurrent dislocation occurs. 1, 2, 3

Immediate Management

Pain Control and Immobilization

• Immobilize the affected limb immediately to minimize pain and prevent further soft tissue injury 4, 1
• Administer regular paracetamol as first-line analgesia unless contraindicated 4
• Use opioids cautiously with dose reduction, particularly if renal dysfunction is present (common in this population) 4
• Avoid NSAIDs due to high prevalence of renal dysfunction in patients with chronic paraplegia 4

Recognition of Autonomic Dysreflexia

• Be alert for autonomic dysreflexia, which occurs during dislocation episodes in paraplegic patients and can be disabling 3
• This is a critical complication unique to spinal cord injury patients that requires immediate recognition and treatment 3

Diagnostic Evaluation

Clinical Assessment

• The affected leg will appear shortened and externally rotated in posterior dislocations (the most common type) 4, 1, 2
• Severe pain on movement and complete inability to weight-bear will be present 4, 1

Imaging Protocol

• Obtain pelvic X-ray for radiographic confirmation, but do not delay reduction in obvious cases 1
• Perform CT scan after reduction to assess for associated fractures, acetabular deficiency, and ensure concentric reduction 1
• MRI is valuable for assessing soft tissue injuries and identifying risk for osteonecrosis 5

Reduction Technique

Timing is Critical

• Closed reduction should be performed within 3 hours (ideally within 85 minutes) to minimize complications including avascular necrosis 6
• Reduction within 6 hours is the traditional threshold, but earlier is significantly better for outcomes 6

Reduction Methods by Dislocation Type

• For posterior dislocations (most common): Apply longitudinal traction with internal rotation on the hip 2
• For anterior dislocations: Use inline traction with external rotation, with an assistant pushing on the femoral head or pulling the femur laterally 2

Special Considerations for Paraplegic Patients

Risk Factors for Recurrent Dislocation

• Flexion-adduction contractures of the hip predispose to recurrent dislocation 3
• Flexion-adduction spasms in spastic paraplegics increase risk 3
• Shallow acetabulum or posterior acetabular deficiency from previous fractures creates instability 3

Surgical Intervention Indications

• For recurrent dislocation in spastic paraplegics: Operative treatment combining soft tissue repair and bone block to augment the acetabulum is recommended 3
• For unilateral dislocations: Reduction is strongly recommended to prevent pelvic obliquity, scoliosis, and pain 7
• Total hip replacement or hip arthrodesis can be considered for painful chronically dislocated hips with degenerative changes, as cerebral palsy or paraplegia is not a contraindication 8

Post-Reduction Management

• Provide appropriate pain management and early mobilization as tolerated 1
• Antibiotic prophylaxis if surgical intervention was needed 1
• Monitor for complications: avascular necrosis (occurs in some cases even with early reduction), heterotopic ossification, and osteoarthritis 6
• Address underlying spasticity if present to prevent recurrence 3

Critical Pitfalls to Avoid

• Do not delay reduction waiting for imaging in obvious cases—time to reduction is the most critical prognostic factor 1, 6
• Do not miss autonomic dysreflexia during dislocation episodes in paraplegic patients 3
• Do not ignore hip injuries at the time of initial spinal cord injury, as inadequately treated fracture-dislocations lead to recurrent instability 3
• Do not assume bilateral dislocations need no treatment—while unilateral dislocations clearly benefit from reduction, bilateral cases may also benefit if treated before significant femoral head deformity occurs 7

Long-Term Prognosis

• Even with early reduction, posterior dislocations have worse outcomes than anterior dislocations (fair/poor results in 53% vs 25%) 6
• Patients with severe multiple injuries have worse outcomes than those with isolated hip dislocation 6
• Half of chronically dislocated hips in paraplegics become painful over time 7
• Pelvic obliquity and scoliosis develop in two-thirds of unreduced unilateral dislocations but only in 29% of reduced dislocations 7