Difficult Dislocations

Transcription

1 Objectives Difficult Dislocations Gregory W. Hendey, MD, FACEP Professor of Clinical EM UCSF Fresno To demonstrate reduction techniques for the following dislocations: Ankle Hip Shoulder Time Top 5 reasons some dislocations are difficult Muscle spasm First dislocation Recurrent dislocation = easier reduction Fracture / other injuries Inadequate sedation / analgesia Reduction technique Sedation options: No sedation (or minimal) Nerve block or Intra-articular injection Procedural sedation Midazolam / Fentanyl Ketamine Methohexital Etomidate Propofol

2 Case 1: THE ANKLE 24 yo M semi-pro football player Someone rolled over his ankle from behind Ankle Dislocation Usually posterior Often associated with fracture Reduction: Hand behind heel, and dorsal foot Anterior traction, plantar flexed Then 90 o dorsiflexion

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4 For the difficult reduction: Flex the knee Exaggerate the injury THE HIP Case 2: 45 year old female passenger in MVA c/o hip pain Exam: hip flexed, internally rotated

5 Hip dislocation should be reduced within 6 hours to reduce which complication? Hip dislocation 1. Acetabular fracture 2. Avascular necrosis 3. Deep venous thrombosis 4. Non-compliance with Core Measures 91% 6% 0% 3% Usually posterior Complications: Fracture (approximately half) Pelvis, acetabulum, femoral neck Avascular necrosis, femoral head Time matters! Reduction within 6 hours A c e t a b u l a r f r a... A v a s c u l a r n e c r... D e e p v e n o u s t h... N o n - c o m p l i a n c e... Reduction The Captain Morgan technique: Stimson technique Allis technique n n Above: illustration by Francis Fung Right: reproduced with thanks to and permission from Diageo, PLC

6 Case 3: The Shoulder n 30 year old male reached up for a can on a shelf and felt shoulder dislocate n Exam: yep, it s dislocated. n X-ray?

7 9 studies say No n Harvey, Am J Emerg Med, 1992 n Hendey, Ann Emerg Med, 1996 n Shuster, Am J Emerg Med, 1999 n Hendey, Ann Emerg Med, 2000 n Shuster, CJEM, 2002 n Emond, Acad Emerg Med, 2004 n Hendey, J Emerg Med, 2006 n Kahn, J Emerg Med, 2007 n Emond, CJEM, 2009 Shoulder dislocation Intra-articular Injection Types: 97% Anterior 1-2% Posterior <1% Luxatio Erectae Sedation vs Intra-articular injection

8 Methods of Reduction External Rotation (Hennepin) Snowbird Traction/Counter -traction Stimson Milch Scapular Manipulation Forward Elevation Eskimo Spaso External Rotation Leidelmeyer (Virginia, 1977) Mirick (Hennepin, 1979)

9 Plus Milch After external rotation: Raise arm into full overhead position, with traction Then return arm to starting position Scapular Manipulation Bosley (1979) Move glenoid relative to humeral head

10 Plus Stimson: Hang weights or pull arm down Internal / external rotation May also try in sitting position

11 Traction/Counter-traction Summary: Techniques for difficult reductions: Ankle Hip Shoulder Thank you! Fair Use Notice: This presentation and syllabus may contain copyrighted material the use of which has not always been specifically authorized by the copyright owner. It is being made available in an effort to advance the understanding of medical, scientific, and other issues. It is believed that this constitutes a 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material on this site is distributed without profit to those who have expressed a prior interest in receiving the included information for research and educational purposes. If you wish to use copyrighted material from this site for purposes of your own that go beyond 'fair use', you must obtain permission from the copyright owner.