[Although technically not physical diagnosis, some bedside procedures rely on discerning anatomical and physiological clues at the bedside, and thus are bedside skills]
A patient presents after a hip injury with a right lower extremity that is flexed, adducted, and internally rotated. You suspect hip dislocation and confirm it quickly with x-rays. You attempt reduction with the traditional Allis technique and this is not successful, nor was the Captain Morgan and Whistler techniques.
You want to use gravity to help you and considered the Stimson technique of placing the patient prone and placing your knee behind the patient’s knee for force. But the patient is morbidly obese and you are concerned about sedating a high risk patient in a prone position. Are there any other techniques that recruit gravity to assist in reduction?
One of the problems with hip reduction is that most of the current techniques involve pulling longitudinally on the femur, but the joint is oriented almost perpendicularly to that. Thus, one must generate considerably more force in order to effect reduction. The femoral head often catches behind the rim of the acetabulum and can not make it over. I suspect that one day we will have many “finesse” procedures for the hip as we do for the shoulder.
Another option is the lateral technique. It does not have the good marketing name of the “Captain Morgan” technique, and its eponymous name would have been Skoff (Orthopedic Review 1986). It does not get a lot of attention but it seems to deserve more study. Lay the patient on the side, flex the affected hip, gravity will adduct it, and you internally rotate it. Somewhat like the Kocher technique for the shoulder, you are trying to roll that joint head over the rim.
You try this technique with success. We wait for emergency medicine literature to answer remaining questions about the comparative efficacy of current techniques.
Take Home Points:
-Hip reduction is difficult because the muscles are strong and traditional techniques apply forces at an almost perpendicular angle (as well as against gravity).
-In the absence of good emergency medicine studies, do consider prone or lateral positioning for the reasons stated above.