1. Upper Limb Dislocations Keith Stafford Profession Teaching Fellow

2. Dislocation Definition : Loss of congruity between the articular surfaces of a joint Therefore displacement usually complete The head of the humerus becomes completely separated from the glenoid fossa of the scapula May be complicated by fracture

3. History Shoulder dislocations May be recurrent, and if so may be trivial history Trauma, force/axial loading from falls and motor bike accidents (e.g. tackler in rugby) Seizures

4. Subluxation AKA partial dislocation Loss of contact of the articulating surfaces is notable but incomplete May proceed to complete dislocation

5. Presentation PAIN +++ Arm guarded in the most comfortable position Often a kinking noted to the outer contour of the shoulder

6. Examination Neurovascular examination,including axillary/circumflex nerve Wounds or other injuries Palpate the outer edge of the acromion

7. Anterior dislocation

8. Posterior dislocation

9. Inferior dislocation/luxio erecta

10. Reduction Reduction is required and needs to be as soon as possible Reduction is often reported to be painful and traumatic. Consider analgesia/sedation Failure to reduce

11. Fares technique: reduction of anterior shoulder dislocation http://www.youtube.com/watch?v=NXFPWxSTK5c

12. Other techniques Kochers/external rotation Stimpsons Milch

13. Treatment/follow up Sling Analgesia Orthopaedic clinic

14. Elbow dislocations Often results from fall onto the outstretched hand Often confused with supracondylar fracture As always assess for neurovascular compromise

15. Radiology

16. Aftercare Post reduction radiographs Above elbow backslab Orthopaedic follow-up

17. Anterior elbow dislocation

18. Finger dislocations

19. Carpal dislocations

20. Carpal dislocations (2)

21. References. Mcrae R and Essler M (2008) Practical fracture treatment. Elsevier. Gudena, R., K. P. Iyengar, et al. (2011). "Irreducible shoulder dislocation - a word of caution." Orthopaedics & traumatology, surgery & research 97(4): 451-453 Huang, I. Y., C. M. Chen, et al. (2011). "Management of long-standing mandibular dislocation." International Journal of Oral & Maxillofacial Surgery 40(8): 810-814 Chechik, O., M. Khashan, et al. (2011). "[Primary anterior shoulder dislocation]." Harefuah 150(2): 117-12 Blaivas, M., S. Adhikari, et al. (2011). "A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department." Academic Emergency Medicine 18(9): 922-927. Longo, U. G., P. E. Huijsmans, et al. (2011). "Video analysis of the mechanisms of shoulder dislocation in four elite rugby players." Journal of Orthopaedic Science 16(4): 389-397. Ashton, H. R. and Z. Hassan (2006). "Best evidence topic report. Kocher's or Milch's technique for reduction of anterior shoulder dislocations." Emergency Medicine Journal 23(7): 570-571. Baykal, B., S. Sener, et al. (2005). "Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic emergency department." Emergency Medicine Journal 22(5): 336-338 Caudevilla Polo, S., E. Estebanez de Miguel, et al. (2011). "Humerus axial traction with acromial fixation reduction maneuver for anterior shoulder dislocation." Journal of Emergency Medicine 41(3): 282-284

22. References Cunningham, N. (2003). "A new drug free technique for reducing anterior shoulder dislocations." Emergency Medicine (Fremantle, W.A.) 15(5-6): 521-524 Dannenbaum, J., C. A. Krueger, et al. (2012). "A review of reduction techniques for anterior glenohumeral joint dislocations." Journal of Special Operations Medicine 12(2): 83-92. Fernandez-Valencia, J. A., J. Cune, et al. (2009). "The Spaso technique: a prospective study of 34 dislocations." American Journal of Emergency Medicine 27(4): 466-469. Harnroongroj, T., J. Wangphanich, et al. (2011). "Efficacy of gentle traction, abduction and external rotation aneuver under sedative-free for reduction of acute anterior shoulder dislocation: retrospective comparative study." Journal of the Medical Association of Thailand 94(12): 1482-1486. Hunter, B. and L. Wilbur (2012). "Can intra-articular lidocaine supplant the need for procedural sedation for reduction of acute anterior shoulder dislocation?" Annals of Emergency Medicine 59(6): 513-514. Marinelli, M. and L. de Palma (2009). "The external rotation method for reduction of acute anterior shoulder dislocations." Journal of Orthopaedics & Traumatology 10(1): 17-20. Sahin, N., A. Ozturk, et al. (2011). "A comparison of the scapular manipulation and Kocher's technique for acute anterior dislocation of the shoulder." Eklem hastaliklari ve cerrahisi = Joint Diseases & Related Surgery 22(1): 28-32. Sayegh, F. E., E. I. Kenanidis, et al. (2009). "Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods." Journal of Bone & Joint Surgery - American Volume 91(12): 2775-2782. Tudor, B. C., R. E. Norris, et al. (2010). "Anterior shoulder dislocation: the scapular manipulation technique." Academic Emergency Medicine 17(6): e40 Ufberg, J. W., G. M. Vilke, et al. (2004). "Anterior shoulder dislocations: beyond traction- countertraction." Journal of Emergency Medicine 27(3): 301-306