Trick of the Trade: Hip dislocation Part II
As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT involve climbing up on the gurney.
Trick of the Trade: Captain Morgan technique for hip dislocation
Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient’s bed.
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Trick of the Trade: Ultrasound-guided injection for shoulder dislocation
Who loves relocating shoulder dislocations as much as I do? I know you do.
Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.
How can you improve your success rate in injecting into glenohumeral joint injection?
Paucis Verbis: Does this DM leg ulcer have osteomyelitis?
We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it’s the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you’ll be surprised by what you find.
Several questions come up with diabetic foot ulcers:
- Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer?
- Is there underlying osteomyelitis?
- How can I best diagnostically work this foot ulcer up for osteomyelitis?
- What is the Wagner grade of this ulcer? (I think it’d be Grade 2.)
Thanks to JAMA‘s Clinical Rational Examination series, there is a systematic review of diabetic leg ulcers and osteomyelitis. Here are the highlights:
PV Card: Diabetic Leg Ulcer and Osteomyelitis
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Below is the Fagan nomogram to help you plot out your post-test probability based on your likelihood ratios. The example given is if your pretest probability is 25% and your LR is 10. Your post-test probability would be 80%.
Reference
- Butalia S. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity? JAMA. 2008;299(7):806. doi: 10.1001/jama.299.7.806
Trick of the Trade: Synovial lactate in septic arthritis
A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.”
Does this patient have a septic joint?
Paucis Verbis: Distracting injuries in c-spine injuries
“Distracting injury” is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of “distracting injury”. Although both are studies at different sites, both conclude the same:
- Chest injuries may be considered “distracting injuries” because of their proximity to the cervical spine.
Example
So let’s say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a “long bone fracture”), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a “distracting injury” because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.
Wait, let’s rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That’s just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.
So for me, these “distracting injury” studies are helpful such that:
- If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
- If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.
PV Card: Distracting Injuries in Cervical Spine Assessment
Go to ALiEM (PV) Cards for more resources.
Trick of the Trade: Crossed straight leg raise test
A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica?
Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is the sciatic nerve.