Rosen & Barkin's 5-Minute Emergency Medicine Consult (347 page)

• Hip dislocation: Uncommon; often spontaneously reduced at time of injury. Concern for tissue trapped in joint space:
  
  • Trivial force required for posterior hip locations in children <10 yr old
    
• Proximal femoral physeal fracture: Fracture at growth plate; great risk for osseous necrosis
  
• Slipped capital femoral epiphysis: Minimal trauma, decreased ROM.
  
• Femoral neck fractures: Relatively common; stress fractures in young athletes
  
• Intertrochanteric fractures: Rare.
  
• Must suspect nonaccidental trauma (NAT)
  
• Consider pathologic fracture with minor trauma.
  

See individual injuries above.

DIAGNOSIS

• Groin, hip, thigh, medial knee pain, pain with ambulation/weight bearing in the setting of trauma
  
• Minor trauma in the elderly due to osteoporosis; high-impact trauma in young adults
  
• Rarely overuse injury, stress fracture.
  

• Obvious signs of trauma:
  
  • Deformity or angulation, swelling, open fracture, or missile entrance wound
    
  • Lower extremity held in position of comfort
    
• Hip fracture: Flexion, abduction, external rotation
  
• Posterior hip dislocation: Flexion,
  adduction, internal rotation
  of hip, flexion of knee, hip immobile
  
• Anterior hip dislocation: Flexion,
  abduction, external rotation
  of hip, thigh shortening, hip immobile
  

• Pediatric fracture patterns different due to developing cartilaginous components:
  
  • Assess for dislocation of the femoral capital epiphysis.
    
• Fracture classification and management are also different.
  
• Suspect NAT without obvious mechanism of injury.
  
• Consider hip pain due to a separate process (limb-length discrepancy, neuromuscular disorders, neoplastic invasion of bone).
  

• Assess distal pulses, palpate compartments, evaluate sensation and motor function.
  
• If pulses are not equal or palpable, bedside Doppler or angiography may be necessary.
  
• Search for associated injuries:
  
  • Neurologic deficits
    
  • Vascular injury
    
  • Pelvic fractures (include acetabular fractures)
    
  • Spinal fractures
    
  • Blunt abdominal trauma
    
• Radiographs as outlined below:
  
  • Remove splints and clothing when taking films.
    
  • Positive exam plus negative standard films indicates hip fracture until proven otherwise; further imaging (CT or MRI scan) is indicated.
    
  • Hip dislocations are orthopedic emergencies and require prompt reduction (<6 hr) with limited attempts.
    

• In suspected child abuse, obtain appropriate radiographs to evaluate for other injuries.
  
• Assess markers for NAT:
  
  • Delay in presentation; history of mechanism inconsistent with injury
    
  • Isolated trauma to the thigh, associated burns, bruises, linear abrasions
    

CBC, type and cross-match, INR if appropriate

• Standard films: AP pelvis and true lateral of hip, oblique view.
  
• Femoral neck fracture: AP pelvis with hip internally rotated 15–20°
  
• Pubic rami and acetabular fractures: Pelvic inlet and outlet views
  
• Acetabular fractures: Judet views (oblique views of hip)
  
• High suspicion with negative plain films: CT, MRI, or bone scan. MRI most sensitive.
  
• Must get postreduction x-ray and/or CT scan.
  

• Joint aspiration with or without arthrogram under fluoroscope if a septic joint, foreign body, or hemarthrosis, especially in gunshot wounds to hip is suspected
  
• Operative repair or wash out
  

• Pubic ramus fracture
  
• Acetabular fracture
  
• Septic joint
  
• Thigh, knee, ankle, or foot injury
  
• Trochanteric bursitis
  
• Iliotibial band tendinitis
  
• Hip contusion
  

TREATMENT

• Neurovascular exam is essential.
  
• Immobilize extremity in position of comfort for patient.
  

• Airway, head, chest, or abdominal injuries take precedence in multiple trauma.
  
• Maintain pelvis and hip stability.
  
• Monitor BP continuously.
  
• Cautions:
  
  • DO NOT apply traction.
    
  • Monitor closely for development of hemorrhagic shock as thigh can contain 4–6 U of blood.
    

• Maintain pelvis and hip stability.
  
• Remove splint and clothing.
  
• Pain control:
  
  • Isolated hip injuries: Parenteral analgesia
    
  • Multitrauma or pediatric patients: Femoral nerve block
    
• Orthopedic consultation:
  
  • Necessary for all hip fractures and dislocations
    
  • Emergent if neurovascular compromise
    
  • Open fractures must go directly to the OR for irrigation and debridement.
    
  • May need reduction in OR after 1–2 quick ED attempts to reduce.
    
• Fractures requiring surgery:
  
  • Cefazolin IV
    
• Open fractures with lacerations, extensive soft-tissue damage, or contamination:
  
  • Add gentamicin/tobramycin, tetanus.
    
• If highly contaminated wound: Add penicillin G to cover clostridial species.
  
• Gunshot wounds:
  
  • Culture missile track, iodine dressing
    
• Hip dislocation:
  
  • A true orthopedic emergency
    
  • Incidence of avascular necrosis and degenerative joint disease increases linearly with time to reduction:
    
    • Perform reduction in ED, ideally <6 hr from onset.
      
    • Allis or Stimson maneuvers
      
    • Also described: With patient in lateral decubitus position, move hip from flexed and adducted position to full external rotation with tibia perpendicular to floor.
      
  • Procedural sedation with etomidate, ketamine, or methohexital + midazolam, propofol + fentanyl
    
  • Look for fractures on postreduction imaging (plain film, CT).
    
  • Patients with prior hip arthroplasty may be reduced in the ED with procedural sedation and appropriate monitoring.
    

• Antibiotics
  
  • Cefazolin: 1 g IM/IV q6–8h (peds: 25–50 mg/kg IM/IV div. q6–8h max. 1 g)
    
  • Gentamicin/tobramycin: 3–5 mg/kg/d IV/IM div. q8h (peds: 2–2.5 mg/kg q8h)
    
  • Penicillin G: 2 million U IV q4h (peds: 100,000–400,000 U/kg/d IV div. q4–6h to max. 24 million U in 24 hr)
    
• Moderate sedation:
  
  • Etomidate: 0.1–0.3 mg/kg IV once (not recommended for <12 yr)
    
  • Fentanyl: 1–4 μg/kg IV over 1–2 min once (peds: >6 mo 1–2 μg/kg IV once)
    
  • Ketamine: Not recommended in adults owing to emergence reaction (peds: 1–2 mg/kg IV, 4 mg/kg IM once)
    
  • Methohexital: 1–1.5 mg/kg IV once (peds: Not recommended)
    
  • Midazolam: 0.07 mg/kg IM or 1 mg slowly q2–3min up to 2.5 mg max. (peds: 0.25–1 mg/kg PO once to a max. of 15 mg PO; 6 mo–5 yr: 0.05–0.1 mg/kg IV titrate to max. 0.6 mg/kg; 6–12 yr: 0.025–0.05 mg/kg IV titrate to max. 0.4 mg/kg
    
  • Propofol: 40 mg IV q10sec until induction; 5–10 μg/kg/min IV continuous infusion
    
• Pain control:
  
  • Hydromorphone: 0.5–2.0 mg IM/SC/slow IV q4–6h PRN; titrate for pain control (peds: 0.015 mg/kg/min per dose IV q4–6h PRN)
    
  • Morphine: 2–10 mg IV q4h, titrate for pain control (peds: 0.1 mg/kg IV q4h, titrate for pain control to max. 15 mg/dose)
    
    • Morphine pediatrics use preservative free preparation.
      

• Antibiotics: Cefazolin IV
  
• Pain: Morphine
  
• Sedation: User dependent. Etomidate, adults; ketamine, children.
  

• Antibiotics: Ceftriaxone + gentamicin
  
• Pain: Hydromorphone, fentanyl, nerve block
  
• Sedation: Methohexital, midazolam, propofol
  

FOLLOW-UP

• All hip fractures
  
• Septic joint
  
• Suspicion of occult fracture
  
• Suspicion of NAT in children
  
• All pediatric hip fractures and dislocations
  
• Most dislocations of hip
  

• Hip pain attributable to other cause
  
• Fracture ruled out (negative radiographs
  plus
  negative clinical exam)
  
• Patient with successful reduction of dislocated hip arthroplasty may be considered for discharge in consultation with orthopedics and with appropriate follow-up.
  
• Stress fracture, crutches, follow-up with bone scan or repeat x-rays.
  

• Chronic pain may need primary physician and pain specialist.
  
• Pediatric patients and elderly may need physical therapy.
  

• Discharged patients with hip pain not due to fracture/dislocation are referred to appropriate primary doctor.
  
• Stress fracture, nonweight bearing: Follow-up orthopedics 2–3 days
  

• Location of fracture determines risk factors for morbidity such as AVN and bleeding.
  
• Hip dislocations are orthopedic emergencies and require prompt reduction and few attempts.
  
• Be suspicious of occult fractures, as x-ray may miss 10% fractures. Follow-up study needed (CT or MRI) and possible admission.