Treatment approach

For joint dislocation, this is often closed reduction as soon as possible to decrease potential complications including soft tissue injury, articular surface injury, and neurovascular compromise. Reduction usually requires sedation and analgesia. A period of immobilisation should be followed by active motion exercises and isometric strengthening exercises.

Shoulder 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 stabilisation 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]

Once the diagnosis has been confirmed, reduction should be attempted. For a successful outcome, adequate analgesia and sedation are necessary before the reduction procedure is attempted. 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). Procedural sedation has the added advantage of reducing spasm in the muscles of the rotator cuff. 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. Monitoring should begin before any medicines are administered and continue until the patient is fully awake. Multiple studies have shown that local anaesthesia on its own is equivalent to intravenous sedation. [36] [37] [38] However, this should be reserved for patients with contraindications to procedural sedation.

Each reduction method works by abduction and external rotation to disengage the humeral head from the glenoid, with axial traction to reduce it. The following are examples of reduction manoeuvres for anterior dislocations.

Traction-countertraction method

• The patient is placed supine on the bed. A sheet is looped around the axilla with one free end on the chest and the other underneath the back. The 2 ends should be of even length. An assistant uses these free ends to apply countertraction. Then the practitioner abducts the arm to 90° and flexes the elbow to 90°. With the forearm, slow longitudinal traction is then applied to the affected extremity. View image

Milch's or modified Milch's technique

• This was initially described by Milch in 1938. The modified technique has been reported to be effective in 100% of dislocations without the use of sedation. [39] The patient is positioned supine on a bed with the head of the bed elevated approximately 20° to 30°. The arm is slowly abducted and externally rotated without application of longitudinal traction. The practitioner pauses in the case of pain or resistance. View image Once the arm has reached a position of 90° abduction and 90° external rotation, the shoulder should spontaneously reduce. If not, the humeral head can be palpated in the axilla, and superolateral pressure can then be applied using the thumb and index finger to help guide the humeral head back into the glenoid. [26] [39] View image

Stimson's method or scapular manipulation technique

• This method is reported to be effective in 96% of shoulder dislocations. [40] The patient is positioned prone on the stretcher with the affected shoulder slightly off the stretcher. The arm is placed perpendicular to the floor (90° forward flexion) with the stretcher high enough to keep the hand from resting on the floor. Weights of 2.3 to 4.5 kg or 1-L bottles of sterile water are wrapped around the wrist using stockinette and hung high enough to not touch the floor. View image Reduction should occur within 10 to 20 minutes. Reduction can be facilitated by external rotation or application of the scapular manipulation technique. For this, one hand is placed on the superolateral border of the scapula with the other hand on the inferomedial border of the scapula, and pressure is applied to rotate the superior border laterally and the inferior border medially. [26] [40] View image

Sitting scapular manipulation technique

• The patient sits upright with an assistant applying scapular pressure as described in the scapular manipulation technique. The practitioner then flexes the affected arm to 90°, placing one hand on the clavicle and the other on the wrist. Gentle traction is applied to the arm with pressure applied to the clavicle. Simultaneously, the assistant performs the scapular manipulation.

Spaso technique

• This is reported to be effective in 88% of shoulder dislocations. [41] The patient is positioned supine on the bed. The affected shoulder is slowly forward flexed to 90°. Gentle longitudinal traction is applied while the shoulder is slowly externally rotated. Care must be taken to keep the medial border of the scapula firmly pressed against the bed.

External rotation method

• This was initially described by Leidelmeyer and is reported to be successful in 78% of patients. [38] The patient is positioned supine on the bed and the affected extremity is gently adducted until it is parallel to the long axis of the body. The elbow is then flexed to 90°. View image By applying gentle pressure to the wrist, the practitioner slowly externally rotates the arm, taking time to allow spasms and contractions to pass. Finally, the arm is externally rotated to 90° (i.e., perpendicular to the long axis of the body). View image After approximately 5 minutes, the shoulder should reduce.

Kocher's method

• This method is more complex than other methods and may be associated with complications (e.g., fractures, brachial plexus injury and vascular injury). It uses in-line traction of the arm while abducted to 45°. While traction is maintained, the arm is externally rotated and the elbow is brought across the chest to the mid-line. View image The arm is then internally rotated until the patient's hand touches the shoulder. View image

FARES (Fast Reliable and Safe) method

• The physician holds the hand of the patient at the patient's side with the elbow extended and in neutral rotation. Longitudinal traction is applied and the arm is moved into abduction (no countertraction needed). As the arm is abducted, short vertical oscillations are performed to relax the musculature. As the arm passes 90° of abduction, the arm is then externally rotated, and at 120° of arm abduction, the arm typically reduces. When compared with the Kocher and traction-countertraction methods, this method is faster and requires less sedation. [42]

Irrespective of the technique used, upon reduction the physician should feel a distinct clunk as the shoulder reduces. The arm should be immobilised and placed in a sling or a sling and swathe. An anteroposterior (AP) and lateral x-ray 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 examination, with emphasis on the axillary, radial, ulnar, and median nerves. The vascular status of the hand should also be re-assessed to ensure that the axillary or brachial artery has not been injured during the reduction.

The patient should wear the sling for approximately 3 weeks. In subsequent weeks, active-assisted range of motion and isometric strengthening exercises should be advised. Generally, by week 12, limited return to sporting activities is permitted, followed by full return to sporting activities as tolerated by week 16.

Finger dislocation

The goal of treatment for finger dislocations is to restore joint congruity by means of closed reductions. Certain situations can make a congruent joint dislocation difficult. These include volar plate entrapment, volar dislocations, and fracture dislocations.

Reduction of finger dislocation often requires the use of a local anaesthetic, typically lidocaine 1%. A neurovascular examination of the digit is essential before reduction is performed because the local anaesthetic may cause complete hypoaesthesia of the finger. Two sets of nerves run on the radial and ulnar side of each digit. Generally, the dorsal nerves lie on the 10-o'clock and 2-o'clock positions, while the palmar digital nerves lie on the 8-o'clock and 4-o'clock positions. Infiltration of lidocaine in these quadrants results in effective anaesthesia for reducing a dislocated finger.

Dorsal PIP and DIP dislocations

• The first step in reduction is to recreate the injury by hyper-extending the PIP or DIP. This should be followed by light axial traction applied to the finger with pressure applied to the base of the dislocated digit until the joint is relocated. Occasionally, these joints will not reduce because of entrapment of the volar plate, and consultation with a hand surgeon will be required. If the joint is stable, buddy taping to an adjacent digit or placement of a splint in slight flexion is an appropriate measure. Neutral splinting for dorsal PIP dislocations can also be used and is reported to avoid post-splinting flexion contractures. [43] Post-reduction x-rays should be obtained to confirm congruency of the joint and to ensure that there are no associated fractures. [10]

Volar DIP and PIP dislocations

• These are more likely to be unstable, but the goals of reduction are the same as for dorsal dislocations. The finger should be flexed with mild axial traction applied to the digit. The physician should then apply pressure to the base of the digit until reduction is complete. Post-reduction x-rays should be obtained to confirm congruence of the joint and to ensure that there are no associated fractures. The finger should be placed in an extension splint immobilising the smallest number of joints possible. If concentric reduction is not possible because of soft tissue entrapment, consultation with a hand surgeon is warranted.

MCP dislocation

• With simple dislocations, the finger is usually held in extension, and there is some contact between the joint surfaces. The wrist should be flexed to relax the flexor tendons, and the affected digit should then be hyper-extended. The physician should then apply a volar-directed pressure to the dorsum of the affected digit. It is paramount that excessive traction not be applied, as a simple dislocation can be converted into a complex MCP dislocation with significant soft tissue entrapment. If this occurs, the joint will often become irreducible and require operative treatment. [17] [44]

Simple dislocations can be buddy taped, while fracture dislocations require immobilisation in a splint. Post-reduction x-rays should be obtained to confirm congruence of the joint and to ensure that there are no associated fractures. Following reduction, the physician should ensure adequate perfusion to the finger by assessing capillary refill. Post-reduction, patients should begin protected range of motion as pain permits. In treating finger dislocations, instituting early motion and providing stability must be balanced.

Patellar dislocation

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. Patellar dislocations have been reported to be accompanied by intra-articular lesions in 5% to 71% cases. [11] [27] [28] In these cases, orthopaedic consultation is warranted, as open reduction surgery may be required.

For a successful outcome, adequate analgesia and sedation is necessary before the reduction procedure is attempted. Lateral dislocation is easily managed using local anaesthesia (i.e., intra-articular lidocaine) combined with procedural sedation (e.g., intravenous morphine, midazolam, or etomidate). Procedural sedation has the added advantage of reducing muscle spasm. 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. Monitoring should begin before any medicines are administered and continue until the patient is fully awake.

Following adequate analgesia and sedation, 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 the patient advised to bear weight on the joint as tolerated.

Merchant, 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. Post-reduction, patients should begin protected range of motion as pain permits.

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]

Elbow dislocation

For a successful outcome, adequate analgesia and sedation are necessary before the reduction procedure is attempted. The reduction is usually performed using local anaesthesia (i.e., intra-articular lidocaine) combined with procedural sedation (e.g., intravenous morphine, midazolam, or etomidate). Procedural sedation has the added advantage of reducing muscle spasm. 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. Monitoring should begin before any medicines are administered and continue until the patient is fully awake.

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 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 examination, with emphasis on the radial, ulnar, and median nerves. The vascular status of the hand should also be re-assessed to ensure that the brachial artery has not been injured during the reduction. Several studies have shown better outcomes with early mobilisation than with immobilisation in patients with simple dislocations. Patients should initially be splinted in a posterior splint for comfort with instructions to begin mobilisation when pain permits. Immobilisation should last no longer than 2 weeks. [14] [47] [48] [49] [50]