What is the most appropriate management for a patient with a right posterior hip dislocation due to a motor vehicle crash, presenting with hip pain, shortening of the right leg, and numbness over the dorsum of the right foot, with a qualified provider unavailable for at least six hours?

Immediate Procedural Sedation with Hip Reduction

The most appropriate management is C: procedural sedation with hip reduction, which must be performed urgently to prevent avascular necrosis and permanent nerve damage. Posterior hip dislocations are orthopedic emergencies requiring reduction within 6 hours to minimize complications, and the 6-hour delay until orthopedic availability makes immediate emergency department reduction mandatory.

Critical Time-Sensitive Nature

• Hip dislocations require reduction within 6 hours to prevent avascular necrosis of the femoral head, with each hour of delay significantly increasing the risk of permanent complications 1
• The presence of numbness over the dorsum of the right foot indicates sciatic nerve injury (specifically the common peroneal division), which occurs in up to 20% of posterior hip dislocations and may become permanent without prompt reduction 1
• Delays beyond 6 hours dramatically increase rates of osteonecrosis, post-traumatic arthritis, and permanent neurologic deficits 1

Why Emergency Department Reduction is Indicated

• ED procedural sedation achieves reduction in approximately 2 hours 21 minutes versus 8 hours 32 minutes for operating room-based reduction, saving nearly 6 hours of critical time 2
• Posterior hip dislocations are reduced by placing longitudinal traction with internal rotation on the hip, a technique well-established for emergency department use 1
• Closed reduction is the initial treatment method and typically occurs in the emergency room 1

Optimal Sedation Protocol

• Propofol is the first-line agent for procedural sedation, demonstrating significantly fewer reduction complications (8.7%) compared to etomidate (24.7%) or opioid/benzodiazepine combinations (28.9%) 3
• Propofol also shows fewer sedation complications (7.3% vs 11.7-21.3%) and faster recovery times (25.2 minutes vs 30.8-44.4 minutes) 3
• Adequate dosing is critical: use at least 0.5 mg/kg/dose of propofol, as undersedation results in longer sedation times, more re-doses, and higher failure rates (10.3% vs 0%) 4

Why Other Options Are Inappropriate

• External pelvic stabilization (Option A) is used for pelvic ring injuries, not hip dislocations 1
• Hare traction (Option B) is indicated for femoral shaft fractures to reduce pain and bleeding, not for hip dislocations which require rotational manipulation 1
• Tibial pin placement with traction weights (Option D) is used for complex fractures requiring prolonged skeletal traction, not for acute dislocations 1

Post-Reduction Management

• Obtain post-reduction radiographs immediately to confirm concentric reduction and rule out associated fractures 1
• Perform repeat neurovascular examination, as the sciatic nerve injury may improve immediately after reduction 1
• CT scan of the hip should follow to identify any occult fractures or intra-articular fragments that would require operative intervention 1

Common Pitfalls to Avoid

• Do not wait for orthopedic availability when reduction can be safely performed in the ED, as every hour of delay worsens outcomes 2
• Do not undersedate patients with propofol doses less than 0.5 mg/kg, as this leads to failed reductions and need for general anesthesia 4
• Ensure adequate countertraction by securing the pelvis to the bed with straps before applying longitudinal traction 5