← Emergency Medicine Cases
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- [00:02]
A
Emergency medicine is more than just ordered chaos. From the recess room to the bedside, we are witness to it all and we're here to help you prepare for it. Bringing you the brightest minds in emergency medicine from around the world for trusted, tried and true free open access medical education. I'm Dr. Anton Hellman. And I'm Dr. Katie Lynn. Katie, let's welcome the listeners from our amazing EM community to the Emergency Medicine Cases Podcast, shall we?
- [00:27]
B
Yeah.
- [00:27]
A
Or let's simply call it EM Cases. Okay, EM Cases. EM Cases is brought to you by shremi, the Schwartz Reisman Emergency Medicine Institute that's a non profit organization dedicated to improving EM care through high quality research and education. The opinions expressed on this podcast are intended for information and education purposes only and should not be used to diagnose, treat or prevent any medical condition, nor should they be used as a substitute for medical advice from a qualified practicing physician.
- [00:49]
C
First, just a quick word from our sponsor Metricade, the experts in complex physician scheduling since 2012. I've been using Metricade's incredible scheduling system for more than a decade and it's been a game changer for me and my colleagues. Shift work comes with its challenges, but Metricade helps minimize the drawbacks by ensuring fair distribution of shifts while integrating circadian rhythm friendly recovery time into its methodology, preserving your precious sleep so that you can perform at your best. Go to metricade.com emcases to see how Metricade can make your scheduling fair and improve your sleep and your performance. That's metricade.com emcases I must admit, I'm
- [01:32]
A
a bit sad, only because between our two guest experts, Dr. Aaron Ciel and Dr. Matt DeStefano, by the end of this podcast we'll have completed an EM Cases episode on every major joint and bone in both the upper and lower extremities. We've done shoulder, we've done elbow, we've done wrist, we've done hand, we've done knee, we've done ankle and foot. The hip is our only last major joint and I love these guys, so I'll have to think a bit more creatively about how I can get them back on EM Cases after this podcast. But I'm going to enjoy their words of wisdom while I got them here at EM Cases Studio. Great to see you two again and thanks so much for taking taking another stab at the last joint.
- [02:19]
D
Our pleasure. Thanks for having us.
- [02:20]
B
Thanks for having us, Anton. I think we can do a four hour special on accessory ossicles though.
- [02:27]
A
All right, maybe we'll save that for another decade. Okay, so hip injuries, hip fractures and atraumatic hip pain, they're kind of bread and butter for any emerge doc, but I gotta say that occasionally they can be anything but straightforward. If you've been practicing long enough, you've seen patients with acute hip pain with a normal X ray and unremarkable blood work that you just can't figure out in the ed. So what we're going to do is we're going to run through the differential diagnosis of hip pain, traumatic and atraumatic, highlighting some clinical pearls and pitfalls that I suspect will make your next mystery hip a slam dunk diagnosis. And of course we'll be talking a lot about hip fractures. So surprisingly, hip fractures carry a really high morbidity and mortality. The 30 day mortality rate after a hip fracture is about 6 or 7%. That's higher than the 30 day mortality rate for acute coronary syndromes in 2025 and the one year mortality rate is about 20%. I remember when my grandmother broke her hip, about a year later she was really sick and dying and in retrospect, the hip fracture seemed to mark the beginning of the end for her. Now, while the one year mortality rate is far down the road for us in the ed, there are moves we can make in the ED that might actually improve the short term mortality rate and almost certainly the morbidity associated with hip fractures. Add to that the equally important hip dislocations and suddenly we've got a topic that demands more than just get an X ray and call ortho. So let's get into it, gentlemen. Aaron, before we jump into the clinical minutia first, why should we care about hip fractures in the ED? Besides the short term mortality of 6 to 7% that I mentioned, what is it that makes the diagnosis so potentially deadly and so morbid in the first place? Like what? Why are hip fractures important for us to learn about?
- [04:26]
D
Yeah, we see a ton of them and we're going to see a ton more over time. It's generally older people, minimal trauma that it takes, not high energy. And it's a couple of things. It's like sort of the, you know, which is the first step once you start falling, that also is a predictor of actually badness down the road. So it's like an indicator. So a lot of these folks, when they fall, it's just a minor little stumble. And technically, oh yeah, it's a mechanical fall, but we need to be careful with that because this actually like falls beget falls when older People start falling, it just keeps happening. And, and that's actually an indicator of lower quality of life coming down. So that's a big issue. Number one, to see it. Number two, as you mentioned, the morbidity mortality of having the fracture, it's so high because the people that end up with these fractures have comorbidities. They're not happening in isolation. So the morbidity mortality, if a 30 year old had a fractured hip, it's gonna be significant is cause it's a lot of trauma to break the hip in a 30 year old. But if the similar fracture in an 80 year old happened in a 50 year old, the morbidity mortality is much more for the 80 year old. And it's a significant operation, it's a significant rehab. And if these patients are already, you know, if they sit in a hospital bed for a few days, it doesn't take long to decondition and then it's hard to get them up. So a lot of times for the elderly, when they have a fractured hip, they will not return back to baseline. They will have a new established baseline postoperatively and it'll be lower than the level that they were at if they do survive.
- [05:49]
A
All right, so that gives us a little understanding of why it's important for us to make the diagnosis of hip fractures in the ED and a sense of what causes the morbidity and the mortality that we might be able to prevent in the ED to some extent. Let's now talk about the duration of time to surgery. Time targets. So we know that the longer it takes to get the patient with a hip fracture to the or, the worse the outcomes. There are time to or thresholds of, you know, under 24 to 48 hours that we're supposed to aim for. So, Matt, what's the actual evidence behind the 24 hour target and what can we do, more importantly, what can we do in the ED to make that time target happen?
- [06:33]
B
Sure. I mean, Arun essentially alluded to this already, talking about the fact that once these people, this cohort, this population, they spend any amount of time in bed, they're going to drop. And I'm happy to answer the question, but I would encourage everyone listening to read a famous paper from 1947. And I say the date because it's really striking that really nothing has changed since the paper was written. Written by Asher a s H E R in a British Medical Journal in 1947. It's a page and a half and it's really an essay and it's Entitled the dangers of going to bed. And it's a danger for all of us. We're not designed to lie around in bed, but particularly in the low reserve elderly. So that's the basis on which multiple studies have been done saying, is there a window of opportunity to fix these people, to get them up and moving? Which begs the question, why do we put metal in people? We put metal in people, particularly in the lower extremity, to get them up and moving, to get them out of bed. A lot of these fractures that we can talk about, they could be managed non operatively, but the consequences of that management would kill the patient. So you could heal the fracture in a way that doesn't involve putting metal in them, but the patient wouldn't survive the treatment. So what's the critical time period to get them up and moving? 24 hours is optimal and the provincial guidelines really argue to try and get people done within 24 hours. In reality, that often gets stretched to 48 hours. Beyond that, the curve really drops off.
- [08:07]
A
All right, yeah. So my understanding is that there's actually pretty good evidence that their mortality rate will go up if you go past that 24 hour mark.
- [08:16]
B
You got it.
- [08:17]
D
You know, there was a large study done, I think it was in the UK it was at 24 hours, five and a half percent mortality rate at one month and at 48 hours it was six and a half percent. So it sounds like it's only one percent. But relative to the mortality rate, like the proportion of patients that die was 20%, you'd save 20% of deaths roughly by doing this. So it is significant and the orthopedic side knows it as well. And they're motivated from an emerged perspective. If they've had breakfast, if they've done something, they're not going to usually get done on that same day, but they'll be prioritized to be done the next day is usually it. So, so it's different than MI treatments and stroke treatments where like time is muscle, time is brain, that sort of stuff. It's not that time critical on our end necessarily to get it to Ortho 20 minutes or a half hour earlier because they probably won't get the delay. The biggest hump is getting them to the operating room.
- [09:07]
A
So we obviously can't force the orthopedic surgeon to do their operation in one hour after we see the patient. But let's say the patient is getting their operation tomorrow, is supposed to get their operation tomorrow. What in the emerge can we do to help get that Patient to the or, because I imagine, you know, if you keep a patient in the emergency department overnight and they're 87 years old and they're on multiple medications and maybe they have a bit of dementia, their chances of becoming delirious overnight and then maybe they can't get to the OR because you got to settle the delirium first, et cetera. So what are the kind of things that we have to think about in the ED to try and get that patient to the or, besides telling the orthopedic surgeon they must go to the or?
- [09:50]
B
Yeah, and trust me, the orthopods want to operate on these people asap. So oftentimes there are system barriers beyond all of our control as physicians. It sounds incredibly sort of basic, but one of the most important things that I think you can do, particularly for this population of boomers that are seem all to be on anticoagulation of some sort or dual antiplatelet therapy. Have someone run down, did they take their medication doses today? Again, sounds so basic. It's not medicine, it's logistics. But it's surprising how often the patient and the family and even the caregivers can't definitively answer when they last had their Coumadin or their Doac or their Noac or their Plavix and Aspirin. So understanding what happens in the or, that's job number one for me. In the emerge, if they're on those drugs, did they take them today or not? Because that has an impact on are they going to get operated on within 24 hours or beyond that, other things
- [10:49]
D
you can do, like make sure the blood work, routine blood work gets done because they'll want that. Do an inr, do a group and screen if it's not ready. That can also delay them going to the operating room, make them NPO from the minute you see them. So these are also other factors that if you know it's not gonna be done, okay, so if it's four in the afternoon, it's not gonna be done tomorrow. Make sure after midnight at least you make it npo, because if that doesn't get done, if you're holding them overnight and they have breakfast, that's gonna delay their surgery. So the things we can do incorporate family. If this is a demented patient in the emergency department, you prime the family that a surgeon will talk to you tomorrow, get consent, be available, Just make sure that they know about these things. Because these things, while we can't get them to the OR faster, if we don't do things Properly, we can delay their getting to the OR when they were ready so we can do things to slow things down. We may not be able to speed things up, but what we do in the emergency department does make a difference.
- [11:41]
B
Absolutely. And just a reminder to try and tune these people up like any preoperative patient and avoid any barriers to delay. Reminder. If they're hyponatremic, there's a good chance they're hypomag as well. And we often don't order extended lights.
- [11:56]
D
Analgesia. If we just say, okay, I'm going to give them some opioids overnight and wait, get a block in them. If you can get a hip block into them, it's going to decrease their risk of getting delirious pre op and that's also going to make it much easier for them to recover. So there are a number of things we can do in the emergency department. Again, that may not move things up faster, but can make a difference in the long run.
- [12:17]
B
Agree. And I'm really explicit about writing my orders for elderly admissions, but particularly for hip fractures. No benzos, no gravel, no Benadryl, hard stop underlined on the admission orders. And what are we talking about here? I'm building on what Aaron was just saying about the hip block, which we'll come back to, and that's avoiding delirium at all costs. How else can we avoid delirium? It's about pain control in the elderly and I think we know this from multiple studies and looking at multiple injuries in this age population. One of our docs in Collingwood, I'm going to give a shout out to him. Jesse Guscott was trying to make it easy for docs to put a hip block in these patients almost the moment they hit the door. So they're shortened, they're externally rotated, they're elderly, they had a low energy fall, they were able to walk before the fall, they can't walk after. It's not a diagnostic mystery. Get a block in them. Do a femoral nerve block. If you're old school, you can do it by feel, but I think the modern standard is ultrasound guided. What makes it easier? What did Jesse do? Hanging on the trauma cart is a hip block kit in a Ziploc bag. And it has everything you need to do the block marking. Xylocaine, appropriate syringes, needles, a little guide for ultrasound images, and even the billing code. No excuses, get the block done.
- [13:41]
A
Excellent. So what really moves the needle to get these patients to the or in under 24 hours is making sure you get that early hip block addressing any blood thinners they might be on and really tracking down, like when they were on their last doac, for example. In some patients, you may even need to reverse the doac. Make sure you've got your blood tests all ordered and ready to go. And they've got, you know, they'll probably need an ECG before they go to the or get all that stuff done for them. And of course, speak to your consultants early because the earlier you speak to them, the earlier they can start planning for the or.
- [14:16]
D
Right. And typically for these hip fractures, you don't need to call them in like sort of a blackout period, like after 10pm or 11pm Whatever your orthopods use in your hospital to call. If you have to refer them to another hospital to get fixed, then, yeah, you get them moving in the middle of the night because that's also going to be another cause for delay. But if you don't, if it's kept in hospital and the ortho surgeon, orthopedic surgeon will see them in the morning, then you don't call them at 2 or 3 in the morning to say, I've got a patient with a hip fracture. They're not going to do anything different in the middle of the night with that.
- [14:44]
A
Yeah, absolutely. And we really do need to think about delirium prevention. And if your hospital has some kind of delirium prevention bundle or something or protocol, you really should be getting that going.
- [14:54]
D
And as you're saying this, this should actually be like the hip fractures are so common with all these EMRs. There should be a hip fracture bundle that your hospital puts together and then it just makes it easy to go and do this. So extended lights are part of it. Group and screen inr. All these things are routinely done as part of it. And then the avoid whatever drugs you want to avoid, as Matt's saying, also can be a part of it. And that's just obviously done with orthopedic surgeons of your hospital. And you can customize that as you need.
- [15:19]
A
Perfect.
- [15:20]
B
And thinking about avoiding delirium in the orthopedic surgeon by avoiding unnecessary 3am phone call.
- [15:35]
A
All right, so up to now, we've talked about what to do once the diagnosis is made. But I'd like to back up a bit and talk about how to make the diagnosis in the first place, which in many cases is very obvious from the foot of the bed or from the X ray. But in some cases it can be really tricky and again, delay time to surgery. So I Want to talk about the patients who don't have the obvious clinical findings, like the shortened, externally rotated leg? Aaron, let's talk about the reliability of some of the other classic clinical findings for hip fracture and what you do at the bedside. So, you know, there's these things like passive, gentle internal rotation of the hip. There's axial load by pushing or tapping on the heel. There is gently rolling the leg to elicit pain in the hip. There's different kinds of exam maneuvers. There's this patellar, pelvic, percussion test. There's all kinds of physical exam maneuvers. If you could just give us a little sense of which of those maneuvers are useful and what you actually do at the bedside when it's not an obvious hip fracture.
- [16:38]
D
Sure. And I'll tell you one thing that even before that, before you go to physical exam, is just think of the history, think of the age of the person. That'll help drive your pretest probability as well. And realize that a lot of old patients, when they break their hip, they actually they break their hips standing up, and the pain is what causes them to fall. So we all expect there to be a fall. And then if they didn't fall, we're like, oh, you didn't break your hip. But old people can break their hip without falling, and that's part of our pre test probability. So it's important to realize that. And why can old people break their hip without falling? Because they have arthritis. And if they have an arthritic joint, you have decreased range of motion. So somebody pivots on one leg and they have an arthritic joint, it basically stops rotating. You have a decreased range of motion. And then when you stop rotating on it, what happens? You put more of a rotational force on the femur. And what's the femur? It's osteoporotic. And you put a rotational force on an osteoporotic bone, and that's how it can fracture.
- [17:32]
A
And they've been on steroids for three months.
- [17:33]
D
And you're certainly exactly right. And if you ask the patients, even the ones that fell, sometimes they'll tell you, you know, I turned, I heard a crack, and I fell because of the pain. Most of them, the fall causes the fracture. But sometimes, if you'll just ask the question, and then what that brings us back to is that sometimes patients can break their hip or without falling, and patients can walk on a broken hip. So therefore, there's a subset of patients that don't fall. They are limping, they're not walking. Normally, but they're limping, they've got a sore hip and there's a subset of patients with hip fractures that can walk on them. If it's short and externally rotated, they're not walking on the hip. But if it's an undisplaced or minimally impacted fracture, they might be able to walk on it. You can't rule out a fracture with a negative X ray. You got to put the history and then to answer your question with the physical exam now. So you do the X ray. If you don't see a fracture, you've got to move them, you've got to see where they're sore. If they're sore more in the pubic symphysis when you compress. If they're sore over the compressed the pelvic rim, maybe they've got a low impact pubic ramus fracture, superior inferior ramus. That's certainly possible. If they're tender when you press on their hip itself, that certainly could suggest an undisplaced radiographically occult hip fracture. Gently log roll them, see what they can do. Ask them to straight leg grace, their opposite leg, their affected leg. If I can get them to straight leg grace, if I can gently internally, externally rotate their hip and it's not sore, that's not a fracture. And if that's really limited, then it has to be on my differential that I'm worried about a fracture. And if it's a patient who's older and osteoporotic, then all of a sudden like, okay, the pretest probability for fracture goes up and you're less likely to rely on the negative test.
- [19:10]
B
I love the mention of an active straight leg raise because it's underutilized for a lot of MSK trauma in the elderly. Think about the origin of the iliopsoas. It's the lumbar spine. So are you trying to rule out clinically a significant lumbar spine fracture like compression fracture in the elderly? If they can do a straight leg raise actively equal both sides, non provocative, they don't have an L spine fracture. And then where does that iliopsoas attach to the lesser trochanter? So you're stressing the hip and you're including all the potential fractures. And if that's pain free and symmetrical, it's essentially off my list. So these simple physical exam maneuvers done well and consistently get you a long way towards the diagnosis and decouple you from over relying on imaging. A few more comments just to add on to what Aaron said. I Spend a lot of time listening to the patient. If they have groin pain, they have an intra articular injury period. So groin pain is a red flag on your physical exam. Look, if they have bruising, bruising over the gt Think about a subcapital fracture, think about an acetabular fracture. Do they have bruising infrapatellar? They came down on their knee. If they didn't break their patella, where'd the energy go? It went up the femur into the hip. If they don't have any bruising, think about the fact they may have broken their hip and then fallen. One last comment. History and physical are king by the time you get to the X ray. Understand your bias. We're talking about hip fractures and the hip includes the ball and the socket. But we have like acetabular neglect. Like we have left sided neglect. With certain CVAs, we have acetabular neglect. When we look at hip films, we think of hip fractures as being femoral. And the way to miss a hip fracture is to not interrogate, not look at the acetabulum and the superior and the inferior pubic rami. So remember to look at the other half of the hip.
- [21:13]
A
We're definitely going to get on to how to interpret the X rays in a little bit. But before we leave the physical exam, there's just two tests that I want to talk about. One is that axial load, so you tap or push on their heel and if they get pain in the hip. And then the other one is the patellar pubic percussion test. And that's the one where the patient is supine with their legs extended and relaxed. You place the stethoscope bell over the pubic symphysis. You tap lightly on the patella of each leg separately, and then you compare the sound transmission through the pelvis. And normally this sounds like a clear, symmetric, resonant and transmitted sound from the patella to the pubic bone. And a positive test would be a duller, decreased or absent sound on the affected side. And that means that there's been disruption in the bone, that is a fracture. So let's start with that test, the patellar pubic percussion test. Useful, not useful. What does the evidence say? Do you use it? Aaron?
- [22:14]
D
I have no idea what the evidence says. Do I use it? No. And I think if I brought that up to an orthopedic surgeon, as I did the patellar pelvic percussion test, and it was abnormal, it wouldn't move the needle in their part in any way at all. So I don't use it if I'm worried enough. I don't think I would have enough reliability on using it to not do a CT scan if I was worried. So therefore I don't think it would be useful in my hands. I haven't used it, haven't really thought about using it, but I don't know if Matt does or not.
- [22:45]
B
I'm actually doing it right now while we're recording the podcast and I sound dull to myself.
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A
So you broke both your hips before you came to the podcast?
- [22:53]
B
I did. I did. I'm really committed to the podcast process. Just so we're clear, I'm listening to
- [22:57]
D
you and you sound dull, too.
- [23:03]
A
Okay, so patellar pubic percussion test. You guys don't use it. We have CTs instead of that. I mean, the evidence is quite remarkable. It's higher than 90% sensitivity and specificity.
- [23:15]
D
I will tell you I'm probably a little biased because we have pretty easy access to a CT scan in our hospital. But imagine if I was rural and didn't have it then maybe that does add something to it. So I don't want to dismiss it. I'm just saying that I have a more reliable test. I think that the orthopedic surgeons will have more weight in. And if you're sitting there in a rural hospital, don't have a CT scanner, you may want to do these extra things, and that just sort of moves the needle a bit for you and you're likely to want to transfer them. So I think there's some value to it for some practitioners, but not where I work.
- [23:45]
A
All right, so that's the patellar pubic percussion test. What about the axial load? So they're lying supine, tap, or you knock or you push the heel and they say, ow, I've got pain in my hip. Helpful, not helpful. Do you do it? Don't do it? Sure.
- [24:02]
B
I think it's part of the whole process. It's just another little data point. And I like those simple tests where you're jarring people. And we know this from other areas. The patient that can hop up and down doesn't have wicked peritonitis or discitis or meningitis. So these ideas where we're tapping, jarring, or shaking people, I think they have value.
- [24:21]
D
Agreed. I don't use it personally. It doesn't come out in my toolbox. If I suspect they've got it, I'll log roll them. I'll try to get them to straight leg grades. I'll try to do internal external rotation and then that'll be sort of the limit for where I'll go. And by then I'll know if I want a CT or not.
- [24:35]
A
Perfect. All right, Aaron, you had mentioned some of the physical exam maneuvers that would lead you down the road of a pelvic fracture. I want to dig a little bit deeper into that. How do you distinguish a pelvic fracture from a hip fracture? On the history and physical, what's making you lean more towards. You know what, The X ray looks fine, but there's something going on. Is this a pelvic fracture which usually requires zero surgery, or is this a hip fracture which almost definitely requires surgery? How do you make that distinction clinically?
- [25:05]
D
So generally patients, when they have a pelvic fracture, they feel pain more in the groin than actually out on the hip. So it's a little more medial where they feel the discomfort. The Venn diagram overlaps in these. It's not 100%, but that's one thing that would sort of lean you in that direction. If you compress, if you push down on the pubic symphysis, so basically pushing down on it, that'll cause discomfort. When there's a pelvic fracture, it doesn't usually do much for a hip fracture. If you press on the iliac wings and compress in on that again, you're compressing what you're compressing the structure of the pelvis. The, that usually doesn't make a difference to the hip. But if you press on the lateral aspect of the hip and push that or log roll that, that's more painful. And then if you just have that pretest probability, you're just going to bring your eyes to the pubic rami superior inferiorly. You're more likely to look there if you're worried about it clinically. So that's what brings you to it. And then you look and sometimes they're also occult and if they're not weight bearing you're not really wearing, they get admitted. Sometimes down the road, someone gets a CT scan if they're worried just a, if they're still not walking in a few days, some might do a CT scan earlier. It all depends on your institution and your availability. So just as we talk about these so called hip fractures, roughly about 5% of hip fractures are radiographically occult. It ranges 2 to 10%, whatever, say 5%. What does that actually mean? It means if in your career you've seen 19 patients with a hip fracture, you probably saw 20 because the 20th one, one in 20, the X ray is normal. So you just have to realize that a negative X ray doesn't mean it's not fractured. A negative X ray just means the probability of fracture is less and what matters is your pre test probability based on history and physical exam.
- [26:48]
A
Just a quick announcement. The complete lineup for the Next International Online EM Cases Summit November 19th to 21st has been finalized. What you'll get at the summit is all your favorite EM Cases guest experts giving high yield talks, each one followed by an interactive Q and A for the ultimate in tacit knowledge transfer to your huge brain. Day one's theme is common Conundrums, Day two masterclasses and day three novel approaches to challenging clinical problems plus riffing off the talks will have Sarah Fuey's virtual recess room simulations where you work in small teams to save virtual lives and get personal feedback with expert debriefers. We've got four rural EM, AI, global EM and eDflow. How to turn your ED into an efficient tight ship. And finally we have three pre conference courses. Harts ECG with Jesse McLaren, the synapse course for EM neuroessentials with Katie Lynn, and the casted course with Aaron Ciel. So mark your calendars for the EM Cases Summit November 19th to 21st and mark your calendars for the date that tickets go on sale. And that'll be July 14th at 10am Eastern Standard Time. All the details are@emcases summit.com that's emcasesummit.com and I hope to see you all there. It's going to be a blast. We've been talking about occult hip fractures and it's so often where someone comes in with a painful hip and we look at the X ray and it's negative. They might be a fracture. As we just said, about 5% are occult to X ray. But then there's this whole other differential diagnosis that we have to think about. You know, it's really interesting that older patients can break their hip without any trauma whatsoever. So sometimes we are faced with these patients that have no history of trauma who have a fracture or they have a whole long list of other things that we can hopefully sort out in the ed. So Matt, in the patient without an obvious fracture, whether it's traumatic or atraumatic, what's your approach to the painful hip?
- [28:59]
B
Well, you want to know is this new or semi new or old? Because that gives you a hint about sort of the chronicity of the pathology. And the thing that we're all inclined to be aware of and think about is Arthritis, of course, and in the weight bearing joints, the knee or the hip, with a preponderance of men over women, the older you get, the more likely you are to have arthritis in one of those joints. So that's going to be our go to. That sets us up to miss some less common things, though. And now I want you to put your medical hat on a little bit. What are the comorbidities or patient behaviors that lead them to be a little bit at risk for avascular necrosis of the femoral head, which is often spontaneous. And it's drinking and smoking all day long. So in patients that present with non traumatic hip pain, that is new and they're middle age or older, you got to ask about drinking and smoking because that puts them at risk for avn. Is that an emergency department diagnosis? Can you easily get the next test to rule in or rule out avn? No. But you can expand your differential diagnosis and be more comfortable managing these cases where there isn't a story of overt trauma, there's not an obvious X ray.
- [30:19]
D
And to build on Matt's point, it's a great point about like understanding the patient a little bit better. If they drink, they smoke. That moves up the list. But what about their past medical history? If they're immunocompromised for some reason, they have lupus, they have inflammatory bowel disease, they have psoriasis, they're on a biologic. If they're immunocompromised, the pretest probability for infected hip sepsis goes up. And you just have to. If you miss that part of the history, it's easy to miss that sepsis is a more likely diagnosis. If a patient is on a doac, sometimes they can just bleed and they can have an iliopsoas bleed. I remember seeing one guy who was like, he had a lot of pain. Older guy. And then eventually when they did the Mr. Three, four days later, still couldn't walk. That was his diagnosis. He had a hematoma of it. Patients can have infections of the muscle back there. And I've also seen another thing to think about is patients who are on long term bisphosphonates can get these atypical femur fractures. They may break through, they may just cause pain. Sometimes it's in the thigh, sometimes it's in the proximal aspect of it. And the plain film just shows you a little bit of a bridging callus and that's a little clue that this person's at risk of actually breaking through that fracture. So there are things in the patient's past medical history that can also just direct you a little bit, these subtle clues that will direct you in one direction or another.
- [31:31]
A
Okay, so there's septic arthritis, there's oa, there's psoas, muscle abscess, there's psoas bleed. Before I ask you about how to differentiate between these things, what else do we have to add to the list, Matt?
- [31:47]
B
Well, I would say, you know, in the first world, in the modern era, in our population, middle age and older, there's a lot of metal in people. And when we have someone come in with hip pain and it's non traumatic and there's not a clear story, and we do an X ray, what are we looking for? Arthritis, most commonly as a simple explanation. Oh, and we find they have metal in their hip or thereabouts. So they have a previous dhs, an intertan, an arthroplasty. All metal in people has biofilm on it. So the older these people are with metal in them, the more that metal's colonized. And if there's some imbalance, they get immunosuppressed for some reason, that can flourish into clinically what's now an infection. So don't just look at metal in the hip as part of their history or look for a periprosthetic fracture. Think about the fact that all of these things are colonized. It's another risk for being infected.
- [32:42]
A
Great Pearl, there it is.
- [32:44]
D
And Matt's point of periprosthetic fractures. If a patient has fallen and they've got a hip that's injured and they've got metal inside it, the break occurs at the tip of the prosthesis. You have to be very careful to scrutinize the X ray properly. And sometimes a hip series, if it's a long stem on, it will not show you the tip of the prosthesis. You always have to see the tip of the prosthesis because that's where the fracture will occur. And look very carefully at that. So this is again, this is not the atraumatic, but the traumatic. With the prosthesis in make sure the X ray always includes the tip of the prosthesis. It might need a femur X ray sometimes to get there.
- [33:19]
A
Fantastic. And Matt, when I was reading about the differential for atraumatic hip pain, I came upon this thing called Greater Trochanteric Pain Syndrome. Gtps. I'd never heard of it. Is it something that we need to know about? What is it? What do you Think, yeah, absolutely.
- [33:37]
B
And I would say, Anton, you already know about it and everyone listening already knows about it because you know about the analogous diagnosis and that is rotator cuffopathy, if you will. So people that have impingement syndrome or bursitis or partial thickness rotator cuff tears, almost always involving supraspinatus, and we know this is age related, function related, rsi, repeated small traumas or one big one, they can all lead to this subacromial shoulder pain. What's the analogy? I'm pointing out the supraspinatus in the shoulder, the main cuff muscle that gets injured. Most commonly we have a rotator cuff in the hip. Glute medius is equivalent to supraspinatus and it undergoes a lot of the same degenerative pathology. So in patients that are a little bit older, that have lateral hip pain, they're tender over the gt and we're so tempted to call it bursitis all the time. Think more carefully about the fact that this is the glute medius getting thinner, getting degenerative tears, partial thickness tears, and that's a pain generator. If you have two kids in the backseat of your car and one starts acting up, probably the other one's going to act up too. If your supraspinatus tendon's unhappy, your subacromial bursa is going to get unhappy. If your glute medius is unhappy, your GT bursa is going to get unhappy. So this idea of bursitis is often smoke. That tells us there's an underlying fire.
- [35:08]
A
Great, Fantastic. So we've talked about some of the historical red flags. You know, immunocompromise around biologics for infection, you know, they're on steroids for fractures, et cetera. What about physical exam, Matt? When you have a patient that has atraumatic hip pain, let's say the X ray is negative and you're trying to figure out is this a tendinopathy, is this arthritis, is this in the joint, Is this first, like, what's your kind of main approach? Do you think of it as like articular, intra articular or extra articular? Do you think of it as like fracture or no fracture? Like, how do you approach that situation when you come back now to, because this happens to me all the time, is I go back and examine the patient a second time. Because like the first time I just did a cursory thing, I thought they had a fracture and then they don't have a fracture. Let me go back now and try and Figure out? Well, based on the history, I'm not convinced that it's a fracture. Maybe it's something else. How do you approach that part?
- [36:05]
B
You answered the question. It's go back and do a good physical exam and often more careful than the first time. Is it groin pain or is it lateral hip pain? In other words, what I'm saying, is it intra articular or extraarticular? Where's the point of maximum tenderness? And you gotta go shopping and you have to know the underlying anatomy to understand, to correlate. Where I'm pushing matches this structure. Ultrasound is an adjunct. I'm not a big ultrasound guy, but I do use it. And what's the question I'm asking to augment my physical exam? Groin pain or lateral hip pain? Where's the point of maximum tenderness? The provocative tests that we were using for fracture or no fracture, Log roll active, straight leg raise. These are all hints about the anatomic generator of the non traumatic pain. Why am I adding ultrasound? Because I really want to answer the question. Is there an effusion? I'm just putting the probe anterior on the hip in the long axis and comparing it to the other side and measuring the distance in the joint space from the superior femoral head to the acetabulum. And more than 2 millimeters side to side is a significant difference. And the question, the knock on question now is what are you going to do about that? And the real answer is put a needle in the joint and aspirate it. Anton, to go on, from what I just said, look, if we're dealing with a kid with hip pain, they had a prodromal viral illness a week or two before. Now they're limping, there's no trauma, they're afebrile, they look well, they don't have a white count. You put an ultrasound probe on the affected hip, they're 2 or 3 millimeters more. Vertical dimension between the femoral head and the acetabulum. Transient synovitis of the hip till proven otherwise. I'm not aspirating that kid advil. Close follow up. But in the adult the differential diagnosis is much broader and may require treatment. Do you want to ask about sexual history? Absolutely. Is this gonorrhea? When you do your tap on that hip, is the synovial fluid normal in appearance and viscosity or is it cloudy and runny? Lower viscosity usually means more inflammatory mediators and you have a problem. Do you want to send it for culture? Absolutely. Are you going to send it for crystals? No, have you ever seen gout in the hip? No. Why? Because it's a warm joint and gout doesn't like warm joints.
- [38:36]
A
Fascinating stuff.
- [38:38]
D
Incredible.
- [38:39]
A
There's the pocus keeners out there who are all probably nodding. When I think about using pocus for a patient with atraumatic hip pain, I think about what's really going to be the use, because if I see an effusion there, it doesn't really help me distinguish between a fracture or an infection or another inflammatory problem. I suppose that putting that probe on there and you're sure that there's no effusion would make all of the above unlikely. And so you're more reassured that it could just be their arthritis or something.
- [39:08]
D
It's actually a good point you're making. But do realize that early on in septic arthritis, you may not see an effusion. So the fluid is very like, it's gravity dependent and it may just. If you have a small effusion, you may not see it on anteriorly in the hip until it becomes bigger. So the pretest probably like no one's going to tap it. But you can't 100% rule out a septic joint. Just tell them, just inform them we don't see anything. And if they come back later with more swelling, more discomfort, then maybe it is. So I don't want you to take any of these. These markers aren't 100% when you do them. The other thing I'd say sometimes the pain, if it doesn't quite fit, maybe it's coming from the back. It's referred pain from a more proximal source. Keep that in mind. And sometimes it's actually just hard to figure out. And I've seen orthopedic surgeons who are like, you know, you got some arthritis in your hip, your hip is sore, I don't know where it's coming from. And they'll send them to interventional radiology just to get lidocaine in the joint. What did that do to your pain? It didn't do anything to my pain. Okay, well, the hip joint's not the source, then. It's coming from somewhere else. So I'm not saying we're going to do that in the emergency department. I'm just trying to say it's okay sometimes not to know because it's pretty hard to figure out.
- [40:14]
A
I want to talk a little bit more about point of care ultrasound, because based on our discussion we just had, if you see an effusion, it doesn't really tell you any closer what the diagnosis is. If you're worried about infection already and the patient's blood work is worrisome, you're going to be going down the road of septic arthritis anyways. And we also established that if you put your probe on the hip and there's no effusion, that doesn't rule out a septic joint, it doesn't rule out a fracture, it doesn't rule out all these things that we're worried about. So I guess I'm going to ask you, Matt again, what would be the yield of doing pocus on the hip for your average emergency doctor?
- [40:57]
B
It's hard to answer that for the average emerge doc because I appreciate that most working emerge docs are not going to put a needle in the hip. But in the context in which I work a significant amount of the time, which is low resource rural hospitals, if I have a patient that has an effusion, it's non traumatic, they have any risk factors for infection, I'm going to put a needle in the hip. So for me, the use of an ultrasound is part of the fall forward algorithm. It drives the next step for me, which is I'm going to aspirate that hip. 18 gauge needle, anterior lateral approach. You're not near any of the stuff that matters. Big red, big blue, big yellow. It's actually a very easy thing to learn how to do. See one, do one, teach one.
- [41:40]
A
Fantastic. Good. Let's take a little break to hear
- [41:42]
C
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- [42:34]
A
from the differential diagnosis, there is one diagnosis that I also read about a little bit in preparing for this podcast that I know nothing about and maybe, Matt, you could elucidate us on. This is the subchondral insufficiency fracture. What is it? What's the typical presentation and what do we need to do about it?
- [42:54]
B
There Are analogies, as always, repetitive stress, other factors that impair bone quality, chronic steroids, again, alcohol and smoking. And then activities that patients do superimposed on those risk factors. So are you repeatedly loading the hip joint with peak loads, Example, running, skiing, sports that are going to focus. Sports or activities are going to focus a lot of load on the weight bearing zone of the superior femoral head and its partner, the acetabulum. And a reminder, when you guys are looking at your hip X rays, it almost looks a little sclerotic in the superior femoral head and the superior acetabulum. And in a normal hip joint, where you see it a little wider there, that's not sclerosis. That's local thickening of the subchondral plate and the supporting bone, because that's where you weight bear when you're upright. So that area of architecture is reinforced as we age, we lose some of that. And so if you're going pounding away on your hip joint, you can get these microscopic fractures of the subchondral plate and it hurts. And many X rays can look normal or near normal. With a critical eye, you can often appreciate a little focal flattening of the femoral head. But CT is really the study if you're interested in this problem. So it goes back to all medicine. Done. Well, get a history. Who's your patient, what do they do, or what are they doing that is loading repetitively with high energy the hip joint, and then ask about those risk factors.
- [44:33]
A
Brilliant. I want to shift gears a little bit. So far we've talked about why early surgery saved lives, what really moves the needle in the ED Management and how to recognize occult and mimicking hip injuries. Now let's dig into the fractures themselves because the kind of break that you're looking at might actually change what you tell orthopedics, how fast the patient needs to get to the OR and what you might actually do in the ed. So, Matt, can you review for us the different kinds of hip fractures so that when we pick up the phone to orthopedics, we can describe the fracture accurately and we get a sense of the urgency and we get the sense of the bleeding risk. And, you know, we're going to talk about all these different things with all the different fractures. So how do you think about the different kinds of fractures? How do you categorize them, in other words?
- [45:35]
B
Well, Anton, I think this goes back to med school, stuff that we all learned, you know, like sub capital, basic cervical intertroke, subtroch, and they're really, just describing the anatomical location, what matters clinically is actually just two things. Is it inside the joint capsule or outside the joint capsule? And in addition to that, you may want to just make a 4x4 table in your head. Young, old, in the joint, outside the joint. Because this really informs risk and treatment and surgery.
- [46:08]
A
All right, yeah, let's dig into that. Let's go through each of those four boxes.
- [46:13]
B
Old people inside the joint. And why does inside the joint matter? Just to back up there a little bit. If you have a fracture that's inside the joint capsule, you bleed in that space and you pressurize the joint capsule. And the older you get, the lower the blood flow to the femoral head. And so if you have a fracture inside the joint, it pressurizes the joint. You can impede blood flow, essentially. Think of it as a compartment syndrome affecting the femoral head. And the femoral head's going to die. The reason why, in a young person, we've all learned that a subcapital fracture is an emergency is because of those principles. You're bleeding inside the joint capsule, you're pressurizing it, and by virtue of that, you're decreasing blood flow to the femoral head and that whole space, and you have a fracture. So in a young person like you, maybe not me, that's an emergency. If door to needle time matters for saving heart muscle, door to fixation time matters for saving the femoral head in a young person. Contrast that with an older person. If you have a fracture within the joint, you can try, and there are surgeons that will put subcapital screws up the pipe. But more often than not, in an old person, the femoral head's going to be done for. So in our minds, and this is why the 4x4 table is so important. Young, old, intracapsular, extra capsular. It's the young person, the needle in a haystack, with an intracapsular fracture that we're worried about, and we gotta push the system to take care of that person.
- [47:52]
A
Fantastic. I love that way of thinking about it. And just if you could review for us, when you say intracapsular versus extracapular, which fractures are you actually talking about?
- [48:02]
B
Sure. And this is where I think, as Aaron would agree with me, even though you're not going to be a surgeon, go to the OR from time to time, see the anatomy, see where the capsule attaches. And it attaches right at the base of the neck. So any fracture that involves the femoral neck is, by definition, intracapsular and you're going to bleed in that space the moment you get to the base of the neck and more distal into the intertroch zone. Hence intratroch fracture, a line that joins the greater trochanter to the lesser trochanter. You're going to bleed outside the capsule and not impact the viability of the femoral head.
- [48:45]
A
That brings up the point of which patients are more likely to bleed and where they can have worrisome bleeding. Because we all learned that if you have a bad femur fracture, they can bleed out from that and really get hemodynamically unstable from a femur fracture. So am I to understand that if it's intracapsular, there's kind of a tamponade that happens there and they don't bleed. And then if it's extra capsular, those are the ones that bleed. And we need to worry about those patients that have extra capsular fractures who are on a doac, for example.
- [49:18]
B
First of all, I would say you nailed it. You know, the intracapsular fractures, they're bleed and they contain tamponades. The perfect thing to think about. You can rupture your pericardium and decompress the tamponade. You can rupture the knee capsule and decompress a hemerthrosis. You're not going to rupture the hip capsule. It's the thickest capsule in the body, especially anterior, so the bleeding is contained. What you're referring to is the risk of bleeding from a subtroch fracture, also called an infratroch fracture. And these tend to be oblique, big surface area and displaced and similar to femoral shaft fractures, they can bleed a lot. And so it's in that fracture in the elderly patient, anticoagulated or dual antiplatelet therapy, that that may inform the risks of significant blood loss and the need for a transfusion.
- [50:12]
D
Right. So subtrochs, I mean, subtrochanteric fractures, when you see them, they're more like, think of them more as a femur fracture, and that'll just change it. But I think from a surgeon's perspective, the blood loss from an intracapsular or extracapsular intratrochanteric fracture, it's not a consideration for them. And I don't think we need to worry about, like, are they going to significantly lose more blood in one or the other? I don't think it will affect us as emergency physicians. Just realize that a lot of Emerge books call subtrochanteric fractures as a type of a hip fracture, we should think of them as a subset of more of a femur fracture.
- [50:46]
A
Great way to think about it. And Aaron, anything else to add in terms of just how you think about the different kinds of fractures and what you're going to tell orthopedics? Like what do you tell the orthopedic surgeon on the phone? And then maybe give us what you're thinking when you're telling them that it's an intertroch versus a greater trochanter versus a subcapital or whatever. Just give us a sense of what you understand about how quickly they need to get to the or which ones are more urgent than other ones and how are you going to communicate that to the orthopedic surgeon?
- [51:20]
D
So Matt has nailed it. The one that you need to worry about is the one that's way less common, which is a young patient with a displaced intracapsular subcapital fracture. Because that that happens in an elderly person. They're going to replace the femoral head, they're going to get a new hip, but if you do it in a young person, they might be able to preserve their femoral head if you get there soon enough. So that's about the only one where we have to do something differently. To be honest with you, if you tell an orthopedic surgeon I've got a three part intertroch or a basic cervical or a subcapital, they're going to thank you very much. And they just want to look at the X rays because they won't necessarily believe us even when I say it sometimes like I'm not sure is that subcapital or bayes cervical. They go, what's the mrn? Can I just look at it? I'm like, okay, sure. And then that's really what they want to cut to the chase. So it doesn't really change from our perspective what we're going to do. We're going to give it to orthopedics to see what does ortho want to know? Is the patient from home or not? Are they ambulatory normally or not? Are they on a doac? When did they last eat? Is family involved? These are the kinds of questions that they would like to know and that'll tee it up and make it easier for them. If you have those answers, great. They'll just very easily be able to understand like construct a plan of what they're going to do if they have that information. So I think those are the main things like where's the patient's situation from ambulatory or not. Doac, when did he last eat?
- [52:38]
A
I want to talk a little bit about isolated greater trochanter fractures. And my understanding has always been that these are pretty benign fractures that don't need to go to the or. Matt, are all of these benign? I mean, I've read all kinds of stuff about if on mri it actually has intertrochanteric extension that goes across the midline. They actually do need an operation. Any greater trochanter fracture, isolated greater trochanter fractures that we need to worry about?
- [53:09]
B
Well, two comments. One would be really anatomic. And in regard to your comment about these QT fractures that may in an occult way extend beyond the midline, keep in mind that the weight bearing zone of the hip runs through the medial axis. What do I mean by that? If you drop a plumb line from the center of the top of the acetabulum through the femoral head, it falls down the medial calcar and that's where the bone's thick and that's where you're bearing weight. So it's the medial cortex of the proximal femur that matters. So if a GT fracture extends in the lateral cortex a little bit to our surgical colleagues, 99% of the time that's non operative crutches. Follow them along. The second answer I would give you around the apparently isolated GT fracture is how old's the patient? What's the bone quality? How'd they do it? What are their functional expectations and the exception? A little bit like in the 2x2 box or 4x4 box we talked about. Are they young or old and young really around physiologic age and bone quality. If they have a big GT fracture, they have yanked off the attachment point of their glute medius and they can really defunction themselves. That is analogous to a full thickness rotator cuff tear in a young, healthy active person. So that exceptional case, big GT fracture, young quote unquote active person, they're getting a hook plate that's going to the operating room.
- [54:41]
D
Great.
- [54:42]
A
So in practical terms, young patient with a displaced femoral neck fracture or subcapital fracture, that's an emergency. You really want that patient to get to the or like now if you can, the typical older patient with the displaced femoral neck, let's say or intertrochanteric fracture, that's urgent. The 24 hour rule would would be there. If it's a non displaced femoral neck or a stable intertrochanteric that's not quite as bad. Still want to get them 24 hours, but maybe 48 is okay. And then the isolated greater trochanter or an insufficiency fracture, those are almost always non operative. They just need protective weight bearing. But if they're young and it's they've just yanked their greater trochanter right off, they actually might need an operation. So, Aaron, in terms of routine hip views, what are they? When do we know they're done right, if they're done wrong, do we miss stuff? And then if we don't see anything on the plane views or the routine views, are there any other views that can help us maybe find a fracture that's occult? Just to the regular views, sure.
- [55:51]
D
So one thing, when you're ordering a hip series routinely, you'll get an AP of the pelvis and it gives you a view of the other hip, of what the alignment is like the little angulation of the femoral neck. Sometimes with these valgus impacted fractures, the head is just a little bit rotated and the only way you can tell is by looking at the opposite side. There are some very subtle clues. There are trabecular lines you can look at. It's nice to have a normal for comparison. How do you know it's a properly done AP pelvis? There are little obturator foramen that are there, which you look at, and they should look symmetric. And if one looks more open and the other's closed, it's because the pelvis is rotated. So knowing that those obturator foramen, the ischial tuberosity, you'll look at the bottom of the pelvis. Just above that is where the little holes are. These obturator foramen, they should look symmetric and therefore, you know, okay, it's a nicely taken AP film. You'll then also get a lateral film. And we often don't spend a lot of time looking at the lateral because it's a lot of confusing. It's a cross table lateral. That's done. We don't pay attention. That's sometimes where you'll see a fracture is displaced. Just train your eye to just trace out the femoral neck, the femoral head, look at alignment. You'll only get that for the one side, you won't get it for the other side. But just get used to seeing that. And then once it's displaced, it'll actually be a little more clear to you what you're looking at in terms of additional views. Sometimes if you're worried about an acetabular fracture, you can do something called a Judet view. If it's a child you're worried about slipped capital femoral epiphysis, you can do a frog leg view. If it's somebody who has a pelvic fracture you're worried about, you can do what's called inlet and outlet views. So there are additional views you can add. But again, if you have access to advanced imaging, that might be where you end up going because even those additional views may not be fully sensitive.
- [57:37]
A
Okay, before we do get to CT and Mr. And when we would order them and how good they are or bad they are, I want to talk a little bit more about acetabular fractures. So Matt, these are missed all the time. What do we need to know about acetabular fractures to help us improve our miss rate and take good care of the patient?
- [57:57]
B
Anton, for the most part it's just about catching the injury and that's about your approach to reading the film. I think you know, most of us from experience would know that most acetabular fractures are managed non operatively. And so it's the really big ones where the acetabulum significantly disrupted. There's a big high energy mechanism, a fall from height, a motor vehicle collision. You're not going to miss those ones. So it's more about getting the diagnosis right the first time so the patient's informed and they can go home with crutches or a walker and the treatment plan starts rather than them being sent home and bouncing back for another series of films, another physician to look at them, et cetera. So it's about pride, I guess, is what I'm saying. In the words of Harvey Winfield, a colleague and sometimes mentor of mine. I hope Harvey's listening to this. Diligence beats brilliance every time. So when you're looking at your pelvic films, you got both sides on your ap. Shoot through, start from the outside and go all the way in, or start from the inside and go all the way out. What am I saying? Outside is the gt inside is a pubic symphysis. And either start from the outside or the inside first, but make sure you're dragging your eyes across all the structures. Again, our bias. Be aware we tend to fixate on the femoral side only. So just have an organized approach to look at the acetabulum. And the small fractures you're going to miss are like die punch injuries. The acetabulum's been punched by the femoral head by 1 or 2 millimeters. It can be a Very small thing.
- [59:31]
A
Excellent. All right, let's move on to CT and mri. So we've got a patient who can't weight bear. They have classic pain with, say, internal rotation, but their films are normal. So, Aaron, what's your next best test? CT or mri? And the reason I ask for this is, you know, most of us just have access to ct, like, now. But my understanding is that CT can actually miss fractures as well. So, I mean, I have to say, personally, when I do an X ray and there's no fracture, and then I do a CT and there's no fracture, I'm like, see you later. I'm done.
- [60:05]
D
Right.
- [60:06]
A
But my understanding is that actually CT can also miss stuff.
- [60:10]
D
Yes. So the sensitivity of ct is not 100%. You're right. The sensitive Mr. Is. But for patients who have a suspected occult hip fracture, the sensitivity in that subset of patients for a CT is probably like 95%. So that's very good. And that's what our orthopods would accept. And if it's negative, The CT is negative. They'll probably admit them, let somebody see if they can manage them or not. If they're still a sore a few days later, then they'll get an mister. We typically don't do an mister out of the emergency department, but generally we're worried they're not ambulatory. They were before. We have a pretest probability there's something that's there. They usually end up getting admitted anyways and watched. But you're absolutely right. A negative CT doesn't mean it's not fractured, but the likelihood is way less.
- [60:53]
A
And, Matt, as a rural physician, what would you recommend for the rural physicians who don't have easy access to either CT or MRI when they have. They suspect a patient has a fracture, X ray is negative. And there's like a wide variety of patients here, you know, but let's just say there's. It's an older person who just has a limp and, you know, they don't need to be admitted for any other reason, and they have a normal X ray. How are you going to manage that patient in terms of next steps in imaging?
- [61:22]
B
Repeat physical exam is King and Anton. What I'm referring to is some subset of these patients actually have an articular cartilage contusion. So they've driven the femoral head into the acetabulum. Nothing's broken. Or maybe there's a subchondral fracture. That would only be appreciated on Mr. And is clinically irrelevant. And these patients are going to get better over time. What about the patient that has a hip pointer? Some of you who are old enough may recall before it was outlawed that in football you could spear another player in the side of the hip with your helmet. Very high risk maneuver for the person doing the spearing. They could hurt their neck, but the idea was to take someone out of the game by causing a contusion or hematoma in the glute muscles. And so a lot of our patients that fall, they have a hip pointer, they'll get better in time measured in days. So for those of us in a lower resource environment that don't have easy access to Mr. It comes back to clinical medicine.
- [62:20]
A
And now a quick word from one of our sponsors, Northern Health. Looking for more than just a shift? What if your next move gave you adventure, balance and a team that has your back? In Prince George, bc, Northern Health is hiring emergency physicians, physician assistants and nurse practitioners to join a high performance emergency department with over 54,000 visits a year, full specialist support and a collaborative team environment. Think short commutes, affordable living and world class hiking, biking and winter sports right outside your door at the center of the province. Flexible scheduling, competitive compensation and real work life. Balance included. Ready to make an impact and actually enjoy where you live? Visit Careers NorthernHealth CA and join the emergency team in Prince George. Today we talked about doing hip blocks to prevent delirium and to manage the pain well. And if you have access to doing a hip block, either yourself or you have a system in your hospital like we do where I work, where an anesthetist will come down and do a hip block like almost immediately. It's really quite a great service. We know Based on Journal Jam number 13, I believe it was. There's pretty good evidence there's like nine RCTs that confirms that regional blocks provide equal or superior analgesia to standard therapy. They reduce opioid use, they reduce delirium, and that they have pretty rare serious adverse complication rate. We gave some procedural tips to minimize complications in the Journal Jam podcast. Any comments about doing hip blocks for hip fractures in the emergency department? Anything else we need to know? Any pearls or pitfalls?
- [63:55]
D
The only thing that I would tell you, where you need to hesitate a little bit is if you're looking at something that's a subtroke or a femur fracture in a younger patient who's at risk of compartment syndrome, that person you don't want to block, but the older person for sure, they're not going to get Compartment syndrome, but just, we just get like, we get attached to that. Oh, I can do a hip block. I can take their pain away. But there are some people where you actually need to know their pain. So hip fractures, not a problem. But then when it migrates down to a femur, a FEMUR In a 60 year old, 7 year old, the chance of getting compartment center is exceedingly small. By all means, block them. But if you see a young athletic person with a higher femur fracture, like, I want to block them, be super careful.
- [64:34]
A
That's what I love about you guys. The pearls and the pitfalls are just so beautiful and simple and effective and amazing. That's a great one. Matt, anything you want to tell us about hip blocks?
- [64:47]
B
One tip, one pearl that I learned from an anesthesia colleague is push hard just a couple centimeters below your block. Use your fist or the palm of your hand. Hang out there for five or six minutes. Push hard, use 20, 25ccs of block. And what you're doing and pushing hard just below your block side is you're keeping that volume from tracking down distal, you're keeping it up high and concentrating it around the femoral nerve. It's more effective.
- [65:16]
A
Great tip. We've talked a bit about DOACs and antiplatelet therapy and bleeding risk and that that's important to at least find out about when patients have been taking their blood thinners and to relay that to the orthopedic surgeon when you give them a call. One of my favorite drugs is tranexamic acid. And I was surprised to learn that there's actually some evidence for emergency doctors giving tranexamic acid for those patients at high risk of bleeding from an extra capsular fracture of the hip. Let me just ask you two, do you think there's any role for giving TXA for patients who are, let's say, on a DOAC and have an extracapular hip fracture?
- [66:02]
D
I would say our surgeons would not want us doing that. They will do that if they wanted to do it as admission orders. They will almost always when they give it, it's preoperatively in the operating room.
- [66:12]
B
Agree.
- [66:14]
A
So interesting to know that most of these patients are going to be getting TXA perioperatively, but that in the emergency department, even in the patient who has an extra capsular fracture, who may be on a DOAC or something, it might be a conversation we have with orthopedic surgeon. Hey, do you want me to give the TXA now? Because I know you're gonna be giving it later. This guy's at high risk for bleeding.
- [66:36]
D
Fair? Yeah, fair enough. I think most of them would probably say no, but by all means, have the conversation once you have it twice, you probably don't have to have it a third time.
- [66:43]
A
Great. Let's switch gears now. From hip fractures to hip dislocations. Matt, first, why is recognition and quick reduction of hip dislocation so important?
- [66:56]
B
Well, Anton, I'm going to sound like a broken record. Is the patient young or old? Is this their own equipment, their original equipment, or not? And really, what I'm getting at again and again here, like we talked about in fractures, time is femoral head. Door to needle time, door to fixation time, door to reduction time. So if this is you, Anton, and you have your own femoral heads and you have a pickleball misadventure,
- [67:26]
A
you know what? That's perfectly accurate because I actually have started playing pickleball. So that's just a little hint of what my age is like.
- [67:35]
B
I could tell. I could tell. So we can argue you're more likely to have an Achilles tendon rupture than a posterior hip dislocation. But for the purposes of this conversation, let's say that you have a posterior hip dislocation. Playing pickleball, that's got to go in. That's an emergency that bumps you to the front of the line. Because time is femoral head in the cases which are much more common that we all have dealt with. And that's the arthroplasty patient that has a hip dislocation. And often it's the same patient coming back in again and again and again. It's their second, third, fourth hip dislocation. It's still an urgency. Why? Why do I say that? It's not the femoral head. The femoral head is steel. It's the sciatic nerve. It's your job to steal a line from Kylie Booth to be the soft tissue manager of orthopedic injuries. It's so easy to be seduced by the bone, or in this case, the fake joint. Think about what's around it. Big red, big blue, big yellow. Are they being hurt by this deformity? And so one of the things you really need to check when you put a hip back in, whether it's original equipment or arthroplasty, is sciatic nerve function.
- [68:46]
D
Another thing to mention is if patients have a native hip that's dislocated, Absolutely. As Matt mentions, this is an orthopedic emergency. But about 40% of the time It's a young person, it's good quality bone, and there's some other injury, significant injury from the trauma. So just make sure there's nothing like life threatening. Before you worry. This isn't really even limb threatening. This is actually like femoral head threatening. It's joint threatening more than limb. But when we go through priorities, it's life threatening, limb threatening, and then you go to the wound or the injury. So don't get too caught up with the fact that they've got a really lot of hip pain. Make sure there's nothing life threatening first. Because if it's a native hip dislocation, if it's the hip that the patient's born with, more likely to be a second injury. And if it's a native hip dislocation, there's more likely a fracture attached to it too, which is usually the posterior acetabulum. It's usually not a pure dislocation. So those are things just to keep in mind. There are differences between a native hip dislocation, like a patient's original hip, and a prostatic hip dislocation.
- [69:49]
A
Great point. We now know that it's key to try and get those hip dislocations back in place as soon as possible. And sometimes, unfortunately, it takes forever to get the patient to the X ray. What can we look for on physical exam that makes us know A, that it's dislocated and B, whether it's posterior or anterior dislocated in the shoulder, the
- [70:14]
D
anterior is way more common. Posterior rear, it's flipped around in the, in the hip. So in the hip, which is a way more stable joint than a shoulder anyways. So in general, hip dislocations are very, very uncommon. If one were to have a hip dislocation, almost always it's posterior, rare that it's anterior. Now, what does a posterior hip dislocation look like? The patient's leg is short, it's internally rotated and adducted. So that's what it looks like and it's a posterior hip dislocation. And if it's an anterior hip dislocation, again, way less common for a dislocation to be anterior, It'll be short and externally rotated. Now, the reason this is actually very important to recognize is because if you work rurally and it's three o' clock in the morning and somebody has a hip fracture, you might not call X ray in at three in the morning to like take a picture to say, I'm gonna send it to ortho. You might wait till 7 in the morning. But if this looks like it's a posterior hip, you better call X ray in at 3 o' clock in the morning. And if you see it clinically in an emergency department where you do have X ray, you're right, Anton. A lot of times it can take a while to get an X ray, but if you think it's posterior, you better jump on that and get it done as soon as possible.
- [71:26]
A
Yeah. So I guess the question is, what's the role of CT in the patient who has a hip dislocation both before you reduce it and after you reduce it?
- [71:37]
D
So I would say if you see the hip is dislocated, there really isn't a role for doing it before. It's just going to delay your reduction. So if somebody has a hip dislocation that you can see no problem, there might be a small little. And often, as I just mentioned, with native, with original equipment, hip dislocations, when you have that, there may be an acetabular, that doesn't stop you from doing the reduction. After it's done. Great. The hips back in, blood supply restored to the femoral head, then Ortho might want a CT to actually just outline the anatomy and figure out a management plan. But from an emergency medicine perspective, if the joint is out of place, try to put it back in.
- [72:14]
B
If you have an anterior shoulder dislocation, there's a chance you have a bony bankart lesion. You knock off the anterior rim of the glenoid. The bigger a piece you knock off, the more unstable the joint is, the more likely they need surgical fixation for stability. But that's not an emergency. If you have a posterior ankle dislocation, the talus goes out the back, you're almost always going to knock the posterior mal off. Small piece doesn't need fixation, big piece does. In a hip original equipment, if you have a posterior dislocation, you're going to knock off a little piece of the posterior acetabulum. The bigger the piece, the more unstable, the more likely fixation. These are questions that are not urgent to find the answers to. This is CT post reduction. As one of our surgeons is fond of saying, I really don't want to see imaging of a dislocated joint because that delayed the reduction.
- [73:13]
A
Are there any situations where you're going to take a piece of bone off when the patient has dislocated their native hip that will block you from your attempts to get it back in?
- [73:24]
D
Sure.
- [73:25]
A
You know, and that might be an argument. Well, you Might want to CT before you reduce it. Or is it that, you know, you try and reduce it, it's not going in. This patient needs a ct. Is it, Is that how you think?
- [73:34]
D
It's like any other joint. If you see a fracture dislocation, that's called a complex dislocation. That's more like if you see an elbow with a fracture dislocation, it'll try to reduce it, but it might be more challenging because there could be a bony fragment that stops it. But it doesn't stop you from trying. If you see a trimal or fracture dislocation of the ankle, occasionally that little fragment can stop, can prevent the reduction. And you need an open reduction. Most of the time it'll go back in with the hip. It's a similar thing. If you see a fragment, it doesn't stop you from trying. Just realize it might be a little more challenging to put it back in. The bigger the piece, the more likely it can block. But it shouldn't stop you from trying the procedure.
- [74:10]
B
Yeah. Just keep in mind that clinically the most common cause of an irreducible hip is actually a soft tissue problem. That the femoral head is buttonholed through the posterior capsule and it's constrained, you can't get it back in. And that's the most common reason. Someone's going to have to go to the operating room for an open reduction.
- [74:30]
A
Great to know. Let's talk about reduction techniques. Now. I'll just tell a little funny story that I worked at Janus General once where the orthopedic surgeons were the ones who did all the reductions in the emergency department. And there was a hip dislocation and there were three very large men with huge muscles, which I guess is a bit of a stereotype for orthopedic residents that came down and tried to get this hip back in. And they stood on the patient's gurney and they were pulling and pulling and two of them were pulling in different directions and they couldn't get it in. And then I had just learned about the Whistler technique and I had a nurse come who was maybe 120 pound nurse, put her arm under the patient's knee and then hold on to the contralateral knee and she just gently stood up and clunk. The hip went back in. So since then I've been totally sold on the Whistler technique and it's what I use for every hip dislocation. Anyhow, those orthopedic surgeons at the time, the Whistler technique was just first being talked about and they were humble enough to ask me about this Whistler technique. First of all, what's your go to technique? And if you can't get it in, do you have any tips or tricks to try and get it in?
- [75:56]
B
First of all, I would say the Whistler technique is a modification of the Captain Morgan technique and it's easier for most people to do. And a shout out to the doc who does not want to be named. He's a very humble guy in Whistler emerge who came up with the technique and rather than naming it after himself, notable exception in medicine named it after the facility. And that physician does half his practice with unhoused patients in Vancouver. So he's a good human being. So that's a really effective technique, especially if you're a smaller person. Anton, I forgot the nature of your question because I wanted to recognize the Whistler folks.
- [76:33]
A
Okay, you need more coffee? Hey. All right, Matt. Yeah. So what's your go to technique and if you can't get it in on your first try, what kind of tips or tricks do you have for us?
- [76:46]
B
Well, I would say first of all, I think what is important more than your technique choice is the patient has to be asleep. Make no mistake about it, you're doing a GA in the emergency department. And so your struggle will be with inadequate sedation rather than technique. If you need someone on airway, get someone on airway, ask for help, get some assist in the room. But fundamentally, it's the right dose of ketamine and propofol to get the job done. And fundamentally, if you struggle and you can't get it in, after a couple good faith attempts and maybe changing up your technique, patient needs to go to the operating room and have a real GA and paralysis. And I'm saying that because the muscles that cross this joint are the biggest, biggest muscles in the body.
- [77:29]
D
I'll agree that I've done them before. The ALICE technique, where you're up on the bed and pulling and you're actually worried about your legs slipping and falling off the bed, it's a bit dangerous. If you want to do that technique, it's totally fine. A lot of orthopedic surgeons do it for sure. I would say you put the patient to sleep, log roll them, put them on a spine board, and then put the patient to the ground. You can still monitor their O2 sats, all that stuff, their area from the ground, and you do it standing on the ground and then have a two person technique. Don't do it standing up on a bed where it's more dangerous. That being said, Whistler is my go to technique for sure. I've done a whole whack of them. The old fashioned, the ALICE technique way. And I've done a whole bunch as well. The Whistler technique, it is 20% of the effort of the ALICE technique of standing on the bed and pulling. It's a way easier way. It's more effective. And very similar to your story, Anton, where the orthopedic residents didn't know about this. We had a similar case where I was assisting in the or. A patient had a dislocated hip. It's a prosthetic hip. There were two wonderful orthopedic surgeons there. Like you ever tried the Whistler technique? They go, no, what's that? And they're young grads, like recent grads. And I went and I explained it to them. I said, do you mind if I try? They said, no, I don't mind at all. And the patient didn't even move off the hospital bed. The patient just got put to sleep, was intubated. I went in and tried the Whistler technique. It went in. They're like, wow, we didn't know anything about it. So the Whistler technique is written up in Emerge literature. So that's why also a lot of the orthopedic surgeons don't know about it because it's not in the orthopedic literature. So it's a great technique. One little tip that I found over the years that really helps is that with the Whissler technique, the patient's lying down, the hip is flexed, the knees are flexed, both feet are on the bed, you're on the ipsilateral side, your arm goes underneath the affected knee and onto the contralateral patellar tendon. That helps to stabilize the pelvis. What you do is if on the ipsilateral side, if you push the knee in, what you're doing is when you push the knee out, you're bringing the femoral head out. And where the femoral head gets caught is trying to come around the acetabulum. So if you put the knee in valgus, if you push the knee in, it levers the femoral head out and it makes it easier to clear the acetabulum to get put in. So just that little maneuver of pushing in on the knee helps come around the acetabulum and help with the reduction.
- [79:49]
C
Great.
- [79:50]
A
We'll have some links to some videos on the Whistler technique in the show notes. Let's say you've used your Whistler technique or your Allison technique or whichever technique you want provided really good sedation. And it clunks in. There's high fives all around. What comes next? Matt, could you just tell us a little bit about immobilization, about disposition, et cetera?
- [80:13]
B
Sure. I would say, like every joint reduction that you do, check it for stability. Your job's not done until you check for stability. So you put the hip back in. If you range it gently, you do a little flexion and internal rotation and it literally falls back out again. That's really important information in an arthroplasty patient. That means they probably need a revision. Cup angle, centering force, soft tissue tension. Do they need a constrained unit? These are questions for our colleagues. But the answer to those questions is predicated on you recognizing it's grossly unstable. So stress them first. Once it's in and you're happy with it, you're going to check sciatic nerve function when the patient's awake. That's really important to document. And then what do they need so they're not going to go out again in the next few days? Put a knee immobilizer on them. I think we've collectively put a lot of knee immobilizer hate out into the world because it causes a lot of morbidity and they're overused for a lot of minor knee injuries. But in this case, they really will keep the hip in. Why is that? Why am I putting a knee device on a hip dislocation patient? You have to be able to flex your knee to be able to flex your hip to a critical degree where the hip is in the unstable position. So if you can't flex your knee, you can't flex your hip. Unless you're really good at goose stepping.
- [81:41]
A
All right, excellent. I think we're close to wrapping it up. Any other words of wisdom you have that we haven't hit on yet in terms of hip fractures, hip dislocations, non traumatic hip presentations, Any other last tips, personal experience?
- [81:56]
D
I will tell you that not everybody with a hip fracture presents with hip pain. So I had a patient that had knee pain. It was actually a hip fracture. I missed it. I saw them in the fracture clinic. I sent them out to come back a week later to see an orthopedic surgeon. And when they came back, their leg was shortened, X ray rotated. I asked the patient if they had hip pain. They said no, but they didn't know they had hip pain. So it had referred pain. So it happens. We know it for Slipped capital femoral epiphysis. That it happens. It can happen with osteoarthritis, that they just have distal thigh or medial knee pain. And I missed a patient with a hip fracture. I've seen orthopedic surgeons who have missed hip fractures because the patient had knee pain and bad arthritis on their X ray and didn't examine it. So with older folks, just always remember, examine the joint above and below just to be careful with that. So that's another little thing. It's not, again, not common. But someone says they hurt their knee and you can't reproduce the pain, that's the red flag that it may be from a more proximal source.
- [82:53]
B
Yeah, Anton, I would say look out for this entity that's far more common than we appreciate. And I would say we've all seen it. That's how confident I would be. We've all seen it, whether we recognize it or not. It's the young patient in their 30s or 40s, more male than female, that presents with groin pain and no trauma. And we may go down the road of thinking really broadly and thinking, oh, is this a hernia? Is it an athletic hernia? Do they have a kidney stone? Is it renal colic? But until you examine them, you may not appreciate that the hip is actually the driver of the problem. And what I'm talking about is fai. Femoral acetabular impingement. And the sure sign of this problem in that young person is no internal rotation on the affected side. How can I plant this in your brain for something that you know so well? Frozen shoulder. What's the hallmark of frozen shoulder? No external rotation. And so what's the hallmark of fai? No internal rotation in the hip. Just be on the lookout for it.
- [83:59]
A
Cool. You know, you say I learn something new every day. I'm learning something new every minute. All right? In the hip world, every delay costs mobility and independence and maybe even a life. Slow down, do a careful physical exam, X rays and even CTs are not perfect. Diagnose efficiently, get that hip block in early, and reduce that dislocation confidently. That's how we change outcomes for these patients. Thank you very much, gentlemen. That was. I might get a bit thicklempt here because it can't be our last podcast. Like I said at the top, we're gonna have to come up with some reason to get you guys back here. Even though we've come covered just about every orthopedic emergency there is, we're going
- [84:42]
D
to make up a new joint. Okay, thank you very much.
- [84:48]
B
Thanks for having us, Anton. Pleasure.
- [85:05]
A
Sa.