dislocations out of joint in the ed. overview joint dislocations require prompt and effective care...

Dislocations Dislocations

Out of Joint In The EDOut of Joint In The ED

OverviewOverview

• Joint dislocations require prompt and Joint dislocations require prompt and effective care in the Emergency Departmenteffective care in the Emergency Department

• Objectives:Objectives:• Discuss several techniques for shoulder Discuss several techniques for shoulder

reductionsreductions• Discuss Hip dislocations/reductionDiscuss Hip dislocations/reduction• Management and complications of knee Management and complications of knee

dislocationdislocation• Elbow dislocations and techniques for Elbow dislocations and techniques for

reductionreduction• Patellar dislocationPatellar dislocation

Shoulder DislocationsShoulder Dislocations

50% percent of all major joint dislocations 50% percent of all major joint dislocations Anterior most common 95-97%Anterior most common 95-97% Posterior 2-4%Posterior 2-4% Inferior ( luxatio erecta-which means “ to place Inferior ( luxatio erecta-which means “ to place

upward”)upward”)

Anatomy: shoulder is an inherently unstable joint.Anatomy: shoulder is an inherently unstable joint. Glenoid is shallow-allows for wide range of movementGlenoid is shallow-allows for wide range of movementLabrum fibrocartilaginous structure surrounds glenoid inserts Labrum fibrocartilaginous structure surrounds glenoid inserts

into edge of joint capsuleinto edge of joint capsule

• Inferoglenohumeral ligament :anterior/inferior Inferoglenohumeral ligament :anterior/inferior portion of the capsule..thicker than the others portion of the capsule..thicker than the others and provides strongest support against and provides strongest support against dislocationdislocation

• Rotator cuff muscles provide additional support:Rotator cuff muscles provide additional support:• subscapularis lies anteriorsubscapularis lies anterior• supraspinatus/infraspinatus/Teres minorsupraspinatus/infraspinatus/Teres minor• (SITS) lie posterior “pull” humeral head into (SITS) lie posterior “pull” humeral head into

glenoid glenoid

• Axillary nerve most commonly Axillary nerve most commonly injured nerve in shoulder dislocationsinjured nerve in shoulder dislocations

• Runs inferior to humeral head.Runs inferior to humeral head.

• Innervates deltoid, teres minor—Innervates deltoid, teres minor—Shoulder badge” distributionShoulder badge” distribution

Types of Shoulder Types of Shoulder dislocationsdislocations• Anterior- majorityAnterior- majority

• subglenoid 30%subglenoid 30%

• subcoracoid 70% subcoracoid 70%

• Very rare infraclavicularVery rare infraclavicular

• Mechanism: usually caused by a blow or Mechanism: usually caused by a blow or force to abducted externally rotated and force to abducted externally rotated and extended arm… Think blocking a basketball extended arm… Think blocking a basketball shotshot

• Also fall on outstretched armAlso fall on outstretched arm

• Mechanism of DislocationMechanism of Dislocation

• Sports/ trauma ectSports/ trauma ect

ExaminationExamination• Anterior dislocation arm slightly Anterior dislocation arm slightly

abductedabducted

• Externally rotated .Pt resists all Externally rotated .Pt resists all movement. Loss of normal rounded movement. Loss of normal rounded appearance appearance

• Typical apperanceTypical apperance

• Arm abducted/ extArm abducted/ ext

• rotationrotation

• Posterior Posterior • Less common 3-5 %Less common 3-5 %• May be difficult to diagnose-may miss on up to May be difficult to diagnose-may miss on up to

50% standard ap view as findings subtle50% standard ap view as findings subtle

• Commonly assoc with greater tuberosity/surgical Commonly assoc with greater tuberosity/surgical neck fx’s can cause a reverse hills sachs deformityneck fx’s can cause a reverse hills sachs deformity

• If plain X rays indeterminate can use CTIf plain X rays indeterminate can use CT• CT also aids ortho as to who needs ORCT also aids ortho as to who needs OR• As % articular surface involved changes careAs % articular surface involved changes care

Exam post shoulder Exam post shoulder dislocationdislocation

• Fullness posteriorly. Somewhat Fullness posteriorly. Somewhat squared off shoulder. Marked squared off shoulder. Marked decreased romdecreased rom

• Helpful radiographic signsHelpful radiographic signs• Lightbulb sign-humeral head internally Lightbulb sign-humeral head internally

rotated. tuberosity no longer project laterally( rotated. tuberosity no longer project laterally( circular look to HH)circular look to HH)

• Rim sign- refers to distance from medial Rim sign- refers to distance from medial aspect of humeral head to ant glenoid rimaspect of humeral head to ant glenoid rim

• If superimposed or widened joint space If superimposed or widened joint space >6mm>6mm

• Suspect post dislocationSuspect post dislocation

• Trough line signTrough line sign

• 2 parallel lines of cortical bone are 2 parallel lines of cortical bone are seen on medial cortex of HH,one line seen on medial cortex of HH,one line is medial cortex of HH other line is is medial cortex of HH other line is “trough of impaction fx ( reverse hill “trough of impaction fx ( reverse hill sachs) anterior articular surface of sachs) anterior articular surface of HHHH

• lightbulblightbulb

• RimRim

• troughtrough

• Mechanism: Mechanism:

• electric shockelectric shock

• seizuresseizures

• trauma ( alchoholics) trauma ( alchoholics)

• Internal rotation/adduction/flexion Internal rotation/adduction/flexion

• posteriorposterior

• Post dislocationPost dislocation

• posteriorposterior

• Reverse hill sachsReverse hill sachs

• Post/ reverse hill sachsPost/ reverse hill sachs

• Post dislPost disl

• Luxatio erectaLuxatio erecta

• Very rare .5 %Very rare .5 %

• Mechanism axial loading foreceful Mechanism axial loading foreceful hyperabduction.hyperabduction.

• Pt falls grasping object above their headPt falls grasping object above their head

• Arm locked in abduction often fore arm Arm locked in abduction often fore arm resting on headresting on head

• 60% of pts have some neurologic 60% of pts have some neurologic dysfunctiondysfunction

• Neurovascular exam-check distal Neurovascular exam-check distal pulses/axillary nerve function:some pulses/axillary nerve function:some dysfunction in 42% of cases( almost dysfunction in 42% of cases( almost all recover)all recover)

• Cant check deltoid teres minor motorCant check deltoid teres minor motor• Can check sensationCan check sensation• Think security guard/ arm forces Think security guard/ arm forces

patch location for axillarypatch location for axillary

Axillary nerve palsyAxillary nerve palsy

• Radial Radial

• Dorsal hand sensation web spaceDorsal hand sensation web space

• Wrist dropWrist drop

• Wrist dropWrist drop

• Radiographic evaluationRadiographic evaluation• Excludes fractures/confirms Excludes fractures/confirms

dislocation/confirms reductiondislocation/confirms reduction• Clinically important fx’s can occur up to 25%Clinically important fx’s can occur up to 25%• Assoc factors : age >40Assoc factors : age >40• 11stst time dislocation time dislocation• traumatic dislocationtraumatic dislocation• If all 3 absent can safely skip prereduction If all 3 absent can safely skip prereduction

xrayxray• ( 96% negative prediction value) ( 96% negative prediction value)

• Routine filmsRoutine films

• AP AP

• Scapular Y viewScapular Y view

• Axillary viewAxillary view

• AP viewAP view

• Y viewY view

• Beam directed parallel to scapular body.Beam directed parallel to scapular body.

• Y formed by body/spine and the Y formed by body/spine and the coracoid process. Glenoid fills in center coracoid process. Glenoid fills in center of Y( normally obscured by humeral of Y( normally obscured by humeral head )head )

• With a dislocation Humeral head With a dislocation Humeral head appears medial to glenoidappears medial to glenoid

• Y viewY view

• Y viewY view

• Ap viewAp view

• Y view dislocationY view dislocation

• Axillary view Axillary view

• Taken with arm abducted plate on Taken with arm abducted plate on shouldershoulder

• Axillary viewAxillary view

• Ax view dislocationAx view dislocation

associated fracturesassociated fractures

• Hill Sachs- cortical depression of humeral Hill Sachs- cortical depression of humeral head from glenoid rimhead from glenoid rim

• Bankart lesions- Glenoid labrum disruptionBankart lesions- Glenoid labrum disruption

• bone frag/avulsion may be seenbone frag/avulsion may be seen

• Greater tuberosity fx’s– up to 10%Greater tuberosity fx’s– up to 10%

• Hill sachsHill sachs

• Bankart lesionBankart lesion

• bothboth

You Know its OutYou Know its Out

• Now What?Now What?• Reduction proceduresReduction procedures• Informed consent risk minimal. rare incidence Informed consent risk minimal. rare incidence

of fractures. axillary artery/nerve injury rare of fractures. axillary artery/nerve injury rare but may occur(esp with more forceful but may occur(esp with more forceful techniques.)techniques.)

• Materials needed noneMaterials needed none• bedsheet/ assistantbedsheet/ assistant• 10-15lb weight for stimson10-15lb weight for stimson• Conscious sedation /Pain management Conscious sedation /Pain management • Operators preferred methodOperators preferred method

• None to complete procedural sedation:None to complete procedural sedation:• Fentanyl/versed/ms/ketamine etomidate/propofolFentanyl/versed/ms/ketamine etomidate/propofol• Intrarticular injection:Intrarticular injection:• Safe avoids complications of sedation/pts with Safe avoids complications of sedation/pts with

significant comorbiditiessignificant comorbidities• 20ml syringe20ml syringe• inject 20ml 1%lidocaine.lateral approach inject 20ml 1%lidocaine.lateral approach

best. Identify acromion process over lat aspect of best. Identify acromion process over lat aspect of shoulder 1cm inferiorshoulder 1cm inferior

• 18 or 20guage direct needle medially and 18 or 20guage direct needle medially and inferiorly to depth of2.5 cm/3.0 cm( CAN USE US inferiorly to depth of2.5 cm/3.0 cm( CAN USE US GUIDANCE)GUIDANCE)

• Intraarticular injectionIntraarticular injection

Reduction TechniquesReduction Techniques

• No clear evidence supports one method over No clear evidence supports one method over another….clinical preferenceanother….clinical preference

• Anterior Shoulder Dislocations:Anterior Shoulder Dislocations:• Try least Traumatic FirstTry least Traumatic First• Scapular manipulationScapular manipulation• Pt prone on stretcher with arm hanging, or sitting upPt prone on stretcher with arm hanging, or sitting up• Rotate inferolateral aspect of shoulder upward Rotate inferolateral aspect of shoulder upward

towards midlinetowards midline• Can modify by pulling arm down by assistant or Can modify by pulling arm down by assistant or

weightsweights

• Sitting scapularSitting scapular

• RotationRotation

• ProneProne

• Can pull downCan pull down

• Or use weightOr use weight

• External rotationExternal rotation• ““Hennepin technique” 80-90 % successHennepin technique” 80-90 % success• Pt supine on stretcherPt supine on stretcher• Hold elbow at pts side flexed 90 degreesHold elbow at pts side flexed 90 degrees• SLOWLY externally rotate shoulderSLOWLY externally rotate shoulder• Have pt try to relax and let arm fall to sideHave pt try to relax and let arm fall to side• Reduction achieved by overcoming spasm of Reduction achieved by overcoming spasm of

internal rotatorsinternal rotators• When pain or spasm occurs stop allow pt to relaxWhen pain or spasm occurs stop allow pt to relax• Usually reduction occurs at 70-110 degreesUsually reduction occurs at 70-110 degrees• Can add milch techniqueCan add milch technique

• Key is slow gradual movementKey is slow gradual movement

• StimsonStimson

• Pt prone with hanging weight 10-Pt prone with hanging weight 10-15lb15lb

• 15-20 minutes . Works by fatigue of 15-20 minutes . Works by fatigue of musclesmuscles

• Can use sand bag/ bucket/ wrist Can use sand bag/ bucket/ wrist brace with attatched weightbrace with attatched weight

• StimsonStimson

• Traction counter tractionTraction counter traction

• Sheet wrapped around pt under Sheet wrapped around pt under axilla one practitioner pulls elbow axilla one practitioner pulls elbow wrist ( can use sheet wrapped wrist ( can use sheet wrapped around your waist and pts flexed around your waist and pts flexed elbow allowing you to use body elbow allowing you to use body weight)weight)

• Assistant provides countertractionAssistant provides countertraction

• Sheet around waistSheet around waist

• Alternate traction counter/tractionAlternate traction counter/traction

• SpasoSpaso

• Gentle vertical tractionGentle vertical traction

• External rotationExternal rotation

• cunninghamcunningham

Techniques to avoidTechniques to avoid

• HippocraticHippocratic

• Foot in axilla with countertractionFoot in axilla with countertraction

• Kocher in line traction uses chest as Kocher in line traction uses chest as fulcrumfulcrum

• Both above have higher rate for Both above have higher rate for fracture /injury and are out of favorfracture /injury and are out of favor

• KocherKocher

Posterior Shoulder Posterior Shoulder DislocationDislocation

• Posterior shoulder dislocationsPosterior shoulder dislocations

• May be difficult to diagnoseMay be difficult to diagnose

• Less common less than 5%Less common less than 5%

• Sz/trauma alchoholicsSz/trauma alchoholics

• Posterior dislocation reductionPosterior dislocation reduction

• Closed reduction only if articular Closed reduction only if articular surface defect less than 20% ( reverse surface defect less than 20% ( reverse hill sachs)hill sachs)

• And duration of dislocation less than 3 And duration of dislocation less than 3 weeksweeks

• Often need OR closed reductionOften need OR closed reduction

• Ortho consultOrtho consult

• PosteriorPosterior

• Can also do tractionCan also do traction

• countertractioncountertraction

• Pt sitting at 90Pt sitting at 90

• Luxatio erectaLuxatio erecta

• Traction countertraction in line with Traction countertraction in line with abducted humerus.usually successful abducted humerus.usually successful unless buttonhole ( humeral head unless buttonhole ( humeral head trapped in tear of inferior joint trapped in tear of inferior joint capsule)capsule)

• EskimoEskimo

• Used in GreenlandUsed in Greenland

• Pt lies on unaffected side Pt lies on unaffected side

• Pull up on affected armPull up on affected arm

• Can push on humeral headCan push on humeral head

• Higher incidence of brachial plexus Higher incidence of brachial plexus injuryinjury

• Self reductionSelf reduction• Hands locked around ipsalateral knee in a Hands locked around ipsalateral knee in a

seated position leans back extends hipseated position leans back extends hip• Pausing when pain is too much then Pausing when pain is too much then

continuing until reduction occurscontinuing until reduction occurs• Snow bird –pt in chair elbow flexedSnow bird –pt in chair elbow flexed• Dr applies downward traction at elbowDr applies downward traction at elbow• With foot in 4” stockinette int /ext rotationWith foot in 4” stockinette int /ext rotation• As neededAs needed

• ComplicationsComplications• Unable to reduce 5-10% interposition of Unable to reduce 5-10% interposition of

biceps tendon ,joint capsule, or fracture biceps tendon ,joint capsule, or fracture fragments within the jointfragments within the joint

• Nerve and vascular injury rareNerve and vascular injury rare• Axillary nerve –more often in Axillary nerve –more often in

elderly. managed conservatively after 4 elderly. managed conservatively after 4 weeks emg nerve study if surgery best weeks emg nerve study if surgery best between3-6 monthsbetween3-6 months

• Brachial plexsus radial/ulnar Brachial plexsus radial/ulnar musculoskelatatal musculoskelatatal

• Axillary artery injuryAxillary artery injury

• Rare. More common in chronic Rare. More common in chronic dislocationdislocation

• 200 cases reported. 90% in pts over 50200 cases reported. 90% in pts over 50

• Due to joint capsule adhesions, Due to joint capsule adhesions, calcifications, loss of elasticitycalcifications, loss of elasticity

• Venous injury rare. Usually thrombosis Venous injury rare. Usually thrombosis

• Follow up careFollow up care• Post reduction shoulder is immobilizedPost reduction shoulder is immobilized• follow up ortho 1 weekfollow up ortho 1 week• Most common complication is recurrent Most common complication is recurrent

dislocationdislocation• 50-90% pt < 2050-90% pt < 20• 5-10%> 405-10%> 40• Immobilization-adduction internal rotation, collar Immobilization-adduction internal rotation, collar

cuff, sling swathecuff, sling swathe• Recent studies (cadaver) recurrent dislocations Recent studies (cadaver) recurrent dislocations

slightly less if shoulder immobilized in 10 degrees slightly less if shoulder immobilized in 10 degrees external rotationexternal rotation

• Orthopedic repair- irreducible Orthopedic repair- irreducible dislocation, significant dislocation, significant fractures/bankhart fx’sfractures/bankhart fx’s

• Rehab may reduce rate of Rehab may reduce rate of reoccurencereoccurence

• By week 12 limited return to sportsBy week 12 limited return to sports

• week 16 full return to sportsweek 16 full return to sports

• External rotation External rotation

• If pt < 30 immobilize for 3 weeksIf pt < 30 immobilize for 3 weeks

• > 30 less redislocation rate > 30 less redislocation rate immobilize 1 week to decrease joint immobilize 1 week to decrease joint stiffnessstiffness

• Gentle pendular ROM excercizes Gentle pendular ROM excercizes decrease risk of frozen shoulderdecrease risk of frozen shoulder

• Ortho referral 1 weekOrtho referral 1 week

Elbow DislocationElbow Dislocation

• Most posteriorMost posterior

• Assoc fx’s commonAssoc fx’s common

• Important to examine for neurovasc Important to examine for neurovasc injinj

• Extremely painful sometimes harder Extremely painful sometimes harder to reduce than shoulderto reduce than shoulder

• Mechanism fall on outstretched handMechanism fall on outstretched hand

• Brachial artery injury in up to 8%Brachial artery injury in up to 8%

Reduction Reduction

• Grab armGrab arm

• Supinate forearmSupinate forearm

• Apply tractionApply traction

• CountertractionCountertraction

• Flex elbowFlex elbow

• Need to clearNeed to clear

• coronoidcoronoid

Bad TechniqueBad Technique

Hip DislocationHip Dislocation

• Most posteriorMost posterior

• Poss acetabular fx( may only be seen Poss acetabular fx( may only be seen on CT)on CT)

• Urgent reduction- to decrease risk of Urgent reduction- to decrease risk of AVNAVN

• Native versus prostheticNative versus prosthetic

• Traumatic mechanismTraumatic mechanism

• Typical appearanceTypical appearance

Reduction Hip dislocationReduction Hip dislocation

Prosthetic usually easier to reduceProsthetic usually easier to reduce

Can have pt prone on stretcher leg Can have pt prone on stretcher leg hanging off end hip and knee flexedhanging off end hip and knee flexed

• at 90at 90

• Apply downward forceApply downward force

• Can have pt supine flex knee hip at 90Can have pt supine flex knee hip at 90

• Pull upPull up

• AssistantAssistant

• Hold pelvis downHold pelvis down

• Modification .put your foot on stretcherModification .put your foot on stretcher

• Knee under pts calf( rather than Knee under pts calf( rather than standing over pt)standing over pt)

• Push down on pts ankle up from behind Push down on pts ankle up from behind knee using your knee as a fulcrumknee using your knee as a fulcrum

• Use assistant or back board straps to Use assistant or back board straps to stabilize pelvisstabilize pelvis

• Prosthetic hip dislocation can go Prosthetic hip dislocation can go home after reduction( need to avoid home after reduction( need to avoid adduction)adduction)

• Native Hip needs ct to r/o acetabular Native Hip needs ct to r/o acetabular fx.fx.

• High force mechanism may need High force mechanism may need further w/u eval admit for further w/u eval admit for concommitant injuryconcommitant injury

Patellar dislocationPatellar dislocation

• Most often 2Most often 2ndnd 3 3rdrd decades of life decades of life

• Girls> boys. familialGirls> boys. familial

• Mech swinging twisting of kneeMech swinging twisting of knee

• Dance/gymnasticsDance/gymnastics

• Lateral most commonLateral most common

• Patella is a sesamoid bone imbedded Patella is a sesamoid bone imbedded in quadriceps tendonin quadriceps tendon

• Usually obviousUsually obvious

• Knee held in 20-30 degrees flexionKnee held in 20-30 degrees flexion

• Patella palpable laterallyPatella palpable laterally

• Often painful/ pts anxiousOften painful/ pts anxious

• Analgesia/sedationAnalgesia/sedation

• X ray not needed prior to reductionX ray not needed prior to reduction

• Reduction techniqueReduction technique

• pt supine hips flexed to relax pt supine hips flexed to relax quadricepsquadriceps

• Medial pressure to patellaMedial pressure to patella

• Post reductionPost reduction

• Knee immobilizer or patellar stabilization Knee immobilizer or patellar stabilization bracebrace

• RICERICE

• Follow up 1 weekFollow up 1 week

• Rehab quad strengtheningRehab quad strengthening

• Athletes return to sports 4-6 weeksAthletes return to sports 4-6 weeks

• Under 15 years old high rate of recurrenceUnder 15 years old high rate of recurrence

• Up to 60%Up to 60%

• Knee dislocationsKnee dislocations• True dislocation rare-but True dislocation rare-but

devastating/potentially limb threateningdevastating/potentially limb threatening• Exam grossly swollen knee clinically Exam grossly swollen knee clinically

obvious, often decreased perfusion lower obvious, often decreased perfusion lower legleg

• If spontaneously reduced must have high If spontaneously reduced must have high index of suspicionindex of suspicion

• Any case of severe bicruciate lig injury Any case of severe bicruciate lig injury with grossly unstable kneewith grossly unstable knee

• DislocationDislocation

• Notice swelling/hematomaNotice swelling/hematoma

• Direction of tibial displacementDirection of tibial displacement

• In relation of femurIn relation of femur

• Anterior>Posterior>med or LatAnterior>Posterior>med or Lat

• CausesCauses

• MVA ( >60%)MVA ( >60%)

• FallsFalls

• SportsSports

• Industrial accidentsIndustrial accidents

• ComplicationsComplications

• Popliteal artery ( 10-30%)!!!Popliteal artery ( 10-30%)!!!

• Common peroneal nerve(20-30%)Common peroneal nerve(20-30%)

• decreased sensation over the decreased sensation over the dorsum of footdorsum of foot

• Tibial nerve Tibial nerve

• decreased sensation over plantar decreased sensation over plantar footfoot

• Compartment syndromes/ fracturesCompartment syndromes/ fractures

• Popliteal injuryPopliteal injury

• Twaddle B study j orthotrauma 2003Twaddle B study j orthotrauma 2003• 60 pts60 pts• 2/3 reduced spontaneously2/3 reduced spontaneously• Lig injury : ACL or PCL84-87%Lig injury : ACL or PCL84-87%• ACL/PCL 71%ACL/PCL 71%• MCL 44% MCL 44% • LCL62%LCL62%• Popliteal injury in 9 knees ( 14%)Popliteal injury in 9 knees ( 14%)• Peroneal nerve 9 (14%)Peroneal nerve 9 (14%)•

Knee ReductionKnee Reduction

• Reduction techniqueReduction technique• Assistant provide sl longitudinal tractionAssistant provide sl longitudinal traction• Operator uses one hand on tibia one on femur to Operator uses one hand on tibia one on femur to

guide it back into positionguide it back into position• Posterior splint 15 degrees flexionPosterior splint 15 degrees flexion• Vasc evaluationVasc evaluation• Angio/Doppler/ Ankle-ankle indexAngio/Doppler/ Ankle-ankle index• Ortho consultOrtho consult• AdmitAdmit• Serial ExamsSerial Exams•