POTD: Those Hips Don't Lie

To kick off the block I’ll be talking about hip dislocations as today is ~Trauma Tuesday~ after all. I have only attempted to reduce one hip myself and it was while I was at Midwood Community hospital a few weeks ago. Dr. Duo Xu and I were pushing and pulling with all our might but despite all our best efforts, ultimately it was unsuccessful and the patient was transferred to MMC main for orthopedics. Honestly, we were not surprised as the patient had dislocated it the prior day and also had a hip replacement. This inspired me to want to delve into this topic some more, especially on reduction techniques. 

Classifications

Posterior: Most common, 90% of hip dislocations

• Occurs when an axial load is applied on a Flexed and ADDducted hip

• ie motor vehicle crashes where patient's knee hits the dashboard

Anterior: 10% of hip dislocations

• Occurs when an axial load is applied on a Extended and ABducted hip 

As with other dislocations, you always want to be mindful of injury to the nearby vessels and nerves. Depending on the mechanism of injury, there may be an underlying fracture. If there is an associated fracture, this becomes a complex dislocation.

Management for simple closed isolated hip dislocation

• Obtain xray films, pain medication 

• Reduce ideally under 6 hours to reduce chances of developing avascular necrosis. One study found that after 6hrs, 53% of patients developed avascular necrosis 

• Procedural sedation 

Management for complex closed isolated hip dislocation 

If there is an associated femoral fracture then you’ll need to get orthopedics on board. They may take the patient to the OR and have everything taken care of intra-operatively. 

Reduction techniques

There are dozens of methods and various combinations/modifications but I'm going over a few that I think are more intuitive and less likely to injure myself.

Rocket Launcher

Patient supine in stretcher almost with both legs hanging off stretcher 

You flex their knee and facing their feet, put your shoulder underneath the posterior fossa/calf with hands around lower tibia/ankle 

Use your shoulder to press upwards while hands pull down

Captain Morgan 

Patient supine in stretcher 

You have one leg flexed on stretcher and other leg flat on ground with patient’s calf on your thigh 

Push down by patient’s ankle, can also plantarflex your foot that’s on the stretcher to get more leverage

For short kings and queens a step stool may be helpful, I could barely get my foot comfortably up on the stretcher without feeling like I was about to dislocate my own hip 

Allis 

Patient supine in stretcher 

You put your hands around ipsilateral tibia, standing on stretcher can get you better leverage 

Pull upwards, remember that consistent traction is key

Some personal takeaways 

• Don’t forget you need a nurse to record vitals / draw meds during the procedural sedation and during that time you are utilizing a lot of resources. 

• You need at least one assistant to help keep the pelvis in place while you are reducing for all these maneuvers shown above

• Maximizing pain relief and relaxation will increase your chances of success, your patient should be loosey goosey. Consider a regional nerve block (femoral, fascia iliaca)

• Dislocated hardware joints are extremely difficult to reduce, once I had three orthopedic residents yanking on a dislocated hip while the EM attending and I helped pull traction

• You may wake up sore the next day 

References: 

1. https://www.orthobullets.com/trauma/1035/hip-dislocation 

2. https://coreem.net/core/hip-dislocation/ 

3. https://www.merckmanuals.com/professional/injuries-poisoning/how-to-reduce-dislocations-and-subluxations/how-to-reduce-a-posterior-hip-dislocation#Equipment_v45399602

4. https://www.annemergmed.com/article/S0196-0644(22)00050-6/fulltext 

VOTW: Distal Radius Fracture

This week’s VOTW is brought to you by myself!

A 72 year old female came in the ED after a FOOSH and suffered a distal radius fracture w/ dorsal angulation seen on x-ray. A POCUS was performed which showed…

Clip 1 shows the dorsal distal radius with sudden cortical disruption and dorsal angulation consistent with the fracture site. The probe marker is facing towards the hand. Clip 2 shows a hematoma block performed w/ ultrasound guidance- the needle is seen entering the fracture site precisely where the fragments meet. Reduction of the fracture was then performed once adequate analgesia was achieved.

Image 1 is prior to reduction. Image 2 is s/p first attempt at reduction. Unhappy with the alignment, reduction was attempted one more time resulting in Image 3 where the alignment is improved. Post-reduction x-rays were obtained, the patient was placed in a sugar-tong splint and discharged with orthopedic follow up.

POCUS for distal radius fractures

In a small study of 83 patients with distal radius fractures, POCUS was 98% sensitive and 98% specific for identifying the fracture when compared to x-rays. Sensitivity and specificity of POCUS ffor the need for reduction was 98% and 100% respectively (1).

While POCUS may not replace x-rays for the management of fractures, it can assist with procedural guidance for hematoma blocks and can evaluate for the adequacy of reduction in real-time rather than waiting for the x-ray tech to come around in between reduction attempts.

How to Identify a fracture

• Use a linear high frequency probe

• Visualize the distal radius in its long axis from multiple planes

• Look for a disruption/angulation in the echogenic cortex

How to perform a ultrasound-guided hematoma block

• Obtain 10ml of lidocaine drawn up in a syringe, connect it to a saline lock and an injection needle

• Locate the fracture site using the linear probe

• Advance the needle into the skin in-line with the probe and guide it into the fracture site

• Have an assistant inject 10ml of lidocaine into the fracture site

References

Kozaci et al. Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures. American Journal of Emergency Medicine Volume 33, Issue 1, 2015, Pages 67-71

Happy Scanning!

Your Sono Team

VOTW: Interscalene Brachial Plexus Block

This week's VOTW is brought to you by the ultrasound team starring one of our interns!

A 16 year old male with a history of a previous shoulder dislocation presented to the Peds ED for L shoulder pain after a fall, and was found to have an anterior shoulder dislocation. The UST was paged to the bedside for a interscalene nerve block. 

In Image 1 (with probe marker directed medially) we see the anterior scalene muscle, middle scalene muscle and nestled comfortably in between in the interscalene groove is the brachial plexus which has the appearance of a "stoplight". The sternocleidomastoid muscle can also be seen superficial to the anterior scalene muscle. Image 2 shows the same images with relevant anatomy labeled

In Clip 1 we see the needle entering the neck from laterally to medially, using the in-plane approach. Spread of local anesthetic is seen within the interscalene groove. The middle scalene muscle is seen being "pushed" away from the brachial plexus

Dr. Zafrina successfully performed this nerve block and the patient underwent a shoulder reduction using external rotation. The shoulder was reduced within 3-5 seconds w/ minimal effort and the pt said "WOW, that was so much better than my last dislocation!"

Indications of the block

The interscalene nerve block provides blockade to the C5 + C6 + C7 nerve distribution (C8 and T1 are not blocked), and can provide effective analgesia for

• proximal humerus fractures

• shoulder dislocations

• deltoid abscess/I&D

It does not reliably provide analgesia to more distal parts of the arm such as the elbow, nor does it block the axilla. For more distal pathology consider the supraclavicular brachial plexus block or a peripheral block (median/ulnar/radial).

Evidence?

Studies looking at the use of interscalene blocks for shoulder reductions have shown decreased length of stay compared to procedural sedation1 and the block allows us to avoid the complications associated with procedural sedation

This block also provides motor blockade and can make a shoulder reduction significantly easier by relaxing the muscles in the shoulder

Potential complications

1. Vascular injury- The hypoechoic circular appearance of the C5-C7 nerve roots can look similar to a vessel so use color flow doppler to differentiate it from the surrounding vasculature

2. Phrenic nerve paralysis- runs along the brachial plexus on the way to the diaphragm. Avoid the procedure in patients with severe lung disease, active respiratory discomfort or a patient with limited lung reserve. Reduce this risk by using low volume of anesthetic (10ml)

3. As with any nerve block, calculate the max anesthetic dose for the patient, make sure your patient is always on a monitor for quick recognition of the feared complication LAST (local anesthetic systemic toxicity), and know where to find intralipid (above cabinet in resus room 53) 

How to perform the block

1. Get a nerve block kit (cabinet in Resus 54)

2. Get 5-10ml of local anesthetic 

   • short-acting like lidocaine for a short procedure such as I&D or shoulder reduction

   • longer-acting like ropivacaine or bupivacaine for a patient going home with a fracture

3. place patient in lateral decubitus or place a shoulder roll to expose more of the lateral neck region

4. place a linear probe in transverse orientation at the level of the larynx and identify the carotid and IJ (see image below)

5. slide the probe laterally to find the sternocleidomastoid, anterior and middle scalene and the brachial plexus- look for the “stoplight”

6. Using the in-plane approach, direct your needle to the space between the middle scalene muscle and brachial plexus, starting laterally

7. Inject local anesthetic and watch the middle scalene be pushed off of the brachial plexus
   

Here is a great resource on how to perform this block from our friends at Highland: https://highlandultrasound.com/interscalene-block

References:

1. Blaivas M, Adhikari S, Lander L. A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department. Acad Emerg Med. 2011;18(9):922-927.

Happy Scanning and Blocking,

Your Sono Team