Hip and pelvis injuries
Hip Dislocation
Summary
Dislocation of the hip can occur in the prosthetic hip (acquired) commonly after replacement or in the native hip as part of polytrauma or in low force injuries. Acquired hip dislocation has the highest incidence rate immediately after hip replacement surgery and continues to have a high incidence throughout the first three months following the surgery. Congenital hip dislocation and its sequellae occurs throughout life and is covered in paediatric resources.
Classification
Simple Vs Complex
- Simple
- Pure dislocation without associated fracture
- Complex
- Dislocation associated with fracture of acetabulum or proximal femur
Anatomic classification
- Posterior dislocation (90%)
- occur with axial load on femur, typically with hip flexed and adducted
- axial load through flexed knee (dashboard injury)
- Position of hip determines associated acetablular injury
- increasing flexion and adduction favours simple dislocation
- associated with
- osteonecrosis
- posterior wall acetabular fracture
- femoral head fractures
- sciatic nerve injuries
- ipsilateral knee injuries (up to 25%)
- occur with axial load on femur, typically with hip flexed and adducted
- Anterior dislocation
- associated with femoral head impaction or chondral injury
- occurs with the hip in abduction and external rotation
- inferior vs superior
- hip extension results in a superior (pubic) dislocation
- flexiion results in inferior (obturator) dislocation
Presentation
Nine out of ten hip dislocations are posterior. The affected limb will be shortened and internally rotated in this case. Posterior dislocations with an associated fracture are categorised by the Thompson and Epstein classification system.
Thompson and Epstein Classification System:
Type | Description |
|---|---|
I | With/without a minor fracture |
II | With a fracture of the posterior acetabular rim |
III | With comminution of the acetabular rim |
IV | With a fracture of the acetabular floor |
V | With a fracture of the femoral head |
In an anterior dislocation the limb will not be shortened as noticeably and will be externally rotated.
In both cases, the affected leg is virtually immovable by the patient, and is usually extremely painful.
Imaging
Plain films will make the diagnosis but CT scans may be required post reduction of the native hip looking for associated injuries.
ED Management Options
Other significant medical or surgical issues withstanding isolated hip dislocation are managed with emergent closed reduction within 6 hours for both anterior and posterior dislocations. This is contraindicated where there are fractures.
Relocation performed with patient supine and apply traction in line with deformity regardless of direction of dislocation, that is adducted internally rotated with posterior dislocation, and varying positions usually not internally rotated with anterior dislocations.
There must have adequate sedation and muscular relaxation to perform reduction, see sedation in the ED. Hip stability should be assessed after reduction.
A post reduction CT scan required to rule out femoral head fractures intra-articular loose bodies/incarcerated fragments and acetabular fractures.
Prosthetic hips should be reduced in the same way and all post reduction patients should have a pillow placed between the legs to maintain position, particularly when waking from sedation where they may have increased movements and less control or pain sensations.
Referral and Follow Up Requirements
Referral for most cases to Orthopaedics and admission will be required. Some prosthetic hips post reduction may be able to be suitable for DC in discussion with their orthopaedic surgeon.
Potential Complications
Ostenecrosis can occur with native hip dislocation.
The staging system for osteonecrosis is as follows:
- Stage 1 – Normal appearance of the femoral head; patient is symptomatic (A technetium-99 bone scan may be used to confirm the diagnosis).
- Stage 2 – Femoral cysts, sclerotic changes, or both
- Stage 3 – Crescent sign of subchondral collapse of the femoral head
- Stage 4 – Joint space narrowing with acetabular cysts, osteophytes, and cartilage damage.
Patient Advice
Further References and Resources
- Patient (UK) - hip dislocations
- Orthobullets - hip dislocation
Neck of Femur
Summary
Fracture Type | Management | Follow-up |
|---|---|---|
Neck of Femur (NOF) | Analgesia, general medical, orthopaedic definitive | As per admitting teams, orthogeriatrics ideally |
Intertrochanteric (IT) | Analgesia, general medical, orthopaedic definitive | As per admitting teams, orthogeriatrics ideally |
Classification
- NOF - impacted, non displaces, displaced
- IT - non displaced/displaced, stable/unstable (stable being intact posterior cortex
Epidemiology
- Both fracture types more common in the elderly and women particularly relating to osteoporotic fractures. Increasing in general with the increasing age of the population.
- Can occur in the young with high energy trauma.
Presentation
- NOF - Impacted or non displaced fractures can present with hip pain on mobilising but still able to mobilise, displaced fractures are painful and deformity as a result of haematoma may be seen, shortening and external rotation.
- IT – pain and non mobilising, deformity from haematoma, and rotation, shortening and external rotation.
Imaging
- Plain X-rays usually adequate for admission
- CT for operative planning
- Bone scan where pain and/or non mobile and no clear radiological evidence of fracture (usually admit geriatrics for this).
ED Management Options
- Assessment of the whole patient must be emphasised in this usually elderly population and often complicated by dementia and or multiple medical conditions
- Adequate pain control , early use of nerve blocks such as femoral and fascia iliaca blocks will reduce the need for narcotic analgesia and inherent risks with that.
- Basic bloods and group and hold along with placement of IDC and testing or urine, chest X-ray for screen in elderly population.
- Early referral for orthogeriatric care, including discussion about essential regular medications the patient may require e.g. insulin, b blockers, in conjunction with any planned fasting.
Referral and Follow Up Requirements
Fracture Type | Urgency | Follow-up |
|---|---|---|
NOF | Early referral, combination with orthogeriatrics | As per admitting teams |
IT | Early referral, combination with orthogeriatrics | As per admitting teams |
Potential Complications
- High risk of missing underlying co-morbidities which may have precipitated fracture from fall or be exacerbated it.
- Blood loss in itself or complicating current conditions such as angina, CHF.
- Risk from narcotic analgesia increasing delirium, hypotension and depressing respiratory drive.
Patient Advice
- As per admitting teams but patients and carers should be informed of the projected course of events, including fasting status and possible time of OT
- ECI patient factsheets
Further References and Resources
- Orthobullets - femeral neck fractures
- Orthobullets - intertrochanteric fractures
Pubic Rami Fracture
Summary
The majority of pubic rami fractures seen in the elderly are in the anterior ring and have non operative treatment. It is possible that associated posterior ring pathology is under appreciated in the elderly population.
Pubic ramus fractures occurring as part of major trauma presents as parasymphysial fractures, midramus fractures, and pubic root fractures in association with distraction and compression injuries of the pelvis.
Classification
Pubic rami fractures are classified as fractures of the anterior pelvic ring, usually occurring secondary to lateral compression. From a biomechanical point of view they are considered stable fractures that allow full weight bearing.
Epidemiology
Pubic rami fractures in the elderly often occur as a result of a fall from standing, however, many are atraumatic, and therefore diagnosis may be missed or delayed. These fractures represent the most frequent type of pelvic fractures.
Strongly associated with low bone density, and osteoporosis is a major risk factor and so peaks in older age. There is also a second peak in younger age in long distance runners.
Presentation
As part of major trauma not covered here.
- Elderly patients following a minor fall, or as part of difficulty mobilising or hip and pelvic pain with mobilising in the elderly or osteoporotic.
- In runners presenting with severe groin pain.
A high level of suspicion is required for both of these cohorts.
Examine for other potential causes of pain e.g. referred abdominal pain, inguinal hernia.
Imaging
- Plain X-rays usually adequate for admission.
- CT or bone scan where pain and/or non mobile and no clear radiological evidence of fracture -usually admit geriatrics (orthopaedics in younger patients) for this.
ED Management Options
These are stable fractures, but nearly always require admission for analgesia and mobilisation. Very occasionally may be appropriate for discharge given very good home or usual residential circumstances if high care available.
Referral and Follow Up Requirements
Geriatrics and orthopaedics where part of major trauma or unstable or complicated fracture suspected.
Potential Complications
- High risk of missing underlying co morbidities which may have precipitated fracture from fall or be exacerbated it.
- Decreased mobility and associated complications e.g. DVT.
- Risk from narcotic analgesia increasing delirium, hypotension and depressing respiratory drive.
Patient Advice
- 6-8 weeks healing time
- Adequate analgesia
- ECI patient factsheets