Dislocation and Fracture Reductions

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Dislocation and Fracture Reductions

• Bucky Boaz, ARNP-C

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Colles Fracture Reduction

• Colles Fracture
• FOOSH
• Dorsal angulation of distal fragment.
• Dinner-fork deformity.

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Colles Fracture Reduction

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

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Colles Fracture Reduction

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

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Colles Fracture Reduction

• Apply a sugartong splint and sling.

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Colles Fracture Reduction

• Alternative Method
• While in supine position, apply finger traction
  device.
• Elbow flexed at right angle.
• Forearm is in neutral position.
• Countertraction is applied using sling and
  weight.
• Traction is maintained for approx 5 minutes to
  pull radial styloid distal to ulnar styloid.

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Colles Fracture Reduction

• Postreduction X-ray
• The normal length of the radius has been
  restored. Radial styloid is distal to ulnar
  styloid.
• The articular plane of the radius is now directed
  toward the ulna.
• The articular surface of the radius is directed
  downward, forward, and inward.

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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.

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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.

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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation
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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation

• Typical deformity (uncomplicated posterior
  dislocation)
• The forearm appears to be shortened.
• The olecranon is very prominent.

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Posterior Elbow Dislocation
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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation
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Posterior Elbow Dislocation
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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation

• Then
• While traction is maintained,
• Gently flex the forearm
• (with reduction, a click is usually felt and
  heard as the olecranon engages the articular
  surface of the humerus)

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Posterior Elbow Dislocation

• Evaluation of Stability Following Reduction
• Gently move the elbow through normal range of
  motion in flexion and extension, and
• 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

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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation

• After muscle relaxation occurs, the olecranon is
  grasped with the operators 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.

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Posterior Elbow Dislocation
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Posterior Elbow Dislocation

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

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Posterior Elbow Dislocation

• Immobilization
• Apply a posterior splint from the upper arm to
  the base of the fingers.
• Flex the elbow to 90º or as much as swelling
  permits.

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Nursemaids 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.

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Nursemaids Elbow
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Nursemaids Elbow

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

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Nursemaids Elbow
Interposition of torn Annular ligament
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Nursemaids Elbow

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

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Nursemaids Elbow

• Manipulative Reduction
• Grasp the wrist with one hand with the forearm
  extended and
• With the other, grasp the elbow with the thumb
  resting over the radial head.

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Nursemaids Elbow

• Manipulative Reduction
• As the forearm is fully supinated
• Apply firm pressure on the radial head and
• Push the forearm directly upward.

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Nursemaids Elbow
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3
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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.

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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

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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.

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Glenohumeral Dislocations
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Glenohumeral Dislocations

• Stabilizing Structures
• Ligaments
• Glenoid fossa
• Glenoid labrum
• Biceps (long head)
• Superior glenohumeral ligament
• Middle glenohumerl ligament
• Inferior glenohumeral ligament
• Subscapular process

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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.

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Glenohumeral Dislocations

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

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Glenohumeral Dislocations
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Glenohumeral Dislocations

• 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

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Glenohumeral Dislocations
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Glenohumeral Dislocations
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Glenohumeral Dislocations

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

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Glenohumeral Dislocations

• Posterior dislocation
• Violent internal rotation levers the humerus
  completely out of the glenoid fossa.
• Posterior capsule is severely torn, thus
  permitting a posterior dislocation.

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Glenohumeral Dislocations

• Types of Anterior Dislocations
• Subcoracoid dislocation (most common)
• Subclavicular dislocation (rare)
• Subglenoid dislocation (rare)

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Glenohumeral Dislocations
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Glenohumeral Dislocations

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

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Glenohumeral Dislocations
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Glenohumeral Reductions

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

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Glenohumeral Dislocations

• Stimsons Technique

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Glenohumeral Reductions

• Hippocratic Method
• Practitioners stockinged foot is place in
  between the patients chest wall and axilla folds
  but not in the axilla.
• Steady traction is maintained while the patient
  gradually relaxes.
• Shoulder is slowly rotated externally and
  abducted.
• Gentle internal rotation reduces the humeral head.

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Glenohumeral Reductions
Hippocratic Method
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Glenohumeral Reductions

• Kochers Maneuver
• Affected elbow is flexed to 90º.
• Wrist and point of elbow are gently grasped as
  the patient relaxes. (at all times the arm is
  kept pressed against the body.
• The arm is slowly externally rotated up to about
  80º where resistance is felt.

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Glenohumeral Reductions
Kochers Maneuver
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Glenohumeral Reductions

• Kochers Maneuver
• The externally rotated arm is lifted upward in
  the sagital plane as far as possible.
• The humerus is internally rotated, and the head
  gently pops into the joint as reduction is
  achieved.
• The internally rotated arm is then brought down
  against the chest with the shoulder reduced.

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Glenohumeral Reductions

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

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Glenohumeral Reductions

• Traction and Counter-traction

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Glenohumeral Reductions
Scapula Maneuver
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Glenohumeral Reductions

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

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Glenohumeral Reductions

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

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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.

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Patella Dislocation

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

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Patella Dislocation
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Patella Dislocation
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Patella Dislocation

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

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Patella Dislocation

• Manipulative Reduction
• Extend the knee gradually while,
• Medialward pressure is made upon the patella,
  pushing it over the lateral femoral condyle.

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Questions?