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Reduction - Hip dislocation

This procedure is usually performed using procedural sedation which is covered separately

Indications

Hip dislocation (prosthetic or non-prosthetic)

and

No fracture demonstrated on X-ray

Contraindications (absolute in bold)

Life or limb-threatening conditions

Fractures of pelvis or femur (risk of displacement during reduction)

Open dislocation

Neurovascular compromise (urgent reduction by orthopaedics recommended)

Delayed presentations for longer than seven days (increased risk of fracture and vascular injury)

Alternatives

Reduction by orthopaedic team in emergency department

Reduction in operating theatre

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications

Failure (of reduction, of immobilisation, or recurrence)

Neurovascular damage (particularly sciatic nerve)

Fracture

Compartment syndrome

Avascular necrosis of femoral head

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Additional clinicians required for procedural sedation

Equipment

None

Positioning

Supine on bed with head slightly elevated

Medication (for procedural sedation)

IV pain relief prior to procedure:

Fentanyl 50-100mcg IV or morphine 5-10mg IV titrated to relief of pain

Often followed by procedural sedation:

No single sedative agent recommended for every patient, typically

Nitrous oxide titrated 50-70% titrated to pain relief or

Bolus ketamine or propofol 1mg/kg (dose reduced to 0.3-0.5mg/kg if frail or elderly)

Further titrated 20mg boluses to minimum level required for patient comfort

Sequence (overall approach)

Provide analgesia

Examination for other injuries and fractures

Vascular assessment of leg (pulses, capillary refill)

Neurological assessment of leg (power and sensation)

Bedside pre-reduction X-rays

If reduction cannot be achieved consult orthopaedics or a more experienced provider

We outline two approaches:

Captain Morgan technique (preferred technique)

Proceduralist stands on the patient’s affected side

Flex hip and knee to 90 degrees

Proceduralist placed one foot up on the bed and knee behind the patient knee

Assistant holds down pelvis by applying pressure over anterior iliac crests

Apply an upward force by plantar flexing the foot to lift the patient’s leg

If unsuccessful, repeat with internal rotation, external rotation, adduction or abduction

Allis technique (traditional method)

Proceduralist stands on the bed (with brakes on)

Assistant holds down pelvis by applying pressure over anterior iliac crests

Axial traction applied behind knee (towards ceiling) with increasing force

Apply rocking internal and external rotation as traction is applied

As the hip begins to reduce, extend the hip and externally rotate

Post-procedure care

Check X-ray, circulation and limb function:

Reassess neurological vascular status (sensation and power)

Reassess pulses and capillary refill

Assess for resolution of shortening and rotational deformity

Assess joint motion through flexion and extension (avoiding extremes of motion)

Obtain post-reduction X-ray (patient should not leave the department until confirmed satisfactory)

Ongoing care:

Tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds

Discuss admission or follow-up with orthopaedic team

Document procedure, neurovascular assessments, X-ray findings and management plan

Patient advice:

Recommend controlled passive range-of-hip motion exercises and early mobilisation

Extremes of motion should be avoided for 4-6 weeks to allow for capsular and soft tissue healing

Posterior dislocation: avoid flexion of the hips past 45 degrees

Anterior dislocation: avoid hyperextension of the hip with external rotation

Tips

Hip dislocation is difficult to reduce unless recurrent in nature

Posterior dislocations (90%) present shortened, flexed, adducted and internally rotated

Anterior dislocation (10%) present mildly shortened, flexed, abducted and externally rotated

Always search for other fractures and serious injuries when treating a dislocated joint

Always perform a neurovascular exam before and after a relocation attempt

Reassurance, verbal distraction, effective pain relief and sedation all aid successful joint relocation

Early orthopaedic team input recommended for fractures or neurovascular compromise

Discussion

Most dislocations of native joints occur after serious trauma, usually with associated fracture. Prompt reduction is with orthopaedic input is recommended to minimise the chance of sciatic nerve injury or avascular necrosis of the femoral head. Prosthetic hip dislocation is a separate issue usually occurring with minimal force without the risk of serious complications. These can usually be safely relocated by emergency physicians under procedural sedation.

We have chosen the Captain Morgan approach as our preferred method of reduction, as it allows the clinician to combine calf and upper extremity strength to facilitate the reduction by the bedside. The Allis technique is effective in approximately 60% of reduction attempts. It is in common use but requires an awkward position and use of lower back muscles risking injury. There are many suitable alternatives.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Gottlieb M. Hip dislocations in the emergency department: a review of reduction techniques. J Emerg Med. 2018;54(3):339-347. doi:10.1016/j.jemermed.2017.12.002

Allis OH (1895): The hip. Philadelphia: Dorman; 1895.

Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011;58(6):536-540. doi:10.1016/j.annemergmed.2011.07.010

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