Joint relocation [advanced]

Introduction

• Wash hands, Introduce self, ask Patients name and DOB, Explain procedure, risks and get consent
• Review X-rays before and after (AP + lateral) to determine pattern of dislocation/confirm re-location and exclude any fractures (don’t manipulate if fractures present unless confident it is the correct course of action)
• Examine neurovascular status before and after (and document it!) i.e. temp, pulses, cap refill, sensation, motor
  • Before: if vascular compromise present, perform immediate reduction and reassessment (emergency)
  • After: if a neurovascular deficit is present, urgent surgical exploration may be required
• Give the patient analgesia, options:
  • Systemic analgesia e.g. Entonox, morphine IV
  • Sedation e.g. midazolam
  • Local nerve block
• Note:
  • The below techniques are often successful due to continued traction (few minutes) relaxing muscles around joint, which allows the joint to re-locate itself
  • ‘Anterior/posterior/medial/lateral’ dislocation refers to the position of the distal bone (with respect to the proximal bone)
  • All patients should be followed up in fracture clinic#
  • Give crutches if required

Shoulder

• Look for specific associated fractures
  • Hill-Sachs lesion – compression fracture of humerus
  • Bankart lesion – some of glenoid breaks off
  • Avulsion fracture of supraspinatus origin
• Examine axillary nerve sensation (over lateral deltoid)
• Use Entonox and/or morphine for analgesia
• Technique depends on pattern of dislocation
  • Anterior (95% of causes, usually due to fall causing external rotation) → any technique below
  • Posterior (common in epileptic fit; humeral head looks like a light bulb on X-ray) → easy – pull arm gently forwards and externally rotate it
  • Inferior (arm above head) → must dislocate to the anterior position first (then use the anterior techniques)
• Aftercare = broad arm sling or polysling for 3 weeks

Elbow

• Usually dislocates posteriorly from fall on outstretched hand
• Examine ulnar nerve, median nerve and brachial artery
• Requires sedation
• Aftercare = collar and cuff sling for 2 weeks

Finger joints

• Almost always dislocate posteriorly due to hyperextension injuries
• Remove any rings!
• Use a digital nerve block for analgesia
• Aftercare = buddy tapping for 2 weeks and high arm sling, advise patient swelling will reduce over 2 years and never completely subside (rings may need to be resized)

Hip

• Usually dislocates posteriorly due to anterior force on femur (e.g. due to car accident)
• The hip will usually be slightly flexed, adducted and internally rotated
• Associated fractures are common (exclude acetabular rim fracture)
• Examine sciatic nerve function (compromised in 10-20%) in posterior dislocation
• Requires sedation minimum, buy typically require reduction under general anaesthesia
• If reduction is not easy, open reduction is needed to avoid sciatic nerve damage
• Aftercare = bedrest for 2-3 weeks

Knee

• Rare
• Usually dislocates anteriorly due to trauma (all ligaments will be torn)
• Popliteal vessels compromised 50% of the time – ankle-brachial pressure index should be performed and a CT angiogram is often required
• Examine the peroneal nerve and tibial nerve function
• Often requires open reduction due to significant neurovascular damage risk (if not, requires sedation)
• Risk of compartment syndrome
• Aftercare = above knee backslab for 6 weeks

Patella

• Usually dislocates laterally
• Pre-procedure x-ray not required
• Use Entonox for analgesia
• Aftercare = cylinder cast for 2-3 weeks

Ankle

• Rare without a bimalleolar/trimalleolar fracture
• Should be manipulated even in presence of a fractures
• Requires sedation
• Aftercare = below knee backslab for 6 weeks; however, these are unstable fractures and usually need surgical fixation – they should be immobilised in mean time