Reducing dislocated or pulled joints

Used to reduce (put back) a joint knocked or pulled out of its proper place

Attention

• Medical consult before attempting reduction of dislocated joints if not experienced
• Need person to be relaxed and comfortable. Speak calmly, move slowly to reassure them. Give sedation if needed
• Always consider possibility of fracture
• Always check and document circulation and neurovascular (sensation) status before trying any manipulation/reduction
• When finished, always check peripheries (hands/feet) for colour, warmth, sensation, movement, swelling, capillary refill, peripheral pulse — F 10.1 to make sure no damage to nerves, arteries, veins

Dislocated shoulder

Mostly seen in younger people following sports injury or fall

Attention

• Always suspect fracture, especially in older people
• Longer the shoulder left dislocated, more the limb will swell, muscle will spasm, making it harder to reduce
• Person will need sedation unless dislocation has just happened, or is recurrent. If so, first try gently without sedation
• Do not try if you suspect a fracture — x-ray first
• If attempted reduction doesn’t work, or posterior dislocation suspected (eg from fall caused by seizure in epileptic person) — refer for x-ray, specialist treatment

Stimson manoeuvre and scapular manipulation

What you need

• Firm, high, narrow examination couch, stretcher, or bench top
• 2.5–5kg weight — sandbag, plastic bottle full of water
• If person sedated — may need sheet to tie them to couch

What you do

• Lie person face down on couch so injured shoulder right on edge, arm hanging straight down — Figure 10.69
• If person sedated — tie sheet around them and couch to make sure they don't roll off 
• Strap/tie weight to wrist of injured arm
• Wait 20–30 minutes to see if traction weight reduces dislocation

• Reduction may be helped by trying following steps in order — Figure 10.69

1. Apply gentle traction down on arm
2. Turn arm outward (externally) until joint has ‘clunked’ back into position
3. Turn arm inward (internally)

If this doesn't work, try scapular manipulation

• Leave weight in place
• Stabilise (support) upper part of scapula (shoulder blade) with one hand and push bottom tip of shoulder blade straight across toward spine (medially) as far as it will go — Figure 10.70
• Can use thumb of supporting hand to help with push — Figure 10.71

Note: May be hard to tell when joint has gone back into position, as movement in arm and shoulder is very small. Ask person if it has worked

• Check circulation and sensation
• After reduction, strap arm with elevation sling
• Specialist review for follow-up, physiotherapy referral

External rotation

What you need

• Firm, high examination couch or stretcher

What you do

• Person lies on back, arm close to side, elbow flexed (bent) to 90°
• Stand facing person on same side as the dislocation
• Grip elbow with one hand keeping it close to person's side. Hold wrist with other hand — Figure 10.72

• Ask person to SLOWLY let arm fall to the side (externally rotate). Guide movement with hand at wrist — Figure 10.73

• Tell person to stop if pain or spasm, support weight of arm for them until pain settles and muscles relax, then have them start movement again
• Full external rotation can take 5–10 minutes
• Shoulder may pop back into place without usual 'clunk'
• Unless it is clear that the shoulder is back in place, continue until arm fully externally rotated
• If shoulder back in position — put arm across person's body, with hand on opposite shoulder. Strap in place with elevation sling
• Check circulation and sensation
• Specialist review for follow-up, physiotherapy referral
• If shoulder not back in position — see Milch technique. Person remains in same position

Milch technique

Attention

• Use immediately after unsuccessful attempt to reduce shoulder with external rotation

What you do

• Person remains on back with arm fully externally rotated — Figure 10.73
• Use your hands at elbow and wrist to move arm out to the side and toward overhead position. Keep elbow bent at all times — Figure 10.74

• When shoulder is at 90° move your hand from elbow to axilla (under arm) and use your thumb or fingers to push head of humerus up and into position — Figure 10.75

• If shoulder back in position — put arm across person's body, with hand on opposite shoulder. Strap in place with elevation sling
• Check circulation and sensation
• Specialist review for follow-up, physiotherapy referral
• If shoulder not back in position — medical consult

Pulled elbow (dislocated radial head) in small child

Attention

• Often caused by adult lifting child from ground while holding them below elbow (eg forearm, wrist, hand)
• Only do if clear story about how injury happened, otherwise send for x-ray
• Warn child’s parents/carer that procedure may cause brief pain

What you do

• When child calm
• Hold elbow, press your thumb on head of radius — Figure 10.76
• With your other hand, hold wrist, then quickly and firmly twist arm from palm down to palm up (supination) — Figure 10.77 while keeping constant pressure on radial head

• Check circulation and sensation
• If still painful — put sling on to rest arm. Take sling off after 24 hours
• Check if child needs specialist review

Dislocated elbow in adult

Attention

• Always do x-ray first
• If no distal (wrist) pulse — medical consult to send to hospital straight away. Get advice. May need to do reduction without x-ray
• Always check for fractures of radius bone

What you do

• Lie person on comfortable couch or flat surface off the floor so arm can hang over the side — Figure 10.78

• Check for wrist pulse (see Attention above)
• Check movement and feeling in elbow, lower arm and hand. If poor — might be nerve damage
• Hold wrist, pull down slowly and continuously along line of forearm — Figure 10.78 until relaxed. May take a while
• When forearm muscles relaxed, use thumb and forefinger of your other hand to move olecranon (tip of elbow joint) down and toward middle (medially). Should put joint back into position — Figure 10.79
• If joint not back in position — medical consult

• Check circulation and sensation
• Put arm in collar and cuff sling, elbow needs to be kept bent at 90° for at least 1 week
• Specialist review for follow-up, physiotherapy referral

Dislocated interphalangeal joint (finger)

What you need

• Rough paper tape or plaster

What you do

• Wrap paper tape around dislocated finger so you can get a good grip — Figure 10.80

• Stand facing person, firmly hold end of taped finger or ends of tape
• Ask person to lean backward while you hold finger or tape — Figure 10.81. Dislocated joint should slip back into position
• If joint not back in position — medical consult

• Check circulation and sensation
• Splint injured finger to finger beside
• Check if person needs specialist review

Lateral dislocation of patella (kneecap)

Attention

• If seen in elderly person — suspect fracture
• Only use this procedure if kneecap dislocated sideways to outside or inside of knee — push it back towards the middle of knee while pushing down on lower leg. Other dislocations very rare, need x-ray and specialist care
• Best to straighten leg quickly, as lessens pain and nervousness. If done slowly — person will tense leg muscles

What you need

• Examination couch
• Splint
• Plaster of Paris and plaster wool for slab
• Special knee immobiliser

What you do

• Sit person comfortably on couch, pillows supporting their back. Knee will be slightly bent from injury
• Hold kneecap — Figure 10.82
• With other hand — push down on lower leg, just below knee (to quickly straighten leg)
• At the same time push kneecap toward middle (medially) — Figure 10.82

• Kneecap should slide back into place over head of femur
• If kneecap not back in position — medical consult
• Check circulation and sensation
• Splint leg in straightened position, using knee immobiliser or plaster slab
• Specialist review for follow-up, physiotherapy referral