Hip dislocation and avascular-necrosis risk — Rapid

Synopsis

Recognise anterior and posterior hip dislocation, document sciatic and femoral neurovascular status, reduce the joint urgently and safely, and detect associated fracture, non-concentric reduction and later avascular necrosis.

Posterior hip dislocation usually presents with a shortened flexed, adducted, internally rotated limb; anterior dislocation is typically abducted and externally rotated.
Run ABCDE after high-energy trauma and inspect the knee, femur, pelvis, abdomen and spine because dashboard force rarely injures the hip in isolation.
Before and after every attempt, document dorsiflexion, great-toe extension, plantarflexion, sole and dorsum sensation, femoral function, pulses and capillary refill.
Obtain immediate AP pelvis and targeted hip radiographs if this does not delay lifesaving care; identify femoral-neck, head and acetabular fractures before choosing reduction setting.
Reduce a native dislocated hip urgently with senior orthopaedic and anaesthetic support; use adequate relaxation, one controlled technique and a theatre route when fracture or failed attempt makes closed reduction unsafe.
Do not perform repeated forceful reductions, especially with a femoral-neck fracture, large acetabular fragment, prosthesis or non-concentric first reduction.
Confirm clinically and radiographically, repeat nerve and vascular examination, then obtain CT to assess congruity and femoral-head, neck or acetabular fragments where indicated.
Arrange fracture-specific weight bearing and long-term follow-up for avascular necrosis, post-traumatic arthritis, nerve recovery, heterotopic ossification and instability.

Key red flags

A cool pulseless limb, expanding groin or buttock swelling, open injury or progressive neurological loss requires immediate trauma, orthopaedic and vascular intervention.

Associated femoral-neck fracture, acetabular fracture, prosthetic hip, delayed presentation or failed gentle reduction makes repeated closed attempts hazardous and requires consultant-led theatre management.

Persistent joint widening, incongruity, mechanical block or new nerve deficit after reduction suggests an incarcerated fragment or iatrogenic injury and requires urgent CT and specialist review.

Investigation priorities

First-line AP pelvis radiographFirst stepFirst line

Confirm direction and identify associated proximal femoral, acetabular and pelvic fracture.

Management branches

ImmediateAssess before reduction

A painful fixed hip deformity follows trauma.

Run ABCDE, support the limb, give analgesia and examine the pelvis, femur, knee, abdomen and spine for associated injury.
Document sciatic and femoral motor and sensory function, distal pulses, refill and skin before sedation or manipulation.
Obtain urgent AP pelvis and a safe lateral view and identify femoral-neck, head and acetabular fracture or prosthetic components.
Call orthopaedics and anaesthesia and choose resuscitation room or theatre according to physiology, fracture, implant and operator experience.

Key medicines

First-line intravenous morphine for severe major-trauma painGive 2 mg intravenously, reassess after 5 minutes and repeat small 1–2 mg increments to effect under monitored local trauma guidance rather than giving an unobserved large bolus.Use lower increments in frailty or cardiorespiratory disease, monitor respiratory rate, sedation, pressure and oxygen saturation and ensure naloxone and airway support are available.

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