Pediatric emergency medicine trisk 1104

FIGURE 130.35 Closed reduction of joint dislocation A Finger/toe B Shoulder C Patella D Elbow Interphalangeal and metacarpophalangeal/metatarsophalangeal dislocations Complications Fracture secondary to attempted reduction Interposition of volar plate into joint space during metacarpophalangeal reductions preventing successful reduction Procedure Check the neurovascular status in the affected phalanx Splint the deformed phalanx for comfort if necessary Radiographs are usually obtained to ascertain the presence of fractures or interposition of the volar plate It is important to note that closed reduction of a dislocation may not be possible when there is dorsal dislocation with interposition of the volar plate or entrapment of the metacarpal/metatarsal head ( Fig 130.35A ) Consider the use of procedural sedation, a digital block, or both If necessary, have an assistant restrain the child Grasp the extremity proximal to the dislocation to stabilize the joint Grasp the tip of the distal phalanx and apply traction longitudinally The joint will usually slide into proper position If this method is unsuccessful, apply pressure distally to accentuate the deformity a few degrees, that is, mild hyperextension, while applying traction to the phalanx longitudinally After reduction, obtain radiographs to ensure proper position of the joints and to evaluate for fractures Immobilize the joint in slight flexion for to weeks in total, usually with a foam-padded splint Distal interphalangeal joints are immobilized in full extension and proximal interphalangeal joints with 20 to 30 degrees of flexion If a small avulsion of the volar lip of the distal phalanx is evident, apply a dorsal splint to prevent hyperextension of the affected joint In cases in which the reduction is unsuccessful, the volar plate is interposed, or the second metacarpal bone is trapped, consult an orthopedic /hand surgeon immediately to assess the need for surgical reduction Volar dislocations are more complicated and often require surgical reduction Shoulder (Glenohumeral) Joint Dislocation Indications Anterior shoulder dislocations For posterior shoulder dislocations, orthopedic consultation is recommended