Trauma, Subluxations & Dislocations

Key Features

• In contrast to fracture reduction, which may be safely postponed, dislocations must be reduced immediately in order to minimize further joint damage

• Dislocations can usually be reduced by gentle sustained traction

• Often, no anesthetic is needed for several hours after the injury due to the protective anesthesia produced by the injury

• A thorough neurovascular examination should be performed and documented pre- and postreduction

• Radiographs should be obtained postreduction to document congruency and assess for the presence of associated fractures

• Following reduction, the joint should be splinted for transportation of the patient

• Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used along with ice for pain control and to reduce inflammation

• The dislocated joint should be treated by immobilization, followed by graduated active exercises through a full range of motion

Clinical Findings and Diagnosis

• Dislocation or separation of the shoulder

  • Usually occurs following traumatic injury

  • Shoulder pain with or without weakness or lack of function is almost always present

  • The vast majority (~90%) of shoulder dislocations occur anteriorly and can have obvious deformity of the shoulder with anterior displacement of the humoral head

  • It is important to examine and evaluate both shoulders for any asymmetry between the two

  • Radiographic evaluation is important for confirming a dislocation or separation diagnosis.

• Acromioclavicular (AC) separation

  • Involves partial or complete tearing of the ligament complex of the AC joint

  • They are among the most common shoulder injuries, but vary significantly in severity (grade I–VI, with the latter the most severe) and treatment

  • Grade I–III AC separations are most common and generally treated nonsurgically (which includes early physical therapy)

  • Grades IV–VI are usually the result of high energy impacts and are treated surgically

• Subluxation of the radial head (nursemaid's elbow)

  • Infants may sustain subluxation of the radial head as a result of being lifted or pulled by the hand

  • Child appears with the elbow fully pronated and painful

  • The usual complaint is that the child's elbow will not bend

  • Radiographic findings are normal, but there is point tenderness over the radial head

  • Occasionally, symptoms last for several days, requiring more prolonged immobilization

• Dislocation of the patella

  • Complete patellar dislocations nearly always dislocate laterally

  • Pain is severe, and the patient will present with the knee slightly flexed and an obvious bony mass lateral to the knee joint associated with a flat area over the anterior knee

  • Radiologic examination confirms the diagnosis

  • When subluxation of the patella occurs, symptoms may be more subtle, and the patient will complain that the knee "gives out" or "jumps out of place"

Treatment

• Subluxation of radial head

  • Can be reduced by placing the elbow in full supination and slowly moving the arm from full extension to full flexion; a click may be palpated at the level of the radial head

  • Relief of pain is remarkable, as the child usually stops crying immediately

  • The elbow may be immobilized in ...