A 35-year-old woman from Mumbai presents with acute onset left hip pain and inability to bear weight after a fall from stairs 6 hours ago. On examination, the left hip is held in flexion, adduction, and internal rotation (classic position). Neurovascular examination is intact. Plain radiographs show anterior displacement of the femoral head relative to the acetabulum. What is the most appropriate immediate next step in management?

Explanation

## Clinical Diagnosis This patient has an **anterior hip dislocation** — a surgical emergency. The classic clinical triad is: 1. Hip flexion, adduction, and internal rotation 2. Acute onset after high-energy trauma 3. Radiographic confirmation of femoral head displacement anterior to acetabulum ## Why This Is an Emergency **Key Point:** Hip dislocation is a time-sensitive orthopaedic emergency. Delay in reduction increases the risk of: - Avascular necrosis (AVN) of the femoral head (risk increases significantly after 12 hours) - Sciatic nerve injury (especially with posterior dislocations) - Soft tissue damage and muscle necrosis - Poorer functional outcomes **High-Yield:** The "golden window" for closed reduction is **within 6–12 hours** of injury. This patient is at 6 hours — immediate reduction is indicated. ## Management Algorithm ```mermaid flowchart TD A[Hip dislocation diagnosed]:::outcome --> B{Neurovascular intact?}:::decision B -->|No| C[Emergent open reduction]:::urgent B -->|Yes| D{Time since injury?}:::decision D -->|< 12 hours| E[Closed reduction under GA]:::action D -->|> 12 hours| F[Consider imaging first, then reduction]:::action E --> G[Post-reduction imaging & assessment]:::action G --> H{Associated fracture?}:::decision H -->|Yes| I[Surgical fixation]:::action H -->|No| J[Immobilization & physiotherapy]:::action ``` ## Why Closed Reduction Immediately? **Clinical Pearl:** Anterior hip dislocations account for ~10–15% of all hip dislocations (posterior is more common). They typically occur with flexion-abduction-external rotation mechanisms. Closed reduction is successful in >90% of cases without associated fractures. **Mnemonic:** **RICE** for hip dislocation management: - **R**eduction (urgent, within 6–12 hours) - **I**maging (post-reduction CT to assess for occult fractures) - **C**omplications (watch for AVN, nerve injury) - **E**xercise/rehabilitation (early mobilization after healing) ## Why NOT the Other Options? | Option | Why Wrong | |--------|----------| | **CT before reduction** | Imaging should NOT delay reduction. The patient is within the critical window. CT can be done AFTER successful reduction to assess for associated fractures. | | **Skin traction + delayed reduction** | Traction is appropriate for some fractures but NOT for dislocations. Prolonged delay increases AVN risk and soft tissue damage. Reduction must be urgent. | | **Open reduction via anterior approach** | Open surgery is reserved for: (1) failed closed reduction, (2) associated fractures requiring fixation, (3) neurovascular compromise. This patient has intact neurovascular status and is a candidate for closed reduction. | **Warning:** Do not confuse anterior dislocation (flexion-adduction-internal rotation) with posterior dislocation (flexion-adduction-internal rotation is also seen in posterior, but mechanism differs). The key is the radiographic position of the femoral head.