Dislocations

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 the two can occur together. If there is clinical doubt the limb should be immobilised, splinted and radiographs taken, before attempting any manipulation. Dislocations are normally associated with a soft tissue injury, which may need to be immobilised pre and post-reduction, to reduce pain and prevent further damage.

Shoulder Dislocations

The shoulder comprises 20% of all rugby injuries being the second most commonly injured joint after the knee.  35% of shoulder injuries are recurrent injuries.  In rugby the part of the 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 in rugby, 95-98% of which are anterior dislocations..

Mechanism: Anterior dislocation of the shoulder is described most commonly as due to a fall with a posteriorly directed force onto an outstretched arm, which is abducted and externally rotated. A study which specifically analysed shoulder trauma in rugby players, described a position of forced abduction and external rotation (ABER), accounting for 32% of recurrent injuries. This was either in a tackle situation or when landing with the upper limb outstretched holding the ball when trying to score a try (Funk and Snow 2007). Posterior dislocation is much less common and usually caused by an anterior force 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 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 a fullness in the clavipectoral groove.

Attempting active shoulder movements, will be painful and severely limited. The player often knows their shoulder has dislocated. Check for, and document, the presence of a radial pulse. 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 and document if the axillary nerve is affected 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, or holding their arm in forward elevation with their opposite hand and complaining of increased pain if they try to lower it and attempting abduction or lateral rotation are painful.. A posterior bulge may be present palpated below the acromion; once again this may be difficult to identify due to clothing and padding. The same 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 will be able to walk off the field, the limb may be supported by the player, the player’s shirt can be rolled up from below, over the arm to provide support, or a Polysling can be applied with a swathe around the chest.

Elbow Dislocation

The elbow joint is the second most commonly dislocated joint of the upper limb, and is more commonly injured in adolescents and young adults. It has been reported that elbow dislocation most frequently occurs in a posterolateral direction (90%) due to the stable bone configuration and muscular support across the joint.

The most common cause of posterior elbow dislocation is a fall onto an outstretched hand or a 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
• Numbness or paralysis in the arm below the dislocation
• Reduced or absent pulse at the wrist

The neurovascular status needs to be checked and documented and adequate analgesia should be administered

Examine the functions of the radial (wrist extension), median (wrist pronation), and ulnar (flexion of 4th and 5th fingers) nerves .