Complications Nerve injury to the axillary nerve, brachial plexus, radial, ulnar, or distal nerves Tear or detachment of the rotator cuff Fractures of humeral head Vascular injury Recurrent dislocation Procedure There are multiple methods to reduce an anterior dislocation of the shoulder Most pediatric emergency physicians prefer techniques that require minimal force such as the external rotation technique, the Stimson technique, or the scapular manipulation technique The traditional traction–countertraction technique is still used in many circumstances but it requires more force and several assistants Reduction of glenohumeral dislocation often requires administration of both intravenous narcotic analgesics and muscle relaxants (i.e., fentanyl and midazolam) However, with less forceful techniques, less medication may be required Intra-articular injection with lidocaine may also be used to alleviate discomfort and facilitate reduction The external rotation technique The patient is sitting upright or lying supine and has the elbow on the affected side adducted and flexed at 90 degrees The clinician usually grasps the wrist and very slowly (over to 10 minutes) externally rotates the shoulder while maintaining the arm adducted The shoulder usually relocates when the arm is externally rotated between 70 to 110 degrees Occasionally, the Milch technique is added to the external rotation technique to achieve reduction After the arm is fully externally rotated, abduct the arm at the shoulder over the head while maintaining external rotation Then apply traction in line with the humerus and apply posterior pressure over the humeral head—either with direct manual pressure over the anterior axilla or pressure to the humeral head in the axilla using the clinician’s thumb The Stimson technique The patient lies prone with the affected arm hanging over the edge of the stretcher with to kg (10 to 15 lb) of weight attached to the wrist Muscular relaxation by use of a benzodiazepine may facilitate reduction Reduction usually takes approximately 20 to 30 minutes ( Fig 130.35B , part A) Scapular manipulation technique The patient lies prone with the affected arm hanging off the edge of the stretcher To facilitate reduction, apply downward traction using either an assistant or to kg (10 to 15 lb) of weight attached to the wrist The clinician then pushes the inferior tip of the scapula medially while pulling the superior aspect laterally ( Fig 130.35B , part B) Muscular relaxation (e.g., benzodiazepine) is a good adjunct for this procedure Traction and countertraction Have an assistant apply countertraction with a folded sheet wrapped around the chest Simultaneously, as the operator, exert traction to the arm as shown in Figure 130.35B , part C After the linear traction frees the humeral head, apply slight lateral traction to reduce the proximal humerus Postreduction Following successful reduction, apply a sling and swath or shoulder immobilizer Traditionally, the shoulder has been immobilized in internal rotation with the humerus in adduction; however some recent studies suggest that the incidence of redislocation is less with 10 degrees of external rotation Obtain postreduction radiographs of the shoulder to document anatomic alignment The patient should be referred for orthopedic follow-up and rehabilitation Patella Dislocation Indications Closed patellar dislocations, particularly laterally displaced Complications Intra-articular hematoma Bony or ligamentous trauma Procedure Assess the joint and extremity for ligamentous stability and neurovascular integrity Most practitioners will obtain a radiograph to evaluate for associated osteochondral fractures, which can be close to 25% For an obvious patella dislocation that occurred without significant associated trauma, radiographs may not be necessary The benefits of the radiograph must be weighed against the increased pain, swelling, and potential neurovascular compromise that may occur with delays by obtaining radiographs Sedation/muscle relaxation and analgesia with administration of a benzodiazepine and narcotic may ease the reduction In many instances, the reduction may be spontaneous after administration of benzodiazepine alone When laterally dislocated, the knee joint is usually held in mild flexion (20 to 30 degrees) Have an assistant stabilize the distal thigh, as shown in Figure 130.35C , part A Then, while extending the knee joint, simultaneously apply gentle pressure on the lateral aspect of the patella to medially reposition it ( Fig 130.35C , part B) Knee mobility should be restored immediately on successful reduction If radiographs were not initially obtained, they should be obtained after reduction The use of an extended knee brace with crutches for a brief time provides appropriate restriction of activity with orthopedic follow-up within week Some patients are at risk of recurrence Elbow Joint Dislocation Indications Posterior elbow dislocation Complications Brachial artery injury Median and ulnar nerve injury as a result of stretching, entrapment, or severance Periarticular fractures of the radial head and/or coronoid process of the ulna are especially common Development of vascular compromise due to hematoma formation or soft tissue swelling Procedure Prepare the patient with intravenous narcotic pain medication and/or muscle relaxant if needed Pharmacologic sedation is strongly advised Prone approach Place the patient in the prone position on an examination table or stretcher, with the injured arm flexed about 90 degrees over the edge Then, correct any medial or lateral translation of the proximal ulna Grasp the wrist of the patient’s injured arm, and apply traction and slight supination to the forearm to distract the coronoid process from the olecranon fossa If an assistant is available, they may help by applying countertraction ( Fig 130.35D ) Using your other hand, apply pressure to the posterior aspect of the olecranon while pronating the arm When a “clunk,” along with the restoration of normal joint contour is appreciated, the reduction is complete Supine approach Place the patient in the supine position on the examination table or stretcher Have an assistant stabilize the humerus against the stretcher with both hands Grasp the wrist, and apply slow, steady, inline traction Ensure that the elbow is slightly flexed, and the wrist is supinated If not successful after approximately 10 minutes, gently flex the forearm or apply traction to the proximal volar surface of the forearm Reduction is complete after hearing or feeling the characteristic “clunk,” coupled with restoration of the normal joint contour and full, free range of motion at the elbow Postreduction Following successful reduction, place the elbow through gentle range-of-motion testing It is important to note that extending the elbow beyond 20 degrees from full extension may cause the elbow to redislocate, and therefore is not recommended Inability to move the elbow smoothly through range-of-motion exercises following reduction raises the concern of a trapped medial epicondyle fracture Repeat the neurovascular examination, and follow-up radiographs to assess for fracture If near-full range of motion is present in the affected elbow, a posterior splint should be applied, with the forearm in neutral or slight pronation and the elbow flexed at 90 degrees Because vascular compromise is an important consideration and may have a delayed presentation, all patients should be observed for to hours postreduction If at the end of the observation period there is no evidence of vascular compromise, the patient may be discharged home with orthopedic referral for follow-up Typically, after to 10 days, range-of-motion exercises are initiated with interval splinting or with use of a sling for comfort and support Immobilization for prolonged periods has been associated with a decreased ultimate range of motion of the elbow DRAINAGE OF A SUBUNGUAL HEMATOMA Indications Blood under pressure (i.e., painful) beneath a nail bed, either proximally or distally Complications Bleeding Infection Procedure Subungual hematomas occur from trauma to the nail bed, as shown in Figure 130.36 Radiographs should be obtained to evaluate for a tuft fracture of the distal phalanx Generally, the hematoma causes pain that is immediately relieved with drainage Oral pain medication and drainage of the hematoma are often all that is required, but a digital nerve block may be considered to facilitate drainage in the case of an extremely painful injury