Archives of Academic Emergency Medicine. 2022; 10(1): e17 CA S E RE P O RT Inferior Hip Dislocation in a 60-Year-Old Man; a Case Re- port Ali Yeganeh1, Nader Tavakoli1, Mohammad Soleimani2, Seyed Nima Taheri1, Sahand Cheraghiloohesara1∗ 1. Trauma and Injury Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. 2. Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran. Received: January 2022; Accepted: January 2022; Published online: 27 February 2022 Abstract: Inferior hip dislocation or luxatio erecta femoris is among the rarest hip dislocations, which has been described in limited studies. The patients usually present with their hip in flexion, abduction, and external rotation. Hip dislocation is an orthopedic emergency, and a reduction needs to be performed promptly to avoid devastating complications such as avascular necrosis. Here, we present a rare case of inferior hip dislocation in a 60-year- old man following a car-motorcycle collision. The patient presented to the emergency department with left hip flexion, abduction, external rotation, and inability to move his leg due to pain. Closed reduction under procedu- ral sedation was attempted in the emergency department once, which was unsuccessful. The patient was then taken to the operating room for another attempt of closed reduction under general anesthesia. The patient was discharged after two days with pin traction and double crutches. After two weeks, the pin was removed, and full weight-bearing was permitted. After 12 weeks, the patient had mild pain with unusual activity and slight limping; however, imaging revealed no signs of any complications. Keywords: Hip dislocation; joint dislocations; case reports; Wounds and Injuries Cite this article as: Yeganeh A, Tavakoli N, Soleimani M, Taheri SN, Cheraghiloohesara S. Inferior Hip Dislocation in a 60-Year-Old Man; a Case Report. Arch Acad Emerg Med. 2022; 10(1): e17. https://doi.org/10.22037/aaem.v10i1.1498. 1. Introduction As the most stable joint, the hip requires much energy to be dislocated; so, hip dislocations comprise 5% of all joint dis- locations (1). Not surprisingly, most hip dislocations are due to high-energy trauma. Hip dislocations are categorized into three main groups: posterior, central, and anterior (2). The most frequently observed subtype of hip dislocations is pos- terior dislocation, whereas anterior dislocation is the rarest, comprising less than 10% of all hip dislocations (1). Anterior dislocations are further categorized into superior and infe- rior dislocation or luxatio erecta femoris (3, 4). Inferior hip dislocation comprises 5% of all traumatic hip dislocations. (1, 5, 6). Here, we present a rare case of inferior hip dislocation with no concomitant injury or fracture, managed through closed reduction. ∗Corresponding Author: Sahand Cheraghiloohesara; Hazrate Rasool Akram Hospital, Niayesh St, Satarkhan Av, Tehran, Iran; Postal Code: 1449614535; Telephone number: 00982164352264, Fax Number: 00982166502248, Email: Sahand.cheraghi@gmail.com, ORCID: https://orcid.org/0000-0001- 7702-7656. 2. Case presentation A 60-year-old man presented to our emergency department following a car vs. motorcycle collision, in which the patient was the biker. He was brought to our hospital by the emer- gency medical service. Upon arrival, the patient was com- plaining of pain, his left hip was in flexion, abduction, and external rotation, and he was unable to move the leg. Apart from skin abrasions and deformity in the left hip, the primary survey was unremarkable. In the secondary survey, there was tenderness in the left hip, limited range of motion, no neurologic deficits, and normal distal pulses of the limb. The patient recalled the incident and complained of constant severe pain in the left groin after the incident, which wors- ened by limb movement. A radiograph showed inferior hip dislocation (Figure 1A). A computed tomography (CT) scan confirmed the diagnosis and showed no sign of fracture (Figure 1B). Physical exami- nation and imaging revealed no other injuries than hip dislo- cation. Closed reduction under sedation with propofol and midazo- lam was tried in the emergency department, which was un- successful. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Yeganeh and et al. 2 Figure 1: (A) Primary pelvic x-ray radiograph, (B) Pre-reduction computed tomography (CT) scan. Next, the patient was taken to the operating room for an- other attempt at closed reduction under general anesthesia. The patient lied in the supine position on the operating table, and the hip was reduced in the first attempt using the Allis maneuver. Then, the range of motion was evaluated, which was normal, and the hip was stable. The concentric reduc- tion was confirmed via fluoroscopy in the operating room, and post-operative pelvic radiograph and computed tomog- raphy (CT) scan (Figure 2). After the reduction, pin traction and a knee immobilizer were used for the patient. Then he was admitted to the orthopedic surgery ward and was on complete bed rest for the next two days until discharge. Upon discharge, he was instructed on partial weight-bearing on the injured limb and using double crutches for the next two weeks. Figure 3 shows the results of the patient’s pelvic imaging dur- ing the 12-week follow-up. Two weeks later, the patient pre- sented to the hip clinic for his first follow-up. He had no com- plaint of pain. In physical examination, the range of motion was normal, and the hip was stable. Also, there was no ten- derness in the left hip. The pin traction was removed, and full-weight bearing was permitted. For his subsequent follow-up, the patient presented to the clinic after another two weeks and reported mild pain and returning to normal daily activity without any difficulty. In the physical examination, he had slight limping in gait, a nor- mal range of motion of the hip, and no tenderness. Also, the imaging showed no sign of any complications. Two months later, 12 weeks after the reduction, the patient returned for his next appointment. He reported mild pain with unusual activities, and the physical examination indi- cated slight limping in the gait, while palpitation, range of motion, and stability of the joint were normal. A Harris Hip Score of 73 was calculated for the patient. Pelvic radiograph and CT scan were obtained, which showed no signs of any complications. Figure 2: Reduction confirmed by fluoroscopy in the operation room, pelvic X-ray radiograph (A), and coronal (B) and axial (C) views of pelvic computed tomography scan. 3. Discussion Bigelow first described traumatic hip dislocation in 1869, since then, hip dislocation’s main injury pattern has changed from horseback riding to motor vehicle accidents (7). These injuries mostly affect young men and result from a motor ve- hicle accident in up to 93% of cases. Other causes include pedestrian accidents, falls, and sports (1, 3, 7). Since the hip is a very stable joint due to the surrounding muscle and ligament structures that provide protection, hip dislocations mainly occur following high-energy trauma (1, 7, 8). However, in children, these injuries generally occur af- ter low-energy trauma due to the acetabulum structure and laxity of joints (9). Hip dislocation comprises 5% of all joint dislocations and is categorized into the anterior, central, and posterior main groups (2). Posterior dislocation is the most common sub- type, and anterior dislocation is the rarest, and the ratio of posterior to anterior dislocations is reported to be between 10:1 to 19:1 (7). Anterior dislocation is itself divided into su- perior and inferior dislocations (2-4, 10). Inferior hip disloca- tions are responsible for almost 5% of all traumatic hip dislo- cations (1, 5, 6). Ocurrence of a superior or inferior dislocation depends on the position of the hip at the time of trauma. Trauma to a hip in extension, abduction, and external rotation results in superior dislocation, while trauma to a flexed, abducted, and externally rotated hip results in inferior hip dislocation (7). Hip dislocation is an orthopedic emergency, and the corner- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e17 Figure 3: Follow-up imaging of patient at various times after reduction. stone of treatment is timely diagnosis and reduction (7). Also, traumatic hip dislocation is usually associated with several other traumas, including head, neck, chest, and abdomen, and femoral head or neck fractures (2, 9). Thus, obtaining pelvic radiographs is required to prevent the overlooking of possible hip dislocations (7). Several studies indicate that the treatment of choice is closed reduction if there is no sign of fracture or loose fragments (5, 9-12). However, several at- tempts on the closed reduction may itself lead to complica- tions and is contraindicated, as the success rates of open and closed reduction are reported to be the same (1, 7). There is no consensus over the post-reduction management (7). Older studies prefer prolonged immobilization, preven- tion of weight-bearing, and traction. However, no studies support these methods, and a shorter period of immobiliza- tion and non-weight-bearing may result in the same out- comes (3, 7). Hip dislocation is an orthopedic emergency and can lead to several complications (5). A terrifying complication of hip dislocation is avascular necrosis (AVN) of the femoral head (5, 13). Jacob et al. indicate a significant reduction in AVN with prompt diagnosis and management, i.e., within the first six hours; thus, promptly reducing the dislocated hip is cru- cial (7, 10, 14). Other significant complications of hip dislocation include arthritis, nerve injury, and myositis ossificans, and the pa- tient should be followed to promptly diagnose and manage these complications (11). 4. Conclusion Hip dislocation is rare and usually occurs following high- energy traumas, and inferior dislocation is among the rarest. These injuries may result in AVN and arthritis, and it is cru- cial to promptly diagnose and manage them within the first six hours to avoid complications. 5. Declarations 5.1. Acknowledgments We would like to thank the patient for granting us permission to use his data. Also, we would like to thank Dr. Amir Sobhani Eraghi and Dr. Masoud Aslani for their contributions to this study. 5.2. Author contribution NT met the patient in the emergency department. AY, NT, and SC reduced the hip in the operating room. NT and AY suggested the concept of work. MS, NT, and SC made data acquisition. MS wrote the first draft, which was read and re- vised by all others. All authors approved the final version for submission and agreed to be accountable for all aspects of the work. 5.3. Funding and support The authors did not receive support from any organization for the submitted work. 5.4. Conflict of Interest None. 5.5. Data Availability Authors guarantee that data of the study is available and will be provided to anyone needing it. 5.6. Ethical issues Written informed consent was obtained from the patient, and the study was approved by the Ethics Committee of the Iran University of Medical Sciences under the code IR.IUMS.REC.1400.765. References 1. de Oliveira AL, Machado EG. Open anterior dislocation of the hip in an adult: a case report and review of literature. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. 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Traumatic anterior hip dislocation with associated bilateral femoral fractures in a child: a case report and review of the literature. Pan African Medical Journal. 2019;32:88. 13. Ceri L, Zanna L, Buzzi R, De Biase P. Obturator disloca- tion of the hip associated with ipsilateral quadrilateral plate fracture: A rare case report. Trauma Case Reports. 2021;32:100451. 14. Jacob JR, RAo JP, Ciccarelli C. Traumatic dislocation and fracture dislocation of the hip. A long-term follow- up study. Clinical orthopaedics and related research. 1987(214):249-263. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References