Dislocations of the Elbow
The elbow is typically a stable joint that requires significant force to alter its integrity and cause dislocation. Therefore, a good number of dislocations are often accompanied by concomitant fractures. The elbow joint is susceptible to anterior and posterior dislocation, the latter being the most widespread. With anterior dislocations, significant force is typically directed at the posterior aspect of a flexed elbow. This mechanism of injury causes the olecranon to move anterior to the humerus. In the most common posterior dislocation, the mechanism of injury is often described as a fall on an outstretched arm. This condition usually presents in an obvious deformity with an exaggerated swelling of the olecranon in the back. Clinical symptoms of both dislocations include severe focal pain in the elbow joint and rapid onset of effusion. Emergency medical care should consist of immobilizing the anatomy in the presentation position with a rigid, pneumatic, or vacuum splint. Due to the complexity of the elbow joint, these dislocations often accompany a high incidence of neurovascular impairment and associated fractures. Therefore, it is strongly recommended that only competent orthopedic specialists perform site-specific reductions. Therefore, elbow joint dislocations require immediate EMS activation for full care and transportation to the nearest medical facility. While waiting for the EMS, the athletic trainer must periodically monitor the neurovascular status. Complications resulting from improper management include brachial artery occlusion, medial or ulnar nerve pathology, myositis ossifying, and arthritis. The fitness coach must also be aware of the possibility of spontaneous reduction of the dislocation and remain alert for the warning signs of any of the complications mentioned above. If spontaneous reduction of a dislocation is suspected, the fitness trainer should evaluate the stability of the elbow complex and adequately fix the area. The injured athlete must also be transported immediately to the nearest emergency medical facility for appropriate follow-up care.
Dislocations of the Shoulder
Of
large articulations throughout the human skeletal system, the GHJ is one most predisposed
to dislocate during athletic activities.8 The majority of GHJ dislocations are described
as anterior and posterior. Inferior dislocations
are
typically associated with concomitant fracture and significant neurovascular
compromise, although such injuries are rare. Glenohumeral joint dislocations
are widespread in contact or collision sports participation and are often the result
of direct trauma. The mechanism of injury most
often
eliciting an anterior dislocation is that of a direct extreme external rotation
and abduction force applied to the GHJ. Posterior dislocations of the GHJ occur
as the result of a significant direct force that drives the humeral
head
posteriorly, thereby disrupting its integrity with the glenoid. Athletes
sustaining GHJ dislocations often present with a significant amount of pain and
tendency to cradle the injured extremity. There is also an unwillingness and inability
to generate range of motion within the affected shoulder complex. Assessing a
GHJ dislocation is best accomplished through visual inspection of the involved anatomy
for obvious deformity. This usually consists of an exaggerated protrusion of
the humeral head and hollow
area
inferior to the acromion.
Emergency
medical care of GHJ dislocations should begin with a thorough examination to
rule out associated neurovascular compromise and potentially related fractures.
Significant spasm of surrounding musculature is usually quickly noted
subsequent to GHJ dislocations. This protective guarding mechanism can pose a
considerable challenge in reducing the joint dislocation. Prompt competent
joint reduction on the field of play typically necessitates less force. Furthermore,
early reduction can provide considerable relief from pain in addition to
diminishing the potential for iatrogenic pathology.Although ideally radiographic images of the injured
joint should be obtained prior to and following reduction to rule out related fractures,
the benefits of early reduction usually outweigh the involved risks. This is especially
evident in those individuals suffering from chronic GHJ instability and recurrent dislocations.
Within this particular population concomitant fractures rarely present. Three
commonly used modes of reduction include the self-reduction
technique, the gravity
(modified Stimson’s) method, and traction/external rotation procedure. Selfreduction calls for the athlete with a GHJ dislocation to interlock
his or her fingers and grasp the flexed knee of the unaffected side. The
athlete then gradually leans backward, inducing slight traction to the GHJ,
which ideally yields relocation.
The
gravity (modified Stimson’s) method requires the athlete to lay prone with the
injured extremity draped over an examination table or similar surface. The
athletic trainer then grasps the wrist of the affected extremity and applies a minimal
amount of gravity-assisted traction. The gravityassisted traction aims to gradually
stretch the surrounding musculature in spasm, thereby facilitating relocation
of the
GHJ.
The
traction/external rotation procedure begins with the injured athlete in a
supine position followed by the athletic trainer inducing mild and continual
traction along the significantly decrease pain. The athletic trainer then
slowly
and
passively guides the GHJ to approximately 90 degrees of abduction while
maintaining the mild traction. Once this has been accomplished the GHJ should
be gradually externally rotated to correct physiological terminal range. This
position is held steadily to relieve muscle spasm. Once the protective muscle
spasm has been decreased, the GHJ dislocation should reduce spontaneously and
be felt by both the injured athlete and athletic trainer. If reduction in this position
proves unsuccessful, the clinician may attempt to gradually increase GHJ abduction to 120
degrees while steadily maintaining traction and GHJ external rotation.
athletic
trainer must remain cognizant that aggressive traction
or
countertraction is not used in this joint reduction
mode.36
Following relocation of the articulation, the GHJ is
returned
to 0 degrees of abduction and internally rotated
until
the hand comes into contact with the torso, all while
maintaining
steady traction.
It
is imperative the athletic trainer periodically reassess
neurovascular
functions following reduction. An arm sling
should
be used for comfort,with careful application of ice for
pain
control.8,37 Referral to an orthopedic specialist for urgent
consultation
is highly recommended following GHJ dislocations.
If
a GHJ dislocation cannot be reduced easily, it must
be
appropriately splinted in a position of comfort and the
injured
athlete must be transported to a hospital by EMS.
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