Transcript Dislocation and Fracture Reductions

Dislocation and Fracture
Reductions
Bucky Boaz, ARNP-C
Colles’ Fracture Reduction

Colles’ Fracture



FOOSH
Dorsal angulation of
distal fragment.
Dinner-fork deformity.
Colles’ Fracture Reduction

Closed Reduction
Method
1.
2.
3.
4.
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.
Colles’ Fracture Reduction

Then
1.
2.
3.
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.
Colles’ Fracture Reduction

Apply a sugartong
splint and sling.
Colles’ Fracture Reduction

Alternative Method
1.
2.
3.
4.
5.
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.
Colles’ Fracture Reduction

Postreduction X-ray
1.
2.
3.
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.
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.
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.
Posterior Elbow Dislocation

Typical mechanism of
an elbow dislocation
1.
2.
3.
4.
5.
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.
Posterior Elbow Dislocation
Posterior Elbow Dislocation

Pathophysiology
1.
2.
3.
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.
Posterior Elbow Dislocation

Typical deformity
(uncomplicated
posterior dislocation)
1.
2.
The forearm appears
to be shortened.
The olecranon is very
prominent.
Posterior Elbow Dislocation
Posterior Elbow Dislocation

Prereduction X-ray

Lateral view
1.
2.

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
3.
4.
Look for displacement
Radius and ulna likely to
maintain anatomic
position in relation to
each other
Posterior Elbow Dislocation
Posterior Elbow Dislocation
Posterior Elbow Dislocation

Anesthesia for
Reduction
1.
2.
3.
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.
Posterior Elbow Dislocation

Manipulative Reduction
1.
2.
3.
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.
Posterior Elbow Dislocation

Then
1.
2.
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)
Posterior Elbow Dislocation

Evaluation of Stability
Following Reduction
1.
2.
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
Posterior Elbow Dislocation

Quigley Technique
1.
2.
3.
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)
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.
Posterior Elbow Dislocation
Posterior Elbow Dislocation

Postreduction X-ray
1.
2.
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.
Posterior Elbow Dislocation

Immobilization
1.
2.
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.
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.
Nursemaid’s Elbow
Nursemaid’s Elbow

Pathology
1.
2.
3.
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.
Nursemaid’s Elbow
Interposition of torn
Annular ligament
Nursemaid’s Elbow

Presentation
1.
2.
3.
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.
Nursemaid’s Elbow

Manipulative
Reduction
1.
2.
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.
Nursemaid’s Elbow

Manipulative
Reduction
1.
2.
3.
As the forearm is
fully supinated
Apply firm pressure
on the radial head
and
Push the forearm
directly upward.
Nursemaid’s Elbow
1
3
2
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.
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
Glenohumeral Dislocations
1.
2.
3.
Capsule is extremely
loose and redundant
superiorly and inferiorly.
Only 30% of humeral
head is covered by or
articulates with glenoid.
Biceps tendon helps
seal off capsule
contributing to suction
effect.
Glenohumeral Dislocations
Glenohumeral Dislocations

Stabilizing Structures

Ligaments
1.
2.
3.
4.
5.
6.
7.
Glenoid fossa
Glenoid labrum
Biceps (long head)
Superior glenohumeral
ligament
Middle glenohumerl
ligament
Inferior glenohumeral
ligament
Subscapular process
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.
Glenohumeral Dislocations

Mechanism for Anterior
Dislocation
1.
2.
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.
Glenohumeral Dislocations
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
Glenohumeral Dislocations
Glenohumeral Dislocations
Glenohumeral Dislocations

X-rays

Careful axillary views
may also show
avulsion fractures of
the anterior rim
Glenohumeral Dislocations

Posterior dislocation
1.
2.
Violent internal
rotation levers the
humerus completely
out of the glenoid
fossa.
Posterior capsule is
severely torn, thus
permitting a posterior
dislocation.
Glenohumeral Dislocations

Types of Anterior
Dislocations



Subcoracoid
dislocation (most
common)
Subclavicular
dislocation (rare)
Subglenoid dislocation
(rare)
Glenohumeral Dislocations
Glenohumeral Dislocations

Typical Deformity of
Subcoracoid Dislocation
1.
2.
3.
4.
5.
6.
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.
Glenohumeral Dislocations
Glenohumeral Reductions

Stimson’s Technique

This should be tried first
(least traumatic)
1.
2.
3.
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.
Glenohumeral Dislocations
Stimson’s
Technique
Glenohumeral Reductions

Hippocratic Method
1.
2.
3.
4.
Practitioner’s stockinged
foot is place in between
the patient’s 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.
Glenohumeral Reductions
Hippocratic Method
Glenohumeral Reductions

Kocher’s Maneuver
1.
2.
3.
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.
Glenohumeral Reductions
Kocher’s Maneuver
Glenohumeral Reductions

Kocher’s Maneuver
1.
2.
3.
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.
Glenohumeral Reductions

Traction and Countertraction
1.
2.
3.
4.
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.
Glenohumeral Reductions
Traction
and Counter-traction
Glenohumeral Reductions
Scapula Maneuver
Glenohumeral Reductions

Postreduction X-ray


The head of the
humerus should be in
normal relationship to
the glenoid cavity.
No fracture should be
evident.
Glenohumeral Reductions


Before and after
techniques examine
patient for
neurovascular
involvement.
Post reduction
immobilize patient in
a sling and swathe.
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 Qangle)
Most often, the high riding patella subluxates or
dislocated with a sudden twisting of the
extended or slightly flexed knee.
Patella Dislocation

Mechanism of Acute
Dislocation
1.
2.
3.
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.
Patella Dislocation
Patella Dislocation
Patella Dislocation

Prereduction X-ray
1.
2.
The patella lies on
the lateral aspect of
the lateral femoral
condyle.
The patella is
displaced slightly
downward.
Patella Dislocation

Manipulative
Reduction
1.
2.
Extend the knee
gradually while,
Medialward pressure
is made upon the
patella, pushing it
over the lateral
femoral condyle.
Questions?