Joint dislocation

Patients under 25 years of age should be referred to an orthopaedic surgeon for assessment, as this age group is at significant risk for recurrence and the literature has begun to support primary stabilization for high-risk patients with dislocations. [34] There is evidence to recommend surgical intervention via an anatomic Bankart's repair as opposed to simple arthroscopic lavage or non-operative treatment for young patients with a first-time shoulder dislocation. A Cochrane review concluded that short-term quality of life and recurrent instability were significantly improved and decreased, respectively, with anatomic Bankart's repair. [35]

There are numerous reduction manoeuvres for shoulder injuries, which are usually performed under local anaesthesia (i.e., intra-articular lidocaine) combined with procedural sedation (e.g., intravenous morphine, midazolam, or etomidate).

The choice for sedation depends on the treating physician and must be accompanied by continuous monitoring of the patient with capnography and pulse oximetry, as well as frequent blood pressure measurements.

Local anaesthesia on its own should be reserved for patients with contraindications to procedural sedation.

Each of the reduction methods works by abduction and external rotation to disengage the humeral head from the glenoid, with axial traction to reduce it.

The arm should be immobilised and placed in a sling or a sling and swathe.

An anteroposterior (AP) and lateral radiograph should be obtained to confirm reduction of the humeral head, and to ensure that no iatrogenic fractures have occurred during the reduction. View image

Once the patient is alert, it is important to perform a neurological and vascular examination.

The patient should wear the sling for approximately 3 weeks.

Patellar dislocation often presents to the emergency department or to the clinic having already spontaneously reduced.

However, once an acute dislocation is diagnosed, a reduction should be subsequently performed with the goal being the concentric reduction of the patella into the femoral notch.

Lateral dislocation is easily managed using local anaesthesia (i.e., intra-articular lidocaine) combined with procedural sedation (e.g., intravenous morphine, midazolam, or etomidate). The choice for sedation depends on the treating physician and must be accompanied by continuous monitoring of the patient with capnography and pulse oximetry, as well as frequent blood pressure measurements.

Local anaesthesia on its own should be reserved for patients with contraindications to procedural sedation.

Following adequate analgesia, the patient should be placed either supine or in a seated position.

The affected knee should be flexed to decrease the tension on the quadriceps muscle.

The physician should apply a medial-directed force to the lateral aspect of the patella while slowly extending the leg.

A palpable clunk should confirm reduction of the patella.

Upon successful reduction, the affected extremity should be placed in a knee immobiliser and patient advised to bear weight on the joint as tolerated.

Merchant, anteroposterior (AP), and lateral knee plain x-rays should be ordered to ensure that the patella is reduced. The x-rays should be closely examined for evidence of any osteochondral defects that may have been created during the reduction.

In cases of intra-articular lesions, orthopaedic consultation is warranted, as open reduction surgery may be required.

A Cochrane review revealed a need for large multicentre clinical trials to determine whether surgical or non-operative management is best suited for the management of both primary and recurrent patellar dislocation. [45]

Reduction is usually performed using local anaesthesia (i.e., intra-articular lidocaine) combined with procedural sedation (e.g., intravenous morphine, midazolam, or etomidate). The choice for sedation depends on the treating physician and must be accompanied by continuous monitoring of the patient with capnography and pulse oximetry, as well as frequent blood pressure measurements.

Local anaesthesia on its own should be reserved for patients with contraindications to procedural sedation.

The patient should be supine on the bed with the physician positioned on the affected side with an assistant close to the head of the bed. In young children, head subluxation/dislocation (nursemaid’s elbow) may be more effective and less painful when performed with the arm in pronation as opposed to supination. [46]

The arm should be initially extended to 30° flexion.

The overall gross alignment of the elbow is then manipulated so that the olecranon appears centred between the medial and lateral condyle of the humerus.

The forearm is then slowly flexed to approximately 90° with the physician providing longitudinal traction to the forearm while the assistant provides countertraction to the patient's humerus.

The arm is then flexed even further with direct downward pressure applied to the olecranon. [23]

If reduction is successful, the physician should feel an audible clunk as the elbow is reduced.

It is important not to flex the arm forcefully if there is significant resistance because the coronoid process is typically perched on the distal humerus. Forceful flexion without adequate traction can cause a fracture of this structure, which will result in future instability.

Upon reduction, the arm is placed in a posterior splint at 90° flexion with neutral rotation of the forearm. [23]

An anteroposterior (AP) and lateral plain film radiograph of the elbow should be obtained to ensure that the joint is concentrically reduced. View image

Once the patient is alert, it is important to perform a neurological and vascular examination.