Traumatic Dislocations of the Hip in Athletes: A Case Report and Review of the Literature

Tara M Connelly, Paul O’Grady

Tara M Connelly, Division of Trauma and Orthopaedic Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland
Paul O’Grady, Division of Trauma and Orthopaedic Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland

Correspondence to: Paul O’Grady, MCh, FRSCI, FRCS (Tr & Orth), Division of Trauma and Orthopaedic Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland
Email: paul.ogrady@hse.ie
Telephone: +353-94-9044453
Fax: +353-94-9044958
Received: April 29, 2015
Revised: June 12, 2015
Accepted: June 18, 2015
Published online: August 23, 2015


AIM: High velocity athletic injuries account for approximately 5% of adult traumatic hip dislocations (TDHs). The aims of this literature review and case study are to highlight the presentation, pathophysiology and treatment of TDH in athletes and to propose a management algorithm.

MATERIALS AND METHODS: A Pubmed search using keywords ‘Traumatic hip dislocation,’ ‘hip injury in athletes’ and ‘sporting injury’ was performed. Each manuscript was individually reviewed. For all cases of TDH secondary to athletic injury, patient presentation, treatment and outcome were recorded. A case of athletics associated TDH from our institution is described.

RESULTS: 55 cases of athletics associated TDH were identified in the literature (82% male, 84% posterior). 54.5 % were sustained in snowboarding, 16.4% in skiing, 14.5% in football, 7.3% in rugby and 1.8% in basketball, skating, gymnastics and tennis. A concomitant femoral or acetabular fracture was demonstrated in 16 and 9 patients respectively. Two sustained a sciatic nerve injury. Conservative closed hip reduction was successful in 100% of cases attempted. We present a case of a 31 year old female who sustained a TDH playing Gaelic football treated with closed reduction.

CONCLUSIONS: TDH from sporting injury is a relatively rare, commonly isolated injury that is amenable to closed reduction in the majority of cases. We report the first documented case of traumatic hip dislocation in Gaelic football and propose a management algorithm.

© 2015 The Authors. Published by ACT Publishing Group Ltd.

Key Words: Traumatic hip dislocation; Athletic injury; TDH; Hip injury; Sports

Connelly TM, O’Grady P. Traumatic Dislocations of the Hip in Athletes: A Case Report and Review of the Literature. International Journal of Orthopaedics 2015; 2(4): 373-378 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/1186


Sports associated hip injuries are relatively uncommon and account for approximately 2.5% of soccer, 1% of basketball, 2% of rugby and 1.5% of karate injuries[1]. These injuries are amongst the most debilitating and cause the longest delay in return to sport[2]. Traumatic dislocation of the hip (TDH) is one of the most severe types of hip injury. Due to the anatomical configuration of the hip joint, namely, a deep socket made deeper by the labrum and a fibrous capsule and a network of ligaments and muscles such as the ischiofemoral ligament, significant force is typically required to dislocate the femoral head. Therefore, the most common mechanism for TDH is road traffic accidents (RTAs) followed by falls. However, in 2-17% of cases, TDH can also occur as the result of a sporting injury with high energy tackles in rugby, American football and soccer and falls in basketball, skiing and snowboarding reported mechanisms[3-8]. The majority of TDH literature is based on data from RTAs and falls and treatment is guided by this literature. In the following literature review and case study, we aim to highlight the presentation, pathophysiology and treatment of TDH in athletes and to propose a management algorithm.


A Pubmed search using keywords ‘traumatic hip dislocation,’ ‘hip injury in athletes’ and ‘sporting injury’ was performed. Each manuscript was individually reviewed. For all cases of TDH secondary to athletic injury, presentation, treatment and outcome were recorded. A case of athletic associated TDH from our institution is described.


Fifteen manuscripts describing TDHs resulting from sporting injury were identified (Table 1). One of the 15 manuscripts provided data on incidence only[4]. In another reporting results from a study on sciatic nerve injury and time to reduction, over 100 TDHs were described. Fifteen were related to skiing or snowboarding. However, details on the outcomes of these 15 patients were not provided separately[9]. Matsumoto provided details on mechanism and associated injuries in 38 skiing and snowboarding associated TDHs; however, no details on outcome were provided[4].

In the literature, TDH was described in 55 individuals and was found predominately in men (45 of 55, 81.8%). Mean age at injury was 29.9 years of age (range 13-50 years). The majority were sustained in snowboarding and skiing (n=30 and 9 respectively), followed by football (n=8), rugby (n=4) and basketball, gymnastics, speeding staking and tennis (all with 1 reported case each). The majority were posterior in nature (46 of 55, 83.6%). Sixteen patients also sustained a concomitant femoral fracture. A posterior acetabular wall fracture was found in nine patients. Three of these nine had other documented hip injuries (2=femoral fractures, 1=ileofemoral ligament tear). Two patients sustained a sciatic nerve injury. Interestingly, no case described in the literature sustained any other non-hip related trauma with the exception of one partial ipsilateral anterior cruciate ligament (ACL) tear in a rugby player[10]. Details on the type of reduction performed were available for 17 patients. Ten underwent successful closed reduction only (3 under a general anaesthetic, 4 under sedation, 3 unknown). Seven underwent closed reduction followed by ORIF. All were successfully reduced using closed methods and the subsequent operative intervention was required to address other pathology (ie acetabular or femoral fracture). One patient experienced subsequent avascular necrosis.


A 31 year old female was struck by another player when her feet were immobilised in mud whilst playing Gaelic football. Gaelic football is not dissimilar to rugby or football. The ball is kicked, carried, passed or punched across a pitch at speed to score points in the opposing team’s goal[22]. At the moment of impact, her knee was in flexion. Immediately after the collision, she complained of pain and the inability to weight bear. On examination, her right leg was shortened and internally rotated. She was immediately brought to the Emergency Department by on site paramedics. Posterior TDH of the right hip was confirmed by xray (Figure 1A). The TDH was reduced under sedation and skin traction was applied post reduction (Figure 1B). No fracture of the acetabulum or femur was identified on CT scan. Traction was removed five days post injury. She was mobilised during physiotherapy and returned to work after eight weeks and Gaelic football 6 months following injury.


In the above literature review, the demographics, mechanisms and outcomes of sports associated TDHs are highlighted. The majority of sports associated TDHs were found in males and in high speed or high impact sports. Our case is unusual as it involves a female athlete and an impact at a relatively lower speed. Like the majority of sports associated TDHs, a posterior dislocation was found and, as a result of lack of concomitant injuries, closed reduction was successfully performed without the need for open surgery.

In our literature review, several differences between TDHs that are sports associated vs TDHs resulting from other aetilogies such as RTAs or falls are demonstrated. Inability to perform or failure of closed reduction requiring conversion to open reduction is documented in up to 15% of TDHs of other aetilogies[7,23-24]; however, interestingly, no cases of failed closed reduction in athletics associated TDHs were found in the literature. Although seven patients required surgery, all intervention was to address other associated hip injuries not the dislocation itself. Additionally, no case of a sports associated TDH with concomitant abdominal, thoracic, head, upper limb or contralateral limb injury has been reported in the literature to date. This is in contrast to TDHs resulting from RTAs and falls, which commonly present with multiple injuries, often of significance. These observations suggest that sports associated TDH is appropriately treated with closed reduction under conscious sedation if possible.

During TDH, the hip is typically in flexion and adduction, as in a seated passenger who strikes his or her knee on the dashboard during a high velocity RTA or in a mechanism similar to that demonstrated in our case. In athletes, documented actions and positions associated with TDH include a fall onto a knee when the hip is flexed, following an impact from another player when the player is down on hands and knees and when the internally rotated and flexed hip is forced into a pivot[12]. Two main forms of dislocation are found. In a posterior dislocation, the head of the femur is displaced posteriorly behind the acetabulum. In comparison, in an anterior dislocation, the head of the femur is forced in front of the acetabulum[13]. The majority of cases in the literature are of posterior dislocation.

As demonstrated in the literature review, TDH can be found with or without a concomitant acetabular or femoral fracture. Several grading systems have been developed, all of which account for the presence of these associated injuries. The most commonly used systems are the Levin (anterior or posterior dislocation), Stewart-Milford (posterior dislocation), Pipkin (posterior dislocation with femoral head fracture) and Thompson-Epstein (posterior dislocation) (Table 2). Our case was a Grade 1 dislocation in all scoring systems.

Complications of TDH include sciatic nerve injury, traumatic osteoarthritis (OA, in up to 25% of patients 2-10 years post injury)[23,26] and avascular necrosis (AVN, in up to 50%)[26]. Sciatic nerve damage may be caused by compression of the nerve by the dislocated femoral head or by traction on the nerve during reduction[27]. Risk is increased in the presence of a femoral fracture[7]. The rate of sciatic nerve damage in the athletic TDHs in our review (3.6%) is lower than that demonstrated in TDHs of all aetiologies (>5%)[8,23,26,29,30]. A 2003 study of TDH (17% of which were sports associated, namely skiing or snowboarding) suggested that increased time to relocation or transfer to a second facility prior to reduction is associated with a higher risk of sciatic nerve damage. This could be due to the nature of the associated injuries which delayed the time to reduction rather than the time itself[9]. The femoral artery is also at risk in anterior dislocations. If damaged, emergency treatment is required. However, this has not yet been reported in the sports literature. The potential for venous thromboembolism is also present due to the immobility, trauma and stasis found in TDH. Similarly, this has not been reported in an athletics associated TDH to date[29]. OA may occur due to trauma to the cartilage during both the dislocation and the reduction[6]. AVN is more commonly caused by obstruction and spasm of the vessels supplying the femoral head through stretching, tearing or thrombosis while the hip is in the dislocated position rather than disruption of these vessels[7]. This supports the paradigm that shorter time to relocation decreases risk[26]. In fact, Hougaard et al report a 4.8% incidence of AVN in patients with posterior TDH reduced within 6 hours in a study of 98 patients with traumatic hip dislocations followed for a minimum of 5 years. The rate rose to greater than 50% in those with a reduction more than 6 hours after the injury[24].

Mechanism of injury should be considered during the diagnosis of a TDH. A shortened, painful limb and the inability to weight bear, as in our case, are characteristic. In the presence of a posterior dislocation, the leg is shortened and can be internally rotated, adducted and/or flexed. In cases of anterior dislocation, the limb may be abducted and internally rotated. Buttock and adductor spasm may also be present[29]. Due to the high rate of concomitant hip and femur injury demonstrated in our literature review, we recommend that any patient with a suspected hip fracture or dislocation should have an xray of the hip performed as a matter of urgency. No attempt should be made to ‘reduce’ a hip injury until a fracture is outruled radiologically. It is the opinion of the authors that attempted ‘blind’ reduction maneuvers of a hip may displace undiagnosed fractures and increase the risk of avascular necrosis. Plain radiographs should be taken in two planes and treatment should be directed following interpretation of these xrays. CT may be a useful adjunct to xrays in determining the presence of a femoral or acetabular fracture. MRI can detect avascular necrosis and/or cartilaginous injury that may result from a dislocation. Prior to reduction, a thorough neurovascular exam should be performed. Reduction should focus on avoiding further cartilage damage when placing the head back into the acetabulum. Several methods can be used. Among the most commonly used is the Allis technique. This entails a gentle flexion of the hip from 60-90 degrees. A modified Allis where a gentle traction is applied laterally to the proximal femur while the pelvis and non-affected leg are held stable, allows the head to slip back into the acetabulum. Alternatively, for posterior dislocations, the Whistler technique may be used. The knee of the affected leg is flexed to 120 degrees is firmly grasped by the physician who is standing on the affected side passing his or her arm under the affected knee. When the pelvis is stablised and the physician raises his or her arm, the femur is forced forward into place. After reduction, the neurovascular exam should be repeated and documented and the X-ray repeated to confirm concentric reduction. A suggested algorithm is presented in figure 2.

The majority of outcomes studies on closed reduction in TDH do not separate the results by mechanism of injury (ie RTA vs fall vs athletic injury) and are comprised mainly of TDHs resulting from RTAs. Outcome is dependent upon several factors, of which the most consistently demonstrated is time to reduction. In a retrospective study of 58 posterior dislocations followed up for a minimum of 24 months (of which 57 patients underwent initial closed reduction within a mean time of 7 hours, followed by traction), complications included OA in 5 patients, residual painful hip in 8 and osteonecrosis in two. Complications were higher in those who underwent traction for 3 weeks (8 of 14) vs those who were maintained in traction for 4 weeks (4 of 22). However, only 3 patients in this cohort had a sports related injury and their outcomes are not reported separately[7]. In a large early study of 194 dislocations of which 90 were treated non-surgically, outcome as measured by hip function was better in those without an associated fracture or a small acetabular chip vs those with greater acetabular damage or femoral fractures. Outcome was also better in those who were reduced within 12 hours vs 24 vs 48 vs ≥49, regardless of other associated injury to the joint. No patient who was reduced after 24 hours experienced a good functional outcome. AVN was seen in 15% of those treated nonsurgically with a mean time to onset of 17 months. Forty nine percent of those treated with closed reduction vs 72% of those treated with surgery developed OA. However, this may be due to the severity of the injury[26]. Dreinhofer et al studied 50 patients with conservatively treated TDHs without associated fractures, reduced within 3 hours (48 of which were reduced by a physician at the scene of the accident) and followed for a minimum of 2 years[8]. Objective and reported subjective clinical measures demonstrated good functional outcomes in 55% and 74% of patients respectively. Time to reduction did not affect OA or AVN. Of these 50 patients, 1 had a skiing accident, 1 was biking and 1 was sledging. Their results were not reported separately. Outcomes may be slightly different in the presence of a concomitant fracture. Chen et al performed a small randomised control trial on patients with non sports associated posterior dislocations with Pipkin type 1 fractures reduced within 12 hours all followed for at least 2 years. Eight patients were treated conservatively with closed reduction and traction for 6 weeks. Eight were initially treated conservatively followed by surgical excision of fragments. Heterotrophic ossification was 4 times more likely in the surgical group. Using Thompson and Epstein and Merle d’Aubigne scores, the surgical group’s functional outcome was demonstrated to be better than the closed reduction group. The only 2 cases of AVN were found in the conservatively treated group[31]. No consensus regarding care after closed reduction of TDH is in place. However, the majority of studies report the use of traction post reduction. A detailed physiotherapy regimen including ortosis for neuropraxia and pool based exercises for non-weight bearing rehabilitation has been described by Yates et al in their case study of a 17 year old football player post closed reduction[13].


Due to the variation in the literature and methods of studies cited, this review has a few limitations. The longest follow up in any study was two years. Therefore, the true incidence of OA or AVN and long term outcomes in this patient population cannot be extrapolated. Additionally, various measures of outcome from survey to validated classifications were used precluding a uniform conclusion on functional or clinical outcome. Only one study utilised MRI to determine ligamentous and/or cartilaginous damage. It is very likely that the incidence would be higher if all studies used MRI evaluation of ligaments. The lack of outcome details on the majority of anterior dislocations leads to the inability to compare both types of dislocations accurately in this review.


TDHs involving athletics differ from those sustained in RTAs in several ways. The velocity of the impact is less than that of an RTA. Patients are almost exclusively under 40 years old and otherwise healthy. Often, the athletic TDH injury is isolated to the hip as compared to the associated head, abdominal, multi-limb injuries commonly found in RTA and falls patients. We present a literature review of sports injuries resulting in a TDH. We also present what we believe is the first case of a female who has sustained TDH playing Gaelic football and have suggested treatment algorithm for the treatment of these injuries.


There are no conflicts of interest with regard to the present study.


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Peer reviewer: Luigi Sabatini, University of Turin, Italy.


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