Dislocation

By Dean Traiger MD, aka Doc-Dean

Dislocations occur when bone ends are out of line at the joint, causing pain and preventing a full range of motion. The pain this causes can be very severe. Why do dislocations occur? There are two important factors when dealing with joints: stability and range of motion. Think of them as a seesaw. For example, you can move your arms in many more directions than you can move your leg. The hip joint is a very stable joint and thus has limited range of motion. In contrast, the shoulder joint has great range of motion and as a result is a less stable joint. The less stable the joint, the more likely it is to become dislocated.

Dislocations can occur in many joints: shoulders, kneecaps, fingers, toes, etc. In the simple park and grab situation above, the evaluation and treatment is simple; go directly to the nearest emergency room. However, when out in the field and help is a long way off, you can try to help the injured person.

The first step is to decide: Is there a fracture or dislocation?

If it appears to be a fracture, then splint the bone and head for help or call for a rescue. If it's not a fracture, the joint looks "wrong" compared to the other joints, and range of motion is restricted, then you are probably looking at a dislocation. If possible, splint the dislocation and seek professional aid. If trained medical help is more than an hour away, it is reasonable to attempt to fix the dislocation (termed reducing the dislocation).

Check to see if the blood supply is being cut off to the connecting limbs by looking for blueness, tingling, numbness, or lack of a pulse in the extremities. If it appears that circulation is impaired, reduce the dislocation immediately. Reducing dislocations is risky because blood vessels or nerves may be damaged when bones and joints are manipulated. Current opinion is that the benefits outweigh the risk to prevent further injury to the joint and limbs. The exception to this is the wrist joint. For a dislocated wrist, splint it well and evacuate.

Ask the person if he/she has ever experienced a dislocation before. If so, how was it treated? If the injured person knows how to put the bones back in line, have him/her guide you through the steps. People who have had a dislocation are at high risk for reoccurring dislocations in the same spot and after the first or second time, they know exactly how to fix the problem.

How to reduce a dislocated knee or kneecap

(two rescuers needed)

The first step in any dislocation is to calm the injured person and make them as comfortable and relaxed as possible. Determine whether reducing the dislocation is necessary. If it is necessary, calmly talk the injured person through each step; you'll need their cooperation and agreement. If they are resisting due to fright and/or pain, it is very difficult to successfully reduce the dislocation. There is no painless way to perform the operation. Let them understand that it's going to hurt, but it will feel much better when the joint is back in place.

Next, have them lay on their back. Have one rescuer positioned at the injured person's head, cradling their upper body by hooking their arms under the person's armpits. The second rescuer is positioned at the foot of the injured. This rescuer must pull the leg gently but firmly so that the bones slide into their natural alignment. Push the kneecap back into place gently if its twisted to one side. The kneecap may pop back into place on its own as the leg is being straightened. In some instances, massage of the thigh makes the reduction easier by helping to minimize muscle spasms. Do not force the knee back into place. Stop immediately if the pain increases or the knee resists manipulation.

Splint the leg securely, being careful not to put pressure on the kneecap. Check the lower leg frequently to make sure that circulation is not being impaired. Loosen the splint if there are any signs of numbness, loss of sensation or lack of a pulse in the foot.

How to reduce a dislocated shoulder

(two rescuers needed)

A person with a dislocated shoulder will be in a great deal of pain and unable to bring the arm up to the chest. Dislocated shoulders are often recurring and the injured person can help the rescuer reduce the shoulder. The first steps are the same as with the knee. Calm the person, make them comfortable and calmly walk them through each step.

Position the injured person so that he is lying on his back. It's ideal to have the person lie about waist high on something like a table, but this may require some creativity in a wilderness setting. Position one rescuer on the uninjured side facing the injured person. Have this rescuer slide a piece of cloth or webbing under the injured person, and wrap one end around the injured person's chest so that both ends of the cloth meet below his armpit. This rescuer should pull on both ends firmly like handles, being careful not to tickle the injured person and make him laugh.

Position the second rescuer next to the dislocated shoulder, facing the injured person. Bend the elbow of the arm connected to the dislocated shoulder so that the fingertips are pointed skyward and the arm is at a 90-degree angle from the body. Have the second rescuer pull gently but firmly on the bent elbow, pulling the shoulder away from the injured person's body while maintaining the forearm at a 90-degree angle from the body. The first rescuer on the opposite side will be pulling against the force of the second rescuer.

Have the second rescuer gently rotate the arm on the shoulder joint as if the injured person is trying to throw a baseball. Move the arm slowly back and forth maintaining steady tension until the shoulder slides back into place. Immobilize the arm by putting it in a sling across the chest after the reduction is completed. Do not force the shoulder back into position. Stop if the shoulder resists manipulation.

If the above technique does not work, or if the dislocation is that of a child, there is another technique that can be used. You will have to find a heavy rock or something of equivalent weight to wrap around the individual's wrist and allow that weight to dangle for a period of time. This period of time will vary, but the arm muscles will fatigue and the shoulder will go back into place. In children, this is much less threatening than grabbing a child's arm and trying the technique described above.

How to reduce a dislocated finger or toe

These dislocations are common but are very painful. It's often relatively easy for a rescuer to reduce these digits and bring quick relief to the injured person.

Position yourself so that you are facing the injured person. Hold the finger or toe firmly with both hands, keeping it in a slightly bent (flexed) position. Do this by placing one hand below the base of the dislocated joint and the other at the end of the tip of the finger or toe. Pull gently on the tip of the finger or toe along the line in which the bones normally lie, as if trying to lengthen it in a straight line, while simultaneously pushing the joint back into place with your other hand. Splint the finger or toe by taping it to the neighboring digit, cushioning the splint with a gauze pad between the two fingers or toes. Do not put tape directly on the joint. Do not force the digit back into place. It may be difficult to reduce a dislocation at the base of the index finger or thumb. If you attempt to reduce the finger and fail, splint the finger and seek medical help immediately. Surgery may be required.

(Disclaimer: This information is not intended as a substitute for professional medical advice or treatment.)