Hip Dislocation in Emergency Medicine


Background

Traumatic dislocations of the hip are an orthopedic emergency. Although the diagnosis of the common posterior hip dislocation may often be straightforward, the emergent diagnosis and reduction of the dislocation, especially in light of multiply traumatically injured trauma patient, can be challenging. High-energy blunt force trauma is the most common cause, although prosthetic hip joints may dislocate with much less force. Multiple studies have shown that timely reduction plays a significant role in reducing later complications and associated comorbidity. As a result, the routine screening for this injury has been adopted in the evaluation of trauma patients. [12345678910]

Congenital dislocation of the hip also occurs and is termed developmental dysplasia of the hip (DDH). The annual incidence of DDH is approximately 2-4 cases per 1000 births; approximately 80-85% of the affected individuals are girls. Routine screening for DDH includes the Barlow and Ortolani tests, with further tests such as ultrasound for cases prompting concern. The focus of this article is on traumatic dislocations.

Pathophysiology

The hip is a modified ball-socket joint. The femoral head is situated deep within the acetabular socket, which is further enhanced by a cartilaginous labrum. The hip is also bolstered by a fibrous joint capsule, the ischiofemoral ligament, and many strong muscles of the upper thigh and gluteal region. Because of this anatomic configuration, the hip is stable, as in the image below.

A normal anteroposterior (AP) pelvis radiograph. A normal anteroposterior (AP) pelvis radiograph.

Subsequently, a large force is required to dislocate the joint. Because a high force mechanism is required, other life-threatening injuries and fractures are common.

Motor vehicle crashes (MVC) account for two thirds of traumatic hip dislocations, but falls from height are also a significant cause, whereas sport injuries are a less common cause.

Hip dislocations can be divided into simple and complex, with the later having associated fractures. The relationship of the femoral head to the acetabulum is used to classify the dislocation. The three main patterns are posterior, anterior, and central.

Posterior dislocation

Posterior dislocations comprise approximately 80-90% of hip dislocations caused by MVCs. The femoral head is situated posterior to the acetabulum. During a MVC, force is transmitted to the flexed hip in one of two ways. During rapid deceleration, the knees strike the dashboard and transmit the force through the femur to the hip. If the leg is extended and the knee is locked, force can be transmitted from the floorboard though the entire lower and upper leg to the hip joint. A posterior dislocation is shown in the image below.

Right posterior hip dislocation in a young woman fRight posterior hip dislocation in a young woman following a high-speed motor vehicle collision (MVC).

Anterior dislocation

The femoral head is situated anterior to the acetabulum. An anterior dislocation is most commonly caused by a hyperextension force against an abducted leg that levers the femoral head out of the acetabulum. Less commonly, an anterior force against the posterior femoral neck or head can produce this dislocation pattern.

Anterior hip dislocations have been reported to account for approximately 5-10% of all hip dislocations. Of all anterior hip dislocations, inferior or obturator dislocations have been found to be more common, constituting approximately 70% of all anterior dislocations. Risk factors for closed reductions of anterior hip dislocations include preexisting osteopenia on plain films, age greater than 65 years, and radiographic femoral head impingement on the surrounding bony pelvis. In one study, closed reduction of both anterior and posterior hip dislocations  were noted to be urgent and should occur within 6 hours after the time of dislocation. [7]

Central dislocation

A central dislocation is always a fracture-dislocation. As shown in the image below, the femoral head lies medial to a fractured acetabulum. This is caused by a lateral force against an adducted femur as commonly seen in side impact MVCs. A central fracture-dislocation is shown in the image below.

Fracture-dislocation of the right hip. The bony frFracture-dislocation of the right hip. The bony fragments are likely part of the acetabulum.

Epidemiology

Frequency

United States

Posterior hip dislocations are more common than anterior ones and account for almost 90% of hip dislocations. The frequency has decreased with the increased use of seat belts and air bags. Anterior dislocations and central fracture-dislocations account for less than 10% of hip dislocations.

Most studies have found the incidence of dislocation after total hip arthroplasty (THA) to be approximately 2-5%, with the almost three fourths of those dislocations occurring in the first 6 weeks after surgery. [11]

International

All claims data from a large sample of a comprehensive health database in Taiwan illustrated several points regarding the epidemiology of hip dislocation that may be generally informative: [12]

  • Hip is the most commonly dislocated joint of the lower extremity, with incidence of 5.2%

  • Closed reduction was achieved for more than 74% of the dislocations

  • Incidence of recurrent dislocation was more than 12%

Additionally, a recent report from a developing country indicate that the incidence of traumatic hip dislocations may be increasing due to a greater number of high-speed motor vehicle accidents, [13a phenomenon that may be repeated globally as larger populations have access to motor vehicles.

Mortality/Morbidity

Hip dislocation is a marker for a high force mechanism. Most mortality is the result of associated injuries. Life-threatening injuries to the pelvis, abdomen, chest, and head should be specifically sought out.

Long-term disability after hip dislocations is a significant risk. Up to 50% of patients will have limited use or chronic pain as a result of hip dislocation. Prognosis becomes worse with delayed diagnosis and management. Complications include deep venous thrombosis (DVT), sciatic nerve injury, avascular necrosis (AVN), vascular injury, recurrent dislocation, arthritis, and chronic pain.

The local venous injury and prolonged immobilization associated with hip dislocations lead to a significant incidence of deep venous thrombosis (DVT) and potentially lethal pulmonary embolus in affected patients. If no contraindications exist, patients should receive DVT prophylaxis as part of the hospital and rehabilitation treatment.

Sciatic nerve injury is common, up to 19% in one study. The femoral head or bony fragments can stretch or tear the nerve as it passes posterior. The neurapraxia is generally transient or minor. A full recovery or recovery with only minor neurological findings can be expected for most patients. Performing and documenting a brief neurological examination before and after relocation is imperative.

Avascular necrosis of the femoral head occurs in 2-17% of patients. This can occur with pure dislocations but is more common with fracture-dislocations of the femoral head. Numerous studies suggest that the risk of AVN rises proportional to the time to relocation. The longer it takes to relocate a hip, the higher the risk of AVN. Early relocation of a hip can make the difference between a healthy joint and a chronically disabled joint.

Vascular compromise is a rare. With anterior dislocations, the femoral artery is at risk. Pulses and perfusion should be checked and documented before and after reduction. If a patient has vascular compromise, reducing the hip should not be delayed. If a patient has a persistent or new-onset perfusion deficit, an open reduction and consultation with a vascular surgeon may be indicated.

Recurrent hip dislocation is uncommon compared to recurrent shoulder dislocation. Risk factors for recurrent dislocation are large capsular defects, intra-articular fragments, or a prosthetic hip.

Posttraumatic arthritis is the most frequent long-term complication following hip dislocation. It occurs in up to 16% of affected individuals and is often associated with life-long gait disturbances and chronic pain. If an associated acetabular fracture is present, the incidence of traumatic arthritis is as high as 80%.

Sex

Hip dislocations are more common in young males than in others because these injuries are associated with risk-taking behavior.

In a study of sports-related hip injuries on the basis of sex and age in young athletes, the main diagnoses for males were labral tear (23.1%), avulsion fracture (11.5%), slipped capital femoral epiphysis (11.5%), dislocation (7.7%), and tendonitis (7.7%). The main diagnoses for females were labral tear (59.0%), tendonitis (14.8%), snapping hip syndrome (6.6%), strain (4.9%), and bursitis (4.9%).  The proportion of hip injuries in the female athletes showed a significantly greater increase with advancing age than that seen in males. [14]

Age

Hip dislocations resulting from traumatic injuries (especially MVCs) are more common in those younger than 35 years than in older people. Hip dislocations resulting from falls are more common in those older than 65 years than in younger people.

Prognosis

The prognosis of the patient with a hip dislocation varies with the type of dislocation, with the associated fractures of the femoral head or acetabulum, and the presence of other injuries. Overall, good-to-excellent results are obtained in 50-93% of patients.

The principal determinants of a poor prognosis are as follows:

  • AVN occurs in 4-21.8% of patients in some reviews and 8-13% in others. The incidence is increased with delays in reduction beyond 6 hours and with open reduction. The severity of AVN increases in patients who undergo early weight bearing. AVN is a severe complication that usually requires replacement with a prosthetic hip.

  • Severe osteoarthritis occurs in at least 10% of patients and is more common in older patients. This seems to be an increased incidence compared to populations without hip dislocations of a similar age, and some authors have found the incidence to range from 30-71% after open reduction.

  • Injury to either the femoral or sciatic nerve usually consists of a neurapraxia, and eventual recovery of function can be expected in these cases. Permanent injury to these nerves can occur, resulting in disabling deficits. If patients have a neurological deficit, surgery is usually not indicated. Electromyography can help determine prognosis.

  • Recurrent dislocation is a complication if supporting ligaments have been disrupted.

Patient Education

For excellent patient education resources, see eMedicineHealth's patient education article Total Hip Replacement.



History

A high index of suspicion for hip dislocation must be present whenever evaluating a patient involved in a major trauma such as an MVC, significant fall, or an athletic injury.

Patients with a hip dislocation will be in severe pain. They may complain of pain to the lower extremities, back, or pelvic areas.

Patients will have difficulty moving the lower extremity on the affected side and may complain of numbness or paresthesias.

Frequently, patients will be a victim of multiple trauma and may not pinpoint pain to the hip as a result of altered mental status or distracting injuries.

Patients with a total hip replacement may present differently (see Special Concerns).

Physical

As with any major trauma victim, assessment of the airway, breathing, and circulation are of primary importance. During the secondary survey, an examination of the pelvic girdle and hip are mandatory. Examination should consist of inspection, palpation, active/passive range of motion, and a neurovascular examination.

Inspection

Isolated anterior and posterior dislocations have classic appearances. In practice, these appearances may be altered by the presence of fracture-dislocations or other bony abnormalities along the leg.

  • Posterior: The hip is flexed, internally rotated, and adducted.

  • Anterior: The hip is minimally flexed, externally rotated and markedly abducted

Palpation

Palpate the pelvis and lower extremity for any gross bony deformities or step-offs. In an anterior hip dislocation, the femoral head can occasionally be palpated. Large hematomas may signify vascular injury.

Range of motion

Patients with a hip dislocation have severely limited range of motion due to pain. Evaluate what the patient can do comfortably. Do not forcefully perform range of motion on a patient who cannot tolerate manipulation. Normal, painless range of motion virtually excludes hip dislocation.

Neurovascular examination

Signs of sciatic nerve injury include the following:

  • Loss of sensation in posterior leg and foot

  • Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch)

  • Loss of deep tendon reflexes (DTRs) at the ankle

Signs of femoral nerve injury include the following:

  • Loss of sensation over the thigh

  • Weakness of the quadriceps

  • Loss of DTRs at knee

Signs of vascular injury include the following:

  • Hematoma

  • Loss of pulses

  • Pallor

Causes

High-speed motor vehicle collisions (MVCs) are by far the leading cause of hip dislocations. Falls from significant height and sports-related injury are also among the top causes.

Hip dislocation has been noted to be one of the most common complications of total hip arthroplasty.


Differential Diagnoses


Laboratory Studies

No specific laboratory studies are indicated for hip dislocation. Laboratory studies should focus on the overall trauma workup and/or preoperative testing. Type and crossmatching of blood products is generally the most useful.

Imaging Studies

Radiography

A portable anteroposterior (AP) pelvis radiograph is often ordered as part of an initial trauma workup. The initial test should be a radiograph of the pelvis and hip. The presence of a hip dislocation can be subtle; however, a careful inspection of the AP pelvis radiograph should reveal most hip dislocations. Lateral views may further classify the type of dislocation.

The position of the femoral head relative to the acetabulum should be symmetrical. The joint space should be examined for bony fragments, widening, or evidence of an effusion.

Both femoral heads should be roughly the same size. In a posterior dislocation, the femoral head may appear smaller than the contralateral side. This is because it is further away from the x-ray beam and is magnified less. The opposite is true of anterior dislocations.

The positions of the trochanters in relation to the femoral shaft may reveal abnormal rotation.

Shenton’s line is a smooth curved line defined by the obturator foramen and the femoral metaphysis. If this line is disrupted, a hip fracture, dislocation, or femoral neck fracture should be suspected.

A thorough inspection of the film for associated fractures must be conducted.

If the AP pelvis film is nondiagnostic and a high index of suspicion exists, a lateral hip film, dedicated hip films, Judet views, or CT scan may be indicated. [5]

The image below is a routine AP pelvis film obtained from a patient who experienced a multiple rollover motor vehicle crash. It demonstrates that sometimes radiographic findings can be more subtle.

Portable AP pelvis with subtle presentation of rigPortable AP pelvis with subtle presentation of right posterior hip dislocation. Abnormal rotation is present, and the right femoral head appears smaller, indicating that it is further away.

CT scan

A CT is an accurate test for diagnosing hip injuries except in patients with prosthetic hips where streak artifact obscures the image. A CT accurately delineates the type of dislocation as well as any accompanying fractures (as shown in the image below). CT scans of the pelvis are routinely obtained on major trauma patients. The information obtained by CT can be used in the emergency department and for long-term prognosis and management. If a CT scan is being performed to evaluate the abdomen and pelvis, the hip should be examined for pathology. However, a dedicated hip CT scan should not delay reduction. After the hip is reduced, a CT scan of the hip will provide valuable information to the orthopedist for further surgical or conservative management.

In a series of adolescents after posterior hip dislocation, CT identified all bone injuries but underestimated the involvement of posterior wall fractures. However, it was possible to assess posterior wall size and fracture displacement with MRI. All soft-tissue injuries that were confirmed at surgery, including avulsion of the posterior labrum, were identified by MRI preoperatively. [6]

Posterior dislocation of right hip with acetabularPosterior dislocation of right hip with acetabular fracture.

MRI

MRI has a limited role in acute diagnosis and delineation of hip dislocations. Patients with multiple trauma are often unstable for MRI. It is time consuming and often unavailable. Once the patient is stabilized and the hip is reduced, MRI can provide valuable information about long-term management and prognosis. [6 An MRI 2-3 months after reduction can verify proper location and to screen for complications, such as avascular necrosis (AVN), osteoarthritis, and heterotopic calcification, at an early stage.

Intra-articular injuries and loose bodies are common in adolescent and young adult patients undergoing arthroscopy following traumatic hip dislocation. In a study of 12 hips in 12 patients (8 males, 4 females; mean age, 16.3 yr; range, 11-25 yr, loose bodies were identified in 6 of 12 patients (50%) on preoperative imaging and in 8 of 12 patients (67%) at arthroscopy. The 2 patients with unidentified loose bodies on imaging did not have a preoperative MRI. In the study, 11 patients had CT scans, 4 had MRI scans, and 3 had both. [5]

Other Tests

Radiographs should be the initial imaging study in patients with suspected AVN. [15]

Radionuclide scanning is a sensitive method for depicting AVN, though MRI, has greater sensitivity and specificity. [15]

Procedures

Reduction techniques for posterior dislocations are described below.

Allis method  [116]

The patient should be supine and under procedural sedation. The combined weight of the patient and physician may exceed the weight limit of the stretcher. It is generally unsafe for the physician to be standing on a stretcher. For these reasons, placing the patient on the floor rather than on the stretcher is often useful.

An assistant should stabilize the pelvis. The physician should initially be toward the patient’s feet, providing in-line traction. The physician should then gently flex the hip 60-90º while maintaining in-line traction. At this point, the physician is standing directly above the patient’s hip, providing traction in-line with the deformity.

Gently adducting the hip can force the head of the femur laterally and help it clear the acetabular rim. Alternately, gentle lateral traction can be applied to the proximal femur.

Reduction can be confirmed by a click that is felt and may be heard as well. The patient should assume normal anatomical position.

Captain Morgan technique  [17]

Another new technique gaining favor is the "Captain Morgan," which is a modification of the technique reported by Lefkowitz. [18Its name is derived from the resemblance of the position to the pose of the "Captain" on the logo of a popular commercially available rum.

In this technique, the patient is placed in the supine position (with the suggestion that the patient be on a backboard with the pelvic strap retained), with the injured side knee flexed to 90 º. The physician stands on the ipsilateral side facing across the stretcher and places his foot upon the stretcher (or backboard) with his knee under the ipsilateral knee of the patient. He then places one hand behind the knee and the other stabilizes by holding the ipsilateral ankle. Traction force is generated by the physician lifting with his hand behind the knee and by plantar flexing his foot that is under the knee. Rotational and abduction/adduction forces can be applied to facilitate the maneuver if necessary.

Other authors have noted that when using this technique, care must be taken to prevent using the knee as a fulcrum because ligamentous disruption of the knee can result. [19]

East Baltimore lift  [20]

The East Baltimore lift is a newer technique that has been used with good success by some centers. The patient is placed in the supine position, with the physician on the ipsilateral side of injury with an assistant facing him from across the table. The physician gently flexes the leg so that the hip and knee are in approximately 90 º of flexion; then the physician faces his assistant, places one hand on the ankle, and the other arm crosses under the proximal calf to place the hand on the assistant’s shoulder, cradling the flexed knee at the elbow. The pelvis is then braced by the assistant or a second assistant while the physician and first assistant squat slightly, bending at the knees, then upon rising, apply gentle, controlled traction to the femur, with manipulation at the ankle by the physician allowing rotational control of the hip to facilitate reduction.

Stimson method  [116]

This method is mechanically the same as the Allis method, but the positioning is opposite. Although some physicians prefer this method because of its technical ease and high success rate, this method has some important disadvantages. It requires the patient to be in a prone position, which may not be possible for the patient with multiple trauma. Monitoring the patient during procedural sedation is also difficult.

The prone patient is placed so the pelvis on the affected side hangs either over the end or over the side of the stretcher. The hip and knee are flexed to 90o. Downward pressure is applied to the popliteal fossa, providing traction in-line with the deformity. An assistant stabilizes the pelvis and trunk preventing the patient from being pulled off the stretcher.

Whistler technique  [1]

The patient is placed supine with ipsilateral knee flexed to 120 º. The physician stands on the affected side and places an arm under the ipsilateral knee with his or her hand resting on the contralateral knee. The pelvis and ankle are stabilized by an assistant or the physician’s free hand. The physician raises his or her arm, which applies an anterior force to the knee and subsequently to the affected hip.

See Joint Reduction, Hip Dislocation, Posterior.

Anterior dislocations

A modified Allis technique may be used. The patient is placed supine. The physician stands at the foot of the stretcher. Traction is applied to a neutral hip while an assistant stabilizes the pelvis. Gentle lateral traction applied to the proximal femur facilitates the femoral head clearing the acetabular rim. 



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.

Once stabilized, patients with multiple trauma may be transferred. A patient with an isolated hip dislocation may be transferred if no neurovascular deficit is suspected and if the transfer time does not extend the dislocation time by longer than 6 hours. In general, hip dislocations are reduced at the receiving facility and, if necessary, the patient is transferred for ongoing inpatient care with appropriate immobilization en route.

Indications for open reduction

Indications for open reduction include the following:

  • 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

Follow-up

Various techniques can be used to accomplish open reduction, acetabular repair, and fixation of associated fractures; these techniques are beyond the scope of this article.

After reduction of the hip dislocation, obtain repeat AP and lateral radiographs of the hip to verify proper reduction.

After either open or closed reduction of a hip dislocation, the patient is instructed to remain on bed rest with his or her legs abducted and with skeletal traction designed to keep the hip from displacing posteriorly.

The duration of traction is approximately 2 weeks, but the recommended period with no weight bearing is controversial and varies from 9 days to 3 months.

Consultations

And orthopedic surgeon and/or trauma surgeon should be consulted.

Complications

AVN of the hip

AVN is common, occurring in 8-13% of patients.

Early diagnosis and treatment of dislocations decreases the incidence of AVN.

The effect of early weight bearing on the occurrence of AVN is controversial. Most studies have shown that early weight bearing after reduction is associated with more severe AVN, but it does not appear to increase the incidence.

The incidence of AVN is increased with delayed reduction, repeated attempts at reduction, and open reduction (40% vs 15.5% with closed reduction). This finding may be due to operative trauma or because those dislocations requiring surgery are inherently more severe.

AVN may not become apparent on plain radiographs for several months. Early diagnosis can be made with MRI or nuclear scanning, and these modalities should be considered in a patient who develops late and persistent pain after a dislocation.

Sciatic nerve injury (posterior dislocation)

Injury to the sciatic nerve occurs in 10-14% of posterior dislocations during the initial trauma or during relocation.

Function of the sciatic nerve should be verified before and after relocation to detect this complication. The finding of sciatic nerve dysfunction mandates surgical exploration to release or repair the nerve.

Femoral-nerve injury

Anterior dislocations are occasionally associated with injury to the femoral artery or nerve.

Dislocations in children can occur with relatively minor trauma (eg, sports activities), and reduction must be gentle to avoid iatrogenic injury to the femoral epiphysis (eg, slipped capital femoral epiphysis).

Other complications

Other complications of hip dislocation are the following:

  • Heterotopic calcification

  • Recurrent dislocation

  • Ligamentous injury of the knee, other fractures

  • Complications of immobilization (DVT, pulmonary embolus, decubiti, pneumonia)

  • Femoral-artery injury (in anterior dislocations)



Medication Summary

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

Class Summary

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.

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.

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.

Sedative hypnotics

Class Summary

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.

Anxiolytics

Class Summary

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.

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.