Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient's bed.
Trick of the Trade:
Captain Morgan technique
You can apply 3 forces of axial traction to the femur.
- Position the patient: 90 degrees of hip and knee flexion
- Step one foot up onto the gurney Captain-Morgan style (flamboyant cape optional).
- Position your knee behind the patient's knee.
- Ideally your foot should be resting on a hard surface like a backboard to allow your foot to push off of it.
- Place one hand (A) under the patient's knee and the other (B) over the patient's ankle.
- Use Hand A to lift up on the patient's femur.
- Plantar-flex your ankle so that your propped knee can lift up on the patient's femur.
- Very gently use Hand B to leverage-down on against the patient's tibia/fibula.
TIPS FOR SUCCESS
Pearls straight from "Captain" Hendey (Dr. Greg Hendey wrote the article):
- Make sure to put the patient on a backboard and attach a strap over the pelvis to stabilize it to the board--this works far better than having some tech trying to lie across the patient, and it's better than tying a sheet around the gurney and the patient. It also provides a firm place to put your foot.
- Make sure to tuck your knee tightly under the patient's knee so that when you lift up on your tiptoes, all the force is transmitted into lifting the patient's hip. If your leg is much shorter than your patient's leg, you may need to put a book under your foot to get your knee tucked under theirs.
- Once you're lifting, keep a steady sustained force, just like any large joint reduction--no sudden jerky movements. Once you feel it start to move, don't stop--sometimes people stop lifting too soon when they feel movement, but before the reduction has occurred.
- If it's not moving, try rocking back and forth, and twisting the leg (internal and external rotation at the hip) while you're lifting.
The provider does not use Hand A to lift up, although it seemed that he kind of wanted to. Note that he was stepping on the hard bed under the soft gurney mattress.
Video 2:
The provider shows you how you really need Hand A to help you to lift.
Thanks to Dr. Graham Walker for letting us know about this great pearl from his new Gmergency! Tumbler site.
Reference
Hendey GW, Avila A. The captain morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011 Dec;58(6):536-40. Pubmed
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Hmm..in the last video it seems like the provider is really hammering down on the patient's tib--would you say that there's any risk of injuring the lower leg here? Or am I overestimating the amount of force needed to pop the hip back into place?
ReplyDeleteHip reduction procedures really require quite a bit of force. And tibial injury is always a concern if too forceful, using the Capt Morgan technique. The trick is to avoid leveraging the tibia as much as possible. That's why you use your propped knee and Hand A to do most of the axial lifting.
ReplyDeleteTotally agree with Michelle. The propped knee or Hand A should be in the popliteal fossa and used as a fulcrum point. It does take a lot of force but gentle, steady force vs. jerking. I've used this technique multiple times and it is great. No more getting up on the gurney and worrying about falling off. Stay tuned for a followup blog about a variation to the above technique.
ReplyDelete@Fred: Ooh! Can't wait to read your variation. Maybe we can called the Colonel Wu technique.
ReplyDeleteDoes this also work with prosthesis dislocations?
ReplyDelete@AJB ACNP: Absolutely!
ReplyDeleteJust used this today - much better leverage and much safer than the standard method!
ReplyDelete@Anonymous: That's fantastic! It's not as amusing watching stuff fall out of the provider's pockets while standing on the gurney, but it seems to be safer and less traumatic for everyone involved. Thanks for commenting!
ReplyDelete