injuries poisoning
Overview of Dislocations
Treatment of Dislocations
Treatment of associated injuries Reduction as indicated, splinting, and analgesia RICE (rest, ice, compression, and elevation) or PRICE (including protection) as indicated Usually immobilization Sometimes surgery Most joint dislocations can be reduced (returned to the normal anatomic position) without surgery. Occasionally, dislocations cannot be reduced using closed manipulative techniques, and open surgery is required. Once a joint is reduced, additional surgery is often not necessary, However, surgery is sometimes required to manage associated fractures, debris in the joint, or residual instability. Serious associated problems, if present, are treated first. Injuries to arteries are surgically repaired unless they affect only small arteries with good collateral circulation. Compartment Syndrome is treated. Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy. Suspected open dislocations require sterile wound dressings, tetanus prophylaxis, broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside), and surgery to irrigate and debride them (and thus prevent infection). Most moderate and severe dislocations, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to decrease pain and to prevent further injury to soft tissues by unstable injuries. Pain is treated as soon as possible, typically with Opioid Analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs). After initial treatment, dislocations are reduced, immobilized, and treated symptomatically as indicated. Dislocations may require surgical repair if Structures supporting the joint are damaged. A joint remains unstable after reduction. Dislocations are reduced. Closed reduction (by manipulation, without skin incision) is done when possible; sedation may be required. If closed reduction is not possible, open reduction (with skin incision) is done; anesthesia is required. Dislocations typically require a cast, splint, sling, or another device (eg, external fixator for the knee) to maintain reduction. Patients with a joint dislocation may benefit from PRICE (protection, rest, ice, compression, elevation), although this practice is not supported by strong evidence. Protectionhelps prevent further injury. It may involve limiting the use of an injured part, applying a splint or cast, or using crutches. Restmay prevent further injury and speed healing. Iceandcompressionmay minimize swelling and pain. Ice is enclosed in a plastic bag or towel and applied intermittently during the first 24 to 48 hours (for 15 to 20 minutes, as often as possible). Injuries can be compressed by a splint, an elastic bandage, or, for certain injuries likely to cause severe swelling, a Jones compression dressing. The Jones dressing is 4 layers; layers 1 (the innermost) and 3 are cotton batting, and layers 2 and 4 are elastic bandages. Elevatingthe injured limb above the heart for the first 2 days in a position that provides an uninterrupted downward path; such a position allows gravity to help drain edema fluid and minimize swelling. After 48 hours, periodic application of warmth (eg, a heating pad) for 15 to 20 minutes may relieve pain and speed healing. Immobilization decreases pain and facilitates healing by preventing further injury. Joints proximal and distal to the injury should be immobilized. is usually used for Immobilization or other injuries that require weeks of immobilization. Rarely, swelling under a cast is severe enough to contribute to Patients with casts should be given written instructions, including the following: Keep the cast dry. Never put an object inside the cast. Inspect the cast’s edges and skin around the cast every day and report any red or sore areas. Pad any rough edges with soft adhesive tape, cloth, or other soft material to prevent the cast’s edges from injuring the skin. When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the edge from pinching or digging into the skin. Elevate the cast whenever possible to control swelling. Seek medical care immediately if pain persists or the cast feels excessively tight. Seek medical care immediately if an odor emanates from within the cast or if a fever, which may indicate infection, develops. Seek care immediately for progressively worsening pain or any new numbness or weakness (which may indicate Compartment Syndrome ). Good hygiene is important. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. © Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. (see figure Joint immobilization as acute treatment: Some commonly used techniques ) can be used to immobilize some stable dislocations. A splint is noncircumferential; thus, it enables patients to apply ice and to move to some degree. Also, it allows for some swelling, so it does not contribute to compartment syndrome. Some dislocations that ultimately require casting are immobilized initially with a splint until most of the swelling resolves. Aslingprovides some degree of support and limits mobility; it can be useful for dislocations that are adversely affected by complete immobilization (eg, for shoulder dislocations, which, if completely immobilized, can rapidly lead to adhesive capsulitis [frozen shoulder]). Aswathe(a piece of cloth or a strap) may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part. Prolonged immobilization (>3 to 4 weeks for young adults) of a joint can cause stiffness, contractures, and muscle atrophy. These complications may develop rapidly and may be permanent, particularly in older patients. Resumption of active motion within the first few days or weeks may minimize contractures and muscle atrophy, thus accelerating functional recovery. Physical therapists can advise patients about what they can do during immobilization to maintain as much function as possible (eg, elbow, wrist, and hand range-of-motion exercises if the shoulder is immobilized). After immobilization, physical therapists can provide patients with exercises to improve range of motion and muscle strength, strengthen and stabilize the injured joint, and thus help prevent recurrence and long-term impairment. 