Traumatic dislocation of the hip in a high school football player

Physical Therapy, June, 2008 by Charlotte Yates, William D. Bandy, R. Dale Blasier

Traumatic dislocation of the hip is an orthopedic emergency requiring early recognition and prompt reduction for successful management, (1,2) In a posterior dislocation, the head of the femur lies posterior to the acetabulum and the injured lower extremity has a clinical presentation of shortening, medial (internal) rotation, flexion, and adduction. In an anterior dislocation, the femoral head lies anterior to the acetabulum and the injured lower extremity has a clinical presentation of abduction and lateral (external) rotation of the hip. (3) According to a retrospective review of 62 patients (mean age = 34.5 years, range = 14-72) with traumatic dislocation of the hip, Sahin et al (2) reported that 57 (92%) were posterior dislocations and 5 (8%) were anterior dislocations. Posterior dislocation as the most frequent direction of dislocation is well supported in the literature. (1,3-6)

The vast majority of dislocations occur as a result of automobile accidents. (5) In their review of hip dislocations in 62 patients, Sahin et al (2) reported 52 (83.9%) of the patients sustained their hip dislocation due to traffic accidents. The most common mechanism of injury for a hip dislocation during an automobile accident is when the person's knee (with hip flexed) strikes the dashboard, forcing the head of the femur posteriorly over the rim of the acetabulum. (4) However, if the thigh is abducted, impact on the knee would cause further abduction and lateral rotation of the hip, leading to an anterior dislocation, which occurs less frequently than a posterior dislocation. (4)

Traumatic dislocation of the hip rarely occurs in sports activities. Sahin et al (2) reported that 2 (3.2%) of the hip dislocations in their study were the result of athletics. Lamke (7) investigated 110 traumatic dislocations of the hip and reported that 5.5% occurred during sports activities. More recently, Chudik et al (8) estimated that only 2% to 5% of all hip dislocations occurred during participation in sports. The injury tends to occur secondary to a collision in sports such as skiing or football. (5,9,10) A frequent mechanism of injury for a posterior hip dislocation is the knee striking the ground with the hip in a flexed position, thereby forcing the femoral head posteriorly over the rim of the acetabulum. (5,9,11)

A review of the literature related to the treatment of patients with traumatic dislocation of the hip reveals frequent discussions of immediate intervention (open versus closed reduction) and the need for frequent follow-up examinations to rule out postinjury complications. (3-5,9,12) Information and details concerning the appropriate plan of care following immediate intervention are lacking. Regardless of whether the hip dislocation is the result of an automobile accident or participation in athletics, no descriptions of the specific intervention and plan of care exist. Paletta and Andrish, for example, suggested that "return to activity is permitted only when strength, motion, and agility have been achieved." (3(p610)) Anderson et al suggested that "a return to sport is allowed if the MRI [magnetic resonance image] is negative and there is pain-free range of motion." (5(p526)) The authors of these articles provided no description of the appropriate plan of care after the immediate reduction of the dislocated hip.

Although previous literature exists as to the immediate emergency treatment for an individual with a traumatic dislocation of the hip, the specific plan of care for the rehabilitation of this type of injury is not described. Therefore, the purpose of this case report is to describe the physical therapy plan of care for a

17-year-old high school football player with a posterior hip dislocation complicated by involvement of the sciatic nerve.

Patient History

The patient was a 17-year-old male football player who was injured during a high school football game while making a tackle. The patient later reported that he felt a "pop" and immediate pain in his right hip when making the tackle and turning when another player fell on the back of his thigh. The patient was evaluated on the field and transported to the emergency department via ambulance.

Emergency Department Examination/Intervention

The patient arrived at the emergency department with his right lower extremity propped on pillows in flexion, adduction, and medial rotation--consistent with a posterior dislocation of the hip. In addition, prior to radiographic evaluation and reduction, the patient had decreased light touch sensation in his foot and was unable to flex or extend his toes or ankle, consistent with a sciatic nerve injury. Radiologic evaluation confirmed that he had a right posterior hip dislocation (Fig. 1).

The hip was reduced with the patient in the supine position. After conscious sedation allowed the patient and his musculature to relax, the reduction was performed. The physician applied traction to the flexed knee in line with the axis of the thigh with the hip flexed 45 degrees while an assistant stabilized the body and trunk to allow countertraction. After a few moments of traction, a gentle external rotation force was applied, and the hip was felt to reduce. The hip was put through gentle range of motion (ROM) to assess for crepitus, which could suggest the presence of a retained intraarticular fragment of bone, cartilage, or soft tissue. No crepitus was present. Post-reduction radiographs were taken to ensure that the hip was successfully reduced and that nothing, such as interposed joint capsule or cartilage, was blocking a full reduction. Post-reduction radiographs revealed a good reduction, with no evidence of fracture or avascular necrosis (Fig. 2).