Table of Contents IntroductionShoulderElbowFinger jointsHipKneePatellaAnkle Introduction Wash hands, Introduce self, ask Patients name and DOB, Explain procedure, risks and get consentReview 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, motorBefore: if vascular compromise present, perform immediate reduction and reassessment (emergency)After: if a neurovascular deficit is present, urgent surgical exploration may be requiredGive the patient analgesia, options:Systemic analgesia e.g. Entonox, morphine IVSedation e.g. midazolamLocal nerve blockNote: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 fracturesHill-Sachs lesion – compression fracture of humerusBankart lesion – some of glenoid breaks offAvulsion fracture of supraspinatus originExamine axillary nerve sensation (over lateral deltoid)Use Entonox and/or morphine for analgesiaTechnique depends on pattern of dislocationAnterior (95% of causes, usually due to fall causing external rotation) → any technique belowPosterior (common in epileptic fit; humeral head looks like a light bulb on X-ray) → easy – pull arm gently forwards and externally rotate itInferior (arm above head) → must dislocate to the anterior position first (then use the anterior techniques)Aftercare = broad arm sling or polysling for 3 weeks Kocher’s technique (leverage) Most commonly usedSlow external rotation of shoulder to 90˚ (to relax subscapularis) – stop if reduction is achievedAdduct the shoulder (to bring the elbow across the chest)Internally rotate the shoulder (to bring the patient’s hand over their opposite shoulder)Risk = humeral head fracture Modified Milch technique (leverage) From in front of patient, place fingers over shoulder and steady displaced humeral head with thumb in axillaWith the other hand folding the patient’s wrist, abduct and externally rotate armWhen full abduction reached, press harder with thumb to push humeral head back into position Stimson’s hanging technique (traction) atient lies prone on a bedAffected arm is allowed to hang freely off side of bed (4kg weight may also be used)Takes 4 hours and may require benzodiazepines to relax muscle spasm Hippocratic technique (traction) With patient lying on bed supine (or on floor), doctor’s heel is gently placed in axillaThis acts as a fulcrum while their arm is adductedRisk ++ = nerve damage Elbow Usually dislocates posteriorly from fall on outstretched handExamine ulnar nerve, median nerve and brachial arteryRequires sedationAftercare = collar and cuff sling for 2 weeks Longitudinal pull Elbow at slight flexionOne person secures the patients upper arm with both hands facing distally, with the thumbs on the olecranonA second person pulls on the 3 long fingersThe first person can then use their thumbs to press the olecranon back into position if reduction is not achieved with traction alone Finger joints Almost always dislocate posteriorly due to hyperextension injuriesRemove any rings!Use a digital nerve block for analgesiaAftercare = 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) Longitudinal pull Assistant applies counter traction to forearmUse non-dominant hand’s thumb and index finger to grasp the phalanx proximal to the dislocated joint and apply counter tractionUse dominant hand to apply and maintain firm axial traction to the phalanx distal to the jointGently hyper-extend the joint (exaggerate original injury)While maintaining traction and hyper-extension, use the non-dominant hand’s thumb to apply pressure to the dorsal aspect to the base of the dislocated pharynx to push back into place 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 rotatedAssociated fractures are common (exclude acetabular rim fracture)Examine sciatic nerve function (compromised in 10-20%) in posterior dislocationRequires sedation minimum, buy typically require reduction under general anaesthesiaIf reduction is not easy, open reduction is needed to avoid sciatic nerve damageAftercare = bedrest for 2-3 weeks Technique Complete muscle relaxation is key to successWith patient lying on a low bed, the assistant should stabilise the pelvis (on the side of the dislocation) from aboveFlex knee and hip to 90˚Apply upward traction to hip (you can use your knee as a lever by resting your shin on the side of the bed with your knee in the patient’s popliteal fossa and flex their knee over yours)While applying traction, manipulate the leg slightly to the opposite direction to where it is (i.e. correct adduction and internal rotation) Knee RareUsually 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 requiredExamine the peroneal nerve and tibial nerve functionOften requires open reduction due to significant neurovascular damage risk (if not, requires sedation)Risk of compartment syndromeAftercare = above knee backslab for 6 weeks Technique Traction and pressure over displaced tibia Patella Usually dislocates laterallyPre-procedure x-ray not requiredUse Entonox for analgesiaAftercare = cylinder cast for 2-3 weeks Technique Stand on the lateral side of the patientFlex their knee to relax quadriceps (e.g. over side of bed)Lift and push patella anteromedially using both thumbsAsk assistant to gently extend patient’s knee while you are doing this Ankle Rare without a bimalleolar/trimalleolar fractureShould be manipulated even in presence of a fracturesRequires sedationAftercare = below knee backslab for 6 weeks; however, these are unstable fractures and usually need surgical fixation – they should be immobilised in mean time Technique Ensure assistant who can plaster is ready to do soPatient’s knee flexed over examination table (or them lying in bed if more practical)Ask assistant to apply stockinette and webrilGrasping their hindfoot, apply traction as if you are ‘taking their shoes off’, in order:Correct posterior subluxation by lifting heel anteriorlyCorrect external rotationCorrect abductionEnsure the ankle is held in the correct position while above/below knee backslab is applied – note it is a very unstable fracture and will fall out of place with gravity if not supported properlyEnsure ab/adduction is correct (i.e. ankle is in line with lower leg)Ensure posterior subluxation is correct (hold ball of foot anteriorly or hold foot up with great toe to ensure heel is in line with back of shin and ankle is at 90˚)Tweak the external rotation of ankle to match other side (look at position of the toe in line with the knee)