Put In Her Place

   It's a beautiful summer day, and the athletes are out in large numbers. The crew of Attack One has been out for several sports injuries throughout the day, including one young softball player who slid into a base and dislocated his ankle. At the ED, the crew watched an emergency physician quickly reduce the ankle back into position, and the patient's pain rapidly resolve.

   This provided an opportunity for the physician to discuss a variety of bone and joint injuries and provide some education for the crew on placing joints back into position. As they reviewed the joints of the lower extremities, the physician explained that ankles and wrists are difficult to reduce, and frequently require putting the patient to sleep. Dislocations of the knees and elbows are very dangerous, and frequently injure the arteries that run through those large joints. Dislocations of the hips are of two types: the high-risk, high-impact injuries from vehicle accidents or falls (these usually require the operating room) and, more frequently, hip dislocations in patients who are older, have artificial hips in place, and typically have had such dislocations before. These are usually very easy to reduce in the emergency department.

   The easier joints to reduce are those of the shoulders, kneecaps, fingers and toes. These are frequently reduced by patients on their own.

   After a good lesson in these injuries, the rest of the day is full of broken bones…until the 4 o'clock call. At that point Attack One responds to an injury at a soccer complex where a big tournament is taking place. They are not directed to the fields, however, but instead stopped out in the parking lot. They find a young woman lying at the back of a minivan, obviously in a great deal of pain. She is dressed in a soccer outfit, her right leg is flexed, and she is beating the ground with her hands in agony.

   Her coach tells the story: The team had played all weekend and won the tournament. They were loading their equipment into the van to head to the airport to fly home. The 15-year-old patient placed her bag in the rear of the van, and when she twisted her body to back away, her patella dislocated. It had happened twice before, and each time the pain was excruciating. No direct trauma had occurred to the knee, either at the time of the injury or over the rest of the weekend.

   The other players are trying to comfort the young lady, telling her they all made it through the entire weekend of play without an injury. "How can we explain you got hurt loading your bag into the car on the way to the airport?" one asks, trying to raise her spirits.

   The crew members find the patient's vital signs to be stable, and there is no obvious injury to the knee or anything else. But her right patella is out of place, and located on the lateral surface of the groove in the femur where it should be. Her knee is flexed at 90 degrees, and she is in extreme pain. Her distal pulses, capillary refill, movement and sensation are all intact. The pulse oximeter placed on her great toe gives a reading of 99%.

   The coach pleads with the crew to make her more comfortable and try to expedite her care. The team's plane is leaving in 90 minutes, and the coach will have to make arrangements to stay with the girl at the hospital and send the rest of the team home with someone else. Some of the parents are already trying to check on flights for the two of them the next morning.

   The Attack One paramedic places a quick call to the same emegency department where the physician had been teaching the crew earlier in the day. She finds the physician still on duty, and asks him to take a call regarding the care of this patient.

   She describes the injury and the tight timeline for the team's travel. The physician asks if the medic would be comfortable reducing the dislocation herself, and the paramedic willingly agrees. The patella had been dislocated without direct trauma, and had been dislocated in the past. That history allows the physician to be comfortable guiding the paramedic on reducing the dislocation without getting an x-ray.

   The physician instructs the paramedic to quickly ask the patient and coach if they are agreeable to treatment of the injury there in the parking lot, which would allow more rapid control of the pain. Both agree, and the patient is particularly supportive of the plan.

   The physician tells the paramedic that she will essentially allow the patella to reduce itself back into its normal position. "Place your fingers on the sides of the kneecap," he says. "Slowly move the lower leg from its flexed position outward, until it is extended completely, and the kneecap will slide right back into position. Stop if the patient reports any severe pain."

   The paramedic tells the patient what she's going to do, and then carries out the procedure as instructed. The patient had gone down with the knee flexed to about 90 degrees. As the paramedic and patient slowly move the knee to full extension, the patella wants to slide back into the middle of its anatomic groove, and the paramedic guides it back to that position. The patient lets out a shriek of glee and reports immediate relief of her pain.

   The physician then asks the medic to have the patient flex her knee to about 15 degrees, which would allow the patella to stay in place in the normal position. The paramedic checks the kneecap and finds no tenderness, and the patient has normal neurovascular status below the knee. No other injuries are found.

   The patient is supported a little as she gingerly places some weight on the leg and takes a few tentative steps. At that point she says the knee feels exactly like normal, and asks if she still has to go to the hospital.

   The physician and paramedic converse, and they agree that at this point the emergency is completely resolved. If the coach agrees and a parent can be contacted for proper consent, the patient can be released for treatment back in her hometown. The patient is already working on that arrangement, and reaches her parents by cell phone at home. She describes what happened, then hands the phone to the paramedic. The parents request their daughter be released with the coach, and they will have her follow up at home with the sports medicine physician who provided care after her prior dislocations. For now the patient will only need treatment with some cold packs and an Ace wrap, and instructions to not hyperextend or twist the knee, lest it dislocate again. If any other problems occur, the patient or coach will contact 9-1-1 or go to an emergency department.

   The emergency physician approves this disposition, and soon the patient and her team are headed to the airport. The Attack One crew completes documentation on the incident, obtains signatures from the patient and coach, and returns to service. On phone follow-up later, the patient reports she did fine on the trip, and the sports medicine physician is having her do quadriceps-strengthening exercises in hopes of decreasing the patella's tendency to dislocate.

Case Discussion

   This patient had a relatively common joint problem that can be managed quickly and easily in many patients. This case demonstrated care of that dislocation, and the immediate relief of pain that comes from placing the patella back into its normal position.

   Training and protocols developed with EMS medical direction will allow prehospital providers to have effective approaches to patients with fractures, dislocated joints and other orthopedic and sports-related emergencies. Reducing dislocations requires specific training on each joint. Worth discussion with medical direction: Dislocations of patients' patellas, fingers and toes. Some patients with recurrent hip and shoulder dislocations can almost reduce the problem themselves with a little help from EMS.

   Very dangerous dislocations occur to the knee itself, elbow, ankle, and wrist, and prehospital providers will need to immobilize these and provide pain relief and rapid transportation. First-time shoulder or hip dislocations are also dangerous and not generally amenable to prehospital reduction.

Initial Assessment

   A 15-year-old girl with a dislocated right kneecap, without a direct blow to the knee.

   Airway: Intact and uncompromised.

   Breathing: No distress, can speak in full sentences.

   Circulation: Normal capillary refill, pink skin.

   Disability: No neurologic deficits.

   Exposure of Other Major Problems: No other injuries. The skin over the knee is intact, and distal pulses, movement and sensation are all normal.

Vital Signs

AMPLE Assessment

   Allergies: None.

   Medications: None.

   Past Medical History: Patient has had this same patella dislocation twice in the past, both times without direct injury.

   Last Intake: Around 11:30 a.m.

   Event: Dislocated right patella.

   Customer Service Opportunity: The athlete or any other member of a youth group who requests emergency care through 9-1-1 should be evaluated promptly, and any emergency medical conditions found should be treated expeditiously. Following the treatment of any emergencies, EMTs will need to determine if parents or other adults in the group have responsibility to consent for any nonemergency treatment. Hospital staff will need to talk with a parent or guardian to be able to provide any elective medical care once the emergency has been stabilized. Emergency medical care cannot be delayed to await consent from an adult who is not present.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.