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Traumatic Hip Dislocation: What
the Orthopedic Surgeon Wants to
Know1
Jacob C. Mandell, MD
Richard A. Marshall, MD
Michael J.Weaver, MD
Mitchel B. Harris, MD
Aaron D. Sodickson, MD, PhD
Bharti Khurana, MD
Abbreviation: AP = anteroposterior
RadioGraphics 2017; 37:2181–2201
https://doi.org/10.1148/rg.2017170012
Content Codes:
1
From the Department of Radiology (J.C.M.,
R.A.M., A.D.S., B.K.), Division of Musculoskel-
etal Imaging and Intervention (J.C.M.), Division
of Emergency Radiology (A.D.S., B.K.), and
Department of Orthopedic Surgery (M.J.W.,
M.B.H.), Brigham and Women’s Hospital, Har-
vard Medical School, 75 Francis St, Boston, MA
02115. Recipient of a Cum Laude award for an
education exhibit at the 2016 RSNA Annual
Meeting. Received February 15, 2017; revision
requested May 18 and received May 25; ac-
cepted June 28. For this journal-based SA-CME
activity, the authors, editor, and reviewers have
disclosed no relevant relationships. Address
correspondence to J.C.M. (e-mail: jmandell@
partners.org).
© RSNA, 2017 • radiographics.rsna.org
RSNA, 2017
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■Describe the most pertinent imaging
findings in traumatic hip dislocation,
both on initial radiographs and at postre-
duction CT, to guide management by the
orthopedic team.
■■Discuss potential pitfalls in imaging of
traumatic hip dislocation.
■■Explain the important treatment impli-
cations of several key imaging findings of
traumatic hip dislocation.
See www.rsna.org/education/search/RG.
2181
TRAUMA/EMERGENCY RADIOLOGY
Hip dislocation is an important orthopedic emergency usually seen
in young patients who have experienced high-energy trauma, often
resulting in significant long-term morbidity. Rapid identification
and reduction is critical, as prolonged dislocation increases the risk
of developing avascular necrosis of the femoral head, and posttrau-
matic osteoarthritis is a common complication, even in the absence
of associated fractures. Identification and timely management of hip
dislocation are highly dependent on imaging, both at presentation
and after attempted reduction. It is imperative for the radiologist
to understand imaging features that guide management of hip dis-
location to ensure timely identification, characterization, and com-
munication of clinically relevant results. Although the importance
of prompt identification of hip dislocation is universally recognized,
the significance of imaging features that guide correct management
and are thought to prevent complications is less emphasized in the
radiology literature. In this article, the authors review the anatomy
of the hip, common injury mechanisms for various types of disloca-
tions, and imaging findings for associated injuries. They review the
most commonly used classification systems and propose a simpli-
fied checklist approach to hip dislocation to aid rapid interpretation
and communication of the most clinically relevant imaging features
to the treating orthopedic surgeon.
©
Introduction
Traumatic hip dislocation is a true emergency that requires immedi-
ate orthopedic evaluation and reduction (1). Hip dislocations are
serious injuries that are associated with significant long-term mor-
bidity, most notably avascular necrosis and posttraumatic osteoar-
thritis (2). They typically occur in young patients in the setting of
high-energy trauma and are increasing in incidence, predominantly
because of motor vehicle crashes, which cause between 62% and
93% of all hip dislocations (3). In contrast, fractures of the femoral
neck are more common in older patients (4), unless there is concom-
itant systemic disease in younger patients (5). Patients with trau-
matic hip dislocation should undergo a complete evaluation by the
trauma service because of the high prevalence of additional injuries,
especially in the setting of a motor vehicle crash. In patients with hip
dislocation resulting from a motor vehicle crash, there is a reported
prevalence of nonorthopedic injuries in 67% of cases, including 24%
with closed-head injuries, 21% with craniofacial fractures, 21% with
thoracic injuries, and 15% with abdominal injuries (6).
Given the inherent stability of the hip due to its osseous, labral,
ligamentous, and muscular anatomy, dislocations require significant
force and are typically associated with fractures of the acetabulum
or femoral head (7). Dislocations without additional fractures may
2182  November-December 2017 radiographics.rsna.org
TEACHING POINTS
■■ Treatment of patients with hip dislocation is performed in two
stages. Initially, the goal is to perform rapid reduction of the
hip. The second stage is focused on definitive management.
■■ The vascular anatomy of the hip is clinically important be-
cause of the direct correlation between the rate of occurrence
of avascular necrosis and the time to reduction of a hip dislo-
cation. The main blood supply to the weight-bearing femo-
ral head is provided by the medial femoral circumflex artery,
which arises from the profunda femoris artery.
■■ It is especially important to note the presence of a femoral
neck fracture, which contraindicates closed reduction because
of the risk for fracture displacement. The presence of a femoral
neck fracture (or suspicion for an occult femoral neck fracture)
necessitates urgent CT followed by surgical intervention.
■■ With posterior hip dislocation, the hip is typically in internal
rotation and the lesser trochanter is less conspicuous or com-
pletely obscured by the femoral shaft. In cases of anterior
dislocations, the femur is typically held in external rotation, al-
lowing nearly the entire cross-sectional diameter of the lesser
trochanter to be visualized.
■■ After reduction is attempted, CT is performed to assess
joint congruence, evaluate for intra-articular fragments, and
search for associated bone and soft-tissue injuries.
be less common than initially thought, owing to
the widespread adoption of computed tomog-
raphy (CT) and the resulting ability to visualize
small fractures that may not have been evident at
earlier radiographic investigations (8). Of histori-
cal interest, the first major malpractice case in the
United States was a case of hip dislocation occur-
ring in 1821, which is said to have influenced the
current malpractice environment (9).
Multiple and somewhat redundant classifica-
tion systems exist to characterize hip disloca-
tions. In general, neither radiologists nor ortho-
pedic surgeons routinely classify hip dislocations
by any one system, although the Pipkin clas-
sification of femoral head fractures is routinely
used if a femoral head fracture is present. Nev-
ertheless, familiarity with the most-used classifi-
cation systems allows a better understanding of
findings that most affect patient care.
Treatment of patients with hip dislocation is
performed in two stages. Initially, the goal is to per-
form rapid reduction of the hip. The second stage
is focused on definitive management. At initial
radiography in the setting of trauma, the radiologist
must identify and characterize the dislocation and
communicate any features that contraindicate rapid
closed reduction. At postreduction CT, the radiolo-
gist must appropriately recognize complicating
features that necessitate further surgical interven-
tion by the orthopedic surgeon.
In this article, we review the anatomy of the
hip and illustrate the classification systems for hip
dislocation and associated femoral head fractures.
Using a checklist approach, we highlight key
imaging findings that guide treatment. Finally, we
review pitfalls encountered at patient presenta-
tion and imaging to prevent misinterpretation and
delays in clinical management.
Osseous, Ligamentous,
and Vascular Anatomy of the Hip
The hip is one of the most stable joints of the
body, with extensive passive and active support.
Approximately 82% of the articular surface of
the femoral head is covered by the bony ac-
etabulum when the hip is in the neutral position
(10). The fibrocartilaginous labrum further adds
to the passive stability of the hip. In addition,
the hip is covered by a thick capsule of longi-
tudinally oriented fibers, which condense into
three discrete ligaments (Fig 1) (11,12). The
iliofemoral ligament (or the Y-shaped or Big-
elow ligament) consists of two bands and is the
primary static stabilizer of the hip in terminal
extension (using the inferior band) and external
rotation (using the superior band) (13). The pu-
bofemoral ligament covers the anterior inferior
aspect of the hip, and the ischiofemoral ligament
covers the posterior aspect. The ligamentum
teres femoris arises from the fovea of the femo-
ral head and inserts onto the transverse acetabu-
lar ligament (14), which is a noncartilaginous
continuation of the labrum at the inferior aspect
of the hip. The function of the ligamentum teres
in the stability of the hip is controversial, but
isolated injuries may be implicated as a source
of hip pain (15). It is the experience of the
authors that the ligamentum teres is invariably
torn in patients who sustain a hip dislocation, al-
though there are rare reports of an intact or only
partially torn ligamentum teres demonstrated at
arthroscopy performed after dislocation (16).
The vascular anatomy of the hip (Fig 2)
is clinically important because of the direct
correlation between the rate of occurrence of
avascular necrosis and the time to reduction of
a hip dislocation. The main blood supply to the
weight-bearing femoral head is provided by the
medial femoral circumflex artery (17), which
arises from the profunda femoris artery. The
extracapsular deep branch of the medial femoral
circumflex artery branches to provide two to
four subsynovial retinacular arteries, which can
completely perfuse the femoral head. The lateral
circumflex femoral artery provides a relatively
insignificant contribution to the femoral head
blood supply. Similarly, the artery of the liga-
mentum teres (or foveolar artery) is a small-
caliber artery arising from the obturator artery
that perfuses the perifoveal region only and is
typically vestigial with an insignificant contribu-
RG  •  Volume 37  Number 7 Mandell et al  2183

Figure 1.  Ligaments of the hip. (a) Drawing of the anterior hip shows the iliofemoral (red) and pubofemoral (blue)
ligaments, with the iliofemoral ligament comprising the superior and inferior bands. (b) Drawing of the posterior hip
shows the ischiofemoral ligament (green) and the posterior aspect of the iliofemoral ligament (red).

Figure 2.  Drawing shows the

vascular supply of the femoral
head. The main contribution to
the femoral head blood supply
is the medial femoral circumflex
artery (MFCA), with the extrasy-
novial portion being the most
susceptible to traumatic injury.

tion in adults. Avascular necrosis of the femoral
head due to nontraumatic causes is thought
to be caused by obstruction of the intraosse-
ous branches of the medial femoral circumflex
artery, whereas trauma may directly rupture,
compress, or kink its extraosseous branches
(17). In traumatic hip dislocations and fractures,
the femoral neck is usually intact and thus the
subsynovial terminal branches also remain in-
tact, although the extracapsular deep branch of
the medial femoral circumflex artery is suscep-
tible to injury (17).
Radiographic Anatomy of the Hip
Several contour lines seen at standard anteropos-
terior (AP) pelvic radiography aid in systematic
interpretation (Fig 3) (18). Both the iliopectin-
eal line (comprising the anterior column of the
acetabulum) and the ilioischial line (comprising
the posterior column) should be continuous and
smooth. Special attention should be paid to the
posterior wall of the acetabulum, as posterior wall
fracture is the most commonly associated acetab-
ular fracture pattern in hip dislocation. Shenton
line disruption can be seen in hip dislocation or
in femoral neck fractures without dislocation. If
a femoral head fracture is present, its location
should be described as involving the femoral head
below or above the fovea capitis.
Mechanisms of Injury
in Hip Dislocation
The most common mechanism of posterior
hip dislocation is a posteriorly directed force
against a flexed knee, with the hip flexed and
adducted, such as from a dashboard injury in
a motor vehicle crash. The force is transmit-
ted through the femur and causes the posterior
aspect of the femoral head to make an impact
upon the posterior wall of the acetabulum.
2184  November-December 2017 radiographics.rsna.org

Figure 3.  Annotated radiographs show the normal anatomy of the hip. (a) The iliopectineal line comprises the anterior column of
the acetabulum, and the ilioischial line is the posterior column. The anterior and posterior walls of the acetabulum can be visualized
through the femoral head. The medial wall of the acetabulum is contiguous with the roof. (b) Of particular importance to hip disloca-
tion is the fovea capitis, which is an important landmark to classify femoral head fractures.

Hip dislocations in sporting activities are rare,
representing only 2%–5% of hip dislocations,
but may occur in high-velocity sports such as
football and rugby (19–21).
The position of the leg at the time of the trauma
determines if the hip dislocates with or without
fracture of the acetabulum or femoral head. Spe-
cifically, if the hip is flexed and adducted, then the
femoral head is most likely to dislocate posteriorly
without fracture. However, a more extended and
abducted position directs the axial load into the
hip joint and increases the risk of fracturing the
posterior acetabulum or femoral head (22). With
progressively greater degrees of abduction, isolated
acetabular fracture without dislocation may result.
The mechanism of anterior dislocation is due
to the rarer combination of extreme abduction,
extension, and external rotation (23).
Some anatomic variations may predispose
an individual to posterior hip dislocation. It has
been observed that despite the millions of car
crashes that occur annually in the United States
(24), hip dislocation remains relatively uncom-
mon, suggesting that there may need to be an
unlikely confluence of external force mecha-
nism and osseous anatomy to dislocate the hip
(25). In contrast, fractures of the femoral shaft
and tibia are much more common than hip
dislocations that involve direct trauma to the
knee region. The two anatomic variations of the
hip that have been described as predisposing a
person to hip dislocation are decreased femoral
anteversion (25) and femoroacetabular impinge-
ment (26,27). Decreased femoral anteversion
is equivalent to relative internal rotation of
the femur, and forcible internal rotation of the
femur with a lever mechanism has been shown
to produce posterior dislocation in cadavers
(25). Persons with femoroacetabular impinge-
ment may be predisposed to traumatic posterior
dislocation, especially in cases of lower-velocity
trauma, such as from sporting activities, with
the proposed mechanism of levering of the
femoral head being due to restricted hip flexion
and internal rotation (26).
Initial Radiographic
Evaluation of Hip Dislocation
The initial imaging evaluation of the acutely trau-
matized patient with suspected hip dislocation is
typically an AP radiograph of the pelvis. Additional
pelvic radiographs, including lateral, oblique, or
Judet views, are not routinely obtained. It is there-
fore important to be able to deduce the direction
of dislocation at frontal imaging. Interpretation
must be performed promptly, as rapid reduction of
the hip is essential. Urgent closed reduction, most
commonly performed in the emergency depart-
ment under sedation, is imperative to reduce the
risk of avascular necrosis. To aid in interpretation
of the initial radiograph, we suggest using a check-
list approach (Fig 4a). It is especially important
to note the presence of a femoral neck fracture,
which contraindicates closed reduction because of
the risk for fracture displacement. The presence of
a femoral neck fracture (or suspicion for an occult
femoral neck fracture) necessitates urgent CT fol-
lowed by surgical intervention.
The femoral head may dislocate in a posterior
or anterior direction depending on the mecha-
nism of injury; the vast majority (approximately
90%) are posterior in direction (3). In posterior
RG  •  Volume 37  Number 7 Mandell et al  2185

Figure 4.  (a) Flowchart demonstrates the integration of imaging and management in patients with hip dislocation. Checklists are
suggested for interpreting the initial pelvic radiograph and subsequent postreduction CT scan. (b) Sample postreduction CT report
is shown for a hypothetical patient with successful reduction of a hip dislocation.

hip dislocation, the femoral head is typically
positioned superolateral to the acetabulum, with
the hip in flexion, internal rotation, and adduction
(Fig 5). The lesser trochanter is often obscured by
the medial femoral cortex owing to internal rota-
tion of the femur. Because of the AP radiographic
technique, the posteriorly dislocated femoral head
may appear to be smaller than the contralateral
femoral head, due to magnification effect.
In contrast, in anterior hip dislocation the
femoral head is most commonly positioned
inferomedial to the acetabulum, and the hip
is typically in marked external rotation, with
smaller degrees of flexion and abduction (Fig 6).
External rotation of the femur causes the lesser
trochanter to be seen en face in anterior disloca-
tions, with greater conspicuity than the contra-
lateral side. In contrast to posterior hip dislo-
cation, the anteriorly dislocated femoral head
may appear larger than the normally positioned
femoral head, owing to magnification effect from
its position being closer to the x-ray source,
although this has been reported to be an unreli-
able sign in anterior hip dislocations (28,29).
A rare type of anterior dislocation is anterior
superior dislocation, with only a few small case
series and case reports in the literature (23). The
more common anterior inferior dislocations are
usually easily recognized on a standard AP radio-
graph of the pelvis. However, the radiographic
appearance of the rare anterior superior hip
dislocation may be less straightforward and may
mimic posterior hip dislocation (28). One helpful
clue to differentiate anterior superior hip disloca-
tion from posterior dislocation is the appearance
of the lesser trochanter. With posterior hip dislo-
cation, the hip is typically in internal rotation and
the lesser trochanter is less conspicuous or com-
pletely obscured by the femoral shaft. In anterior
dislocation, the femur is typically held in external
rotation, allowing nearly the entire cross-sectional
diameter of the lesser trochanter to be visualized.
Postreduction Imaging
of Hip Dislocation
After reduction is attempted, CT is performed to
assess joint congruence, evaluate for intra-articular
fragments, and search for associated bone and
2186  November-December 2017 radiographics.rsna.org

Figure 5.  (a) Drawing demonstrates the typical position of the femur in a posterior dislocation. (b) Posterior hip dislocation in a
19-year-old man with a basketball injury who struck the foot of another player with the knee in extension. Frontal radiograph of the
pelvis shows that the femoral head (orange arrow) is typically positioned superolateral to the acetabulum, with the hip in flexion,
internal rotation, and adduction. Internal rotation of the femur causes decreased conspicuity of the lesser trochanter (yellow arrow).
The dislocated femoral head may appear smaller than the normally positioned femoral head owing to AP radiographic technique and
magnification effect. Note the tiny posterior acetabular wall fracture (red arrow) in this case.

Figure 6.  (a) Drawing demonstrates the typical position of the femur in an anterior dislocation. (b) Anterior dislocation in a 25-year-
old woman who was on a sled that crashed into a tree. Frontal radiograph of the pelvis shows the femoral head (orange arrow)
typically positioned inferomedial to the acetabulum, with the hip in marked external rotation, with milder flexion and abduction.
Anterior superior dislocation of the hip is rare in comparison. External rotation of the femur causes increased conspicuity of the lesser
trochanter (yellow arrow). The dislocated femoral head may appear larger than the normally positioned femoral head owing to AP
technique and magnification effect.

soft-tissue injuries. CT is clearly superior to
radiography for enabling detection of abnormali-
ties about the hip (30), including small acetabu-
lar fractures, intra-articular fragments, step and
gap deformities of the acetabulum (31), fracture
and impaction injuries of the femoral head, and
residual articular incongruities (32). Radiographs
are not adequate to show small intra-articular bone
fragments that can be seen reliably at CT (33).
Evaluation of pure chondral fragments at CT is dif-
ficult, but they may be identified by using narrow
soft-tissue window settings (34), or their presence
may be inferred if there is any incongruity of the
hip joint compared with the contralateral hip joint.
A comprehensive checklist approach (Fig 4a)
and sample dictation (Fig 4b) to aid in interpreta-
tion of the CT study are suggested. Specific bone
findings to include in the search pattern include
the presence of posterior or medial acetabular
fracture, femoral head fracture, and intra-articular
osseous fragments. The congruence of the joint
must be carefully analyzed, as noncongruent joints
require additional surgery. Additional fractures,
such as of the femoral neck, greater trochanter,
or pelvis, should also be assessed. The soft tissues
should also be carefully scrutinized, with particular
attention being paid to the sciatic nerve, the ves-
sels, and any hematomas.
The role of magnetic resonance (MR) imag-
ing in the evaluation of patients with hip dislo-
cation is currently evolving. Muscular injuries,
sciatic nerve injuries, displaced or incarcerated
RG  •  Volume 37  Number 7 Mandell et al  2187
Figure 7.  Summary of the Levin and Thompson-Epstein classifications of posterior hip fractures and dislocations.
labral tears, femoral head contusions, and intra-
articular chondral fragments can be best seen
at MR imaging (35). Although MR imaging is
highly sensitive for detection of pure chondral
fragments, it may be less sensitive than is CT
for detection of small intra-articular osseous
fragments (36). At our institution, MR imaging
is not routinely performed in these cases, and
any future role for MR imaging would likely be
complementary to that of CT. There may also be
some role for MR imaging in helping to predict
the possible development of avascular necrosis,
although previous studies in this regard have not
shown a consistent benefit for MR imaging (37).
Classification of Hip Dislocation
There have been several proposed classification
systems of posterior hip fractures and/or disloca-
tions in the past 66 years, including Thompson
and Epstein in 1951 (38), Stewart and Mil-
ford in 1954 (39), and Levin in 1992 (40). The
Thompson-Epstein and Stewart-Milford clas-
sifications are the most frequently described in
the orthopedic literature (10). Both are based on
the presence and severity of acetabular fracture
and the presence of femoral head fracture. The
Stewart-Milford classification incorporates stabil-
ity of the hip joint. The Levin classification is less
commonly used in the literature but includes
important information about the success of the
initial reduction attempt as well as postreduction
joint congruence. These classifications overlap
substantially and are seldom used in clinical prac-
tice at our institution. None of the classification
schemes can reliably predict functional outcome
and prognosis on the basis of the initial clini-
cal and imaging findings, and several additional
important patterns of injury can be seen that are
not included in these classification systems (41).
A summary of the Thompson-Epstein and Levin
classifications is provided for reference (Fig 7),
although we focus here on describing the key
imaging findings that predict and guide manage-
ment with the most relevant classifications given
in parentheses, rather than focusing on any single
classification system. The Pipkin classification of
femoral head fractures is separately applied and is
also discussed (42).
An additional Epstein classification exists for
anterior dislocations (43), but some authors ad-
vocate using the more established classifications
for posterior dislocation, prefixed by “anterior”
(13). We do not routinely classify anterior disloca-
tions by any system. Instead, we simply describe
any concomitant injuries.
Posterior Dislocation with No or
Insignificant Acetabular Fracture
A posterior hip dislocation with either no
fracture or an insignificant acetabular frac-
ture (Levin 1, Thompson-Epstein 1) (Fig 8)
is typically treated with closed reduction only.
An insignificant acetabular fracture does not
affect hip joint stability. It has been reported
that the size of acetabular fracture that is likely
stable and therefore seen as insignificant is less
than 20% involvement of the posterior wall,
whereas more than 40%–50% involvement is
considered to be probably unstable (44,45).
However, it is not always obvious what size or
location of acetabular fracture would more likely
lead to instability. Occasionally even small (less
2188  November-December 2017 radiographics.rsna.org

Figure 8.  (a) Drawing shows the typical appearance of posterior hip dislocation without acetabular frac-
ture. (b, c) Posterior dislocation with insignificant acetabular fracture in a 19-year-old man (same patient
as in Fig 5) with a basketball injury who struck the foot of another player with the knee in extension.
Frontal radiograph of the right hip (b) demonstrates a posterior dislocation. There is a tiny posterior ac-
etabular fracture (arrow) seen on the radiograph and on the subsequent postreduction CT image (c), which
does not require fixation and is considered an insignificant acetabular injury.

than 20% posterior wall involvement) fractures

are unstable, particularly those that involve the
superior aspect of the posterior wall (46) or a
Bankart-like avulsion of the posterior acetabu-
lar rim (47). To test stability after successful
hip reduction, the orthopedic surgeon obtains
fluoroscopic stress views, with the patient under
general anesthesia. The decision to perform
fluoroscopic evaluation of stability is depen-
dent on the imaging findings and the surgeon’s
discretion. In the authors’ opinion, the radiolo-
gist should describe the size and approximate
percentage of the acetabular fracture if even a
tiny or small fracture is present.
Posterior Dislocation
Not Initially Reducible
If the surgeon is unable to initially reduce a
posterior dislocation (Levin 2), then urgent CT
and definitive surgical management should be
undertaken. Multiple attempts at closed reduc-
tion should not be performed, because of the
risk for iatrogenic femoral neck fracture. The
radiologist can usually deduce the presence of
an irreducible dislocation if initial radiographs
show a dislocation and subsequent CT images
show a persistent dislocation, as the orthopedist
will almost always attempt to reduce the fracture
before CT. In these patients, careful scrutiny of
the CT images following attempted reduction
is especially important to evaluate for intra-
articular osseous fragments that widen the joint.
Other reasons for failure of closed reduction
that may not be evident at CT include a dis-
placed labral tear and herniation (buttonholing)
of the femoral head through a traumatic tear of
the capsule (48,49).
Posterior Dislocation with a
Nonconcentric Joint after Reduction
The presence of any perceptible incongruity
of the joint at postreduction imaging (Levin 3)
(Fig 9) requires further surgical management. It
is imperative for the radiologist to carefully eval-
uate the patient for any asymmetry in the joint
space after reduction and, if asymmetry is pres-
ent, to search for intra-articular osteochondral
fragments by using both bone and soft-tissue
windows. An additional reason for an incongru-
ent joint after reduction is a displaced labral
tear, which is not typically evident at CT. As the
adequacy of reduction determines the long-term
outcome (50), management of an asymmetric
joint is with either arthrotomy (open surgery)
or arthroscopy (51–53) to remove the fracture
fragments, fix the labral tear if necessary, and
RG  •  Volume 37  Number 7 Mandell et al  2189

Figure 9.  (a) Drawing shows posterior dislocation with a nonconcentric joint after reduction (Levin 3).
(b–d) Posterior hip dislocation in a 19-year-old woman who was in a car-versus-tree motor vehicle crash. (b) Initial
frontal radiograph demonstrates the dislocation. (c) Postreduction radiograph shows anatomic reduction but subtle
widening (yellow arrows) of the medial joint space. (d) Postreduction axial CT image demonstrates osseous fracture
fragments (red arrows) in the joint space, which necessitated surgical removal.

attain a perfectly congruent hip joint. MR imag-
ing may be helpful in evaluating the patient for
chondral fragments or a displaced labral tear.
Posterior Dislocation with Acetabular
Fracture Requiring Fixation
A posterior dislocation with an unstable acetabu-
lar fracture (Levin 4; Thompson-Epstein 2, 3,
or 4) requires definitive surgical management
after closed reduction, typically involving open
reduction and internal fixation of the acetabular
fracture. Following closed reduction, skeletal
traction is often used to maintain the reduction,
in anticipation of definitive surgical management.
Three common patterns of unstable acetabular
fracture are a single dominant posterior acetabu-
lar wall fracture fragment (Thompson-Epstein 2)
(Fig 10), a comminuted posterior acetabular wall
fracture (Thompson-Epstein 3) (Fig 11), and a
medial acetabular wall/floor fracture (Thomp-
son-Epstein 4) (Fig 12). An additional fracture
pattern that the radiologist should recognize is
marginal impaction of the acetabulum (Fig 13),
which describes rotation and impaction of the
subchondral bone into the underlying cancellous
bone (54,55). Marginal impaction is typically
treated with elevation and bone grafting and, when
unidentified at imaging or surgery, can lead to
imperfect reduction and an increased occurrence
of osteoarthritis. Three-dimensional reformation
of CT scans may be helpful in assessing fracture
morphology and percentage loss of the posterior
acetabular wall (56). Acetabular injury is not lim-
ited to the articular surface, as plastic deformation
and impaction of the extra-articular retroacetabu-
lar surface have also been described, which may
prevent anatomic reduction if left untreated (57).
Posterior Dislocation
with Femoral Head Fracture
The management of posterior hip dislocation
with femoral head fracture (Levin 5, Thompson-
Epstein 5) is dependent on fracture involvement
of the weight-bearing dome of the femoral head.
If the fracture does not involve the weight-bearing
dome, then surgical treatment is not required in
2190  November-December 2017 radiographics.rsna.org

Figure 10.  (a) Drawing shows a posterior dislocation and a single dominant posterior acetabular wall fracture fragment
(Thompson-Epstein 2) requiring fixation. (b, c) Initial pelvic radiograph (b) and postreduction axial CT image (c) in a 27-year-
old man in a car-versus-tree motor vehicle crash show a posterior dislocation with a dominant posterior acetabular fracture
fragment (arrow).

Figure 11.  (a) Drawing shows a posterior dislocation and a comminuted posterior acetabular wall fracture (Thompson-Epstein 3).
(b, c) Posterior dislocation and fracture of the left hip in a 24-year-old man who was tackled while playing football. (b) Initial pelvic
radiograph demonstrates a cortical irregularity (arrows) of the acetabulum. (c) Coronal CT image after attempted reduction shows a
comminuted posterior acetabular wall fracture with fracture fragments (arrows) superior to and within the joint.

all cases. The fovea capitis, the focal concavity of
the medial femoral head where the ligamentum
teres originates, is the anatomic landmark that
demarcates the weight-bearing dome (above the
fovea capitis) from the non–weight-bearing por-
tion (below the fovea capitis) of the femoral head.
The Pipkin classification (42) (Fig 14) is often
used to characterize the location of the fracture as
inferior to the fovea (Pipkin 1) (Fig 15) or involv-
ing the weight-bearing dome (Pipkin 2) (Fig 16).
The Pipkin 3 and 4 classifications are less clini-
cally useful because involvement of the weight-
bearing dome is ambiguous. A Pipkin 3 fracture
(Fig 17) is a femoral head fracture (either Pipkin
1 or 2) with a concomitant femoral neck fracture.
A Pipkin 4 fracture (Fig 18) is a femoral head
fracture (Pipkin 1, 2, or 3) with a concomitant
acetabular fracture.
The main goal in treatment of femoral head
fractures is anatomic reduction of the fracture,
particularly in injuries that extend into the
weight-bearing portion of the femoral head (22).
However, these are rare injuries and the optimal
management of femoral head fractures is contro-
versial owing to the small number of cases seen
at any one institution (58). Nonsurgical man-
agement may be appropriate for nondisplaced
fractures not involving the weight-bearing dome
(Pipkin 1; below the fovea capitis), although
surgical treatment options can include excision of
RG  •  Volume 37  Number 7 Mandell et al  2191

Figure 12.  (a) Drawing shows a

posterior dislocation and a medial
acetabular wall and floor fracture
(Thompson-Epstein 4). (b) Initial
pelvic radiograph in a 59-year-old
man who tripped on wires and
fell from standing, landing on his
right side, demonstrates a frac-
ture through the entire medial
acetabular wall (arrow). (c) Pos-
terior dislocation is more clearly
evident on a lateral radiograph,
which demonstrates an empty
acetabular fossa (arrows) and
posterior dislocation of the femo-
ral head. (d) Axial postreduction
CT image demonstrates commi-
nution of the medial acetabulum
(arrows).

Figure 13.  Marginal impaction in a 25-year-old man who was in a motor vehicle crash.
(a) Axial postreduction CT image demonstrates marginal impaction (yellow arrows) of
the inferior posterior wall, where subchondral sclerosis (red arrow) represents impacted
trabeculae. (b) More superior CT image also demonstrates a large posterior wall fracture
(blue arrow). In addition to fixation of the large posterior wall fracture, the marginal im-
paction was treated with loosening of the impacted fragments with an osteotome and
elevation with bone cement.

fracture fragments, open reduction internal fixa-
tion of the femoral head, and arthroplasty (59).
The prognosis for complete functional recovery
for a Pipkin 1 or 2 injury is usually good, for a
Pipkin 4 injury it is dependent on the size and
morphology of the acetabular fracture, and for
Pipkin 3 injuries it is generally poor (60).
An important pattern of femoral head injury
not included in the Pipkin classification but none-
theless essential for the radiologist to describe
is impaction injury to the femoral head (61,62).
This spectrum of injury can be considered analo-
gous to a Hill-Sachs lesion of the shoulder and
may range from cartilage impaction without sepa-
ration of the fracture fragment to subchondral
signal changes only evident at MR imaging (35).
The size, severity, and location of such an impac-
tion injury leads to highly variable management
2192  November-December 2017 radiographics.rsna.org

Figure 14.  Summary of the Pipkin classification of femoral head fractures.

Figure 15.  (a) Drawing shows a Pipkin

1 fracture. Arrow = fovea. (b) Pipkin 1
fracture in a 17-year-old female adoles-
cent who was in an motor vehicle crash.
Coronal CT image demonstrates a small
fracture (arrow) of the right anteroinfero-
medial femoral head, located inferior to
the fovea (which is positioned more pos-
teriorly than in a).

options ranging from conservative management
(Fig 19) to arthroplasty (Fig 20).
Classification of Anterior Dislocation
Anterior hip dislocations (Figs 21–23) are much
less common than posterior hip dislocations, ac-
counting for approximately 10% of hip dislocations
(63). Additional osseous injuries commonly include
impaction injuries of the femoral head in 35% of
cases (29). Anterior hip dislocations can be inferior
or superior. Anterior inferior hip dislocation (ob-
turator dislocation) (Figs 21, 22) is by far the most
common direction of anterior dislocation. Anterior
superior hip dislocation (Fig 23) is rare, with only
a few case reports in the literature (23,28), and is
also called pubic or iliac dislocation, depending
on the position of the femoral head. As previously
discussed, anterior superior hip dislocation may
mimic posterior dislocation on a frontal radiograph,
except that the hip is not internally rotated, so that
the lesser trochanter remains clearly visible.
Although a classification of anterior disloca-
tion has been described by Epstein, this classifi-
cation scheme is not in widespread use given the
relative rarity of these injuries and the fact that
associated fractures are uncommon.
Central Dislocation: A Misnomer
The term central dislocation is considered an
outdated phrase that is no longer relevant to the
classification of hip injuries (13). A central dis-
location (Fig 24) refers to medial displacement
of the femoral head due to a displaced acetabu-
lar fracture. In these cases, it is best to describe
the acetabular fracture and the femoral head as
protruding medially into the pelvis.
RG  •  Volume 37  Number 7 Mandell et al  2193

Figure 16.  (a) Drawing shows a Pipkin 2 fracture. (b, c) Pipkin 2 fracture in a 27-year-old man who was tackled on
his left side while playing football. Coronal (b) and axial (c) CT images show a fracture of the femoral head above
the level of the fovea capitis (arrow in b). The hip was initially posteriorly dislocated but reduced at the time of CT.

Figure 17.  (a) Drawing shows a Pipkin 3 fracture. (b, c) Pipkin 3 fracture in a 52-year-old man who was in a
motorcycle-versus-automobile crash. Coronal (b) and axial (c) CT images demonstrate a highly comminuted
fracture and a posterior dislocation of the femoral head (yellow arrows), with a fracture (red arrow in b) of the
femoral neck.

Figure 18.  (a) Drawing shows a Pipkin 4 fracture. (b, c) Coronal (b) and axial (c) CT images in a 24-year-old
man in an motor vehicle crash, who swerved to avoid a truck but hit a tree, demonstrate a fracture of the inferior
femoral head (yellow arrow in b) and a fracture of the posterior acetabulum (red arrow). Note the tiny intra-
articular fragment seen on the coronal image (blue arrow in b).
2194  November-December 2017 radiographics.rsna.org

Figure 19.  Femoral head impaction injury in a 57-year-old woman who was in a car that crashed into a tree. (a) Frontal pelvic radio-
graph demonstrates a reduced dislocation with a posterior acetabular fracture (yellow arrow). There is subtle flattening (red arrow) of
the inferomedial femoral head. (b) Coronal CT image allows confirmation of the impaction injury of the inferomedial femoral head
(red arrow). The patient was treated surgically for the acetabular fracture, but if the femoral head impaction were an isolated injury it
likely would have been treated conservatively.

Figure 20.  Femoral head impaction injury requiring arthroplasty in a 65-year-old woman who tripped and fell
from a standing height. (a) Frontal pelvic radiograph demonstrates posterior subluxation of the right femoral
head and a posterior acetabular fracture, which is difficult to characterize at radiography. (b) Coronal CT image
better demonstrates the posterior acetabular fracture (yellow arrow). (c) Sagittal CT image shows that the femoral
head is perched onto the posterior acetabulum with impaction (red arrow) of the articular surface of the femoral
head. (d) Surgical specimen after resection of the femoral head demonstrates extensive impaction injury (arrows).
(e) Radiograph shows the acetabular reconstruction and total hip arthroplasty.

Pitfalls in Imaging Hip Dislocations

There are several circumstances in which the clini-
cal and imaging signs of hip dislocation may be
subtle. Two potential pitfalls in the imaging of hip
dislocations are hip dislocations that do not exhibit
the typical varus angulation and internal rotation
(Fig 25) and hip dislocations that have spontane-
ously reduced before imaging (Fig 26). Cases of
hip dislocation where the femur does not exhibit
the typical varus angulation and internal rotation
can be difficult to diagnose, as findings on the
initial pelvic radiographs can appear nearly normal
at first glance. However, closer scrutiny may reveal
loss of the joint space on the affected side, typi-
cally with the top of the femoral head projecting
superior to the acetabular roof. rithm is identical to a hip dislocation reduced
It is important to recognize a spontaneously by the orthopedist. The presence of an intracap-
reduced hip dislocation, as the treatment algo- sular gas bubble in the hip joint (Fig 21) (in the
RG  •  Volume 37  Number 7 Mandell et al  2195

Figure 21.  Anterior hip dislocation without fracture in a 25-year-old woman (same patient as in Fig 6b) who was on a sled that
crashed into a tree. (a) Initial pelvic radiograph demonstrates an anterior inferior (obturator) dislocation, with a characteristic
inferomedial position (yellow arrow) of the femoral head, and prominence of the lesser trochanter (red arrow) due to external
rotation. The right femoral head appears subtly larger than the normally located left femoral head owing to its position closer
to the x-ray source. (b) Postreduction CT image shows anatomic reduction with a congruent joint. Note the small focus of
gas (blue arrow) abutting the anterolateral aspect of the femoral head. The presence of intra-articular gas in the setting of hip
trauma implies a prior dislocation.

Figure 22.  Anterior hip dislocation with associated fractures.

(a) Initial pelvic radiograph in a 29-year-old woman who fell from a
first-floor window shows an anterior inferior (obturator) dislocation
of the left hip (yellow arrow) and marked widening of the pubic
symphysis (red arrow), in keeping with an anterior-posterior com-
pression pelvic injury. (b, c) Subsequent postreduction axial (b)
and coronal (c) CT images demonstrate right pubic and left ace-
tabular fractures (green arrows in b) and a vertically oriented sacral
fracture (blue arrows in c).

femoral head is positioned superior and lateral

absence of penetrating trauma or joint aspiration)
is considered a reliable indicator of hip disloca-
tion, thought to be due to release of intracapsular
nitrogen produced by forcible distraction and re-
sulting vacuum phenomenon (64). Another clue
is an isolated posterior acetabular wall fracture.
In these cases, it is especially important to care-
fully scrutinize the joint space for any asymme-
try or intra-articular debris, which may warrant
surgery. If there is debris in the weight-bearing
portion of the hip joint, many orthopedic sur-
geons will place the patient in skeletal traction to
prevent any further chondral injury while await-
ing definitive management in the operating room.
As previously discussed, another pitfall is the
rare anterior superior hip dislocation, where the
to the acetabulum, thereby mimicking a poste-
rior dislocation on a frontal radiograph of the
pelvis. The appearance of the lesser trochanter
may be the only clue to differentiate between
these two directions of dislocation. The lesser
trochanter in an anterior superior hip disloca-
tion remains clearly visible, whereas the lesser
trochanter is usually obscured in a posterior hip
dislocation owing to internal rotation of the fe-
mur. This distinction is important, as the reduc-
tion maneuver for an anterior dislocation differs
from that for a posterior dislocation.
Associated Osseous Injuries
In addition to fractures of the femoral head
and acetabulum, proximal femur fractures as-
sociated with hip dislocation (Fig 27) include
femoral neck and greater trochanteric fractures.
Femoral neck fractures greatly increase the risk
2196  November-December 2017 radiographics.rsna.org

Figure 23.  Anterior superior hip dislocation in a 45-year-old woman who was in a car struck by a semitrailer in a motor vehicle
crash. (a) Frontal projection CT topogram demonstrates the anterior superior dislocation, where the femoral head (yellow arrows)
is dislocated superiorly. In contrast to a posterior dislocation, the femur is in external rotation, and the lesser trochanter (red arrow)
is clearly visible. (b) Axial CT image demonstrates the anterior direction of the dislocation. (c) Three-dimensional volume-rendered
reconstruction in a sagittal orientation shows the anterior superior dislocation of the femoral head (yellow arrow) and a displaced
fracture of the greater trochanter (blue arrow).

Figure 24.  Medial acetabular fracture with medial displacement of the femur in a 75-year-old man who tripped and fell from
standing. (a) Pelvic radiograph demonstrates medial displacement of the femoral head (yellow arrows) into the pelvic cavity due to
a displaced medial acetabular fracture. (b) Coronal CT image demonstrates the articular surface gap (red arrow) of the acetabular
roof and medial displacement of the femoral head. This pattern of injury is not considered a hip dislocation, and the description of
“central dislocation” is no longer considered appropriate or useful.

Figure 25.  Pitfall in imaging of hip dislocation: Posterior hip dislocation without typical varus angulation and internal rotation in
a 46-year-old man who flipped over the handlebars while riding an off-road motorcycle. (a) Initial pelvic radiograph demonstrates
absence of the left hip joint space, with the superior aspect of the femoral head overlapping the acetabular roof (yellow arrows),
disruption of the Shenton line (dashed lines; compare with the right side that demonstrates a continuous Shenton line), and an
acetabular fracture fragment projecting superior to the hip (red arrow). In addition, the left femoral head appears smaller than the
right femoral head owing to magnification effect. (b) Axial CT image allows confirmation of the posterior dislocation with a fat-fluid
level (green arrow) in the acetabular fossa.

for avascular necrosis, and closed reduction is radiologists should be aware of a high preva-
contraindicated in the presence of a femoral lence of knee injuries associated with posterior
neck fracture owing to the risk of displacement. hip dislocation due to the mechanism of force
In addition to fractures of and around the hip, transmission through the flexed knee. Up to a
RG  •  Volume 37  Number 7 Mandell et al  2197

Figure 26.  Pitfall in imaging of hip dislocation: Spontaneously reduced dislocation in a 34-year-old man who was
the unrestrained driver of a truck in a motor vehicle collision. (a) Initial coronal CT image demonstrates a small osteo-
chondral fracture (yellow arrow) of the medial right femoral head just above the level of the fovea. (b) Axial CT image
demonstrates a fracture (red arrow) of the right posterior acetabulum. The findings are consistent with a Pipkin 4, Levin
5 fracture dislocation that has spontaneously reduced. Surgical fixation of the acetabulum was performed because of
instability of the hip.

Figure 27.  Proximal femur frac-

tures in two patients with hip dis-
location. (a) Right femoral neck
fracture in a 52-year-old man who
was in a motorcycle-versus–sport
utility vehicle crash. Frontal ra-
diograph of the right hip demon-
strates a posterior hip dislocation
with a large posterior acetabular
fracture (yellow arrow). There is a
mildly displaced femoral neck frac-
ture (red arrow) through the lesser
trochanter. (b) Greater trochanter
fracture in a 45-year-old woman
who was in a semitrailer crash.
Frontal radiograph of the right hip
demonstrates a posterior hip dislo-
cation with internal rotation of the
femoral head and a laterally dis-
placed greater trochanter fracture
(arrow).

93% prevalence of ipsilateral knee injuries has
been reported at MR imaging; these include ef-
fusion, contusion, and meniscal tears (65).
Associated Soft-Tissue Injuries
Soft-tissue injuries associated with hip disloca-
tion include nerve injury, labral and ligamentous
tears, muscle tears, and hematomas. Nerve inju-
ries occur in approximately 10% of hip disloca-
tions in adults and 5% of those in children (66).
The three most significant nerves around the
hip are the femoral nerve anteriorly, the lateral
femoral cutaneous nerve located subcutaneously
medial to the anterior superior iliac spine, and
the sciatic nerve posteriorly.
The sciatic nerve is the most commonly
injured nerve in posterior hip dislocations. The
sciatic nerve includes the L4–S3 nerve roots and
divides into tibial and peroneal branches before
exiting the pelvis in most patients at the greater
sciatic notch anterior to the piriformis muscle
(66). Of the two branches, the peroneal branch
is more susceptible to traumatic injury, pos-
sibly because of its fixed tethering at the fibular
neck and sciatic notch. The mechanism of acute
neural injury is usually due to stretching and
compression of the nerve by the posteriorly
dislocated femoral head, with acute laceration
significantly less common in the absence of a
penetrating injury. The rate of occurrence of ma-
jor sciatic nerve injury (Fig 28) is correlated with
the length of time that a hip remains dislocated,
with a higher rate of occurrence in patients
with prolonged dislocation (67). At least partial
recovery of nerve function has been shown to oc-
cur in 60%–70% of patients (67). Injuries of the
femoral nerve (68) and lateral femoral cutaneous
nerve due to hip dislocation are exceedingly rare.
Late neurologic sequelae may be due to encase-
ment by heterotopic ossification (69).
2198  November-December 2017 radiographics.rsna.org

Figure 28.  Sciatic nerve injury in an 18-year-old man who was an unre-
strained driver ejected in a motor vehicle rollover. (a) Initial pelvic radio-
graph demonstrates a right posterior hip dislocation without acetabular
fracture, which was subsequently reduced. (b) Axial CT image (soft-tissue
window) demonstrates a congruent hip joint, but there is hematoma
formation posteriorly with effacement of the fat plane (yellow arrows)
between the quadratus femoris and gluteus maximus muscles, along
the expected course of the sciatic nerve. (c, d) Axial fat-suppressed T2-
weighted MR image (c) demonstrates expansion of the right sciatic nerve
with surrounding edema (red arrow). The blue arrow indicates the normal
left sciatic nerve. A more inferior image (d) shows a tear of the obturator
externus muscle (green arrows).

Long-term Complications
of Hip Dislocation
The most common long-term complication of
hip dislocation is posttraumatic osteoarthritis,
with the rate depending on the severity of the
acetabular fracture. The rate of occurrence of
posttraumatic osteoarthritis ranges from 24% for
simple dislocations to up to 88% in patients with
complex acetabular fractures (70).
Avascular necrosis (Fig 29) is the second
most common complication and is thought to
be due to a combination of disruption of the
blood supply at the time of dislocation, arterial
vasospasm, and/or compromised venous outflow.
The time to reduction directly influences the
incidence of avascular necrosis, which ranges
from 4.8% in hips reduced within 6 hours to
52.9% in hips reduced more than 6 hours after
the injury (60). The odds ratio to develop avas-
cular necrosis in dislocations reduced after 12
hours have elapsed is 5.6 compared with those
reduced before 12 hours (71). It is important
for the radiologist to be alert to subtle findings
of dislocation on the AP radiograph of the pelvis
obtained as part of the trauma series, as hip
dislocation seen at initial trauma CT or radiog-
raphy should be communicated urgently to re-
duce this risk of vascular compromise. The type
of injury also influences the risk for avascular
necrosis, with a significantly higher incidence of
avascular necrosis in higher-grade injuries (60).
Early diagnosis of avascular necrosis is chal-
lenging. Although MR imaging is able to depict
abnormal subchondral marrow signal, this
finding is nonspecific and is more likely than
not to be transient (37). Similarly, although
single photon emission computed tomography
(SPECT) with technetium 99m medronate
can demonstrate a transient global decrease
of femoral head blood flow in the early injury
period in 10% of patients with hip disloca-
tion, this pattern of decreased blood flow does
not correlate with the incidence of avascular
necrosis (72). There may be a role for contrast
material–enhanced MR imaging in the predic-
tion of avascular necrosis, although this has so
RG  •  Volume 37  Number 7 Mandell et al  2199

Figure 29.  Avascular necrosis as a late complication of posterior hip dislo-

cation in a 38-year-old man found down with facial lacerations. (a, b) Initial
pelvic radiograph (a) shows a left posterior hip dislocation without ace-
tabular fracture. Initial attempts at reduction were unsuccessful (Levin 2),
with persistent dislocation seen on an axial CT image (b). There is hem-
orrhage in the acetabular fossa (yellow arrow in b) and a focus of intra-
articular gas (red arrow in b), which is a common finding in dislocation.
The hip was successfully reduced (not shown) under general anesthesia.
(c) Follow-up radiograph 18 months after the initial injury demonstrates
subchondral sclerosis, articular surface irregularity, and osteophyte forma-
tion consistent with avascular necrosis and osteoarthritic changes.

necrosis. Evaluation of hip dislocation requires

far demonstrated mixed results in the setting of
femoral neck fractures (73).
Heterotopic ossification may occur in up to
32% of patients with posterior dislocation and
associated acetabular wall fractures, despite the
routine use of indomethacin as prophylaxis (50).
Heterotopic ossification associated with hip dis-
location is usually low grade when it occurs, and
the radiographic findings of heterotopic ossifica-
tion can often be overestimated (74). Clinically
significant heterotopic ossification is rare (75).
Sciatic nerve entrapment by heterotopic ossifi-
cation following a hip fracture dislocation has
been reported (69).
Conclusion
The hip is a highly stable joint owing to its osse-
ous, labral, ligamentous, and soft-tissue anat-
omy, usually requiring high-energy trauma to
dislocate. Hip dislocations represent a spectrum
of injuries, all of which are orthopedic emer-
gencies with a relatively high rate of morbidity,
predominantly due to posttraumatic osteoar-
thritis and avascular necrosis. Treatment by the
orthopedic team is performed in two stages.
At the initial stage, the goal is to perform rapid
closed reduction of the hip. The second stage is
focused on definitive management. Time from
injury to reduction has been shown to be highly
correlated with the risk for developing avascular
not only radiographic detection of subtle find-
ings of dislocation and urgent communication
to the treating physician, but also the inference
of potential associated secondary osseous and
soft-tissue injuries that could place the patient at
risk for early osteoarthritis. The key features that
guide management can be succinctly described
by using a checklist approach.
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