# Question about a dislocation



## Nickb (Feb 20, 2012)

Is it possible for a dislocation to go back into a some what normal position for a while and then go back into a abnormal position?
I feel like this is a stupid question but this seemed like the best place to ask.


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## Akulahawk (Feb 20, 2012)

Nickb said:


> Is it possible for a dislocation to go back into a some what normal position for a while and then go back into a abnormal position?
> I feel like this is a stupid question but this seemed like the best place to ask.


Not a stupid question. Yes, it is possible. A dislocated joint can sometimes spontaneously reduce. It doesn't fix the laxity in the joint capsule or ligaments that were torn to allow the dislocation in the first place. Further dislocations in the same "direction" as the original are quite likely. Sometimes you can get a subluxation, which is a partial dislocation that doesn't go all the way out and then returns to normal postioning, which weakens the structures enough that the next time stress is placed on the joint in that same direction, a dislocation occurs instead. 

I've seen a few of those over the years... but you'd see them more frequently in sports environments.


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## EpiEMS (Feb 20, 2012)

Speaking of dislocations, are there any regular protocols that allow EMTs to reduce them? I was reading through a WEMT protocol (protocols giving skills permitted by Maine and New Hampshire if you're more than 2 hours out from the ER), and they seem to permit reduction of dislocated shoulders and dislocated knees.


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## Akulahawk (Feb 20, 2012)

EpiEMS said:


> Speaking of dislocations, are there any regular protocols that allow EMTs to reduce them? I was reading through a WEMT protocol (protocols giving skills permitted by Maine and New Hampshire if you're more than 2 hours out from the ER), and they seem to permit reduction of dislocated shoulders and dislocated knees.


WEMT protocols are there for a reason. Normally, there are no protocols to allow a reduction of a dislocated joint. That has to generally be done by the ED because of the (usually) high risk of impinging the limb's neurvascular bundle within the joint. That being said, I _do_ know how to reduce those injuries relatively safely. I won't do it unless I have to... and certainly not while I'm on-duty unless I'm working under protocols (such as WEMT type) that allow me to do so. The other variable is "time." There is a small window of time post-injury when a reduction without anesthesia is very possible. EMS usually arrives on scene outside that window. After that window closes, it's best to splint in the position that's most comfortable (or position found) and allow the ED Physician or Surgeon to anesthetize the patient for a more successful (and easy) reduction.


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## EpiEMS (Feb 20, 2012)

That makes sense. Of course, I should learn more A&P, as always.


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## Akulahawk (Feb 20, 2012)

Learning more anatomy and physiology is always a good thing, however learning how to reduce dislocations is a specialized skill that requires some additional training. I learned how to do it in the course of learning how to become an athletic trainer. That is what my first bachelor's degree is in. Athletic trainers learn how to do reductions because they are quite often immediately available at the time of injury and can properly evaluate the injury prior to the onset of muscle splinting, not to mention the onset of edema. Reduction of a dislocation at this time is relatively easy. After that, the patient may need to be anesthetized or even paralyzed for a successful reduction to occur because of muscular tetany. While reduction of a dislocation will not reduce the damage that has already occurred, it may reduce the amount of damage that occurs subsequent to the dislocation because the dislocated parts have been returned to normal position. This should result in less inflammation, therefore, less edema and less overall damage. 

The problem with reductions early on in the process is that you don't know if the neurovascular bundle has been compromised. You don't know if you compromised the neurovascular bundle through your attempt to reduce the dislocation. In the setting of the W EMT, the goal of reduction is to return the victim to a more functional state so that the victim can either walk out or more easily tolerate a more lengthy evacuation to a medical facility. Ultimately, stabilization of a dislocation may require surgery.


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## mycrofft (Feb 21, 2012)

*Knew guys who could dislocate at will*

Shoulders, that is.
A joint can be prone to dislocation due to genetics or prior dislocation. If it is one of the "right ones" and hasn't really gone a-roaming, it will tend to relocate...then fall out again.


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## Melmd (Feb 25, 2012)

Nickb said:


> Is it possible for a dislocation to go back into a some what normal position for a while and then go back into a abnormal position?
> I feel like this is a stupid question but this seemed like the best place to ask.



Mostly seen on patients with TMJ (temporo-mandibular joint) dysfunction or better known as lock-jaw... when the masseter muscle goes to spasm the jaw(mandible) is pulled back from its socket  thus resulting to an open mouth locked position and for some reason it relaxes the mandibular joint returns back to its socket...


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## Cindigo (Feb 27, 2012)

In class one of the instructors specifically said "never, never, never reduce. That being said, if *you* dislocate *your* patella almost all the time if *you* straighten *your* own leg, it will reduce by itself." 

It's not outside your scope of practice if it happens spontaneously. Not saying I would tell someone to try and straighten their leg. Good god, with the limited amount of training I have right now I'm surprised they even let me on a ambulance.


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## medicdan (Feb 27, 2012)

Patients with particularly loose joints who are prone to dislocations know that with time (sometimes 12+ hours), they will relocate, often aided by relaxing the whole body and trying to sleep (pain meds help with this of course).


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## Cindigo (Feb 27, 2012)

emt.dan said:


> Patients with particularly loose joints who are prone to dislocations know that with time (sometimes 12+ hours), they will relocate, often aided by relaxing the whole body and trying to sleep (pain meds help with this of course).



Oh yeah! I was talking to my paramedic friend about dislocations after class, and he was saying that sometimes people will be so tense for so long that eventually they get exhausted. When they do and "relax" then the dislocation sometimes spontaneously reduces.

So as a paramedic, for someone with a dislocation it would be within your scope to give drugs to help the PT/PT's muscles relax?


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## Akulahawk (Feb 27, 2012)

Cindigo said:


> Oh yeah! I was talking to my paramedic friend about dislocations after class, and he was saying that sometimes people will be so tense for so long that eventually they get exhausted. When they do and "relax" then the dislocation sometimes spontaneously reduces.
> 
> So as a paramedic, for someone with a dislocation it would be within your scope to give drugs to help the PT/PT's muscles relax?


No, if the reason to give the drugs is specifically to allow muscles to relax and make a reduction (manual or spontaneous) possible. If I had to give the drugs for another reason, say for airway control purposes, and the dislocation reduced on it's own, that would be a happy coincidence and therefore I wouldn't get into trouble for that. 

The problem is that sometimes, it is necessary to sedate and paralyze in order to get the musculature to relax sufficiently to allow a reduction to take place. In effect, you'd have to RSI and do airway control and then attempt the reduction measures before the paralytic wears off... and for something that is mostly an elective thing (as in don't have to reduce in the field), I won't want to do it in the field... I'd rather have that done in the ED or an OR setting. 

As a Paramedic, my response time would be well outside the timeframe when it would be relatively easy to reduce a dislocation. Muscular tetany will generally be well under-way by the time I would get on scene. Do I know how to do it? Yes. I learned through my sports med education. Was I trained to do it through any Paramedic program? No. When I'm on duty as a Paramedic, guess which set of instruction controls what I do...


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## systemet (Feb 27, 2012)

Cindigo said:


> So as a paramedic, for someone with a dislocation it would be within your scope to give drugs to help the PT/PT's muscles relax?



Depending on your region, you may be allowed to do some form of "conscious sedation", and mix benzos and opiates to address the pain and the muscle spasm.  Sometimes this is enough that the joint may relocate.

I think it should be in scope to reduce lateral patellar dislocations without a history of significant trauma.  But it isn't in most places.  I will admit to having been sorely tempted to do so a few times.

[That being said, a lot of places will allow you to attempt to reduce/realign if there's evidence of compromised perfusion.  This is still a little dangerous, as someone else mentioned, because it's hard to prove that you didn't cause any lasting injury.]

Shoulders are a different story.  You will meet people who are able to reduce their own dislocations, often after they've failed to do so this time.


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## Cindigo (Feb 27, 2012)

Akulahawk and Systemet.....thanks for the info. Good stuff.


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