The patient, after consuming 8 pints of alcohol, slipped and fell off a kerb sustaining a twisting injury to his right leg. At examination his right hip was held in external rotation, flexion and abduction. There were no other injuries or distal neurovascular deficit.
The patient presented at 1 am. to the Casualty with complaints of severe pain in his right hip following a twisting injury when he slipped off the edge of the kerb. Patient had consumed about 8 pints of beer and smoked narcotic agents. The patient did not give any history of significant illnesses or medication or allergies. At examination the patient was found to be conscious, oriented, with GCS score of 15. There was no evidence of any neurological deficit or withdrawal symptoms. The injury was localised to the right hip which was held in flexion, abduction and external rotation (Fig 1). Any movement of the hip produced severe pain. There was no distal neurovascular deficit. Patient did not have any signs of hyper laxity of joints.
Radiographic examination of the right hip showed inferior type anterior dislocation with no associated fractures (Fig 2).
About 5 hours after injury, under general anaesthesia the hip was easily reduced by applying traction in line with the deformity. The hip was stable after reduction.
Post reduction radiograph showed concentric reduction of the hip (Fig 3). There were no neurovascular complications. Patient was treated in skin traction for a week to let the pain settle down. Post reduction Computerised Tomography of the right hip did not reveal any intra articular bony fragments or bony contusions (Fig 4). Hence, patient was mobilised toe touch weigh bearing for two weeks followed by progressive increasing weight bearing over six weeks with aid of physiotherapy. At one year follow up there were no hip symptoms. Patient continues to be under follow up.
Traumatic anterior dislocation of the hip is a high energy injury, usually the result of road traffic accidents (1). Anterior dislocations are uncommon and account for about 10-15% of traumatic hip dislocation (2). Epstein classified anterior hip dislocations as Superior or Inferior (3). Hip dislocations constitute an orthopaedic emergency and require urgent reduction. Unlike dislocated shoulders, time between dislocation and reduction plays a major part in the prognosis of the condition. If the hip is reduced within twelve hours the incidence of complications like avascular necrosis and early secondary hip arthritis are significantly reduced (4). Presence of small bony fragments within the joint space increases the risk of osteoarthritis. Other complications include – neurovascular complications (femoral artery and nerve), irreducible dislocations (due to bony fragments or muscular interposition) and recurrent dislocations (rare). Closed reduction should be performed as soon as possible under general anaesthesia, if not possible under spinal anaesthesia or intravenous sedation.
In the case described the mechanism of injury was unusual as it was due a simple fall off the kerb. One possible explanation is, due the inebriated state of the patient the muscular reflexes that protect the joint could have been compromised. Although the usual mechanisms of hip dislocations are high energy injuries, a high index of suspicion should be maintained especially when the hip is kept in the characteristic position (Fig 1). Triaging these patients as emergency will initiate appropriate investigations and immediate treatment.
Anterior dislocation of right hip following a simple fall.
Based on the provided X-ray and CT images, the following can be observed:
1. The right femoral head is clearly positioned anterior to the acetabulum, with the hip joint in external rotation, slight flexion, and abduction.
2. There is an abnormal displacement of the joint space, indicating disruption of the normal relationship between the femoral head and the acetabulum, consistent with an anterior hip dislocation.
3. No obvious large fracture fragments are noted initially, yet small bone fragments or cartilage injuries should be ruled out, as such injuries can increase the risk of later joint complications.
4. Soft tissue swelling in the surrounding area may be present, but there are no obvious signs of neurovascular compromise. Further clinical evaluation is necessary to assess distal circulation and neurological function.
Considering the patient’s history of a fall with a twisting injury and the radiological findings, possible diagnoses include:
1. Anterior hip dislocation (abducted or superior type): The externally rotated, abducted, and slightly flexed position aligns with a classic presentation of an anterior hip dislocation.
2. Hip dislocation with potential occult fractures: Although no significant large fragments are visible on current imaging, anterior dislocations can sometimes be associated with occult rim fractures of the acetabulum or femoral head/neck. Further evaluation is required to rule out small fracture fragments.
3. Other traumatic hip injuries: Such as femoral neck fractures or avulsion fractures around the joint. However, their typical presentations and current signs do not fully match, making these less likely.
Considering the patient’s young age (25 years old), injury mechanism from an accidental fall, decreased protective muscle tension due to alcohol intoxication, and the abnormal hip joint appearance on imaging, the most likely final diagnosis is:
Anterior dislocation of the right hip (likely anterior-superior dislocation).
For further confirmation, more detailed thin-slice CT scans can be performed to detect small fracture fragments or cartilage surface damage.
Since hip dislocations are considered orthopedic emergencies, closed reduction should be performed as soon as possible under general anesthesia or adequate analgesia/sedation.
It is recommended to complete the reduction within 12 hours of injury to reduce the risk of femoral head avascular necrosis and subsequent arthritis.
If closed reduction is not feasible, factors such as fractures or soft tissue interposition may be present. Vigilant monitoring of neurovascular status is required, and open reduction should be considered if necessary.
After reduction, X-ray or CT imaging should be repeated to confirm proper joint alignment and to check for any retained bone fragments.
Following the FITT-VP principles for rehabilitation:
1. Early Stage (Weeks 1-2)
- Monitor for complications such as femoral head avascular necrosis, cartilage damage, or neurovascular compromise.
- Seek prompt medical attention if severe pain, swelling, or restricted joint movement occurs.
- For patients with osteoporosis or poor cardiopulmonary function, exercise intensity and methods should be adapted based on professional medical advice.
Disclaimer: The above report is for reference only and does not replace in-person consultation or professional medical diagnosis and treatment. If you have any doubts or experience any changes in your condition, please consult a qualified medical institution promptly.
Anterior dislocation of right hip following a simple fall.
