Archive for the ‘dislocations’ Category

New! From The Wilderness Medicine Newsletter

February 10, 2012

For decades the Wilderness Medicine Newsletter has provided up-to-date information to pre-hospital and definitive care providers. Since becoming an on-line journal, the readership of the WMN has become international. Now the WMN has it’s own web site:

Subscribers pay the same $15 a year subscription rate but have access to more than 165 articles from back issues as well as current issues. You can search the site either by category, or by key words making the Wilderness Medicine Newsletter site a much more useful reference for everything from reviewing splinting to the prevention and treatment of tropical diseases.

Check it out!


December 11, 2007


Injury caused by direct impact to the patella.
Pain on palpation.
Palpable deformity of the patella.
Can be very swollen and ecchymotic.
A fractured patella can make it difficult to walk, but not impossible.
Once splinted straight, patient can walk a short distance relatively pain-free.

For comfort and long-term care, splint with a posterior knee splint that maintains the knee
at a 20 – 30 degree angle, the position of comfort.
RICE to control swelling if appropriate, but not in a cold environment.


Injury caused by a direct force to the patella tendon just inferior to the patella.
When the patella tendon ruptures, the patella will retract up the leg.
The patella with the ruptured  tendon will be noticeably more proximal compared to the other knee.
Minimal pain and discomfort.
They can walk with the knee held straight.
They can flex but not extend the knee.

Splint with a posterior knee splint in the position of comfort, usually slightly bent.
Ace wrap to control swelling. Usually minimal bleeding from the rupture.


A common sports injury.
When the patella dislocates, it moves laterally.
The affected knee will be flexed to about 30 – 45 degrees.
Can be very painful.

The patella can be easily reduced.
Place your hand on the lateral aspect of the knee, with your fingers in the popliteal fossa and thumb against the patella.
As you straighten out the lower leg with your other hand, push your thumb against the patella forcing it back into the patella groove of the femur.
As the leg straightens, the patella will pop back into place.
The sooner this maneuver is performed, the better it works.
Once reduced into proper anatomical position, the knee should be splinted and an Ace wrap applied.
If possible RICE the knee.

Relocation of Patella

Anterior and Posterior Cruciate Ligament Injuries
Medial and Lateral Collateral Ligament Injuries

Examination & Evaluation of the Knee:

1.  History/MOI: How were the forces applied to the knee?
Does the knee feel stable when standing and weight bearing?

2.  Drawer test: With the knee at 90 degrees, push and pull.
Instability can indicate a cruciate injury.

3.  Lachman test: With the knee at 30 degrees push and pull.
Instability can indicate a cruciate injury.

4.  Med/lat distraction: With knee slightly bent try to distract med/lat.
Instability can indicate a med. or lat. collateral ligament injury.

The most comfortable splint is a posterior knee splint that maintains the knee at a 20 – 30 degree angle.


A dislocated knee is a very painful and destructive injury.
In order for the knee to dislocate, support ligaments had to be torn.
There is obvious deformity of the knee joint; typically, the tibia is pushed posterior to the femur.
Pressure on the arteries behind the knee can compromise the circulation to the lower leg.
All dislocated knees are surgical knees.


Because the supporting ligaments have been torn, it is usually simple with minimal discomfort to realign and reduce the dislocation.

Gently place knee in proper anatomical postion.

Check and monitor circulation distal to the knee.

Splint in position of comfort with a well-padded, posterior splint in position of comfort, usually bent at about 20 – 30 degrees.
Ace wrap to control swelling.

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September 10, 2007

Dislocated Shoulder:
The shoulder was forced past the normal range of motion.
The shoulder is locked in position and painful to motion.

Techniques of reduction:
Depends upon the position of the humerus.
If the humerus is abducted past 60 degrees then use the Mosher Technique.

Mosher Technique is a gentle passive technique using position and gravity.
1. Have them place the hand of the affected arm on top of their head.
2. Have them place their other hand on top of their head also and interlock their fingers.
3. Lay them flat on their back, and then allow the elbows slowly relax, under the tug of gravity, towards the ground. The dislocated shoulder will spontaneously reduce back into proper anatomical position over then next 5 – 15 minutes.

If the humerus is hanging down next to the body then use the Traction at the Elbow Technique.
Traction Sling at the Elbow:
1. Have them sit up in a chair or on a rock, whatever is comfortable.
2. Have someone else stand behind them and place their hands on the patient’s shoulders to support them sitting up straight.
3. With the affected arm beside the body and with the elbow flexed at 90 degrees, place a wide sling at elbow.
4. The sling needs to be in a loop to support your foot.
5. Place one foot in the loop and apply gently in-line traction to the upper arm. Do not move the arm, keep the forearm bent at 90 degrees and maintain gentle traction.
6. After about 5 minutes of gentle traction, without straightening the forearm, externally rotate the arm, if there is sufficient traction the shoulder will reduce and pop back into place.
7. If not then continue to maintain traction, if necessary slowly increase the traction-in-line.
8. After about 5 minutes again externally rotate the forearm to about 90 degrees or until the shoulder reduces.
9. Once the shoulder has reduced back into proper anatomical position, place in a sling and swathe and monitor circulation.
10. Transport, may walk if comfortable.

Fractured Humerus: 
May be angulated, if angulate straighten out with traction-in-line.
Apply a sling and swathe to support the humerus and forearm.

Fracture/Dislocation of the Elbow: 
Fractures and dislocations very painful.
Treatment is to support with sling & swathe.
May have to straighten if circulation impaired distal to injury.
Straighten with traction-in-line, initially maintain elbow at 90 degrees,
Once under traction, and the elbow has slid into proper anatomical position, you may slowly extend the forearm until circulation restored (pulse at wrist).

Fractured Radius/Ulna:
Fractures with deformity arm common (Colles’ and Smith’s deformities)
May need to straighten if circulation is impaired, but this is unusual.
Splint with wrist at 30degrees of extension, and the fingers at the MCP joints relaxed at about 60 degrees of flexion.

Fractured Wrist:
Most common carpal fracture is of the scaphoid,
Pain in the anatomical snuffbox can indicate a fracture scaphoid.
Splint with wrist at 30 degrees extension & fingers at 60 degrees of flexion.

Fracture/Dislocation of the Hands/Fingers:
Reduce dislocated fingers with TIL, may require ant/post pressure.
Buddy tape fractured fingers.
Splint fingers in position of function, flexed as if holding a soda can.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.


March 28, 2007

The next series of blogs will be an in-depth review of the recognition and management of musculoskeletal trauma in the wilderness, marine, disaster, and military environments.  This body of knowledge is the best example of the difference between urban, or street medicine, and the extended care environment. 

In the urban realm, typically, the ER is just minutes away and the primary concern is to stabilize the fracture or dislocation in the position found, and transport. Once outside the golden hour, the primary concern becomes circulation distal to the site of the injury. This may require straightening out angulated fractures, reducing dislocations, proper long-term splinting with big, ugly, fat, fluffy splints, and monitoring the circulation every 15 minutes for the duration of the evacuation.



Consist of a dense cortex surrounding an inner, soft marrow and they provide the rigid framework to which everything attaches. Bones also store calcium, an essential electrolyte, and produce the blood cells in the bone marrow.
Acts as a lubricated durable cap on the ends of the bones so that your joints can
flex and rotate smoothly and without friction. Cartilage also provides support for muscle in areas where more flexibility than bone offers is needed.
Is the tough fibrous layer that covers the bones and which contains the nerves that produce the pain associated with injuries.
Synovial fluid:
Is the lubricant in the joint space produced by the synovial lining of the joint capsule that surrounds the joint, allowing for friction-free movement.
Are like bundles of bungee cords. In response to signals sent from your brain through your central nervous system, they contract and relax, which flexes your joints and allows you to move. All muscles work by contracting, 
Are the ties connecting muscles to bone. They span joints and allow for movement.
Are like nylon cords and attach bones to other bones. They span joints, maintaining proper alignment and setting the limits of range of motion.

PHYSIOLOGY:  Musculoskeletal system functions:

The contraction of muscles provides us with purposeful movement.
Heat Production:
The contraction of muscles produces heat.
The strength and flexibility of  muscle protects many internal structures including the bundles of nerves, arteries, and veins beneath the muscles.
Calcium storage: 
The bones act as a large calcium store.  Calcium is an electrolyte that allows for the contraction of muscle, including the heart muscle, and the conduction of nerves impulses.
The process by which the various blood cells (red blood cell, white blood cell, and platelets), are produced in the bone marrow.
The muscular and skeletal structures contribute greatly to how we look.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Reducing a dislocated patella

November 11, 2006

How to Reduce a Dislocated Patella

A dislocated patella typically occurs when a force is applied to the medial side of the patella forcing it laterally out of the femoral groove in which it rides. The patella is held in place inferiorly by the patella tendon and supported on the sides by the medial and lateral patella femoral ligaments.

The patella almost always dislocates laterally. When this occurs, the patient will be in significant pain with their knee flexed and the patella displaced laterally. As with most dislocations, the longer the patella remains out of joint, the more swelling there will be in and around the joint. This swelling makes it harder to reduce. So, the sooner the joint can be reduced back into normal anatomical position, the better.

reducing dislocated petella


Examine closely

Palpate the patella for fractures

Gently check the stability of the knee

To reduce the patella:

With one hand grasp the ankle. Place the other hand on the lateral aspect of the knee with the fingers in the popliteal space and the thumb against the lateral aspect of the patella.

As you push against the patella with your thumb, slowly straighten out the leg with the hand that is on the ankle. As the leg extends, the patella will reduce back into normal anatomical position.

Once reduced, wrap the knee with a 6” ace wrap for gentle compression and to minimize swelling, then splint the leg straight. Because of the risk that the medial patella ligament has been partially torn and there may be other ligamentous damage, the knee has to be splinted straight. Once the knee is wrapped and splinted, the patient may try to walk with the leg stiff and straight. If the injury was only a dislocated patella and ligamentous sprain, walking should be pain free.

Please note: in the event that the patella does not reduce, splint the leg in the position found and transport in a litter.

For more information see the Sept/Oct 2004 issue of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.