HPI: 
Patient 1: Restrained passenger of a head on MVC. 
Patient 2: Elderly patient with fall from standing.
 
Physical Exam: 
Patient 1: Hip flexed and internally rotated. Unable to straighten the leg. Unable to walk.
Patient 2: Hip flexed and externally rotated. Unable to straighten the leg. Unable to walk.
 
Imaging: 
Patient 1: Posterior hip dislocation of native hip. 
Patient 2: Superolateral hip dislocation of prosthetic hip. 

Treatment: 

• Posterior hip dislocations: Stand on the bed over the patient, flex/internally rotate/adduct the hip and pull traction, then attempt to straighten out the leg while continuing traction.
  

 

• Anterior hip dislocations: With leg extended, externally rotate and extend off the edge of the bed. Then pull traction and slowly internally rotate the leg while still in traction.
  

 

• Native hip - Highest risk for femoral neck fractures w/ relocation. Emergently intubate, paralyze, and try to reduce as soon as possible (within 6 hours) before the muscles tighten down. Contraindication to reduction is a femoral neck or acetabular fracture whether displaced or non-displaced. Up to 20% chance of associated sciatic nerve injuries. Perform post-reduction CT bony pelvis for all traumatic hip dislocations of native hips.
  

 

• Operative repair of native hip dislocation if... delayed presentation, femoral neck fracture, irreducible dislocation, or incarcerated bone fragment. Associated fractures of the acetabulum also require ORIF. 
  

 

• Prosthetic hip - Patients go to the PACU w/ ortho for a propofol sedation and hip relocation. Discharged from the PACU if hip stable after relocation. No post-reduction CT required. 
  

 

• 4-6 weeks of touch down weight bearing after native hip relocation.
  

****Don't forgot you can find the ED Policy for Deep Sedation on the Top 20 Page.  Anesthesia must be present for intubation.  Click here to read more.  

HPI: 
Patient 1:  Restrained MVC.  Presented with knee pain and swelling.
Patient 2:  Fall from height and chief complaint of shoulder and knee pain.

Physical Exam: 
Patient 1: Swollen left knee with tenderness to palpation.
Patient 2: Knee visibly deformed, swollen, and bruised. Small open deformity w/ active bleeding. High risk for compartment syndrome. 

Imaging: 
Patient 1: Schatzker type 2 fracture (see table below for classifications of Schatzker fracture)
Patient 2: Schatzker type 6 fracture

Dispo: 
Patient 1: Admitted. Splinted w/ ORIF as inpatient.
Patient 2: Admitted. Splinted w/ closed reduction and external fixation. Plan for definitive repair in ~2 weeks after soft tissue swelling has subsided. 

Treatment: 
1) Hinged knee brace w/ passive ROM - for patients w/ minimally displaced or split depressed fractures or minimal baseline mobility.
2) External fixation - for patient w/ open or comminuted fractures or significant soft tissue swelling.
3) ORIF - for >3mm articular step off or varus/valgus instability.

HPI:  Patient presents with a grossly deformed right upper extremity.

PE:  Gross deformity of humerus, no open fracture.  Unable to extend wrist. Unable to hyper-extend MP joints of fingers and unable to flex IP joint of thumb.  Radial and ulnar pulses intact.

IMAGING:  Multi-factorial fracture along the mid third of humerus along the expected course of the radial nerve.

DISPO (if at free standing ED):  Transfer patient to ED with on-call orthopedics for definitive fixation.  Reduce and splint prior to transfer.

TREATMENT:  Nonoperative managment.  Splinted and cast at bedside.  Follow radial nerve palsy clinically for improvement.