1

When is an emergent reduction of a fracture or dislocation indicated?

The majority of fractures and dislocations can either be reduced in a nonemergent fashion in the urgent care center, splinted and stabilized for future reduction, or, in the case of certain fractures, not require reduction. However, if there are any signs of neurovascular compromise, emergent reduction is indicated. Symptoms of neurovascular compromise include absent or diminished pulses, cyanosis, pallor, and/or loss of sensation or motor function distal to the fracture.

2

A 17-year-old girl has not been able to close her mouth since yawning 1 hour ago. What is another mechanism for this injury?

Mandibular dislocation can occur after prolonged or extreme mouth opening, or following a direct blow to an open mouth. Either of these mechanisms stretches the ligaments, allowing the mandibular condyles to move anterior to the articular eminence. The dislocation can be either unilateral or bilateral.

3

Why is sedation useful prior to reduction of a mandibular dislocation?

In addition to providing anxiolysis and analgesia, sedation helps to overcome the muscle spasm that prevents the patient from closing her mouth. Benzodiazepines may be particularly helpful in this respect.

4

How does one reduce a mandibular dislocation?

After wrapping his thumbs in gauze to protect them, the provider should apply downward pressure to the molars. Backward pressure to the chin or molars may also be required. This allows the condyles to slip below the articular eminence and back into the mandibular fossa.

5

What postreduction care is indicated for this patient?

The patient should be counseled to eat a soft diet and should have follow-up with otolaryngology or a maxillofacial surgeon.

6

A 20-year-old female presents after sustaining an injury to her left shoulder while playing basketball when she attempted to block a shot. X-rays confirm an anterior shoulder dislocation. How does an anterior shoulder dislocation most commonly occur?

Anterior shoulder dislocations are most commonly caused by sudden external rotation of the shoulder while in abduction (e.g., getting hit on the volar aspect of the arm while reaching for a loose ball).

7

What complications can occur during a shoulder dislocation?

A Bankhart lesion occurs when the inferior labrum is avulsed from the glenoid rim. A Hill-Sachs lesion occurs when the posterior aspect of the humeral head sustains trauma as it strikes the anterior glenoid rim. Rotator cuff tears are also common.

8

What nerve is at risk of injury from a shoulder dislocation? How do you test its function?

The axillary nerve is at risk, and its function can be tested by assessing for deltoid muscle function and sensation over the lateral aspect of the shoulder.

9

How do I best provide analgesia for reduction of a dislocated shoulder?

In addition to providing the patient with either oral or parenteral analgesia as soon as possible, additional medication may be necessary for the reduction itself, as it can be a painful procedure that requires significant force. Choices for procedural analgesia include conscious sedation or intraarticular lidocaine.

10

What are some common mechanisms to reduce an anterior shoulder dislocation?

There are many different mechanisms available for reducing a shoulder dislocation. They include (but are not limited to) external rotation, scapular manipulation, and traction–countertraction.

11

How does one reduce a shoulder using the external rotation method?

The patient lies supine or sits supported with the affected arm completely adducted and elbow flexed to 90 degrees. The elbow is then supported while the arm is slowly rotated externally. The arm is then slowly flexed at the shoulder. The technique is completed by then rotating the shoulder internally. Relocation may occur during either external or internal rotation.

12

Describe the scapular manipulation method of anterior shoulder dislocation reduction

The patient lies prone, with the affected arm hanging off the side of the bed. A weight is taped or strapped to the affected wrist to provide axial traction, or a second clinician can manually provide traction. The inferior aspect of the ipsilateral scapula is pushed medially, toward the spine, while the superior aspect is rotated laterally, away from the spine ( Fig. 45.1 ).

Scapular manipulation to reduce an anterior shoulder dislocation. The inferior aspect of the scapula is rotated toward the spine while the patient is lying in the prone position.

13

What is the traction–countertraction method of shoulder reduction?

The patient is placed supine with the affected arm abducted and elbow flexed to 90 degrees. A sheet is wrapped around the clinician’s waist and the affected forearm with the clinician stabilizing the forearm. A second clinician places a sheet around his or her waist and the patient’s trunk just below the axilla. The clinicians both lean backward, providing slow, steady traction (and countertraction), until reduction is achieved ( Fig. 45.2 ).

Traction–countertraction to reduce an anterior shoulder dislocation. The clinicians lean backward, providing steady traction until reduction is achieved.

14

How do I know that my reduction was successful?

Reduction of a dislocated shoulder is not subtle. There is usually an audible “clunk” as the humeral head returns to the glenoid fossa. Additionally, the shoulder regains its normal contour and the patient has decreased pain and increased range of motion.

15

What should I do after successful reduction of a dislocated shoulder?

Patients are at risk of redislocation as the integrity of the rotator cuff is not the same after a dislocation. The arm should be placed in a sling and the patient should have follow-up with an orthopedic surgeon.

16

When is reduction of an anterior dislocation contraindicated?

Reduction of an anterior shoulder dislocation is contraindicated if there is an associated fracture.

17

A 3-year-old girl is brought to your urgent care center for a right arm injury. Her mother was holding her hand when she tripped and fell, and she has not moved her arm since. On exam, her arm is immobile in slight flexion and pronation. What injury did this child likely sustain?

“Nursemaid’s elbow” is the most common joint injury in children less than 5 years of age, frequently resulting from traction on an outstretched and slightly pronated hand. This causes displacement and entrapment of the annular ligament at the radial head.

18

What are options for reduction of a nursemaid’s elbow?

The two options for reduction are:

• a.
  

  Supination-flexion: The arm is held in flexion at the elbow with the provider’s thumb over the radial head and the other hand holding the patient’s hand. Applying mild longitudinal traction, the provider then supinates the forearm while flexing at the elbow.

  
  
• b.
  

  Hyperpronation: The affected arm is stabilized at the elbow with the provider’s thumb over the radial head and the other hand holding the patient’s hand. Applying mild longitudinal traction, the hand can then be hyperpronated ( Fig. 45.3 ).

  
  

  
  

  
  

  

  
  

  
  

  Hyperpronation for reduction of a nursemaid’s elbow. The forearm is slowly rotated into hyperpronation, with the stabilizing hand situated to feel the reduction at the radial head.

  
  

19

How do you know if you are successful in reducing a nursemaid’s elbow?

In either technique, the provider may feel a click when the reduction is successful. As this is not always the case, the provider should observe the child to ensure function returns.

20

Is one reduction method preferable to the other?

A number of studies suggest that hyperpronation is more effective and less painful than the supination-flexion method, with success rates in one study nearly 96% in the former and only 68% in the latter (Gunaydin); however, both are commonly accepted methods of reduction.

21

How long after reduction should return of function be expected?

Function typically returns rapidly, within the first 10–15 minutes after reduction. This may take longer for a more remote injury.

22

What should the provider do if function does not return within a reasonable time frame?

If the history and physical exam are convincing for a nursemaid’s elbow, the initial maneuver may be reattempted or the alternate maneuver may be employed. If repeated attempts are unsuccessful or the diagnosis is not certain, the provider should consider imaging to evaluate for a fracture. In the absence of another injury, the arm should be placed in a sling and the child referred for outpatient orthopedic follow-up.

23

A 24-year-old playing basketball went up to grab a rebound; however, the ball bounced off the tip of his finger, resulting in significant pain and an obvious deformity. An x-ray shows a dorsal dislocation of the proximal interphalangeal (PIP) joint. What is the nomenclature used for finger dislocations?

The distal aspect of the finger is described relative to the proximal aspect. For example, in a dorsal dislocation of the PIP joint, the distal and middle phalanges are located dorsal to the proximal phalanx.

24

What is the proper analgesia for reduction of finger fractures or dislocations?

Proper analgesia can typically be obtained by performing a digital nerve block.

13

What is the traction–countertraction method of shoulder reduction?

The patient is placed supine with the affected arm abducted and elbow flexed to 90 degrees. A sheet is wrapped around the clinician’s waist and the affected forearm with the clinician stabilizing the forearm. A second clinician places a sheet around his or her waist and the patient’s trunk just below the axilla. The clinicians both lean backward, providing slow, steady traction (and countertraction), until reduction is achieved ( Fig. 45.2 ).

Traction–countertraction to reduce an anterior shoulder dislocation. The clinicians lean backward, providing steady traction until reduction is achieved.

14

How do I know that my reduction was successful?

Reduction of a dislocated shoulder is not subtle. There is usually an audible “clunk” as the humeral head returns to the glenoid fossa. Additionally, the shoulder regains its normal contour and the patient has decreased pain and increased range of motion.

15

What should I do after successful reduction of a dislocated shoulder?

Patients are at risk of redislocation as the integrity of the rotator cuff is not the same after a dislocation. The arm should be placed in a sling and the patient should have follow-up with an orthopedic surgeon.

16

When is reduction of an anterior dislocation contraindicated?

Reduction of an anterior shoulder dislocation is contraindicated if there is an associated fracture.

17

A 3-year-old girl is brought to your urgent care center for a right arm injury. Her mother was holding her hand when she tripped and fell, and she has not moved her arm since. On exam, her arm is immobile in slight flexion and pronation. What injury did this child likely sustain?

“Nursemaid’s elbow” is the most common joint injury in children less than 5 years of age, frequently resulting from traction on an outstretched and slightly pronated hand. This causes displacement and entrapment of the annular ligament at the radial head.

18

What are options for reduction of a nursemaid’s elbow?

The two options for reduction are:

• a.
  

  Supination-flexion: The arm is held in flexion at the elbow with the provider’s thumb over the radial head and the other hand holding the patient’s hand. Applying mild longitudinal traction, the provider then supinates the forearm while flexing at the elbow.

  
  
• b.
  

  Hyperpronation: The affected arm is stabilized at the elbow with the provider’s thumb over the radial head and the other hand holding the patient’s hand. Applying mild longitudinal traction, the hand can then be hyperpronated ( Fig. 45.3 ).

  
  

  
  

  
  

  

  
  

  
  

  Hyperpronation for reduction of a nursemaid’s elbow. The forearm is slowly rotated into hyperpronation, with the stabilizing hand situated to feel the reduction at the radial head.

  
  

19

How do you know if you are successful in reducing a nursemaid’s elbow?

In either technique, the provider may feel a click when the reduction is successful. As this is not always the case, the provider should observe the child to ensure function returns.

20

Is one reduction method preferable to the other?

A number of studies suggest that hyperpronation is more effective and less painful than the supination-flexion method, with success rates in one study nearly 96% in the former and only 68% in the latter (Gunaydin); however, both are commonly accepted methods of reduction.

21

How long after reduction should return of function be expected?

Function typically returns rapidly, within the first 10–15 minutes after reduction. This may take longer for a more remote injury.

22

What should the provider do if function does not return within a reasonable time frame?

If the history and physical exam are convincing for a nursemaid’s elbow, the initial maneuver may be reattempted or the alternate maneuver may be employed. If repeated attempts are unsuccessful or the diagnosis is not certain, the provider should consider imaging to evaluate for a fracture. In the absence of another injury, the arm should be placed in a sling and the child referred for outpatient orthopedic follow-up.

23

A 24-year-old playing basketball went up to grab a rebound; however, the ball bounced off the tip of his finger, resulting in significant pain and an obvious deformity. An x-ray shows a dorsal dislocation of the proximal interphalangeal (PIP) joint. What is the nomenclature used for finger dislocations?

The distal aspect of the finger is described relative to the proximal aspect. For example, in a dorsal dislocation of the PIP joint, the distal and middle phalanges are located dorsal to the proximal phalanx.

24

What is the proper analgesia for reduction of finger fractures or dislocations?

Proper analgesia can typically be obtained by performing a digital nerve block.

25

How is a digital nerve block preformed?

A classic digital nerve block involves injection of local anesthetic without epinephrine into the web spaces on both sides of the digit immediately distal to the metacarpophalangeal (MCP) joint. This should provide anesthesia for the entire digit as the dorsal and palmar digital nerves run alongside the phalanx traversing the web spaces.

13

What is the traction–countertraction method of shoulder reduction?

The patient is placed supine with the affected arm abducted and elbow flexed to 90 degrees. A sheet is wrapped around the clinician’s waist and the affected forearm with the clinician stabilizing the forearm. A second clinician places a sheet around his or her waist and the patient’s trunk just below the axilla. The clinicians both lean backward, providing slow, steady traction (and countertraction), until reduction is achieved ( Fig. 45.2 ).

Traction–countertraction to reduce an anterior shoulder dislocation. The clinicians lean backward, providing steady traction until reduction is achieved.

14

How do I know that my reduction was successful?

Reduction of a dislocated shoulder is not subtle. There is usually an audible “clunk” as the humeral head returns to the glenoid fossa. Additionally, the shoulder regains its normal contour and the patient has decreased pain and increased range of motion.

15

What should I do after successful reduction of a dislocated shoulder?

Patients are at risk of redislocation as the integrity of the rotator cuff is not the same after a dislocation. The arm should be placed in a sling and the patient should have follow-up with an orthopedic surgeon.

16

When is reduction of an anterior dislocation contraindicated?

Reduction of an anterior shoulder dislocation is contraindicated if there is an associated fracture.

17

A 3-year-old girl is brought to your urgent care center for a right arm injury. Her mother was holding her hand when she tripped and fell, and she has not moved her arm since. On exam, her arm is immobile in slight flexion and pronation. What injury did this child likely sustain?

“Nursemaid’s elbow” is the most common joint injury in children less than 5 years of age, frequently resulting from traction on an outstretched and slightly pronated hand. This causes displacement and entrapment of the annular ligament at the radial head.