Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Wilderness and Rescue Medicine 106

You will probably need to wrap the end of your patient’s finger in gauze or a bandanna to help keep your grip. Some crepitus will be felt during manipulation. After manipulation, test passive range of motion to be sure that reduction was successful. The joint will likely be a little swollen and sore with reduced active range of motion. Splint the joint in the mid- range, or by padding and taping the finger to the one adjacent (buddy taping). Remember to check CSM before and after reduction. Pain should improve with your treatment. Medical follow-up should occur within a week, if possible. Difficult Dislocations In the backcountry, any dislocation that resists your efforts at reduction can become a serious problem. Pain may be severe, and the potential for tissue damage due to ischemia increases with time. If CSM is significantly impaired and cannot be restored by traction and repositioning, immediate evacuation to medical care is warranted. Hip dislocations are difficult to distinguish from hip or pelvis fractures in the field. Pulling on a hip or pelvic fracture could lead to increased deformity and bleeding. Even if the diagnosis of dislocation is clear, significant analgesia and seda- tion are required for a successful reduction. Elbow dislocations are notoriously painful to reduce and there is a high incidence of long term complications. Like dislocations of the hip, pain medication and sedation are required. Manipulation of either in the field should be performed only to restore distal circulation in an ischemic limb. Risk Versus Beneft Dislocation reduction is a medical procedure usually reserved to licensed practitioners. Many emergency physicians even defer the procedure to orthopedic surgeons. That luxury does not often exist in the remote setting. Fortunately, reduction as described here is a low risk procedure for a high-risk problem.

Without the x-ray, it would be difficult to distin- guish a hip dislocation from this intertrochanteric fracture of the femur. The leg of this patient was shortened and rotated.

General Principles

Elbow Dislocation x-ray inset

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Although most medical control physicians are more comfortable with time and distance criteria for field reduction, for example two hours from definitive care for a dislocated shoulder, there is little reason to prolong pain and disability any lon- ger than necessary. There is clear benefit to early reduction of simple dislocations, and the inci- dence of complication is extremely low. The risks associated with prolonged dislocation include ischemia and infarction of joint structures and the distal extremity. There is also increased risk to the patient and rescuers in the urgent evacuation of a disabled patient in severe pain.