Fracture and dislocation reduction — the data-viva

(1) Posterior shoulder dislocation (post-seizure).

^[1]- Diagnosis: posterior glenohumeral dislocation — the arm locked in internal rotation after a seizure, the AP showing the subtle lightbulb sign; confirm with the axillary lateral or scapular-Y (a single AP is the trap — posterior dislocations are missed on the frontal view).

• Technique: longitudinal traction combined with lateral traction on the humeral shaft to lift the head over the glenoid rim, then gentle external rotation once the head clears; less readily reduced than the anterior dislocation, often needs general anaesthesia and muscle relaxation because of the intense spasm and the reverse Hill-Sachs lesion.
• Analgesia/sedation: procedural sedation to the ACEP standard — ketamine 1 to 1.5 mg per kilogram IV, or convert to general anaesthesia if the closed attempt fails.^[12][13]
• Post-reduction: neurovascular check (axillary nerve — deltoid sensation), AP-plus-axillary radiograph, immobilise in external rotation (the opposite of the anterior dislocation, the position of stability).
• Disposition: orthopaedic follow-up; admit if reduced under GA or if unstable.

(2) Pulled elbow (nursemaid elbow).

• Diagnosis: radial head subluxation — classic age (3 years) and mechanism (longitudinal pull on the arm); the radiograph is normal and is not required before reduction in the classic presentation.
• Technique: hyperpronation first-line — support the elbow, grasp the wrist, fully supinate then hyperpronate the forearm (or hyperpronate directly); higher first-attempt success than supination-flexion per the systematic review and meta-analysis and the Cochrane review, with uncertain pain differences.^[5][9]
• Analgesia/sedation: none required — a quick manoeuvre; the parent holds the child.
• Post-reduction: no neurovascular structure at risk; the diagnosis is confirmed by the return of normal arm use, usually within minutes; no radiograph unless the arm is not used or there is bony tenderness (seek the occult supracondylar fracture).
• Disposition: discharge with parent education — avoid lifting the child by the hand or forearm; recurrence is common (14% in a large case series; nearly half in a questionnaire cohort).^[10][11]

^[5](3) Posterior hip dislocation.

• Diagnosis: posterior hip dislocation — the leg shortened, adducted, flexed and internally rotated after the dashboard force; confirm on AP pelvis and cross-table lateral; the most time-critical dislocation the ED sees.
• Technique: Allis — patient supine, assistant fixes the pelvis, flex the hip and knee to 90 degrees, apply upward longitudinal traction with gentle internal/external rotation; or the Captain Morgan knee-lever technique; convert to general anaesthesia with full muscle relaxation after 2 to 3 failed attempts.
• Analgesia/sedation: procedural sedation (ketamine 1 to 1.5 mg per kilogram IV) or general anaesthesia — often with orthopaedics present.^[12][13]
• Post-reduction: neurovascular check — sciatic nerve (dorsiflexion of the ankle, the peroneal division injured first) and the distal pulses; AP pelvis and a CT of the hip to confirm concentric reduction and exclude a femoral-head or acetabular fracture or intra-articular fragments.
• Disposition: admit — high-energy trauma with associated injuries; protected weight-bearing and avascular-necrosis surveillance; reduce within 6 hours from injury to cut the AVN risk (delay beyond 6 hours carried a 20-fold higher risk in a long-term series) — the audit target.^[8][14]