Dislocations of the Hip, Knee, and Ankle: Diagnosis and Management
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Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department

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Table of Contents
 
About This Issue

Dislocations of the hip, knee, or ankle are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation. This issue presents an evidence-based approach to:

Quickly assess the dislocation based on the mechanism of injury

Manage fractures often associated with dislocations

Quickly and safely diagnose and treat dangerous knee dislocations

Order diagnostic studies to determine the exact nature of the dislocation: x-rays or CT?

Decide whether to immediately reduce the dislocation, or whether urgent surgical consultation is needed first

Choose the best methods for reduction, based on provider and patient needs

Correctly disposition the patient: do all patients need to be admitted?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  6. Differential Diagnosis
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  9. Diagnostic Studies
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  10. Treatment
    1. Hip Dislocation
    2. Reduction of Hip Dislocation
    3. Knee Dislocation
    4. Reduction of Knee Dislocation
    5. Ankle Dislocation
      1. Reduction of Ankle Dislocation
  11. Disposition
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  12. Complications
    1. Hip Dislocation
    2. Knee Dislocation
    3. Ankle Dislocation
  13. Special Circumstances
    1. Hip Dislocation Following Total Hip Arthroplasty
    2. Knee Dislocation Following Knee Replacement
    3. Patellar Dislocation
    4. Knee Dislocation in Children
  14. Controversies and Cutting Edge
    1. Ultrasound-Guided Procedural Sedation
  15. Summary
  16. Key Points
  17. Risk Management Pitfalls in Management of Lower-Extremity Dislocation
  18. Time- and Cost-Effective Strategies
  19. Case Conclusions
  20. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Suspected Hip Dislocation
    2. Clinical Pathway for Emergency Department Management of Suspected Knee Dislocation
    3. Clinical Pathway for Emergency Department Management of Suspected Ankle Dislocation
  21. Tables and Figures
    1. Table 1. Differential Diagnosis for Traumatic Hip Pain
    2. Table 2. Differential Diagnosis of Ankle Dislocation
    3. Table 3. Injuries Associated With Traumatic Hip Dislocation
    4. Table 4. Complications of Ankle Dislocation
    5. Figure 1. Blood Supply of the Femoral Head
    6. Figure 2. Anatomy of the Knee
    7. Figure 3. An Irreducible Lateral Knee Dislocation That Demonstrates Dimpling
    8. Figure 4. Major Nerves of the Knee
    9. Figure 5. Ankle Joint Ligaments
    10. Figure 6. Posterior Hip Dislocation With Fracture of Acetabular Wall
    11. Figure 7. X-Ray Images of Knee Dislocations
    12. Figure 8. Ankle Dislocations
    13. Figure 9. The Allis Method
    14. Figure 10. The Bigelow Method
    15. Figure 11. The Captain Morgan Technique
    16. Figure 12. The Rocket Launcher Technique
    17. Figure 13. Patellar Dislocations
  22. References

Abstract

Dislocation of the major joints of the lower extremities--hip, knee, and ankle--can occur due to motor-vehicle crashes, falls, and sports injuries. Hip dislocations are the most common, and they require emergent management to prevent avascular necrosis of the femoral head. Knee dislocations are uncommon but potentially dangerous injuries that can result in amputation due to the potential for missed secondary injury, especially if they are reduced spontaneously. Isolated ankle dislocations are relatively rare, as most ankle dislocations involve an associated fracture. This review presents an algorithmic approach to management that ensures that pain relief, imaging, reduction, vascular monitoring, and emergent orthopedic consultation are carried out in a timely fashion.

Case Presentations

A 25-year-old man is brought in by ambulance after being involved in a high-speed motor vehicle crash as an unrestrained driver. He is complaining of right hip pain and lower abdominal pain. During his primary trauma survey, you note that his right leg is shortened and internally rotated. You suspect a native hip dislocation and/or fracture and wonder which diagnostic studies you should obtain and whether you should attempt a reduction before consulting orthopedic surgery.

Later that evening, an elderly woman arrives with right hip pain, unable to ambulate. She states, “I was just bending over to put on my shoes when I felt a ‘pop,’ and then I fell to the ground.” She then informs you that she recently underwent right total hip arthroplasty. You notice her right leg appears internally rotated, adducted, and shortened. You suspect a dislocation of her prosthesis and wonder whether you should involve orthopedics or reduce it yourself and, if reduction is successful, whether she can be discharged home.

19-year-old man arrives by EMS, saying that while he was playing a pick-up game of football, he was tackled and felt a “pop” in his right knee. His friend told EMS that his knee looked like it “bent backwards.” His knee was immobilized by EMS, but it doesn’t look deformed. You are concerned that he may have dislocated and spontaneously reduced his knee and wonder if any diagnostic studies are needed.

A 27-year-old man presents to the ED with right ankle pain and obvious deformity. He has severe pain and cannot stand after landing awkwardly in a hole with his right foot when he jumped down from a tree branch. He is unable to bear weight or move his ankle due to severe pain. He appears to have an ankle dislocation and possible fracture; you wonder which takes priority: reduction or imaging?

Introduction

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. Rapid assessment and timely reduction can minimize pain and complications, but there are many circumstances when emergent orthopedic consultation is needed and surgical referral required. This issue of Emergency Medicine Practice discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle.

Critical Appraisal of the Literature

A literature search was performed in PubMed, EMBase, Medline®, Allied and Complementary Medicine Database, SportDiscus, and Google Scholar using the search terms hip dislocation, anterior hip dislocation, posterior hip dislocation, knee dislocation, ankle dislocation, talar dislocation, subtalar dislocation, hip reduction, knee reduction, and ankle reduction. A total of 163 articles were found regarding hip dislocations, 187 on knee dislocations, and 167 on ankle dislocations. The Cochrane Database of Systematic Reviews was searched, using the terms hip dislocation, knee dislocation, and ankle dislocation, resulting in 8 articles related primarily to knee dislocations. The American College of Emergency Physicians does not endorse any guidelines related to lower-extremity dislocations.

The majority of the applicable literature for lower-extremity dislocations is found in orthopedic and trauma surgery journals. ED-specific studies are limited, though the approach and initial management is the same, regardless of location or provider. Most of the articles in the literature are case reports, case series, and retrospective reviews; there are no large randomized trials assessing diagnosis or management strategies for lower-extremity dislocations.

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Publication Information
Authors

Caylyne Arnold, DO; Zane Fayos, MD; David Bruner, MD, FAAEM; Dylan Arnold, DO

Publication Date

December 1, 2017

CME Expiration Date

January 1, 2021

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