Orthopedic Emergencies: Expert Management for the Emergency Physician 1st Ed.

Chapter 3. Pelvic emergencies

Michael C. Bond

Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.

Pelvic fractures

Key facts

·        Pelvic fractures represent 3% of all fractures, and are associated with significant morbidity and mortality

·        The mortality rate for high-energy pelvic fractures is between 10% and 20%

·        Pelvic fractures can result in significant hemorrhage, and a large volume of blood loss (up to 4 liters)

o   About 50% of the patients admitted with pelvic fractures will require a blood transfusion

o   Non-displaced fractures are not associated with large volume blood loss, so if the patient is hypotensive with this type of injury a search for another more serious injury needs to ensue

·        Twenty percent of pelvic fractures are associated with neurologic injuries

o   Acetabular and sacroiliac fractures are most highly associated with neurologic injuries

o   Fractures medial to the sacral foramina have an incidence of 57% of a neurologic injury

·        The pelvis is an anatomic ring that typically will have two disruptions in the ring. This can consist of two fractures, or a fracture and dislocation

Anatomy

·        The pelvis consists of the ilium, pubis, and ilium on each side forming the innominate bones that are then joined at the pubis symphysis anteriorly and the sacrum posteriorly

·        Some of the strongest ligaments in the body secure the innominate bone to the sacrum. Disruption of these ligaments will affect normal weight bearing

·        Strong interpubic ligaments hold the pubic symphysis in place. Disruption of these ligaments can result in an “open book” pelvis

Signs of pelvic fracture

·        Destot’s sign: a superficial hematoma above the inguinal ligament or on/in the scrotum

·        Earle’s sign: a large hematoma, or abnormal bony prominence, or tender fracture line that is felt on a rectal examination

·        Roux’s sign: radiologic sign. Sign is present when the distance measured from the greater trochanter to the pubic spine is diminished on one side

Physical examination

·        The patient should be disrobed in order to look for signs of ecchymosis, lacerations, deformity or swelling

·        Special attention should be accorded to the rectum and penis/vagina to ensure there is no bleeding that could denote a more serious injury

·        Pelvic instability can often be felt on physical examination though retesting should not be performed if instability is noted as this increases the risk of pelvic bleeding from disruption of bone fragments or a hematoma

·        Test for instability by applying internal and external compression forces on the iliac wings to check for instability

·        Vertical instability can be checked by applying traction and axial loading to the leg while one hand is palpating the iliac wing on the ipsilateral side

·        Sensation should be checked over the perineum and in both legs, as sacral fractures can cause neuropathies, and acetabular fractures are associated with injuries to the sciatic nerve

·        Radiographs should be obtained

o   Plain radiographs are a good initial screening test to look for displaced pelvic fractures

o   CT may be needed for non-displaced fractures and for operative planning of complex fractures

Classification system

·        Several classification systems have been developed to describe pelvic fractures

·        The initial classification system was developed by Pennal and Sutherland and was based on the mechanism of injury

·        The Pennal and Sutherland system was modified by Burgess and Young in an attempt to correlate the injury with the degree of hemodynamic instability

·        The Burgess and Young system is the most commonly used one now

o   Based on mechanism of injury

o   Subdivided by degree of predicted hemodynamic instability

o   Does not address fractures not involving the pelvic ring

§  Avulsion fractures

§  Coccyx fractures

Specific pelvic fractures

Avulsion fractures

·        Mechanism: Generally caused by a forceful muscular contraction that causes an apophyseal center to be pulled off the pelvic ring

o   Can occur at:

§  Anterior–superior iliac spine at the insertion of the sartorius muscle

§  Anterior–inferior iliac spine at the insertion of the rectus femoralis muscle

§  Ischial tuberosity at the insertion of the hamstring muscles

Symptoms

·        Typically have pain and tenderness over the site

·        Often have increased pain with ambulation, and with ischial tuberosity fractures can have increased pain when sitting down

Diagnosis (Figure 3.1)

·        Often based on symptoms and plain radiographs

·        If there is significant ambulatory dysfunction may need to obtain a CT in order to exclude more serious fractures



Figure 3.1 Avulsion fracture of the anterior inferior iliac spine (AIIS) is noted on the right. The AIIS is the insertion site of the rectus femoralis muscle. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Treatment is non-operative and is aimed at controlling symptoms

·        Anterior–superior iliac spine fractures:

o   3 to 4 weeks bed rest with the hip in flexion and abduction

o   Complete recovery can take more than 8 weeks

·        Anterior–inferior iliac spine fractures:

o   3 to 4 weeks bed rest with the hip in flexion but not abducted

·        Ischial tuberosity fracture:

o   Bed rest with the thigh in extension with external rotation and slight abduction

o   A donut pillow can help when sitting

·        All patients would benefit from analgesics

o   Ibuprofen 800 mg orally every 6–8 hours as needed

o   Naproxen 500 mg orally every 6–8 hours as needed

o   Oxycodone/acetaminophen 5/325 mg; one or two tablets every 4–6 hours as needed for severe pain

o   Hydrocodone/acetaminophen 5/325 mg; one or two tablets every 4–6 hours as needed for severe pain

Non-displaced pelvic fractures

Pubic ramis fractures

Mechanism

·        Fractures involving a single pubic ramis are usually caused by a fall in the elderly, though in the young it is often the result of persistent tension/stress on the adductors or hamstrings resulting in a fracture at their site of origination

·        Fractures through both pubic rami are typically caused by direct trauma (i.e., horizontal or compressive forces)

Symptoms

·        Patients will often complain of persistent groin pain after a fall (i.e, elderly) or with a more insidious onset in the young

·        The pain is often worse with deep palpation or walking/running

·        A lateral compression force will often exacerbate fractures involving both rami

Diagnosis

·        Pain on palpation over the pubic ramis

·        Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis

·        CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury, especially if there is tenderness over the sacroiliac joint

Treatment

·        Single pubic rami fractures (Figure 3.2)

o   Symptomatic treatment

§  Pain control with NSAIDs or narcotics as needed

§  Weight-bearing as tolerated for 8–12 weeks. Patients benefit from crutches to limit the amount of weight (i.e., crutch walking)

·        Dual pubic rami fractures are generally stable though these fractures should be referred to orthopedics early as they may require operative repair if there is any posterior pelvic injury

o   Symptomatic treatment

§  Pain control with NSAIDs or narcotics as needed

§  Weight-bearing as tolerated for 8–12 weeks. Patients benefit from crutches to limit the amount of weight (i.e., crutch walking)

·        Straddle fracture is a fracture through both pubic rami bilaterally as can happen when falling from a height and landing on the perineum. Figure 3.3 demonstrates this fracture pattern



Figure 3.2 Fracture of the superior pubic rami on the right. (Image courtesy of Michael C. Bond, MD.)



Figure 3.3 A straddle fracture. Notice the bilateral dual pubic ramis fractures. (Image courtesy of Michael C. Bond, MD.)

Ischial body fractures

Mechanism

·        Typically caused by a fall on to the buttocks. Can be associated with fractures of the lumbar and thoracic spine

Symptoms

·        Patients will often complain of buttock pain that is worse with deep palpation or contraction of the hamstrings

Diagnosis

·        Pain on palpation over the ischial body

·        Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis

·        CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury

Treatment

·        Symptomatic treatment

o   Pain control with NSAIDs or narcotics as needed

o   Bed rest for 4 to 6 weeks with physical therapy to prevent loss of range of motion

o   Inflatable seat cushion (i.e., donut pillow) for comfort when seated

Ilium fractures

Mechanism

·        Iliac wing fractures: Result from a medially directed force against the iliac wing. Because of the high energy needed for these fractures the emergency provider should ensure that other injuries are not also present, such as

o   Acetabular fractures

o   Solid and hollow organ injuries

o   Thoracic injuries

·        Ilium body fractures are usually the result of a direct force on the ilium that pushes the ilium postomedially

Symptoms

·        Iliac wing fractures: Patients will complain of pain over the iliac wing that is worsened by palpation, walking or stressing of the hip abductors

·        Ilium fractures: Patients will have tenderness over the posterior pelvis near the sacrum that is often exacerbated by straight-leg raises, and anterior and lateral compressive forces

Diagnosis

·        Pain on palpation over the iliac wing or ilium. Worse with compression or distraction

·        Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis. Oblique views may help demonstrate the fracture better

·        CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury

Treatment

·        Iliac wing fractures

o   Symptomatic treatment

§  Pain control with NSAIDs or narcotics as needed

§  Bed rest for 4 to 6 weeks or until there is no pain with stressing of the hip abductors

·        Ilium fractures

o   Early referral to orthopedics

o   Symptomatic treatment

§  Pain control with NSAIDs or narcotics as needed

§  Pelvic sling or belt may help provide comfort and stability

§  Bed rest that will be advanced to crutch walking by orthopedics

§  Typically takes 3 to 4 months to return to baseline

Sacral fractures

Mechanism

·        Horizontal fractures result from a direct blow to the sacrum or from a fall with the patient landing in the seated position

·        Vertical fractures are the result of anterior forces on the pelvis that drive the pelvic ring posteriorly

Symptoms

·        Patients will complain of pain over the sacrum, and ecchymosis may be noted. Patients will also have increased pain on rectal examination if pressure is applied to the sacrum. Pain is often increased with lateral and anterior compression applied to the pelvis. Patients may have loss of sensation or neurologic dysfunction if the sacral nerves are compressed as they exit the sacral foramina

Diagnosis

·        Pain on palpation over the sacrum. A digital rectal examination needs to be performed to ensure that the fracture is not open as evidenced by a laceration of the rectum

·        Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis. An AP outlet view is often better at noting displayed fractures

·        CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury

Treatment

·        Vertical fractures should be referred to orthopedics early because of the higher risk of neurologic involvement

o   Vertical fractures can also be treated with a pelvic binder/belt

·        Fractures that are associated with any neurologic dysfunction need immediate referral to orthopedics for possible operative repair

·        Symptomatic treatment

o   Pain control with NSAIDs or narcotics as needed

o   Bed rest to advance to crutch walking as tolerated

o   An inflatable seat cushion can be used for comfort

·        Open fractures require immediate antibiotic coverage and orthopedic consultation

Coccyx fractures

Mechanism

·        Usually caused by a fall and landing in a sitting position

Symptoms

·        Patients will complain of pain over their buttocks near their rectum. Spasms of the anococcygeal muscle may also be noted during bowel movements or when trying to sit

Diagnosis

·        Pain on palpation over the coccyx, and pain on digital rectal examination with palpation of the coccyx. Rectal examination must be done to ensure there is no rectal laceration

·        Plain radiographs (AP view of the pelvis and lateral coccyx view) are normally enough to make the diagnosis

·        CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury

Treatment

·        Symptomatic treatment

o   Pain control with NSAIDs or narcotics as needed

o   Bed rest as needed

o   An inflatable seat cushion can be used for comfort

o   Stool softeners should be prescribed in order to prevent straining with bowel movements

Displaced pelvic fractures

Mechanism

·        Varies depending on fracture pattern seen as outlined in Table 3.1. All of these fractures are the result of high-energy forces and can be associated with other significant injuries

Table 3.1 Burgess and Young classification system of pelvic ring injuries.


Lateral compression (LC)

LC 1: Pubic rami fracture (transverse) and ipsilateral sacral compression

LC 2: Pubic rami fracture (transverse) and iliac wing fracture

LC 3: Pubic rami fracture (transverse) and contralateral “open-book” injury

Anteroposterior compression (APC)

APC 1: Symphyseal diastasis (1–2 cm) with normal posterior ligaments

APC 2: Symphyseal diastasis or pubic rami fracture (vertical) with anterior SI joint disruption

APC 3: Symphyseal diastasis or pubic rami fracture (vertical) with complete SI joint disruption

Vertical shear (VS)

Symphyseal diastasis or pubic rami fracture with complete SI joint disruption, iliac wing, or sacrum (with vertical displacement)

Combined mechanical (CM)

Combination of other injury patterns (LC/VS or LC/APC)


Symptoms

·        Patients will complain of pain and tenderness over their pelvis, may have gross deformity (e.g., open book pelvis), be hypotensive, and one may even note leg length discrepancies

·        Associated injuries may distract the patient from these injuries so a careful examination needs to be performed

Diagnosis

·        Pain on palpation of the pelvis, or pelvic instability may be noted when lateral, medial, or anterior compressive forces are applied to the pelvis

·        Plain radiographs (AP view of the pelvis) can make the diagnosis

o   Figure 3.4A, B, C: Anterior–posterior compression fracture class 3

o   Figure 3.5: Lateral compression fracture

·        CT of the pelvis with 3-D reconstruction views is often needed to exclude secondary injuries and for operative planning



Figure 3.4 Anterior–posterior compression fracture class 3. A shows the original “open book” fracture pattern with diastasis of the pubic symphysis, and fractures through the sacroiliac joints. B shows the application of an external fixator to stabilize the pelvis. C shows the patient post-ORIF with stabilization of the sacroiliac joints and pubic symphysis. (Image courtesy of Michael C. Bond, MD.)



Figure 3.5 Lateral compression fracture with fractures noted of the left iliac wing, sacrum, and inferior pubic symphysis. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Immediate orthopedic consultation

·        The pelvic cavity should be returned to its normal size with the use of a pelvic binder, sheet or external fixation device

o   For pelvic binder application follow the directions of the device manufacturer

o   For placement of a sheet one should:

§  Take a long bed sheet and place it behind the patient at the level of the ischial wings

§  Two providers each grab the end of the sheet that is furthest from them

§  The providers then pull the opposite end of the bed sheet toward themselves, until the pelvis is reduced

§  Reduction is assumed when there is no gross deformity and the pelvic girdle appears normal in appearance

§  The edges of the sheet are then twisted together and then tied in order to prevent loosening

§  This procedure alone can have a profound effect on reducing blood loss into the pelvis

o   Associated injuries need to be excluded

§  Uretheral, vaginal, and rectal injuries

§  Abdominal or thoracic injuries

§  Lower-extremity fractures

o   Symptomatic treatment

§  Pain control with narcotics as needed

§  Bed rest

Acetabular fractures

Anatomy

·        The acetabulum consists of four parts:

o   Anterior column: from iliac crest to the symphysis pubis and includes the anterior wall

o   Posterior column: from the sciatic notch to the ischial tuberosity and includes the posterior wall

o   Anterior wall

o   Posterior wall

·        Fractures of the posterior column are more common, and are often associated with posterior hip dislocations

Mechanism

·        The result of high-energy trauma

·        A medially directed force can drive the femoral head into the acetabulum and fracture it

o   If femur is internally rotated at time of impact a posterior column fracture occurs

o   If femur is externally rotated at time of impact an anterior column fracture occurs

·        A blow to the knee with the hip flexed can drive the femur back into the acetabulum causing a transverse acetabular fracture or posterior column fracture

Symptoms

·        Patients will complain of pain and tenderness over their pelvis near their hip. They may have leg length shortening, and will have increased pain with weight-bearing

·        Can be associated with vascular and neurologic injuries

Diagnosis

·        Pain on palpation of the pelvis and hip can confirm diagnosis

·        Plain radiographs (AP view of the pelvis, and Judet views) can make the diagnosis (Figure 3.6)

o   80% of intra-articular fragments are not seen on plain radiographs

·        CT of the pelvis with 3-D reconstruction views is often needed to evaluate the fracture fully and for operative planning



Figure 3.6 A posterior dislocation with fracture of the posterior rim wall is noted on the right. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Immediate orthopedic consultation

o   Patients will require surgical repair if:

§  Femoral head is subluxed

§  Fracture fragments are displaced > 2 mm

o   Non-operative care can range from bed rest to weight-bearing

§  Early immobilization is a primary goal

·        Associated injuries need to be excluded

o   Vascular

o   Visceral

o   Neurologic: Sciatic nerve injury can be seen in 10%–13% of cases

·        Symptomatic treatment

o   Pain control with narcotics as needed

Hip fractures

Anatomy

·        The hip joint is the articulation of the proximal femur with the acetabulum of the pelvis

·        The joint’s integrity is maintained by:

o   A joint capsule that is attached to the acetabulum and femoral neck

o   Three ligaments strengthen the joint capsule

§  Iliofemoral ligament – located anteriorly and strongest of the three ligaments

§  Pubofemoral ligament – inferior

§  Ischiofemoral ligament – posterior ligament that is the widest

o   Ligomentum teres – attaches the femoral head to the acetabulum centrally

·        The blood supply to the proximal femur is limited and consists of three sources

o   Femoral circumflex and retinacular arteries – disruption of this blood supply often leads to avascular necrosis (AVN) of the femoral head

o   Medullary vasculature

o   Vessel of the ligamentum teres

Fracture classification

·        Five major classes within two subdivisions

o   Intracapsular

§  Femoral head fractures

§  Femoral neck fractures

o   Extracapsular

§  Intertrochanteric fractures

§  Trochanteric fractures

§  Subtrochanteric fractures

Femoral head fractures

·        Described as single fragment or communited (multiple fragments)

Mechanism

·        Single fragment fractures are usually the result of a dislocation

·        Communited fractures are usually the result of high-energy direct trauma

Symptoms

·        Patients will complain of pain and tenderness over their hip that increases with weight-bearing

Diagnosis

·        Pain on palpation of the pelvis and hip can confirm diagnosis

·        Plain radiographs (AP view of the pelvis, and hip views [oblique and lateral]) can make the diagnosis

·        CT or MRI of the femur may be needed for occult fractures (U+223C5% incidence) in patients where the provider has a high index of suspicion but initial radiographs are non-diagnostic

Treatment

·        Orthopedic consultation

o   Arthoplasty is often needed for communited fractures

o   Simple fractures may be managed with bed rest and immobilization

·        All patients should be placed on bed rest and have the hip immobilized

·        Dislocations should be reduced

·        Symptomatic treatment

o   Pain control with narcotics as needed

Femoral neck fractures

PEARL: Femoral neck fractures are at very high risk for development of avascular necrosis.

Mechanism

·        More common in the elderly who have osteoporotic bones. Can occur with no trauma in these patients

·        In young patients these are caused by high-energy trauma

Symptoms

·        Patients may have suffered a fall, or only complain of thigh or knee pain when they have an impacted fracture

·        Patients will complain of pain and tenderness over their hip that increases with weight-bearing or ROM

Classification system

·        Garden system which is based on the degree of displacement present on the AP radiograph

o   Type I – Incomplete or impacted fractures

o   Type II – Complete, but non-displaced

o   Type III – Partially displaced or angulated fractures

o   Type IV – Displaced fractures with no contact between the fragments

·        Type I and II can be described as non-displaced and Type III and IV as displaced fractures

Diagnosis

·        Plain radiographs (AP view of the pelvis, and hip views [oblique and lateral]) can make the diagnosis (Figure 3.7)

·        CT or MRI of the femur may be needed for occult fractures (U+223C5% incidence) in patients where the provider has a high index of suspicion but initial radiographs are non-diagnostic



Figure 3.7 A subcapital fracture of the right femur is noted. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Orthopedic consultation

o   Operative management has improved outcomes

§  Operative care – 10% mortality

§  Supportive care with bed rest – 60% mortality

o   Displaced fractures will often require immediate operative repair or reduction in order to reduce the risk of AVN

o   Non-displaced fractures will often need operative repair though it can be done in a less urgent manner

·        All patients should be placed on bed rest and have the hip immobilized

·        Symptomatic treatment

o   Pain control with narcotics as needed

o   Consider a femoral nerve block in the elderly, who may have increased sedation with narcotics

Intertrochanteric fractures

General

·        Most common proximal femoral fracture

·        Classified as:

o   Stable – single fracture line through the cortex without any displacement

o   Unstable – multiple fracture lines or communition with associated displacement

Mechanism

·        Mostly caused by direct trauma – fall on to the hip, specifically the greater trochanter

·        Indirect trauma (e.g., trauma to femur or knee) can be transmitted up the femoral shaft and cause a fracture

Symptoms

·        Patients may have suffered a fall and complain of pain over the hip

·        Leg is often shortened and externally rotated

Diagnosis

·        Plain radiographs (AP view of the pelvis, and hip views [oblique and lateral]) can make the diagnosis (Figure 3.8)

·        CT or MRI of the femur may be needed for occult fractures (U+223C5% incidence) in patients where the provider has a high index of suspicion but initial radiographs are non-diagnostic



Figure 3.8 An intertrochanteric fracture of the femur is noted. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Orthopedic consultation for operative repair

·        All patients should be placed on bed rest

·        Symptomatic treatment

o   Pain control with narcotics as needed

o   Consider a femoral nerve block in the elderly, who may have increased sedation with narcotics

Trochanteric fractures

General

·        Uncommon

·        Classified as:

o   Displaced

o   Non-displaced

Mechanism

·        Mostly caused by direct trauma – fall on to the hip

·        Can also be the result of a forceful muscle contraction and avulsion of a trochanter from the femur

·        Lesser trochanter fractures are often pathologic and should prompt an additional evaluation into its cause

Symptoms

·        Patients will complain of pain over their hip and thigh that is often worse with abduction (greater trochanter) or flexion and rotation of the hip (lesser trochanter)

Diagnosis

·        Plain radiographs (AP view of the pelvis, and hip views). Consider getting internal and external rotation views to fully visualize the trochanters

·        CT or MRI of the femur may be needed for occult fractures (U+223C5% incidence) in patients where the provider has a high index of suspicion but initial radiographs are non-diagnostic

Treatment

·        Consult orthopedics

o   Displaced fractures are treated with operative repair. General guidelines are:

§  Greater trochanteric fracture displaced more than 1 cm

§  Lesser trochanteric fracture displaced more than 2 cm

o   Non-displaced fractures are treated symptomatically with crutch walking as tolerated

·        Symptomatic treatment

o   Pain control with narcotics as needed

Subtrochanteric fractures

General

·        Includes all fractures within 5 cm of the lesser trochanter

Mechanism

·        In the elderly this fracture is typically caused by a fall with a rotational force involved

·        In the young it is secondary to a high-energy trauma

Symptoms

·        Patients may have pain and swelling of the hip and thigh

·        Increased pain with weight-bearing if possible

·        In the young, associated injuries of the ankle, knee, and leg may also be present

Diagnosis

·        Plain radiographs (AP view of the pelvis, and hip views, and femur) can make the diagnosis (Figure 3.9)

·        CT or MRI of the femur are rarely needed for this fracture type



Figure 3.9 A subtrochanteric fracture of the femur is noted. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Orthopedic consultation for operative repair

·        All patients should be placed on bed rest

·        Immobilize the leg in a splint or consider placing in traction

·        Symptomatic treatment

o   Pain control with narcotics as needed

o   Consider a femoral nerve block in the elderly, who may have increased sedation with narcotics

Hip dislocations

General

·        Represent U+223C5% of all joint dislocations

·        Posterior dislocations are the most common and account for 90 to 95% of all hip dislocations

·        Anterior dislocations are second most common

·        Inferior dislocations are extremely rare but have been reported

Classification of posterior hip dislocations

·        Grade I – a simple dislocation with no fracture

·        Grade II – a dislocation with an acetabular rim fracture that is stable post reduction

·        Grade III – a dislocation associated with an unstable or communited fracture

·        Grade IV – a dislocation associated with a femoral head or femoral neck fracture

Mechanism

·        Most native hip dislocations are secondary to a high-energy trauma

·        Most dislocations are secondary to a blow to the knee while the hip is flexed causing transmission of the force down the femur, and pushing the femoral head out of the acetabulum

·        Lower-energy trauma can result in a dislocation in the young and those with prosthetic hips

Symptoms

·        Patient will complain of hip pain that is increased with weight-bearing, if able, and movement

·        Leg is often shortened, internally rotated, and the hip adducted

·        The femoral head may be palpable in the buttock

Diagnosis

·        Plain radiographs (AP view of the pelvis, and hip view) is often all that is needed to confirm the diagnosis (Figure 3.10)

·        CT or MRI of pelvis and hip may be needed if there is suspicion of an occult fracture

o   If you suspect a femoral neck fracture, this should be confirmed, before closed reduction is attempted. Closed reduction increases the risk of disrupting the blood flow and increases the incidence of AVN in those patients with a femoral neck fracture

·        Associated injuries:

o   Femoral head fracture

o   Acetabular fractures

o   Femoral neck fractures

o   Avascular necrosis of the femoral head

o   Sciatic nerve injury

o   Ipsilateral knee injuries

o   Vascular injuries, rare with posterior dislocations, but can occur with anterior dislocations



Figure 3.10 A posterior hip dislocation with associated fracture of the posterior wall is shown. (Image courtesy of Michael C. Bond, MD.)

Treatment

·        Reduction should occur within 6 hours in order to minimize risk of AVN

·        Dislocations with fractures should be evaluated by orthopedics emergently for consideration of open reduction in the operating room

·        All patients should be placed on bed rest

·        Reduction techniques (see Chapter 9: Procedures for orthopedic emergencies)

·        Symptomatic treatment

o   Pain control with narcotics as needed

o   Consider a femoral nerve block in the elderly, who may have increased sedation with narcotics

Femur fractures

General

·        The mortality rate of femoral shaft fractures was as high as 50% when they were treated conservatively with bed rest. Now that operative repair is the norm, the mortality rate is much lower

·        The femoral shaft has an excellent blood supply so these fractures tend to heal very well

·        Classification of femoral shaft fractures is based on the operative management:

o   Spiral, transverse or oblique fractures

o   Comminuted fractures. Further divided into four grades based on the size of the fracture fragment and degree of comminution

§  Grade I – minimal or no comminution

§  Grade II – fracture fragment is 25–50% of the width of the femoral shaft

§  Grade III – large butterfly fragment (> 50%)

§  Grade IV – circumferential comminution with complete loss of contact with the two ends of the cortices (Figure 3.11 and Figure 3.12)

o   Open fractures



Figure 3.11 A mid-shaft femur fracture is noted with complete loss of contact of the two ends of the cortexes. (Image courtesy of Michael C. Bond, MD.)



Figure 3.12 An oblique comminuted fracture of the femur is shown. A traction rod can be seen. (Image courtesy of Michael C. Bond, MD.)

Mechanism

·        Result of high-energy trauma as seen in motor vehicle collisions, falls, direct blows, or gunshot wounds

·        Femoral shaft fractures in children aged 1 to 5 are associated with child abuse in up to 35% of cases

Symptoms

·        Patients will complain of pain in their thigh, and may have shortening of the leg with a rotational deformity

·        Ecchymosis may be noted

·        Femoral shaft fractures can result in significant blood loss (1–1.5 L) so hypotension should be treated aggressively with intravenous fluids and blood

Diagnosis

·        Plain radiographs (AP and lateral view of femur) are often all that is needed to confirm the diagnosis

o   Consider adding views of the hip, knee, and pelvis to exclude additional fractures/dislocations

·        Associated injuries:

o   Arterial injuries

o   Neurologic injuries

o   Secondary bony injuries at the hip, knee, or pelvis

Treatment

·        Orthopedic consultation for operative repair

·        Immobilize the leg. Traction may be needed initially to restore the leg to its proper length and realign the two ends of the bone

o   Traction and immobilization alone can provide significant pain relief and stop the powerful quadriceps muscles from spasming

·        Symptomatic care

o   Narcotic pain medication as needed

o   Can consider a femoral nerve block

·        For open fractures –

o   Clean the skin

o   Dress the wound appropriately

o   Update tetanus status

o   Start antibiotics

§  Cefazolin 2 gm IV

Bursitis

·        There are four bursa of the hip that are clinically important:

o   Deep trochanteric – lies between the greater trochanter and the tendinous insertion of the gluteus maximus

o   Superficial trochanteric – lies between the greater trochanter and the skin

o   Iliopsoas – lies between the iliopsoas muscle and the iliopectineal eminence that is along the anterior surface of the joint capsule

o   Ischiogluteal – lies on top of the ischial tuberosity

Mechanism

·        The bursae typically get inflamed from overuse, excessive pressure, or trauma

·        Can also be caused by systemic inflammatory diseases such as –

o   Sepsis

o   Gout

Symptoms

·        Deep trochanteric bursitis – pain and tenderness localized to the posterior portion of the greater trochanter

o   Increased pain with flexion and internal rotation of the hip

o   May have Trendelenburg’s sign

§  A positive sign occurs when you ask the patient to stand on the affected leg and the pelvis drops to the unaffected side

§  Caused by inhibition of the gluteus muscle

·        Superficial trochanteric bursitis – pain and tenderness over the bursa that is increased with extreme adduction of the thigh

·        Iliopsoas bursitis – pain and tenderness over the lateral edge of the femoral triangle

o   Can irritate the femoral nerve, which will refer pain to the anterior thigh

o   Common in individuals that use hip flexors a lot (e.g., dancers, soccer players)

o   Pain is increased with extension, abduction, and internal rotation

o   Therefore, the patient typically holds the leg flexed, adducted, and externally rotated

·        Ischiogluteal bursitis – seen often in individuals who sit for prolonged periods on hard surfaces

o   Pain and tenderness over the ischial tuberosity

o   Pain can radiate down the leg into the hamstrings and be confused with a radiculopathy

Diagnosis

·        Clinical diagnosis. Radiographs and laboratory studies are not required unless you are attempting to exclude another disease process or a specific cause (e.g., gout)

Treatment

·        Rest

·        Heat

·        Non-steroid anti-inflammatory agents

·        Ischiogluteal bursitis can also benefit from the use of a seat cushion or donut pillow

·        Chronic cases can be referred for possible corticosteroid injection or, if really severe, surgical excision of bursae