Date: Mon, 17 Jun 2002 13:09:41 -0400
Subject: Hip Dislocation - Closed Reduction
Dear Members of the Trauma List:
I recently watched with great interest a segment on Trauma Care by The Learning Channel. It was quite interesting, there was a segment where a young woman presented to the Trauma Center with a Hip Dislocation. Under IV sedeation, during which she was talking, had two failed attempts at reduction in the trauma center. She eventually had a third reduction attempt -under IV sedation-while awake enough to talk.
All the while there was no mention of an Othopaedic Surgery consult, as the manuevers were performed by the ED and surgical physicians.
My inquiry is this:
In YOUR hospital are hip dislocation-reductions performed by non-orthopaedic physicians?
In YOUR hospital such reductions are performed under what type of anesthesia?
In YOUR hospital how are failed closed reduction attempts handled?
In YOUR hospital/practice how is the stability of the reduced hip determined?
Thanks to all for taking the time to respond/comment
Sam
Date: Mon, 17 Jun 2002 17:33:05 +0000
From: b.meinhard
Reductions are by Orthopedic resident/attendings rarely orthopedic PAS, but never ER MD's Local anes, regional, and conscious sedation by credentialed physicians or PAs are all used for reductions...general anesthesia is done in the OR when one fails in other attempts or if other methods are contraindicated. Stability of the hip is determined by the CT morphology and by the range of motion under appropriate anesthesia post reduction.
BPM
Date: Mon, 17 Jun 2002 12:35:43 -0500
From: Steven Rabin
In our hospital, Orthopaedic surgeons or residents reduce the hip, usually under conscious sedation which is supervised by the E/R doctor (ie, the anesthesia is performed by the E.R. attending, but the reduction is by the Orthopaedic service. Failed reductions go to the O/R. Stability is determined clinically and radiographically.
Date: Mon, 17 Jun 2002 13:43:35 -0400
From: Kevin Pugh
A dislocated native hip is a mandatory orthopaedic consult. All reductions are done by orthopaedic residents/attendings under heavy conscious sedation (we get anesthesia to give propofoll) in the ED. If this is an isolated dislocation without fracture, we would go to full general in the OR if the first attempt downstairs failed. If there is a fracture associated, and thus the vessels may be relatively decompressed, we might try is again in the ED. Stability (need for traction with a fracture) is determined by ROM. We flex the hip to 90-100, adduct a bit and push a bit on the knee. If it comes out or subluxes, it needs to be fixed. Stability with a fracture (does the fracture need to be fixed) is determined by CT/films.
Date: Mon, 17 Jun 2002 13:24:38 -0500
From: Adam Starr
Dr Agnew,
At our hospital, hip reductions are performed by the ortho team.
We make one attempt at closed reduction under conscious sedation. This is done in the trauma hall of our ER. Pulse ox and EKG monitoring are available, crash cart, Narcan, etc. Having the equipment - and personnel - to deal with an arrest makes the ortho team more comfortable giving a lot of sedative and pain medicine. A patient whose hip I'm trying to reduce is never awake enough to talk - he's sedated and anesthetized.
Prior to attempted reduction, we get consent to go to the OR for a general anesthetic and possible open reduction if we fail in the ER.
We make one attempt. If we can't get it reduced, we go to the OR.
We assess stability by physical exam. On hip flexion, does the hip start to re-dislocate? I don't have any test more sophisticated than that, sorry to say.
We obtain post-reduction Judet views and a CT scan if the plain films are suspicious for a fracture.
Adam Starr
Dallas, Texas
Date: Mon, 17 Jun 2002 15:11:33 -0400
From: J. Tracy Watson
All isolated hip (without fracture) dislocations are managed by the ortho trauma service...They get an initial closed reduction in the pre-op hold area with significant sedation provided by an anesthesiologist (the e.r physicians refused to "monitor " conscious sedation...I guess they felt it beneath their skills to "watch" the orthopods perform their magic...so we've bypasssed the E.R. and go directly to the pre-op hold. arena........If this fails they then go to the O.R. for a general anesthetic for closed reduction....the stability is assessed by the reduction team.....JTW
Date: Mon, 17 Jun 2002 15:27:07 -0400
From: Sam Agnew
Tracy Thanks, how do they asses the reduction initially?
sga
Date: Mon, 17 Jun 2002 12:37:58 -0700
From: Chip Routt
In YOUR hospital are hip dislocation-reductions performed by non-orthopaedic physicians?
Sometimes, but rarely.
In YOUR hospital such reductions are performed under what type of anesthesia?
IV sedation usually, but sometimes in the OR using general if they're crashing down for another reason...also sometimes in the angio suite under fluoro while the angiographer is setting up...that's a good time to do some work.
In YOUR hospital how are failed closed reduction attempts handled?
Depends on who's failed...sometimes just call someone that has more experience. Maybe it's the injury pattern obstructing reduction...depends on the situation.
In YOUR hospital/practice how is the stability of the reduced hip determined?
If it was dislocated, it was unstable. We review the imaging studies. Sometimes the patient warrants an exam under anesthesia and fluoro to assess stability.
Chip
Date: Mon, 17 Jun 2002 15:32:38 -0400
From: Sam Agnew
To all:
If Hip dislocation or fracture dislocation post reduction stability is assessed "clinically" then what are the parameters that one is assessing, is this objective criteria or subjective?
Thanks
SGA
Date: Mon, 17 Jun 2002 16:08:17 -0400
From: Benedetti Gary E Maj 74 MDOS/SGOSO
1] Except for shoulders, our ER physicians do not reduce anything.
2] Hip dislocations are usually reduced acutely in the ER-Trauma Roomusing "conscious" sedation......I saw that episode on TV as well and sort of snickered at the inadequate sedation-relaxation......we put the patient down deeper than that, they are usually not talking.
3] If adequate, safe "conscious" sedation was used andan attempt failed in competent hands, I would look again closely for something blocking the reductions, and then take the patient to the OR where complete muscle relaxation can be achieved.
4] Following reduction we range the hip to check stability.
Gary E. Benedetti, LtCol, USAF, MC, FS
Orthopaedic Trauma Surgery
Date: Mon, 17 Jun 2002 14:07:16 -0700
From: Bruce Sangeorzan
Sam
reductions done with sedation by ortho in ED unless going to OR immediately [not done by ER docs or gen surg]
taken to OR if failed in ER. anesthesia determined by patient safety
ROM done after reduction to assess stability
bruce
Date: Mon, 17 Jun 2002 17:49:11 -0400
From: David Goetz
1. Only by ortho
2. Heavy monitored sedation
3. General anes with or without paralysis
4. If fracture pattern suggests the possibility of closed treatment, hip is
flexed to 90 and gently pressure applied to the knee.
David R. Goetz MD
Medical Director, Orthopaedic Trauma
Date: Mon, 17 Jun 2002 17:32:05 -0500
From: Adam Starr
Dr Agnew,
"Stability" is a tricky word.
It's given that SOMETHING has been torn, wripped or busted to get the head out of the socket. But, even if that something remains incompetent after reduction, surgery may not be necessary if the hip will remain reduced, and there's no other reason to operate (fragment in joint, displaced fracture, soft tissue interposition, recurrent instability).
The method we (guess I should say I use) is to flex the hip up to about 90 degrees after reduction, and see how it feels.
It's great to do this under fluoro, if you have it in your ER. If the hip isn't concentrically reduced, or if there's a fracture, or if it starts to sublux out of socket, then I start to think about surgery.
I'll be the first to admit that most of that is subjective.
Adam