What’s the Diagnosis? By Dr. Loran Hatch

20 yo male presents to the ED with left hip pain after MVC PTA. Patient was restrained back seat passenger, no LOC. Patient appears very uncomfortable on stretcher, with left leg propped on rolled blanket. Tenderness at left hip but no obvious deformity. LLE with DP pulses 2+, sensation intact, will wiggles toes.

Diagnosis: Left Posterior Hip Dislocation

• Typically high energy trauma, most commonly MVC
• Posterior force to flexed knee
• Orthopedic emergency - reduce ASAP, within 6 hours to prevent complications
• Exam: Extremity shortened with internal rotation and adduction
• Reduction Techniques in the ED:
• Allis maneuver- flex knee and hip to 90 degrees, continuous upward traction of femur while assistant applies downward pressure on pelvis, can apply gentle internal and external rotation of femur

• Captain Morgan- your foot on stretcher with knee posterior to patient’s knee, pull downward on patient’s ankle with upward forward of patient’s hips (lifting your heel), also stabilize pelvis with downward pressure
• Stimson maneuver- Patient prone, downward traction of femur at knee with internal and external rotation. Also with direction pressure on pelvis and femoral head.

• Complications: Fractures, Sciatic nerve injury, Avascular necrosis of femoral head (proportional to delay in reduction)
• Post reduction: gentle ROM, NV exam and post reduction X-Ray
• Consult Ortho for further management: may recommend post reduction CT pelvis to evaluate for fracture not obvious on x-ray (fractures of acetabulum or femoral head), abduction pillow, brace or hip binder

References

Steele M, Stubbs AM. "Hip and Femur Injuries." Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 1853-55.

Steele MT, Stubbs AM. Chapter 270. Hip and Femur Injuries. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e New York, NY: McGraw-Hill; 2011.

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