Chapter 9 – Procedures for orthopedic emergencies



Chapter 9 Procedures for orthopedic emergencies




Moira Davenport

Dennis Hanlon

Ryan Friedberg



Local anesthetics



Key facts





  • Ester anesthetics: procaine, tetracaine



  • Amide anesthetics: bupivacaine, lidocaine



  • Cardiac lidocaine is preservative free and may be used in patients with previous lidocaine allergy



  • Onset of action and duration of action varies based on agent used, concentration of agent, amount of agent and location of injection



  • Attention should be paid to the amount of anesthetic given to avoid toxicity




    • Lidocaine w/o epi max dose = 4 mg/kg



    • Lidocaine with epi max dose = 7 mg/kg




  • CNS excitation and lightheadedness are typically associated with toxicity



  • Lidocaine with epinephrine may be used on digits, nose, etc



  • Ensure that anesthesia is achieved prior to starting the procedure



  • Always use sterile gloves when administering local anesthetic agents



Indications





  • Local anesthesia for procedures




    • Sutures



    • Fracture/dislocation reduction



    • Incision and drainage




Contraindications





  • Cellulitis/infection at injection site



  • Bleeding disorders (relative)




    • Anticoagulant use




  • Previous allergic reactions to anesthetic agent



Risks





  • Infection



  • Bleeding



  • Nerve damage



  • Anxiety/agitation (particularly in children)



  • Tissue distortion (particularly with larger volumes)



General suggestions





  • Always obtain informed consent before performing a block or a procedure



  • Aspirate slightly before injecting anesthetic to ensure that the needle is not in a vascular structure



  • If paresthesias are elicited during a block it is likely that the needle is in close proximity to a nerve/nerve sheath. If this occurs withdraw the needle slightly and reassess location before continuing the injection



Regional anesthetics



Hematoma block





  • Easily performed



  • Achieves reasonable anesthesia



  • Ideal for distal radial fractures, gaining popularity with ankle fractures



  • Time to onset: approximately 5 minutes



Contraindications





  • Open fracture



  • Grossly contaminated skin




Supplies needed





  • Chlorhexidine swabs (or other cleaning solution)



  • Lidocaine 1% or 2%



  • 10 cc syringe



  • 25-gauge needle (length dependent on patient habitus) for injection



  • 18-gauge needle (for preparation/aspiration of solution to be injected)



Technique





  • Place the injured extremity in a position of relative comfort



  • Clean the skin overlying the hematoma with chlorhexidine swabs



  • Fill the 10 cc syringe with lidocaine



  • Insert the needle into the center of the hematoma




    • Enter the skin at a 90° angle




  • Advance the needle until it hits bone



  • Pull the needle back 0.5–1 cm



  • Draw back blood to confirm placement of the needle in the hematoma



  • Inject the lidocaine in a fan-like distribution




    • Goal: Anesthetize bone and periosteum




  • Remove the needle



  • Cover the injection site with a sterile bandage



  • Proceed with necessary reduction(s)



Regional anesthesia



(Bier block)



Indications





  • Anesthesia of large portion of a limb




    • Large lacerations



    • Burn



    • Foreign body



    • Long-bone fracture




Contraindications





  • Hypertension



  • Altered mental status patient



  • Crush injury (relative contraindication)



Supplies





  • Lidocaine 0.5% solution




    • Dose: 3 mg/kg



    • Mini Bier block dose: 1.5 mg/kg




  • Sterile saline (for dilution)



  • Pressure control pneumatic tourniquet



  • 20-gauge (or larger) IV catheter



  • 50 cc syringe



  • Compression bandage



  • Gauze pads



  • 18-gauge needle for preparation/aspiration of anesthetic



  • Chlorhexidine swabs (or other cleaning solution)



Procedure





  • Dilute the lidocaine to 0.5% (if not prepackaged at this concentration)



  • Apply the pressure controlled pneumatic tourniquet to the proximal aspect of the affected extremity



  • Place the 20-gauge IV on the affected extremity



  • Secure the IV



  • Elevate the extremity to facilitate effective exsanguination




    • Compression of proximal arteries (axillary artery in the upper extremity, femoral artery in the lower extremity) may increase the efficacy of exsanguination




  • Wrap the extremity (distally to proximally) with a compression bandage to further facilitate exsanguination



  • Inflate the tourniquet to 50 mm Hg above systolic blood pressure



  • Place the extremity in a neutral position



  • Slowly inject the lidocaine 0.5%



  • If less than complete anesthesia is achieved, inject 10–20 cc of normal saline



  • Perform the necessary procedure



  • Deflate the tourniquet in a cyclic fashion




    • Do not deflate the tourniquet until 30 minutes after infusion of the anesthetic



    • Deflate for 10 seconds, reinflate for 1–2 minutes



    • Repeat four to five times before removing tourniquet completely




  • Remove the IV



  • Serial neurovascular checks should be performed every 15 minutes following the procedure until neurologic function returns to baseline



Two-tourniquet technique





  • Updated technique designed to limit systemic lidocaine toxicity



  • Place two tourniquets in close proximity to each other on the proximal aspect of the affected extremity



  • Proceed with the exsanguination process as in a classic Bier block



  • Inflate the proximal cuff first (to 50 mm Hg above systolic blood pressure)



  • Inject the anesthetic



  • Inflate the distal tourniquet to 50 mm Hg above systolic blood pressure




    • Do not inflate the distal tourniquet until at least 25 minutes after anesthesia is achieved




  • Deflate the proximal tourniquet as per the classic technique



  • Perform therapeutic procedure



  • Deflate the distal tourniquet as per the classic technique



Results





  • Anesthesia progresses distally to proximally



  • Onset of anesthesia: 3–5 minutes



  • Complete anesthesia: 10–20 minutes



  • Muscle relaxation typically follows complete anesthesia



  • Sensation returns within 5–20 minutes of cuff deflation



Ulnar nerve block at the elbow





  • Not recommended because of high rate of chronic nerve complications



Ulnar nerve block at the wrist



Supplies





  • 25-gauge needle for injection (length dependent on patient habitus)



  • 18-gauge needle for preparation/aspiration of anesthetic



  • 10 cc syringe



  • Skin cleaning solution



  • Lidocaine 1% or 2%



Positioning





  • Place the patient in a position of comfort



  • Keep the elbow in a position of comfort



  • Supinate the hand



Anatomy





  • Identify the flexor creases of the wrist (Figure 9.1)



  • Palpate the ulnar artery



  • Identify the flexor carpi ulnaris tendon by flexing the patient’s wrist



  • The ulnar nerve runs between the flexor carpi ulnaris tendon and the ulnar artery in the area between the proximal and distal palmar creases





Figure 9.1 The needle cap is pointing to the location of the ulnar nerve where the block should be placed. The correct location is between the flexor carpi ulnaris tendon and the ulnar artery, which is medial to the nerve.


(Image courtesy of Michael Bond, MD.)


Procedure





  • Identify the landmark



  • Clean the skin



  • Enter the skin at a 90° angle



  • Inject 1–2 ml of lidocaine to the skin and subcutaneous tissue



  • Advance the needle to the anatomic location of the ulnar nerve




    • The ulnar nerve is relatively superficial, sitting less than 1 cm deep




  • Inject 3–5 ml of lidocaine



Radial nerve block at the elbow





  • Not recommended because of high rate of chronic nerve complications



Radial nerve block at the wrist



Supplies





  • 25-gauge needle for injection (length dependent on patient habitus)



  • 18-gauge needle for preparation/aspiration of anesthetic



  • 10 cc syringe



  • Skin cleaning solution



  • Lidocaine 1% or 2%



Positioning





  • Place the patient in a position of comfort



  • Keep the elbow in a position of comfort



  • Place the hand in a neutral position



Anatomy





  • Identify the flexor creases of the wrist (Figure 9.2)



  • Palpate the radial artery at the level of the proximal flexor crease



  • The radial nerve runs just lateral to the radial artery at this location





Figure 9.2 The needle cap is pointing to the location of the radial nerve where the block should be placed. The radial nerve is just lateral to the radial artery at the flexor crease.


(Image courtesy of Michael Bond, MD.)


Procedure





  • Identify the landmark



  • Clean the skin



  • Enter the skin at a 90° angle



  • Inject 1–2 ml of lidocaine to the skin and subcutaneous tissue



  • Advance the needle to the anatomic location of the radial nerve




    • The radial nerve is relatively superficial, sitting less than 1 cm deep




  • Inject 3–5 ml of lidocaine



Digital block



Supplies





  • 25-gauge needle for injection (length dependent on patient habitus)



  • 18-gauge needle for preparation/aspiration of anesthetic



  • 3 cc syringe



  • Skin cleaning solution



  • Lidocaine 1% or 2%



Positioning





  • Place the patient in a position of comfort



  • Keep the elbow in a position of comfort



  • Pronate the hand



Anatomy





  • Fingers are innovated via digital nerves, which run along both sides of the phalanx



  • Identify the web space on both the radial and the ulnar aspects of the affected digit



  • Identify the metacarpal head of the affected digit



Procedure





  • Identify the landmarks



  • Clean the skin



  • Enter at the midportion of the web space (Figure 9.3) or at the base of the metacarpal (Figure 9.4)



  • Hold the needle at a 90° angle to the skin



  • Advance the needle to the anatomic location of the digital nerve




    • The digital nerves are relatively superficial, sitting less than 1 cm deep




  • Inject 1 ml of lidocaine



  • Repeat the procedure on the other side of the affected digit





Figure 9.3 The needle cap is pointing to one of the locations where a digital nerve block can be placed.


(Image courtesy of Michael Bond, MD.)




Figure 9.4 An alternate location for a digital nerve block is at the base of the metacarpal head. The needle cap is pointing to this location.


(Image courtesy of Michael Bond, MD.)


Ring block



Supplies





  • 25-gauge needle for injection (length dependent on patient habitus)



  • 18-gauge needle for preparation/aspiration of anesthetic



  • 3 cc syringe



  • Skin cleaning solution



  • Lidocaine 1% or 2%



Positioning





  • Place the patient in a position of comfort



  • Keep the elbow in a position of comfort



  • Pronate the hand



Anatomy





  • Fingers are innovated via digital nerves, which run along both sides of the phalanx



  • Identify the web space on both the radial and ulnar aspects of the affected digit



  • Identify the metacarpal head of the affected digit



Procedure





  • Identify the landmarks



  • Clean the skin



  • Enter the radial aspect of the affected digit at the metacarpal head (Figure 9.5)



  • Advance the needle horizontally across the base of the affected phalanx



  • Inject 1 ml of lidocaine across the dorsum of the phalanx while withdrawing the needle to the point of insertion



  • Remove the needle and then reinsert the needle, advancing toward the volar aspect of the digit



  • Inject another 1 ml of lidocaine along the side of the digit



  • Remove the needle



  • Supinate the hand



  • Insert the needle at the radial side of the volar aspect of the affected digit



  • Advance the needle horizontally across the base of the affected phalanx



  • Inject 1 ml of lidocaine across the volar surface of the phalanx while withdrawing the needle to the point of insertion





Figure 9.5 A ring block can be performed by infiltrating anesthetic in a ring-like distribution around the base of the finger. The needle is shown where you would typically enter the skin to place the anesthetic.


(Image courtesy of Michael Bond, MD.)


Femoral nerve block



Supplies





  • 25-gauge needle for injection (length dependent on patient habitus)



  • 18-gauge needle for preparation/aspiration of anesthetic



  • 30 cc syringe



  • Skin cleaning solution



  • Lidocaine 1% or 2%



Positioning





  • Place the patient supine on a stretcher



  • Externally rotate the leg approximately 15–20°



Anatomy





  • The femoral nerve runs in parallel with the femoral artery and femoral vein in the inguinal area




    • The mnemonic NAVEL (nerve, artery, vein, empty space, lymphatic) is often used to remember the anatomy, with the femoral nerve being the most lateral of the structures




  • The ideal approach is at the midpoint between the anterior superior iliac spine and the lateral aspect of the pubic symphysis, approximately 2 cm distal to the inguinal ligament



Procedure





  • Identify the landmarks



  • Clean the skin



  • Palpate the femoral artery



  • Inject 1–2 ml of lidocaine to the skin and subcutaneous tissue just lateral to the palpable femoral pulse



  • Enter the skin at a 90° angle



  • Advance the needle to the anatomic location of the femoral nerve




    • The needle is in the correct area when the patient develops paresthesias




  • Pull the needle back 5 mm (or until paresthesias resolve) before injecting 15–20 ml of lidocaine



Arthrocentesis



Indications





  • Diagnosis of joint disease (septic versus crystal-induced arthritis)



  • Relief of pain from a large, tense joint effusion or acute hemarthrosis



  • Inject lidocaine or steroids for pain relief in inflammatory arthritis



  • Evaluating a joint to see if a laceration violates the joint capsule



Contraindications





  • Absolute




    • Infection overlying the joint




  • Relative




    • Known bacteremia



    • Bleeding diathesis



    • Prosthetic joint




Equipment





  • Sterile drapes and gloves



  • Skin preparations



  • Local anesthetic



  • Syringe



  • Needles



  • Collection tubes



Technique





  • Use strict aseptic technique



  • Local anesthesia



  • Identify landmarks



  • Ultrasound may help to localize the joint fluid collection



  • 18–22-gauge needle attached to syringe (a 3-way stopcock may be used with large effusions)



  • Aspiration of synovial fluid should flow easily. If fluid stops, advance or retract slightly, rotate bevel, or decrease the force of aspiration. If the needle is blocked, a small amount of sterile fluid may be injected



  • Remove as much synovial fluid as possible



Key anatomy





  • Specific sites




    • Knee




      • The knee should be near full extension (flexed 10–15°) but not locked as the quadriceps must be relaxed



      • The middle or superior portion of the patella is the landmark



      • Insert an 18-gauge needle 1 cm inferior to the medial aspect of the patella (Figure 9.6). Alternatively, a lateral approach can be used



      • Compression of the joint effusion can increase the amount of fluid removed




    • Wrist




      • Lister’s tubercle, the dorsal radial tubercle, is a prominence located in the center of the distal end of the dorsal radius



      • The extensor pollicis longus (EPL) runs in a groove on the radial aspect of this tubercle



      • Flex the wrist 20–30° with some ulnar deviation while applying traction to the hand



      • Insert a needle perpendicularly distal to Lister’s tubercle on the ulnar side of the EPL (see Figure 9.7)




    • Elbow




      • Palpate the radial head with the arm extended then flex the elbow to 90° with the forearm pronated



      • Insert the needle from the lateral aspect at the center of the triangle between the radial head, olecranon, and the lateral epicondyle. Palpate a depression just proximal to radial head to identify this entry site (see Figure 9.8)



      • Direct the needle toward the distal edge of the antecubital fossa while keeping it perpendicular to the radius




    • Ankle (medial approach)




      • The medial malleolus sulcus is bordered by the medial malleolus medially and the anterior tibial tendon laterally



      • Plantar flex the foot



      • Insert a 20–22-gauge needle just medial to the anterior tibial tendon directed at anterior edge of medial malleolus and advance 2–3 cm to penetrate joint







Figure 9.6 An arthrocentesis of the knee is performed by placing an 18-G needle 1cm inferior to the medial aspect of the patella as shown.


(Image used with permission from McGraw-Hill; originally published in Emergency Orthopedics.)




Figure 9.7 The optimal site for arthrocentesis of the wrist is shown.


(Image used with permission from McGraw-Hill: originally published in Emergency Orthopaedics.)




Figure 9.8 The optimal site for arthrocentesis of the elbow is shown. The needle should be inserted into the palpable depression just proximal to the radial head.


(Image used with permission from McGraw-Hill; originally published in Emergency Orthopedics.)


Fluid analysis





  • Gram stain, culture, and sensitivity



  • Cell count with differential



  • Crystals



  • Lactate



  • Glucose, protein



  • May see fat globules if occult fracture



Complications





  • Infection



  • Bleeding




    • In hemophiliacs, clotting factor is administered before arthrocentesis




  • Dry tap



• PEARLS:




  • Aseptic technique is essential



  • Most important aspect of technique is palpating the bony landmarks to define joint space. Ultrasound may assist



  • Approach is usually on the extensor surface as major vessels and nerves are located on the flexor side



  • Mild flexion and traction may open up the joint spaces that are being tapped from the extensor surface



  • Prosthetic joints are at high risk for infection. Have a low threshold for orthopedic consultation



Nail trephination



Indications





  • Subungal hematoma




    • Common, painful



    • Caused by nailbed injury



    • Described by the percentage of nail under which blood can be seen




Techniques





  • Hot microcautery unit




    • Prep with povidone–iodine solution (not alcohol, which catches fire)



    • Apply slight downward pressure



    • Stop applying pressure when resistance gives way, to avoid damage to the nailbed




  • Heated paper clip




    • Same as above




  • Needle




    • Prep with povidone–iodine solution



    • Apply slight downward pressure to needle as you rotate it back and forth



    • Widen opening to encourage continued drainage



    • Some authorities advocate multiple holes




Complications





  • Nail loss or deformity (always warn patient)



  • Paronychia



  • Osteomyelitis (rare)



PEARLS:




  • > 50% subungal hematoma may warrant nail removal for nail bed repair (traditional teaching, now controversial)



  • Intact nail provides splint and better long-term results (modern philosophy)



  • X-ray to rule out underlying fracture (not mandatory, may use clinical judgement)



  • Trephination provides excellent pain relief



General fracture-reduction techniques



Indications





  • Displaced fracture with neurovascular compromise requires immediate reduction



  • Displaced fracture that will be definitively managed with a closed reduction



Key anatomy/techniques





  • General principles




    • Always assess and document neurovascular status before and after reduction



    • The periosteum on the side of the fracture to which the fragment is displaced usually remains intact



    • This periosteum forms a hinge to relocate the displaced distal fragment (see Figure 9.9)



    • The type of fracture and the degree of displacement will determine how much force and manipulation are required (see Figure 9.10)



    • After a regional block, hematoma block, or procedural sedation, traction is applied to the distal fragment with countertraction applied to the proximal fragment



    • The deformity is exaggerated if necessary, and any rotational deformity is corrected



    • The distal fragment is then reduced as the angular deformity is corrected



    • Appropriate immobilization is then applied. The method of immobilization varies with the specific injury involved



    • How do you tell if reduction is adequate?




      • Rotational deformity is completely corrected regardless of age



      • Angular deformity is corrected for adults



      • Children tolerate some angular deformity (15–20°) if it is near the joint and in the same plane of motion



      • Weight-bearing joints require precise, anatomic reduction



      • Proper length is mandatory in lower extremity injuries



      • Anatomic reduction is confirmed by repeat radiographs, portable fluoroscopy, or bedside ultrasonography as clinical assessment of reduction is difficult







Figure 9.9 A diagram of how the periosteum acts as a hinge is shown.





Figure 9.10 A: The fracture at baseline before any reduction attempt is made. Notice how the distal fragment is displaced superiorly in the photo; this could be reduced with longitudinal traction. B: Shows a distal fragment that is shortened and overlaps the proximal bone. The longitudinal traction will need to be applied to the distal fragment to disengage the bone from the proximal portion and pressure is applied to push the distal fragment into its proper position. C: Demonstrates the next step where the distal fragment is then swung into proper position. D: Shows how the well-reduced bone is properly aligned. Force was applied to points 1 and 2 while point 3 was stabilized in order to get a good reduction.



Specific sites





  • Distal radius fractures




    • Colles fracture – refer to orthopedist after reduction because of high incidence of complications (stiffness, arthritis, compartment syndromes)




      • Only reduce those without intra-articular involvement



      • Procedural sedation, hematoma block, or Bier block can be used for anesthesia



      • Longitudinal traction (finger traps if available) to disimpact the distal fracture fragment (see Figure 9.11)



      • Recreating the mechanism of injury and the position of the bony fragments at injury to relax the periosteal ligaments allows more effortless reduction of the fracture




    • Extend the wrist to 90°, with the elbow fixed and the forearm supinated, and pull the distal segment back, up, and out at approximately 120°



    • Apply dorsal pressure over distal fragment with both thumbs and apply volar pressure. With the thenar eminence of physician’s hand over fracture site, direct the fragment in an ulnar and volar direction to achieve proper position



    • Immobilize the wrist at 15° of flexion and with 20° of ulnar deviation. (Though some orthopedists prefer pronation) application of a plaster sugar tong splint or bivalve cast with the wrist held in slight flexion, with slight ulnar deviation and pronation of the forearm



    • Obtain post-reduction radiographs




      • Goals for adequate reduction



      • Restore length of radius. Normal distance from articular surface of ulnar to tip of radial styloid is 12 mm




        • Normal radial inclination is 15–30° (see Figure 9.12)


          Achieve at least a neutral volar tilt (0°). Optimally, re-establish a normal volar tilt (10–15°) (see Figure 9.13)



        • Reassess and document neurovascular status of the extremity after reduction. Document function of the median nerve and the sensory branch of the radial nerve






  • Metacarpal neck fractures




    • Evaluate for rotational deformity



    • Mechanism of injury results in angulation of distal segment toward palm (volarly); usually occurs as a result of a direct blow to the knuckles



    • Index(2nd) and middle(3rd) fingers:




      • Eliminate angulation at the fracture sites of these fingers. Patients cannot tolerate more than 10–15° angulation of these fractures. Goal is minimal angulation to precise anatomic reduction




    • Ring(4th) and little(5th) fingers:




      • The metacarpals of the ring and little fingers allow flexion and extension at carpal attachments. These patients can tolerate greater angulation at the fracture site without loss of function. Although up to 30–40° of angulation is acceptable, the goal is 10–15° of angulation or less for 4th metacarpal neck fractures and 20–30° of angulation or less for 5th metacarpal neck fractures




    • Closed reduction




      • After hematoma block, apply longitudinal traction either manually or with finger traps to disimpact the distal fragment



      • Flex the involved finger to 90° at MCP joint and 90° at PCP joint with the palm facing the floor



      • Stabilize the metacarpal and apply force longitudinally upward through the proximal phalanx to reduce angulation deformity (see Figure 9.14)



      • Immobilize with ulnar gutter splint for 4th and 5th metacarpal fractures with the wrist extended 20–30° and the MCP joint flexed 90°. Immobilize with a radial gutter splint for 2nd and 3rd metacarpal fractures



      • Metacarpal neck fractures are easy to reduce but hard to maintain. These fractures often require wire placement to maintain alignment







Figure 9.11 A: The fingers are placed in fingertraps and weight is applied to the flexed elbow in order to introduce traction that will separate the bone fragments. B: The fracture, that is under traction, is then manipulated with volar pressure to reduce the fracture. C: Longitudinal traction can be further applied to ensure proper alignment. D: A posterior arm or sugar tong splint can be applied while traction is maintained to ensure the reduction is maintained until splinted. E: The arm is shown with finished splint in place.





Figure 9.12 A goal of reduction is to ensure there is a normal radial inclination of 15–30°.





Figure 9.13 A goal of reduction is to ensure there is a normal volar tilt of 10–15°, but you need to ensure that the volar tilt is at least neutral. The volar tilt angle is shown.





Figure 9.14 In order to reduce a metacarpal shaft fracture, longitudinal traction is applied to the distal finger while palmar pressure is applied to the dorsal proximal metacarpal to cause the reduction.



Complications of closed reductions





  • Irreducible fractures



  • Failure to maintain reduction



  • Neurovascular injuries



  • Malrotation



PEARLS:




  • Closed reduction is ineffective for spiral fractures or comminuted fractures as the ends cannot be engaged to prevent shortening



  • Accurate reduction of the fracture is essential for obtaining good functional results



  • Early reduction lessens morbidity and improves patient comfort



  • Pediatric Salter–Harris Type III and IV fractures require precise anatomic reduction to prevent growth disturbance



Ankle dislocation



Key facts





  • Tibiotalar dislocations without fracture are rare and often are open dislocations caused by the amount of force required to cause the dislocation



  • Bimalleolar and trimalleolar fractures often are associated with tibiotalar subluxation or dislocation



  • Early reduction is recommended to prevent further osteochondral injury and vascular injuries



  • Subtalar dislocations are rare with medial dislocation making up 85% of these dislocations



Clinical presentation (see Chapter 5: Foot and ankle emergencies)




PEARL: Evaluate for vascular compromise, specifically dorsalis pedis artery, which is often compressed with anterior dislocations.




Fast facts





  • Lateral ankle fracture dislocations are most common, followed by posterior and then anterior. Usually there is obvious deformity of the foot and ankle with foot displaced laterally and skin very taut medially



  • Foot is usually plantar flexed and shortened



  • Decreased dorsalis pedis pulse is common with anterior dislocations



  • Open dislocations occur in up to 25% of ankle dislocations



Reduction techniques (see Figure 9.15)





  • Always flex hip and knee to 90° to relax gastroc-soleus complex



  • Posterior dislocation: Grasp heel with one hand and dorsum of mid-foot with other hand. Pull longitudinal traction and then anterior traction. Second practitioner can place hands under distal thigh and pull countertraction while hip and knee are 90° flexed. Can also perform one person reduction while patient is seated with leg hanging off edge of stretcher



  • Anterior dislocation: Grasp foot in same way as posterior dislocation. Initially dorsiflex the foot slightly to disengage the talus. Then apply axial traction followed by pushing foot posteriorly. Second practitioner can hold traction on tibia while pulling it anteriorly



  • Lateral dislocation: Apply distal traction to plantar flexed foot and then rotate to proper anatomic position





Figure 9.15 Ankle dislocation reduction. An assistant should stabilize the proximal leg as marked by the red arrow. The provider will apply longitudinal traction as noted by (1) while applying first an upward force (2) and then a downward force (3) to cause the reduction.


(Images courtesy of Ryan Friedberg, MD.)


Post reduction





  • Check pulses after reduction. If pulses are not palpable after reduction, emergent orthopedic and vascular consultation are needed



  • Splint in posterior and sugar tong splint




    • Often dislocation is very unstable and proper splinting with foot in 90° flexion is important to maintain reduction




Clavicle dislocations/fractures



Key facts





  • Sternoclavicular joint is made up of sternoclavicular ligament and costoclavicular ligament



  • Acromioclavicular joint is made up of acromioclavicular ligament, coracoclavicular ligament and coracoacromial ligament



  • Posterior sternoclavicular dislocation can be a true orthopedic emergency because of other injuries including tracheal rupture, pneumothorax, esophageal injuries or vascular injuries, thus requiring emergent reduction

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Jan 19, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 9 – Procedures for orthopedic emergencies
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