Ankle Dislocations

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Happy New Years Eve everyone! Before people head out for some NYE festivities lets talk Ankle Dislocations!
One was seen in the ED this week and managed beautifully from what I hear, so lets make sure we all know what to do as this is an orthopedic emergency!
Mechanism:
  • Mc= Post dislocation of talus can be medial, ant, lateral and superior
  • HIGH force injury --> plantar flexion
    • Greatest instability as talus becomes narrower
    • Inversion? posteromedial discplacement + injury to ATF and CF Ligaments
    • Eversion? Lateral dislocation
  • Fall with axial load, car accident
  • mc Young males, pt with previous ankle injuries, Ehrles Danlos
 
Complications:
  • High association with fractures
  • High risk of Neurovascular injury so need FAST RECOGNITION AND REDUCTION!
    • Can lead to avascular necrosis of the talus, sensation loss and LE tissue necrosis--> gangrene
  • Nonunion/malunion, tendon entrapment, cartilaginous injury chronic arthritis, rarely a/w compartment syndrome
Work up:
  • PE: Edema, tenting os skin, tip along joint line, deformity
  • ALWAYS CHECK FOR PULSES and SENSATION
  • XR- A/P, Late and Mortise views
When to Reduce:
  • Indications:
    • NV compromise- Just reduce! don't need X-rays 1st if high clinical suspicion
    • No compromise- confirm with X-ray first
      • Can be open, can be a/w fracture
  • Contraindications:
    • Multiple failed attempts
    • Subtalar Dislocation
      • Rare, high force on forefoot
      • 20% are irreducible and need OR
Reduction
  • Pre-Procedure:
    • Sedation and pain control is key
    • Have material ready to cast following reduction
  • POST:
  • ANT: Same 1st steps but apply anterior traction to distal tibia and posterior force to foot
Post Reduction:
  • Immbolize with LONG LEG POST splint w/ SUGAR TONG component
  • Repeat X-ray
  • Can cause conversion to open injury during reduction--> give Tdap and abx
  • Ortho Follow up for ORIF
Surgical Indications:
  • Failure to reduce x 2-3 attempts
  • Increasing tension or tenting of skin
  • multiple other intra-articular fractures, subtler dislocation
  • Amputation
Sources: OrthoBullets, Medscape
Wishing everyone a happy and healthy New Years, see you in 2018!
Julie
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Jaw Dislocations

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Today we're talking TMJ dislocations. Ever seen one of these? They're kind of cool to reduce. We'll be discussing several ways to reduce these, starting with the classic way, and followed by 2 creative approaches. How do these occur? After extreme opening of the mouth - ex: yawning, dental work, biting into a very large sandwich (not kidding).

Diagnosis is clinical! These are typically anterior dislocations, meaning the mandibular condyle is displaced anteriorly from its articular groove in the temporal bone. Pictures below.

Now let's talk reduction!

First, the classic intra-oral approach: this involves the physician placing his/her thumbs into the patient's mouth along the lower molars, and applying posterior and inferior force to guide the mandible back into its groove, like so:

Downsides: - Often requires procedural sedation - Requires a surprisingly large amount of force - You have to put your hands into the patient's mouth, which is risky

Luckily, there is not one, but two better ways! The extra-oral reduction technique, and the hands-free "syringe technique." Intrigued?

Extra-oral technique: When the mandible is dislocated, the coronoid process is palpable externally over the cheek. By applying steady posterior pressure over the coronoid, the mandible can be easily reduced. You'll know it's in when the coronoid process is no longer palpable.

Use your other hand to provide support and gentle counter-traction (figure 4).

This video shows it's really as easy as it sounds: https://youtu.be/N3edJvp5DoA

And if that doesn't work, try the hands-free syringe method (diagram below):

- Place a 5 or 10 mL syringe between the patient's molars on the dislocated side. - Instruct the patient to bite down and roll the syringe back and forth between the teeth until reduction is achieved. - This method utilizes the patient's own jaw musculature to create the posterior/inferior forces for jaw relocation.

 

A nice 2 min video overview where the syringe technique is demonstrated: https://coreem.net/procedures/tmj-reduction/

That's all for today. Happy New Year's, everyone!

References: https://www.aliem.com/2016/01/trick-of-the-trade-extra-oral-technique-for-reduction-of-anterior-mandible-dislocation/ https://coreem.net/journal-reviews/syringe-technique/

 

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POTD- PVT

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Todays POTD inspired by a resuscitation case from Drs Kaplan and Odashima- a cardiac arrest pt whose reported initial rhythm was PEA got 4x Epi and bicarb and was then noted to have something similar to the following on EKG:

So lets talk Polymorphic Vtac and what we need to know
PVT- comes from multiple ventricular foci
  • Varying QRS complexes with different amplitudes, axis and duration
  • Normal QT?  think ischemia
    • Usually within 12hrs of onset of symptoms
    • Can be from severe CHF or cardiogenic shock
    • HIGH mortality with NO evidence of specific anti-arrythmic therapy improving mortality
    • TRX: 
      • Unstable> Defib
      • Stable> 5mg Metoprolol Q5min if BP tolerates
        • IV amiodarone may prevent recurrence
        • Urgent CATH, IABP
        • Mag is less effective
    • Can also be Familial catecholaminergic PVT
      • TRX:  Beta Blockers!
 
  • Torsades-must have PVT and QT prolongation
    • QRS "twist " around the isoelectric line
    • Often short lived and self terminating
    • MCC: Drugs
    • Electrolyte abnormalities- hypoK, hypoMg
      • Hypoglycemia? Can cause prolonged QT , but not commonly a/w ventricular dysrhythmias
        • The above patients BGM was around 30 could this be the cause of PVT?
        • Attached is an article regarding hypoglycemia induced arrythmias!  http://diabetes.diabetesjournals.org/content/63/5/1738
    • Initiates when PVC occurs during T wave= " R on T"
    • TRX: 
      • Unstable> Defib
      • Stable>MAG!!!
        • TV overdrive pacing at !100bpm
        • Congenital long QT- use BB to shorten QT
        • 2* bradycardia- Isoproterenol 2mcg/min
A few more Pearls courtesy of LITFL!
Sources: Uptodate, LITFL
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