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1842 SECTION 22: Orthopedics  RECTAL INJURY Rectal injuries are uncommon and are usually associated with urinary injuries and ischial fractures. Diagnosis is by careful rectal examination or proctoscopy, during which gross blood is found in the rectum. Treatment includes early diverting colostomy with washout of the distal colon and presacral space drainage. Administer antibiotics that cover gramnegative organisms as soon as the injury is discovered.  NERVE ROOT INJURY Nerve root or peripheral nerve injuries can occur because of traction, pressure from hemorrhage, callus or fibrous tissue, and impingement laceration by bone fragments. The onset of symptoms and signs may be delayed, but deficits usually follow a nerve root pattern. Lumbar nerve root injuries are associated with sacroiliac joint dislocation or fracture and longitudinal displacement of the fracture. 42 Sacral root injuries are associated with transverse fractures of S1 and S2 as can be seen secondary to trauma from an intentional suicide attempt by jumping from a height. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Femoral head Femoral neck Femoral neck Intracapsular Extracapsular Intertrochanteric Subtrochanteric FIGURE 273-1. Fractures of the proximal femur are traditionally classified as intracap sular and extracapsular. Most hip dislocations are posterior due to the more common ante rior-posterior mechanisms of injury and the relatively weaker posterior joint capsule. Blood is supplied to the femoral head from the medial and lateral femoral circumflex arteries forming a ring with branching arteries that extend into the joint capsule. The foveal artery, a branch of the obturator artery, contributes blood to the femoral head through the teres ligament connecting the hip and the acetabulum. Dislocation always results in rupture of this ligament and its artery. Patients with circulation dependent on this foveal branch will almost inevitably develop avascular necrosis. Femoral neck fractures often disrupt the primary circulation from the circumflex femoral arteries. This explains why femoral neck frac tures with minimal or no displacement may be amenable to reduction and internal fixation while grossly displaced fractures are more likely to require a partial or THA. Avascular necrosis occurs in 15% to 35% of patients with hip fractures when capsular vessels are disrupted. Intertrochanteric and subtrochanteric fractures are unlikely to result in vascular compromise. CLINICAL FEATURES  HISTORY Any fall in an elderly patient should raise suspicion for hip fracture. Altered patients “found down” should be considered high risk for occult fractures. Motor vehicle collisions and high-energy mechanisms should raise suspicion for hip dislocation or femoral shaft fracture. Chronic kidney disease and prolonged steroid use increase the risk of avascular necrosis, and pathologic fractures should be considered in patients with known or suspected malignancy. Complaints can vary. Patients with a hip fracture or dislocation may complain of knee pain or groin pain. Patients with altered sensorium may have no complaints, and demented patients may even ambulate on occult hip fractures. Hip and Femur Injuries Chris Courtney INTRODUCTION AND EPIDEMIOLOGY Over 350,000 hip fractures occur annually, costing nearly $6 billion. Hip fractures are a life-changing injury.

pain or groin pain. Patients with altered sensorium may have no complaints, and demented patients may even ambulate on occult hip fractures. Hip and Femur Injuries Chris Courtney INTRODUCTION AND EPIDEMIOLOGY Over 350,000 hip fractures occur annually, costing nearly $6 billion. Hip fractures are a life-changing injury. Forty percent of patients fail to regain preinjury ambulation status at 6 months and fail to return to independent living at 1 year, and nearly 25% of those suffering from this injury die within 12 months. Morbidity and mortality result from pro longed immobilization. Compromised preinjury ambulation status and dependent living are predictors of poor functional outcome and longterm mortality. 1,2 Hip dislocations are associated with devastating complications. Disruption of vascular supply can result in avascular necrosis and is estimated to occur in up to 25% of hip dislocations. This life-changing complication nearly always mandates total hip arthroplasty (THA). Femur fractures are most often associated with trauma and occur across a much broader demographic. These high-energy fractures can result in life-threatening blood loss. ANATOMY AND PATHOPHYSIOLOGY Hip fractures are defined by their anatomic location ( Figures 273-1 and 273-2 and Table 273-1) and classified as intracapsular (femoral head and neck) or extracapsular (trochanteric, intertrochanteric, and subtrochanteric). Treatment will vary considerably with fracture type (Table 273-2). The extracapsular bone between the greater and lesser trochanter defines the intertrochanteric region. The greater trochanter is the insertion for the gluteal hip abductors. The lesser trochanter is the insertion for the iliopsoas, which is the strongest hip flexor. Fractures extending from the greater to lesser trochanter are considered intertrochanteric hip fractures. Fractures in the region 5 cm below the lesser trochanter are subtrochanteric hip fractures . The femoral shaft describes the diaphysis, beginning 5 cm below the lesser trochanter and extending to but not including the femoral condyles. CHAPTER Tintinalli_Sec22_p1767-1880.indd 1842 8/2/19 6:19 PM

hanteric hip fractures. Fractures in the region 5 cm below the lesser trochanter are subtrochanteric hip fractures . The femoral shaft describes the diaphysis, beginning 5 cm below the lesser trochanter and extending to but not including the femoral condyles. CHAPTER Tintinalli_Sec22_p1767-1880.indd 1842 8/2/19 6:19 PM CHAPTER 273: Hip and Femur Injuries 1843 FIGURE 273-2. Hip and joint capsule. TABLE 273-1 Proximal Femur Fractures: Demographics and Clinical Features Fracture Incidence/Demographics Mechanism Clinical Findings Concomitant Injuries Femoral head Isolated fracture rare; seen in 6%–16% of hip dislocations Usually result of high-energy trauma; dashboard to flexed knee most common Limb shortened and externally rotated (anterior dislocation); shortened, flexed, and internally rotated (posterior dislocation) Closed head injury; intrathoracic and/ or intra-abdominal injuries; pelvic fracture, knee injuries Femoral neck Common in older patients with osteoporosis; rarely seen in younger patients Low-impact falls or torsion in elderly; high-energy trauma or stress fractures in young Ranges from pain with weight bearing to inability to ambulate; limb may be shortened and externally rotated Ipsilateral femoral shaft fracture Greater trochanteric Uncommon; older patients or adolescents Direct trauma (older patients); avulsion due to contraction of gluteus medius (young patients) Ambulatory; pain with palpation or abduction — Lesser trochanteric Uncommon; adolescents (85%) > adults Avulsion due to forceful contraction of iliopsoas (adolescents); avulsion of pathologic bone (older adults) Usually ambulatory; pain with flexion or rotation — Intertrochanteric Common in older patients with osteoporosis; rare in younger patients Falls; high-energy trauma Severe pain; swelling; limb shortened and externally rotated Anemia from blood loss into thigh; concomitant traumatic injuries Subtrochanteric Similar to intertrochanteric; 15% of hip fractures Falls; high-energy trauma; may also be pathologic Severe pain; ecchymosis; limb shortened, abducted, and externally rotated Vascular injuries, anemia/hypovolemic shock from fracture itself or other traumatic injuries TABLE 273-2 Proximal Femur Fractures: Treatment Issues Fracture ED Management Disposition and Follow-Up Complications Femoral head Immediate orthopedic consultation; emergent closed reduction of dislocation; ORIF if closed reduction is unsuccessful Admission to orthopedic or trauma service AVN; posttraumatic arthritis; sciatic nerve injury; heterotopic ossification Femoral neck Orthopedic consultation; ranges from nonoperative to total hip arthroplasty Admission to orthopedic service AVN; infection; DVT and/or pulmonary embolus Greater trochanteric Analgesics; protected weight bearing Orthopedic follow-up 1–2 wk; possible ORIF if displacement >1 cm Nonunion rare Lesser trochanteric Analgesics; weight bearing as tolerated; evaluate for possible pathologic fracture Orthopedic or PCP follow-up in 1–2 wk; admit or urgent follow-up for pathologic fracture Nonunion rare Intertrochanteric Orthopedic consultation Admit for eventual ORIF; may need preoperative testing and clearance by PCP or hospitalist DVT and/or pulmonary embolism; infection Subtrochanteric Orthopedic consultation; consider Hare® or Sager® splint Admit for ORIF DVT and/or pulmonary embolism; infection; malunion (shortened limb); nonunion Abbreviations: AVN = avascular necrosis; DVT = deep venous thrombosis; ORIF = open reduction and internal fixation; PCP = primary care physician. Tintinalli_Sec22_p1767-1880.indd 1843 8/2/19 6:19 PM

sider Hare® or Sager® splint Admit for ORIF DVT and/or pulmonary embolism; infection; malunion (shortened limb); nonunion Abbreviations: AVN = avascular necrosis; DVT = deep venous thrombosis; ORIF = open reduction and internal fixation; PCP = primary care physician. Tintinalli_Sec22_p1767-1880.indd 1843 8/2/19 6:19 PM 1844 SECTION 22: Orthopedics FIGURE 273-3. Shortened, abducted, externally rotated limb ( arrow) seen in femoral neck fracture. [Image used with permission of Dr. Allan Mishra, http://www.emedx.com.]  PHYSICAL EXAMINATION After primary survey, evaluate for deformities, shortening, rotation, lacerations, bruising, or instability of the limb. Identify focal bony tender ness or crepitance. Axial load is extremely sensitive in identifying occult hip fractures. If no significant deformities are noted then perform range of motion of the hips. Identification of a hip or pelvic injury in trauma should raise suspicion for intra-abdominal or urologic injuries. Perform a rectal exam if concern exists for concurrent spinal or pelvic injuries. Complete a neurovascular exam of the motor and sensory function of the perineum and lower extremities along with vascular exams at the groin, popliteal fossa, and ankle. If concern exists for vascular injury, CT angiography may be indicated with concurrent evaluation of associated bony trauma. DIAGNOSIS  IMAGING Consider radiographic evaluation of the pelvis and hips in all uncon scious patients who have sustained trauma or have fallen. Hip radio graphs should include anterior and lateral views along with a complete anteroposterior view of the pelvis. Conventional radiographs are estimated to be 90% to 98% sensitive for hip fractures. When femoral shaft fracture is suspected, images of the femur should include an anteroposterior view along with a lateral view. Radiographs should include a joint above and below the suspected injury . HIP FRACTURES  FEMORAL HEAD FRACTURES Isolated femoral head fractures are uncommon and typically associ ated with dislocations (Table 273-1). Metastatic or pathologic lesions in the femoral head increase the risk for sustaining this rare injury. Reduction is extremely challenging and usually requires operative intervention. Consult orthopedic surgery prior to reduction, but avoid delays as these injuries are at risk for avascular necrosis. If orthopedic surgery is not readily available, at least one ED attempt at reduction is recommended. CT may be required to characterize the position of the retained fragment. Treatment may or may not involve internal fixation (Table 273-2). Prognosis is related to the severity of the initial trauma, associated injuries, delay in reduction, and repetitive unsuccessful reduction attempts.  FEMORAL NECK FRACTURES Femoral neck fractures are one of the most common orthopedic injuries seen in the ED. These injuries typically occur in older adults and occur more frequently in women. Falls are the most common mechanism (90%), but stress or traumatic femoral neck fractures may be seen in younger patients. 8 Consider the possibility of pathologic fractures in all pediatric hip fractures, with unicameral bone cyst the most likely lesion. 9 Consider underlying malignancy in all ages with an unusually low-energy mechanism.10,11 The symptoms seen with femoral neck fractures range from mild pain in the groin or inner thigh, to severe pain with subtle movement. Patients with nondisplaced fractures may be somewhat ambulatory. Those with displaced fractures are typically unable to bear weight. Dis placed fractures typically result in shortening and external rotation of the affected extremity (Figure 273-3). Obtain an anteroposterior view of the pelvis and a lateral view of the hip.

ents with nondisplaced fractures may be somewhat ambulatory. Those with displaced fractures are typically unable to bear weight. Dis placed fractures typically result in shortening and external rotation of the affected extremity (Figure 273-3). Obtain an anteroposterior view of the pelvis and a lateral view of the hip. Any altered or demented patient with a fall should undergo a thorough examination with low threshold to obtain radiographs. Any patient with a change in ambulatory status should undergo radiographic evaluation of the hip. The femur and knee should be imaged in altered or demented patients or those unable to clearly localize their pain. Displaced fractures are obvious on the anteroposterior view, but a lateral view may be helpful in identifying subtle fractures. Approximately 6% to 9% of patients with a femoral neck fracture will have an ipsilateral femoral shaft fracture. 12 These concurrent injuries occur in high-energy trauma patients. In this setting, consider obtaining femur and knee radiographs. The most reliable radiographic finding in identifying femoral neck fractures is disruption of the bony cortex or disruption of the trabecular lines (Figures 273-4 and 273-5). Shenton line and neck shaft angle have been proven unreliable and to yield significant interuser variability even among radiologists. They are rarely used by orthopedists and are unreliable methods for identifying fracture. They are also highly dependent on radiographic angle and technique. There are multiple classification systems for femoral neck frac tures, but it is most useful to describe them as displaced or nondis placed. Because femoral neck fractures are intracapsular, displaced fractures often disrupt blood supply, resulting in avascular necrosis. Displaced femoral neck fractures are more likely to undergo partial hip arthroplasty (bipolar arthroplasty). This procedure involves replacing the hip component without relining the acetabular com ponent. It also allows patients to ambulate immediately following surgery, which is crucial in avoiding complications associated with immobilization. Internal screw fixation is performed in younger, more active patients and preserves the native femoral head but does not allow early weight bearing. Once a fracture is identified, maintain the extremity in a position of comfort. Additional external immobilization is unnecessary. Skel etal traction is contraindicated for femoral neck fractures because it may result in avascular necrosis. “Bucks” boot traction is no longer FIGURE 273-4. Radiograph of femoral neck fracture. The disruption of the bone is most visible when following the superior surface of the femoral neck. Also notice the shortening and impaction of the femoral neck. Tintinalli_Sec22_p1767-1880.indd 1844 8/2/19 6:19 PM

avascular necrosis. “Bucks” boot traction is no longer FIGURE 273-4. Radiograph of femoral neck fracture. The disruption of the bone is most visible when following the superior surface of the femoral neck. Also notice the shortening and impaction of the femoral neck. Tintinalli_Sec22_p1767-1880.indd 1844 8/2/19 6:19 PM CHAPTER 273: Hip and Femur Injuries 1845 consistently used during admission, although some orthopedists may continue this dated practice. It is not necessary in the ED. All patients with hip fractures hoping to return to ambulation will require surgery. For both displaced and nondisplaced fractures, surgical fixation results in decreased morbidity and mortality when compared with nonoperative management. 13,14 Decisions regarding the timing and type of operative intervention depend on the patient’s physiologic age, activity level, and fracture severity. 15 Nonoperative treatment is rarely considered and only appropriate in nonambulatory patients with reasonable pain control. A decision to forgo operative intervention for a hip fracture should be considered an end-of-life decision. Nonambulatory, hospice, or palliative care patients may still undergo operative intervention for pain control. This includes patients with pathologic fractures from diffuse metastatic disease. The complications of femoral neck fractures are significant (Table 273-2). Discuss expected management with the patient and family, emphasizing the importance of early ambulation and physical therapy. Consider efforts to facilitate early operative intervention. Mortality significantly increases after a 24-hour delay. 16 Facilitating preoperative clearance can impact clinical outcome. This can include ordering preoperative diagnostics or early communication with consultants. A multidisciplinary team, including social services for home safety evaluation, and early involvement of the patient’s primary care physician or a hospitalist can improve outcomes.  ISOLATED TROCHANTERIC FRACTURES Greater trochanteric fractures are usually avulsions at the insertion of the gluteus medius. In younger patients (7 to 17 years of age), this is a true epiphyseal separation. In adults, the cause is usually direct trauma. Lesser trochanteric fractures are avulsions secondary to forceful contraction of the iliopsoas. They are commonly seen in children and young adult athletes, particularly gymnasts and dancers. Lesser trochanter fractures in older patients with minimal trauma should raise concern for pathologic fracture.17 Standard anteroposterior and lateral views are recommended. CT of the pelvis may be helpful if a fracture is strongly suspected but difficult to visualize. In most instances, the treatment is nonoperative. Crutch ambulation with touch–toe weight bearing is recommended until orthopedic follow-up in 3 to 5 days. Full recovery is expected in patients with healthy bone. Operative fixation may be indicated in cases where there is significant displacement of a large fracture fragment.  INTERTROCHANTERIC FRACTURES Intertrochanteric fractures are defined as extracapsular fractures occurring in a line between the greater and lesser trochanters. They generally occur in the elderly and are more common in women. The mechanism of injury is usually a fall. Patients typically have pain and deformity on examination. Fractures are usually seen on standard anteroposterior and lateral views. Intertrochanteric fractures are classified based on the number of fracture lines and the amount of displacement. 18 When fractures extend perpendicular to the intertrochanteric line, they are referred to as reverse obliquity intertrochanteric fractures. Perform the same assessment with intertrochanteric fractures as with femoral neck fractures. Traction of any form is contraindicated.

racture lines and the amount of displacement. 18 When fractures extend perpendicular to the intertrochanteric line, they are referred to as reverse obliquity intertrochanteric fractures. Perform the same assessment with intertrochanteric fractures as with femoral neck fractures. Traction of any form is contraindicated. 19,20 Intertrochanteric hip fractures require a unique operative technique. The femoral head is preserved, and a sliding “dynamic” screw is used to cross the fracture site and hold fixation into the femoral head. The complications and prognosis are related to associated injuries, prior disease, and immobilization. Blood loss can be significant, and some patients will require crystalloid or blood transfusion. 21 Infection and pulmonary embolism are significant complications. Avascular necrosis and nonunion are uncommon.  SUBTROCHANTERIC FRACTURES Subtrochanteric fractures are defined as fractures anywhere 5 cm below the lesser trochanter. They are seen in older patients who fall, younger patients with major trauma, and patients with bony metastases. Symptoms include localized pain, deformity, swelling, and crepitance. Significant blood loss may occur. Obtain standard anteroposterior and lateral views of the hip along with radiographs of the pelvis, femur, and knee. ED treatment consists of pain control, immobilization, and orthopedic consultation. As with femoral shaft fractures, Hare  (Dynamed, Westbury, Tasmania) or Sager (Minto Research and Development, Inc., Redding, CA) splints are commonly employed in the prehospital setting. Traction splinting may ease pain and provide some fracture reduction (See Video: Hare Traction Splint). 20 Operative reduction with internal fixation or intramedullary nailing is almost universally indicated.  OCCULT HIP FRACTURES Any patient unable to ambulate or experiencing severe pain with ambulation and who has negative radiographs should undergo CT or MRI. Stress, incomplete, or nondisplaced fractures may not be evident on plain radiographs for days or weeks after injury. MRI is the preferred imaging study and nearly 100% sensitive in identifying occult fractures (Figure 273-5). When MRI is unavailable, CT is a reasonable but less sensitive alternative. In recent years, a rapid-sequence MRI protocol dedicated to rapid ED evaluation of occult hip fractures has been developed and validated. The rapid hip protocol MRI involves only two sequences (large field of view T1 and inversion recovery/fat saturation T2) and takes only 7 to 8 minutes. All nonspecialist radiologists can accurately assess it at the time of acquisition. MRI offers the added benefit of identifying metabolic or pathologic lesions. 22 Imaging should include the pelvis and extend to the lesser trochanter. Any change in ambulatory status should raise suspicion for occult fracture. If MRI is unavailable, fracture should be presumed in all patients unable to weight bear even in the setting of a normal CT. 22-27 FEMORAL SHAFT FRACTURES Fractures of the femoral diaphysis or “femoral shaft” most often occur in young patients with high-energy trauma. Associated traumatic injuries are common. The mechanism of injury varies from direct trauma resulting in transverse fractures to axial load, which typically results in oblique FIGURE 273-5. MRI demonstrating right hip fracture in a patient with a plain radio graph of the right hip that did not reveal the fracture. [Photo contributed by Brooke Beckett, MD, Department of Radiology, Oregon Health & Science University.] Tintinalli_Sec22_p1767-1880.indd 1845 8/2/19 6:19 PM

ally results in oblique FIGURE 273-5. MRI demonstrating right hip fracture in a patient with a plain radio graph of the right hip that did not reveal the fracture. [Photo contributed by Brooke Beckett, MD, Department of Radiology, Oregon Health & Science University.] Tintinalli_Sec22_p1767-1880.indd 1845 8/2/19 6:19 PM 1846 SECTION 22: Orthopedics fractures often with a free-floating triangular “butterfly” fragment. A rotational mechanism may contribute to a spiral pattern and may also cause ligamentous injury at the knee. Pathologic fractures are typically the result of bone metastases. Pathologic fractures in young patients can be benign lesions or malignant primary bone tumors. Unicameral bone cysts are among the most common cause of pathologic femur fractures in pediatric patients. Femoral shaft fractures are generally evident in the prehospital set ting because of the shortening, deformity, and associated swelling. Initiate traction in the field to minimize pain, prevent further fracture comminution, and minimize blood loss. Traction splints are contraindicated in cases of open fracture or in suspected nerve, knee, or vascular injury. For the latter, splint placement without traction is indicated. Neurovascular examination with focus on the sciatic nerve is always indicated. The fracture is typically evident on standard anteroposterior and lateral views of the femur, but radiographic evaluation should include the joints above and below the injury (pelvis, hips, knees). Open femur fractures require broad-spectrum antibiotics and copious irriga tion. Cover the open wound or exposed bone in saline-soaked gauze. Open femur fractures require operative washout and debridement. Blood loss can be life threatening. It is estimated that the average blood loss in femur fractures can be as high as 1200 mL. It is possible to exsanguinate from a femur fracture, and the threshold to transfuse should be low. Intramedullary nailing is the preferred treatment for most femoral shaft fractures. Severely contaminated open fractures, patients with concomitant injuries, or highly comminuted fractures may require external fixation and delayed operative fixation. HIP DISLOCATION Dislocations of native hips result from high-energy trauma, and up to 95% of patients have other associated injuries. 30 Motor vehicle collisions are the most common mechanism. Posterior dislocations of native hips account for >90% of all dislocations. The remaining 10% are anteriorsuperior or anterior-inferior.31 Dislocations of prosthetic hips occur with minimal trauma. Native hip dislocations are orthopedic emergencies and should be reduced as quickly as possible and no more than 6 hours after the injury. Risk of avascular necrosis increases from <10% to nearly 25% when delay extends from 10 hours to 15 hours. If closed reduc tion under procedural sedation fails or is not an option, open or closed reduction under general anesthesia is required. Anterior hip disloca tions mandate reduction in the operating room. Open reduction by an orthopedic surgeon is indicated for irreducible fractures, unsatisfactory reductions, and complex fracture dislocations.  POSTERIOR HIP DISLOCATION AND REDUCTION MANEUVERS Posterior hip dislocations ( Figure 273-6) result from a posterior force applied to a flexed knee, most commonly a dashboard injury. These injuries are associated with acetabular, femoral neck, and femoral shaft fractures. Ligamentous injury to the knee is also common. On examination, the extremity is shortened, adducted, and internally rotated, which differentiates the injury from femoral neck fractures that are typically externally rotated. A careful neurovascular examination to identify associated sciatic nerve or vascular injury is essential.

us injury to the knee is also common. On examination, the extremity is shortened, adducted, and internally rotated, which differentiates the injury from femoral neck fractures that are typically externally rotated. A careful neurovascular examination to identify associated sciatic nerve or vascular injury is essential. Anteroposterior and lateral radiographs of the pelvis and hip identify posterior dislocations ( Figure 273-7). When identified, perform addi tional evaluation of acetabulum and femur with CT. Complications of posterior dislocation include sciatic nerve injury in approximately 10% of patients. The risk of avascular necrosis of the femoral head increases in direct proportion to delay in reduction. Multiple techniques have been described for closed reduction of posterior hip dislocations ( Figures 273-8 to 273-11); it is advisable for the emergency physician to be proficient with more than one technique. Nearly all techniques require in-line traction while flexing the hip to 90 degrees and adducting the hip. The Allis maneuver is the most commonly performed technique. In-line traction is performed with simultaneous hip flexion and internal FIGURE 273-7. Radiograph of posterior hip dislocation. There is also a concomitant acetabular fracture visible. FIGURE 273-6. Posterior dislocation of the hip. A. Schematic representation. B. The clinical appearance of a posterior dislocation of the right hip. Tintinalli_Sec22_p1767-1880.indd 1846 8/2/19 6:19 PM

ternal FIGURE 273-7. Radiograph of posterior hip dislocation. There is also a concomitant acetabular fracture visible. FIGURE 273-6. Posterior dislocation of the hip. A. Schematic representation. B. The clinical appearance of a posterior dislocation of the right hip. Tintinalli_Sec22_p1767-1880.indd 1846 8/2/19 6:19 PM CHAPTER 273: Hip and Femur Injuries 1847 rotation (Figure 273-8). While flexing both the patient’s knee and hip to 90 degrees, apply in-line traction upward toward the ceiling and slightly toward the contralateral side, resulting in the desired flexion and adduction necessary for reduction. While under traction, perform gentle internal rotation if necessary. Aggressive or forced rotation can result in spiral fracture of the femur. An assistant should apply down ward pressure to the anterior superior iliac spines. Stabilizing the pelvis is essential. Direct pressure can also be applied to the dislocated femoral head on the posterolateral aspect of the buttocks. The femoral head can often be palpated and pressure can be applied in line with the direction of traction. With the Bigelow maneuver, the patient is supine with the affected hip and knee flexed 90 degrees (Figure 273-9). Secure the patient’s knee with your flexed elbow, and grasp the patient’s foot with the oppo site hand. Have an assistant apply downward pressure to the anterior superior iliac spines. Now, using your flexed elbow, lift upward at the patient’s knee to apply traction to the femur. Gently externally rotate and extend the hip while applying traction to the femur at the patient’s knee. Another variation is represented in Figure 273-10. Another method is the Captain Morgan technique, in which the physician’s knee is used as a fulcrum (Figure 273-11) (See Video: Posterior Hip Dislocation Reduction). In all reduction maneuvers, be gentle, not forceful, when apply ing any rotation. The posteriorly dislocated hip is locked in internal rotation. While gentle external rotation may assist in rotation, torsion with only minimal force can easily result in a spiral femoral shaft fracture in osteoporotic bone. After reduction, gently range the hip and recheck neurovascular status. Confirm reduction with postre duction imaging. Immobilization to prevent recurrent dislocation is required. Because flexion and adduction cause posterior dislocations, the opposite, extension and abduction, protect against it. This can be achieved with a triangular “abduction pillow” (Figure 273-12). A knee immobilizer prevents extreme extension at the hip while limiting internal rotation and is a reasonable substitute. Because dislocation of a native hip typically results from extreme trauma, most patients will require admission. If several attempts at reduction are unsuccessful, emergency orthopedic consultation is required. Difficulties with reduction may be due to Downward pressure on pelvis Downward pressure on pelvis External and internal rotation and upward pull on femur Following reduction Upward pull on femur FIGURE 273-8. A and B. Allis maneuver for reduction of posterior hip dislocation. Tintinalli_Sec22_p1767-1880.indd 1847 8/2/19 6:19 PM

ies with reduction may be due to Downward pressure on pelvis Downward pressure on pelvis External and internal rotation and upward pull on femur Following reduction Upward pull on femur FIGURE 273-8. A and B. Allis maneuver for reduction of posterior hip dislocation. Tintinalli_Sec22_p1767-1880.indd 1847 8/2/19 6:19 PM 1848 SECTION 22: Orthopedics occult fracture or incarcerated soft tissue. A postreduction CT is recommended to identify associated acetabular or femoral head fractures that were not evident on plain radiographs.31  ANTERIOR HIP DISLOCATION Anterior hip dislocations are rare and result from forced abduction that causes the femoral head to be levered out through an anterior capsular tear ( Figure 273-13, A and B ). Anterior dislocations can be superior FIGURE 273-9. The Bigelow maneuver for reduction of posterior hip dislocation. A. The physician applies upward traction on the femur while an assistant stabilizes the pelvis. B. The hip is externally rotated and extended while the femur is distracted. [Reproduced with permission from Reichman EF, Simon RR: Emergency Medicine Procedures. © 2004, McGraw-Hill, New York.] (1) (2) (3) FIGURE 273-10. (1) Flex the patient’s knee 90 degrees and place your flexed elbow under the patient’s knee while placing your hand on the other knee to stabilize the pelvis. (2, 3) With the other hand, externally rotate the leg. [Reproduced with permission from Reichman EF, Simon RR: Emergency Medicine Procedures. © 2004, McGraw-Hill, New York.] FIGURE 273-11. The Captain Morgan technique for reduction of posterior hip disloca tion. (1) Stabilize the patient’s pelvis by placing the patient on a backboard in the supine position and strapping the pelvis to the board, or have an assistant stabilize the pelvis on the stretcher by placing both hands on the patient’s iliac crests and using pressure to keep the pelvis stable. (2) To reduce the dislocation, place your foot on the stretcher or board with your knee posterior to the patient’s knee. (3) With the patient’s knee in flexion, gently pull downward at the patient’s ankle while applying an upward force to the patient’s hip by lifting your heel by stepping on your toes and contracting your calf. Gently rotate the patient’s hip while applying the upward traction behind the patient’s knee. FIGURE 273-12. Abduction pillow. Tintinalli_Sec22_p1767-1880.indd 1848 8/2/19 6:20 PM

patient’s ankle while applying an upward force to the patient’s hip by lifting your heel by stepping on your toes and contracting your calf. Gently rotate the patient’s hip while applying the upward traction behind the patient’s knee. FIGURE 273-12. Abduction pillow. Tintinalli_Sec22_p1767-1880.indd 1848 8/2/19 6:20 PM CHAPTER 273: Hip and Femur Injuries 1849 (pelvic) or inferior (obturator) depending on the degree of hip flexion at the time of injury. The affected extremity is in abduction and exter nal rotation (the opposite position of most posterior dislocations). The clinical appearance of superior versus inferior dislocations is dramati cally different (Figure 273-13, C and D). Neurovascular compromise is an unusual complication. However, a thorough exam is warranted to detect injury to the femoral artery or nerve. An anteroposterior view of the pelvis can easily demonstrate the femoral head to be anterior to the acetabulum. A lateral view illustrates the anterior dislocation more clearly, although it may be difficult to C D FIGURE 273-13. Anterior hip dislocation. A. Anterior superior dislocation of the hip. B. Inferior dislocation. C. Clinical appearance of a superior-type anterior dislocation of the hip. D. Clinical appearance of an inferior-type dislocation of the hip. Tintinalli_Sec22_p1767-1880.indd 1849 8/2/19 6:20 PM