Dislocations- Upper Limb Flashcards
GENERAL REDUCTION TECHNIQUE:
REDUCTION:
- Analgesia vs Intraarticular vs PSA
- Position: prone/ supine
- Traction/ counter-traction
POST ASSESSMENT:
- Stability
- Smooth ROM
- ‘Stuck’ = bone or cartilage fragment/ capsule tear
- Crepitus/ resistance = not reduced, soft tissue interposition
POST FILMS:
–> Enlocation
–> Fractures
DISCHARGE:
- Monitor for compartment Sx
- Immobilise (sling, slab)
- Follow up:
–> Referral
–> Non-ROM exercises
Complications of ANTERIOR shoulder dislocation?
- Bankart
- Hill-Sachs
- Greater tuberosity #
- Axillary nerve injury
–> Traction neuropraxia
–> Permanant (rare) - Axillary artery/ vein injury (rare)
- Recurrent dislocation
- Post traumatic arthritis
- Rotator cuff
Clinical + radiological appearance of ANTERIOR shoulder dislocation:
CLINICAL:
- Sagging/ flat shoulder contour
- Depression under acromion
- Palpable bulge subcoracoid
- Elbow bent, slight abducted, arm supported.
XRAY:
- Humeral head under coracoid
- Y view: anterior displacement
Clinical + radiological appearance of POSTERIOR shoulder dislocation:
CLINICAL:
- Electrocution, seizure, FOOSH
- Shoulder sitting back, with internal rotation
XRAY:
- SUBTLE, EASILY MISSED: get multiple views.
- AP: Lightbulb appearance (fixed internal rotation)
- Widened joint space >6mm
- Y view: posterior displacement
Complications of POSTERIOR shoulder dislocation:
- Reverse Bankart
- Reverse Hill-Sachs
- Greater tuberosity #
- Axillary nerve injury
–> Traction neuropraxia
–> Permanant (rare) - Axillary artery/ vein injury (rare)
- Recurrent dislocation
- Post-traumatic arthritis
Clinical and radiological appearance of INFERIOR shoulder dislocation:
CLINICAL:
- Hyperabduction
- Arm stuck above head (full abduction)
- High rate axillary nerve injury (60%)
XRAY:
- Obvious
Intra-articular Lignocaine for shoulder reduction:
As effective as PSA.
- As per shoulder arthocentesis- ant or post approach +/- USS.
- 20ml 1% lignocaine
Reduction Techniques (8): ANTERIOR shoulder dislocation
1 Stimsons
- Prone with traction (4L saline)
2 Scapular Rotation
- Add to Stimson
- Grasp scapula, tilt inferior tip medially
3 Cunningham
- Sit patient, put their hand on your shoulder. Drape over their forearm + gentle traction downwards
- Massage deltoid/ traps/ biceps
4 FARES (FAst, REliable, Safe)
- Supine or prone
- Neutral traction
- Oscillate ant-post, whilst abducting. At 90 deg, ext rotate + continue.
_________________
5 Traction/ countertraction
- Sustained neutral traction to disimpact, then tire muscles.
6 Spaso
”Reaching up to Space(o)”
- Vertical traction (towards ceiling) –> external rotation
7 Modified Kocher
”Not Kocher to Beg”
- Arm by side, elbow bent, palm up
- Neutral traction
- GRADUAL external rotation
- Cross chest –> internal rotation
8- Milch
”Opening a book”
- Abduct out
- Traction
- External rotation
- +- push on humeral head
Reduction Technique: POSTERIOR shoulder dislocation
Sit up
Countertraction to torso
In line traction
Push on humeral head from behind
Reach into axilla and pull upper arm out laterally away from body to disimpact
Extend arm forward and should clunk in
Reduction Technique: INFERIOR shoulder dislocation
Traction up on arm in its current position
–> Upwards pressure on humeral head in axilla
–> Swing into adduction.
Cunningham
Gentle, steady downwards traction
Massage deltoid/ bicep/ traps
Milch
“opening a book”
Concurrent:
- Abduct out
- Traction
- External rotation
FARES
Supine or prone
Traction + ant-post oscillations (10-15cm)
WHILST abducting
Once at 90 deg abduction, externally rotate and continue until arm above head
Traction-Countertraction
Firm, sustained neutral traction until muscles tire
Stimson
4-6kg (eg. saline bags)
+/- scapular rotation
Allow up to 30mins
Spaso
Vertical traction
External rotation
Follow up care after shoulder dislocation
- Reduction, post-reduction films, assess for fractures.
- Broad arm sling/ shoulder immobiliser 1 week- NO evidence of benefit beyond this
- Once out, passive ROM exercises
- For 6 weeks, do not ext rot beyond neutral, do not abduct beyond 90 deg
- Follow up at 1-2 weeks (Ortho, PT)
AC joint injury grading:
Look for:
- AC injury: AC widening
- CC injury: Elevation of distal clavicle
- Compare to other side
__________________
I
- AC sprain
- Normal
II
- AC torn
- AC joint wide
III
- AC torn, CC sprain
- AC joint wide
- Clav elevated <100%
________________
IV
- Clavicle POSTERIOR
V
- Clavicle SUPERIOR >100% (skin tenting)
VI
- Clavicle INFERIOR
Management of AC injuries:
I and II
–> Conservative
–> Broad arm sling 1 week. Early ROM exercises.
Usually functional at 6 weeks, normal at 12 weeks.
III
–> Either.
IV, V, VI
–> OT
Elbow dislocation patterns:
Usually, radius/ulna stay together, and dislocate relative to humerus.
Posterior most common (FOOSH)
Anterior with direct blows
Simple
vs
Complex (fracture-dislocations).
–> Incl: Monteggia, Terrible triad
Injuries associated with elbow dislocations:
ALWAYS SCRUTINISE XR FOR:
- “Terrible Triad”
- Radial head #/disloc
- coronoid/olecranon
- epicondyle #*
- Monteggia
Examine for neurovascular injury:
–> ULNAR nerve and brachial artery most common.
“Terrible Triad”
Elbow fracture-dislocation:
- Posterior dislocation
- Radial head #
- Coronoid process #
Very highly unstable, often even after surgery. High rates arthritis/ complications.
Reduction and aftercare for simple posterior elbow dislocation:
- Prone is easiest
- Simple traction/countertraction
- +- thumbs on olecranon
Complex/#disloc usually need ORIF
Locations where ‘wrist’ dislocation can occur:
- Radiocarpal
- Midcarpal- most common
–> Lunate
–> Perilunate
–> Scapholunate - Radioulnar (DRUJ)
Carpal Bones
SLTPTTCH
Scaphoid
Lunate
Triquetrum
(Pisiform)
Trapezius
Trapezoid
Capitate
Hamate
Dislocations about LUNATE:
Progressive spectrum:
1- SCAPHOLUNATE disloc.
- Wide Terry Thomas
2- PERILUNATE disloc:
- Carpals dislocate from lunate
- ‘Empty teacup’
3- LUNATE disloc:
- Lunate dislocates from carpals AND RADIUS
- ‘Spilled teacup
________
Easily missed
Acute carpal tunnel
Very unstable, need OT
–> Arthritis/ functional impairment
Scapholunate dislocation
Wide >4mm
Easily missed
Very unstable, need OT
–> Arthritis/ functional impairment
Perilunate dislocation
Empty teacup on lateral
Easily missed
Acute carpal tunnel
Very unstable, need OT
–> Arthritis/ functional impairment
Lunate dislocation
Spilled teacup on lateral
Acute carpal tunnel
Very unstable, need OT
–> Arthritis/ functional impairment
Carpometarcarpal dislocation
Unstable, need OT
