1. Tiffany Weiss-Feldkamp D.O
Joint Dislocations
Tiffany Weiss-Feldkamp D.O

2. Outline What is Osteopathic Medicine? Shoulder dislocation
Elbow dislocation
Hip dislocation
Board questions

3. Osteopathic Medicine What is Osteopathic Medicine?
-philosophy of medicine proposed by
Andrew Taylor Still, M.D., in 1874
-developed around what he thought
was inappropriate use of medications
resulting in poor medical practice
-focuses on the unity of the body
-the role of the physician was to
enhance the bodies capacity to
maintain health

4. Osteopathic Medicine A.T. Still’s philosophy
-alterations in the musculoskeletal can affect total body health and recovery
-structure and function of the body are interrelated
-manipulation can help restore the body’s functional capacity enhancing wellness and assisting in recovery

5. Osteopathic Medicine
The focus of manual medicine is the musculoskeletal system.
Manipulation is used to increase the mobility of restricted musculoskeletal areas and to reduce pain.
The body functions as a whole. Therefore, alterations in the musculoskeletal system can influence the rest of the body, frequently resulting in pain.
The musculoskeletal system is innervated by the sympathetic division of the ANS.
The musculoskeletal system compromises more than 60% of the human.

6. Shoulder dislocation Most frequently dislocated joint
Maintained by the glenohumeral joint capsule, cartilaginous glenoid labrum, and rotator cuff muscles
Anterior displacement is most common followed by posterior (inferior, superior and intrathoracic are rare)
Most frequently secondary to trauma
Some studies suggest that up to 98% are anterior dislocations

7. Shoulder dislocation Peak in males is age 20-30 years
Peak in females is years
Patients usually complain of shoulder pain with a decreased range of motion
Peaks are due to sports activities and susceptibility to falls in the elderly

8. Shoulder dislocation
Certain injury patterns may suggest a specific type of dislocation
-seizures, lightning injuries and electrical injuries suggest posterior dislocation
-punch, forceful pulling of arm or throwing injury may suggest anterior dislocation
-axial loading of a fully abducted arm may indicate inferior dislocation

9. Anterior Shoulder dislocation
3 types of anterior dislocation: subclavicular, subcoracoid, and subglenoid
Arm is held in slight abduction and external rotation
Patient resists adduction and internal rotation (unable to touch opposite shoulder)
Compare radial pulses to help look for vascular injury
Axillary nerve- evaluate before and after reduction (sensation over deltoid, abduction)
Causes-fall on outstretched hand, motion including abduction, extension and external rotation of the arm
Axillary nerve injury occurs in approximately 12% of anterior shoulder dislocations.

10. Imaging Essential for first time dislocations
AP and axillary or scapular Y view
Pre-reduction films- document dislocation, look for fracture
Post-reduction films- document reduction, another chance to look for fractures

11. Anterior Shoulder Dislocation

12. Reduction Contraindication to reduction:
-subclavicular or intrathoracic dislocations
-possible major arterial injury: angiography
-associated fracture of humeral neck
-??

13. Reduction
Key to successful reduction is pain control and muscle relaxation
Procedural sedation
Intra-articular lidocaine
-advantages: drainage of hemarthrosis, no IV access needed, less risk of respiratory or cardiac compromise
-disadvantage: joint space infection

14. Kocher’s Method For anterior dislocation
Flex elbow, press arm against the body, externally rotate until resistance is felt.
Raise the externally rotated arm in a sagittal plane forward as far as possible and then rotate medially bringing the patients hand towards the opposite shoulder
Not performed often due to complications including: brachial plexus, axillary vessels, humerus fracture, rotator cuff injury
Some individuals feel that this should not be performed in the emergency department due to complications.

16. Hennipen Technique Reduction of anterior shoulder dislocation
Pt seated or at 45 degrees
Support pt’s elbow with right hand and slowly externally rotate the arm to 90 degrees with your left hand
If the shoulder doesn’t reduce slowly elevate the arm lifting the humeral head into the socket
Sedation may not be needed but this requires complete relaxation of the pt

17. Stimson technique Reduction of anterior dislocation
Pt prone on gurney with dislocated arm hanging downward at 90 degrees
5-10 lb weight attached at wrist ( 2-4 L NS)
Gentle internal and external humeral rotation can be applied
Reduction requires complete muscle relaxation
20-30 minutes
No assistance required, minimal force needed, however it takes time and complete muscle relaxation which may require sedation

18. Stimson Maneuver

19. Scapular Manipulation
Reduction of anterior shoulder dislocation
Pt positioned prone with weight as in the Stimson technique
Gently rotate the inferior tip of the scapula medially and the superior edge laterally
Can be performed with pt seated with an assistant providing traction-countertraction (at wrist and bracing chest)
This can be relatively painless, fast and successful if provider is experienced
With or without sedation
The borders of the scapula can be difficult to palpate if the pt is obese

20. Hand Placement for Scapular Manipulation

21. Milch Technique Reduction of anterior dislocation
Pt supine or prone with affected arm close to the edge of the bed
Have the patient place their affected arm in full abduction over/behind head. Assist if needed.
Apply gentle longitudinal traction and external rotation
If reduction is not complete, use the other hand to push the humeral head upward into the glenoid fossa accompanied by gradual adduction of the extended arm, while keeping it in traction.
Gentle, procedural sedation is not needed.
Requires minimal force and a single operator.

22. Traction-Countertraction
Reduction of anterior shoulder dislocation
Pt is supine with arm abducted and elbow flexed to 90 degrees
A sheet is tied around the thorax of the patient and waist of the assistant
Another sheet is tied and placed around the pt forearm and waist of physician
Gentle traction and countertraction can be applied along with internal or external rotation or pressure on the proximal humerus to assist in reduction

23. Traction-Countertraction

24. Legg Reduction Maneuver
Reduction of anterior shoulder dislocation
Pt is seated in straight-backed chair, and assistant stabilizes pts uninjured shoulder by slight downward pressure
Pt abducts injured arm to 90 degrees to the body, if unable to perform, physician provides assistance
Flex pt elbow to 90 degrees
Keep abducted elbow and forearm behind a coronal plane passing through the patient’s occiput
Adduct arm toward pt’s side, fully flexing elbow
Have pt actively internally rotate arm across the chest
No premedication required

25. Legg Reduction Maneuver
The motions of this maneuver are designed to neutralize the muscles that resist shoulder relocation
Abduction of arm- relaxes supraspinatus and deltoid
External rotation- relaxes infraspinatus and teres minor
Flexion of elbow- coracobrachialis and biceps
Reduction occurs with adduction and internal rotation of arm with this assistance of the subscapularis and latissimus dorsi

27. Posterior Shoulder Dislocation
Most commonly missed major dislocation of the body
3 types: subacromial, subglenoid, and subspinous
Arm is held in adduction and internal rotation
Pt resists external rotation and abduction
Neurovascular deficits are uncommon
Causes- seizure, fall on outstretched arm, electrocution, direct blow
Commonly due to a strong internal rotational force as occurs when falling on a forward flexed internally rotated arm;.

28. Posterior Shoulder Dislocation
May notice a prominence in the posterior aspect of the shoulder with anterior flattening
Commonly associated with fracture of the humerus and posterior glenoid rim
An isolated fracture of the lesser tuberosity should lead one to suspect posterior dislocation until proven otherwise

29. Posterior Shoulder Dislocation
The “light bulb sign” due to internal rotation of the humerus

30. Posterior Shoulder Dislocation
Reduction is similar to the Stimson technique
Traction is applied and then the humeral head is pushed forward over the glenoid rim
Slow external rotation may be needed for reduction to occur
2 person technique
sedation suggested

31. Inferior (luxatio erecta) Shoulder dislocation
Arm is fully abducted, elbow maybe flexed on or behind head
There is almost always an associated fracture or soft tissue injury
Axillary nerve is most commonly injured nerve
Highest incidence of vascular injury
Causes- hyperabduction of the arm, axial force applied to an abduction arm
These individuals may appear as if they are raising their hand to ask a question.
There may be an associated fracture of the acromion, inferior glenoid rim, or greater tuberosity.

32. Inferior Shoulder dislocation
Humeral head is facing inferiorly

33. Inferior Shoulder dislocation
Reduction:
-pt is supine with a sheet wrapped around the supraclavicular region and pulled diagonally across the pts body
-apply longitudinal traction to the patients humerus and then rotate inferiorly
-slowly adduct the arm after reduction

34. Complications of Shoulder Dislocations
Recurrent dislocation (most common)
Hill Sachs lesion- compression fracture resulting in a groove in the posterolateral aspect of the humeral head
Bankart lesion- fracture of the anterior rim of the glenoid fossa
Greater tuberosity avulsion fracture
Rotator cuff injury
Nerve injury- most frequently axillary n

35. Shoulder Dislocation
Always remember, orthopedic consultation may be helpful for dislocations with associated fractures, for posterior or inferior dislocations, and for cases in which the patient's shoulder cannot be reduced in a timely fashion.
Follow-up
-orthopedic follow-up in 5-7 days
-Shoulder immobilizer
-NSAIDs and possibly narcotics for analgesia
-no participation in sports or activities that require movement of the arm similar to that of the direction of injury

36. Which of the following is true regarding posterior shoulder dislocations?
External rotation is usually intact
Neurovascular injury is more common than in anterior dislocations
The absence of pain excludes the diagnosis
Seizures are a common mechanism of injury
Recurrent injury is more common than in anterior dislocations
d. They usually can’t abduct or externally rotate the affected arm.

37. Which of the following is true regarding reduction of an anterior shoulder dislocation?
The Kocher maneuver is most reliable
Adequate muscle relaxation is the most important factor in successful reduction
The Hippocratic method should be the first one attempted
Scapular manipulation is the method of choice in third trimester pregnant patients
Intra-articular anesthetic injection is contraindicated
b. There is a high rate of complications assoc with the Kocher and Hippocratic method. Scapular manipulation is performed with the pt prone and should not be used with a pregnant pt in the 3rd trimester due to compression of the uterus.

38. Base of the neck Sternum Deltoid Triceps Dorsolateral foot
A 55 yr old man presents with an anterior shoulder dislocation. Skin overlying which of the following areas is most likely to have diminished sensation?
Base of the neck
Sternum
Deltoid
Triceps
Dorsolateral foot
c.- axillary nerve, loss of sensation in the region of the deltoid and impaired deltoid function resulting in loss of muscle contraction with abduction against resistance

39. Which of the following is the most common complication of anterior shoulder dislocation?
Axillary nerve injury
Brachial artery injury
Recurrence
Rotator cuff tear
Adhesive capsulitis
C. Recurrence is especially common in young patients

40. Elbow Dislocation 2nd most commonly joint dislocated
Most commonly dislocates posteriorly
Simple dislocation-one without an associated fracture
Complex-accompanying fracture
Requires a large force to dislocate
Immediate reduction is essential to reduce the risk of neurovascular or cartilagenous complications

41. Elbow Dislocation Radiographs are essential prior to reduction
Post reduction films-confirm joint surface opposition, and a second look for bony injury

42. Posterior Elbow Dislocation
Commonly due to falling onto an extended and abducted arm
Present with elbow flexed at 45 degrees
Prominent posterior olecranon
When palpated, the olecranon is displaced from the plane of the epicondyles (opposite of supracondylar fracture)
Neurovascular exam should be documented pre and post-reduction
Ex: falling backward while rollerblading

43. Parvin Maneuver Reduction technique for posterior dislocation
Give analgesia and sedation
Pt prone, with the humerus resting on the bed and the elbow hanging perpendicular off the bed
Apply slight traction at the wrist or hang five pounds of weight from the wrist and place the elbow in 30 degrees of flexion
Reduction will occur over minutes
May guide olecranon into place if needed

44. Traditional Traction-Supine
Reduction technique for posterior dislocation
Consider regional anesthesia and IV analgesia
Pt supine on stretcher
Have assistant stabilize the humerus against the stretcher.
Grasp the wrist and apply slow, steady traction, with slight flexion of elbow and while keeping the wrist supinated.
If in 10 minutes you are unable to reduce the elbow, flex the forearm or apply traction to the volar surface of the forearm.
Requires 2 people

46. Anterior Elbow Dislocation
Less common
Due to a force while the elbow is flexed driving the olecranon anterior
Vessel and nerve injury is more common
Arm is usually extended, appears shortened and the forearm is supinated and appears elongated

47. Anterior Elbow Dislocation Reduction
Advise- call ortho
Apply distal traction on the wrist and backward pressure on the forearm
Be careful not to hyperextend the elbow which could cause neurovascular injury

48. Complications of Elbow Dislocations
Nerve injury- Ulnar, median, brachial
Fractures- medial epicondyle, coronoid process
Brachial artery injury
Entrapment of bone fragments in the joint space
Joint stiffness and decreased range of motion (extension in particular)
Compartment syndrome

49. Elbow Dislocation Follow-up
-indications for admission and close neurovascular monitoring: children, unreliable pt, extensive edema, evidence of neurovascular compromise
-splint elbow at 90 degrees of flexion with a posterior long splint
-follow up with orthopedics in 5-7 days

50. Hip Dislocation Dislocation can represent a high energy injury
25% have an associated knee injury
Need to be reduced promptly to minimize the risk of avascular necrosis of the femoral head
Often due to MVA with the knee striking the dashboard or as with pedestrian automobile accidents.

51. Posterior Hip Dislocation
Account for 80-90% of hip dislocations
Often occur after a blow to the knee with the hip and knee in flexion
Affected extremity is found to be shortened, internally rotated, and adducted
AP, lateral and oblique films to look for associated fractures

52. Posterior Hip Dislocation

53. Posterior Hip Dislocation
Stewart and Milford classification of posterior hip dislocations.
1. simple dislocation (no fracture)
2. dislocation with large acetabular rim fragments stabilized after reduction
3. dislocations with unstable or comminuted fractures
4. dislocation with femoral head or neck fractures

54. Posterior Hip Dislocation
If there is no fracture present, perform closed reduction within 6 hours of injury
Conscious sedation suggested

55. Allis Method For reduction of the posteriorly dislocated hip
Conscious sedation encouraged
With patient supine apply inline traction, gentle flexion of the hip to 90 degrees.
Gently internally and externally rotate
the hip for reduction to occur. Slight adduction of the hip can also promote reduction.

56. Stimson Method For reduction of a posteriorly dislocated hip
Patient is prone with the pelvis of the affected side hanging over the side of the gurney.
Flex the hip and knee to 90 degrees.
An assistant stabilizes the pelvis and trunk with the provider applies downward pressure at the popliteal fossa, providing traction.
Positioning may be difficult for trauma patients, pregnant, etc. Monitoring for procedural sedation is more difficult with the patient prone.

57. Posterior Hip Dislocation
Complications:
-sciatic nerve injury
-avascular necrosis
-femoral head fractures
-ipsilateral knee injury
-traumatic arthritis
Follow-up with orthopedics.
-NSAIDs for pain
-Rehabilitation and ROM exercises are important

58. Anterior Hip Dislocation
10% of hip dislocations
Can be superior or inferior depending on the amount of hip flexion at the time of injury
-hip abduction, external rotation and flexion = inferior dislocation
-hip abduction, external rotation and extension = superior dislocation
Extremity will appear abducted and externally rotated

59. Anterior Hip Dislocation
Neurovascular compromise is unusual however be sure to document it in all patients
AP and lateral film
Reduction-
-Conscious sedation
-Reduce by strong in-line traction with simultaneous flexion and internal rotation
-Abduct the hip once the femoral head clears the acetabulum
Lateral film will show the anterior dislocation more clearly.

60. Anterior Hip Dislocation
Complications
-avascular necrosis
-venous thrombosis
-traumatic arthritis
Follow up with Orthopedics
-NSAIDs for pain
-ROM exercises

61. Central Hip Dislocation
This is a fracture-dislocation involving the femoral head lying medial to the fractured acetabulum
Consult to Ortho

62. Posterior hip dislocations:
Less common than anterior hip dislocations
Most commonly result in compression of the femoral nerve
Are more commonly associated with fractures of the femoral head than anterior dislocations
Present with the leg shortened, hip internally rotated and adducted.

63. References
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Aponte, E. Dill, C. Anterior Shoulder Dislocation Joint Reduction. eMedicine. August 2009.
Chicharoen, N. Kwon N. Posterior Elbow Dislocation Joint Reduction: Treatment & Medication. eMedicine. April 2009.
Crooks, C. Geoghan, J. Funk, L. Shoulder Relocation Techniques
Dyck, D. Porter, N. Dunbar, B. Legg Reduction Maneuver for Patients With Anterior Shoulder Dislocation. Journal of the American Osteopathic Association. Vol No 10. October
Greenman, P. Principles of Manual Medicine. 3rd Edition, 2003.
O’Connor DR, Schwarze D, Fragomen AT, Perdomo M. Painless reduction of acute anterior shoulder dislocations without anesthesia. Orthopedics Jun;29(6):
Radiology images.
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