Hip dislocations
Low back pain
Shoulder
dislocations
Transfer of
orthopaedic trauma
patients
HIP DISLOCATIONS
1.
TRAUMATIC

90% posterior; often RTC with hip and knee flexed
 10% have sciatic nerve injury
 May have acetabular injury

10% anterior
 Usually neurovascularly intact

Few central
 Dislocated through acetabulum
2.
DISLOCATED THJR


Usually minor trauma or movement
Usually posterior
ASSESSMENT
History
 ABC’s
Examination
 Secondary survey, look for other injuries
 Usually short and internally rotated
 Neurovascular examination of limbs
MANAGEMENT
Analgesia
 IV opiate prior to x-ray
 Entonox
Reduction
 Traumatic require urgent reduction usually in theatre under GA
 THJR can usually be relocated in Emergency Department
 Posterior
- Patient supine, preferably on mattress on floor
- Gentle flexion of hip and knee to 90o with slight adduction and internal
rotation
- Traction upwards whilst an assistant stabilises the pelvis
- Rotation can be applied gently if required but forceful rotation should be
avoided as it may result in a femoral neck fracture
 Anterior
- Patient supine
- Hip and knee flexed to 900 with assistant stabilising pelvis
- Femur rotated to neutral
- Traction upwards (i.e. vertically)
- May require gentle internal rotation (avoid adduction which can fracture
the femur)
- Lower the leg whilst maintaining traction
REASSESSMENT
 Examine hip
 Neurovascular examination
 X-ray
DISPOSITION
1.
Traumatic
 Admission
2.
THJR
 Zimmer splint to prevent re-dislocation of hip
 Orthopaedic Clinic in one week or discuss with orthopaedics if frequent occurrence or xray shows loosening of prosthesis.
LOW BACK PAIN
Patients presenting to the Emergency Department can be divided into 3 broad
groups :
Those with acute low back pain
Those with recurrent low back pain
Those with chronic low back pain
Epidemiology


Commonest cause of disability in the under 45
9 out of 10 patients with acute back pain experience resolution of pain
within 4 weeks without specific intervention
APPROACH TO PATIENT WITH BACK PAIN
Aim
 To identify signs of serious disease
 Prevent long term disability and chronicity
 Promote early return to normal level of physical activity
History – identify




Clinical
Examination




Risk factors for serious disease
Limitation of activity
Similar previous episodes
Factors that might limit early return to normal activity
Identify neurological deficit especially Cauda Equina Syndrome Nerve
root lesions – L5 or S1 roots most commonly involved
Temperature must be taken
Bladder and bowel function needs to be documented
Anal tone and saddle area sensation should be examined
Red Flags










Cauda Equina Syndrome
Significant trauma
Weight loss
History of carcinoma
Fever
IV drug use
Steroid use
Patient over 50 years
Severe unremitting night-time pain
Pain that worsens when patient lies down
Investigations –
depending on red
flags identified





FBC – if infection suspected
ESR – if infection, carcinoma suspected
XRAY – if tumour, infection or significant trauma
CT
) in consultation with ED consultant or orthoMRI ) paedic registrar
Management

Provide assurance and explanation


If history and examination negative for serious problem further
investigation not warranted, encourage activity and continuance of usual
daily activities.
Control symptoms : Provide simple analgesia.
-


Paracetamol, codeine
Voltaren
Avoid morphine and pethidine. If drug seeking not suspected, a
good dose of narcotic will enable patient to mobilise while in
the department.
Diazepam 5 mg orally can be given as a muscle relaxant
Use of muscle relaxants – diazepam (supported by few studies ) should
be short term / minimum dose


Encourage patient to mobilise in the department.
Patient should be discharged with advice to watch for neurological esp
cauda equina symptoms.

Work activities modified e.g. lifting, bending, twisting, alternative duties

Bed rest for more than 2 days to be discouraged


Patients suffering from chronic back pain are difficult to manage. They
are usually on full analgesic therapy. Adding a TCA may be beneficial.
Patient should be referred to the Pain Clinic.
Referred pain requires management of the primary disease process
Admission criterion
Refer urgently to orthopaedic services if
 Cauda equina lesion, or other significant neurological deficit, multiple
root involvement.
 Infection
 Tumour
 Trauma, significant or inability to mobilise with analgesia
Admit to medical short stay ward / HSE if
 Elderly, unable to mobilise.
 No home support
Treat on its own merit
 Pain referred by other organ pathology
Follow up



Provide a discharge letter
Instruct patient to see GP
Physiotherapy is prescribed by GP if necessary
DIFFERENTIAL DIAGNOSIS
ACUTE BACK PAIN
Local Causes






Important Cause of
Referred Pain



Acute non-specific soft tissue / musculoligamentous discord
Prolapsed interverterbral disc
Trauma – fractures, soft tissue injury
Tumour
Infection
Metabolic bone disease
Retroperitoneal – pyelonephritis, renal colic
Abdominal – cholecystitis, pancreatitis, peptic ulcer, aortic aneurysm,
dissection of the aorta.
H zoster
SHOULDER DISLOCATIONS
ASSESSMENT
History

First vs recurrent
Examination

Deformity
 Neurovascular function
X-rays

For ALL first
 Traumatic recurrent
Views:
 Axillary lateral view – detects anterior and posterior dislocations
 Transcapular lateral – if axillary lateral is impossible because of pain. NB corocoid points
anteriorly, allowing the relationship of the humeral head to the corocoid to be deduced.
MANAGEMENT
Analgesia
 IV opiod prior to x-ray + entonox
Sedation
 May be required
Reduction
 Many methods have been described, having a success of 70 – 90% each
1.
Milch Method


2.
Suitable for anterior or posterior dislocations
Well tolerated. Often reduces without a palpable clunk
 Patient supine
 Operator braces one thumb against humeral head
 Slow, gentle abduction to overhead position
 External rotation with gentle traction
Scapula Manipulation


3.
Well tolerated
Difficult in obese or very muscular patients
 Patient prone
 Arm hanging over side of the trolley with a sandbag, or traction provided by an assistant
 After 5 minutes, the inferior angle of the scapular is pushed medially.
Kocher



Indicated in muscular patients or when the presentation is delayed
Painful
Increased incidence of injuries to humerus and labium






4.
Patient semi-erect
Elbow flexed
Caudal traction on flexed elbow
External rotation of arm
Arm adducted across chest
Internal rotation of arm to place hand on opposite shoulder
Traction


Well tolerated
Often no analgesia or sedation required
 Patient supine, preferably on mattress on floor
 Traction vertically applied to arm whilst patient relaxes shoulder into the bed
REASSESSMENT


Reassess for neurovascular injury
X-ray
FOLLOW UP


Broad arm sling
Orthopaedic Clinic in one week
TRANSFER OF ORTHOPAEDIC TRAUMA PATIENTS
Purpose
Protocol for transfer of Orthopaedic Trauma Patients
Scope
Between Auckland Hospital Department of Emergency
Medicine and Middlemore Hospital
Policy
statement(s)
A.
Conditions that should not be transferred:
1.
2.
3.
4.
Open fractures - except phalanges
Unreduced dislocations of any kind
Unstable spinal or pelvic injuries
Femoral shaft fractures
5. Patients with a significant arterial injury or
compartment
syndrome
B.
Conditions that could be transferred following
assessment by
an Orthopaedic Registrar / Consultant or
Emergency
Medicine Consultant:
1. Stable spinal injuries
2. Stable pelvic injuries
When a particular clinical case falls outside the criteria of this protocol the
Orthopaedic Registrar / Consultant involved can request an Orthopaedic
assessment prior to transfer.