eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Hip: Treatment & Medication
Updated: Dec 2, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Patients with hip dislocation often have associated injuries that may take precedence during stabilization, both in the field and in the ED. Attempts to reduce the dislocation in the field are ill advised.
- Establish the ABCs with appropriate spinal immobilization.
- If hip dislocation is detected in the field, the patient should be placed on a backboard and allowed to assume the leg position that is most comfortable (ie, hip slightly flexed, leg adducted).
- The patient should be transported to a level of trauma center appropriate for his or her overall clinical status.
Emergency Department Care
- Patients with hip dislocations often have life-threatening injuries that take precedence. Once life-threatening injuries have been stabilized or ruled out, the hip dislocation can be addressed. A proper neurovascular examination should be performed. If a neurovascular deficit exists, there is even more urgency to reduce the dislocation.
- Appropriate analgesia should be provided. If hemodynamic status permits, intravenous narcotics are usually indicated.
- Radiographs to detect hip pathology should be obtained.
- Reduction is greatly facilitated by the use of procedural sedation. Unless sufficient sedation and muscle relaxation is achieved, attempts at relocation are futile. A variety of medications may be used for this purpose depending on physician preference and hospital protocol. A combination of agents with muscle relaxant and analgesic properties is optimal. The patient should be appropriately monitored during procedural sedation according to institutional protocol.
- Simple hip dislocations without associated fracture are within the practice scope of most emergency physicians. Consider orthopedic consultation if it will not delay relocation beyond a reasonable amount of time, usually within 6 hours.
- Once procedural sedation has been achieved, the hip may be reduced by one of the preceding methods. Reducing a hip usually takes a significant amount of space and resources. Usually, one person applies traction and one or two people supply counter traction. A nurse or other physician provides sedation. More than 3 attempts at closed reduction in the ED is not recommended. The incidence of AVN increases with multiple attempts. If the dislocation cannot be reduced, an emergent CT scan is indicated to visualize any bony or soft tissue fragments that may hinder reduction. Closed reduction may be attempted in the operating room under general anesthesia. However, a majority of these patients may require open reduction.
- Fracture-dislocations or concomitant fractures of the femoral neck usually require the expertise of an orthopedic specialist. Practice styles vary widely. Some orthopedists make an attempt at closed reduction, whereas others immediately perform an open reduction if a fracture-dislocation exists.
- After closed reduction, confirm placement with a repeat radiograph. A repeat neurovascular examination should be performed and documented as well. A CT scan or MRI of the hip can provide valuable information about further treatment and prognosis.
- If relocation of the hip is successful, immobilize the legs in slight abduction by using a pad between the legs to prevent adduction until skeletal traction can be instituted.
- After reduction, patients with hip dislocation should be admitted to the hospital. Patients will be nonambulatory and require a great deal of supportive care. Pain will be significant, even after reduction, and patients may require parenteral narcotics.
- The duration of traction and non–weight-bearing immobilization is controversial. Evidence suggests that early weight bearing (eg, 2 wk after relocation) may increase the severity of aseptic necrosis when it occurs. Early weight bearing decreases the incidence of other complications (eg, venous thromboembolism, decubiti), and some studies have found equivalent outcomes with early and delayed weight bearing.
- Indications for open reduction
- Irreducible dislocation (approximately 10% of all dislocations)
- Persistent instability of the joint following reduction (eg, fracture-dislocation of the posterior acetabulum)
- Fracture of the femoral head or shaft
- Neurovascular deficits that occur after closed reduction
Consultations
- Orthopedic surgeon
- Trauma surgeon
Medication
Administer adequate parenteral analgesia. The emergency physician, consultant, and patient must decide on the most appropriate type and place for reduction: open versus closed and emergency department versus operating room.
If a closed reduction is attempted in the ED, the patient requires procedural sedation. Procedural sedation policies should be established to define who can administer medication, who must monitor the patient, the classes and doses of procedural sedation medications, and the resources on hand for resuscitation.
In addition to airway protection and rescue, the procedural sedation goals must include pain relief, muscle relaxation, and procedure amnesia.
General anesthesia in the operating room may be required for patients with dislocations that are irreducible by closed means as well as for those with significant associated fractures, central dislocations, or associated neurovascular injury.
Analgesics
Pain control is essential to good-quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. The analgesic must have a rapid onset, predictable action, and be easily titratable.
Morphine sulfate (Duramorph, MS Contin, MSIR)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
Infants and children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Fentanyl citrate (Duragesic, Sublimaze)
More potent narcotic analgesic with shorter half-life than that of morphine sulfate. Suitable for procedural sedation analgesia. Excellent choice for pain management and sedation; has short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
Adult
0.5-2 mcg/kg/dose IV/IM initially; titrate <2 years: 2-3 mcg/kg/dose IV/IM q30-60minPediatric
2-12 years: 1-2 mcg/kg/dose q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation
Meperidine (Demerol)
Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Adult
50-150 mg PO/IV/IM/SC q3-4h prn
Pediatric
1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose
Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors
Documented hypersensitivity; concurrent MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant anticipated
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in head injuries (may increase respiratory depression and CSF pressure, use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels, because of tolerance, may aggravate or cause seizures even if no history of convulsive disorders; monitor closely for meperidine-induced seizure activity if prior seizure history; caution in elderly patients when repeated doses anticipated; caution when creatinine clearance <50 mL/min
Sedative hypnotics
Use these agents for procedural sedation with rapid onset and short duration.
Propofol (Diprivan)
Phenolic compound; sedative hypnotic agent used for induction and maintenance of anesthesia or sedation; has anticonvulsant properties.
Adult
Induction dose for ASA class I/II: 1-2 mg/kg IV; if too fast, rapid sedation and apnea possible; if too slow, desired sedation and relaxation might not occur
Pediatric
General anesthesia induction:
<3 years: Not established
>3-16 years and ASA class I/II: 2.5-3.5 mg/kg IV over 20-30 sec; then 125-150 mcg/kg/min IV during initiation
Maintenance: 200-300 mcg/kg/min IV during first 30 min
Doses listed are for patients categorized as ASA I/II who have not received premedication or light premedication (eg, PO benzodiazepines, IM opioids)
Reduce dose with concomitant benzodiazepines, opiates, phenothiazines, ethanol, and narcotics; may potentiate neuromuscular blockade of vecuronium; theophylline may weaken effects (may need to increase dose)
Documented hypersensitivity; those who are not mechanically ventilated
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not administer with blood or blood products using the same IV catheter; patients may develop apnea; may experience a decrease in systemic vascular resistance leading to hypotension
Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a decreased dose of an analgesic to achieve the same effect.
Diazepam (Valium)
By increasing activity of GABA, major inhibitory neurotransmitter, depresses all levels of CNS including limbic and reticular formation. Individualize dose and increase it cautiously to avoid adverse effects.
Adult
5 mg PO/IV/IM q2-4h prn; not to exceed 30 mg/8 h
Pediatric
0.05-0.3 mg/kg/dose IV/IM over 2-3 min; repeat in 2-4 h prn; 0.12-0.8 mg/kg/d PO divided q6-8h; not to exceed 10 mg/dose
Phenothiazines, barbiturates, alcohols, and MAO inhibitors increase CNS toxicity when administered concurrently
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing activity of GABA, major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent medication when patient needs to be sedated for >24 h.
Adult
1-10 mg/d IV divided bid/tid; not to exceed 4 mg/dose
Pediatric
0.05-0 .1 mg/kg IV slowly over 2-5 min; may repeat with 0.5 mg/kg IV slowly; not to exceed 4 mg/dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAO inhibitors
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
More on Dislocation, Hip |
| Overview: Dislocation, Hip |
| Differential Diagnoses & Workup: Dislocation, Hip |
 Treatment & Medication: Dislocation, Hip |
| Follow-up: Dislocation, Hip |
| Multimedia: Dislocation, Hip |
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References
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Further Reading
Keywords
hip dislocation, dislocation hip, traumatic hip dislocation, prosthetic hip dislocation, hip dysplasia, congenital hip dislocation, CDH, developmental dysplasia of the hip, DDH, hip fracture-dislocation
