Novel Hip Reduction Technique: The Captain Morgan

I wrote about posterior hip dislocation and how to reduce it using the “standard” technique quite some time ago (see link below). Emergency physicians and orthopedic surgeons at UCSF-Fresno have published their experience with a reduction technique called the Captain Morgan.

Named after the pose of the trademark pirate for Captain Morgan rum, this technique simplifies the task of pulling the hip back into position. One of the disadvantages of the standard technique is that it takes a fair amount of strength (and patient sedation) to reduce the hip. If the physician is small or the patient is big, the technique may fail.

In the Captain Morgan technique, the patient is left in their usual supine position and the pelvis is fixed to the table using a strap (call your OR to find one). The dislocated hip and the knee are both flexed to 90 degrees. The physician places their foot on the table with their knee behind the patient’s knee. Gentle downward force is placed on the patient’s ankle to keep the knee in flexion, and the physician then pushes down with their own foot, raising their calf. Gentle rotation of the patient’s hip while applying this upward traction behind the patient’s knee usually results in reduction.

Some orthopedic surgeons use a similar technique, but apply downward force on the patient’s ankle, using the leverage across their own knee to develop the reduction force needed. The Captain Morgan technique use the upward lift from their own leg to develop the reduction force. This may be gentler on the patient’s knee.

The authors report a series of 13 reductions, and all but one were successful. The failure occurred due to an intra-articular fragment, and that hip had to be reduced in the operating room.

I’m interested in hearing comments from anyone who has used this technique (or the leverage one). And does anyone have any other techniques that have worked for them?

Reference: The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med 58(6):536-540, 2011.

Posterior Hip Dislocation

Although posterior hip dislocation is an uncommon injury, the consequences of delayed recognition or treatment can be dire. The majority are caused by head-on car crashes, and 90% of these are posterior dislocations. The femoral head is forced across the back wall of the acetabulum, either by the knee striking the dash, or by forces moving up the leg when the knee is locked. This occurs most commonly on the right side when the driver is standing on the brake pedal, desperately trying to stop.

On exam, the patient presents with the hip flexed, internally rotated and somewhat adducted. Range of motion is limited, and increasing resistance is felt when you try to move it out of position. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.

These injuries need to be reduced as soon as possible to decrease the chance of avascular necrosis of the femoral head. Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. The ED cart needs to be able to handle both the patient’s weight and your own. I also recommend a spotter on each side of the cart.

Standing on the cart near the patient’s feet, begin to apply traction to the femur and slowly flex the hip to about 90 degrees. Then gently adduct the thigh to help jump the femoral head over the acetabular rim. You will feel a satisfying clunk as the head drops into place. Straighten the leg and keep it adducted. If you are unsuccessful after two tries, there is probably a bony fragment keeping the head out of the socket. See an instructional video on this tomorrow.

Regardless of success, consult your orthopedic surgeon for further instructions. And be sure to thoroughly evaluate the rest of the patient. It takes a lot of energy to cause this injury, and it is flowing through the rest of the patient, breaking other things as well.

GCS At 40: The New GCS-40

As discussed in my first post in this series, the original Glasgow Coma Scale (GCS) was described in 1974. It was originally intended to be a chart of all three components, trended over time. Ultimately, the three values for eye opening, verbal, and motor responses were combined into a single score ranging from 3-15. This combined score has become the main focus of our attention, with less interest in the individual components.

Here is the original GCS:

Forty years later (2014), there was interest in tweaking it to overcome a few of the perceived shortcomings. Two relatively small changes were made. First, a few terminology changes were made in the eye opening and verbal response components. Eye opening was clarified to indicate opening to pressure, not pain, and speech, not sound. Verbal response was also clarified, changing “incomprehensible” to “sounds”, and “inappropriate” to “words.”

Additionally, when eye opening or verbal response could not be tested (swelling, intubation), the value was scored as a 1. This was changed in 2014, so that the non-testable components are now marked “NT” and the total score should not be calculated.  Here’s an example:

  • Original GCS: E1 V1T M3 = 5T
  • GCS-40: E1 V-NT M3   (no total)

Here’s the new GCS-40 description published in 2014:

Finally, this year Teasdale and associates added one final tweak. They incorporated an indicator of pupillary response. This table shows the levels of response:

This factor is subtracted from the GCS-40, now resulting in score that can range from 1-15. Addition of this component greatly improves our ability to predict outcome.

Why does all this matter? One important reason is that the American College of Surgeons Trauma Quality Improvement Program will begin accepting data in 2019 with GCS 40 data. The National Trauma Databank data definitions will also incorporate GCS 40 in next tear. It looks like there will be a phase-in period where either system can be used. I could not find any indication that the pupillary score would be included any time soon.

I’m sure research will continue on this staple of trauma evaluation. Expect more tweaks in the future as we try to improve our ability to follow our patients clinically and predict how well they will do.

GCS At 40: Pediatric Glasgow Coma Scale

I’ve been discussing the Glasgow Coma Scale (GCS), but only the adult version so far. The pediatric GCS was created about 10 years after the classic adult scale after it was recognized that several of the scores were not appropriate for younger non-verbal children, typically less than one year of age. It has been validated several times over the ensuing years and has been integrated into our trauma practices.

So what is different about the pediatric GCS scale? It has the same three main components, eye opening, best verbal response, and best motor response. The number of scores under each remains the same as well. The major changes occurred in the verbal response scores. Here’s the breakdown; I’ve highlighted the differences.

Eye Opening

  • All components are the same as for adults

Best Verbal Response

  1. No response to stimuli
  2. Inconsolable, agitated
  3. Inconsistently inconsolable, moaning
  4. Cries but consolable. Has appropriate interactions.
  5. The child smiles, orients to sounds, follows objects, and interacts with adults

Best Motor Response

  1. No response to stimuli
  2. Decerebrate posturing (extension to stimulation, see the adult post for details)
  3. Decorticate posturing (flexion to stimulation, see the adult post for details)
  4. Withdraws from pain
  5. Withdraws from touch
  6. Spontaneous, purposeful movement

In my next post in the series, I’ll review what’s new with the GCS-40 score.

Reference: Neurologic evaluation and support in the child with an acute brain insult. Pediatric Annals 15(1):16-22, 1986.

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