BONES AND BRUISES
| ADVANCED TIPS FOR REDUCTION OF JOINT DISLOCATIONS —Gregory W. Hendey, MD, Associate Clinical
Professor of Medicine, Emergency Medicine, University of California, San Francisco, School of Medicine, and Research
Director, UCSF Fresno Medical Education Program
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| General principles: joints sacrifice stability for mobility; stable joints (eg, elbow) difficult to dislocate; joints with large
range of motion (eg, shoulder) have fewer bony limitations and dislocate more easily; nomenclature—dislocation described
by movement of distal fragment relative to proximal fragment
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| Muscle spasm: primary obstacle when reducing dislocations of large joints; many patients require sedation and analgesia;
procedural sedation sometimes necessary; options for procedural sedation—cocktail of midazolam and fentanyl
commonly used; methohexital has fast onset of action and short duration (was temporarily removed from market); etomidate
fast-acting and associated with good cardiovascular stability, but problems with myoclonus (disadvantage
when reducing dislocated joint); propofol has fast onset of action, short duration, and fewer problems with myoclonus
(good option for sedation); no sedation—patients who experience recurrent dislocations and and those who present
immediately after dislocation has occurred often have less muscle spasm and may not need sedation; local
anesthesia—intra-articular injection of anesthetic described for shoulder dislocations but does not result in direct relaxation
of muscle; good alternative when procedural sedation has high risk
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| Shoulder: dislocations almost always anterior (1%-2% posterior; luxatio erecta [inferior dislocations] rare); most cases
caused by blunt trauma or chronic instability; posterior dislocations sometimes caused by seizure or electrocution;
radiographs—anteroposterior (AP) view generally sufficient to visualize anterior dislocations (diagnosis often made
clinically); second view (eg, lateral, axillary, or transaxial) important for diagnosing posterior dislocations, especially if
patient has altered state of consciousness or has multiple traumatic injuries; abnormal overlap between humeral head
and glenoid on secondary view indicates posterior dislocation (humeral head internally rotated; greater tuberosity appears
abnormally rounded); joint stability—bony limitations consist of glenoid with cartilaginous lining and labrum;
muscle attachments (eg, rotator cuff muscles) primarily responsible for integrity of joint; complications—chronic instability
common; subtle fractures occur in 20% of patients; Hill-Sachs deformity associated with recurrent dislocations
(unknown whether condition predisposes to dislocation or just result of recurrent dislocation); fracture or avulsion of
greater tuberosity may occur (patient less likely to experience recurrent dislocation); 90% of patients with Bankart fracture
(avulsion of inferior rim of glenoid) experience recurrent dislocation; note—presence of fracture does not affect
ability to reduce joint
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| Reduction techniques for shoulder: many effective techniques; proficiency with >1 technique recommended; external
rotation—adduct elbow (flexed at 90°) to patient’s side; slowly rotate shoulder externally until it slides into place;
Milch technique—begin with elbow flexed and shoulder externally rotated; raise arm into overhead position, then
return to side; combination technique—with patient lying on back, externally rotate shoulder until horizontal with
floor; if reduction has not occurred, apply downward traction on joint and slowly raise arm into overhead position;
scapular manipulation—push lateral border of scapula toward base of neck and hold there (technique moves glenoid
rather than humeral head); Stimson technique—patient lies face-down, with arm hanging toward floor;
weights attached to arm; shoulder reduces without further manipulation (in ≈30 min); combination—begin as in
Stimson technique, with weight on arm, then manipulate scapula; or manipulate scapula as assistant applies downward
traction to arm; traction-countertraction—effective method, but not as gentle as other techniques; assistant applies
traction to arm; countertraction supplied by wrapping sheet around chest wall and using body weight to pull in opposite
direction
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 | Recovery: shoulder immobilization for 3 wk; after 5 to 7 days, older patients should begin simple exercises to increase
range of motion and to prevent capsulitis
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| Elbow: most dislocations posterior; fall on outstretched arm most common mechanism of injury; 50% of dislocations
associated with fractures (avulsion of medial epicondyle most common); neurovascular injury more common than
with shoulder dislocation (important to document pulses and note expanding hematomas)
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| Reduction techniques for elbow: traction-countertraction—supinate patient’s forearm and grab wrist on volar side;
place other hand in antecubital fossa and lock arm straight; flex patient’s elbow to 90°, pull wrist, and push humerus
toward shoulder; or, fix upper arm over back of chair and apply downward traction to forearm; if necessary, push joint
laterally, or have assistant press olecranon process with thumbs as traction-countertraction applied; preferred
method—place patient on stretcher; place elbow in patient’s antecubital fossa and grab supinated wrist; maintain your
position as you slowly flex patient’s elbow, bringing arm through arc (similar motion as in arm wrestling); if necessary,
use other hand to apply force to elbow medially to laterally
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| Hips: dislocations almost always posterior, and typically caused by blunt trauma (eg, motor vehicle accident); fractures
common (especially occult fractures of acetabulum); patient in classic posture has flexed, internally rotated hip; importance
of time to reduction—muscle spasm significantly impedes reduction; compromise of blood supply to femoral
head increases risk for ischemia and avascular necrosis; reduce within 6 to 8 hr (exact critical time unknown)
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| Reduction techniques for hips: Stimson technique—position patient over table, hips and knees flexed to 90°; grab ankle
and place knee in patient’s popliteal fossa; apply downward force over proximal calf (use body weight) while
supporting ankle; note—patients with native hips almost always require procedural sedation; analgesia without sedation
often sufficient for patients with prosthetic hips; supine version of Stimson—perform technique with patient
on backboard on floor (avoid performing maneuver on stretcher); flex hip and knee to 90°; apply straight (posterior-
anterior) force to hip, slightly rotating femur by twisting your body, if necessary; preferred method—perform technique
with patient on backboard on floor; flex hip and knee to 90°; place your knee into patient’s popliteal fossa;
push down on ankle and pull up from behind knee, using your knee as fulcrum (good mechanical advantage)
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| Acetabular fractures: often subtle on radiograph; computed tomography (CT) recommended; important to identify, because
most patients will need hip replacement; if no acetabular fracture and no other injuries, patient discharged with
instructions for non–weight-bearing and follow-up
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| Knee dislocation: injury threatens limb (and possibly life); popliteal artery injured in 10% to 30% of patients; dislocation
may occur in many directions and requires significant force (knee strongly protected by ligaments); note—dislocated
knees often reduce spontaneously; grossly unstable knee (eg, injuries to both cruciate ligaments) suggests dislocation;
examination for neurovascular integrity required
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| Reduction: patients with vascular compromise require immediate attention; reduction easy to accomplish because ligaments
often injured (just guide joint into place)
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| HOW NEVER TO MISS CHILD ABUSE —Steven M. Selbst, MD, Professor of Pediatrics, and Vice-Chair for Education,
Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia
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| Definition: any interaction or lack of interaction that results in nonaccidental harm to physical or developmental state of
child; although parents have right to discipline children, determination of abuse not affected by intent; marks and injuries
indicate abuse, regardless of intent
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| Incidence: stressful situations at home (eg, recent divorce or unemployment) increase risk for abuse; more cases reported
in families of low socioeconomic status (associated with higher levels of stress), but failure to report cases may
occur more frequently in higher socioeconomic groups; parents more likely to abuse—abuse more commonly perpetrated
by single mothers, teenage mothers, and parents of multiple children; abusive tendencies more common in alcoholic
parents, parents who experienced abuse as children, emotionally immature, depressed, or demanding parents,
and parents who have poor impulse control or unrealistic expectations; most incidents isolated (ie, parent does not repeatedly
abuse child); children more likely to suffer abuse—children <6 yr of age (cannot escape abuser); children
set apart by differences (eg, child looks different or has different father); twins or multiple births; children of unwanted
pregnancies; chronically or acutely ill child, eg, colicky child
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| History: be suspicious of every injury; look for stress in family; history of infant deaths (very unlikely for >1 child to
suffer sudden infant death syndrome [SIDS]); “unknown” mechanism of injury red flag for abuse, especially if injury
serious (eg, broken bone); if history of incident changes over time, consider abuse until proven otherwise; delay in
treatment (especially if long delay or serious injury) increases index of suspicion; mechanism of injury inconsistent
with child’s age or developmental ability, history of serious injuries, or parents who appear unconcerned about injury
also increase index of suspicion for abuse
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| Physical examination: injury inconsistent with history, critical for diagnosis of abuse; multiple injuries of various ages increase
suspicion; pattern or location may indicate abuse (injuries to genitalia and abdominal injuries [eg, duodenal hematoma
in young child], generally diagnostic for abuse); pattern of injuries—loop marks (from cord or belt); falls do
not typically result in multiple marks; bite marks (intercanine distance of 3 cm identifies adult; DNA sample sometimes
attainable from recent bite); age of bruises—although bruises at different stages of healing suggest repeated injuries,
some studies show color of bruise insufficient to date injury; acute injuries typically swollen and tender; yellow, green,
and brown bruises generally associated with older injuries; bruises in nonambulatory children suggestive of abuse; anatomic
location—injuries occurring on ears, genitalia, abdomen, back, hands, and frenulum likely intentional; failure to
thrive—may indicate neglect or psychologic abuse; commonly caused by poor bonding between mother and baby
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| Burns: common injuries (accidental and intentional); appearance should reflect history (eg, burns resulting from spilled
liquid have splatter and drip marks); intentional burns often deeper and have line of demarcation or suspicious pattern
(eg, children held in hot water often press feet into wall of bathtub, resulting in less intense burn on soles of feet)
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| Radiology: accidental fractures rare in nonambulatory children; falls from bed or crib do not usually cause serious injury;
abuse more likely to result in fractures in young children (cannot escape; subject to severe impact); extremities most
common locations for fractures; transverse fractures—generally indicate abuse; caused by significant impact; spiral
fractures—associated with twisting falls (need consistent history); increased index of suspicion when present in upper
extremities; metaphyseal chip fractures—caused by yanking or vigorously shaking child; diagnostic for child abuse;
rib fractures—rarely accidental; inconsistent with history of direct trauma; generally caused by squeezing chest; rarely
occur during resuscitation; skull fractures—rare in infants; increase index of suspicion for abuse; history—old fractures
need adequate explanation; multiple fractures in various stages of healing, very suspicious; skeletal survey—
recommended by American Academy of Pediatrics when abuse suspected in children <2 yr of age
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| Taking histories from children: separate older children from parents or guardians when taking history; ask open-ended
questions (eg, “Why are you here today?”); avoid leading questions (eg, “Did mommy hit you?”); use quotation marks
when recording questions and answers
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| Examination procedure: have child undress completely, even if presenting injury easy to access without undressing;
protect modesty of older children
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| Reporting suspected abuse: physician has responsibility to report abuse but not to make accusation or identify perpetrator;
team approach (eg, involvement of social workers or child abuse experts) recommended when possible; legal
obligation to report suspected abuse (failure to do so characterized as misdemeanor, may result in loss of medical license);
notification of parent or guardian about report required; admission to hospital—physicians obligated to protect
patient; child abuse justifies admission, even in absence of severe injury; documentation—photographs helpful
(Polaroid recommended; potential to alter digital images renders them less suitable for documentation); identification
of child in photograph critical (face, name, or medical record number visible in frame); drawing in chart accompanied
by detailed written description acceptable
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| Additional tests: blood studies recommended for children with multiple bruises; bone scans have limited use; skeletal
surveys recommended in children <2 yr of age; CT often useful in cases of head injury, especially in children ≤1 yr of
age (may identify subtle injuries)
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Educational Objectives
| The goal of this activity is to describe various techniques for reducing dislocations of large joints and to provide information to
aid in the identification of cases of child abuse. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Assess need for analgesia and sedation in patients with joint dislocations.
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| 2. Diagnose patients with joint dislocations and assess neurovascular integrity.
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| 3. Reduce dislocations of large joints.
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| 4. Identify child abuse in children presenting to emergency department.
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| 5. Document and report potential cases of child abuse.
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Discussed on This Program
Etomidate [Amidate]
Fentanyl citrate [Sublimaze]
Methohexital sodium [Brevital Sodium]
Midazolam HCl [Versed]
Propofol [Diprivan]
Suggested Reading
Adlercreutz C, et al: Computed tomography for evaluation of rotation dislocation of supracondylar elbow fractures in children.
Acta Radiol 46:725, 2005; Brousseau TJ, et al: Vitamin K deficiency mimicking child abuse. J Emerg Med 29:283,
2005; Chitgopkar SD, Khan M: Painless reduction of anterior shoulder dislocation by Kocher’s method. Injury 36:1182,
2005; Dunn MJ, et al: Evaluation of propofol and remifentanil for intravenous sedation for reducing shoulder dislocations in
the emergency department. Emerg Med J 23:57, 2006; Friedlaender EY, et al: Patterns of health care use that may identify
young children who are at risk for maltreatment. Pediatrics 116:1303, 2005; Frymann SJ, et al: Reduction of dislocated hip
prosthesis in the emergency department using conscious sedation: a prospective study. Emerg Med J 22:807, 2005; Funk L,
Smith M: Best evidence topic report. How to immobilise after shoulder dislocation? Emerg Med J 22: 814, 2005; Hollis JD,
Daley BJ: 10-year review of knee dislocations: is arteriography always necessary? J Trauma 59:672, 2005; Jones LM, et
al: Criminal investigations of child abuse: the research behind “best practices.” Trauma Violence Abuse 6:254, 2005;
Laursen B: Injury patterns in children with frequent emergency department visits. Emerg Med J 23:59, 2006; Sagarin MJ:
Best of both (BOB) maneuver for rapid reduction of anterior shoulder dislocation. J Emerg Med 29:313, 2005; Spencer EE
Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: report of two cases. J Shoulder
Elbow Surg 14:650, 2005; van Riet RP, et al: Associated injuries complicating radial head fractures: a demographic study.
Clin Orthop Relat Res 441:351, 2005; Ziegler DS, et al: Assessment and follow-up of suspected child abuse in preschool
children with fractures seen in a general hospital emergency department. J Paediatr Child Health 41:251, 2005; Zun LS, et
al: Who are the young victims of violence? Pediatr Emerg Care 21:568, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Hendey was recorded in San Francisco at High Risk Emergency Medicine, sponsored by University of California,
San Francisco, School of Medicine, Department of Emergency Medicine, and Division of Emergency Services, San
Francisco General Hospital, and held May 11-13, 2005; Dr. Selbst was recorded in San Diego at the 11th Annual Scientific
Assembly of the American Academy of Emergency Medicine (AAEM) held February 17-19, 2005. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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