A 53-year-old man is brought to the emergency department after a fall while skiing. The patient immediately felt severe pain in the right hip and had to be brought down the mountain by ski patrol. He does not have any other injuries. Medical history is unremarkable, and the patient does not take any medications. Blood pressure is 168/94 mm Hg, pulse is 100/min, and respirations are 24/min. Pulse oximetry is 96% on room air. On examination, the patient appears uncomfortable and in pain. The right hip is flexed, displays an obvious deformity, and is tender to palpation. Hip range of motion is limited, and the right leg is shortened and internally rotated. Distal pulses are intact. X-ray of the pelvis is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 53-year-old man is brought to the emergency department after a fall while skiing.  The patient immediately felt severe pain in the right hip and had to be brought down the mountain by ski patrol.  He does not have any other injuries.  Medical history is unremarkable, and the patient does not take any medications.  Blood pressure is 168/94 mm Hg, pulse is 100/min, and respirations are 24/min.  Pulse oximetry is 96% on room air.  On examination, the patient appears uncomfortable and in pain.  The right hip is flexed, displays an obvious deformity, and is tender to palpation.  Hip range of motion is limited, and the right leg is shortened and internally rotated.  Distal pulses are intact.  X-ray of the pelvis is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d85c_a582_bc81_17153d981ee2_MD0003_00 This patient has a posterior hip dislocation. Posterior hip dislocation, which accounts for approximately 90% of hip dislocations, is typically caused by an axial load on the femur while the hip is flexed and adducted (eg, dashboard injury). Patients usually have severe pain and difficulty walking. On examination, the hip is flexed, adducted, and internally rotated, and the limb often appears shortened. Plain x-ray is usually diagnostic, but both anteroposterior and lateral views may be necessary to differentiate a posterior from an anterior dislocation. adducted, and internally rotated Due to the violent nature of injury, hip dislocation is often associated with additional injuries, including fracture (eg, acetabular, femoral head) and sciatic nerve injury. Chronic complications include osteonecrosis of the femoral head (ONFH). Treatment of hip dislocation requires expedited reduction, typically within 6 hours of injury: Dislocation without associated fracture is usually managed with closed (ie, nonoperative) reduction (eg, in the emergency room). Dislocation with fracture warrants open (ie, operative) reduction. Delayed reduction (>6 hr) is associated with increased risk of ONFH. Therefore, discharging the patient or admitting without reduction is inappropriate (Choices A and C). (Choice D) Some experts recommend noncontrast CT scan to rule out fracture in traumatic dislocation. Although CT angiogram is indicated for patients with signs of limb ischemia (eg, absent distal pulses) or vascular injury (eg, expanding hematoma), it is unnecessary for this patient with an uncomplicated dislocation. (Choice E) Pelvic binders are used to minimize bleeding prior to surgery in patients with unstable pelvic fracture. They are not indicated for hip dislocation. Educational objective: Hip dislocation should be reduced within 6 hours of injury to minimize the risk of osteonecrosis of the femoral head. Dislocation without associated fracture is usually managed with closed (ie, nonoperative) reduction, whereas dislocation with fracture warrants open (ie, operative) reduction.

A 53-Year-Old Man Is Brought to the Emergency Department After