EMS Patch: On scene with a 25 year-old male unrestrained driver who just crashed his car into a tree going ~50 mph.
 
EMS cellphone photo of the crash:

 

 
The patient presents in c-collar and on backboard, yelling in pain, “Doc, my right leg! I can’t move my right leg! It hurts so much!”
 
HPI:
25 yo unrestrained male driver with no significant past medical history lost control of his car going ~50 mph and crashed head-on into a tree. He called 911 because of the pain and inability to use right leg. No loss of consciousness, non-ambulatory on scene, airbags deployed, denies substance use. EMS found steering column intact but significant passenger space intrusion.
 
The patient’s only complaint is right leg pain.
 
Vitals

 
T: 38C
BP: 136/88 mmHg
HR: 110 bpm
RR: 24 bpm
O2 sat: 98% on RA
 
 
Physical Exam
 
Primary Survey:
A: intact and clear of foreign bodies
B: bilateral breaths present
C: femoral, radial, and PT pulses intact
D: GCS 15
E: patient completely undressed, no gross bleeding, no foreign bodies, but lying on stretcher with right hip flexed and adducted, and right knee flexed with right knee lying on top of left knee.
 
Secondary Survey:
HEENT: no crepitus, PERRL & EOMI, no midface instability, no septal hematoma, no hemotympanum, no Battle signs nor orbital ecchymosis
Neck: in c-collar, trachea midline, no cervical spine tenderness
Chest: bilateral breath sounds intact, no chest wall tenderness, equal excursion of ribs bilaterally
Abdomen: NTND, no ecchymosis
Pelvis: stable and no crepitus but right leg flexed at hip and knee, internally rotated and shortened
Extremities: no penetrating trauma, ecchymosis nor abrasions including in groin (as best as can be assessed) or axilla. Distal pulses intact.
Back: No ecchymosis, penetrating trauma or abrasions. No gross blood on rectal and tone intact.
Neuro: moves all distal extremities but will not move right hip nor knee due to pain
 
 
 
Differential Diagnosis
    Right hip dislocation +/- pelvic fracture
    Intracranial hemorrhage: less likely 2/2 lack of LOC and GCS 15 now
    Cervical spine pathology (bony vs. ligamentous): less likely given lack of midline tenderness and grossly intact neuro exam
    Deceleration injuries: aortic dissection, duodenal perforation, etc.: again less likely given normotension
 
 
Adjuncts to Primary and Secondary Survey
 
CXR: no PTX, no grossly displaced ribs nor clavicles
 
eFAST: (indicated?) but negative
 
Pelvic x-ray:

 

 
 
What injuries does this patient currently have?
 
Right posterior hip fracture (and possible pelvic fracture with slight symphysis widen and asymmetric SI joints
 
 
 
Can you clear the patient's c-collar?
 
No. Based on NEXUS criteria this patient’s distracting injury prevents one from safely clearing his c-collar. The Canadians agree as well.
 
 
 
What is the most common type of native hip dislocation?
 
Posterior hip dislocation represent 80-90% of all hip dislocations. Anterior, superior, and inferior, the last of which is seen almost exclusively in pediatric patients, are all much less common.
 
Of note, hip dislocations occur more commonly in general in those with hip protheses than in those with native hips.
 
 
 
What is the common mechanism of posterior hip dislocation?
 
Axially loading of flexed hip and flexed knee AKA unrestrained driver in head-on collision where knee hits dashboard.
 
 
 
What are the associated neurovascular and osseous injuries with a posterior hip dislocation?
    Nerve:

      Sciatica nerve –> peroneal muscle paralysis
      Femoral nerve –> quads
    Artery:

      Femoral artery: rarely injured
      Retinacular branches of circumflex femoral artery –> AVN of femoral head
    Osseous:

      Acetabular or femoral head fractures (50% of the time)
 
 
In what time frame does one need to reduce this dislocation?
 
If no associated fracture, this dislocation should be reduced in the ER urgently within 6 hours to minimize the risk of AVN.
 
 
 
How does one reduce a posterior hip dislocation?
 
Make sure that you have adequate sedation and muscle relaxation as one is working against some of the strongest muscles in the body!

“Navy Football”, by Damon J. Moritz via America’s Navy
    The Allis Method AKA Traction-Countertraction Method: a two-person technique

      Provider #1 = “Countertraction”: with the patient supine on the stretcher, restrain the patient’s hips so that they are not lifted off the bed once traction is applied
      Provider #2 = “Traction”: with the patient supine, flex the knee and the hip to or past 90 degrees, apply axial traction along the length of the femur away from the body, and internally and externally rotate the hip to free the femur head from behind the rim of the acetabulum. Since you are working against the quadriceps and hamstring muscles, one might have to stand on the stretcher over the patient, straddle the injured leg, and hugging the shin to one’s chest use one’s legs to generate adequate traction.
    Captain Morgan Technique: can be done with only one person, but countertraction can help

     

      Provider #1 = “The Captain”: Place one’s foot on the edge of the stretcher so that one’s knee is underneath the patient’s knee on the injured side. One’s ipsilateral hand should also be in the popliteal fossa to aide with traction and positioning. Flex one’s calf to elevate the knee while pushing down on the patient’s tibia. Of note, make sure that the fulcrum is the popliteal fossa and that traction is constant and gradually increasing to minimize risk of tibial injury. Again, internal and external rotation may be necessary
      Provider #2 = optional countertraction. Alternatively, leave the patient on the backboard and strap their pelvis down (thanks, ALiEM!)

 

 
 
What is this patient's disposition?
Orthopedic consultation and likely admission as patients will have to be non-weight bearing for 24-48 hours, require pain control, are often placed in hip immobilizers (think huge foam-wedge between the patient’s legs) and require frequent neuro-checks.
 
 
Bibliography:
Germann, C. A., & Fix, M. L. Chapter 043. Hip and Femur Injuries. In A. B. Wolfson, R. L. Cloutier, G. W. Hendey, L. J. Ling, C. L. Rosen, & J. Schaider (Eds.), Harwood-Nuss’ Clinical Practice of Emergency
Medicine (6th ed.). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=booktext&D=books2&AN=01817268/6th_Edition/3&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/EDITORS%5b1%5d.
 
Hendey, G. W., & Avila, A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med [serial online]. 2011; 58: (6), 536-540. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21839540.
 
Lin, Michelle. Trick of the Trade: Captain Morgan technique for hip dislocation. Academic Life in Emergency Medicine. Accessed July 15, 2015. Posted December 13, 2011. http://www.aliem.com/trick-of-the-trade-captain-morgan-technique-for-hip-dislocation/

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