Protocol 5 - Dislocation Reduction

This protocol specifically applies to dislocations of the shoulder, patella, and digits resulting from an indirect force; all other potential dislocations should be treated as one would treat any other potentially unstable joint injury (i.e., splint in a position that maintains stability & neurovascular function while facilitating transport).

A history confirming that there has been no direct injury to the affected joint and an examination with findings consistent with a dislocation must be obtained prior to treatment. The following procedures should be stopped if pain increases and/or resistance are encountered.

Recent data suggest that reduction of dislocations in the wilderness setting by non-medical personnel may be safe and effective, and significantly decreases the time to reduction. These findings may help guide future instruction of participants in high-risk wilderness sports.

Anterior Shoulder Dislocations

Any manipulative technique that is performed slowly and gently on an awake and cooperative patient is generally safe. For the purposes of this protocol the Cunningham, External Rotation, Baseball, Hanging, and Scapular Manipulation are described.

These techniques can be used in sequence or in combination as needed to achieve a successful reduction. Discontinue the procedure if pain significantly increases and/or if physical resistance is encountered.

Neurovascular status is documented before and after reduction. Non-emergent medical evaluation is advised but may be delayed by up to 10 days if distal circulation and sensation have returned to normal.

Cunningham Technique:

This technique encourages muscle relaxation which may allow the humeral head to return to normal position without additional manipulation. The patient is positioned sitting upright with the shoulders back and chest out facing the practitioner.

The patient’s arm remains adducted (against the body) while the hand is placed on the practitioner’s shoulder (right dislocation, right hand on practitioner’s left shoulder). The practitioner massages the trapezius, deltoid, and biceps muscles until reduction is achieved.

Hanging Traction:

Have the patient lie face down with the affected arm hanging, unsupported, over a ledge. Secure approximately 10 to 15 pounds to the patient’s upper arm or wrist and allow the weight and gravity to fatigue the muscles until the shoulder is reduced. This typically takes upwards of 20 to 30 minutes or more.

External Rotation:

This is essentially the same as the Cunningham technique with the addition of manipulation. The practitioner gently applies external rotation of the patient’s arm with the elbow remaining adducted against the chest.

Baseball Position:

With the patient supine and while still sitting adjacent to the dislocated shoulder, apply gentle traction to the arm to overcome muscle spasms. Gradually abduct and externally rotate the arm until it is at a 90-degree angle to the patient’s body.

This is most easily achieved by keeping the elbow in the 90 degrees of flexion throughout the maneuver. Hold the arm in this position (“baseball throwing position”) and maintain traction until the dislocation has been reduced.

Scapular Manipulation:

This procedure may require 2 rescuers. Have the patient either lie face down (as above) or sit upright. Apply traction to the affected arm and bring it forward to shoulder level. While maintaining traction, stabilize the upper portion of the scapula with one hand and rotate the lower tip medially with the other hand. This technique is often an effective adjunct to the other techniques described.

NOTE: If the patient cannot adduct the arm against the chest, techniques such as the baseball position, hanging traction, and scapular manipulation are more likely to be successful.

Medial Patellar Dislocations

The following only applies to a medial patellar dislocation (rotated inward, not out):

1. Check and document distal neurovascular function.

2. Have the patient gently straighten out their knee and flex their hip. If the patella has not spontaneously reduced once the knee is fully extended, gently guide the displaced patella medially back into its normal anatomic position. Discontinue the procedure if pain significantly increases and/or if physical resistance is encountered.

3. Stabilize the patella with tape or an elastic wrap.

4. Reassess and document distal neurovascular status.

5. Arrange for non-emergent medical evaluation. Patients may walk out if the pain is tolerable.

Phalanges (Digits) Dislocations

The following applies to all phalanges (digits) including big toe and thumb dislocations:

1. Check and document distal neurovascular function.

2. Apply axial traction distal and counter-traction proximal to the dislocated joint until the dislocation has been reduced. Discontinue the procedure if pain significantly increases and/or if physical resistance is encountered.

3. Splint in the anatomical position.

4. Reassess and document distal neurovascular status.

5. Arrange for non-urgent medical evaluation.