To continue reading, please log in or purchase access.
Episode 11 Shownotes | Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department (Trauma CME)
Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.
This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter.
Follow The Podcast
Why to Use
The Bastion Classification was developed as a classification system to comprehensively describe the injury pattern of lower extremities after blast injuries. It correlates with treatment need, such as the requirement for operative proximal vascular control or amputation level. The criteria are helpful for facilitating communication between clinicians and for operative management.
When to Use
Management depends on the injuries diagnosed. Using the Bastion Classification and its suffixes, emergency department physicians and trauma surgeons can anticipate the need for other surgical consultations and the resources required for treatment.
Jennie Kim, MD
Travis Polk, MD
A panel of military surgeons, Jacobs et al, developed the Bastion Classification and performed a prospective validation study with 103 patients who sustained 179 lower limb injuries caused by improvised explosive devices treated at Camp Bastion, Afghanistan, from November 2010 to February 2011.
The primary aim of the proposed classification was to provide a pragmatic, comprehensive, and clinically relevant system to better facilitate the transfer of information. Currently existing lower limb injury classification systems fail to describe the complete injury pattern or correlate with management. The Internal Committee of the Red Cross classification is broad and does not provide information on the severity of injury. The Mangled Extremity Severity Score (MESS), Gustilo and Anderson, and Müller AO classifications do not provide information on injury level. The Müller AO classification also does not take into account soft tissue injury. The secondary aim of the study by Jacobs et al was to facilitate the assessment of interventions. The Bastion Classification did show a predictable association with the level of initial musculoskeletal debridement and/or amputation and the level of vascular control.
The original study was not designed to correlate class of injury with outcomes such as mortality, transfusion requirements, or definitive amputation level, and thus, this information is not provided in the publication nor in the conclusions made.
A study in 2013 by Lundy and Hobbs looked at 67 patients with 117 injured limbs caused by dismounted blast exposure. The authors noted that the Bastion Classification appeared to be predictive of initial musculoskeletal treatment but was less useful in predicting the need for proximal vascular control, especially in the most common Class 3 injuries. The original study by Jacobs et al showed that Class 3 injuries correlated with a higher rate of intra- or extraperitoneal iliac vessel control (23% of 83 Class 3 injured limbs without associated abdominal injuries) compared to the study by Lundy et al that only had 1 patient with a Class 3 injury without associated abdominal injury and 6 (5%) of all injured limbs requiring iliac vessel control. The 2013 study does not comment on correlation of the Bastion Classification to mortality rates.
Neal Jacobs, MD
Copyright © MDCalc • Reprinted with permission.
Caylyne Arnold, DO; Zane Fayos, MD; David Bruner, MD, FAAEM; Dylan Arnold, DO
December 1, 2017
December 31, 2020
Physician CME Information
Date of Original Release: December 1, 2017. Date of most recent review: November 10, 2017. Termination date: December 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2017. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC to access the online archived articles and CME testing.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies