Last Updated on October 29, 2023
Hip dislocation is a less common injury. Therefore, very little has been written about neglected traumatic hip dislocations. Most of the literature is in form of case reports only.
The common causes of a neglected hip dislocation are the presence of a femoral shaft fracture that causes injury being missed. Delay in seeking health care, a major factor in older times, is decreasing but sporadic cases of delay may be found.
The hip joint is inherently stable, requiring significant force to dislocate. Thus pure hip dislocation or dislocation with femoral head fracture is generally a result of high-energy trauma and is often accompanied by associated injuries like labral tears or avulsions, muscular injury and neurovascular injuries.
Dislocations of the hip are classified as anterior or posterior according to the position of the femoral head.
Reduction of the hip joint is an emergency.
Interposition of soft tissues [capsule, rectus femoris and iliopsoas muscles] hip capsule and a “buttonhole” entrapment of the femoral head by the capsule are potential obstructions to reduction.
If neglected the reduction of the hip becomes difficult with time.
In younger children, lesser trauma can produce dislocation in younger children due to generalized joint laxity and because the acetabulum is soft with pliable cartilage. As the children grow, the amount of cartilage decreases and joint laxity resolves and relatively more force is required to dislocate the hip.
Presentation
There would be a definitive history of significant trauma in the past following which the patient was unable to get up and bear weight on the affected limb.
There could be a history of severe injury to limb [say femoral fracture] which was treated and the patient was not able to bear weight properly even after the passage of the time. [Dislocation was present at the time of initial injury but was missed.]
In either case, there would be deformity of the lower limb and there would be difficulty in walking. The pain after an acute period of onset diminishes with time.
On examination, the limb would be in flexion adduction and internal rotation in posterior dislocation of the hip and externally rotated with mild flexion and abduction in anterior dislocation.
There would be a limitation of movement and there would be supratrochanteric shortening.
Hip would be found unstable and the head of the femur would be palpable outside the socket.
Diagnosis
X-rays are the basic investigation and are often able to reveal the full profile of the injury. X-rays would show dislocation and the presence of any associated fracture fragments [malunited or ununited].
CT is useful to reconstruct images in case of acetabular fractures.
MRI may be done to know the viability of the head.
Treatment of Neglected Hip Dislocation
Closed Reduction with Heavy Traction
This option can be considered if the dislocation is of short duration (2-4 weeks. The limb is placed in heavy skeletal traction (15–20% of the patient’s body weight) for 3–5 days.
X-rays are taken every other day. When the head of the femur is at the level of the acetabulum, the limb is gradually abducted to achieve the reduction.
Once the hip becomes concentric, the traction weight is reduced and maintained for an additional 3 weeks.
Open reduction
This is considered the best option though there is risk of complications like avascular necrosis and heterotopic ossification.
Girdlestone Operation
Girdlestone operation severs the head and neck of the femur to provide a pain-free functional hip.
Hip Arthroplasty
For cases with changes of avascular necrosis of femoral head and acetabular changes, total hip replacement is a good option for treatment.
Subtrochanteric Osteotomy
alters the weight-bearing pattern and can be considered in children.
Wait and Watch
This is especially true in children where symptomatic treatment is done until after skeletal maturity when a reconstruction can be performed.
Complications
- Avascular Necrosis
- Damage to the growth plate
- Coxa vara
- Coxa valga
- Widening of the femoral neck.
- Heterotopic Ossification
- Painful hip
References
- Aggarwal ND, Singh H. Unreduced anterior dislocation of the hip. Report of seven cases. J Bone Joint Surg Br 1967; 49 (2): 288–92.
- Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001; 83 (8): 1119–24.
- Hamada G. Unreduced anterior dislocation of the hip. J Bone Joint Surg Br 1957; 39-B (3): 471–6
- Nagi O N, Dhillon MS, Gill S S. Chronically unreduced traumatic anterior dislocation of the hip: a report of four cases. J Orthop Trauma 1992; 6 (4): 433–6
- Epstein HC. Traumatic dislocations of the hip. Clin Orthop Relat Res 1973;92:116-42.
- DeLee JC, Evans JA, Thomas J. Anterior dislocation of the hip and associated femoral-head fractures. J Bone Joint Surg Am 1980;62:960-4.
- Agarwal N.D., Singh H. Unreduced anterior dislocation of hip. A report of seven cases. JBJS 1967;49(B):288-92.
- Singaravadivelu V, Mugundhan M, Sankaralingam K. Neglected intrapelvic dislocation of femoral head. Indian J of Orthopaedics 2010;44:224-26.
- Alva A, Shetty M, Kumar V. Old unreduced traumatic anterior dislocation of the hip. BMJ case reports 2013; doi:10.1136/bcr-2012-008068.
