Jeff’s hands gripped the side rails of the gurney, and his right thigh frog-legged out at a near right angle to his body, supported by at least five pillows stuffed between him and the rail.
“Don’t touch me,” he said, moving only his eyes when he heard me enter. Then he saw that I was carrying X-rays. “Are you the surgeon?” he asked. “What’s the matter with my hip?”
“I’m the orthopedist on call,” I replied, putting a hand gently on his left shoulder. “How are you feeling? Do you hurt anywhere besides your hip?”
“Don’t touch my leg,” he moaned. “They haven’t given me anything for pain. They said you would.”
The emergency room doctor who had paged me described this 25-year-old’s cartwheeling slide along a median strip after losing control of his motorcycle an hour earlier. X-rays of his pelvis showed the ball of the hip joint sitting below its usual position. It was the only injury. The thighbone had levered the femoral head forward and down, ripping the strong ligaments that hold the joint together.
“Your hip is out of its socket,” I said. “The first thing we need to do is get it back where it belongs, and we need to do that in the operating room. Have you ever had a general anesthetic before?”
“When I was 14,” he said. “I had my appendix out. Is my hip going to be all right?”
“The quicker we can reduce the dislocation, the better it’s likely to be.” I explained what would happen in the operating room, reviewed the immediate risks of anesthesia, and the possibility that I’d need to make an incision to get inside to work with the bone. And I explained that permanent damage to the hip was possible. After he signed the surgical permit, I gave him a dose of intravenous morphine, and when he was drowsy, I managed to examine his right foot and leg to confirm normal circulation and nerve function.
Any dislocated joint becomes more difficult to reposition if enough time goes by to allow ligaments and soft tissues to shrink. In most cases, the shrinkage occurs within days. The hip joint is vulnerable to far worse consequences if it remains dislocated longer than about six hours. The femoral head, the ball of this ball-and-socket joint, receives its blood supply via arteries running in the ligaments and the capsule that hold the hip together. When high-energy trauma disrupts the joint, some of these vessels are torn, and those that remain intact may be stretched and distorted, further diminishing blood flow. Healing can begin as soon as the dislocation is reduced, so recovery of normal joint function is possible. But if reduction is delayed, bone cells in the femoral head will die of starvation, initiating a process called avascular necrosis, a dreaded complication that occurs in about 40 percent of hip dislocations.
The death of bone cells, or osteocytes, is only the beginning of avascular necrosis. Over a period of a year or two, new blood vessels invade the injured areas, as dead bone is absorbed by scavenger cells. Without enough living osteocytes remaining to synthesize new bony substance, the femoral head will soften. If it is forced to bear weight, it can cave in like a Ping-Pong ball, destroying its perfect congruence with the acetabulum, or socket. A rapid, severe, and painful form of joint degeneration ensues, often necessitating total hip replacement.
When I saw Jeff 45 minutes later, he looked very comfortable. He was lying on the gurney under general anesthesia with an endotracheal tube taped to his face. I took one last long look at the X-rays on the view box. It appeared to be a simple dislocation, the best kind. “Is he relaxed?” I asked Dave Schmidt, the anesthesiologist.
“No, but he will be,” Dave said. “How long do you think this will take?” He had a number of muscle relaxants to choose from and wanted to paralyze the patient for as short a time as possible.
“Oh, give me 20 minutes,” I said. “We’ll need postreduction films.”
“I’ll call the X-ray tech as soon as this goes in,” he said, deftly breaking an ampoule and drawing up the contents into a syringe. In seconds, Jeff was deeply paralyzed, with no response to the nerve stimulator Dave laid against his jaw muscles.
