A 48-year-old female presents to the emergency department after a high-speed motor vehicle collision (MVC). She is complaining of left hip pain. Her radiographs are shown (Image 1 courtesy of Dr Ayaz Hidayatov, Radiopaedia.org, rID: 52760). What is your diagnosis? What is the likely mechanism of injury? What physical exam findings are expected? What is your management in the emergency department and when should you consult orthopedics?

The injury seen in the above radiograph is a posterior hip dislocation of the left hip.

  • Pearl: Posterior dislocations (90%) are the most common hip dislocation. Anterior dislocations (10%) are further classified as superior or inferior [1,2].
Posterior dislocations are typically caused by axial loading on a flexed hip and require a high amount of force. They are most commonly seen in MVCs. This is known as a “dashboard” injury, when the flexed hip hits the dashboard [1-6].

The hip is often held in slight flexion, adduction, and internal rotation [1-6].

  • Pearl: As previously mentioned, these injuries most commonly occur from MVCs and can potentially distract from other life-threatening injuries. ATLS should be initiated on arrival and a full head-to-toe assessment should be performed.
  • Pearl: A careful neurovascular exam must be conducted to evaluate for associated nerve or vascular injury, with sciatic nerve injury occurring in 10-20% of hip dislocations. The longer the wait time until successful reduction the greater the likelihood of nerve injury [1-4,6].
  • Plain film imaging: AP and lateral views to assess for location of dislocation and associated hip and pelvis fractures.
  • Complete neurovascular exam
  • Reduction with procedural sedation: While there are multiple techniques (Allis, Whistler, Captain Morgan, etc), their commonality is in-line traction while flexing the hip to 90 degrees, then gentle internal-to-external hip rotation [1-4,6].
  • Post-reduction: Assess hip stability and obtain post-reduction films to assess for successful reduction. Patients may be placed in an abductor pillow, knee immobilizer, or hip binder per orthopedic preference [2,6].
  • Disposition: For simple dislocations, patients may potentially discharge with orthopedic follow-up, preferably their primary surgeon for any prosthesis. If there was severe trauma or associated fracture, most patients will be admitted to a trauma or orthopedic service.

Orthopedics should be consulted if there are associated fractures or neurovascular compromise, an emergent orthopedic consult should be placed. Additional reasons for consultation are management of an unsuccessful reduction or prosthetic joint as these may require operative intervention [1-4,6].

  • Pearl: If the dislocated joint is a newly placed hip prosthesis (< 1 year) or if the dislocation is recurrent, consultation with orthopedics is recommended.

REFERENCES

  1. Clegg TE, Roberts CS, Greene JW, Prather BA. Hip dislocations–epidemiology, treatment, and outcomes. Injury. 2010;41(4):329-334. PMID: 19796765
  2. Stapczynski, JS, Tintinalli, JE. Hip and Femur Injuries. In Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York, NY: McGraw-Hill Education; 2016: 1853-1854
  3. Beebe MJ, Bauer JM, Mir HR. Treatment of Hip Dislocations and Associated Injuries: Current State of Care. Orthop Clin North Am. 2016;47(3):527-549. PMID: 27241377
  4. Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg. 2010;18(4):199-209. PMID: 20357229
  5. Masiewicz S, Johnson DE. Posterior Hip (Femur) Dislocation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. PMID: 29083669
  6. Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. PMID: 30275789
Kayla Prokopakis, DO

Kayla Prokopakis, DO

Resident
Emergency Medicine
St. Elizabeth Boardman Hospital
Kayla Prokopakis, DO

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Mark Hopkins, MD

Mark Hopkins, MD

Loma Linda University Health
Mark Hopkins, MD

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William Denq, MD CAQ-SM

William Denq, MD CAQ-SM

Assistant Professor
Department of Emergency Medicine
University of Arizona
William Denq, MD CAQ-SM

@willdenq

Clinical Assistant Professor Emergency Medicine and Sports Medicine University of Arizona George Washington University '18 University of Pittsburgh '14 and '10
William Denq, MD CAQ-SM

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