1. Dislocation and Fracture Reductions Bucky Boaz, ARNP-C

2. Colles’ Fracture Reduction Colles’ Fracture FOOSH Dorsal angulation of distal fragment. Dinner-fork deformity.

3. Colles’ Fracture Reduction Closed Reduction Method 1. An assistant holds the elbow and offers countertraction. 2. Apply traction with the right hand and thumb applied to the distal fragment. 3. The forearm is supinated and held with the opposite hand. 4. The fracture is then disimpacted by allowing dorsal angulation while maintaining supinated position.

4. Colles’ Fracture Reduction Then 1. The reduction is locked by pronating the forearm and wrist. 2. The left hand remains stationary while pronation is done entirely by the reducing hand. 3. The wrist is directed into ulnar deviation by this maneuver to correct a radial and dorsal angulation of the distal fragment.

5. Colles’ Fracture Reduction Apply a sugartong splint and sling.

6. Colles’ Fracture Reduction Alternative Method 1. While in supine position, apply finger traction device. 2. Elbow flexed at right angle. 3. Forearm is in neutral position. 4. Countertraction is applied using sling and weight. 5. Traction is maintained for approx 5 minutes to pull radial styloid distal to ulnar styloid.

7. Colles’ Fracture Reduction Postreduction X-ray 1. The normal length of the radius has been restored. Radial styloid is distal to ulnar styloid. 2. The articular plane of the radius is now directed toward the ulna. 3. The articular surface of the radius is directed downward, forward, and inward.

8. Posterior Elbow Dislocation Except for the shoulder, the elbow is the joint most frequently dislocated, and in children less than 10 years of age elbow dislocation occurs more than any other luxation. Considerable violence is absorbed and 30-40% are associated with adjacent fractures.

9. Posterior Elbow Dislocation Dislocated elbows are at risk of vascular injury. (not as high as supracondylar fractures) Due to extent of trauma, posterior splinting after reduction better than casting. Usually, reduction is quite simple. Most elbows are stable after reduction.

10. Posterior Elbow Dislocation Typical mechanism of an elbow dislocation 1. A fall backward on the arm with the elbow in a flexed position and 2. The forearm supinated is the most common mechanism. 3. The injury causes radius and ulna to dislocate posterior to the humerus. 4. There may also freq. Be an associated fracture of the radial head or 5. The coracoid process of the ulna.

11. Posterior Elbow Dislocation

12. Pathophysiology 1. Soft tissue injury associated with dislocation progresses in a circle from lateral to medial in three stages. 2. The lateral capsule fails first, followed by the anterior and posterior capsule. 3. Complete or partial disruption of the medial collateral ligament may also occur with severe injury.

13. Posterior Elbow Dislocation Typical deformity (uncomplicated posterior dislocation) 1. The forearm appears to be shortened. 2. The olecranon is very prominent.

14. Posterior Elbow Dislocation

15. Prereduction X-ray Lateral view 1. Both bones of the forearm are displaced 2. The coronoid process of the ulna impinges on the posterior aspect of the humerus in the olecranon fossa AP View 3. Look for displacement 4. Radius and ulna likely to maintain anatomic position in relation to each other

16. Posterior Elbow Dislocation

18. Anesthesia for Reduction 1. Insert a 20-gauge needle into the joint proximal to the dislocated radial head. 2. Aspirate hemarthrosis. 3. Inject 10cc anesthetic and wait 10 minutes before reduction.

19. Posterior Elbow Dislocation Manipulative Reduction 1. While an assistant holds the arm and makes steady countertraction, 2. Grasp the wrist with one hand and make steady traction on the forearm in the position in which it lies. 3. While traction is maintained, correct any lateral displacement with the other hand.

20. Posterior Elbow Dislocation Then 1. While traction is maintained, 2. Gently flex the forearm (with reduction, a click is usually felt and heard as the olecranon engages the articular surface of the humerus)

21. Posterior Elbow Dislocation Evaluation of Stability Following Reduction 1. Gently move the elbow through normal range of motion in flexion and extension, and 2. Medial and lateral stressing. If the elbow is unstable, several diagnoses are possible: (a) in a child, entrapment of the medial epicondyle; (b) in an adult, unstable fracture of radial read or olecranon; or (c) medial or lateral disruption of the capsule

22. Posterior Elbow Dislocation Quigley Technique 1. Patient is prone on table 2. Forearm is allowed to dangle toward the floor and 3. Operator applies traction by grasping the wrist and slowly pulling in the direction of the long axis of the forearm. (Gently)

23. Posterior Elbow Dislocation 4. After muscle relaxation occurs, the olecranon is grasped with the operator’s other hand using the thumb and index finger. The olecranon is then guided to the reduced position without force. In this way, medial or lateral components of the dislocation can be controlled and corrected.

24. Posterior Elbow Dislocation

25. Postreduction X-ray 1. The articular surface of the humerus is in its normal position in relation to the ulna. 2. Both bones have been restored from a lateral position to their normal position in relation to the humerus.

26. Posterior Elbow Dislocation Immobilization 1. Apply a posterior splint from the upper arm to the base of the fingers. 2. Flex the elbow to 90º or as much as swelling permits.

27. Nursemaid’s Elbow Relatively common disorder in children between 1 to 4 years of age. Sudden traction on the extended pronated forearm is the usual mechanism. X-ray examination tends to be normal. The child resists any movement of the elbow. Parents usually present the child with complaint of wrist pain.

28. Nursemaid’s Elbow

29. Pathology 1. The mechanism of this injury is a tear of the distal attachment of the orbicular ligament. 2. The radial head is able to slip partially through this ligament with the forearm pronated. 3. The orbicular ligament then becomes interposed between the articular surface of the radial head and the capitellum.

30. Nursemaid’s Elbow Interposition of torn Annular ligament

31. Nursemaid’s Elbow Presentation 1. The patient is a young child (less than 4 years old) 2. The elbow is tender laterally, but it can be moved in flexion and extension. 3. The child holds the arm pronated and slightly flexed and refuses to supinate it.

32. Nursemaid’s Elbow Manipulative Reduction 1. Grasp the wrist with one hand with the forearm extended and 2. With the other, grasp the elbow with the thumb resting over the radial head.

33. Nursemaid’s Elbow Manipulative Reduction 1. As the forearm is fully supinated 2. Apply firm pressure on the radial head and 3. Push the forearm directly upward.

34. Nursemaid’s Elbow 1 2 3

35. Glenohumeral Dislocations The glenohumeral joint is the most mobile and unstable joint in the body. Only 25-30% of the humeral head is covered by the glenoid in any position. The capsule of the shoulder is a relatively lax and redundant structure to allow the wide mobility required of the glenohumeral articulation.

36. Glenohumeral Dislocations The capsule is particularly important is resisting anterior or posterior dislocation of the humeral head out of the relatively shallow glenoid. The major force preventing downward dislocation of the glenohumeral joint is the net effect of suction. The muscles about the shoulder contribute minimally to shoulder stability. For most patients with shoulder instability, the major defect is caused by the capsular ligaments and attachments of these ligaments to the glenoid and glenoid labrium

37. Glenohumeral Dislocations 1. Capsule is extremely loose and redundant superiorly and inferiorly. 2. Only 30% of humeral head is covered by or articulates with glenoid. 3. Biceps tendon helps seal off capsule contributing to suction effect.

38. Glenohumeral Dislocations

39. Stabilizing Structures Ligaments 1. Glenoid fossa 2. Glenoid labrum 3. Biceps (long head) 4. Superior glenohumeral ligament 5. Middle glenohumerl ligament 6. Inferior glenohumeral ligament 7. Subscapular process

40. Glenohumeral Dislocations Cause of dislocation If rotation of the humerus is obstructed, the greater tuberosity impinges against the acromion and becomes locked in this position. Forcing the humerus beyond the locked position results in either a dislocation or a fracture of the humerus. Most individuals sustain an anterior dislocation from vigorous activities, i.e. sports.

41. Glenohumeral Dislocations Mechanism for Anterior Dislocation 1. Acromion impinges against the greater tuberosity and levers out of the joint anteriorly. 2. Anterior ligaments and capsule are severely stretched and torn, thus permitting a dislocation.

42. Glenohumeral Dislocations

43. X-rays AP view of the shoulder should be perpendicular to the plane of the scapula rather than standard AP shoulder view. Permits full view of glenoid rim

44. Glenohumeral Dislocations

46. X-rays Careful axillary views may also show avulsion fractures of the anterior rim

47. Glenohumeral Dislocations Posterior dislocation 1. Violent internal rotation levers the humerus completely out of the glenoid fossa. 2. Posterior capsule is severely torn, thus permitting a posterior dislocation.

48. Glenohumeral Dislocations Types of Anterior Dislocations Subcoracoid dislocation (most common) Subclavicular dislocation (rare) Subglenoid dislocation (rare)

49. Glenohumeral Dislocations

50. Typical Deformity of Subcoracoid Dislocation 1. Arm is fixed in slight abduction and directed upward and inward. 2. Shoulder is flattened. 3. Acromion process is unduly prominent. 4. Elbow is flexed. 5. Forearm is rotated internally. 6. Abnormal prominence exists in the subcoracoid region.

51. Glenohumeral Dislocations

52. Glenohumeral Reductions Stimson’s Technique This should be tried first (least traumatic) 1. Patient is prone on the edge of the table 2. Then 10-kg weights are attached to the arm, and the patient maintains this position for 10-15 min. 3. Occasionally, gentle external and internal rotation of the shoulder aids in reduction.

53. Glenohumeral Dislocations Stimson’s Technique

54. Glenohumeral Reductions Hippocratic Method 1. Practitioner’s stockinged foot is place in between the patient’s chest wall and axilla folds but not in the axilla. 2. Steady traction is maintained while the patient gradually relaxes. 3. Shoulder is slowly rotated externally and abducted. 4. Gentle internal rotation reduces the humeral head.

55. Glenohumeral Reductions Hippocratic Method

56. Glenohumeral Reductions Kocher’s Maneuver 1. Affected elbow is flexed to 90º. 2. Wrist and point of elbow are gently grasped as the patient relaxes. (at all times the arm is kept pressed against the body. 3. The arm is slowly externally rotated up to about 80º where resistance is felt.

57. Glenohumeral Reductions Kocher’s Maneuver

58. Glenohumeral Reductions Kocher’s Maneuver 1. The externally rotated arm is lifted upward in the sagital plane as far as possible. 2. The humerus is internally rotated, and the head gently pops into the joint as reduction is achieved. 3. The internally rotated arm is then brought down against the chest with the shoulder reduced.

60. Glenohumeral Reductions Traction and Counter- traction 1. For larger patients or if help is available, wrap a swathe through the axilla to stabilize chest. 2. After sedation, gentle traction for 5-10 min at the arm in line with deformity. 3. Gradually increase traction and internally or externally rotate to disengage head of humerus. 4. With gentle maneuver, head slips into socket.

61. Glenohumeral Reductions Traction and Counter-traction

62. Glenohumeral Reductions Scapula Maneuver

63. Postreduction X-ray The head of the humerus should be in normal relationship to the glenoid cavity. No fracture should be evident. Glenohumeral Reductions

64. Before and after techniques examine patient for neurovascular involvement. Post reduction immobilize patient in a sling and swathe. Glenohumeral Reductions

65. Patella Dislocation Most often occurs in persons susceptible to instability of the patella because of a high riding (patella alta) or abnormality of a laterally displaced patella in a valgus knee (increased Q- angle) Most often, the high riding patella subluxates or dislocated with a sudden twisting of the extended or slightly flexed knee.

66. Patella Dislocation Mechanism of Acute Dislocation 1. Typically, the patient bears weight on the slightly flexed knee, and 2. A sudden external rotation or twisting load to the femur causes the patella to slide superiorly over the lateral femoral condyle. 3. As the knee flexes, the patella jumps over the lateral condyle and the knee collapses.

67. Patella Dislocation

69. Prereduction X-ray 1. The patella lies on the lateral aspect of the lateral femoral condyle. 2. The patella is displaced slightly downward.

70. Patella Dislocation Manipulative Reduction 1. Extend the knee gradually while, 2. Medialward pressure is made upon the patella, pushing it over the lateral femoral condyle.

71. Questions?