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Hip dislocation
Hip dislocation
Hip dislocation
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Dislocation of hip
X-ray showing a joint dislocation of the left hip.
SpecialtyOrthopedics
SymptomsHip pain, trouble moving the hip[1]
ComplicationsAvascular necrosis of the hip, arthritis[1]
TypesAnterior, posterior[1]
CausesTrauma,[1] hip dysplasia
Diagnostic methodConfirmed by X-rays[2]
Differential diagnosisHip fracture, hip dysplasia[3]
PreventionSeat-belts[1]
TreatmentReduction of the hip carried out under procedural sedation[1]
PrognosisVariable[4]

A hip dislocation refers to a condition in which the thighbone (femur) separates from the hip bone (pelvis).[1] Specifically it is when the ball–shaped head of the femur (femoral head) separates from its cup–shaped socket in the hip bone, known as the acetabulum.[1] The joint of the femur and pelvis (hip joint) is very stable, secured by both bony and soft-tissue constraints.[1][4][5] With that, dislocation would require significant force which typically results from significant trauma such as from a motor vehicle collision or from a fall from elevation.[1] Hip dislocations can also occur following a hip replacement or from a developmental abnormality known as hip dysplasia.[6]

Hip dislocations are classified by fracture association and by the positioning of the dislocated femoral head.[7][8] A posteriorly positioned head is the most common dislocation type.[5] Hip dislocations are a medical emergency, requiring prompt placement of the femoral head back into the acetabulum (reduction).[9] This reduction of the femoral head back into the hip socket is typically done under sedation and without surgery, through maneuvers including traction on the thighbone in line with the dislocation.[9] If this is unsuccessful or if there is an associated fracture in need of repair, surgery is required.[10] It often takes 2–3 months for a dislocated hip to fully heal, and it can take even longer depending on associated injuries such as fracture.[11]

Typically, people with hip dislocations present with severe pain and an inability to move the affected leg.[1][4] Diagnosis is made by physical exam and plain X-rays of the hips. A CT scan is recommended following reduction to rule out complications. Complications include osteonecrosis, femoral head fractures, and posttraumatic osteoarthritis.[12][13]

Males are affected more often than females.[3] Traumatic dislocations occurs most commonly in those 16 to 40 years old.[4] Half of all hip dislocations are accompanied by a fracture.[4] The condition was first described in the medical press in the early 1800s.[14][15]

Classifications

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Dislocations are categorized as simple if there is no associated fracture, and complex if there is.[5] In addition, hip dislocations are classified depending on the location of the head of the femur as follows:

Posterior dislocation

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Posterior dislocations is when the femoral head lies posteriorly after dislocation.[5] It is the most common pattern of dislocation accounting for 90% of hip dislocations,[5] and those with an associated fracture are categorized by the Thompson and Epstein classification system, the Stewart and Milford classification system, and the Pipkin system (when associated with femoral head fractures).[7][8]

Anterior dislocation

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Anterior dislocations is when the femoral head lies anteriorly after dislocation. Anterior dislocations are subdivided into two types being inferior (obturator) dislocation and superior (iliac or pubic) dislocation.[4][5] There is also a Thompson and Epstein classification system for anterior hip dislocations.[8]

To note, Central dislocation is an outdated term for displacement of the femoral head towards the body's center into a fractured acetabulum and is no longer used.[7] Moreover, the term "congenital" dislocation is no longer recommended, except for very rare conditions, in which there is a "teratologic" fixed dislocation location present at birth.[16]

Signs and symptoms

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The affected leg is usually extremely painful, precluding weight-bearing and movement.[4][17] Nerve injuries also can accompany dislocations, necessitating careful neurovascular examination.[4][5] Deformity is also present, which is based on concomitant injuries and the type of dislocation:

Posterior dislocation

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For posterior dislocation, the affected limb will be in a position of flexion, adduction, and internal rotation.[4][5][16] This is to say, the affected leg will be bent upwards at the hip, while being shifted and pointed towards the middle of the body.[11][17] Sciatic nerve injury is also present in 8%-20% of cases, conferring numbness and weakness to aspects of the lower leg.[4][5]

Anterior dislocation

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For anterior dislocation, the affected limb will be in a position of abduction and external rotation.[4][5][16] The degree of flexion depends on whether it is a superior or inferior dislocation, with the former resulting in hip extension and the latter, hip flexion.[4][5][13] This is to say that with superior and inferior anterior dislocations, the affected leg will be bent at the hip backwards and upwards respectively, while being shifted and pointed away from the body. Femoral nerve palsies can also be present, conferring leg numbness and weakness, however are uncommon.[16]

Mechanism

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Functional anatomy

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The hip joint includes the articulation of the spherical femoral head (of femur) and the concave acetabulum (of pelvis). It forms a ball-and-socket joint that is encased by an articular capsule, reinforced and stabilized by muscle, tendon, and ligaments.[18] Even so, the joint is quite flexible in movement, allowing three degrees of freedom.[19]

Major ligaments conferring stability to the hip joint include the iliofemoral ligament, the ischiofemoral ligament, the pubofemoral ligament, and the ligament of the head of the femur.[20] The former three ligaments form the zona orbicularis or annular ligament which encases the femoral neck, stabilizing the joint capsule.[20] The strength of a healthy hip, reinforced and stabilized by the aforementioned structures can withstand over 1000 lbs. of force.[20]

Cause

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With this, to dislocate a healthy hip requires a great deal of force.[5] About 65% of cases are related to motor vehicle collisions, with falls from elevation and sports injuries causing the majority of the rest.[5] Moreover, wear and tear of the body with aging increases the older population's susceptibility to hip dislocation.[21]

Posterior dislocations happen with direct trauma to a bent (flexed) knee as is the case with a dashboard injury in a motor vehicle accident.[4][5] The positioning of the hip at the time of impact determines associated injuries, with abduction of the hip making a complex hip dislocation more likely, while adduction and flexion of the hip favors a simple hip dislocation.[citation needed]

Anterior dislocations happen with trauma forcing external rotation and abduction of the hip.[4][5] In the setting of forced external rotation and abduction of the hip, the hip flexed and extended leads to the inferior and superior sub-types of anterior hip dislocation, respectively.[4][5] Hip dysplasia also makes one more susceptible to hip dislocation.[22] Hip dysplasia is a congenital condition in which the hip is deformed in a way that decreases the congruency between the head of the femur and the acetabulum of the pelvis.[22] Bony congruence is a stabilizing factor to the hip joint, so the decrease in this conferred by hip dysplasia makes one more susceptible to dislocation.[22]

Diagnosis

[edit]
Reimer's migration index can be used to indicate hip dislocation. The migration index (MI) is normally less than 33%.[23]

An anterior-posterior (AP) X-ray of the pelvis and a cross-table lateral X-ray[24] of the effected hip are ordered for diagnosis.[4][5][16] The size of the head of the femur is then compared across both sides of the pelvis. The affected femoral head will appear larger if the dislocation is anterior, and smaller if posterior.[7] A CT scan may also be ordered to clarify the fracture pattern.[20]

Dislocation of the left hip, secondary to developmental hip dysplasia. Closed arrow marks the acetabulum, open arrow the femoral head.

Management

[edit]

Hip dislocations are a medical emergency, requiring timely placement of the femoral head back into the acetabulum (reduction) in order to reduce the risk of osteonecrosis of the femoral head.[9] Most professionals recommend closed reduction (nonoperative) barring operative indications such as irreducible dislocation, delayed presentation, non-concentric reduction, fracture requiring excision and/or open reduction internal fixation (ORIF) among other operative indications.[4][5] Prognosis is worsened if reduction is delayed more than 6 hours.[4][5] If the reduction is stable, the patient can proceed to protective weight bearing which includes crutch-assisted walking (ambulation) with weight bearing as tolerated for 4–6 weeks succeeding a short period of bed rest.[4] If reduction is unstable, 4–6 weeks of skeletal traction is necessary before protective weight bearing.[4]

Nonoperative

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The hip should be reduced as quickly as possible to reduce the risk of osteonecrosis of the femoral head.[4] This is done through manual traction of the thigh inline with the dislocation under general anesthesia and muscle relaxation, or conscious sedation.[4][7] Fractures of the femoral head and other loose bodies should be determined prior to reduction. Of note, femoral neck fractures, femoral head fractures, and incarcerated fracture fragments preventing joint reduction are contraindications.[25][5][26] Common closed reduction methods include the Allis method, Stimson Gravity Technique, and the Bigelow maneuvers.[4][27] Once reduction is completed, management becomes less urgent and appropriate workup including CT scanning can be completed.[7]

Operative

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Open (surgical) reduction indications include an irreducible dislocation, fracture with fragments preventing congruent reduction, fracture requiring an ORIF, delayed presentation, and non-concentric reduction.[4][5] Approaches to surgical reductions include the posterior approach for posterior dislocations (Kocher-Langenbeck), and the anterior (Smith-Petersen) approach for anterior dislocations.[4][5][28] A CT scan or Judet views should be obtained prior to transfer to the surgical suite.[7]

Rehabilitation

[edit]

Individuals with hip dislocation should participate in physical therapy and receive professional prescriptive exercises based on their individual abilities, progress, and overall range of motion. The following are some typical recommended exercises used as rehabilitation for hip dislocation. It is important to understand that each individual has different capabilities that can best be assessed by a physical therapist or medical professional, and that these are simply recommendations.[29]

A set of ankle weights.
Modified side plank.

Exercises

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  • Bridge- Lie flat on back. Place arms with palms down beside body. Keep feet hip distance apart and bend knees. Slowly lift hips upward. Hold position for three to five seconds. This helps strengthen the glutes and increase stability of the hip joint.[29]
  • Supine leg abduction- Lie flat on back. Slowly slide leg away from body and then back in, keeping the knees straight. This exercises the gluteus medius and helps to maintain stability in the hip while walking.[29]
  • Side Lying Leg abduction- Lie on one side with one leg on top of the other. Slowly lift the top leg towards the ceiling and then lower it back down slowly.[29]
  • Standing Hip abduction- Standing up and holding on to a nearby surface, slowly lift one leg away from the midline of the body and then lower it back to starting position. This is simply a more advanced way to do any of the lying hip abduction exercises, and should be done as the person progresses in rehab.[29]
  • Knee raises- While standing and holding onto a chair, slowly lift one leg off the ground and bring it closer to the body while bending the knee. Then lower the leg back down slowly. This helps to strengthen the hip flexor muscles and retain stability in the hip.[29]
  • Hip flexion and extensions- Standing, hold on to a nearby chair or surface. Swing one leg forwards away from you, and hold the position for three to five seconds. Then swing the leg slowly backwards and behind your body. Hold for three to five seconds. This exercise helps to increase range of motion, as well as strengthening the hip flexor and hip extensor muscles that control much of the hip joint.[29]
  • Adding ankle weights to any exercises can be done as progress is made in rehabilitation.[29]

Prognosis

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Hip dislocations can take anywhere from 2–3 months to fully heal, and even longer depending on associated injuries such as fracture.[11] Moreover, the outcome ranges from a fully healthy hip to a painful, arthritic one.[4] With simple posterior dislocations, literature reports great outcomes in 70%-80% of cases.[4] With complex dislocations, the outcome is often governed by the associated fracture.[4] Anterior dislocations are noted to have worse outcomes with their higher likelihood of being associated with femoral head injuries.[4] Those without associated femoral head injuries do better.[4]

Complications of hip dislocation that impact prognosis include post-traumatic arthritis, femoral head osteonecrosis, femoral head fracture, neurovascular injury, and recurrent dislocation.[4][5] Post-traumatic arthritis is the most common long-term complication and happens in 20% of hip dislocations, having higher rates among complex dislocations.[4] Femoral head osteonecrosis happens in 5-40% of dislocations, with rates rising the longer time to reduction (>6 hours).[4] Similarly increasing in rates with time to reduction, neurovascular injury with most notable being sciatic nerve injury, occurs in 8-20% of cases.[4][5] Femoral head fractures accompany 10% of posterior dislocations and 25-75% of anterior dislocations.[5] Lastly, recurrent dislocations can also occur, however is rare (<2%).[4][5]

Epidemiology

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Males are affected more often than females.[3] Most common cause is high energy trauma such as from a motor vehicle collision or a high-level fall.[1][4] Traumatic dislocations occur most commonly in those 16 to 40 years old.[4] Of note, restrained passengers are at a lower risk for a hip dislocation than those unrestrained.[5] With the hip being inherently stable, dislocations are rare, however have high rates of associated injuries.[4][5] For example, half of all hip dislocations are accompanied by a fracture.[4] Refer to "Prognosis and Complications" section for rates of other associated injuries. The condition was first described in the medical press in the early 1800s.[14][15]

Other animals

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Main article: Dislocation of hip in animals

References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Hip dislocation

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from Grokipedia
Hip dislocation occurs when the ball-shaped head of the is forced out of its socket in the of the , typically as a result of high-energy trauma that overwhelms the stabilizing structures of the , including the labrum, capsule, ligaments, and muscles. This injury is classified by direction, with posterior dislocations accounting for approximately 90% of cases and anterior dislocations comprising the remaining 10%. Posterior dislocations often result from axial loading on a flexed and adducted , such as in collisions where the strikes the , while anterior dislocations arise from forceful abduction and external rotation, commonly in similar high-impact scenarios or falls. Up to 95% of -related dislocations are associated with other injuries, including acetabular fractures (in approximately 70% of traumatic cases), requiring comprehensive evaluation. Symptoms of dislocation include severe pain in the and , inability to bear weight, and characteristic limb deformity: in posterior dislocations, the leg appears shortened, adducted, flexed, and internally rotated, whereas anterior dislocations may present with the leg abducted, extended, and externally rotated, sometimes with the palpable in the or below the . Neurological deficits, such as injury leading to or numbness, affect about 10% of posterior dislocation cases. is confirmed through and , starting with anteroposterior and cross-table lateral X-rays, followed by computed (CT) to assess for fractures, loose bodies, or residual displacement. Treatment is a medical emergency to minimize complications, prioritizing closed reduction under or using maneuvers like Allis or Bigelow, ideally within 6 hours of injury to reduce the risk of (osteonecrosis) of the , which occurs in 2-10% of cases and increases with delays beyond 6-12 hours. If closed reduction fails or fractures are present, open reduction and are necessary, often followed by immobilization and protected for 2-3 months. Long-term complications include , recurrent dislocation, and heterotopic ossification, with outcomes improving through early intervention and multidisciplinary care.

Anatomy and Stability

Bony and Ligamentous Structures

The hip joint is a multiaxial ball-and-socket synovial articulation formed between the head of the and the of the , providing a wide while supporting substantial body weight. The is a smooth, spherical structure at the proximal end of the , covered by articular except at the fovea capitis, with an average diameter of 40-50 mm in adults. The , a deep cup-shaped cavity formed by the confluence of the ilium, , and pubis, accommodates the and has an average depth of approximately 22 mm in adults, enhanced by the fibrocartilaginous . The labrum is a triangular wedge of attached to the acetabular rim, encircling the and deepening the socket by up to 21% while distributing compressive forces across the joint. The primary ligamentous stabilizers of the hip are the three extracapsular ligaments—iliofemoral, pubofemoral, and ischiofemoral—which arise as thickenings of the joint capsule and reinforce its integrity against dislocation. The iliofemoral ligament, the strongest of the trio, originates from the anterior inferior iliac spine and acetabular margin, inserting onto the intertrochanteric line of the femur, and primarily resists hip hyperextension. The pubofemoral ligament extends from the superior pubic ramus and iliopectineal eminence to the intertrochanteric line and lesser trochanter, limiting excessive abduction and external rotation. The ischiofemoral ligament arises from the ischial portion of the acetabular rim, passing posteriorly to insert on the greater trochanter and intertrochanteric crest, where it helps constrain internal rotation and adduction. The joint capsule is a fibrous sheath that envelops the , attaching proximally to the acetabular rim and the transverse acetabular ligament, and distally to the intertrochanteric line anteriorly and about 1 cm proximal to the intertrochanteric crest posteriorly. It thickens anteriorly into the , inferiorly into the pubofemoral ligament, and posteriorly into the ischiofemoral ligament, with the zona orbicularis forming a circumferential band of circular fibers around the that acts as an aperture to maintain containment. These bony and ligamentous elements collectively provide the 's inherent static stability, resisting through their geometric and tensile properties.

Biomechanical Stability

The hip exhibits inherent biomechanical stability primarily due to its ball-and-socket configuration, where the deep acetabular socket envelops approximately 40% of the across various positions of motion, providing substantial containment and resistance to . This osseous architecture creates a favorable leverage for load distribution, minimizing shear forces on the during activities. In addition to the bony structures, the marginally increases the effective depth of the socket, further augmenting containment without compromising mobility. A critical dynamic stabilizer is the negative intra-articular pressure, which generates a vacuum seal effect that maintains cohesion and resists distractive forces, contributing significantly to the total restraining force in neutral positions. This suction mechanism, facilitated by the intact labral seal, enhances overall stability by promoting uniform distribution and reducing the risk of migration under physiological loads. Surrounding musculature provides active stabilization through balanced force vectors that counteract potential dislocating moments. The , particularly the and maximus, generate compressive forces across the during and single-leg stance, comprising about 33% of the 's muscular cross-sectional area and essential for pelvic stability and abduction control. Similarly, the muscle contributes anterior stability by flexing the and countering posterior shear, with its activation patterns optimizing pelvic alignment and joint centering during dynamic movements. Biomechanically, the femoral neck-shaft angle, averaging approximately 127 degrees (normal range 125-135 degrees) in adults, influences stability by determining the moment arms of abductor muscles and the overall leverage ratio for joint loading. Deviations from this angle alter force transmission, potentially increasing joint reactive forces and reducing the efficiency of muscular stabilization, as evidenced by musculoskeletal modeling showing variations in hip contact pressures with angular changes.

Classification and Types

Posterior Dislocation

Posterior dislocation represents the predominant form of traumatic hip dislocation, comprising 90-95% of all cases. This high prevalence stems from common mechanisms such as dashboard injuries in motor vehicle accidents, where axial loading on a flexed and adducted hip forces the femoral head out of the acetabulum posteriorly. Anatomically, the displaces posterosuperiorly relative to the , typically positioning superior and slightly lateral to the socket while remaining posterior to it. This displacement frequently involves an associated of the posterior acetabular rim, which occurs in 50-70% of instances and contributes to joint instability. Posterior wall fractures predominate among these, often resulting from the impacting the rim during the traumatic event. Posterior dislocations are classified using the Thompson-Epstein system based on associated bony injuries: type I (simple dislocation with or without minor wall fragment), type II (large posterior wall ), type III (comminuted wall ), type IV (acetabular floor ), and type V ( ). Associated injuries are notable, with damage occurring in 10-20% of cases, primarily affecting the peroneal division due to stretching or compression during dislocation. This may manifest briefly as leg shortening or altered , though detailed symptoms are addressed elsewhere.

Anterior Dislocation

Anterior hip dislocation represents a less common variant, accounting for approximately 5-10% of all traumatic hip dislocations, compared to the predominant posterior type. This injury typically arises from hyperextension combined with abduction and external of the , often in high-energy scenarios such as accidents or falls from height. In anterior dislocation, the displaces anteroinferiorly from the , potentially positioning it adjacent to the or pubic region. The condition is subclassified into superior (pubic or iliac) and inferior (obturator) types, with the inferior subtype comprising about 70% of cases. The superior subtype occurs with hip extension and external , directing the superiorly toward the pubic or iliac area, whereas the inferior subtype involves flexion with abduction and external , driving the head inferiorly through the . Associated injuries in anterior hip dislocation include compression of the , which can lead to in the due to direct pressure from the displaced . Additionally, the mechanism often results in significant capsular tears, conferring a higher of recurrent compared to other types, particularly when accompanied by acetabular or fractures.

Etiology and Mechanisms

Traumatic Mechanisms

Traumatic hip dislocations typically result from high-energy impacts that overcome the joint's inherent stability, most commonly occurring in accidents, falls from height, and high-impact . In collisions, a classic mechanism involves the striking the flexed , transmitting an axial load through the to a flexed and adducted , often leading to posterior dislocation. Falls from significant heights produce similar axial loading forces on the lower extremity, while sports-related incidents, such as those in football or rugby, involve direct blows or twisting forces during contact. The biomechanical forces driving these dislocations depend on the 's position at the time of injury. Posterior dislocations, which account for approximately 85-90% of cases, arise from a combination of hip flexion, adduction, and internal , which directs the posteriorly through a weakened or torn posterior capsule. In contrast, anterior dislocations, comprising about 10% of traumatic cases, result from hyperextension combined with external and often abduction, propelling the anteriorly. These positional vulnerabilities exploit the acetabulum's limited coverage in extreme ranges of motion. Dislocating the requires substantial forces, such as axial loads exceeding 4000 N in high-energy trauma scenarios like impacts, far exceeding routine loads and necessitating high-energy trauma to disrupt the strong ligamentous and capsular restraints. Such events frequently involve concomitant injuries, with pelvic fractures—particularly acetabular fractures—occurring in up to 70% of cases due to the transmitted forces fracturing the bony socket.

Non-Traumatic Causes

Non-traumatic dislocations are uncommon and typically arise from underlying congenital, pathologic, or iatrogenic conditions that compromise joint stability rather than acute injury. One primary cause is developmental dysplasia of the (DDH), a spectrum of abnormalities in development characterized by a shallow that fails to adequately cover the , leading to instability, , or frank dislocation. This condition often manifests in the neonatal period due to in utero positioning factors, such as breech presentation, or genetic predispositions, resulting in progressive displacement if untreated. The prevalence of DDH is approximately 1 to 2 per 1,000 live births, with about 1 per 1,000 exhibiting dislocation at birth. Pathologic conditions, particularly neuromuscular disorders like , contribute to hip dislocation through chronic muscle imbalance, spasticity, and impaired motor control that erode capsular integrity over time. In children with who cannot walk independently by age 5, or dislocation occurs in 30% to 60% of cases, often bilaterally and worsening with disease severity. Similarly, connective tissue disorders such as Ehlers-Danlos syndrome (EDS) cause ligamentous laxity and joint hypermobility, predisposing to recurrent or congenital dislocations; the arthrochalasia type of EDS frequently presents with bilateral hip dislocations at birth due to defective synthesis. Iatrogenic dislocations commonly occur following total hip arthroplasty, with an incidence of 1% to 2% in primary procedures, often resulting from surgical malpositioning of components, such as excessive anteversion of the acetabular cup or inadequate tension. These events typically manifest in the early postoperative period due to patient positioning errors or component instability rather than external force. Septic or inflammatory processes represent rare non-traumatic etiologies, where joint infections or erosive arthropathies like weaken the hip capsule and supporting structures, potentially leading to pathologic dislocation. In pediatric cases, acute can cause secondary dislocation through purulent effusion and capsular destruction, though this is infrequent and often associated with delayed diagnosis in vulnerable populations.

Clinical Features

General Signs and Symptoms

Hip dislocation typically presents with severe acute in the affected or groin area, often described as immediate and intense following a traumatic event, which severely limits any movement of the joint. This is a hallmark symptom that arises from the disruption of the , ligaments, and surrounding soft tissues. A characteristic deformity is often visible, including apparent shortening of the affected leg in posterior dislocations or apparent lengthening in anterior dislocations due to the femoral head's displacement from the acetabulum, along with rotation of the leg—internal rotation for posterior dislocations and external rotation for anterior ones. Functional impairment is profound, with patients unable to bear weight on the affected leg and exhibiting markedly limited range of motion in the hip, often rendering ambulation impossible. In cases stemming from high-energy trauma, systemic signs such as shock or evidence of multiple associated injuries may accompany the dislocation, necessitating comprehensive trauma evaluation.

Type-Specific Presentations

Posterior hip dislocations, which account for approximately 90% of cases, typically present with the affected leg held in a characteristic position of flexion, adduction, and internal rotation, with the foot rotated inward toward the midline of the body. On , the may be palpable in the gluteal region posteriorly, indicating displacement from the , and this finding can be accentuated by performing a log roll maneuver, where the supine patient's leg is gently rolled to assess for posterior prominence or irregularity. Neurovascular deficits occur in 10-20% of posterior dislocations, most commonly involving the due to stretch or compression, leading to symptoms such as , weakness in dorsiflexion or plantar flexion, diminished ankle reflexes, and in the posterior leg and foot. In contrast, anterior hip dislocations, comprising about 10% of cases, manifest with the leg positioned in extension or slight flexion, marked abduction, and external , often with the knee and foot turned outward away from the midline, and the affected leg may appear lengthened. may reveal a mass or prominence in the area due to anterior displacement of the , particularly in obturator or inferior subtypes where it protrudes into the or . Neurovascular complications are less frequent but can include involvement, resulting in sensory deficits over the anteromedial , , or foot, quadriceps weakness, and reduced knee reflexes; vascular injuries to the or vein are rare but warrant immediate assessment for or absent pulses. The log roll test remains useful here to evaluate overall stability and detect any asymmetric mobility or provocation specific to the anterior displacement.

Diagnosis

Clinical Assessment

Clinical assessment of hip dislocation begins with a thorough history to identify the mechanism of and immediate post-event limb position, which are critical for suspecting the . High-energy trauma, such as accidents involving impacts, is the most common cause, typically resulting in posterior dislocation when axial force is applied to a flexed, adducted, and internally rotated . Anterior dislocations may occur from hyperextension or abduction mechanisms, like falls onto an abducted . Patients often report the assuming a characteristic position immediately after : flexed, adducted, and internally rotated for posterior types, or abducted, extended, and externally rotated for anterior types. Severe in the and , along with inability to bear weight, is a hallmark symptom. Physical examination requires careful and while avoiding axial traction to prevent further damage to neurovascular structures. reveals obvious deformity, such as limb shortening, apparent internal rotation, or adduction in posterior dislocations, with the affected often appearing shorter and held in a guarded position. should gently assess for the femoral head's position—posteriorly in the gluteal region for posterior dislocations or anteriorly in the for anterior ones—while checking skin integrity and soft-tissue swelling. Neurovascular evaluation is essential, including assessment of distal pulses (femoral and dorsalis pedis), sensation in dermatomes (particularly L4-S1 for involvement), and motor strength; injury occurs in 10-20% of cases, more commonly with posterior dislocations. Key diagnostic maneuvers include testing for inability to perform a straight-leg raise, which elicits severe pain and instability due to the disrupted . These findings, combined with the history, heighten suspicion before . Hip dislocation is an orthopedic emergency requiring urgent reduction, ideally within 6 hours, to minimize the risk of of the , which arises from disrupted blood supply and affects 2-10% of cases if addressed promptly but rises to 60% with delays beyond 12 hours.

Imaging and Confirmation

The initial imaging modality for suspected hip dislocation is plain radiography, typically consisting of anteroposterior (AP) and lateral views of the hip and , which demonstrate the position of the relative to the and confirm the direction of dislocation (posterior, anterior, or inferior). These views also reveal associated bony injuries, such as acetabular rim fractures or fractures, and disruption of Shenton's line—an arc formed by the inferior border of the superior pubic ramus and the medial aspect of the —indicating displacement of the proximal . Computed tomography (CT) scanning is the gold standard for evaluating associated fractures following initial plain films or after attempted closed reduction, as it provides detailed multiplanar images to detect small acetabular rim fragments, intra-articular loose bodies, or fractures that may be missed on radiographs. CT is particularly valuable for preoperative planning in cases requiring surgical intervention, quantifying fragment size and displacement to guide fixation or reconstruction. In post-reduction scenarios, routine CT is recommended to ensure concentric reduction and identify injuries that could lead to complications like . Magnetic resonance imaging (MRI) plays a limited role in the acute setting due to time constraints and patient instability but is indicated for assessing soft tissue injuries, such as labral tears or capsuloligamentous damage, particularly in chronic dislocations or after reduction to evaluate persistent symptoms. MRI effectively identifies associated injuries like labral tears from traumatic dislocation, muscle strains, joint effusions, and potential nerve involvement (e.g., sciatic nerve in posterior dislocations), providing superior soft tissue contrast compared to CT. It is especially useful in cases with suspected intra-articular pathology or when plain films and CT are inconclusive for non-bony structures. Ultrasound has a restricted role in acute traumatic dislocation in adults, as it is less effective for evaluating deep bony structures and is primarily reserved for screening and diagnosis of developmental dysplasia of the (DDH) in pediatric patients under 6 months of age, where it assesses coverage and acetabular morphology without . In neonates and infants at risk for DDH, dynamic using techniques like the Graf method can detect or by visualizing the cartilaginous position relative to the . It is not routinely used for confirming acute traumatic dislocations in older children or adults due to acoustic shadowing from bone and limited field of view.

Management

Closed Reduction and Nonoperative Care

Closed reduction is the initial management approach for uncomplicated traumatic hip dislocations, particularly posterior types without associated fractures, aiming to restore joint alignment non-surgically under sedation to minimize complications such as . This procedure is ideally performed emergently within 6 to 12 hours of to optimize outcomes. Common techniques include the Allis maneuver, performed with the patient , where an assistant provides countertraction via a sheet around the while the operator applies inline traction to the flexed and , followed by gentle rotation to relocate the . The Stimson maneuver involves positioning the patient prone with the and flexed over the edge of the bed, allowing gravity-assisted reduction with downward pressure on the , often requiring less force and considered the least traumatic option. Both methods necessitate procedural for muscle relaxation and pain control. Success rates for closed reduction of posterior hip dislocations without fracture range from 70% to 90%, with higher rates achieved in timely interventions by experienced providers in the emergency setting. Failure may necessitate open reduction, particularly if intra-articular fragments or interposition is present. Following successful reduction, immediate post-reduction anteroposterior and lateral radiographs confirm concentric alignment, supplemented by computed tomography to exclude retained loose bodies or occult fractures. Protected is recommended for 4 to 6 weeks. is managed with intravenous analgesics such as opioids, and ongoing monitoring assesses for stability through clinical examination and serial .

Surgical Interventions

Surgical interventions are indicated for hip dislocations that cannot be successfully managed with closed reduction, such as cases involving incarcerated intra-articular fragments, persistent instability following attempted reduction, or associated acetabular fractures that require internal fixation. Incarcerated fragments, often soft tissue or bony debris blocking the joint space, necessitate surgical removal to achieve stable reduction and prevent ongoing damage to the articular surfaces. Similarly, post-reduction instability, where the femoral head fails to remain congruent within the acetabulum, warrants operative stabilization to avoid recurrent subluxation or further dislocation. Associated acetabular fractures, particularly posterior wall or column fractures common in posterior dislocations, demand surgical intervention for anatomic reconstruction and fixation to restore joint stability and function. The primary surgical procedure for these indications is open reduction with or without , most commonly performed via the posterior Kocher-Langenbeck approach for posterior hip dislocations, which account for the majority of traumatic cases. This approach provides direct access to the posterior , allowing visualization and clearance of any interposed tissue or fragments, followed by reduction of the into the . For fracture-associated dislocations, is achieved using screws, plates, or a combination to secure the acetabular fragments, ensuring stable joint congruence and minimizing the risk of or . Anterior dislocations may require alternative approaches, such as the Smith-Petersen or Watson-Jones, to address anterior structures, though these are less frequent. Arthroscopic techniques are emerging as minimally invasive options for select cases, particularly for capsule repair, labral refixation, or removal of small intra-articular fragments in irreducible dislocations without major fractures. These procedures utilize small portals and an arthroscope to address pathology, such as labral tears or capsular defects contributing to instability, offering reduced morbidity compared to open surgery in appropriately selected patients. However, arthroscopy is typically reserved for cases without complex bony involvement, as open approaches remain the standard for fracture fixation. Timing of surgical intervention is critical, with emergent operation recommended within 6 hours of injury to minimize the risk of (AVN) of the , a major complication arising from prolonged dislocation-induced vascular compromise. Meta-analyses confirm that reductions or surgeries performed within this window significantly lower AVN rates compared to delays beyond 6-12 hours. Delays often stem from failed closed reduction attempts, underscoring the need for rapid escalation to operative management when nonoperative efforts prove insufficient.

Rehabilitation and Recovery

Immediate Postoperative Protocols

Following closed reduction of a traumatic dislocation, immediate postoperative protocols emphasize stability, prevention of complications, and early initiation of supportive care to facilitate recovery while minimizing risks such as and recurrent injury. Patients are typically admitted to the hospital for observation, with legs maintained in slight abduction using pillows or a pad to avoid adduction forces that could precipitate redislocation. For more complex dislocations (e.g., those with associated fractures), an abduction brace is often applied to hold the in neutral to slight external rotation and abduction, allowing limited flexion-extension while restricting other motions; this immobilization is maintained for 4-6 weeks alongside protected restrictions, such as toe-touch or non-weight-bearing status using crutches or a walker. In select cases, particularly involving or in pediatric patients, a spica cast may be used for immobilization, though abduction bracing is more common in adults to promote earlier mobility. Skeletal traction is sometimes employed for 1-2 weeks post-reduction to maintain alignment and reduce intra-articular pressure, especially in posterior dislocations. Monitoring begins immediately with repeat neurovascular assessments and post-reduction radiographs (anteroposterior and lateral views) to confirm concentric reduction and joint stability, followed by a to evaluate for occult fractures, loose bodies, or incongruity. Serial X-rays are performed at intervals (e.g., 2 weeks, 6 weeks, and 3 months) to detect redislocation, which occurs in approximately 1% of cases but warrants vigilant surveillance given the potential for associated damage. Deep vein thrombosis (DVT) prophylaxis is initiated promptly, typically with (LMWH) or aspirin, continuing for the duration of immobilization due to the elevated thromboembolic risk from bed rest and injury-related hypercoagulability. Pain management employs a multimodal approach, including parenteral narcotics for acute severe , nonsteroidal anti-inflammatory drugs (NSAIDs) for , and application to reduce swelling during the initial 24-48 hours. Gentle passive range-of-motion (ROM) exercises, such as swings, are introduced as early as day 1 post-reduction if stability is confirmed, progressing under supervision to avoid excessive stress on the capsule. A multidisciplinary team, including orthopedic surgeons, physical therapists, and nurses, coordinates care from the outset; physical therapy involvement focuses on safe non-weight-bearing transfers, bed mobility, and patient education on hip precautions to prevent inadvertent dislocation during daily activities. This integrated approach ensures compliance with restrictions and supports a transition to outpatient follow-up within 1-2 weeks.

Long-Term Rehabilitation Exercises

Long-term rehabilitation for hip dislocation typically begins after the initial healing phase, once the has been stabilized through reduction and immobilization, focusing on restoring (ROM), strength, and functional stability to minimize the risk of redislocation. Rehabilitation protocols vary based on the type of dislocation, presence of associated injuries, and factors such as age, with no universally established standard; individualized programs under medical supervision are recommended. These programs progressively challenge the while protecting healing tissues, emphasizing muscle strengthening around the hip to enhance stability. For simple dislocations without fractures, full activity may be possible in 3-4 months. Rehabilitation is often divided into phases, though timelines and specifics differ by case: Early Phase (typically weeks 4-12 post-injury): This phase prioritizes gentle ROM restoration and isometric strengthening to rebuild muscle activation without stressing the joint. Common exercises include isometric gluteal sets (contracting the by squeezing the buttocks for 5-10 seconds, 10-15 repetitions several times daily) and heel slides ( sliding of the heel toward the buttocks to improve flexion to 0-90 degrees, 10-20 repetitions). Core exercises like bridges may be added for pelvic stability. can provide low-impact ROM work toward the end of this phase. Intermediate Phase (months 2-4): This phase incorporates dynamic strengthening and conditioning to improve endurance and function. Stationary biking with low resistance (10-15 minutes, 3-5 times weekly) promotes flexion and extension. Progressive resistance exercises, such as clamshells (side-lying knee lifts with feet together, using a band after initial weeks, 8-12 repetitions), target abductors like the gluteus medius. Closed-chain exercises like mini-squats or step-ups (8-12 repetitions) integrate strength with balance, progressing as tolerated. Advanced Phase (4+ months): Focus shifts to functional training for return to pre-injury activities. Balance exercises, such as single-leg stance (30-60 seconds), enhance . Cardiovascular activities like elliptical training or walking on soft surfaces build to 20-30 minutes. Sport-specific drills are tailored for athletes. Regular assessments ensure safe progression.

Prognosis and Complications

Short-Term Outcomes

Short-term outcomes following treatment for traumatic hip dislocation are generally favorable when reduction is achieved promptly, with anatomic reduction succeeding in approximately 90-95% of cases using closed techniques in timely interventions. Emergent closed reduction, ideally within 6-12 hours of , minimizes early risks and allows for concentric positioning confirmed by post-reduction . In simple dislocations without associated fractures, outcomes are optimized, enabling early under protected conditions. Early complications, though relatively uncommon, include redislocation rates of less than 2% in native hips post-reduction, rising to 2-10% in cases with capsular or intra-articular fragments. Postoperative occurs in 1-2% of surgical interventions, such as open reductions or fracture stabilizations, necessitating vigilant monitoring and prophylactic antibiotics. Heterotopic , an abnormal bone formation in soft tissues, develops in 7.5-64% of cases depending on trauma severity, often detectable within weeks via and potentially limiting motion if severe. Recovery timelines typically involve pain resolution within 4-6 weeks, transitioning from acute with analgesics to functional improvement. Partial is introduced by 6 weeks for uncomplicated cases, supported by crutches or braces to protect stability, with exercises beginning around 1 week post-reduction. Outcomes are superior in isolated dislocations compared to those in settings, where associated injuries occur in up to 95% of cases, complicating rehabilitation and increasing early morbidity.

Long-Term Complications

One of the most significant long-term complications following traumatic hip dislocation is (AVN) of the , with reported incidences ranging from 5% to 40%. The risk of AVN increases substantially if closed reduction is delayed beyond 12 hours, with a showing an of 5.627 compared to reductions performed within 12 hours. This interruption of blood supply to the can progress to structural collapse, often resulting in severe pain, joint degeneration, and the need for in advanced stages. Post-traumatic arthritis represents another prevalent delayed , affecting 16% of patients with uncomplicated dislocations and rising to as high as 88% in cases involving associated acetabular or femoral fractures, typically manifesting within 10 years post-injury. The development of this stems from initial damage and joint incongruity, leading to progressive , , and functional decline that may ultimately require . Recurrent instability occurs in approximately 2% of traumatic hip dislocations, though rates can vary with injury severity and may necessitate revision surgical procedures such as capsulorrhaphy or to restore stability. Additionally, functional deficits persist in up to 24% of cases long-term, manifesting as a persistent , reduced , and limitations in daily activities, particularly when AVN or complicates recovery. These outcomes underscore the importance of timely intervention to mitigate quality-of-life impacts.

Epidemiology

Incidence and Demographics

Traumatic hip dislocation is a rare orthopedic injury, with an estimated global incidence of approximately 5 to 6 cases per annually, though rates vary by and data source. The condition predominantly affects adults in the 20- to 50-year age group, reflecting the typical demographics of high-energy trauma victims. Demographically, traumatic hip dislocation exhibits a marked male predominance, with a male-to-female ratio of approximately 3:1, attributed to greater male exposure to high-risk activities such as operation and contact sports. Up to 70% of cases are associated with accidents, underscoring the role of dashboard injuries or unrestrained impacts in posterior dislocations, the most common subtype. Geographically, incidence is elevated in low- and middle-income countries, where road traffic injuries contribute disproportionately due to limited safety infrastructure. In high-income countries, such as the , there has been a slight decline in incidence over recent decades, with age-standardized rates decreasing by about 21% from to 2019, largely attributable to improved vehicle safety measures and seatbelt usage.

Risk Factors and Prevention

Hip dislocation can occur due to traumatic, congenital, or iatrogenic factors, with certain predisposing elements elevating the likelihood. High-energy trauma, such as accidents or falls from significant heights, is a primary cause of traumatic hip dislocation, often involving forces that exceed the joint's stability. Alcohol impairment contributes to this by increasing the probability of involvement in such accidents, as it is associated with a substantial portion of road traffic injuries worldwide. Prior hip surgery, including procedures like total hip arthroplasty or fixation, significantly elevates the odds of subsequent dislocation, with studies indicating at least a doubled compared to patients without such history. Congenital conditions, particularly untreated developmental dysplasia of the hip (DDH), predispose individuals to dislocation by resulting in a shallow that compromises joint stability and increases the potential for or full dislocation later in life. This dysplasia often stems from risk factors like breech presentation during pregnancy, female sex, and family history, which can lead to abnormal hip development if not addressed early. Prevention strategies focus on mitigating trauma and addressing congenital risks proactively. Seatbelt use in vehicles substantially lowers the risk of hip dislocation from impacts during collisions, reducing overall severity by approximately 45-50% in frontal crashes. In and high-risk activities, wearing protective gear such as padded shorts or hip guards can help absorb impact forces and prevent dislocation. For congenital prevention, early screening with is recommended for high-risk infants, such as those with breech presentation or family history, typically performed between 4-6 weeks of age to detect DDH and enable timely intervention like bracing. On a level, organized trauma systems play a crucial role by streamlining patient transport and care, thereby reducing the time from injury to reduction—ideally within 6 hours—which minimizes complications like associated with delayed treatment.

Veterinary Aspects

Occurrence in Animals

Hip dislocation, also known as coxofemoral luxation, is a notable orthopedic condition in , with varying incidence across that often differs from the trauma-centric patterns observed in humans. In dogs, it represents one of the most common joint luxations, comprising up to 90% of all reported joint dislocations in this . The condition is particularly prevalent in large breeds such as Retrievers and German Shepherds, where it accounts for approximately 20% of all hip disorders in clinical surveys. Trauma, including blunt force from accidents or falls, is the primary cause in over 80% of cases, while serves as a significant predisposing factor that can lead to spontaneous or recurrent luxation due to instability. In cats, hip dislocation is less common than in dogs but frequently arises from high-impact trauma, such as falls from heights or vehicular collisions, which disrupt the and ligaments. Although occurs in up to 20% of purebred cats and can contribute to or luxation over time, traumatic dislocation predominates in domestic shorthair cats, where the overall incidence of dysplasia-related issues remains low at around 5%. Species variations highlight further differences; in , hip luxation is rare and uncommon compared to smaller animals, primarily affecting young foals, ponies, or miniature breeds due to traumatic events like dystocia during foaling or slips on slick surfaces. In , the condition is a leading cause of proximal lameness, often triggered by calving trauma that ruptures supporting structures, with craniodorsal luxation being the predominant form and caudoventral luxation as the secondary type.

Treatment Differences

In , treatment for hip dislocation, or coxofemoral luxation, diverges significantly from human approaches, which prioritize joint preservation through techniques like open reduction and internal fixation. In animals, management often emphasizes salvage procedures due to anatomical differences, economic considerations, and the animal's inability to comply with prolonged immobilization, leading to higher rates of or conservative care in severe cases. For dogs, closed reduction under is attempted but succeeds in only about 50% of cases and is rarely pursued long-term due to frequent reluxation from ligamentous instability. Instead, femoral head ostectomy (FHO) serves as a primary salvage procedure, involving removal of the and neck to eliminate painful articulation while allowing formation of a fibrous pseudojoint. Total hip replacement (THR) is an alternative for younger, larger-breed dogs where superior and joint preservation are feasible, though it is more costly and invasive. In large animals such as , conservative management with slings, , and stall rest is preferred for minor or craniodorsal luxations, achieving survival to discharge in all treated cases and long-term return to use in approximately 71%. However, severe traumatic luxations—often resulting from high-impact falls—carry a guarded , with 50% or fewer surviving due to complications like or , frequently necessitating as a humane option. Femoral head ostectomy is reserved for small equids or ponies as a salvage measure, given the technical challenges and poor outcomes in full-sized . Postoperative protocols in veterinary patients highlight shorter rehabilitation timelines compared to human care, with small animals like dogs typically requiring 4-8 weeks of controlled activity, passive range-of-motion exercises, and to restore function. Emphasis on perioperative antibiotics, such as cephazolin or amoxicillin-clavulanate administered intravenously during and orally for 7-10 days postoperatively, aims to prevent in the high-risk orthopedic environment. Outcomes reflect these pragmatic goals, with 93-96% owner satisfaction and good-to-excellent limb function in dogs following FHO, prioritizing relief over anatomic restoration—contrasting human objectives of full congruence. In equine cases, successful conservative or surgical interventions yield functional recovery in select , but overall remains lower than in small animals.

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