# Reducing broken/dislocated joints??



## xavierengle (Aug 4, 2009)

A question for all you medical professional buzzard types. If, hypothetically, your buddy had a broken collarbone and a dislocated shoulder, should you try and reduce the shoulder? Mostly wondering if pulling on the shoulder could increase damage to/around the broken bone, beyond just hurting a shit ton.

Also with ankles, and I guess the rest of the breakable joints, if the ankle/joint is broken AND dislocated, is it worth trying to reduce, or do you just risk causing more damage?


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## KSC (Oct 22, 2003)

I seem to recall Dr. so and so talking about this (the shoulder) on an In Between Swims podcast. It's embedded in the middle of this one somewhere:
In Between Swims:The Whitewater Podcast


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## st2eelpot (Apr 15, 2008)

I am not very highly trained (current WFR and way out of date EMT-B). First, we’re only allowed to do what is within our scope of training, so my answers will likely be different than an ER doc who happens to be on the same trip in the field.

What one is allowed to do greatly depends on if you're in the front country or a wilderness setting. I was taught that if working as an EMT-B in the front country to never touch it- load in the ambulance. In a wilderness setting things can be argued differently, but in general I was still taught do not touch unless the person has a limb-threatening injury and has lost CMS (circulation, motion, sensation) or it could be in consideration of some other life threat (need the arm to operate the snowmobile to keep from dying of hypothermia from the blizzard for example). So, if the person has lost circulation to the hand due to a shoulder injury in a wilderness setting, and you’re operating in the scope of one’s training, then one would likely want to move/possibly reset the joint (until CMS is restored, or the patient indicates an abnormal amount of pain or an unusually high amount of resistance is encountered). 

There are only a few dislocations I was taught how to do, so the exact joint, and the mechanism for knocking the joint out is also a huge consideration (example would be direct or indirect trauma, is it a dislocated femur/pelvis or is it a finger, etc.).

If a dislocation and broken bone is suspected, I really really don't want to touch it. Don't want to try to stick it in w/ bone fragments in the way for example.


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## smet.cep (Jul 10, 2009)

To reduce a dislocated shoulder, one does not pull on the arm so much as externally or internally rotate the arm. That said, yes, pulling on the arm could potentially make the clavicle fracture worse. If I absolutely needed to, I would apply pressure to the clavicle to stabilize it, and then externally rotate the patients arm, but that is in a worst case, 2 days from a hospital type situation.
The problem with the scenarios you list are that there are so many variables. Reducing any dislocation and/or fracture in the field is situation dependent. I think patient comfort and situation survivability probably rank highest. Gentle traction is a good indicator, either they will tolerate it, or not. Pain killers, if available are also your friend.
Not trying to bag on the question, I guess I have more questions than answers. Do no harm, and only fix something only if it's the last resort.


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## goldcamp (Aug 9, 2006)

From the perspective of someone who has had multiple shoulder dislocations it almost always seems better to set the shoulder then try to get help. However I know how to do this and have never had one extremely diffficult to reset the longest was about 10 minutes. It seems to me you run the risk of more tissue damage the longer it is out of the joint. But again I am no doctor...


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## rg5hole (May 24, 2007)

I have had both injuries but not at the same time. I can tell you that if your buddy has a busted collar bone you are not going to be pulling on it without getting punched in the face. In this case from my experience the pain is much less while simply stabilized and immobile, also it is time to call the pros that have been studying for 8 years while we have been kayaking for some help, this is way above us.

I can also tell you that having had a violent dislocation with a simple fracture on the end of my humorous the pain is severe, but 50% less painful in the joint (reduced) than out. So, traction then external rotation and stabilization = much less pain for the hike out.

In both cases I can tell you your buddy's kayaking is pretty much done, in other words it is time to start hiking if possible.


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## NathanH. (Mar 17, 2010)

There are several inherit risks of not reducing the shoulder injury. The most serious of which would be artery damage as the longer you leave the shoulder out the more likely it is that a nerve/artery/ vein could slip into the socket and cause extreme pain or hemorrhage when it the shoulder is eventually reduced. This risk is also taken when a shoulder is reduced improperly, and the nerve/vein/artery is pushed in unknowingly. 

Immobilize the shoulder and limit movement, I am sure movement is already limited with the broken collar bone. Maintain good posture as the collar bone could easily begin setting in the wrong position, meaning even more pain later when a doctor has to undo the wrong work the body has started.


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## Kendi (May 15, 2009)

As a wilderness first aid instr- my training says- it isn't hard to put a dislocated shoulder back in via gentle traction, but putting the other injuries in the mix makes it dicey. So I'd say it very much depends on the situation and the pain tolerance of the individual.


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## danger (Oct 13, 2003)

as an er nurse i would consider a direct impact shoulder dislocation to be a contraindication to a reduction in the field. there are just too many unknowns. also, i've never heard of someone breaking their collar bone paddling. 

dan


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## hojo (Jun 26, 2008)

I've seen a few shoulder dislocations both on the water and, well, hockey is technically played on water too I suppose... anyhow, if you can get to definitive care (that translates to a hospital) in a reasonable time (no clear definition on that) then do it. A shoulder can stay out for a good 1 to 2 hours with little threat to the limb unless it starts turning purple immediately, in which case you may be hosed no matter what. Different wilderness protocols exist and they usually consider 2 to 2.5 hrs travel time within the range of definitive care. The pain endured for that time is well worth averting a chip (or worse) due to a bad reduction. Having said that, someone trained in a field reduction can try provided it's within the scope of their training. The procedure is GENTLE and NOT rapid (NO JERKING). If it won't go in then it won't go in. It doesn't matter how caviler the EMT, EMT wanna-be or even paramedic is, sometimes you need a muscle relaxant. 

I've seen a bad shoulder reduction and it's both painful and completely avoidable if you're close to a hospital. The risks are not worth the benefit if you can get to a hospital. danger has it right. As far as the collar bone is concerned, provided it's not puncturing the skin then there really is little first aid to be done. Get to definitive care for x-rays and get your hiking boots out.


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## TGettel (Jul 15, 2007)

*Ortho doc says "I've never seen it happen"...*

Saw the thread while at work with a Denver orthopedic surgeon (ironically getting ready to perform a shoulder stabilization)--asked him about the liklihood of seeing the two injuries simultaneously. He's never seen it in the twenty years he's been in practice (not that it's absolutely impossible-just highly improbable). He's reduced both shoulder and elbow dislocations in the backcountry (but he knows exactly what he's doing too). If it were me and I weren't paddling close to help and had an isolated shoulder dislocation (eg no clavicle fracture)-I'd be happy to get it reduced in the field (and then follow up with a doc when possible--we usually get post reduction x-rays except in habitual dislocators).


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