Fracture and dislocation reduction in the ED

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Target exams

Red flags

• Always perform a pre- AND post-reduction neurovascular check — the axillary nerve (deltoid sensation, the regimental-badge patch) is injured in around 1 in 6 anterior shoulder dislocations, and a new deficit after reduction is a surgical emergency. Forgetting the post-reduction check is the classic Fellowship error.
• Posterior shoulder dislocation is missed on a single AP film — the arm is locked in internal rotation and the AP looks deceptively normal (the lightbulb sign is subtle). Order an axillary lateral or scapular-Y before declaring a shoulder reduced or normal, especially after a seizure, electrocution or fall onto the outstretched internally-rotated hand.
• A hip dislocation must be reduced within 6 hours — reduction delayed beyond 6 hours carries a markedly higher risk of avascular necrosis of the femoral head. It is the most time-critical dislocation the ED encounters; reduce first, investigate after.
• Use plain lidocaine for a digital block — adrenaline is traditionally avoided in end-arterial territories (finger, toe, penis, nose). Observe the weight-based maximum; no fixed plain mg/kg ceiling is evidence-based.
• After two failed reduction attempts with good sedation, stop and escalate to orthopaedics or theatre — repeated forceful attempts convert a simple dislocation into a fracture-dislocation or a neurovascular injury.