Managing Dislocations of the Hip in the ED

Posted on by David Traficante

Source: EM Practice Podcast – Dec 2017
** There are no existing ACEP guidelines on this topic.

Pre-Hospital Management
  • Stabilizing and pain control
  • Neurovascular compromise
    • If suspected then d/w med control for considerate of immediate reduction and splinting vs. rapid transport to ED
    • If no suspicion the patient can be immobilized in current position
  • Don’t forget C-spine precautions as these injuries are often distracting
Overview

Etiology:

  • Typically traumatic in origin
  • Over 2/3 Hip dislocations occur in patients who present after MVCs without seat belts with the knee hitting the dashboard and the body moving forward over a fixed femur.
    • Often associated with posterior wall/lip fractures of the acetabulum

Definitions:

  • Simple vs. Complex
    • Simple Dislocation – does not involve fracture
    • Complex Dislocation – involves fracture

Pathophysiology:

  • Posterior & Inferior dislocations are most common – about 90% of dislocations
  • Fracture of >40% of the acetabular rim is considered an UNSTABLE FRACTURE (requires ORIF)
    • If there is a posterior acetabular fracture you must get a CT to eval for unstable fractures
  • Sciatic nerve injury
    • Seen in about 14% of traumatic hip dislocations
    • Check sensory along the posterior leg, ability to dorsiflex the ankle and ankle reflexes
  • 95% of traumatic hip dislocations will have another associated injury
    • Be sure to complete a full trauma survey on these patients per ATLS guidelines
Imaging
  • Initial image should be a bedside AP pelvic radiograph
  • Look for Shenton’s Line

  • Lateral film can seal the diagnosis if unsure based on initial bedside AP
  • CT if neeeded
Treatment for Native Hips (non-prosthetic)

Consultation

  • Ortho Consultation are required for the following:
    • Complex hip dislocations
    • Irreducible dislocations
    • Non-concentric reductions
    • Neurovascular deficits despite reduction

Reductions

Who:
– Simple dislocations can & should be reduced by the ED physician!

When:
– Reduction should be performed within 6 hours of injury to decrease risk of avascular necrosis
– No more than 3 attempts at reduction should be made by the ED provider

Transfers:
– If patient requires transfer to a different hospital, an attempt at reduction should be made by the ED provider.
– Patients transferred without reduction had a 4-fold risk of severe sciatic nerve compared to those transferred after reduction (16% vs 4%).

Analgesia:
– Be sure pain is controlled prior to attempting reduction

  • Ultrasound guided fascia iliaca compartmental block work great
    • Reduces need for systemic analgesics
    • Improves patient comfort
    • Increases likelihood of successful reduction
    • Reduce need for procedural sedation
    • Be sure to have completed a full neurological exam prior to blocking your patient
      LINK TO VIDEO
  • In many cases, procedural sedation and systemic analgesia may also be needed (in addition to nerve block) in order to adequate pain control and muscle relaxation.

Reduction Techniques

Old School:
Allis’s Maneuver

Newer techniques:
Captain Morgan
Over-Under/Whistler
East Baltimore Lift

No evidence exists to recommend one technique over the other.

Immobilization

After successful reduction the hip should be immobilized in extension and external rotation with slight abduction
– Use an abduction pillow to help hold this position
– Knee immobilizer can be used if no abduction pillow is available

Don’t forget to obtain a post reduction film to confirm alignment

Other Recommendations
– Early passive range of motion and rehab is usually recommended
– Patients should remain non-weight bearing until seen by an Orthopedist

Notes on Prosthetic Hip Dislocations
  • Quite common
    • Incidence of ~2% of patients who undergo THA
    • 60% occur within first 3 mo, 77% occur within the first year
  • Often the result of minimal force like bending over to pick something up off the floor
  • Use the same techniques as a native hip reduction
  • Do not need abduction bracing after the reduction
  • If the patient can walk after the reduction, they can be safely discharged (after discussion with their orthopedist)
  • Less urgency, no risk of avascular necrosis as the femoral head has already been replaced
  • Remember, these injuries are painful and although less urgent, the reduction should occur as soon as possible

 

EM Conference Pearls (7/26/17)

Posted on by David Traficante

Pediatrics Trauma Radiology Review (Dr. Flannery) – When in doubt splint

  • Salter Harris: Take home memorize classification and management
    • SH1: Clinical Dx – Splint and f/u
    • SH2: Splint and f/u, most common
    • SH3: Ortho consult
    • SH4: OR
    • SH5: OR
  • Supracondylar Fx : Take home: Type II/III requires OR
    • SC Fx type I: Look for posterior/anterior fat pads
      • Tx: Posterior splint, f/u ortho
    • SC Fx type II: Splint and Ortho consult
    • SC Fx type III: OR
  • Misc Fx
    • Greenstick fracture
    • Toddle Fx: Tx with posterior splint and out pt f/u (For non displaced)
      • When in doubt splint and f/u ortho
    • Buckle Fx: Volar splint
  • SCFE
    • Klein’s line should intersect the femoral head
    • Can be bilateral
  • SCIWORA
    • Always recheck spinal (ROM/focal findings) after a negative CT cervical

Trauma Board Review (Dr. Patel)

  • Hip/Femur fracture
    • Most are operative, recognize they are sick patients.
    • Fermoral head fx, neck fx, trochanteric (Inter/sub)
    • Pain control, Ortho consult, Most cases OR
  • Tibial plateau fracture
    • Maybe radiographically occult
    • Patella alta
  • Maisonneuve fracture
    • Proximal fibular fx + medial malleolar fracture ( or disruption of deltoid ligatment, IO membrane syndesmosis)
  • Lisfranc fracture
    • Tarso-metatarsal fracture-dislocation
    • Mal-alignment Metatarsals with cuneiforms.
  • Calcaneal fractures
    • 10% associated lumbar fractures
    • Boehler’s angle <20
  • Jones fracture: High rate on non-union
  • Pseudojones fractures: Bulky dressing and pain control
  • Hip dislocations
    • MC: Posterior dislocation (90%)
    • High rate of AVN femoral head, peroneal nerve dysfx, sciatic nerve injuries)
  • Knee dislocation
    • 50% will spontaneous reduce!!!
    • Need a good Neurovascular evaluation
    • ABI < 0.9
    • Vascular surgery/ortho eval à Arteriography or CT Angio
  • Ankle Sprain:
    • Ottawa ankle rule
  • Scapular fracture
    • Associated with concomitant injuries such as internal thoracic injuries
  • Clavicle fracture
    • Op: Open fx, unstable floating shoulder, NV compromise.
  • Radial head fx
  • Monteggia fracture
  • Galeazzi fracture
  • Scaphoid fx – Thumb spica, risk of non-union and AVN
  • Bannette’s fx – Thumb spica,
  • Rolando fx
  • Posterior shoulder dislocation: Light bulb / Drum stick appearance
  • Compartment syndrome
    • 6P’s. Money is on pain and paresthesia.
  • High pressure injury injection injury
    • Limb threatening
    • Surgical emergency

Trauma in pregnancy (Dr. Kashani)

  • Prepare for difficult airway
  • Be aware of Hemodynamic changes
  • Rh sensitization
  • >20 weeks with abdominal trauma monitor for 4 hrs
  • Peri mortem C-section best outcome if performed within 4 – 5 minutes of CPR 

Thanks to Chief Mike Hong, DO PGY-4 for writing up today’s CONFERENCE PEARLS

Antibiotics for chest tubes

Posted on by terrancemcgovern

Things to keep in mind:

Prophylactic antibiotics for surgical patients in tube thoracostomy is usually limited to 24hrs duration and is 1st generation cephalosporin. It is meant to cover s. aureus the most common organism found in post traumatic empyema

increasing antibiotic use is leading to increase incidence of drug resistance

Potential infectious complications of penetrating or blunt chest trauma:

  • Post Traumatic Empyema
  • Pneumonia

Literature is mixed on whether antibiotics should be given for chest tubes placed for trauma.

In 1998 EAST guidelines gave a level 3* recommendation to give antibiotics prophylacticly to reduce incidence of pneumonia based off of Class I and Class II** data. AND there was insufficient data to give prophylactic antibiotics for post traumatic empyema

This recommendation remains controversial because 

  •    In order for antibiotics to be prophylactic they have to be given prior to a procedure and must reach a steady state concentration in the tissue before an incision is made.
  •    In the case of antibiotics given after a trauma has already occurred, the pleura has already been violated regardless of whether it is penetrating or blunt trauma. Therefore antibiotics do not reach needed concentration before contamination has concerned so these antibiotics are considered presumptive antibiotics.
  •    Non standard definitions of pneumonia and empyema were used, as well as various antibiotics were used in the different studies

In 2012 EAST guidelines reviewed the use of presumptive antibiotics for chest tubes (Tube thoracostomy):

They decided that they cannot make a recommendation for or against the routine use of presumptive antibiotics for chest tubes placed for traumatic hemopneumothorax.

Nor are they able to recommend an optimal duration of antibiotic prophylaxis when antibiotics are administered for traumatic hemopneumothorax because there are insufficient published data to support the routine use of antibiotics.

They concluded:

No single published study has been powered to adequately address the practice of administering presumptive antibiotics in TT for traumatic hemopneumothorax to decrease the incidence of empyema or pneumonia. Until a large and likely multicenter, randomized, controlled trial can be performed, the routine practice of presumptive antibiotics in TT for chest trauma will remain controversial.

If you want to read the article it isn’t a long read:
Post by: Dr. Ashley Guthrie, DO

Lisfranc injuries

Posted on by terrancemcgovern

Quick Review of Lisfranc Injuries

Lisfranc injures are a spectrum which result in a sprain or complete disruption of the tarsometatarsal joints of the midfoot.  They most commonly occur at the base of the 2nd metatarsal with oftentimes subtle or even absent findings on standards x-ray views, especially when they result from low velocity injury.

What is mechanism of Injury?

Usually a result of plantar flexion with external rotation of the ankle (ie. fall from a horse with the foot caught in the foot stirrup, MVC, foot planted in a hole or step off a curb)

Physical Exam on Suspected Lisfranc Fracture

  • Unable to bear weight
  • Hematoma/ecchymosis on medial plantar aspect of foot
  • Dorsal midfoot swelling

Lisfranc foot

For suspected Lisfranc injuries you’ll need three views (AP, lateral and oblique).  On normal foot x-rays you should notice alignment of the 2nd metatarsal on AP view and the medial edge of the base of the 2nd metatarsal should line up with the medial edge of the medial cuneiform.   On the oblique view the 3rd and 4th metatarsal should have the medial edge of the 3rd and 4th metatarsal lining up with the medial edges of the middle and lateral cuneiform.

Lisfranc xray1Lisfranc xry2

Common X-ray findings for Lisfranc Fracture.

  • Widening of > 2mm between the base of the 1st and 2nd or 3rd and 4th metatarsal bases needs surgical intervention
  • “ Fleck Sign” is pathognomonic for a Lisfranc Injury. This is a small bony fragment avulsed from the 2nd metatarsal base or medial cuneiform

lisfranc xray3

What if the X-ray is normal but a Lisfranc injury is still clinically suspected?

  • Add a 30 degree oblique X-ray view
  • Consider ankle nerve block with standing views (Weight bearing stress views).  Similar to the example below with a normal appearing non weight bearing x-ray (left) and then weight-bearing (right) revealing the injury.
  • In patients with clinically suspected Lisfranc injuries and normal or indeterminate radiographic findings, CT or MRI imaging is recommended.
  • Given the superior depiction of soft tissue supporting structures and the ability of soft tissue supporting structures and the ability to detect soft tissue injuries in patients with unstable injuries on MR images, the American College of Radiology Appropriateness Criteria guidelines favors the use of MR imagining
  • Orthopedics surgeons may request high resolution 3D CT images for preoperative planning and for depicting and further characterizing fractures.

 

lisfranc 6       lisfranc6b

 

ED management for patients with Lisfranc Injury

For nondisplaced or suspected injury without radiographic findings, you may place the patient in a posterior back slab. Patient should be non-weight bearing and arrange for orthopedic outpatient follow up two weeks later.  For significantly displaced injury or dislocation (> 2mm widening at the Lisfranc Joint) , Immediate orthopedic referral is needed for urgent outpatient surgical intervention

Post by: Yenis Paez-Perez, DO

Lunate and perilunate dislocations

Posted on by terrancemcgovern

A weekend warrior trying to finish up painting that last side of the house takes a tumble off his ladder and lands on his left hand.  He has a palpable deformity on the volar aspect of the distal radius and painful active and passive ROM but is otherwise neurovascularly intact with no median nerve neuropathy.  The following x-ray is obtained:

Lunate dislocationSp splint

You realize something is not where it’s supposed to be!  The patient has a lunate dislocation to the point where it has migrated proximally to the forearm.  After attempts at closed reduction by the Orthopedist, a CT is obtained which shows associated triquetral fracture and improved position of the lunate.  The patient is admitted and scheduled for open reduction and repair of intercarpal ligaments in the OR.

Lunate and perilunate dislocations come in a variety of shapes and sizes but the orthopedists organize them into 4 different stages of instability that we’ll go over here.

Stage 1 instability: Scapholunate dissociation 

Typically these patients FOOSH’d onto their wrist sustaining the injury with minimal swelling and pain on physical exam.  On xray we are looking for widening of the scapholunate space of > 2-4mm which is our indication that there has been disruption of the ligament.  You’ll hear the term, the “Terry Thomas” sign to describe the gaping of the metacarpals similar to his teeth.  Depending on the orthopedist these can be managed conservatively with a sugar tong splint or operatively.

terry thomas

Stage 2 instability: Perilunate dislocation 

These injuries will typically be a higher mechanism of injury with more significant physical exam findings than the stage 1’s we just discussed.  On x-ray you’ll notice that the lunate remains aligned with the distal radius while the remaining carpal bones are displaced, usually dorsally.  Most of the time these are going to need a CT to look for any radiooccult fractures of the scaphoid and radial styloid.  These will need operative management to prevent any of the nasty sequelae of median nerve palsy, compartment syndrome, long term wrist dysfunction, etc.

stage2

Stage 3 instability: Midcarpal dislocation

These are going to have a similar mechanism of injury but result in disruption of the triquetrolunate ligament or a triquetral fracture. The radiographs will show neither the capitate or lunate aligned with the distal radius.  You’re going to need ortho for this one.

midcarpal

Stage 4 instability: Lunate dislocation

These aren’t known to be the most common, but they are more severe.  The differentiating factor between this and a perilunate dislocation is that the lunate and distal radius articulation is preserved in perilunate dislocation, but not so in lunate dislocations.  On the AP film you’ll see the “piece of pie” sign (below, left) and on the lateral you’ll see the “spilled teacup” (below, right).  This is yet another one that you’re going to get ortho involved with pretty early on for an urgent reduction and operative management.

spilled pie

ct lunate

We talk a lot about those pesky radiooccult scaphoid fractures and have seen enough distal radius fractures to make us physically ill, but there’s a lot more that can go wrong in the wrist.  These are, for the most part, relatively apparent injuries that have devastating consequences if missed.  So get ortho involved early in these cases so the patient can receive the treatment they need.

Post by: Katrina D’Amore DO, MPH

Blunt chest trauma

Posted on by terrancemcgovern
Being in even the most benign car accident imaginable, can be stressful for patients.  Inherently, if they have any chest pain they’re going to be convinced that they’ve sheared their aorta right off its hinges.  While that may be of concern to them, we are pretty certain that their aorta is still intact if they still are alive, but did they sustain a cardiac contusion? How do we figure out if they had one?  And what the heck do we do with them if they did in fact have a cardiac contusion?
1) What are we concerned about in blunt chest trauma?
There are many clinically significant injuries possible in the setting of blunt chest trauma. One that comes to mind is the nebulus diagnosis of “cardiac contusion.”  A lot of the controversy and uncertainty comes from the unclear definition of cardiac contusion which seems to encompass things like myocardial rupture, valvular injury, arrhythmias, cardiac dysfunction, etc. In my mind these types of patients would be more clinically apparent so we’ll focus on the patients who may appear well or relatively so.
2) Do we need to get a troponin in blunt chest trauma?
The answer is yes and no. There is a “guideline” answer and a practical one.
The guideline answer is yes. The 2012 EAST practice guideline for blunt trauma recommends BOTH an EKG and troponin. They state based on their references that a normal EKG in blunt chest trauma has a NPV of 95%. This increases to 100% with a normal troponin. There are several studies that support the use of troponin in this setting and there are instances when EKGs may be normal with a positive troponin. One recent study showed a troponin at 24 hours had 100% NPV for severe cardiac injury.
But the practical answer may be no. There are other studies that are less optimistic regarding the sensitivity and specificity and discourage the use of troponin as a gold standard for diagnosing cardiac contusion from blunt trauma. Another study showed that positive troponins were not a strong predictor of abnormalities on echocardiogram. So getting a troponin may not even matter. However other studies suggested that a positive troponin may be indicative of cardiac contusion or underlying cardiac issue, which brings us to our next question.
3) What do we do with a positive troponin in blunt chest trauma?
One of the arguments against getting a troponin is not knowing what to do with it. If it is negative can they go home? If it’s positive do they need to stay? A 2013 prospective study out of Iran does not recommend troponin as a gold standard in cardiac injury but does encourage intensive cardiac monitoring if an elevated troponin is found. Another study showed that elevated troponin was linked to arrythmias during the patients stay.  So this would suggest admission and tele monitoring for a patient that may have otherwise gone home.
4) Does this change the patients outcome?
Probably not. Three older studies looked at outcomes of patients with cardiac contusions and they really have no long term sequelae and do well.
What’s the bottom line?
Being in a trauma center I would follow the trauma guidelines of getting both an EKG and troponin in the setting of blunt chest trauma. If this is negative with a negative EKG and the patient appears well clinically then likely discharge. However if they have an isolated positive troponin then I would consider admission for 24 hour monitoring for arrythmias with a consideration for inpatient echocardiogram with a reassuring knowledge that they will almost absolutely do well long term.
Post by: Dr. Jordan Jeong, DO (@jeongjom)

Gone fishin’

Posted on by terrancemcgovern

The weather is finally starting to warm up and the fish are biting.  Unfortunately, amateur and pro fishermen alike will also either catch themselves or their friend while out on the waterways this summer.  While a small fishhook lodged in a finger may seem trivial compared to some of the more traumatic injuries we see, the process of removing a fishhook can still be challenging and time consuming.  In this month’s issue of ACEP Now we published four different ways of removing these pesty hooks. Check it out here. 

Post by: Terrance McGovern DO MPH (@drtmcg13)

Fat embolism syndrome

Posted on by terrancemcgovern

Typically when we start talking about anything related to fat embolisms our minds go immediately to trauma and long bone fractures as the cause, but this isn’t always the case. The constellation of signs and symptoms of respiratory insufficiency, neurologic dysfunction and petechial rash which are typically associated with fat embolism syndrome can also be caused by pancreatitis, sickle cell disease and liposuction; all of which show up regularly in the Emergency Department. With mortality rates as high as 20%, despite the fact that FES usually doesn’t present for at least 12 hours after the initial event, it should be something that we are aware of.

There are two competing theories as what causes FES. Some believe more in the mechanical-obstruction theory where the fat globules act similarly as other embolic events, showering throughout the end organs and wreaking havoc by those means. The new challenger to this theory is the biochemical theory where proponents support the notion that the fat is broken down into free fatty acids and the damage is caused by the endothelial damage and subsequent increased vascular permeability. No matter which theory you support, the clinical diagnosis is going to be equally as challenging. There are a few criteria/scores that have been developed in the past that are non-specific diagnostic tools to identify patients with FES, but they have not been compared head-to-head in their accuracy. In the Emergency Department we are limited with the tests that we can routinely order. Unfortunately, CXRs are going to be essentially useless in diagnosing FES, but MRI may hold more promise. The starfield pattern seen on MRI is not specific to FES, but has been seen routinely in patients who have disease processes associated with FES along with neurologic symptoms. Otherwise, in the ED this is going to essentially be a clinical diagnosis with a good history and a little bit of luck. There is some evidence that earlier fixation and specific orthopedic surgery techniques may decrease the rate of FES, but from an EM point-of-view it is essentially supportive care. Research seems to be lacking into the non-trauma causes of FES, so maybe there is somewhere for us to intervene in those patients…

Post by: Terrance McGovern DO, MPH (@drtmcg13)