Clinical features

 There is usually history of trauma

 • The patient has a flexion, adduction and medial rotation deformity of the
affected limb
 • There is marked shortening and gross
restriction of all hip movements
 • Head of the femur is felt as a hard mass in the gluteal region and it moves along
with the femur.
 Vascular sign of Narath is negative. 
 There could be features of sciatic nerve
palsy.

THOMPSON AND EPSTEIN

CLASSIFICATION
Type I: With or without minor fracture.
Type Il: With a large single fracture of
the posterior acetabular rim. 
Type III: With communition of the rim of the acetabulum with or
without a major fragment. 
Type IV: With fracture of the
acetabular floor.
Type V: With fracture of the femoral
head.

ANTERIOR DISLOCATION
 •Hyperextension force against an abducted leg that levers head out of acetabulum.
Femoral head dislocated anterior to acetabulum In RTA's, when the knee strikes the dashboard
with the thigh abducted.
• Violent fall from the height. 
• Forceful blow to the back of the patient in a squatted
position

The hip is minimally flexed, externally rotated and

markedly abducted

EPSTIENS CLASSIFICATION
Type I: Superior dislocation (includes pubic and subspinous dislocation).
• Type IA: No associated fracture
• Type IB: Associated facture of the head and/or neck of the femur.
• Type IC : Associated fracture of the acetabulum Type II: Inferior dislocation (includes
obturator, and perineal
dislocation).
• Type IIA: No associated fracture
• Type IIB: Associated fracture of the head and/or neck of the femur.
• Type IC : Associated fracture of the acetabulum

CENTRAL DISLOCATION
 • This is the least common and most difficult of all dislocations
of the hip joint.
 • Mechanism of Injury- It could be due to direct blow on the greater trochanter as in the
case of RTA or fall on the sides
 • It is invariably associated with the fractures of the acetabulum and this is what makes it a very
difficult
problem to treat

Management
History and Evaluation:
• Significant trauma, usually RTA.
• Awake, alert patients have severe pain in hip region.
• Inability to stand or walk

Physical Examination ( posterior

dislocation)
1) Inspection 
• Lower limb is flexed, adducted and internally rotated
• Shortening +
2) Palpation
- Femoral head palpated post - Narthes sign (i.e. Difficulty to palpate femoral pulse due to
backward migration of femoral head).
3) Movement Painful limitation of all hip movements.

Physical Examination ( anterior dislocation

1. Inspection: Limb is slightly flexed, abducted & externally rotated.
• May be lengthening.

2. Palpation: Head may be felt over pubic bone perineum.

3. Movement :
Painful limitation

Neurovascular examination
- Signs of sciatic nerve injury
• Loss of sensation in posterior leg and foot Loss of dorsiflexion (peroneal branch) or plantar
flexion (tibial branch)
- Loss of deep tendon reflexes at the ankle $1,2 - Signs of femoral nerve injury include the
following:
- Loss of sensation over the thigh
• Weakness of the quadriceps
• Loss of deep tendon reflexes at knee L3, 4

TREATMENT
 • All hip dislocations are emergencies and need to be reduced
 • To prevent troublesome late complications like AVN and traumatic degenerative hip

Methods of Closed Reduction

Allis method
Bigelow method
Classical Watson Jones method
Stimson's gravity method
Whistler's technique(over-under)

Allis Method
 •The patient is placed supine the surgeon standing above the
patient on the stretcher or table
 • Initially, the surgeon applies in- line traction while the assistant applies counter traction
by stabilizing the patient's pelvis. 
•While increasing the traction force, the surgeon should slowly increase the degree of flexion to
approximately 70 degrees.
 • Gentle rotational motions of hip as well as slight adduction will often help the femoral head to
clear the lip of the
acetabulum.
 • A lateral force to the proximal thigh may assist in reduction. An audible "clunk" is a sign of a
successful closed reduction.

Bigelow's Method
• Patient is supine.
 • An assistant applies counter
traction on both the ASIS 
• Surgeon applies longitudinal traction in the line of the
deformity.
 • The hip is gently adducted, internally rotated and bent on the abdomen. This relaxes the Y-
ligament and brings the femoral head near the poster inferior
aspect of the acetabulum.
 • By adduction, external rotation and extension of the hip, head is
levered back into the acetabulum.

• REVERSE Bigelow's method

Here the hip is in partial flexion and abduction. He has described two methods:
The traction method: Here the traction is applied in the line of the deformity and the hip is
adducted, internally rotated and extended.
The lifting method: Here a flexed thigh is lifted with a sudden jerk. However, this method is not
successful in pubic dislocations.

WATSON - JONES METHOD

This technique is useful in both anterior and posterior dislocation of the hip.
 Irrespective of the type of dislocation the limb is first brought to the neutral position.
 In this position the head of the femur lies posterior to the acetabulum even in anterior
dislocation
 Now with an assistant steadying the pelvis the head of the femur is reduced into the
acetabulum by applying a longitudinal traction in the long axis of the femur.

STIMSONS GRAVITY
MEnt lad Alis method of reduction.
The steps are as follows:
• Patient is prone
• Patient is brought to the edge of the table.
• An assistant stabilizes the pelvis by applying downward pressure over the
sacrum
• The affected hip and knees are flexed to
90 degrees.
• Downward pressure is applied on the
flexed knee.
• To facilitate the reduction, gentle rotations
needs to be done.

Whistler's technique(over-under)
The patient lies supine on the gurney.
Unaffected leg is flexed with an assistant stabilizing the leg. The assistant can also help
stabilize the pelvis.
Provider's other hand grasps the lower leg of the affected leg, usually around the ankle
The dislocated hip should be flexed to 90
degrees.
The provider's forearm is the fulcrum and the affected lower leg is the lever.
When pulling down on the lower leg, it flexes the knee thus pulling traction along the femur.

Nonoperative Treatment
If hip stable after reduction.
• Maintain patient comfort - skin traction, analgesia
• Avoid Adduction, Internal Rotation.
• No flexion > 60°.
• Early mobilization usually few days to 2 weeks
• Repeat x-rays before allowing full weight-bearing.

Indications for Open Reduction

Indications for Open Reduction
• Failed closed reduction.
• Failed stability test.
• Big posterior lip fragment.
• Bone fragment within the acetabulum.
• Fracture of the femoral head.
• Sciatic nerve palsy.

Technique of Open
Reduction approach is favoured
• Debridement: Joint is thoroughly irrigated to remove all pieces of bone and cartilage.
• Reduction of the hip, if it has not been done previously.
• Reposition of the fracture fragments carefully and reconstruct the acetabulum.
• In Type II injury with the large Acetabular chunk can be fixed by a single cancellous screws.
• In Type III with several fragments - reconstruction is attempted as accurately as possible and
fixation is done with cancellous screws or small malleable plate, etc. In severe comminution-
reconstruction is done through a full thickness iliac graft/auto graft
• In type IV fractures are fixed based on the location
Complications
Myositis ossificans (2%):
It is seen commonly in posterior dislocation with head injury and is unknown in simple posterior
dislocation.
• It may be seen after reduction also.
• It can be prevented by avoiding repeated manipulation, early immobilization and by
immobilizing for 6 weeks in hip spica.

Traumatic osteoarthritis due to vascular necrosis (35%):

 For head of the femur major blood supply enters from the capsule and to a lesser extent
through the ligamentum teres.
 If both these sources are damaged, it gradually leads to AVN followed by osteoarthritis
of the hip joint. Incidence is about 10 percent.

Sciatic nerve injury:

Incidence of this injury is 10 to 13 percent
It is 3 times more common in fracture dislocation simple dislocation.
Usually, it is a neuropraxia and the peroneal division is commonly affected.
It may be due to stretch of the nerve or may be due impalement between the fracture fragments.
If it is associated with acetabular fracture the nerve should be explored. Prognosis is variable.

Irreducible dislocation (31%): This may be due to bony (acetabular fragments, femoral head,
etc.) or soft tissue (acetabular labrum, etc.) obstruction. It may also be due to coma, ipsilateral
fracture femur or dislocation of opposite hip. It may
require exploration and open reduction.