Emergency management of common dislocations

This is a presentation on the management of common dislocations of the body with focus on the shoulder, elbow, hips and knees.

1. Emergency Management of Common Dislocations Dr. M. Yigah

2. Overview Dislocation is the complete separation of separation of two articulating bony surfaces often caused by a sudden impact to the joint. Simple dislocation or complex dislocation (fracture dislocation) It is an orthopaedic emergency Most dislocations can be acutely reduced and stabilized.

3. Types of Joints

4. Types of Joints

5. Anatomical Perspective Static stabilizers Articular anatomy Joint capsules Ligaments Dynamic stabilizers Muscles

6. Types of dislocations Congenital dislocations E.g. Congenital acetabular dysplasia Acquired dislocations Traumatic – Sports, RTA, Pathological – TB of the hip, septic arthritis Paralytic disorders – poliomyelitis, cerebral palsy Inflammatory disorders – rheumatoid arthritis

7. Epidemiology Common sites of joint dislocation Shoulders Elbows Hip Metacarpophalangeal joints Cervical spine facet joint dislocation Acromio-clavicular joint

8. General Principles Accurate diagnosis Mechanism of injury Neurovascular assessment Radiological assessment Closed Reduction Know your anatomy Any contraindications to closed reductions Select a method you are most comfortable with. Have a post-reduction plan

9. General Principles Ask for help Analgesia and sedation Morphine + Ketamine/Midazolam General anaesthesia Avoid multiple failed attempts Checking if the reduction is successful Clinically Radiologically

10. Reduction Manoeuvre What constitutes a good manoeuvre It should be able to reduce the dislocation Gentle Technically sound Minimal attempts Well tolerated

11. DOCUMENTATION !!!!

12. Upper Limbs

13. Shoulder Dislocation ( Gleno -humeral) The large round humeral head articulates with the relatively shallow glenoid cavity of the scapula which is glenoid labrum. Sacrifices stability for mobility Types of Dislocation Anterior dislocation Posterior dislocation Inferior dislocation

14. Anterior Dislocation Mechanism of injury Fall on the hand with an abducted and externally rotated arm . Risk of developing a Bankart lesion or Hill-Sachs lesion

15. Anterior Dislocations Presentation

16. X-ray AP View The overlapping shadows of the humeral head and glenoid fossa, The head usually lying below and medial to the socket

17. Scapular-Y view Humeral head out of line with the socket.

18. Stimson Technique Patient is prone on the table with the affected limb hanging freely over the edge. Gravitational traction can be aided with a 5kg mass

19. Kochers Technique Longitudinal traction to the humerus. With the elbow flexed at 900 and arm adducted, the arm is externally rotated until there is resistance. The elbow is lifted and adducted across the chest toward the midline until it is reduced. The hand of the affected limb is placed on the left shoulder.

20. Techniques for reducing anterior dislocation Hippocratic Technique Traction-counter traction

21. Traction-Counter traction

22. Treatment Systematic review failed to support any specific reduction technique. Easier to reduce if patient has recurrent dislocations and likewise it easier to dislocate again Post reduction Assess the ROM and neurovascular status of hand Post-reduction Xray Immobilize in a broad-arm sling

23. Posterior Dislocations Mechanism of Injury Indirect force producing marked internal rotation and adduction needs be very severe to cause a dislocation e.g. convulsions or with an electric shock. fall on the flexed, adducted arm, a direct blow to the front of the shoulder a fall on the outstretched hand

24. Posterior Dislocations Clinical presentation Frequently missed The arm is held in internal rotation and is locked in that position The front of the shoulder looks flat with a prominent coracoid Seen from above the posterior displacement is usually apparent.

25. Posterior Dislocations X-ray features AP view Medial rotation of the humeral head – electric bulb appearance Empty glenoid sign

26. Posterior Dislocations Treatment Continuous traction along the humerus The arm is then gently rotated laterally while the humeral head is pushed forwards. Post reduction status If stable after reduction – immobilize in a sling for 3 weeks Unstable - airplane- type splint for 3–6 weeks

27. Inferior Dislocation ( Luxatio Erecta ) Rarest type Mechanism of injury The injury is caused by a severe hyper-abduction force. Clinical features The startling picture of a patient with his arm locked in almost full abduction should make diagnosis quite easy

28. Inferior Dislocation Treatment Pulling upwards in the line of the abducted arm. With countertraction downwards over the top of the shoulder. Neurovascular examination post reduction The arm is rested in a sling until pain subsides Abduction is avoided for 3 weeks

29. Elbow Dislocations

30. Dislocations of the Elbow 2 nd commonest major joint dislocation. Mechanism of injury and pathology Fall on the outstretched hand with the elbow in extension (often with a valgus force). The medial collateral ligaments are invariably torn The lateral collateral ligaments are either intact or have a partially torn – 20%

31. Dislocations of the Elbow Clinical features Elbow is held in a position of comfort – slight flexion Abnormally placed landmarks (olecranon and epicondyles). The elbow may very swollen and tender Examine the hand for vascular and/or nerve injury

32. Dislocations of the Elbow X-rays

33. Treatment Reduction under sedation and anaesthesia. Haematoma block is preferred Manoeuvre Correct lateral or medial displacement first Gentle traction of an extended supinated forearm. One can wrap fingers around olecranon to bring it distal and anterior The elbow is then taken from an extended to a flexed position.

34. Post-reduction Management The arm is held in a collar and cuff with the elbow flexed above 90 degrees. After 1 week the patient gently moves the elbow while lying supine with the shoulder flexed to 90 degrees and the forearm in neutral rotation. Discard collar and cuff once comfortable.

35. Lower Limbs

36. Hip Dislocations Hip joint is the strongest joint in the body Congruent bony anatomy Strong capsular and ligamentous stabilizers Muscles Requires a high energy injury to dislocate Often associated with femoral fractures or the polytraumatized patient (40–75%).

37. Posterior Hip Dislocations The commonest type (80-85%) Mechanism of injury and pathology Force is applied to a flexed knee (e.g. Striking the knee against a dashboard). The femur is thrust proximally to displace the head. Often the acetabulum is chipped off (fracture-dislocation ).

38. Clinical features The limb is shortened, flexed, adducted and internally rotated. May be atypical when associated with a femoral fracture. Bruising and swelling of the knees Neurovascular nerve assessment Sciatic nerve runs posterior to the hip

39. Posterior Hip Dislocation X-ray features High riding femoral head The femoral head appear smaller than the contralateral side There may be associated femoral head and acetabular wall fractures

40. Posterior Hip Dislocation (Allis technique) Should reduced as soon as possible. Closed reduction should not be attempted if there is a femoral neck fracture. Requires an assistant to steady the pelvis Traction in the line of the femur with the knees flexed While ,maintaining traction, the hip is gently flexed followed by internal rotation and adduction.

41. Allis technique

42. Whitlers technique

43. Captain Morgans Technique

44. Posterior Hip Dislocation Assessing reduction A satisfying ‘clunk’ indicates that reduction has been achieved Stability is tested by flexing the hips to 90 and then applying a posteriorly directed longitudinal force. The hip is assessed with an Xray post reduction Post-reduction management Apply a skin/skeletal traction for 1-2weeks

45. Anterior Hip Dislocation (10 – 20%) of all hip dislocations Mechanism of injury High energy force to an abducted and externally rotated hip More commonly associated with femoral head fractures. Presentation The leg lies externally rotated, abducted and slightly flexed Anterior bulging of the femoral head in the groin

46. X-ray features The dislocation is usually obvious, but occasionally the head is almost directly in front of its normal position. The femoral will appear larger than the unaffected contralateral side. A lateral film helps confirm the diagnosis.

47. Anterior Hip Dislocation Reduction Manoeuvre The affected leg is held in external rotation, abduction and flexion, before longitudinal traction is applied. The leg is gently internally and externally rotated until the hip reduces. Pressure anteriorly over the palpable femoral head may assist the reduction. Post-reduction management Same as that for the posterior dislocation

48. Knee Dislocations Uncommon but serious injuries with variable prognosis Complete disruption of the tibiofemoral articulation. Associated with multiligament injuries Causes Road traffic accidents Sports injuries Simple falls

49. Knee Dislocations Clinical Presentation High degree of suspicion . Be aware of the spontaneously reduced ones!!! Severe knee swelling and bruising from haemarthrosis. Ischaemic limb from compressed or torn popliteal artery. Foot drop in 20% of patients

50. AP and Lateral Xray Views

51. Knee Dislocations Closed reduction under conscious sedation or anaesthesia Gentle traction in the line of the leg. Avoid hyperextension of the knee due popliteal vessels. Assess NV status after reduction Stabilize the knee with brace, plaster or external fixator

52. Take Home Message Mechanism of Injury is key Know your anatomy Avoid multiple attempts Stay within your comfort zone