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Patients present with hip pain and how you approach a patient should be methodical. Matt and Sarah discuss a step by step approach to hip pain, including how to evaluate intra-articular and extra-axial causes of hip pain and how to evaluate for referred pain as well.
Tom G. - September 6, 2016 12:37 AM
By way of introduction, I am an EP at a major teaching hospital in Canada, and am a fellowship trained sports medicine doctor.
First I will say nice summary and review for ED docs. I am liking the series on MSK injuries. In my experience, we can do a much better job with non fracture MSK injuries, so these reviews are awesome.
I agree with Mel that it is well outside the scope of the ED doc to aspirate a hip!!!
If I could make one comment. I was surprised in the treatment section of the discussion that the only thing that came up was NSAIDs. In my practice, physiotherapy is a mainstay of soft tissue hip injuries. In fact, this includes the management of symptomatic femoroacetabular impingement and labral tears which, like meniscus tears in the knee, should initially be treated with rehab and physio. I often hear my residents advising patients to go and see their family doctors who can then refer to physic if appropriate...... When they work with me, they do this at their peril.
Thanks for your work
Abe S. - September 10, 2016 7:58 AM
Can anyone speak more to the management with some of these pains. Would you recommend mostly using NSAID's and referral to PT or is there more we can do for them in the ED? For a bursitis, what about doing an injection and if so what would you use?
Matthew D. - September 10, 2016 11:34 AM
There doesn't seem to be great data in terms of which analgesic may be most effective. NSAIDs are a decent option, and recently there has been decent data supporting topical NSAIDs, which appear to offer similar pain relief with a lower rate of serious side effects.
I'm not sure how many folks out there are injecting the trochanteric bursa in the ED. Anecdotally I know of a few family medicine trained docs who are comfortable with this injection, but I couldn't find much in the ED literature to support or refute this practice. Interestingly there is some data to suggest that providers may not be too accurate when trying to blindly inject bursa.
http://bja.oxfordjournals.org/content/94/1/100.full.pdf
David G. - September 29, 2016 10:38 PM
I think Mel may have overreacted a bit to Dr. Gould's suggestion that aspirating a hip was inside our scope of practice. Just because most EPs aren't comfortable with the procedure, doesn't mean it's completely outside our scope of practice. Like any procedure, if you haven't been trained to do something, it might not be the best idea to try it. But for those EPs that are trained in a procedure like this, I think it is perfectly fine to stretch what many consider the "Scope of practice" in the ED. There are WAY more difficult and dangerous procedures we attempt with more regularity.
For full disclosure, I am fellowship trained in Sports Medicine and also an RDMS "ultrasound nerd", and now I work in a single-coverage critical access hospital that can no longer afford an orthopedic surgeon on staff. So some of us out here in the boonies don't have Ortho or IR to come do procedures like these. And if a hip needs diagnostic aspiration, it needs diagnostic aspiration.
Basically, I agree that hip aspiration might not be in the comfort zone for many EPs. But I would argue that 1) EPs can be trained in this, and 2) if properly trained and/or in the right circumstance, this definitely could be in the "scope of practice" for EPs.
Matthew D. - September 30, 2016 8:38 AM
David,
I think you're right on.
It certainly seems like aspirating a hip could be something we could add to our skill set, but as Mel said I think its really important that folks who don't have your skill set take the right steps in terms of training and credentialing before jumping in to this procedure. You make a good point about working in a critical access hospital, as it would be difficult and arguably reckless to transfer every patient that needs a procedure that you can competently perform in the ED. I think scope of practice varies from department to department, and for anyone going to a new shop its worth talking with people and trying to get an idea of what falls into the "scope" of that particular department.
Erik A. - December 14, 2016 11:47 PM
I agree with David G. I was surprised at how big of a deal this procedure was made out to be. Doing a hip aspiration with ultrasound is very easy, and if you are not at a large medical center it is very difficult find someone to do this. I also work at a single coverage rural hospital without orthopedics and transferring someone for this simple procedure is a huge burden on families.
Here is an ACEP now article about how to do this:
http://www.acepnow.com/article/bedside-ultrasound-septic-hip/