SAQ 123 – Trauma – hip dislocation and femoral shaft fracture analgesia

Question 2. hip dislocation and femoral shaft fracture analgesia.

a. Initial analgesia

• Continue penthrane or redose penthrane if only a single dose was given.
• Inhalational nitrous oxide 50/50.
• Intranasal fentanyl; anticipate greater than usual doses may be needed. Usual 1.5 mcg/kg, accept up to 2 mcg/kg, repeat same dose in 10 minutes if inadequate.
• IM ketamine after history is taken: 2-3 mg/kg, followed by ketamine 10-20 mg IV when IV access is obtained.
• IV opioid when IV access is obtained. Morphine may need high total doses, 15-20 mg or more, but may aggravate hypotension. Fentanyl 25-50 mcg titrated is a better option.

b. X-ray abnormalities

• Comminuted fracture of the right femur at the junction of proximal and mid third.
• 100% off-ending and angulation.
• Dislocated right hip, likely anterior with inferomedial displacement.
• Transverse fracture of the right pubic bone; symphysis is not widened.
• Fracture of right superior pubic ramus / acetabular floor with medial displacement.
• Metal and material artefact in the right thigh.

c. Ongoing analgesia

• Reduce the femur fracture and apply longitudinal traction.
• Further IV ketamine: 10 mg bolus or background infusion.
• Femoral nerve block under ultrasound guidance using local anaesthetic, for example 0.5% solution at 2-3 mg/kg.
• Given the history of IVDU, PCA is relatively contraindicated.