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Hip Dislocations

11/25/2014

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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. 

Posterior Hip Dislocation

Picture

Prosthetic Hip Dislocation

Picture
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.  
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Tibial Plateau Fractures

11/21/2014

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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
Picture
Picture
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.
Types of Schatzker Fractures:
Picture
Picture
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radial nerve palsy

11/13/2014

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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.
Picture
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    Orthopedics Blog

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    CMC ER Residents 
    (for learning purposes, imagine all cases present to a free standing ED for dispo and treatment options)

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    Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Patient identifiers have been redacted/changed or patient consent has been obtained.  Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction