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- Differential Diagnosis: Combined fracture/dislocation; muscular contusion; concomitant sciatic nerve injury;
pelvic fractures. - Diagnostic Tests: AP pelvis film and cross table lateral X-rays needed.
- Procedure:
a. Follow ATLS protocols. If able to MEDEVAC, DO SO STAT. If not, and injury is uncomplicated by
ipsilateral fractures distal or pelvic fractures, proceed as below.
b. Evaluate for crepitus with gentle IR/ER/log rolling of limb. Sedation with morphine and Valium if
available. Place patient on the ground/floor and have an assistant stabilize the pelvis by pushing down
on the iliac wings. Flex the hip and knee 90° each. Position yourself between the patient’s leg and
grasp the affected leg in both arms and pull the hip and leg on a 90° axis to the floor. This will
take lots of force and may take 5-10 minutes of work, so use your legs and gently IR/ER the leg
as you distract. Reduction should be manifested by a satisfying clunk. If you are unable to reduce
the joint, it may be more complicated than you expect, so splint the patient in situ with pillows and
make an EVAC happen.
c. Reduction may require general anesthesia. Rapid reduction in less than eight hours is necessary to
minimize the risk for neurologic dysfunction and avascular necrosis of the femoral head. - Post Treatment: Even if you get the hip to reduce, keep the patient non-weight bearing until a CT exam is
acquired to rule out incarcerated bony fragments.
Patellar Dislocation:
- Assessment: History may reveal that there was direct blow to the medial aspect of the patella, or
the ailment began suddenly, following a “cutting movement” away from the fixed foot, which causes
contraction of the quadriceps and external rotation of the tibia on the femur. Patient will usually
present in considerable pain with the knee slightly flexed, and the patella obviously located adjacent to
the lateral femoral condyle. Some patients may report that this is a periodically repeated occurrence. - Differential Diagnosis: Fractures; soft tissue contusion
- Diagnostic Tests: X-ray with patellar views if available, to rule out concomitant fractures (28-50%)
- Procedures:
a. If traumatic, perform ATLS protocols.
b. Provide immediate reduction- Address patient’s concerns that you will not execute any sudden painful movements.
- Anesthesia/analgesia is generally not required, but you can aseptically put 15-20 cc of 1%
lidocaine in the knee make them more comfortable. Inject right under the laterally displaced
patella after a good prep. - Gently grasp the patella while stabilizing it with mild lateral traction and maintaining its position
to prevent sudden movement. - Support the limb and flex the patient’s hip to relax the quads. Request the patient to slowly
extend the knee. - When knee is fully extended, release traction on the patella, which will usually slip comfortably
back into its normal anatomic location.
- Post Treatment:
a. Provide patient with a knee immobilizer or a long leg splint and crutches to maintain straight leg
position. Weight bearing as tolerated is authorized
b. Provide NSAIDs - Patient education:
a. General: Avoid the motion that contributed to the injury.
b. Medications: Control pain and inflammation with NSAIDs on regular basis (ibuprofen 800 mg tid x 7
days or diclofenac sodium 150 mg am and hs x 7 days)
c. Recurrence or no improvement: return NLT 24 hours, or ASAP after recurrence - Follow-up actions
a. Return evaluation: ASAP if recurrence
b. Consultation criteria: Schedule orthopedic evaluation within 72 hours if available and particularly if
related to trauma.