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Managing Dislocations of the Hip, Knee, and Ankle in the Emergency

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Managing Dislocations of the Hip, Knee, and Ankle in the Emergency December 2017 Managing Dislocations of the Volume 19, Number 12 Authors Hip, Knee, and Ankle in the Caylyne Arnold, DO Clinical Faculty, Emergency Department, Naval Medical Center San Diego, San Diego, CA Emergency Department Zane Fayos, MD Resident Physician, Emergency Medicine, Naval Medical Center San Diego, Abstract San Diego, CA David Bruner, MD, FAAEM Staff Physician, Scripps Mercy Hospital San Diego, San Diego, CA Dislocation of the major joints of the lower extremities—hip, Dylan Arnold, DO knee, and ankle—can occur due to motor-vehicle crashes, falls, Assistant Professor of Military and Emergency Medicine, Uniformed Services and sports injuries. Hip dislocations are the most common, University of the Health Sciences; Assistant Program Director, Emergency Medicine Residency, Naval Medical Center San Diego, San Diego, CA and they require emergent management to prevent avascular necrosis of the femoral head. Knee dislocations are uncommon Peer Reviewers but potentially dangerous injuries that can result in amputa- Melissa Leber, MD, FACEP Assistant Professor of Emergency Medicine and Orthopedics, Director of tion due to the potential for missed secondary injury, especially Emergency Department Sports Medicine, Icahn School of Medicine at Mount if they are reduced spontaneously. Isolated ankle dislocations Sinai, New York, NY are relatively rare, as most ankle dislocations involve an associ- Christopher R. Tainter, MD, RDMS ated fracture. This review presents an algorithmic approach to Associate Clinical Professor, Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, University of California management that ensures that pain relief, imaging, reduction, San Diego, San Diego, CA vascular monitoring, and emergent orthopedic consultation are carried out in a timely fashion. Prior to beginning this activity, see “Physician CME Information” on the back page. This issue is eligible for 4 trauma CME credits. Editor-In-Chief Daniel J. Egan, MD Shkelzen Hoxhaj, MD, MPH, MBA Alfred Sacchetti, MD, FACEP Joseph D. Toscano, MD Andy Jagoda, MD, FACEP Associate Professor, Department Chief Medical Officer, Jackson Assistant Clinical Professor, Chairman, Department of Emergency Professor and Chair Emeritus, of Emergency Medicine, Program Memorial Hospital, Miami, FL Department of Emergency Medicine, Medicine, San Ramon Regional Director, Emergency Medicine Thomas Jefferson University, Medical Center, San Ramon, CA Department of Emergency Medicine; Eric Legome, MD Residency, Mount Sinai St. Luke's Philadelphia, PA Director, Center for Emergency Chair, Emergency Medicine, Mount Medicine Education and Research, Roosevelt, New York, NY Sinai West & Mount Sinai St. Luke's; Robert Schiller, MD International Editors Icahn School of Medicine at Mount Nicholas Genes, MD, PhD Vice Chair, Academic Affairs for Chair, Department of Family Medicine, Peter Cameron, MD Sinai, New York, NY Associate Professor, Department of Emergency Medicine, Mount Sinai Beth Israel Medical Center; Senior Academic Director, The Alfred Emergency and Trauma Centre, Emergency Medicine, Icahn School Health System, Icahn School of Faculty, Family Medicine and Monash University, Melbourne, Associate Editor-In-Chief of Medicine at Mount Sinai, New Medicine at Mount Sinai, New York, NY Community Health, Icahn School of Medicine at Mount Sinai, New York, NY Australia Kaushal Shah, MD, FACEP York, NY Keith A. Marill, MD Associate Professor, Department of Assistant Professor, Department Scott Silvers, MD, FACEP Giorgio Carbone, MD Emergency Medicine, Icahn School Michael A. Gibbs, MD, FACEP of Emergency Medicine, Harvard Associate Professor and Chair, Chief, Department of Emergency of Medicine at Mount Sinai, New Professor and Chair, Department Medical School, Massachusetts Department of Emergency Medicine, Medicine Ospedale Gradenigo, York, NY of Emergency Medicine, Carolinas Medical Center, University of North General Hospital, Boston, MA Mayo Clinic, Jacksonville, FL Torino, Italy Editorial Board Carolina School of Medicine, Chapel Charles V. Pollack Jr., MA, MD, Corey M. Slovis, MD, FACP, FACEP Suzanne Y.G. Peeters, MD Saadia Akhtar, MD Hill, NC FACEP Professor and Chair, Department Attending Emergency Physician, Associate Professor, Department of Steven A. Godwin, MD, FACEP Professor and Senior Advisor for of Emergency Medicine, Vanderbilt Flevo Teaching Hospital, Almere, Emergency Medicine, Associate Dean Professor and Chair, Department Interdisciplinary Research and University Medical Center, Nashville, TN The Netherlands Clinical Trials, Department of for Graduate Medical Education, of Emergency Medicine, Assistant Hugo Peralta, MD Emergency Medicine, Sidney Kimmel Ron M. Walls, MD Program Director, Emergency Dean, Simulation Education, Chair of Emergency Services, Medical College of Thomas Jefferson Professor and Chair, Department of Medicine Residency, Mount Sinai University of Florida COM- Hospital Italiano, Buenos Aires, University, Philadelphia, PA Emergency Medicine, Brigham and Beth Israel, New York, NY Jacksonville, Jacksonville, FL Women's Hospital, Harvard Medical Argentina Michael S. Radeos, MD, MPH William J. Brady, MD Joseph Habboushe, MD MBA School, Boston, MA Dhanadol Rojanasarntikul, MD Associate Professor of Emergency Professor of Emergency Medicine Assistant Professor of Emergency Attending Physician, Emergency Medicine, Weill Medical College and Medicine; Chair, Medical Medicine, NYU/Langone and Critical Care Editors Medicine, King Chulalongkorn of Cornell University, New York; Emergency Response Committee; Bellevue Medical Centers, New York, Memorial Hospital, Thai Red Cross, Research Director, Department of William A. Knight IV, MD, FACEP Medical Director, Emergency NY; CEO, MD Aware LLC Thailand; Faculty of Medicine, Emergency Medicine, New York Associate Professor of Emergency Management, University of Virginia Chulalongkorn University, Thailand Gregory L. Henry, MD, FACEP Hospital Queens, Flushing, NY Medicine and Neurosurgery, Medical Medical Center, Charlottesville, VA Clinical Professor, Department of Director, EM Advanced Practice Stephen H. Thomas, MD, MPH Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Provider Program; Associate Medical Calvin A. Brown III, MD Vice-Chair, Emergency Medicine, Professor & Chair, Emergency Director of Physician Compliance, of Michigan Medical School; CEO, Director, Neuroscience ICU, University Medicine, Hamad Medical Corp., Medical Practice Risk Assessment, Massachusetts General Hospital, of Cincinnati, Cincinnati, OH Credentialing and Urgent Care Boston, MA Weill Cornell Medical College, Qatar; Services, Department of Emergency Inc., Ann Arbor, MI Scott D. Weingart, MD, FCCM Emergency Physician-in-Chief, Medicine, Brigham and Women's John M. Howell, MD, FACEP Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Hamad General Hospital, Hospital, Boston, MA Clinical Professor of Emergency FAAEM, FACP Medicine; Director, Division of ED Doha, Qatar Medicine, George Washington Assistant Professor of Emergency Critical Care, Icahn School of Medicine Peter DeBlieux, MD Edin Zelihic, MD University, Washington, DC; Director Medicine, The University of at Mount Sinai, New York, NY Professor of Clinical Medicine, Head, Department of Emergency of Academic Affairs, Best Practices, Maryland School of Medicine, Interim Public Hospital Director Medicine, Leopoldina Hospital, Inc, Inova Fairfax Hospital, Falls Baltimore, MD Senior Research Editors of Emergency Medicine Services, Schweinfurt, Germany Church, VA Louisiana State University Health Aimee Mishler, PharmD, BCPS Science Center, New Orleans, LA Emergency Medicine Pharmacist, Maricopa Medical Center, Phoenix, AZ Case Presentations cine Database, SportDiscus, and Google Scholar using the search terms hip dislocation, anterior hip A 25-year-old man is brought in by ambulance after dislocation, posterior hip dislocation, knee dislocation, being involved in a high-speed motor vehicle crash as an ankle dislocation, talar dislocation, subtalar dislocation, unrestrained driver. He is complaining of right hip pain hip reduction, knee reduction, and ankle reduction. A and lower abdominal pain. During his primary trauma total of 163 articles were found regarding hip dislo- survey, you note that his right leg is shortened and inter- cations, 187 on knee dislocations, and 167 on ankle nally rotated. You suspect a native hip dislocation and/or dislocations. The Cochrane Database of Systematic fracture and wonder which diagnostic studies you should Reviews was searched, using the terms hip disloca- obtain and whether you should attempt a reduction before tion, knee dislocation, and ankle dislocation, resulting in consulting orthopedic surgery. 8 articles related primarily to knee dislocations. The Later that evening, an elderly woman arrives with right American College of Emergency Physicians does not hip pain, unable to ambulate. She states, “I was just bend- endorse any guidelines related to lower-extremity ing over to put on my shoes when I felt a ‘pop,’ and then I dislocations. fell to the ground.” She then informs you that she recently The majority of the applicable literature for underwent right total hip arthroplasty. You notice her right lower-extremity dislocations is found in orthopedic leg appears internally rotated, adducted, and shortened. You and trauma surgery journals. ED-specific studies are suspect a dislocation of her prosthesis and wonder whether limited, though the approach and initial manage- you should
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