Case of the Month – Hip Injury – Part 1 Now Live

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While returning to camp, a small convoy of coalition soldiers traveling in a mine resistant vehicle triggered an improvised explosive device (IED). The vehicle rolled over in the blast, injuring the passengers.

Spc Walsh, a 32-year-old soldier, was treated by a field medic who reported, “The patient was in extreme pain but remained hemodynamically stable.” The medic immobilized Spc Walsh, including his leg, which was in a flexed position, locked in internal rotation. Walsh was then transported, within an hour including flight time, by a medevac helicopter to the nearest level 2 combat hospital.

What would be your initial diagnosis and treatment?

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4 Responses to Case of the Month – Hip Injury – Part 1 Now Live

  1. Hartel, René says:

    My initial diagnosis , based on the leg in fixed flexion and the x-ray would be a posterior dislocation of the left hip. Fast reduction under general anaesthesia followed by a CT scan to rule out acetabular fracture or head fracture would be my therapeutic proposal.

  2. Ben Kam says:

    Rene,
    You would be correct.
    Any suggestions on how you would perform the reduction? Any suggestions to if you ran into problems achieving the reduction in the austere environment?

    • René Hartel says:

      Hi Ben,

      Obviously, under ketalar in the austere environment, there could be a problem. With curarisation, I haven’t seen yet a problem with closed reduction standing on the table with the hip in 90 degrees flexion and pulling the hip upwards. I have seen just a few of them. Eventually, I suppose one could put one or two schwanse pins in the proximal femur, connect them as an external fixator and ask a second person to use this as a handhold to pull sidewards, thus levering the hip into the acetabulum. Never done this however…

  3. Ben Kam says:

    Rene,
    I’ve had a similar experience. Have not yet had an irreducible closed native hip dislocation (I have had someone present with an open posterior hip dislocation with the femoral head exposed through the buttock that was button-holed through soft tissue that could not be reduced). I use a similar technique to you as I can use my legs to assist the reduction rather than my arms.
    I do think that if necessary, your suggestion of using a threaded pin in the femur is a very good backup plan to assist in reduction as you or your assistant will then have definitive control over the proximal femur. This can be done in the “austere environment” as these pins are available in a sterile peel pack in an external fixator set with a hand drill. The palpable landmark is the lateral aspect of the greater trochanter and the pin can be put in distal to this in the shaft for control without image intensification by hand.
    Even with these options, closed reduction maneuvers can be unsuccessful in certain situations.

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