Pelvis and Lower Extremity Reduction

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Chapter 11 Pelvis and Lower Extremity Reduction

Pelvis reduction

Overview

1. Application of a pelvic binder is a key step in the initial management of an unstable pelvic fracture.
2. Commercial pelvic binders are available, or a simple bed sheet may be used as a pelvic binder.
3. Venous bleeding is the most common cause of hemorrhage in a patient with hemodynamic instability and an unstable pelvic fracture.
4. By applying a binder, stability is provided to the fracture, allowing tamponade and organization of the hematoma.

Indications for Use

Unstable “open book” pelvic injury (Tile B injury or anterior-posterior compression [APC] II or III injuries)

1. Note that placement of a pelvic binder is not contraindicated in a patient with a lateral compression–type injury.
2. The benefit of using a pelvic binder for a lateral compression–type injury is not likely to be as great as for an open book pelvic injury.

Precautions

1. Close coordination with the trauma team and trauma anesthesiologist is mandatory.
2. Perform a careful physical examination before applying a binder. Determine if the fracture is open or closed.
3. Correct placement of a pelvic binder is vital for it to function properly.

a. The binder should be centered around the greater trochanters.
b. The binder should not be centered at the patient’s waist.

Pearls

1. Although commercial binders are easier to apply than a bed sheet, not all emergency departments are equipped with commercial binders, so it is important to know how to use both a commercial binder and a bed sheet.
2. Place a towel over the perineal area to protect the structures therein.
3. After a commercial binder or a bed sheet is placed, postreduction radiographs are mandatory.
4. If the sheet will be used for more than emergent stabilization, use two to four towel clips rather than tying the sheet to prevent loosening and pressure necrosis.

Equipment

1. Two people are required to reduce the pelvis and apply a binder appropriately (not shown).
2. Commercial pelvic binder (Figure 11-1) or a bed sheet
3. Towel clamps, Kelly forceps, or other large clamps
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Figure 11-1

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Greater trochanters
b. Anterior superior iliac spines (ASIS)

3. Steps:

a. Position the patient.
b. Palpate landmarks.
c. Roll the patient.
d. Reduce the pelvis.
e. Place the commercial binder or bed sheet.

Detailed Technique

1. Position the patient.
2. Palpate landmarks; feel both greater trochanters and ASIS (Figure 11-2).
3. Roll the patient. A standard trauma log-roll technique should be used to place the commercial binder or bed sheet under the patient (Figure 11-3), with additional people at the legs and the head.
4. If a bed sheet is being used, place it as widely as possible over the greater trochanter and ASIS.

a. Reduce the pelvis by applying an inward force.
b. Use towel clips if available, If not, tie a very tight knot around the pelvis and add a second square knot (Figure 11-4).

5. Procedure for placing a commercial binder:

a. Wrap the binder around the patient (Figure 11-5).
b. Ensure correct placement. The binder must be centered on the greater trochanters.
c. Trim any excess (Figure 11-6).
d. Reduce the pelvis by applying an inward force.
e. Pull the cords to tighten the binder (Figure 11-7).

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Figure 11-2

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Figure 11-3

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Figure 11-4

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Figure 11-5

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Figure 11-6

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Figure 11-7

Hip reduction

Overview

1. Numerous maneuvers have been described for reduction of dislocated hips.
2. All maneuvers basically function to recreate the deforming force.

a. Posterior dislocations (Figure 11-8): flexion, adduction, and internal rotation
b. Anterior dislocations: abduction and external rotation in extension

3. The incidence of dislocated hips is much higher in patients with hip arthroplasty compared with patients who do not have hip arthroplasty.
4. The vast majority of hip dislocations are directed posteriorly.
5. Relocation of hips can be difficult because of the significant muscular and ligamentous impediments inherent to the joint.
6. In patients with traumatic dislocations, relocation is easier because of the associated posterior wall acetabular fracture.
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Figure 11-8

Indications for Use

Posterior hip dislocation using the modified Bigelow technique

Precautions

An assistant is required for the modified Bigelow to apply countertraction.

Pearls

Conscious sedation is virtually mandatory in most patients. The typical exception to this rule is a patient with a total hip arthroplasty whose hip becomes dislocated on a chronic basis.

Equipment

Bed sheet

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Anterior superior iliac spine
b. Greater trochanters

3. Steps:

a. Obtain conscious sedation.
b. Position the patient.
c. Perform a reduction maneuver.
d. Apply an abduction pillow.

Detailed Technique

1. Obtain conscious sedation.
2. Position the patient. The patient should be completely supine.
3. Tie a bed sheet loosely around your waist (Figure 11-9).
4. Perform a reduction maneuver:

a. The surgeon mounts the stretcher and straddles the affected extremity between his or her legs (Figure 11-10).
b. The patient’s knee is flexed to 90 degrees, and the hip is also flexed to 90 degrees.
c. The surgeon’s arms are locked together under the knee.
d. An assistant applies countertraction via the ASIS (Figure 11-11).
e. The surgeon applies an upwardly directed force.
f. The hip is then adducted.
g. The hip is then internally rotated (Figure 11-12).
h. Once the hip is reduced in this position:

(1) Maintain traction and externally rotate and abduct the hip.
(2) Bring the hip into extension.
(3) Apply an abduction pillow if appropriate.

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Figure 11-9

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Figure 11-10

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Figure 11-11

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Figure 11-12

Knee reduction

Overview

1. Dislocation of the knee is associated with a high incidence of associated vascular and nerve injuries. The popliteal artery and peroneal nerve are most commonly injured.
2. The overall management of a patient with a knee dislocation is of paramount importance compared with the actual reduction maneuver.

a. Many knee dislocations can be reduced easily.
b. Posterolateral dislocations occasionally cannot be reduced via closed methods and require open reduction.

3. The reduction maneuver is essentially longitudinal traction along with a reversing of the direction of the dislocation.

Indications for Use

Knee dislocation (Figure 11-13)

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Figure 11-13

Precautions

1. A thorough clinical examination must be undertaken before reduction and immediately thereafter.
2. Examine the limb for motor strength, sensation, pulses, and capillary refill.
3. Altered sensation that occurs only over the dorsum of the foot suggests a neurologic injury.
4. Altered sensation in the calf and entire foot (a “stocking type” distribution) suggests a vascular injury.
5. Some surgeons recommend arterial-brachial index (ABI) measurements.
6. If the ABI is less than 0.9, then arteriography is recommended.
7. Other surgeons suggest that if a knee requires reduction, an arteriogram should be performed without regard to ABI measurement.
8. During the reduction, do not place pressure over the popliteal fossa.
9. Postreduction radiographs must be obtained.

Pearls

A dislocated knee is a true orthopedic emergency.

Equipment

Knee immobilizer

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Patella
b. Tibial tuberosity
c. Femoral condyles

3. Steps:

a. Position the patient.
b. Obtain a physical examination.
c. Perform a reduction.
d. Perform a postreduction physical examination.
e. Proceed with neurovascular management.

Detailed Technique

1. Position the patient supine on a stretcher.
2. Perform a physical examination:

a. Check motor strength, sensation, pulses, and capillary refill.
b. Examine the popliteal fossa for an expanding hematoma.
c. Determine what direction the dislocation is in.

3. Perform a reduction:

a. Stabilize the femur.
b. Apply longitudinal traction via the tibia (Figure 11-14).
c. Apply a reversing force to the direction of dislocation also via the tibia (Figure 11-15).
d. Typically the knee will reduce.

4. Perform a postreduction physical examination.
5. Place a knee immobilizer at 15 degrees of knee flexion (Figure 11-16).
6. Proceed with neurovascular management.
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Figure 11-14

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Figure 11-15

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Figure 11-16

Ankle fracture reduction

Overview

1. The majority of ankle fractures are fractures of the supination, external-rotation type.
2. The traction reduction method is based on a modification of the reduction maneuver described by Quigley.
3. The principle is to elevate the limb in such a way that the ankle falls into a pronation, internal rotation position.
4. A manual reduction technique can be performed if traction is unavailable or not desired.

Indications for Use

Supination external rotation ankle fractures (Figure 11-17) or fracture dislocations

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Figure 11-17

Precautions

1. Do not use an intravenous (IV) stand attached to the ceiling unless it is specifically designed to handle large weights.
2. Ensure that the IV pole is safely secured to the bed.
3. In some cases, the IV pole can be wedged in behind the wheels of the bed.
4. In other cases, heavy tape must be used to secure the IV pole to the bed.
5. Heavy weights should be placed on the IV pole stand.

Pearls

1. Perform an intra-articular ankle block prior to performing this maneuver (see Chapter 7).
2. Many patients will require conscious sedation.
3. Be patient! This maneuver may require several minutes to become effective. The patient will naturally attempt to counter the forces and only time will result in muscle fatigue, causing relaxation and allowing reduction.
4. Forewarn patients that their toes may hurt more than their ankles by virtue of the toe traps. Also inform them that the toes will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the toe traps are removed.

Equipment

1. If using traction:

a. 2-inch rolled gauze
b. IV pole
c. Weights

2. Supplies for an AO splint (see Chapter 14)

Basic Technique: Traction

1. Patient positioning:

a. Supine on stretcher
b. IV pole secured at head of bed on contralateral side

2. Landmarks:

a. Malleoli
b. Calcaneus

3. Steps:

a. Set up the equipment.
b. Position the patient.
c. Perform an intra-articular ankle block.
d. Attach toe traps.
e. Elevate the limb.
f. Await reduction.
g. Apply a splint.

Detailed Technique: Traction

1. Set up the equipment:

a. Place an IV pole at the head of the patient’s bed.
b. The IV pole should be toward the opposite side of the injury.
c. Securely fasten the pole to the bed either by wedging it in between the wheels and the handles or by using heavy tape.
d. Ensure that the IV pole has the ability to be raised and lowered.

(1) Completely lower the IV pole.
(2) If the IV pole cannot be raised and lowered, ensure it is at a height that will allow elevation of the limb.

2. Position the patient.
3. Perform an intra-articular ankle block. Inject the ankle with lidocaine and ropivacaine (see Chapter 7).
4. Attach toe traps.
5. Attach the stockinette to your finger using a dual-ring construct:

a. Make a loop of stockinette (Figure 11-18).
b. Place the loop between the web space of the hallux and second toe.
c. While holding one side of the stockinette taut, place your other hand into the loop.
d. Spread your fingers and pull upward.
e. Hook each side around the hallux and second toe (Figure 11-19).
f. Pull the free end so it is taut.

6. Elevate the limb:

a. Take the free end of the stockinette and pull it so it is taut.
b. Secure the stockinette to the top of the IV pole.
c. Raise the IV pole to elevate the limb (Figure 11-20).

7. Await reduction. Wait 2 to 5 minutes.
8. Apply a splint.
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Figure 11-18

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Figure 11-19

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Figure 11-20

Basic Technique: Manual Reduction

1. Patient positioning:

a. Supine or sitting on stretcher with the knee and lower leg off the table

2. Landmarks:

a. Malleoli
b. Calcaneus

3. Steps:

a. Set up equipment.
b. Position the patient.
c. Perform an intra-articular ankle block.
d. Perform a reduction maneuver if necessary.
e. Apply a splint while an assistant holds the reduction.
f. Apply a mold.

Detailed Technique: Manual Reduction

1. Position the patient.
2. Perform an intra-articular ankle block. Inject the ankle with lidocaine and ropivacaine (see Chapter 7).
3. Cup the heel with your hand and place your other hand on the subcutaneous portion of the mid tibia while resting the ball of the foot on your thigh (Figure 11-21); alternatively, use your forearm to maintain a plantigrade foot position (Figure 11-22).
4. Have an assistant hold the reduction by pulling up on the great toe and maintaining traction (if an assistant is not available, perform the reduction maneuver after the splint is applied but before it is set).
5. Apply an AO splint (see Chapter 14).
6. Perform a reduction maneuver as previously described to apply a mold.
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Figure 11-21

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Figure 11-22

Subtalar dislocation

Overview

1. Subtalar dislocations are rare and typically cause marked deformity of the foot.
2. The majority of dislocations are medial and are caused by forceful inversion of the plantarflexed foot.
3. The reduction maneuver is longitudinal traction, exaggeration of the deformity, and subsequent reversing of the direction of dislocation.

Indications for Use

Subtalar dislocation (Figures 11-23 and 11-24)

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Figure 11-23

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Figure 11-24

Precautions

1. Because subtalar dislocations have a high rate of associated injuries, a computed tomography scan should be obtained after the reduction.
2. Approximately one third of medial dislocations and half of lateral dislocations cannot be closed in a reduced manner. Excessive attempts at reduction should be avoided.

Pearls

1. An assistant should be used to keep the hip and knee flexed so as to relax the pull of the gastrocnemius.
2. Conscious sedation is virtually mandatory in most patients.
3. Typically, a pop or clunk signifies successful reduction.

Equipment

None

Basic Technique

1. Patient positioning:

a. Supine on stretcher

2. Landmarks:

a. Medial and lateral malleoli
b. Calcaneus

3. Steps:

a. Obtain conscious sedation.
b. Position the patient.
c. Perform a reduction maneuver.

Detailed Technique

1. Obtain conscious sedation.
2. Position the patient. The patient should be completely supine.
3. Perform a reduction maneuver:

a. The patient’s knee is flexed to 90 degrees and the hip is also flexed to 90 degrees by an assistant. Countertraction should be held above the ankle.
b. Medial dislocation:

(1) The surgeon should grasp the calcaneus with his or her dominant hand and place the opposite hand over the dorsum of the forefoot (Figure 11-25).
(2) The surgeon pulls longitudinal traction with the assistant holding countertraction.
(3) The position of the foot should be exaggerated by hyperinverting and plantarflexing the foot while maintaining longitudinal traction (Figure 11-26).
(4) The foot can then be everted and dorsiflexed to achieve reduction (Figure 11-27).

c. Lateral dislocation:

(1) The surgeon should grasp the calcaneus with his or her dominant hand and place the opposite hand over the dorsum of the forefoot with a thumb over the navicular.
(2) The surgeon pulls, providing longitudinal traction, while an assistant provides countertraction.
(3) The position of the foot should be exaggerated by hypereverting and abducting the foot while maintaining longitudinal traction.
(4) The foot is inverted with plantarward and medialward pressure applied by the thumb to achieve reduction (Figure 11-28).

4. Splint the extremity with a posterior splint or an AO splint (see Chapter 14).
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Figure 11-25

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Figure 11-26

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Figure 11-27

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Figure 11-28

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Intra-articular Ankle Block Hematoma Block Basic Principles of Analgesia Calcaneal Skeletal Traction Forearm, Wrist, and Hand Reduction Lower Extremity Splints and Casts