Discharge criteria for isolated simple dislocation
Safe outpatient pathway prerequisites
Concentric reduction on imaging
Post-reduction CT without operative indication
Pain controlled with oral regimen
Neurovascular exam normal or stable and documented
Reliable follow-up within 1 to 2 weeks
Mobility plan
Protected weight-bearing plan per orthopedics
Crutches or walker training completion
Treatment
Immediate life-saving interventions
Resuscitation actions when indicated
Hemorrhage control in associated trauma
Massive transfusion protocol activation criteria per local system
Pelvic binder use when pelvic instability suspected
Limb ischemia actions when indicated
Immediate reduction attempt prioritization over nonessential testing
Vascular surgery consultation for persistent ischemia after reduction
Immobilization and Splinting
Post-reduction positioning
Hip precautions aligned to dislocation direction
Posterior dislocation precautions
Avoid hip flexion beyond local protocol threshold
Avoid adduction
Avoid internal rotation
Anterior dislocation precautions
Avoid extension
Avoid external rotation
Immobilization adjuncts
Knee immobilizer for comfort and motion control when recommended
Abduction pillow use when available and recommended
Reassessment after immobilization
Repeat neurovascular exam documentation
Pain trend after immobilization
Reduction
Indications for emergent reduction
Native hip dislocation as orthopedic emergency
Time-to-reduction target within 6 hours to reduce osteonecrosis risk
Contraindications or caution triggers
Ipsilateral femoral neck fracture suspicion
Avoid forceful closed reduction attempts
Urgent orthopedic involvement
Open dislocation
Antibiotics and tetanus pathway without delaying life-saving reduction
Incarcerated fragment or nonconcentric reduction suspicion
Limited attempts
Early operative consultation
Analgesia and anesthesia strategy
Local and regional options
PENG block
Ropivacaine 0.2% to 0.5% volume per local protocol
Maximum local anesthetic dose by weight per local protocol
Fascia iliaca block
Bupivacaine 0.25% volume per local protocol
Local anesthetic systemic toxicity monitoring plan
Procedural sedation preparation
Monitoring standards
Continuous pulse oximetry
Continuous capnography as adjunct
ACEP Level B recommendation for capnography adjunct use
Blood pressure interval monitoring
ECG monitoring in higher-risk patients
Fasting time management
No delay based on fasting time
ACEP Level B recommendation
Staffing
Dedicated monitor clinician in addition to proceduralist
ACEP Level C recommendation
Sedation medication options and dosing
Ketamine
IV 1 to 2 mg/kg
ACEP Level A recommendation for pediatric use
ACEP Level C recommendation for adult use
Additional IV 0.5 mg/kg for inadequate depth
Emergence reaction mitigation plan
Propofol
IV 0.5 to 1 mg/kg initial
ACEP Level A recommendation for adult and pediatric use
Additional IV 0.25 to 0.5 mg/kg titration doses
Hypotension risk plan
Etomidate
IV 0.15 mg/kg
ACEP Level B recommendation for adult use
Myoclonus anticipation
Fentanyl for analgesia supplementation
IV 1 mcg/kg
Chest wall rigidity risk with rapid high dosing
Reduction techniques
General principles
Traction and countertraction
Gentle sustained force
Avoid repeated forceful attempts
Team roles and pelvic stabilization
Allis technique
Supine position
Hip and knee flexion
Inline traction with assistant countertraction
Stimson technique
Prone position
Knee flexion
Downward traction with gravitational assist
Captain Morgan technique
Supine position
Provider lever under knee with traction
Post-reduction requirements
Immediate neurovascular reassessment
Post-reduction radiographs
Post-reduction CT
Occult fracture and loose body evaluation
Pain reassessment and compartment concerns in associated injuries
Failed reduction pathway
Two to three attempts maximum depending on physiology and suspicion profile
Urgent orthopedic escalation for irreducible hip
Operative reduction planning
Open fracture medications and timing
Open dislocation or open fracture-dislocation pathway
Antibiotics without delaying time-critical reduction
Cefazolin 2 g IV
Redose interval per local protocol for prolonged course
Severe beta-lactam allergy alternative per local protocol
Tetanus prophylaxis logic
Tdap if not up to date
Tetanus immune globulin for unknown or incomplete immunization with dirty wound
Sterile dressing coverage
Early irrigation principles per trauma and ortho guidance
DVT prophylaxis when relevant
Venous thromboembolism risk planning
Lower limb immobilization and reduced mobility risk context
Anticoagulation contraindications assessment
Prophylaxis decisions aligned to orthopedic service and local protocol
Special Populations
Pregnancy
Maternal and fetal considerations
Left lateral tilt positioning when feasible
Obstetric consultation for viability gestational age context
Imaging considerations
Radiographs when needed with shielding considerations
CT use when benefits outweigh risks in trauma
Analgesia and sedation considerations
Shared decision-making for sedation agents with maternal physiology
Aspiration risk awareness without delaying emergency reduction
Geriatric
Fragility and comorbidity context
Lower physiologic reserve
Delirium risk with sedatives and opioids
Injury pattern considerations
Lower-energy dislocation consideration in severe osteoporosis or prior arthroplasty contexts
Higher threshold for admission and observation
Pediatrics
Growth and remodeling context
Lower sciatic nerve injury incidence compared with adults in literature
Sedation and monitoring
Weight-based dosing
Ketamine safety support in ED procedural sedation
ACEP Level A recommendation for pediatric ketamine use
Nonaccidental trauma consideration when mechanism inconsistent with injury pattern
Background
Epidemiology
Frequency and context
Traumatic native hip dislocation as rare injury with high associated injury burden
Posterior dislocation as most common traumatic direction in high-energy mechanisms
Nerve injury frequency
Neurologic injury incidence approximately 10% in adults
Neurologic injury incidence approximately 5% in children
Pathophysiology
Mechanism to pattern mapping
Posterior dislocation
Axial load through femur with hip flexion and adduction
Posterior capsule disruption
Posterior wall acetabular fracture association
Anterior dislocation
Abduction and external rotation force vectors
Femoral head displacement anteriorly
Osteonecrosis mechanism
Femoral head perfusion compromise duration dependence
Increased osteonecrosis risk with delayed reduction beyond 6 hours
Therapeutic Considerations
Time dependence rationale
Reduction within 6 hours associated with lower osteonecrosis rates in studies
Imaging rationale
Post-reduction CT to detect occult fractures and loose bodies missed by radiographs
Neurologic injury expectations
Sciatic nerve most commonly affected
Peroneal branch commonly involved
Patient Discharge Instructions
Copy discharge instructions
Discharge packet
No driving until cleared by orthopedics and off sedating medications
Protected weight-bearing per orthopedic plan
Hip precautions based on dislocation direction
Pain plan
Acetaminophen dosing per local protocol
NSAID use if no contraindications
Short opioid course only if needed with constipation prevention plan
Ice and elevation guidance for associated soft tissue swelling
Return to ED now triggers
Worsening pain uncontrolled with prescribed plan
New numbness or weakness in foot or toes
Cold, pale, or blue foot
Increasing swelling with severe tightness
Fever or wound drainage if open injury
Follow-up timing
Orthopedics within 1 to 2 weeks or sooner per imaging findings
Repeat imaging plan per orthopedics
Sedation aftercare
No alcohol or sedatives for 24 hours
Responsible adult supervision period per local policy
References
Clinical guidelines and key sources
Source file
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Reduction timing and osteonecrosis risk
Meta-analysis and cohort data supporting lower osteonecrosis with reduction within 6 hours
Post-reduction CT rationale
CT described as standard of care after closed reduction to identify occult fracture or loose bodies
Sciatic nerve injury incidence
Literature review reporting approximately 10% in adults and 5% in children
Procedural sedation evidence and ACEP levels
ACEP Clinical Policy Procedural Sedation and Analgesia in the ED
No delay based on fasting time
Level B recommendation
Capnography as adjunct for earlier hypoventilation detection
Level B recommendation
Dedicated monitoring individual in addition to proceduralist
Level C recommendation
Ketamine pediatric safety
Level A recommendation
Propofol adult and pediatric safety
Level A recommendation
Etomidate adult safety
Level B recommendation
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