Dislocations (HB)

Reduction of dislocations is one of the allowed extended transport protocols.

We will only reduce dislocations for injuries created with an indirect force (or a rotational force). We do not reduce the dislocation created by a direct force because the force needed will likely have caused other damage to the joint. This could include an avulsive Tear of the bone or even fully snapping the tendons and ligaments.

Also, we need to understand that reducing is a gentle smooth action. You’re not Mel Gibson in Lethal Weapon – you do not slam or use force to restore the joint. You need to be careful about the language you do use in your notes. Do not say, “I am going to pop the joint back into place.”–that could indicate to a downstream provider that you did not safely reduce the joint.

After reducing a dislocated joint, you need to check CSM (and continue checking throughout your extraction).

Digit

Digits are relatively easy to reduce. It does not take a lot of force to dislocate a digit. The tendons and connective tissue that hold the bones in place are relatively small but not very well protected with muscle or other tissues.

Anchor the person’s arm to your body and, with one hand, grab the part of the digit just below the dislocation. With a piece of gauze for traction, hold the part of the digit above the dislocation and gently pull traction out and away while attempting to realign the digit. It should not take a lot of force, and the digit should slide back into place.

You can protect the digit by splinting it to an adjacent digit or cutting a small piece of an aluminum splint and using it to secure the digit.

Patella

The patella is an easy dislocation to reduce. It is crucial to make the distinction that we are not reducing a dislocated knee.

The patella is generally dislocated with patient plants on a foot and rotates their body in that direction. You see this in soccer and other sports where there are lots of pivoting movements. The lower part of the leg stays anchored to the ground, and the body’s mass causes everything above the knee to rotate. The patella then slides to the outside of the leg.

The patellar tendons are very thick and strong. Once the patella has dislocated, these tendons contract and cause the leg to bend uncontrollably.

Reducing a dislocated patella is pretty straightforward. Position yourself on the outside of the patient’s leg. On the side closest to the patient’s torso, place a hand just above the patient’s knee and place the thumb below the patella supporting it. Put the other hand below the calf. Then gently begin straightening the leg while supporting it and while applying upward pressure to the patella with the thumb.

After the patella has slipped back into position, you will want to support it by taping above and below the knee. You can also run a couple of lines of tape starting above the knee, running under the patella and back up to the other side of the knee, and then starting below the knee, running up over the top of the patella and back down to the other side of the knee. Do not attempt to reduce the patella if it is on the inside of the leg. Dislocations of the patella to the inside are a result of a direct impact on the knee.

Shoulder

https://www.youtube.com/watch?v=MkdCGV_MOCM

The shoulder is the most challenging dislocation that we will reduce. We must ensure the mechanism was from an indirect force. The shoulder is a very complex joint. Several bones come together, and there are a lot of muscles, tendons, and ligaments involved. There is also a large neurovascular bundle that supplies the entire arm.

Typically the shoulder will dislocate down and slightly toward the front of the chest. It only really needs to get outside of the shoulder socket itself. You can confirm that the shoulder is dislocated because the patient will be unable to touch their opposite shoulder with their fingertips.

A lot of large muscles surround the shoulder socket. You need to overcome and fatigue these muscles to allow the shoulder to reduce.

The easiest method to reduce the shoulder is using the Cunningham method. This is demonstrated in the above video, but we will repeat the steps and note specific checkpoints.

First, you need to have the patient sitting upright. If they are leaning, it will make it much more difficult. Next, position yourself to the outside of the arm that has been dislocated. You want to provide firm downward traction on the arm. The easiest way is to grab hold of the arm just above the elbow and have the patient’s arm resting over yours. Then you can use a downward force to apply the traction. While applying that traction, you will need to massage the muscles above the shoulder and the arm’s top. These muscles will be the trapezius and the deltoid.

As you are massaging and applying downward traction, you can (gently) start externally rotating the lower arm. You want to keep the humerus as vertical as possible.

In most cases, once the muscles relax, the connective tissue’s elasticity will help pull the joint back together. After the shoulder is back in place, you should sling and swathe it to protect it from coming out again.