So one thing about joint dislocations in general is they can really vary from pretty simple to obviously limb-threatening when we get into the realm of knee dislocations. Commonly, we see things like fingers, elbow, and shoulder, with really fingers and shoulders probably being the leading causes of, or the leading amount of dislocations that we see in athletes with elbows followed, you know, somewhat close behind. I will tell you at our ski clinic, we tend to see probably somewhere between 60 to 80 shoulder dislocations a winter, and we probably see somewhere around 10 to 15 elbow dislocations, if that gives you some sense of the ratio that we see them in. That may not be the same for everybody, and I think also, you know, in these particular lectures, you know, you're going to get my experience. I'm going to do my best to throw the evidence in there, but, you know, your attending's experience and your experience may vary a little bit. So I think we'll try to give you some pearls that will help serve you regardless of what level you're at. So we're going to focus a little bit on pre-hospital reduction, because often in sports, that's when we're going to see them on the sidelines, and the truth is there's really not much evidence for that, although it's commonly done. I think most of us that have performed sports medicine for a long time have seen some dislocations on the sideline. Certainly, if you read textbooks, they will often talk very much about getting x-rays and doing certain things before reduction, but in practicality, that's not always the case. And so one of my goals, in addition to what we talked about in terms of the goals and objectives, would be to make you comfortable enough to give an attempt at a reduction, even if you've never done it. There's lots and lots of techniques. Certainly, what I talk about tonight are not the only techniques you can use. The purpose here was not to say, hey, here's the best techniques, but we're going to really focus on our experience with doing lots and lots of dislocations. I think we'll allude to it later, but I personally have probably done close to 500 shoulder dislocations and probably somewhere in the realm of 80 to 100 elbow dislocations. That does not necessarily make me an expert overall, but it certainly gives me a breadth of experience to be able to hopefully speak to you guys in a way that will help you moving forward. So general principles. Obviously, we want to know our anatomy. I mean, that's an important thing. It's certainly something that the board focuses on, but the careful assessment of the anatomy often helps us understand whether or not we're dealing with a dislocation or we're dealing with actually a displaced fracture. Now, you can obviously have a fracture dislocation where you combine the two of them. The other thing that's, I think, important to remember is we always want to document our neurovascular status. Why? Well, certainly there's the medical legal side of things, but it's also because you want to understand what is the patient like when you see them, what is the patient like after you do a reduction and as you follow them along. But probably the most important thing that I can emphasize to you, and it's something that I was not taught well when I trained, is that really when you look at dislocations, when somebody has a nerve injury or a vascular injury, almost always that occurs at the time the force is applied that caused the dislocation. That injury doesn't occur because of the attempts at reduction. Now, there certainly may be a rare case here and there where somebody does something where they use maybe a non-judicious amount of force, try to relocate something. But that's a lot of force. And for anybody who's actually spent any time in the operating room pulling on things like femurs and trying to reduce humerus fractures, there's a lot of force that's applied that does not cause neurovascular damage. So just be sure that you know what's going on ahead of time, but it shouldn't dissuade you from trying a reduction because you're worried that you might hurt something else. Again, one of the other things, this is kind of more of a pearl, but a general principle is when you go to do a reduction, the patient has to cooperate with you. I think this is quite obvious. Even in someone who is not very muscularly developed, for example, with a shoulder dislocation, if they're resisting you, it can be quite difficult to apply enough traction and enough force to get the joint reduced. So you want somebody to be calm. You want to use gentle, slow movements. You always want to support the joint, no matter what joint you're trying to reduce. And in general, you want to use gradual amount of force rather than one big force to try to reduce a reduction, I mean, to try to affect reduction. So here's one of the pearls, and we'll try to point out a few of them. And this goes to a lot of experience, but it also goes to the fact that, again, even if you're not experienced with reductions, it's certainly reasonable if you think something's dislocated to attempt it. And that's it. Inline traction will reduce a lot of them. You don't always need a lot of special techniques for many of these things, particularly if done early on before there's muscle spasm and we get to them quickly. Inline traction will reduce a joint without difficulty. Now, as everything is an exception to a rule, the exception tends to be the metacarpophalangeal joint dislocations, where instead of pulling on a joint, you really want to push the joint over the top. I know we're not talking about that specifically tonight. It doesn't mean that those joints aren't occasionally reduced well with inline traction, but we want to be thoughtful about just understanding that there's always an exception. Here's the other thing. And if there's anything, again, I can emphasize beyond what we talked about with the neurovascular, it's this, is that in general, if you look at somebody and they have a big swollen joint, that's fractured. If somebody has a deformity, so if you look at the guy with his shoulder down and would be my left of the screen looking at the computer, that's a dislocation. If we look at the pictures on the right side where you kind of have a sort of oblique view and then the side view, you can see that's very swollen. So when you see a joint that's swollen, in general, that's going to be a broken joint or there's going to be a broken bone that's displaced. It doesn't mean at some point it's going to not need reduction, but it may not be something that we want to attempt right away. And here we can see in this particular patient, this is a displaced fracture rather than a dislocated shoulder. Here's the other exam pearl when you're looking at somebody acutely with a shoulder is, and we see this a lot in the wintertime at Killington because you're reaching up under a lot of layers of clothing because it's cold or certainly on the football field or lacrosse field or hockey where they're wearing pads, is when you reach up underneath, the step off of a grade three AC separation and the step off of an anterior shoulder dislocation are going to feel relatively similar and they're sometimes difficult to assess. One of the things we've learned over the years, and I would call this level of evidence M, level of evidence mat, because it's certainly not been studied, but that if you have an AC separation, if you support the athlete's elbow, they will let you internally and externally rotate the shoulder without creating much pain. If you either have a dislocation or certainly a fracture associated with the glenohumeral joint, they're not going to let you do that. So that's one of the ways sometimes you can tell the difference between the two. Now let's go back to fractures. Certainly, we're always concerned that there may be a fracture associated with a dislocation, but that should not necessarily dissuade us from attempting reduction. We need to understand that it may be a more painful attempt at reduction that based on our level of experience and how often we've reduced these and how sure we are this is a fracture versus a dislocation that we may not make many attempts, but it certainly is okay to attempt. I mean, if you make a mistake, and I've done this before, and I've actually done it live with a similar type of humeral fracture that I just showed where I actually pulled on it and reduced it on the hill, not thinking it was a dislocation when it was actually a fracture, then again, the risk there is really causing pain, and maybe we don't want to cause athletes or patients that much pain, but the risk of causing more damage is incredibly low. So just be thoughtful about it, but it's okay. We don't have to worry that there's something else broken in there that we're going to cause a big problem with. And when you have fracture dislocations, again, it doesn't mean we shouldn't try to reduce them. This is an example of an anterior shoulder dislocation with sort of a metaphyseal-diaphyseal humeral shaft fracture. This particular patient, we were able to reduce without actually anesthesia, and you can see here that sometimes just pulling on it works, particularly again, if you get there early. Here's another example where there's almost a split between the sort of end of the ball and the greater tuberosity going down, but this is another one that didn't require anything additional than the normal techniques we use for shoulder reduction.

2nd Edition, CASE 50

2nd Edition

Shoulder

joint dislocations

athletic injuries

pre-hospital reduction

neurovascular status

inline traction