1. Case Report on Anterior Hip Dislocations
PROF N. DEEN MUHAMMAD ISMAIL
Director I/C
Institute of Orthopaedics & Traumatology
MMC-RGGGH CHENNAI
DR.NALLI .R.GOPINATH & DR. Senthil sailesh
Senior Assistant Professor
Ortho 1 unit
Institute of Orthopaedics & Traumatology : MMC-RGGGH
Presentor - DR.NAVEENKUMAR.K
M.S.ORTHO POST GRADUATE
UNIT ORTHO 1

2. Case history-1
H/o RTA : collision over median while driving an 3 wheeler
Position of limb during injury- Abducted & Externally rotated
C/o pain, deformity & swelling over left hip

3. On examination Inspection: Palpation: Movements
Limb in abduction & externally rotation deformity
Marked shortening of left lower limb
Swelling over scarpa’s triangle
Ecchymoses around knee joint
Palpation:
Hard bony swelling over scarpa’s triangle
Tenderness present
Femoral pulse more prominent on the affected side
No Neurologic deficits
Movements
Restricted & Painful

4. On presentation

5. Radiographic findings

6. Radiographic findings
Loss of congruence of femur head with roof of acetabulum
Femoral head was located anterosuperiorly
Femural neck not seen
Greater & lesser trochanters not visible

7. PRE OP CT

8. PRE OP CT

9. PRE OP CT

10. PRE OP CT

11. PRE OP CT

12. Diagnosis & management
Anterior dislocation of left hip – Epstein Superior Pubic type
Closed manual reduction under general anaesthesia (Allis method- walker modification)

13. PRE OP

16. Post reduction xray

17. Post reduction xray

18. Post reduction xray

19. Post reduction CT

20. Case history-2 80 year female
H/o RTA : hit by an 2 wheeler from behind while crossing the road
Position of limb- not known
C/o pain, deformity & swelling over left hip

21. On examination Inspection: Palpation: Movements
Limb in abduction & externally rotation deformity
shortening of left lower limb
Swelling over scarpa’s triangle
Palpation:
Hard bony swelling over scarpa’s triangle
Tenderness present
Femoral pulse more prominent on the affected side
No Neurologic deficits
Movements
Restricted & Painful

22. Radiographic findings
Loss of congruence of femur head with roof of acetabulum
Prominent lesser trochanter & Femoral neck
Dislocated femur head

23. Diagnosis & management
Anterior dislocation of left hip Epstein- Inferior Obturator type
Closed manual reduction under general anaesthesia (Allis method- walker modification)

24. Post reduction xray

25. Post reduction Ct

26. Post reduction protocol
Skeletal traction
Non weight bearing for 2 weeks
Static quadriceps & patellar gliding exercises
Continuous passive motion
Walking with support after 1st week
Avoid extremes of movement for 6 to 8 weeks
Full weight bearing after 6 weeks
For femur head / Acetabulum # - non weight bearing for 8 to 12 weeks

27. results Both hips reduced within 6 hours of presentation
Reduction method applied- Walker modification of Allis method
No post reduction neurological deficits
One patient post reduction CT shows Acetabulum fracture

28. HIP dislocations Hip dislocations account for 0.8% of all dislocations
Anterior hip dislocation accounts for 9 % of all hip dislocations
Common in young population with high energy trauma.
Unrestrained motor vehicle accident occupants are at significant higher risk for sustaining a hip dislocation

29. HIP dislocations
Traumatic dislocation of the hip is broadly classified into anterior and posterior dislocations on the basis of a dividing line that connects the anterior superior iliac spine with the ischial tuberosity.
Anterior and posterior dislocations are further classified into superior and inferior dislocations based on a line connecting the superior pubic ramus withthe greater sciatic notch.

30. Superior Dislocation
This injury is associated with forced abduction, external rotation, and extension of the femur.
The femoral head ruptures through the anterior capsule between the iliofemoral (bigelow)
And pubofemoral ligaments or avulses the anterior inferior iliac spine, the site of proximal attachment of the iliofemoral ligament
Superior dislocations are frequently referred to as pubic dislocations, although these injuries are more appropriately classified as pubic and iliac types on the basis of the resulting position of the femoral head

32. Inferior (Obturator) Dislocation
Inferior anterior hip dislocation is associated with forced Abduction, external notation, and flexion of the hip.
In this Injury, the femoral head extrudes through the anterior capsule Beneath the pubofemoral ligament and comes to rest Anterior to the obturator ring
Inferiorhip dislocation is easily recognized on plain nadiognaphs by the position of the femoral head over the obturator foramen and by abduction and external Rotation of the femur

34. Epstein Classification of Anterior Hip Dislocations
Type I: Superior dislocations, including pubic and subspinous
IA: No associated fractures
IB: Associated fracture or impaction of the femoral head
IC: Associated fracture of the acetabulum
Type II: Inferior dislocations, including obturator, &perineal
IIA: No associated fractures
IIB: Associated fracture or impaction of the femoral head
IIC: Associated fracture of the acetabulum

35. Features distinguishing
A feature that may help distinguish the superior type of anterior hip dislocation from posterior hip dislocation is the appearance of the lesser trochanter.
In cases of anterior hip dislocation, the hip is predictably held in external notation and the lesser trochanter is prominent
With posterior hip dislocation, the femur is typically rotated internally and the lesser trochanter is less prominent or is completely obscured by the overlying femur.
Magnification of the femonal head on anteroposterior radiographs of the pelvis in anterior hip dislocation has been described but

36. CT Scan Most helpful after hip reduction. Reveals:
Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.

37. MRI Scan Will reveal labral tear and soft-tissue anatomy
Has not been shown to be of benefit in acute evaluation and treatment of hip dislocations.

38. Clinical Management: Emergent Treatment
Dislocated hip is an emergency.
The goal is to reduce risk of avn and degenerative joint disease.

39. Benefits of early Reduction
Allows restoration of flow through occluded or compressed vessels.
Literature supports decreased avn with earlier reduction(< than 6 hours)

41. Irreducible anterior hip dislocation
Smith-peterson approach ,watson-jones approach, extended iliofemoral, ilioinguinal approach.
Allows visualization and retraction of interposed tissue.
Placement of schanz pin in intertrochanteric region of femur will assist in manipulation of the proximal femur.
Repair capsule, if this can be accomplished without further dissection.

42. Complications Early: Late:
Sciatic nerve injury (posterior dislocation)
Femoral-nerve injury
Fractures of head and neck
Femoral-artery injury (in anterior dislocations)
Late:
AVN of the hip
Osteoarthritis
Heterotopic calcification
Recurrent dislocation
Ligamentous injury of the knee, other fractures

43. Conclusion
It is highly stable joint that needs high energy trauma to dislocate
Early reduction of the dislocated hip (within 6 hrs) can improve blood flow to femoral head.
Up to 5 views of xrays/c-t may be needed for proper evaluation( pre and post reduction)

44. References
M. Stewart and L. Milford, “Fracture-dislocation of the hip: an end-result study,” Journal of Bone and Joint Surgery, vol. 36, pp. 315–342, 1954
2. Gillespie WJ. The incidence and pattern of knee injury associated with dislocation of the hip. J Bone Joint Surg Br 1975;57:376–8.
Izquierdo RJ, Harris D. Obturator hip dislocation with subcapital fracture ofthe femoral neck. Injury 1994;25:108– 10
MACFARLANE, J. A. (1936): Anterior Dislocation of the Hip. British Journal of Surgery