Dislocation of a joint occurs when there is a separation of two bones at a joint. It can be very difficult sometimes to clinically distinguish between a fracture and dislocation and sometimes the two can occur together. Therefore, if there is clinical doubt the limb should be immobilised, splinted and X-rayed before attempting any manipulation. Dislocations are normally associated with a soft tissue injury which may need to be immobilised to reduce pain and prevent further damage.
The shoulder comprises 20% of all rugby injuries being the second most commonly injured joint after the knee. Thirty five per cent of all injuries of the shoulder are recurrent injuries. The part of the rugby game most strongly associated with shoulder injuries is the tackle accounting for 49% of all injuries (Brooks et al 2005). Acute shoulder dislocation is a relatively common injury within rugby, 95-98% being anterior dislocation, although posterior dislocation can occur.
Mechanism: The commonly defined cause of anterior dislocation described in literature is due to a fall on an outstretched arm which is in a position of combined abduction and external rotation with a posteriorly directed force. Recent studies which has specifically analysed shoulder trauma in rugby players, and has described a position of forced abduction and external rotation (ABER), accounting for 32% of reordered injuries. This was either in a tackle situation or landing with the ball outstretched when trying to score a try (Funk and Snow 2007). Posterior dislocation is much less common and usually caused by anterior forces when the shoulder is held in internal rotation and adduction.
Presentation: Most often this will follow a contact episode and the player will complain of shoulder pain and dysfunction.
Anterior Dislocation: The player will generally cradle the arm to their side. Typically there is loss of the deltoid roundness, although in modern day players, the wearing of shoulder pads generally makes this almost impossible to see. It may be detected by palpation, although once again, this may be difficult due to the tight shirts and shoulder pads. Sometimes it is possible to palpate the humeral head as fullness in the clavi-pectoral groove.
Active movements, when tried will be painful and severely limited. The player is often aware that their shoulder has dislocated. Check for the presence of a radial pulse and document. If possible check the sensation over the “Regimental Badge” area adjacent to the insertion of Deltoid; this may be impractical due to clothing and padding. This is to assess whether the Axillary nerve is implicated in the injury, findings must be documented. The integrity of the Radial nerve can be assessed by assessing wrist and elbow function, and testing for reduced sensation over the dorsum of the hand.
Posterior Dislocation: The player may present with the arm adducted and internally rotated, but may well present with them holding their arm in forward elevation with their opposite arm, complaining of pain if they try to lower it. A posterior bulge may be present and palpated below the acromion; once again this may be difficult due to clothing and padding. The movements of abduction and lateral rotation are painful. Similar neurovascular checks need to be carried out as for an anterior dislocation.
Removal of player from field of play: If a dislocation is suspected the player will need to leave the field of play. Generally the player is able to walk off the field, and so the limb may be supported by the player, the player’s shirt can be rolled up from the bottom over the arm to provide support, or a Polysling can be applied with a swathe around the chest.
Reduction Techniques: When possible, give pain relief, such as Entonox (if no contraindications exist for its use). Early reduction is recommended to be performed when dislocation has occurred, so to reduce the amount of muscle spasm that must be overcome and minimise the amount of stretch and compression of neurovascular structures (Christofi T, et al 2007).
If the person attempting reduction is not confident when applying these techniques they will result in failure, and will induce spasm into the joint and make the player more anxious. So be firm and controlled when carrying out any of the techniques. DO NOT FORCE THE RELOCATION, there may be other damage!
Spaso Technique: The player is placed in the supine position. The carer stands on the same side as the dislocation and takes hold of the affected arm by the wrist with a two handed grip and gently raised to approximately 90° flexion whilst applying gentle traction. The shoulder is then externally rotated, reduction usually occurs spontaneously.
Kocher's Method: With the player seated on a chair with back support, bend the affected arm at 90º at the elbow, ask the player to hold the elbow adducted against their body. The carer grasps their wrist and slowly externally rotates the arm between 70º to 85º until resistance is felt. Lift the externally rotated upper arm as far as possible forwards. From this point internally rotate the shoulder bringing the patient's hand towards the opposite shoulder. The humeral head should now slip back into the glenoid fossa
Modified Milch: Have the player seated on a chair with back support, stand behind the affected shoulder and place your near hand over the superior aspect of the shoulder girdle to fix the scapula. Holding the arm at the wrist, slowly and gently abduct the arm to 100°, whilst gradually externally rotating the arm as it is lifted. If the relocation does not occur an assistant can gently push the humeral head anteriorly.
Stimson Method: This method can be utilized in the treatment room. Position the player prone on an examination table with the affected arm hanging over the side of the table. An assistant applies a downward traction force on the arm or attaches a 5 to 10 kg weight to the wrist, should not touch the floor. Spontaneous reduction should ensue as the shoulder muscles relax.
Following reduction, re-assesses the neurovascular status, and document. Place the arm in a Polysling with Swathe around the chest and transport to hospital for x-ray, any further necessary treatment and appropriate follow up.
The elbow joint is the second most commonly dislocated joint of the upper extremity, being more commonly injured in adolescents and young adults. It has been reported that dislocation of the elbow most frequently occurs in a posterolateral direction, occurring 90% of the time due to the stable configuration of the bony congruity and muscular support across the joint.
The most common cause of posterior elbow dislocation is a fall onto an outstretched hand or direct blow to the elbow.
Signs & symptoms
- Severe pain at the time of injury.
- Loss of elbow function.
- Visible deformity
- Tenderness over the dislocation.
- Swelling and bruising around the elbow.
- Possible numbness or paralysis in the arm below the dislocation
- Possible decreased or absent pulse at the wrist
Prior to reduction neurovascular status needs checking and documenting.
Examine the functions of the radial (wrist extension), median (pronation), and ulnar (flexion of 4th and 5th fingers) nerves before reduction.
The median nerve can be injured at the time of reduction by becoming entrapped in the joint. The brachial artery may also be trapped in the joint along. Altered neurology or vascular status indicates a medical emergency and necessitates rapid transport to hospital. Prior to relocation administer appropriate pain relief.
Reduction; with the patient lying supine with the affected arm extended to the side in slight flexion, or standing, an assistant applies counter-traction to the humerus, whilst the examiner stands to the same side facing the player and supports the flexed, and slightly supinated forearm, with his near arm and supports the player’s arm against his body. At the same time the operator “hooks” his fingers of both hands over the superior aspect of the prominence of the olecranon whilst applying in-line traction to the forearm.
An alternative method is to lay the player face down on a table with the shoulder in abduction, and the humerus supported by the table, and the elbow flexed. The examiner takes hold of the forearm just above the wrist, and uses the other arm to stabilize the humerus around the elbow and the thumb resting on the olecranon, then applies gentle in-line traction to the forearm traction, while the thumb is utilized to apply gentle pressure to facilitate reduction.
Following reduction, neurovascular status must be re-checked and recorded. Player‘s arm is then placed in a sling and transported for x-ray.
- injury to brachial artery
- injury to the nerves
- fractures of the head of radius and/or coronoid process of ulna
- fracture and entrapment of medial epicondyle
- heterotropic ossification ( Myositis ossificans)