Bradley Dunlap, MD, John F. Sarwark, MD
+
++
++
+
+
+
• Inability to reduce the shoulder.
• Additional damage to the humeral head, glenoid, or labrum during
the reduction maneuver.
• Traction injury to the brachial plexus and especially the axillary
nerve (rare).
+
• An adequate level of conscious sedation is critical.
The patient must have muscle relaxation and should not be “fighting” the
reduction maneuver.
• Do not let go once traction is applied to the arm.
• Continuous traction helps relax the muscles that may be holding
the humeral head out of the glenoid fossa in a shortened position.
• Perform and document a neurovascular examination both before
attempting reduction and after the reduction.
+
+
+
+
++
+
+
++
+++
Interpretation
and Monitoring
+
• Obtain radiographs (2 views) to confirm the reduction.
• The patient is placed in a shoulder immobilizer.
• If an immobilizer is not available, a sling with an elastic bandage
wrap holding the arm to the torso can be substituted.
+
• Recurrent shoulder instability.
• Neurologic injury, which often results from traction injuries
and generally resolves over weeks to months.
• Fracture.
+
++
++
+
• Clinical evidence of radial head subluxation.
• Usually there is a history of a pull to the arm, followed by patient
refusal to use the arm.
• The arm is held in a slightly flexed and pronated position against
the body. There is no swelling or bruising.
+
+
+
+
• The elbow joint consists of the humerus that
articulates with the radius and ulna of the forearm.
• The radial head articulates with the capitellum of the humerus,
while the ulna articulates with the trochlea of the humerus (Figure 53–3).
++
+
• Apply gentle pressure on the radial head (the
hand cradles the proximal forearm).
• With the other hand, apply gentle longitudinal traction to the
distal forearm, supinate, and flex the arm at the elbow (Figure 53–4A).
+
++
+
• Once the reduction is complete, the child slowly
begins to use the arm since it is no longer painful.
• Full painless pronation and supination of the forearm as well
as flexion and extension indicate that reduction has been successful.
• No immobilization is necessary.
+
++
+
• Elbow dislocation, which is often obvious on
radiographs.
• Subtle abnormalities include failure of the radial head to align
with the capitellum of the humerus on any radiographic view of the
elbow.
+
+
+
+
+
+
+
++
+
• An assistant is needed to hold the humerus steady.
• The joint is first aligned in the medial/lateral plane,
then traction is applied for the final reduction (Figure
53–6).
+
++
+
• Place the arm in a long-arm posterior mold splint
because the elbow can be quite unstable, especially in extension.
• Obtain radiographs to confirm reduction.
+
• Neurovascular injury.
• Elbow stiffness. While loss of motion is common after an elbow
dislocation, it is generally less of an issue in children (when
compared with adults).
• Recurrent elbow instability.
+
++
++
+
+
++
+
+
+
+
+
+
+
• The finger consists of 3 phalanges: the proximal,
middle, and distal.
• Collateral ligaments limit side-to-side movement, while the volar
plate supports the volar joint.
+
++
+++
Interpretation
and Monitoring
+
+
+
+
• Reduce simple dislocations promptly so that there
is no undue stretch on the surrounding soft tissues and neurovascular
structures.
• Fracture dislocations are more complex but may need to be reduced
by a primary care clinician if there is neurovascular compromise.
++
++
+
+
+
+
• Be careful not to cause a burn to a patient by
using water that is too hot. In addition, the plaster gives off
heat while it sets.
• Use cast padding liberally. Be sure that all bony prominences
are well padded to prevent pressure injury.
• Do not apply the elastic wrap too tightly because it can have
a tourniquet effect.
+
+
• Wrap the extremity circumferentially with cast
padding (this is cotton and is generally not strong enough to cause a
compartment syndrome).
• Usually 10 strips of plaster are used to make the splint.
• Measure the length of the plaster needed while it is dry, and
then cut appropriately.
• The width depends on the extremity. Choose a width that allows
for coverage of approximately half of the circumference of the affected
extremity.
• Dunk the plaster in the water and squeeze out the excess.
• The plaster can also be milked to remove more water so that it
is moist but not dripping.
• Place the plaster splint over the padded extremity.
• An additional layer of cast padding is placed to hold the plaster,
and to prevent the elastic wrap from sticking to the plaster.
• An elastic wrap is used over the top to hold the splint in place
(Figure 53–10).
+
++
+
+
Beaty JH, Kasser JR, eds. Rockwood
& Wilkins’ Fractures in Children. 5th ed. Philadelphia:
Lippincott Williams & Wilkins; 2001.
Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation
and management.
J Am Acad Orthop Surg. 1998;6:15–23.
[PubMed: 9692937]
Kang R, Stern PJ. Fracture dislocations of the proximal interphalangeal
joint. J Am Soc Surg Hand. 2002;2:47–60.
Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion
to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998;102:e10.
Walton J, Paxinos A, Tzannes A, Callanan M, Hayes K, Murrell
GA. The unstable shoulder in the adolescent athlete.
Am J Sports Med. 2002;30:758–767.
[PubMed: 12239016]
Bradley Dunlap, MD, John F. Sarwark, MD
+
+
• Skin or soft tissue infection (eg, cellulitis,
septic bursitis) because there is an increased risk of causing a
septic joint.
• Corticosteroid injection into a known or suspected septic joint.
+
• Coagulopathy. The procedure may result in hemarthrosis, but
one needs to weigh the risk against the need to diagnose a septic
joint.
• Bacteremia, because of the increased risk of causing septic joint.
+
• Syringes (20 mL for knee; 10 mL for ankle).
• 21–25-gauge needles; they must be long enough to enter joint.
• Sterile collection container.
• Povidone-iodine and alcohol for sterile preparation of skin.
• Sterile gloves.
• 4 × 4 gauze.
• Ethyl chloride (optional).
• Lidocaine (optional).
+
• Infection occurs in < 1/10,000 when
performed under sterile conditions.
• Bleeding into joint is exceedingly rare, even in patients who
are taking anticoagulant medication.
• If corticosteroids are being injected, there is a risk of skin discoloration
and fat atrophy following the procedure.
+
• Do not make an ink mark directly over injection/aspiration
site because it will enter the joint when the needle passes through
it.
• Instead, use the wood end of a sterile cotton swab or another
round object to make an indentation in the skin prior to cleaning
with povidone-iodine.
• If infection is a concern, a larger bore needle (18 gauge or 19
gauge) may be needed to aspirate because sometimes purulent fluid
will not be drawn into a smaller needle.
• Do not overtighten the needle on to the syringe, and check to
make sure the needle easily twists off the syringe before starting
the procedure.
• This allows you to empty a full syringe and reattach it without
ever pulling the needle out of the joint.
• Lidocaine can be used to numb the skin prior to aspiration/injection,
but it can distort anatomic landmarks.
• Alternatively, a topical agent such as ethyl chloride can be used.
+
+
+
• With the knee extended, have the patient relax
the quadriceps.
• Palpate the superior and lateral edge of the patella.
• Mark the insertion site just posterior to this edge.
• Prepare the entire area with povidone-iodine.
• Aim the needle at a 45-degree angle posteriorly and a 45-degree
angle distally. It should fall under the patella but over the femoral
condyle (Figure 54–1A).
+
• Aspirate as the needle progresses into the joint
space.
• If you feel the needle hit bone, pull back slightly and re-direct
it.
• Remove as much fluid as possible.
• You may need to move the needle as fibrous septa can create pockets
of fluid.
++
++
+
• Have the patient flex the knee to approximately
90 degrees.
• Palpate the inferior edge of the patella. Palpate 2 cm medially
or laterally, and 2 cm inferiorly, feel the soft spot, and mark.
• Prepare the area with povidone-iodine.
• Aim the needle at a 30-degree angle superiorly and aspirate as
the needle enters the joint (Figure 54–1B).
• Remove as much fluid as possible.
• You may need to move the needle as fibrous septa can create pockets
of fluid.
+
+
• The distal tibia and fibula articulate with the
talus to make up the ankle joint. This joint is crossed by many
tendons that function to move the ankle, foot, and toes.
• Knowledge of location of neurovascular structures, particularly
the anterior tibial vessels with the deep peroneal nerve and the
superficial peroneal nerve, are essential to prevent iatrogenic
injury.
+
+
• Prepare the area with povidone-iodine.
• Aspirate as the needle progresses into the joint space.
• If infection prevents medial access, the lateral entry site is at
the lateral one-third of the joint.
• Avoid the superficial peroneal nerve, which can sometimes be
seen through the skin.
++
+++
Interpretation
and Monitoring
+
• Visually inspect joint fluid.
• Fluid should be sent to the laboratory for analysis of cell count
with differential and glucose, and Gram stain and culture (Table 54–1).
++
+
+
Cole BJ, Schumacher Jr HR. Injectable corticosteroids
in modern practice.
J Am Acad Orthop Surg. 2005;13:37–46.
[PubMed: 15712981]
Luhmann SJ. Acute traumatic knee effusions in children and adolescents.
J Ped Orthop. 2003;23:199–202.
[PubMed: 12604951]
Nade S. Acute septic arthritis in infancy and childhood.
J Bone Joint Surg Br. 1983;65:234–241.
[PubMed: 6841388]
Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial
fluid tests. What should be ordered?
JAMA. 1990;264:1009–1014.
[PubMed: 2198352]
Bradley Dunlap, MD, John F. Sarwark, MD
+
• 5- or 10-mL syringe.
• 18-gauge needle to draw medicine; 25–27-gauge needle to
inject medicine.
• Alcohol swabs to clean skin.
• 1% or 2% plain lidocaine (no epinephrine) or
0.25% bupivacaine (can be combined 1:1).
+
• Complete and document a neurologic examination
before injecting the anesthetic.
• Do not use epinephrine in the digits because it can result in
ischemia, necrosis, and potential loss of the digit.
• The maximum lidocaine dose is 5 mg/kg (1% lidocaine has
10 mg/mL; 2% has 20 mg/mL).
• The maximum bupivacaine dose is 2 mg/kg.
• A lidocaine injection provides approximately 2 hours of pain
control, while a lidocaine/bupivacaine mixture (1:1) provides
approximately 5–7 hours of pain relief.
+
• For a digital block, pronate the patient’s
hand and place it on a flat surface.
• For the hematoma block, place the patient’s affected extremity
on a flat surface.
+
+
• It is advanced palmar/plantar to anesthetize
those digital nerves.
• Aspirate to be sure the needle is not intravascular.
• Inject the lidocaine as the needle is slowly pulled out dorsally.
• Repeat the procedure on the other side of the digit.
• This is not a large area; commonly 3–5 mL total of anesthetic
is sufficient.
• Massage the area to help spread the agent.
++
+
+
• Continue to aspirate until a flash of blood appears,
redirecting the needle as necessary.
• After the flash of blood, slowly inject the lidocaine.
++
Beaty JH, Kasser JR, eds. Rockwood
& Wilkins’ Fractures in Children. 5th ed. Philadelphia:
Lippincott Williams & Wilkins; 2001.
McCarty EC et al. Anesthesia and analgesia for the ambulatory management
of fractures in children.
J Am Acad Orthop Surg. 1999;7:81–91.
[PubMed: 10217816]