Hip reduction

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CSingh

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I was told by an attending that if a patient comes in with a hip dislocation in an artificial hip, that ortho needs to reduce it. Basically since there's hardware involved it needs to be done by them and most end up going to the OR. Thoughts? I got some push back from the ortho res for not trying.
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This is cultural and practice-dependent. At my center, the orthopedists would want to be called about this before anything was done. I have the sense that in private practice, an EP might give this a whirl, then call ortho after if either not successful or to obtain follow up.
 
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RustedFox said:
I reduce them all the time.
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Me too. We have a good relationship with ortho. They trust our group and we don't usually even call about these unless it's the extremely rare one that doesn't go back in.
 
We reduce 95% of them in the ED with no ortho involvement. Ortho gets all attitudinal if we can't get it back in. At that point, what they usually need is general anesthetic and it's much easier. Or, they have a huge clot or loosened hardware that makes the reduction impossible and they get revised in the OR anyway.
 
In my limited experience, seems the artificial ones are easier to reduce than the natural ones
 
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CSingh said:
I was told by an attending that if a patient comes in with a hip dislocation in an artificial hip, that ortho needs to reduce it. Basically since there's hardware involved it needs to be done by them and most end up going to the OR. Thoughts? I got some push back from the ortho res for not trying.
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Yea, I was also trained in this way but in private practice, as said earlier... you'll end up reducing them. I reduce them all the time. Like dotcb said, I think it's a cultural thing.

Speaking of hip reductions. I'm totally digging the Captain Morgan reduction technique. I had a colleague show me this one about a year ago and I love it. I sweat and curse much less than before...
 
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I love me some Captain Morgan. Best. Named. Technique. Ever.

I put in artificial hips all the time.
 
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Do you guys discharge your reduced hips home? Sorry for the thread hijack.
 
Yup - they go home. If they're minimally weight bearing at baseline (old, demented etc), I strap them into an abductor pillow. But the majority just turned wrong, and it's exactly the same as the last couple times it's come out.
 
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BJJVP said:
Do you guys discharge your reduced hips home? Sorry for the thread hijack.
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Yes, in an abduction brace and in consultation (via phone or in person) with Orthopedics.

This is the sort of thing that is totally OK to do if your Orthopods are on board, but can get you into a lot of meetings if you do it unilaterally.

If the culture at your shop is for the ED to reduce prosthetic hips, drain peritonsilar abscesses, cardiovert and discharge new a fib, etc then great. But if no one else in your shop does this, and you start doing it without discussing it with the consultants who are going to follow up on your cases, then people are going to think you're a dangerous cowboy.

EM has a very culture-dependent scope of practice. I'm not saying that it should be, but you ignore the culture at your own peril.
 
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These are ridiculously easy. Do them unless ortho wants to. I don't know why they would, unless you weren't able, or it's a cultural thing in the ortho group or at your residency program. Don't defy your supervising EM or Ortho attendings, but these are usually very easy. Much, much easier than a non-surgical hip reduction. Do they really want to come in a 4 am for a 30 second hip pull? These come out easy, go in easy. Bill for the hip reduction.
 
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If you work at a place with a group of orthopods, then your group will know what the protocol is. There is no "group" where I work, just several independent orthopods. Half of the dislocated hips that show up were not done locally. I have no way of contacting their doc, so I'll pull on the hip. If it was done by one of our local guys, I'll page them and see what they want me to do, and if they dont call back, I'll just pull on the hip.
In the end, just do what needs to be done, after proper consent has been obtained.
 
At my residency, we call ortho first for prosthetic hips, but I have yet to see them do anything that we don't or can't do. They do the same thing for prosthetic hips as we do for "normal" hips. I understand they need the experience, too. But, when one considers that they're not going to come in from home for every prosthetic hip once they're in the community, it seems silly for the procedure to not be shared.
 
I haven't seen an orthopedist in our ED in about a year. Which is not necessarily a bad thing. If you are productivity based, the orthopedic procedure codes are among the highest payers.
 
Eh..always reduce. propofol is a Godsend!
I, personally, have had a much tougher time with THA reductions.
One time, which always a very positive. And memorable time in a community ED, the ortho was HOURS out but was able to call his fav anesth.
Anesth came down to ED and I reduced it as he placed pt in full anesthesia and LMAd in the ED with short little spurt of Propofal, fentanyl, and low dose succ. All done in a. Few min.!
Was a very collaborative moment that was quite enjoyable.
And hips go in like BUTTER with succ.
 
Anyone have success and it reduced sedation need city regional block here?
Bet a good area to study if enough #s
 
LaBusqueda said:
Anyone have success and it reduced sedation need city regional block here?
Bet a good area to study if enough #s
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Not sure it would work unless you could block the obturator (+/- sciatic) as well as the femoral.
 
LaBusqueda said:
Anyone have success and it reduced sedation need city regional block here?
Bet a good area to study if enough #s
Click to expand...
No benefit to this, never even really heard of this being done, just use propofol
 
WilcoWorld said:
Not sure it would work unless you could block the obturator (+/- sciatic) as well as the femoral.
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facia Iliaca block done high (bow tie sign)with ultrasound would "theoretically" help as its a triple block if done right. Learned these when I'm training during anesthesia and ortho.

I do these at times for frail elderly pts for pain control and find tremendous improvement and see great improvement and and minimal opioid need afterwards. I sometimes wonder if these would help and/or reduce sedation burden for hip dislocations.
Mostly in those people that you would think twice about taking too deep.
 
Just and anatomical effect due to the location of the block (high volume) that the anesthetic travels and infiltrates the fem, LFC, and obturator. There is a traditional 2 pop technique, but with US it is much easier,more reproducible, and safer.
I usually just do US femoral n block and get very good results with fractures.
 
LaBusqueda said:
facia Iliaca block done high (bow tie sign)with ultrasound would "theoretically" help as its a triple block if done right. Learned these when I'm training during anesthesia and ortho.

I do these at times for frail elderly pts for pain control and find tremendous improvement and see great improvement and and minimal opioid need afterwards. I sometimes wonder if these would help and/or reduce sedation burden for hip dislocations.
Mostly in those people that you would think twice about taking too deep.
Click to expand...

I used to do these in residency while I was on my regional kick, primarily for mid shaft femur fx's, large thigh lacs requiring complex repair and tried it on occasional hip dislocations. I haven't really found the need in PP. I would probably only consider it with the femur fx/complex lac. It definitely helps in those cases. I didn't notice any sig advantage in a hip dislocation. Virtually all are going to require sedation anyway and the block interferes with your NV exam afterwards and wastes time. I never really saw the point, really. Also, in my exp the FN and FCN are easy to block with this technique but I had abysmal success with blocking obturator.
 
About to board a plane. But here is a quick link to a video I found.

 
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