Dislocations

What are the complications associated with elbow dislocation?

"Terrible triad" - elbow dislocation with fractures of the radial head and coronoid Brachial artery injury -5-13% Ulnar nerve damage- up to 20% of time Median nerve damage

What are some common complications of shoulder dislocations?

*Hill-Sachs* deformity of the humeral head *Bankart lesion*- glenoid labral defect Neurovascular injuries- rare Recurrent dislocations

Native hip dislocations are ortho emergencies and should be reduced as quickly as possible - no more than _ hours after the injury

6

displacement of the talus and foot from the tibia.

Ankle dislocation

95% of all shoulder dislocations are (anterior or posterior)?

Anterior

What is the most common type of knee dislocation?

Anterior

Usually well tolerated with activities of daily living 'Sliding' sensation during exercises or strenuous activities such as throwing May be less symptomatic Can often undergo spontaneous reduction, with pain resolving days after onset

Atraumatic shoulder instability

The patient is supine with the affected hip and knee flexed 90 degrees. Secure the patient's knee with your flexed elbow, and grasp the patient's foot with the opposite hand. Have an assistant apply downward pressure to the anterior superior iliac spines. Now, using your flexed elbow, lift upward at the patient's knee to apply traction to the femur. Gently externally rotate and extend the hip while applying traction to the femur at the patient's knee.

Bigelow maneuver

the physician's knee is used as a fulcrum 1) Stabilize the patient's pelvis by placing the patient on a backboard in the supine position and strapping the pelvis to the board, or have an assistant stabilize the pelvis on the stretcher by placing both hands on the patient's iliac crests and using pressure to keep the pelvis stable. (2) To reduce the dislocation, place your foot on the stretcher or board with your knee posterior to the patient's knee. (3) With the patient's knee in flexion, gently pull downward at the patient's ankle while applying an upward force to the patient's hip by lifting your heel by stepping on your toes and contracting your calf. Gently rotate the patient's hip while applying the upward traction behind the patient's knee.

Captain Morgan technique

combination of humerus and scapular positioning and specific massage of a spasming biceps muscle. Seat the patient comfortably, as upright as possible, with shoulders relaxed. Supporting the affected arm, slowly and gently move the humerus into full adduction with the elbow in flexion. Have the hand of the affected extremity resting against the physician's shoulder. Gently massage the trapezius and deltoids, which helps to relax the patient. Then, gently massage the biceps at the mid-humeral level. Ask the patient to elevate and shrug or retract the shoulders (attempting to touch the scapulae together) and continue the biceps massage. The goal is to wait for the patient to relax fully and have the humeral head slip back into place

Cunningham technique

What is the tx of a phalangeal dislocation?

Digital nerve block for PIP and DIP joints Ulnar, median or radial nerve blocks necessary for MCP joints

complete disruptions in the normal relationship of the articular surfaces of the bones making up a joint. They may be associated with fractures. Dislocations should be described by the relationship of the distal bone to the more proximal bone.

Dislocation

Place the patient supine with the affected arm adducted to the patient's side. With the elbow at 90 degrees of flexion, slowly externally rotate the arm. No longitudinal traction is applied. Perform the movement slowly to allow time for spasm and pain to resolve. Reduction is usually complete before reaching the coronal plane and is often not noted either by the patient or physician. If needed, the elbow may be brought anteriorly and internally rotated to the opposite shoulder.

External rotation Technique (Kocher's technique)

external rotation, arm abduction to 180 degrees with simultaneous pressure on the humeral head, and in-line longitudinal traction with continued pressure on the humeral head

Milch technique

clinical findings of ankle dislocation?

Neurovascular status should be determined quickly along with rapid reduction Gross deformity of the ankle joint X Ray can be used but should not be delayed if any tenting or neurovascular compromise

What is the second most common dislocation?

Patellar

What are some complications of a knee dislocation?

Popliteal artery injury Peroneal nerve injury- foot drop Ligamentous injury Meniscal injury

(Anterior or posterior) is the most common type of elbow dislocation

Posterior (80%) Results from an axial force applied to the extended elbow Both collateral ligaments are disrupted

Tx of ankle dislocation

Reduction Then reassess the neurovascular status Splint Repeat of original xray Ortho consult- often admission

Mechanism of injury of a knee dislocation

Result of tremendous ligamentous disruption due to either high-velocity mechanism (MVC or fall from height) Or low velocity mechanism (martial arts, walking or trampoline falls) Can occur spontaneously in morbidly obese patients

The patient is positioned with weights in the same manner as the Stimson technique. After adequate sedation, the physician pushes the tip of the scapula medially using the thumbs, while stabilizing the superior aspect with the cephalad hand. This technique reports a 96% success rate.

Scapular manipulation

why would you order an MRI in a shoulder dislocation?

Shows soft tissue injuries to the labrum Visualizes associated rotator cuff tears MRI arthrograms better identify labral tears and ligamentous structures

Pt lies prone with the dislocated arm hanging off the exam table with a weight applied to the wrist to provide traction for 20-30 minutes Afterward, gentle medial mobilization can be applied manually to assist the reduction

Stimpson technique

most commonly performed technique. In-line traction is performed with simultaneous hip flexion and internal rotation. While flexing both the patient's knee and hip to 90 degrees, apply in-line traction upward toward the ceiling and slightly toward the contralateral side, resulting in the desired flexion and adduction necessary for reduction. While under traction, perform gentle internal rotation if necessary. Aggressive or forced rotation can result in spiral fracture of the femur. An assistant should apply downward pressure to the anterior superior iliac spines. Stabilizing the pelvis is essential. Direct pressure can also be applied to the dislocated femoral head on the posterolateral aspect of the buttocks. The femoral head can often be palpated and pressure can be applied in line with the direction of traction.

The allis maneuver

What is the tx of a knee dislocation?

Timely reduction is essential Apply longitudinal traction to the affected knee Document neurovascular status before and after reduction Splint the lower extremity with knee at 20 ⁰ of flexion after dislocation reduction (in a manner that allows for serial vascular exams) Reimage after reduction Emergent ortho consult and admission

What are the three main categories of reduction techniques?

Traction Leverage Scapular manipulation

A modification of the Hippocratic method uses traction-countertraction. The patient is supine with the arm abducted and elbow flexed at 90 degrees. A sheet is tied and placed across the thorax of the patient and then around the waist of the assistant. Another sheet is tied and placed around the forearm of the patient at the elbow and the waist of the physician. Gradually apply traction to the proximal forearm as the assistant provides countertraction. Gentle internal and external rotation or outward pressure on the proximal humerus may aid reduction.

Traction-countertraction technique

Mechanism of injury for posterior shoulder dislocation?

Usually a result of falls from a height, *epileptic seizures* or electric shocks

Mechanism of injury for anterior shoulder dislocation?

Usually caused by a fall on an outstretched and abducted arm

Mechanism of injury of posterior hip dislocation

a posterior force applied to a flexed knee (most commonly a dashboard injury)

What is the mechanism of injury for a patellar dislocation?

a twisting injury to the extended knee

mechanism of injury of an ankle dislocation?

axial loading to the foot in plantar flexion and are seen in sporting injuries and in high-energy trauma such as MVC Associated fractures often present

Mechanism of injury of phalangeal dislocations

dislocated dorsally - caused by hyperextension and axial compression and may have associated volar plate damage

What is the second most common major joint dislocation?

elbow

T/F phalangeal dislocations only occur at 1 of the finger joints

false, it can occur at all 3 finger joints

subluxation

incomplete dislocation.

What is the treat meant for a elbow dislocation?

initiated after documenting the neuromuscular exam reduction

atraumatic shoulder dislocation are usually caused by what?

intrinsic ligament laxity or repetitive microtrauma leading to joint instability

Orthogonal views are used to identify a ___ shoulder dislocation

posterior

Tx for acute shoulder dislocation?

reduced

What is the tx for a patellar dislocation?

reduction knee imbolizer and crutches

What is the most common dislocation

shoulder

clinical diagnosis of hip dislocation

the extremity is shortened, adducted and internally rotated Femoral neck fractures are typically externally rotated and shortened Careful neurovascular exam

What is a complication of a phalangeal dislocation?

volar plate fracture

Knee dislocations primarily occur in which population?

younger male populations