Luxation of the hip

 
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Original Editors

Top Contributors - Annelies Noppe  

Search Strategy

Keywords: Luxation of the hip, hip luxation, dislocation of the hip, physical therapy hip luxation, congenital dislocation hip, Hip dysplasia, comparison, differential diagnosis, symptoms


Databases: PubMed

Definition/Description

Luxation of the hip is a dislocation of the hip. Which means that the head of the femur comes out of the acetabulum. Most of the times this causes damage at the tissues around the hip.

Clinically Relevant Anatomy

The hip anatomy exist of the acetabulum and the caput femoris. The acetabulum has the shape of a cup and the caput femoris has the shape of a ball. These caput femoris placed in the acetabulum creates the hip joint which is an ball-and-socket or articulatio spheroidea. So The femoral head has to ‘roll’ in the acetabulum. 6

The hip is a bearing ball joint with as main function support. The stability of the hip joint is provided mainly by the capsule and by the muscles and ligaments who are located there. They stabilize the femoral head in the acetabulum and ensure that the hip joint can make all the necessary movements.

Epidemiology /Etiology

Characteristics of patients with an increased risk of developing a luxation: female gender, alcohol abuse, various preoperative disorders and older age because decreased muscle mass reduces the stress on the hip prosthesis and decreases the natural protection against hip dislocation.
Older people often have balance disorders, making them often have fall and this increases the risk of dislocation. Moreover, they often have neuromuscular dysfunction. In particular, neuropathy causes an increased luxation risk. Even with a (pre) cerebrovascular accident (CVA) is the risk high. Cognitive impairment is also associated with more dislocations.
The biggest risk factors for hip luxation are great dexterity, poor follow instructions and increased tendency to fall 10.


There are two main causes for a luxation of the hip :


- Congenital hip dislocation


- Acquired hip dislocation
          Hip dislocation after an accident (posterior / anterior) or hip dislocation after hip replacement surgery.



Congenital hip dislocation (CHD)
This condition has recently been renamed developmental dysplasia of the hip or DDH. All newborn babies have their hips checked for DDH within a few days of birth and at six weeks by doctors, so that treatment can be started early if necessary, long before damage occurs14. CHD occurs with an incidence that vary between 1.5 and 20 per 1.000 births and 8 times more commonly in girls than in boys 1,2 . This is explained by the greater mobility of the hip by women 3.


Acquired hip dislocation
The traumatic luxation of the hip, mostly caused by car accidents, is always the result of an external force with high intensity. This means that this is rarely the only injury being suffered. In the direction of the force, we distinguish 2 main types of hip dislocations: luxatio posterior, where the caput femoris is pushed out of the acetabulum (by far the most common, 85% - 90% 4) and the luxatio anterior, whereby the femoral head is moved forward. By posterior dislocation the hip is in a fixed position, bent and twisted in toward the middle of the body. By the anterior dislocation, the femur has slip out of its socket in a forward direction where the hip will be bent only slightly and the leg will twist out and away from the middle of the body.
Dislocation after hip replacement surgery has the highest incidence rate immediately after the surgery or in the first three months. The incidence of hip dislocation following hip replacement surgery greatly depends on patient, surgical and hip implant factors. In general, the larger the head of the femur post surgery, the less likely a patient is to experience dislocation.

Characteristics/Clinical Presentation

Pain
Severe pain is the most common symptom. Because the femur is separated, muscles and tendons can be damaged as well. The knee can also hurt.


Swelling
There can be a swelling at the site of the injury. The surrounding skin is puffy.


Hip or leg deformity
In most of the cases is the affected leg shortened. The hip joint appears deformed


Hip immobility
Patients can experience difficulty moving the affected hip and so the inability to walk because of the pain and swelling.

Differential Diagnosis

Hip luxation occurs from a lower-energy forward fall on the flexed knee and hip. These patients present with painful and limited ROM.7 But these symptoms are not only the symptoms of a hip luxation but also of a hip dysplasia.9 The term hip dysplasia means an abnormality of shape or size of the acetabulum or femoral head, or of their proportions or alignment one to the other. 13 There is still a difference, in the case of a luxation, the patient isn’t able to walk and a patient with a hip dysplasia can still walk but he has muscle pain in his upper leg. 9 In both cases there can be radiating pain to the knee and the range of motion will be reduced. Actually, in the most cases, a hip luxation is a result of a hip dysplasia. Patients with more chronic hip instability may be able to voluntarily sublux or dislocate their hip.7 Because when the femoral head or the acetabulum is abnormal, the femoral head can easy go out of the cup and in that case you have a luxation of the hip. When they think about a luxation of the hip, they must take a x-ray photo for the security. The x-ray photo is also necessary for to know sure that the luxation doesn’t have a fracture also. When they definitely want to know that there is nothing wrong with the spine, a CT-scan is an option.12

Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

In the recognition and treatment of patients with hip dislocation, the following points are important:


Radiographic examination before and after you put the hip in the right place to determine the type of dislocation and potential fractures.
There should be a radiographic examination of the pelvis with patients who have a severe injury at their thigh (fracture of the femur).
A dislocated hip should be placed in position as soon as possible. Otherwise, the risk of Avascular necrosis, nerve damage, and second luxation increases.
Repositioning of the hip without surgery is done by a traction performed in the opposite direction of the dislocation, with 90° flexion in the hip. This should preferably be done under general or regional anesthesia and muscle relaxation; this to prevent greater damage to cartilage and soft tissue5.
After the repositioning, the stability of the hip should be tested very carefully.
If the repositioning fails, with instability or there are fractures of acetabulum or femoral head, operation must take place.
In surgery, the joint must be cleaned of any loose bone fragments or soft tissue that would prevent proper articulation. The purpose of the operation is to let the femoral head make the same movements like before. They have to take attention for the emergence of a osteonecrosis from the femoral head.11


Hip arthroscopy can be used to remove intra-articular fragments, evaluate intra-articular fractures and chondral injuries.

Physical Therapy Management

More than 80% of clinically unstable hips noted at birth have been shown to resolve spontaneously5. In newborn babies, flexion / abduction maneuvers can be sufficient. Another way to treat DDH is to holding the hip flexed and abducted (with the leg pulled up and turned out) for one or two months by the use of a brace, splint or harness. This keeps the top of the femur in the right position while the ligaments and bones grow and strengthen around it. If all this fails, surgical management is indicated. A study 7 suggests that the surgeon release the adductor longus, lengthen the psoas tendon, and insert a Kirschner wire. This simple and safe surgical procedure results in marked improvement in hip function and prevents complications later.


Traction treatment is very common and important part of the therapy treatment.
Hip flexion can help increase strength and muscular support in the hip. Hip flexion can help increase strength and muscular support in the hip. We do hip flexion passive ! Hip extension is a very good way to work on the range of motion of the hip, especially for person with a Hip dysplasia.
If a person has a luxation of the hip, there is always also a hip dysplasia. If you have a hip dysplasia however, it is not always the case that you have a luxation.
Stretching and joint mobilization is a notable way necessary for the rehabilitation. Step by step the patients learn to use the hip to its full extent.

Key Research

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Resources

Articles
2Patel H. Canadian Task Force on Preventive Health C. Preventive health care, 2001 update : screening and management of developmental dysplasia of the hip in newborns. Can Med Assoc 2001; 164(12): 1669-1677(3A , Grades of recommendation : D)
6 Barlow T. Congenital Dislocation of the Hip. J. Bone Joint Surg. 1962;44:292-301 (3B)
7 J. Pediatr. Ortop. B. 2012 Nov. Traumatic Hip Dislocation In Children; 21(6):542-51 (2B)
8 Navarro-Zarza JE. Clinical anatomy of the pelvis and hip. Reumatol Clin. 2012 Dec.(3B)
9 Lisa M. Tibor, Differential Diagnosis of Pain Around the Hip Joint, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 12 (December), 2008: pp 1407-142.1 (5)
10Mw.M.van der Grinten, prof.dr.J.A.N.Verhaar, orthopedisch chirurg. Luxatie van totale heupprothese risicofactoren en behandeling (2B)

13 K. Klaue, C. W. Durnin, R. Ganz, The acetabular rim syndrome – a clinical presentation of dysplasia of the hip, may 1991 (5)



Sites
http://www.ntvg.nl/publicatie/luxatie-van-totaleheupprothese-risicofactoren-en-behandeling/volledig/print
5 http://emidicine.medshape.com/article/86930-treatment
14 http://orthoinfo.aaos.org/topic.cfm?topic=a00347



Books
1 Orthopedic Radiology by Adam Greenspan, J.B. Lippincott 1988.
4 DeLee JC. Fractures and Dislocations of the Hip. In: Rockwood CA Jr, Green DP, Bucholz R (eds): Fractures in Adults. Vol 2. 4th ed. Philadelphia: Lippincott-Raven, 1996, pp. 1756-1803.
11 ‘De grote medische encyclopedie’, publishing Heideland, Hasselt, botten en gewrichten, spieren en huid
12 ‘Gezin en gezondheid’, publishing Cambium B.V. , Zeewolde, 1995, David E. Larson, M.D, translated by Prof. DR J.W. Van Ree and Prof. Em. DR R. De Smet



Visual
http://www.rightdiagnosis.com/animations/hip-dysplasia-pediatric.htm

Clinical Bottom Line

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References

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