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Difficulty: HardOrthopedic Surgery

A 32-year-old male is brought to the emergency department via ambulance after being involved in a high-speed motor vehicle collision. Primary and secondary trauma surveys reveal that he is hemodynamically stable with no life-threatening injuries. The patient reports excruciating left hip pain and is unable to move his left leg. On physical examination, the left lower extremity is shortened, internally rotated, and adducted. The skin is intact. Initial assessment reveals palpable dorsalis pedis and posterior tibial pulses, as well as normal sensation over the dorsum and plantar aspects of the left foot.

Arrange the following interventions in the most appropriate chronological sequence for the definitive evaluation and management of this patient's orthopedic injury.

  1. 1Obtain an anteroposterior (AP) plain radiograph of the pelvis.
  2. 2Perform urgent closed reduction of the hip joint under procedural sedation.
  3. 3Reassess the patient's distal lower extremity motor and sensory function.
  4. 4Obtain a computed tomography (CT) scan of the pelvis and affected hip.
  5. 5Initiate protected weight-bearing and early mobilization with physical therapy.

Answer

The correct sequence of management is: AP plain radiograph -> Urgent closed reduction -> Neurovascular reassessment -> CT scan of the hip -> Protected weight-bearing and physical therapy.
The standard of care for a posterior hip dislocation involves a strict chronological sequence to balance diagnostic accuracy with the urgency of joint reduction. Initial plain radiographs confirm the dislocation and rule out femoral neck fractures. Urgent closed reduction must then be performed, ideally within 6 hours, to minimize the risk of avascular necrosis of the femoral head. Immediately following reduction, a repeat neurovascular examination is required to ensure the sciatic nerve was not iatrogenically injured. Only after the hip is reduced and clinical status verified should the patient undergo a CT scan to assess for intra-articular fragments or subtle acetabular fractures. Finally, if the joint is stable and clear of fragments, the patient can begin protected weight-bearing rehabilitation.

Step-by-Step Solution

1
Confirm the clinical suspicion of posterior hip dislocation and rule out contraindicating fractures.
Obtain an anteroposterior (AP) plain radiograph of the pelvis.
Plain films are rapid and necessary to ensure no femoral neck fracture is present before attempting reduction.
2
Restore native joint anatomy to prevent avascular necrosis.
Perform urgent closed reduction of the hip joint under procedural sedation.
Reduction should be completed within 6 hours to decompress vessels and the sciatic nerve.
3
Ensure no iatrogenic injury occurred during the reduction maneuver.
Reassess the patient's distal lower extremity motor and sensory function.
The sciatic nerve is highly vulnerable in posterior dislocations and can be injured during manipulation.
4
Evaluate the joint for concentric reduction and occult injuries.
Obtain a computed tomography (CT) scan of the pelvis and affected hip.
CT provides detailed visualization of intra-articular loose bodies or acetabular wall fractures that dictate surgical management.
5
Transition to the subacute rehabilitation phase.
Initiate protected weight-bearing and early mobilization with physical therapy.
Once a stable reduction is confirmed, capsular healing is promoted through protected mobilization.

Key Concept

Acute management of posterior hip dislocations prioritizes rapid plain film confirmation followed immediately by closed reduction (to prevent avascular necrosis), prior to advanced imaging with a CT scan.
Estimated Time:2m 0s
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Orthopedic Surgery

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