Dislocated Hip Replacement

You are the orthopaedic CT1 called to A&E to assess a 55-year old man who fell out of his sports car. He had a left hip operation a week ago but is unsure what it was. He is not currently in pain. A&E have performed an x-ray which confirms a dislocated hip replacement. How would you proceed?

Example answer introduction
This is an confirmed dislocated hip replacement on X-ray. This will require urgent closed reduction in A&E under sedation or in theatre. I would focus on ensuring the patient is stabilised and then optimised for surgery and then escalate to the orthopaedic registrar.
Initial Assessment and Simultaneous Resuscitation:
On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.
  • Airway with C-spine control
    • Check that airway is patient
  • Breathing
    • oxygen saturations, examine chest, examine work of breathing, breathing depth
    • if concerns give high flow oxygen through a non-rebreathe mask
  • Circulation
    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output
    • ensure IV access- 2 large bore etc- bloods as above, consider catheter
    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds
    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage
  • Disability - GCS, pupils, blood sugar, temperature
  • Exposure-  systemic signs of shock, other injuries
Provide constant reassessment during this acute phase.
Specific Limb Examination
  • Lower limb position – 90% of dislocations are posterior and appear shortened and internallyrotated. Although beware, with anterior dislocations the limb is held in external rotation with mild flexion and abduction.

  • Range of movement

  • Neurovascular status – Documenting this is key!

Cover patient with blanket at the end to prevent hypothermia.

Focused history
Focused history
  • Allergies
  • Medications – anticoagulants, consider reversal
  • Past medical history including previous surgery
  • Last meal
  • Events leading up to this point
Initial management
  • Fluid resuscitation
  • Analgesia according to WHO pain ladder
  • Bloods, keep nil by mouth
  • Escalate to Orthopaedic Registrar 
  • Anaesthetist/Emergency theatres
  • Keep patient and any relatives informed
  • Document, document, document!!!
Further investigations
Ensure the required views have been performed – AP and lateral hip, femoral views. On the x-rays you should be looking for signs of periprosthetic fracture, native bone fracture or implant loosening. In cases where the x-ray is equivocal, or it is a recurrent dislocation, a CT pelvis/hip will garner more information and aid surgical planning. 
This patient should be discussed with the orthopaedic registrar immediately. If it is a simple dislocation, then the patient will need an urgent closed reduction in A&E or in theatre under sedation/anaesthetic. However, they will need revision surgery if there is evidence of implant failure, loosening or malposition. This will be beyond your competence and you should be aware of your limitations. 
Useful Resources

​Dislocation After Total Hip Arthroplasty

Hip Dislocation: Evaluation and Management

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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