Pre-hospital stage and anesthesia
Primary medical care at the scene must be as gentle as possible. It includes only two basic components: adequate administration of analgesics and reliable transport immobilization.
Strictly prohibited to attempt self-reduction of displaced bones. This can lead to soft tissue entrapment, vascular rupture, and damage to nerve trunks.
The success of hospital reduction largely depends on anesthesia management:
- For dislocations in large joints (shoulder, elbow), complete muscle relaxation is required, so the manipulation is performed under general anesthesia or regional block.
- For injuries to small joints (e.g., fingers), adequate local anesthesia is sufficient.
Hospital stage: time-dependent approach
Specialized medical care is based on a clear classification of dislocations according to the time elapsed since the injury:
- Fresh dislocations (up to 3 days): emergency one-stage closed reduction is indicated.
- Stale dislocations (from 3 days to 4 weeks): due to early tissue retraction and scar formation, the strategy becomes variable. Either an attempt at one-stage closed reduction or immediate open surgery is used.
- Old (chronic) dislocations (over 4 weeks): closed techniques are ineffective and traumatic, therefore exclusively open reduction is indicated.
Exception to the rule: in elderly patients with uncomplicated old or irreducible dislocations (most commonly of the shoulder joint), it is advisable to forego major surgery. If surgery is expected to yield a worse functional outcome, conservative management (exercise therapy and physical therapy) is applied.
Management of special types of injuries
In addition to classic closed injuries, traumatologists regularly encounter special forms requiring a specific approach:
- Open dislocations. Regarded as an emergency surgical pathology. The algorithm includes: reduction, surgical wound debridement, mandatory repair of the joint capsule, and subsequent reliable immobilization.
- Complicated dislocations. Accompanied by fractures, vascular or nerve compression. Treatment is primarily aimed at eliminating specific complications.
- Recurrent dislocations. Characterized by multiple relapses due to joint instability. Treated exclusively surgically — surgeons perform plasty to reinforce the joint capsule.
Rehabilitation program
Following successful reduction (both closed and surgical), the extremity must be immobilized. Restorative treatment is divided into two stages:
- During the immobilization period: physical therapy and isometric exercises are prescribed to maintain tissue trophism and muscle tone without joint movement.
- In the post-immobilization period: active mobilization begins after the bandage is removed. Therapeutic gymnastics with progressively increasing loads, courses of muscle electrical stimulation, and physical therapy are applied. Professional massage is of particular importance for the full functional recovery of large joints.
Dislocations of the acromial end of the clavicle
This pathology stands out as an important separate group. In clinical practice, the synonym acromioclavicular joint rupture is also used.
According to statistics, the frequency of such injuries reaches 15% of the total number of all dislocations. Epidemiologically, the injury is most characteristic of males of active working age — from 25 to 50 years old.
Briefly: answers to topical questions
What methods of closed reduction are used for a fresh shoulder dislocation?
Several methods are used for the closed reduction of a fresh shoulder dislocation.
- Janelidze method — based on muscle relaxation in the lateral decubitus position, followed by smooth downward pressure on the forearm with slight rotational movements.
- Chaklin method — the least traumatic method, involving axial traction of the adducted shoulder with simultaneous lateral displacement of the humeral head.
- Multi-stage method — involves using the forearm as a lever for sharp internal rotation of the arm.
Which nerve trunks are most frequently damaged in complicated shoulder dislocation?
In complicated shoulder dislocation, the axillary nerve is most frequently injured, although damage to other nerve trunks is also possible.
- Axillary nerve (n. axillaris) — is most commonly affected, leading to paralysis of the deltoid muscle and sensory loss over the lateral surface of the shoulder.
- Median nerve (n. medianus) — injury is possible during trauma.
- Ulnar nerve (n. ulnaris) — is also at risk of injury.
- Radial nerve (n. radialis) — can be damaged during displacement of the humeral head.
Which ligaments are ruptured in a dislocation of the acromial end of the clavicle?
Complete dislocation of the acromial end of the clavicle involves the rupture of two main ligaments.
- Acromioclavicular ligament — ruptures in both subluxation and complete dislocation.
- Coracoclavicular ligament — its rupture distinguishes a complete dislocation from a subluxation (on radiography, the distance between the clavicle and the coracoid process increases by 5 mm or more).
What bone fractures are typical for a complicated elbow dislocation?
Complicated dislocation of the elbow (forearm) is typically associated with fractures of the bony blockers of anteroposterior displacement.
- Fracture of the coronoid process — often combined with posterior dislocation of the forearm.
- Fracture of the olecranon — possible in anterior dislocation of the forearm, often comminuted, and may be combined with a fracture of the coronoid process.
What types of surgical interventions are used to treat recurrent shoulder dislocation?
To treat recurrent shoulder dislocation (post-traumatic instability), surgical interventions are used to strengthen the joint capsule and prevent relapses.
- Endoscopic capsule repair — minimally invasive restoration of capsule integrity.
- Strengthening the capsule wall — placement of duplicature sutures or arthroscopic coagulation.
- Labral fixation — performed for Bankart lesions using sutures or implants.
- Reconstruction of intra-articular lesions — treatment of rotator cuff tears without arthrotomy.
The «3–4» rule of timing: up to 3 days — fresh, up to 4 weeks — stale, more than 4 weeks — old (chronic).
Class and exam questions
Is it permissible to attempt dislocation reduction before the ambulance arrives?
Strictly prohibited. Any attempts at reduction at the pre-hospital stage can lead to severe complications. Only analgesics and transport immobilization are permitted.
Are chronic dislocations always treated surgically?
As a rule, yes. However, elderly patients with uncomplicated dislocations are often managed without surgery in favor of exercise therapy to avoid unwarranted surgical risks.
What anesthesia is used for closed reduction?
The choice depends on the localization. For large joints, general or regional anesthesia is necessary to relax the muscles. For small joint dislocations, local anesthesia is sufficient.
What else to study on this topic
- Technique of one-stage closed reduction for acute dislocations
- Types and treatment of complications (vascular and nerve injuries)
- Capsular stabilization surgeries for recurrent dislocations
- Specifics of exercise therapy (LFK) and isometric exercises during the immobilization period
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