Legg-Calve-Perthes<\/p>\n
Avascular necrosis of femoral head seen in 5-7 y\/os<\/p>\n
Slipped Capital Femoral Epiphysis (SCFE)<\/p>\n
10-16 y\/o, obese, m>f<\/p>\n
C\/o knee discomfort, especially with sports<\/p>\n
AP Bilat hips c frogs view<\/p>\n
Hip will be externally rotated<\/p>\n
Septic Arthritis<\/p>\n
Hip will be flexed, abducted, and externally rotated<\/p>\n
Temp>38.3, pain in hip is increased c gentle motion<\/p>\n
Diagnosis is assured if rapid response to antibiotics<\/p>\n
Bursitis<\/p>\n
<\/p>\n
Morel-Lavalle lesion<\/strong><\/h4>\n ![\"\"](\"\/wp-content\/images\/part1\/case051603_small.jpg\")
<\/a><\/p>\nThis patient sustained a Morel-Lavalle lesion. The Morel-Lavalle lesion is a closed internal degloving injury that is recognized clinically as significant soft-tissue ecchymosis, typically in the region of the greater trochanter.\u00a0 It is seen in association with pelvic trauma and is frequently associated with acetabular fractures. A cavity of hematoma and liquefied fat is produced from a shear injury in which the subcutaneous tissue is torn away from the underlying fascia.\u00a0 These injuries have been reported to result in serious infection in over 45% of patients (1). The clinical significance of this injury may not be initially apparent: its clinical appearance may not convey the serious soft tissue injury that is indicated by the lesion and it may be overlooked as attention is focused on bony injuries. As noted, there is a high incidence of bacterial colonization in closed degloving injuries associated with severe pelvic trauma. The Morel-Lavalle lesion should be treated by thorough debridement prior to or at the time of the pelvic or acetabular surgery. (Emedhome.com)<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Hip Dislocations<\/span><\/h2>\nMust be reduced ASAP<\/p>\n
<\/span>Captain Morgan Approach<\/span><\/h3>\n![\"\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/12\/capmorgan-150x150.jpg\" "\\"capmorgan\\"")
<\/a><\/h3>\n(Ann Emerg Med 2011;58:536)<\/p>\n
<\/h4>\nHow to reduce a posterior hip dislocation<\/h4>\n
Foot fulcrum technique<\/p>\n
(Injury 2010;41:665)<\/p>\n
![\"\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/07\/hip-11-150x150.jpg\" "\\"hip-1\\"")
<\/a>![\"\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/07\/hip-21-150x150.jpg\" "\\"hip-2\\"")
<\/a>![\"\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/07\/hip-3-150x150.jpg\" "\\"hip-3\\"")
<\/a>![\"\"](\"https:\/\/crashingpatient.com\/wp-content\/uploads\/2011\/07\/hip-41-150x150.jpg\" "\\"hip-4\\"")
<\/a><\/p>\n <\/p>\n
<\/p>\n
<\/span>Fracture of the Iliac Crest<\/span><\/h3>\nknown as a hip pointer.\u00a0 Consider abd trauma.\u00a0 A 5-8 day course of burst steroids may reduce disability.<\/p>\n
<\/span>Fracture of Distal Femur<\/span><\/h3>\nComplications:\u00a0 hip fx, vascular trauma, peroneal nerve, quad muscle damage<\/p>\n
<\/p>\n
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
PELVIS and HIP<\/strong>The pelvis and hip are radiographically complex structures, and fractures in these areas comprised a substantial portion of malpractice claims as studied by ACEP in 1974-1985.\u00a0 Overlapping bones and the oblique orientation of many structures on the AP view are often the cause of radiographic misinterpretations.\u00a0 The normal anatomy of the pelvis and hip are depicted in Figure 13.Figure 13.\u00a0 AP radiograph and diagram of the pelvis ![\"\"](\"\/wp-content\/images\/part1\/news041403w_small.jpg\")
<\/a> ![\"\"](\"\/wp-content\/images\/part1\/news041403w_small.gif\")
<\/a><\/strong>Hip \u0093D\u0094islocations can be classified as anterior and posterior.\u00a0 Posterior hip dislocations are more common and are often caused by a dashboard intrusion injury against the knees in motor vehicle crashes.\u00a0 On physical exam, patients with posterior dislocations lie with their affected leg shortened and internally rotated.\u00a0 Conversely, patients with anterior dislocations lie with their affected leg shortened and externally rotated.\u00a0 Radiographically, the femoral head no longer approximates with the acetabular fossa (Figure 14).\u00a0 In the event of an unsuccessful hip reduction, computed tomography (CT) imaging is recommended to evaluate for obstructive intra-articular bone fragments.\u00a0 Often, hip dislocations are also associated with femoral head and acetabular fractures.<\/p>\nFigure 14.\u00a0 Left hip posterior dislocation (AP view) ![\"\"](\"\/wp-content\/images\/part1\/news041403x_small.jpg\")
<\/a>\u00a0 ![\"\"](\"\/wp-content\/images\/part1\/news041403y_small.gif\")
<\/a><\/strong>There are three extremely important \u0093O\u0094ccult fractures of the pelvis and hip which require careful scrutiny.\u00a0 The first is a femoral neck fracture (Figure 15)– the most commonly missed hip fracture.\u00a0 Occurring primarily in the elderly and osteoporotic population after a fall directly onto the hip, femoral neck fractures can be extremely subtle on plain radiographs.\u00a0 Approximately 2-9% of hip fractures are, in fact, radiographically normal (15,16).\u00a0 Underappreciated findings include cortical discontinuity, hyperlucency along the line of impaction, interruption of the smooth cortical transition from femoral neck to femoral head, and trabecular disruption.\u00a0 A study by Parker demonstrated that 16 of 825 hip fractures were initially overlooked.\u00a0 Because of the delayed diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced, were displaced upon re-presentation (17).\u00a0 Because of this significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice in the ED for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip.\u00a0 The sensitivity and specificity of an MRI in detecting such fractures is 100% (18).\u00a0 As a less sensitive and less specific alternative, CT imaging may be used instead with the risk of missing fractures that are oriented in the axial plane.Figure 15.\u00a0 Right femoral neck fracture (AP view) ![\"\"](\"\/wp-content\/images\/part1\/news041403y_small.jpg\")
<\/a>\u00a0\u00a0 ![\"\"](\"\/wp-content\/images\/part1\/news041403z_small.gif\")
<\/a><\/strong>The second \u0093O\u0094ccult fracture is of the sacrum.\u00a0 One study demonstrated that 72% of sacral fractures were missed initially (19).\u00a0 When radiographically examining the pelvis, be sure to look specifically at the sacrum.\u00a0 Detection of a subtle break in the smooth alar lines suggests a sacral fracture as seen in Figure 16.\u00a0 Upon visualizing a sacral fracture, subsequent CT imaging is often necessary to evaluate the extent of the sacral fracture because neurological deficits such as cauda equina and radiculopathy occur 22% of the time (20), and associated pelvic fractures are frequently overlooked on plain radiographs.\u00a0 When neurological deficits are present, sacral fractures often undergo surgical repair.\u00a0 Consultation with an orthopedist or neurosurgeon is necessary for all sacral fractures because of these significant co-morbidities (21).Figure 16.\u00a0 Right-sided sacral fractures (AP view) ![\"\"](\"\/wp-content\/images\/part1\/news041403z_small.jpg\")
<\/a>\u00a0\u00a0 ![\"\"](\"\/wp-content\/images\/part1\/news041403aa_small.gif\")
<\/a><\/strong>And the third \u0093O\u0094ccult fracture involves the acetabulum, the pelvic articulation site for the femoral head.\u00a0 The acetabulum can be divided into anterior and posterior columns.\u00a0 The disruption of the iliopubic line suggests an anterior acetabular fracture as seen in Figure 17, and a disruption of the ilioischial line suggests a posterior acetabular fracture.\u00a0 Additionally, when looking for a posterior acetabular fracture, one must carefully examine the portion of the acetabulum behind the superimposed femoral head.\u00a0 Using this approach, a subtle posterior acetabular fracture can also be visualized in Figure 17.Figure 17.\u00a0 Right anterior and posterior acetabular fractures (AP view)<\/strong> ![\"\"](\"\/wp-content\/images\/part1\/news041403bb_small.jpg\")
<\/a>\u00a0 ![\"\"](\"\/wp-content\/images\/part1\/news041403cc_small.gif\")
<\/a> Pelvic and hip fractures often occur in multiples because the pelvis structurally resembles a closed ring.\u00a0 By the law of physics, a fracture through one part of a ring will expectedly cause a fracture through another part of the ring.\u00a0 Thus, the diagnosis of an isolated fracture of the pelvis may only represent \u0093H\u0094alf of the injuries present.\u00a0 Special attention must be paid to the aforementioned fractures in addition to subtle rami fractures, sacroiliac dissociation, and L5 transverse process fractures as potential additional sites for pelvic ring disruption<\/p>\n <\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Femoral 3:1 Nerve Block<\/span><\/h2>\nRCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)<\/p>\n
<\/p>\n
<\/p>\n
A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60\u00b0 cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10\u00b0 laterally.\u00a0 If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.<\/p>\n
![\"\"](\"\/wp-content\/images\/part1\/fem%20nerve%20block_small.jpg\")
<\/a><\/p>\nHowever, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10\u00b0 at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.<\/p>\n
<\/p>\n
In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)<\/p>\n
<\/p>\n
MRI is the gold standard for dx<\/p>\n
<\/p>\n
Trochanteric fxs do not need treatment<\/p>\n
<\/p>\n
femoral neck fxs are at risk for AVN<\/p>\n
<\/p>\n
Clinical scenario A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting. Search strategy Medline using Ovid interface 1966\u0096March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”. Search outcome 137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry. View this table: [in this window] [in a new window] Table 2 Cochrane: 21 citations found but no new papers. Comment(s) Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department. CLINICAL BOTTOM LINE Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block. References Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia 1997 Oct;85(4):854\u00967. Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia and Pain Medicine 1998 Nov-Dec;23(6):584\u00968.<\/p>\n
<\/p>\n
Hip Dislocation AB pillow substitute<\/a><\/p>\n <\/p>\n
Occult Hip Fracture Flow<\/p>\n
![\"\"](\"\/wp-content\/images\/part1\/case051603.jpg\")
<\/a><\/p>\nThis patient sustained a Morel-Lavalle lesion. The Morel-Lavalle lesion is a closed internal degloving injury that is recognized clinically as significant soft-tissue ecchymosis, typically in the region of the greater trochanter.\u00a0 It is seen in association with pelvic trauma and is frequently associated with acetabular fractures. A cavity of hematoma and liquefied fat is produced from a shear injury in which the subcutaneous tissue is torn away from the underlying fascia.\u00a0 These injuries have been reported to result in serious infection in over 45% of patients (1). The clinical significance of this injury may not be initially apparent: its clinical appearance may not convey the serious soft tissue injury that is indicated by the lesion and it may be overlooked as attention is focused on bony injuries. As noted, there is a high incidence of bacterial colonization in closed degloving injuries associated with severe pelvic trauma. The Morel-Lavalle lesion should be treated by thorough debridement prior to or at the time of the pelvic or acetabular surgery. (Emedhome.com)<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Hip Dislocations<\/span><\/h2>\nMust be reduced ASAP<\/p>\n
<\/span>Captain Morgan Approach<\/span><\/h3>\n<\/a><\/h3>\n(Ann Emerg Med 2011;58:536)<\/p>\n
<\/h4>\nHow to reduce a posterior hip dislocation<\/h4>\n
Foot fulcrum technique<\/p>\n
(Injury 2010;41:665)<\/p>\n
<\/a><\/a><\/a><\/a><\/p>\n <\/p>\n
<\/p>\n
<\/span>Fracture of the Iliac Crest<\/span><\/h3>\nknown as a hip pointer.\u00a0 Consider abd trauma.\u00a0 A 5-8 day course of burst steroids may reduce disability.<\/p>\n
<\/span>Fracture of Distal Femur<\/span><\/h3>\nComplications:\u00a0 hip fx, vascular trauma, peroneal nerve, quad muscle damage<\/p>\n
<\/p>\n
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
PELVIS and HIP<\/strong>The pelvis and hip are radiographically complex structures, and fractures in these areas comprised a substantial portion of malpractice claims as studied by ACEP in 1974-1985.\u00a0 Overlapping bones and the oblique orientation of many structures on the AP view are often the cause of radiographic misinterpretations.\u00a0 The normal anatomy of the pelvis and hip are depicted in Figure 13.Figure 13.\u00a0 AP radiograph and diagram of the pelvis <\/a> <\/a><\/strong>Hip \u0093D\u0094islocations can be classified as anterior and posterior.\u00a0 Posterior hip dislocations are more common and are often caused by a dashboard intrusion injury against the knees in motor vehicle crashes.\u00a0 On physical exam, patients with posterior dislocations lie with their affected leg shortened and internally rotated.\u00a0 Conversely, patients with anterior dislocations lie with their affected leg shortened and externally rotated.\u00a0 Radiographically, the femoral head no longer approximates with the acetabular fossa (Figure 14).\u00a0 In the event of an unsuccessful hip reduction, computed tomography (CT) imaging is recommended to evaluate for obstructive intra-articular bone fragments.\u00a0 Often, hip dislocations are also associated with femoral head and acetabular fractures.<\/p>\nFigure 14.\u00a0 Left hip posterior dislocation (AP view) <\/a>\u00a0 <\/a><\/strong>There are three extremely important \u0093O\u0094ccult fractures of the pelvis and hip which require careful scrutiny.\u00a0 The first is a femoral neck fracture (Figure 15)– the most commonly missed hip fracture.\u00a0 Occurring primarily in the elderly and osteoporotic population after a fall directly onto the hip, femoral neck fractures can be extremely subtle on plain radiographs.\u00a0 Approximately 2-9% of hip fractures are, in fact, radiographically normal (15,16).\u00a0 Underappreciated findings include cortical discontinuity, hyperlucency along the line of impaction, interruption of the smooth cortical transition from femoral neck to femoral head, and trabecular disruption.\u00a0 A study by Parker demonstrated that 16 of 825 hip fractures were initially overlooked.\u00a0 Because of the delayed diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced, were displaced upon re-presentation (17).\u00a0 Because of this significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice in the ED for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip.\u00a0 The sensitivity and specificity of an MRI in detecting such fractures is 100% (18).\u00a0 As a less sensitive and less specific alternative, CT imaging may be used instead with the risk of missing fractures that are oriented in the axial plane.Figure 15.\u00a0 Right femoral neck fracture (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>The second \u0093O\u0094ccult fracture is of the sacrum.\u00a0 One study demonstrated that 72% of sacral fractures were missed initially (19).\u00a0 When radiographically examining the pelvis, be sure to look specifically at the sacrum.\u00a0 Detection of a subtle break in the smooth alar lines suggests a sacral fracture as seen in Figure 16.\u00a0 Upon visualizing a sacral fracture, subsequent CT imaging is often necessary to evaluate the extent of the sacral fracture because neurological deficits such as cauda equina and radiculopathy occur 22% of the time (20), and associated pelvic fractures are frequently overlooked on plain radiographs.\u00a0 When neurological deficits are present, sacral fractures often undergo surgical repair.\u00a0 Consultation with an orthopedist or neurosurgeon is necessary for all sacral fractures because of these significant co-morbidities (21).Figure 16.\u00a0 Right-sided sacral fractures (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>And the third \u0093O\u0094ccult fracture involves the acetabulum, the pelvic articulation site for the femoral head.\u00a0 The acetabulum can be divided into anterior and posterior columns.\u00a0 The disruption of the iliopubic line suggests an anterior acetabular fracture as seen in Figure 17, and a disruption of the ilioischial line suggests a posterior acetabular fracture.\u00a0 Additionally, when looking for a posterior acetabular fracture, one must carefully examine the portion of the acetabulum behind the superimposed femoral head.\u00a0 Using this approach, a subtle posterior acetabular fracture can also be visualized in Figure 17.Figure 17.\u00a0 Right anterior and posterior acetabular fractures (AP view)<\/strong> <\/a>\u00a0 <\/a> Pelvic and hip fractures often occur in multiples because the pelvis structurally resembles a closed ring.\u00a0 By the law of physics, a fracture through one part of a ring will expectedly cause a fracture through another part of the ring.\u00a0 Thus, the diagnosis of an isolated fracture of the pelvis may only represent \u0093H\u0094alf of the injuries present.\u00a0 Special attention must be paid to the aforementioned fractures in addition to subtle rami fractures, sacroiliac dissociation, and L5 transverse process fractures as potential additional sites for pelvic ring disruption<\/p>\n <\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Femoral 3:1 Nerve Block<\/span><\/h2>\nRCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)<\/p>\n
<\/p>\n
<\/p>\n
A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60\u00b0 cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10\u00b0 laterally.\u00a0 If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.<\/p>\n
<\/a><\/p>\nHowever, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10\u00b0 at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.<\/p>\n
<\/p>\n
In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)<\/p>\n
<\/p>\n
MRI is the gold standard for dx<\/p>\n
<\/p>\n
Trochanteric fxs do not need treatment<\/p>\n
<\/p>\n
femoral neck fxs are at risk for AVN<\/p>\n
<\/p>\n
Clinical scenario A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting. Search strategy Medline using Ovid interface 1966\u0096March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”. Search outcome 137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry. View this table: [in this window] [in a new window] Table 2 Cochrane: 21 citations found but no new papers. Comment(s) Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department. CLINICAL BOTTOM LINE Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block. References Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia 1997 Oct;85(4):854\u00967. Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia and Pain Medicine 1998 Nov-Dec;23(6):584\u00968.<\/p>\n
<\/p>\n
Hip Dislocation AB pillow substitute<\/a><\/p>\n <\/p>\n
Occult Hip Fracture Flow<\/p>\n
<\/a><\/h3>\n(Ann Emerg Med 2011;58:536)<\/p>\n
<\/h4>\nHow to reduce a posterior hip dislocation<\/h4>\n
Foot fulcrum technique<\/p>\n
(Injury 2010;41:665)<\/p>\n
<\/a><\/a><\/a><\/a><\/p>\n <\/p>\n
<\/p>\n
<\/span>Fracture of the Iliac Crest<\/span><\/h3>\nknown as a hip pointer.\u00a0 Consider abd trauma.\u00a0 A 5-8 day course of burst steroids may reduce disability.<\/p>\n
<\/span>Fracture of Distal Femur<\/span><\/h3>\nComplications:\u00a0 hip fx, vascular trauma, peroneal nerve, quad muscle damage<\/p>\n
<\/p>\n
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
PELVIS and HIP<\/strong>The pelvis and hip are radiographically complex structures, and fractures in these areas comprised a substantial portion of malpractice claims as studied by ACEP in 1974-1985.\u00a0 Overlapping bones and the oblique orientation of many structures on the AP view are often the cause of radiographic misinterpretations.\u00a0 The normal anatomy of the pelvis and hip are depicted in Figure 13.Figure 13.\u00a0 AP radiograph and diagram of the pelvis <\/a> <\/a><\/strong>Hip \u0093D\u0094islocations can be classified as anterior and posterior.\u00a0 Posterior hip dislocations are more common and are often caused by a dashboard intrusion injury against the knees in motor vehicle crashes.\u00a0 On physical exam, patients with posterior dislocations lie with their affected leg shortened and internally rotated.\u00a0 Conversely, patients with anterior dislocations lie with their affected leg shortened and externally rotated.\u00a0 Radiographically, the femoral head no longer approximates with the acetabular fossa (Figure 14).\u00a0 In the event of an unsuccessful hip reduction, computed tomography (CT) imaging is recommended to evaluate for obstructive intra-articular bone fragments.\u00a0 Often, hip dislocations are also associated with femoral head and acetabular fractures.<\/p>\nFigure 14.\u00a0 Left hip posterior dislocation (AP view) <\/a>\u00a0 <\/a><\/strong>There are three extremely important \u0093O\u0094ccult fractures of the pelvis and hip which require careful scrutiny.\u00a0 The first is a femoral neck fracture (Figure 15)– the most commonly missed hip fracture.\u00a0 Occurring primarily in the elderly and osteoporotic population after a fall directly onto the hip, femoral neck fractures can be extremely subtle on plain radiographs.\u00a0 Approximately 2-9% of hip fractures are, in fact, radiographically normal (15,16).\u00a0 Underappreciated findings include cortical discontinuity, hyperlucency along the line of impaction, interruption of the smooth cortical transition from femoral neck to femoral head, and trabecular disruption.\u00a0 A study by Parker demonstrated that 16 of 825 hip fractures were initially overlooked.\u00a0 Because of the delayed diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced, were displaced upon re-presentation (17).\u00a0 Because of this significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice in the ED for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip.\u00a0 The sensitivity and specificity of an MRI in detecting such fractures is 100% (18).\u00a0 As a less sensitive and less specific alternative, CT imaging may be used instead with the risk of missing fractures that are oriented in the axial plane.Figure 15.\u00a0 Right femoral neck fracture (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>The second \u0093O\u0094ccult fracture is of the sacrum.\u00a0 One study demonstrated that 72% of sacral fractures were missed initially (19).\u00a0 When radiographically examining the pelvis, be sure to look specifically at the sacrum.\u00a0 Detection of a subtle break in the smooth alar lines suggests a sacral fracture as seen in Figure 16.\u00a0 Upon visualizing a sacral fracture, subsequent CT imaging is often necessary to evaluate the extent of the sacral fracture because neurological deficits such as cauda equina and radiculopathy occur 22% of the time (20), and associated pelvic fractures are frequently overlooked on plain radiographs.\u00a0 When neurological deficits are present, sacral fractures often undergo surgical repair.\u00a0 Consultation with an orthopedist or neurosurgeon is necessary for all sacral fractures because of these significant co-morbidities (21).Figure 16.\u00a0 Right-sided sacral fractures (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>And the third \u0093O\u0094ccult fracture involves the acetabulum, the pelvic articulation site for the femoral head.\u00a0 The acetabulum can be divided into anterior and posterior columns.\u00a0 The disruption of the iliopubic line suggests an anterior acetabular fracture as seen in Figure 17, and a disruption of the ilioischial line suggests a posterior acetabular fracture.\u00a0 Additionally, when looking for a posterior acetabular fracture, one must carefully examine the portion of the acetabulum behind the superimposed femoral head.\u00a0 Using this approach, a subtle posterior acetabular fracture can also be visualized in Figure 17.Figure 17.\u00a0 Right anterior and posterior acetabular fractures (AP view)<\/strong> <\/a>\u00a0 <\/a> Pelvic and hip fractures often occur in multiples because the pelvis structurally resembles a closed ring.\u00a0 By the law of physics, a fracture through one part of a ring will expectedly cause a fracture through another part of the ring.\u00a0 Thus, the diagnosis of an isolated fracture of the pelvis may only represent \u0093H\u0094alf of the injuries present.\u00a0 Special attention must be paid to the aforementioned fractures in addition to subtle rami fractures, sacroiliac dissociation, and L5 transverse process fractures as potential additional sites for pelvic ring disruption<\/p>\n <\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Femoral 3:1 Nerve Block<\/span><\/h2>\nRCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)<\/p>\n
<\/p>\n
<\/p>\n
A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60\u00b0 cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10\u00b0 laterally.\u00a0 If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.<\/p>\n
<\/a><\/p>\nHowever, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10\u00b0 at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.<\/p>\n
<\/p>\n
In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)<\/p>\n
<\/p>\n
MRI is the gold standard for dx<\/p>\n
<\/p>\n
Trochanteric fxs do not need treatment<\/p>\n
<\/p>\n
femoral neck fxs are at risk for AVN<\/p>\n
<\/p>\n
Clinical scenario A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting. Search strategy Medline using Ovid interface 1966\u0096March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”. Search outcome 137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry. View this table: [in this window] [in a new window] Table 2 Cochrane: 21 citations found but no new papers. Comment(s) Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department. CLINICAL BOTTOM LINE Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block. References Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia 1997 Oct;85(4):854\u00967. Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia and Pain Medicine 1998 Nov-Dec;23(6):584\u00968.<\/p>\n
<\/p>\n
Hip Dislocation AB pillow substitute<\/a><\/p>\n <\/p>\n
Occult Hip Fracture Flow<\/p>\n
How to reduce a posterior hip dislocation<\/h4>\n
<\/a><\/a><\/a><\/a><\/p>\n<\/p>\n
<\/p>\n
<\/span>Fracture of the Iliac Crest<\/span><\/h3>\nknown as a hip pointer.\u00a0 Consider abd trauma.\u00a0 A 5-8 day course of burst steroids may reduce disability.<\/p>\n
<\/span>Fracture of Distal Femur<\/span><\/h3>\nComplications:\u00a0 hip fx, vascular trauma, peroneal nerve, quad muscle damage<\/p>\n
<\/p>\n
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
PELVIS and HIP<\/strong>The pelvis and hip are radiographically complex structures, and fractures in these areas comprised a substantial portion of malpractice claims as studied by ACEP in 1974-1985.\u00a0 Overlapping bones and the oblique orientation of many structures on the AP view are often the cause of radiographic misinterpretations.\u00a0 The normal anatomy of the pelvis and hip are depicted in Figure 13.Figure 13.\u00a0 AP radiograph and diagram of the pelvis <\/a> <\/a><\/strong>Hip \u0093D\u0094islocations can be classified as anterior and posterior.\u00a0 Posterior hip dislocations are more common and are often caused by a dashboard intrusion injury against the knees in motor vehicle crashes.\u00a0 On physical exam, patients with posterior dislocations lie with their affected leg shortened and internally rotated.\u00a0 Conversely, patients with anterior dislocations lie with their affected leg shortened and externally rotated.\u00a0 Radiographically, the femoral head no longer approximates with the acetabular fossa (Figure 14).\u00a0 In the event of an unsuccessful hip reduction, computed tomography (CT) imaging is recommended to evaluate for obstructive intra-articular bone fragments.\u00a0 Often, hip dislocations are also associated with femoral head and acetabular fractures.<\/p>\nFigure 14.\u00a0 Left hip posterior dislocation (AP view) <\/a>\u00a0 <\/a><\/strong>There are three extremely important \u0093O\u0094ccult fractures of the pelvis and hip which require careful scrutiny.\u00a0 The first is a femoral neck fracture (Figure 15)– the most commonly missed hip fracture.\u00a0 Occurring primarily in the elderly and osteoporotic population after a fall directly onto the hip, femoral neck fractures can be extremely subtle on plain radiographs.\u00a0 Approximately 2-9% of hip fractures are, in fact, radiographically normal (15,16).\u00a0 Underappreciated findings include cortical discontinuity, hyperlucency along the line of impaction, interruption of the smooth cortical transition from femoral neck to femoral head, and trabecular disruption.\u00a0 A study by Parker demonstrated that 16 of 825 hip fractures were initially overlooked.\u00a0 Because of the delayed diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced, were displaced upon re-presentation (17).\u00a0 Because of this significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice in the ED for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip.\u00a0 The sensitivity and specificity of an MRI in detecting such fractures is 100% (18).\u00a0 As a less sensitive and less specific alternative, CT imaging may be used instead with the risk of missing fractures that are oriented in the axial plane.Figure 15.\u00a0 Right femoral neck fracture (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>The second \u0093O\u0094ccult fracture is of the sacrum.\u00a0 One study demonstrated that 72% of sacral fractures were missed initially (19).\u00a0 When radiographically examining the pelvis, be sure to look specifically at the sacrum.\u00a0 Detection of a subtle break in the smooth alar lines suggests a sacral fracture as seen in Figure 16.\u00a0 Upon visualizing a sacral fracture, subsequent CT imaging is often necessary to evaluate the extent of the sacral fracture because neurological deficits such as cauda equina and radiculopathy occur 22% of the time (20), and associated pelvic fractures are frequently overlooked on plain radiographs.\u00a0 When neurological deficits are present, sacral fractures often undergo surgical repair.\u00a0 Consultation with an orthopedist or neurosurgeon is necessary for all sacral fractures because of these significant co-morbidities (21).Figure 16.\u00a0 Right-sided sacral fractures (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>And the third \u0093O\u0094ccult fracture involves the acetabulum, the pelvic articulation site for the femoral head.\u00a0 The acetabulum can be divided into anterior and posterior columns.\u00a0 The disruption of the iliopubic line suggests an anterior acetabular fracture as seen in Figure 17, and a disruption of the ilioischial line suggests a posterior acetabular fracture.\u00a0 Additionally, when looking for a posterior acetabular fracture, one must carefully examine the portion of the acetabulum behind the superimposed femoral head.\u00a0 Using this approach, a subtle posterior acetabular fracture can also be visualized in Figure 17.Figure 17.\u00a0 Right anterior and posterior acetabular fractures (AP view)<\/strong> <\/a>\u00a0 <\/a> Pelvic and hip fractures often occur in multiples because the pelvis structurally resembles a closed ring.\u00a0 By the law of physics, a fracture through one part of a ring will expectedly cause a fracture through another part of the ring.\u00a0 Thus, the diagnosis of an isolated fracture of the pelvis may only represent \u0093H\u0094alf of the injuries present.\u00a0 Special attention must be paid to the aforementioned fractures in addition to subtle rami fractures, sacroiliac dissociation, and L5 transverse process fractures as potential additional sites for pelvic ring disruption<\/p>\n <\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/span>Femoral 3:1 Nerve Block<\/span><\/h2>\nRCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)<\/p>\n
<\/p>\n
<\/p>\n
A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60\u00b0 cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10\u00b0 laterally.\u00a0 If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.<\/p>\n
<\/a><\/p>\nHowever, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10\u00b0 at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.<\/p>\n
<\/p>\n
In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)<\/p>\n
<\/p>\n
MRI is the gold standard for dx<\/p>\n
<\/p>\n
Trochanteric fxs do not need treatment<\/p>\n
<\/p>\n
femoral neck fxs are at risk for AVN<\/p>\n
<\/p>\n
Clinical scenario A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting. Search strategy Medline using Ovid interface 1966\u0096March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”. Search outcome 137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry. View this table: [in this window] [in a new window] Table 2 Cochrane: 21 citations found but no new papers. Comment(s) Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department. CLINICAL BOTTOM LINE Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block. References Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia 1997 Oct;85(4):854\u00967. Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia and Pain Medicine 1998 Nov-Dec;23(6):584\u00968.<\/p>\n
<\/p>\n
Hip Dislocation AB pillow substitute<\/a><\/p>\n <\/p>\n
Occult Hip Fracture Flow<\/p>\n
Complications:\u00a0 hip fx, vascular trauma, peroneal nerve, quad muscle damage<\/p>\n
<\/p>\n
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
<\/p>\n
PELVIS and HIP<\/strong>The pelvis and hip are radiographically complex structures, and fractures in these areas comprised a substantial portion of malpractice claims as studied by ACEP in 1974-1985.\u00a0 Overlapping bones and the oblique orientation of many structures on the AP view are often the cause of radiographic misinterpretations.\u00a0 The normal anatomy of the pelvis and hip are depicted in Figure 13.Figure 13.\u00a0 AP radiograph and diagram of the pelvis Figure 14.\u00a0 Left hip posterior dislocation (AP view) <\/p>\n <\/p>\n <\/p>\n <\/p>\n RCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)<\/p>\n <\/p>\n <\/p>\n A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60\u00b0 cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10\u00b0 laterally.\u00a0 If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.<\/p>\n However, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10\u00b0 at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.<\/p>\n <\/p>\n In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)<\/p>\n <\/p>\n MRI is the gold standard for dx<\/p>\n <\/p>\n Trochanteric fxs do not need treatment<\/p>\n <\/p>\n femoral neck fxs are at risk for AVN<\/p>\n <\/p>\n Clinical scenario A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting. Search strategy Medline using Ovid interface 1966\u0096March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”. Search outcome 137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry. View this table: [in this window] [in a new window] Table 2 Cochrane: 21 citations found but no new papers. Comment(s) Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department. CLINICAL BOTTOM LINE Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block. References Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia 1997 Oct;85(4):854\u00967. Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia and Pain Medicine 1998 Nov-Dec;23(6):584\u00968.<\/p>\n <\/p>\n Hip Dislocation AB pillow substitute<\/a><\/p>\n <\/p>\n Occult Hip Fracture Flow<\/p>\n<\/a> <\/a><\/strong>Hip \u0093D\u0094islocations can be classified as anterior and posterior.\u00a0 Posterior hip dislocations are more common and are often caused by a dashboard intrusion injury against the knees in motor vehicle crashes.\u00a0 On physical exam, patients with posterior dislocations lie with their affected leg shortened and internally rotated.\u00a0 Conversely, patients with anterior dislocations lie with their affected leg shortened and externally rotated.\u00a0 Radiographically, the femoral head no longer approximates with the acetabular fossa (Figure 14).\u00a0 In the event of an unsuccessful hip reduction, computed tomography (CT) imaging is recommended to evaluate for obstructive intra-articular bone fragments.\u00a0 Often, hip dislocations are also associated with femoral head and acetabular fractures.<\/p>\n<\/a>\u00a0 <\/a><\/strong>There are three extremely important \u0093O\u0094ccult fractures of the pelvis and hip which require careful scrutiny.\u00a0 The first is a femoral neck fracture (Figure 15)– the most commonly missed hip fracture.\u00a0 Occurring primarily in the elderly and osteoporotic population after a fall directly onto the hip, femoral neck fractures can be extremely subtle on plain radiographs.\u00a0 Approximately 2-9% of hip fractures are, in fact, radiographically normal (15,16).\u00a0 Underappreciated findings include cortical discontinuity, hyperlucency along the line of impaction, interruption of the smooth cortical transition from femoral neck to femoral head, and trabecular disruption.\u00a0 A study by Parker demonstrated that 16 of 825 hip fractures were initially overlooked.\u00a0 Because of the delayed diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced, were displaced upon re-presentation (17).\u00a0 Because of this significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice in the ED for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip.\u00a0 The sensitivity and specificity of an MRI in detecting such fractures is 100% (18).\u00a0 As a less sensitive and less specific alternative, CT imaging may be used instead with the risk of missing fractures that are oriented in the axial plane.Figure 15.\u00a0 Right femoral neck fracture (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>The second \u0093O\u0094ccult fracture is of the sacrum.\u00a0 One study demonstrated that 72% of sacral fractures were missed initially (19).\u00a0 When radiographically examining the pelvis, be sure to look specifically at the sacrum.\u00a0 Detection of a subtle break in the smooth alar lines suggests a sacral fracture as seen in Figure 16.\u00a0 Upon visualizing a sacral fracture, subsequent CT imaging is often necessary to evaluate the extent of the sacral fracture because neurological deficits such as cauda equina and radiculopathy occur 22% of the time (20), and associated pelvic fractures are frequently overlooked on plain radiographs.\u00a0 When neurological deficits are present, sacral fractures often undergo surgical repair.\u00a0 Consultation with an orthopedist or neurosurgeon is necessary for all sacral fractures because of these significant co-morbidities (21).Figure 16.\u00a0 Right-sided sacral fractures (AP view) <\/a>\u00a0\u00a0 <\/a><\/strong>And the third \u0093O\u0094ccult fracture involves the acetabulum, the pelvic articulation site for the femoral head.\u00a0 The acetabulum can be divided into anterior and posterior columns.\u00a0 The disruption of the iliopubic line suggests an anterior acetabular fracture as seen in Figure 17, and a disruption of the ilioischial line suggests a posterior acetabular fracture.\u00a0 Additionally, when looking for a posterior acetabular fracture, one must carefully examine the portion of the acetabulum behind the superimposed femoral head.\u00a0 Using this approach, a subtle posterior acetabular fracture can also be visualized in Figure 17.Figure 17.\u00a0 Right anterior and posterior acetabular fractures (AP view)<\/strong> <\/a>\u00a0 <\/a> Pelvic and hip fractures often occur in multiples because the pelvis structurally resembles a closed ring.\u00a0 By the law of physics, a fracture through one part of a ring will expectedly cause a fracture through another part of the ring.\u00a0 Thus, the diagnosis of an isolated fracture of the pelvis may only represent \u0093H\u0094alf of the injuries present.\u00a0 Special attention must be paid to the aforementioned fractures in addition to subtle rami fractures, sacroiliac dissociation, and L5 transverse process fractures as potential additional sites for pelvic ring disruption<\/p>\n<\/span>Femoral 3:1 Nerve Block<\/span><\/h2>\n
<\/a><\/p>\n