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.
To save time, I had elected to do the reduction with the patient still on the gurney. Tom, the scrub tech, Carole, the circulating nurse, and I lowered the gurney as far as it would go, locked the wheels, and put down the side rails, removing all of Jeff’s pillows.
Standing on two stacked lifts for leverage, I cradled Jeff’s leg in my arms, rocking it just slightly, visualizing how the femur pivoted on its attachments. I needed to move it in the reverse direction of the path it had taken out of the socket. Carole stood on Jeff’s left, leaning on his pelvis with both hands solidly planted to stabilize it. I asked Tom, a muscular six-footer, to brace Jeff’s pelvis with his right hand and place his left hand on the inside of the injured thigh. “Ready?” I asked my team.
Then, using Jeff’s leg as a handle, I slowly began to pull, with my trunk more than my arms, along the axis of his thigh. I felt the leg elongate, then stop. Then I rotated it outward just a bit, unlocking the dislocation. “Give me some lateral pressure, Tom,” I directed, and as he pushed outward, I rolled Jeff’s thigh inward, keeping the traction strong and steady.
I felt—and we all heard—a satisfactory clunk. Cautiously, I moved Jeff’s hip through a full range of motion to test its stability. “Is X-ray here yet?” I asked, gently laying his leg down on the gurney. It had been less than four hours since the accident.
The X-rays showed a perfect match between the right and the left hips, reassuring me that I would see no stray bone chips on a postreduction CT scan. We transferred Jeff to a hospital bed before he was awake, applying light traction to his right leg through a foam-and-Velcro boot. In the recovery room, he groggily said he felt fine, and the next morning his nurse told me he had slept all night.
Jeff’s mother, an elegantly dressed woman, sat by his bed as I entered the room. “Thank you so much for taking care of Jeff,” she said, rising to take my hand. “He’s feeling really good. In fact, he was wondering when you were going to let him out of here so he can go check on his motorcycle.” Her attempt at a smile came off as a grimace. “I’d thought his injury was more serious than that.”
“He was very lucky,” I began. “Lucky to have no other injuries, lucky he had a simple dislocation and not a fracture-dislocation, lucky that we were able to get him into the operating room without delay, lucky that the joint reduced so easily. If we see no other damage on his scan, then he really does have the best possible prognosis after a hip dislocation. But he’s not out of the woods.”
Mother and son looked at each other.
“Even if he doesn’t develop avascular necrosis over the next two years, his hip has a higher chance of becoming arthritic earlier in life than if this hadn’t happened,” I added. ”There’s nothing we can really do to prevent it. For now, I’m going to keep him in bed for a couple of days and then begin physical therapy, to keep him from getting weak and stiff.
He’ll probably go home in four or five days, but he’ll need to walk without putting full weight on that hip for at least a month. After that, it depends on how he’s feeling and how his X-rays look. He may have to go back on crutches if we see changes in the femoral head.”
Jeff looked upset. “I guess I won’t be able to work anytime soon,” he said. “They don’t have light duty at the body shop.”
“If you ever wanted to learn another line of work, this might be the year,” I said. “Most people don’t do the same thing their whole lives these days, anyway.”
As the months passed, Jeff showed no signs of avascular necrosis, and after nearly a year of follow-up I was ready to release him to go back to work. By then, he was halfway through an associate’s degree in computer science and had decided to finish it. The last I heard from him was a short thank-you note on the stationery of a software-engineering firm. Enclosed was a picture of himself on a big new sky blue BMW motorcycle.
Sharon Sussman, an orthopedic surgeon in Julian, California, has written about treating ankylosing spondylitis and hip dislocation in infants for Discover. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.
