Dislocated Hip Replacement
You are the orthopaedic CT1 called to A&E to assess a 55-year old man who fell out of his sports car. He had a left hip operation a week ago but is unsure what it was. He is not currently in pain. A&E have performed an x-ray which confirms a dislocated hip replacement. How would you proceed?
Example answer introduction
This is an confirmed dislocated hip replacement on X-ray. This will require urgent closed reduction in A&E under sedation or in theatre. I would focus on ensuring the patient is stabilised and then optimised for surgery and then escalate to the orthopaedic registrar.
Initial Assessment and Simultaneous Resuscitation:
On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.
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Airway with C-spine control
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Check that airway is patient
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Breathing
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oxygen saturations, examine chest, examine work of breathing, breathing depth
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if concerns give high flow oxygen through a non-rebreathe mask
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Circulation
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pulse, blood pressure, capillary refill time, skin turgor, fluid input/output
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ensure IV access- 2 large bore etc- bloods as above, consider catheter
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Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds
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If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage
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Disability - GCS, pupils, blood sugar, temperature
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Exposure- systemic signs of shock, other injuries
Provide constant reassessment during this acute phase.
Specific Limb Examination
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Lower limb position – 90% of dislocations are posterior and appear shortened and internallyrotated. Although beware, with anterior dislocations the limb is held in external rotation with mild flexion and abduction.
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Range of movement
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Neurovascular status – Documenting this is key!
Cover patient with blanket at the end to prevent hypothermia.
Focused history
Focused history
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Allergies
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Medications – anticoagulants, consider reversal
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Past medical history including previous surgery
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Last meal
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Events leading up to this point
Initial management
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Fluid resuscitation
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Analgesia according to WHO pain ladder
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Bloods, keep nil by mouth
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Escalate to Orthopaedic Registrar
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Anaesthetist/Emergency theatres
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Keep patient and any relatives informed
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Document, document, document!!!