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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Wednesday, April 02, 2014
The Approach: How to Help Heal
We promised you some information about soft tissue injuries, and you’ve got to hand it to us: we delivered! Last month, we discussed incision and drainage of large burns to the hand. Review it here before reading further:
http://bit.ly/RobertsBurn. This month, we want to take an in-depth look at wound care management for burns and highlight other pearls needed for top-notch healing.
You should try to follow a few simple rules when it comes to treating burn patients. Soft tissue skin injuries heal in stages and are dependent on direct and correct treatment of the area, nutrition, and hydration. Most providers fail to mention the benefits of protein and fluid intake to burn patients, especially if they are minor injuries. Nutrition and hydration play a major role in the healing process along with keeping the area clean, dry, and properly bandaged.
Be sure to familiarize yourself with the proper essential wound care materials: What is Kerlix? When do I use Xeroform? What type of splint is best? Know where things are in your emergency department stockroom. Actively involve and engage your patient in managing his burn care during your first application of the bandage. Print proper written instructions reiterating the information with phone numbers for local burn centers and specialists. Provide pain management, and take time to answer the “dumb question.” Infected burns are painful and can be debilitating, not to mention that patients are worried about the cosmetic appearance. Complications can be avoided if you spend the time talking to your patient about how to treat his injury properly.
The Procedure: Assessing the Damage and Treatment Essentials
Our previous hand injury is a great example of a volar hand burn that needs a bulky dressing and splint.
Other injuries include dorsum burns, treated in similar fashion with full debridement.

How to treat the blister is always a question for all burns. Preserve the skin and use it as a protective barrier for the first 24-48 hours for volar hand burns. After that, however, the wound requires debridement, and all dead skin has to be removed by our favorite local artist, the hand surgeon. The burn to the dorsum of the hand was debrided on the initial visit and treated in a similar fashion, with close follow-up. Here is a step-by-step approach on how to apply the proper dressing for this type of burn, which can be modified for any extremity burn depending on the affected area. Examples of burn dressings:

  • Provide necessary tetanus vaccination or booster.
  • Ensure that the patient has been adequately medicated for pain.
  • Provide a layer of gauze padding to the debrided sites when applying your bulky dressing. It’s key to have the gauze draw fluid away from the burned surface during healing.
  • Cover all affected areas with liberal but even amounts of your chosen barrier and healing cream (sulfadiazine/Silvadene for larger burns, bacitracin for smaller ones, etc.). Some apply an Adaptic pad or Xeroform to the affected areas before using gauze. Wet gauze sticks when the dressing is changed; this can also help with secondary debridement.
  • Note: Separate all fingers with gauze pads (A). This was not done in figure D, and skin maceration of normal skin occurred.
  • Tell the patient to make his first dressing change in 24-48 hours.
  • Start applying bulky dressing wrap. Do not apply a splint directly to the injured area without a bulky dressing barrier!
  • Apply a volar splint (for this burn because it is a palmar burn) or thumb-spica-like splint to accommodate injury. Be sure to have it in a dependent position where fingers are able to move freely if at all possible. The splint serves as a protective garment and skin stabilizer as healing occurs over the next seven to 21 days.
Discharge Paperwork Considerations
Provide your patient with written instructions for dressing changes at home:
1. Time your dressing change for half an hour after taking your pain medication.
2. You may need someone to help with your dressing changes.
3. Prepare all materials before you get started.
4. Remove all parts of the old dressing and remove or wash off the prior cream that was applied with liquid soap like Dove or Dial.
5. Inspect the area. Is it infected? Look for redness, swelling, warmth, and streaking. Some dislocation and discharge may be normal. Excessive amounts of either are not normal.
6. Perform range-of-motion exercises in the same ways you would use your hand, foot, finger, etc.
7. “Fluff up” your gauze by pulling at it slightly and stretching it before applying.
8. Apply the new ointment or cream with a sterile tongue blade or piece of gauze.
9. Apply “fluffed up” gauze. Do this in a bulky dressing style, as shown to you in the emergency department.
10. If you have a splint, apply it after.
11. Wound care is done daily.
(This list was adapted from “How to Change a Burn Dressing at Home: Patient Instructions” from Roberts & Hedges, Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
Cautions: Focus on Nutrition and Hydration
The past few decades of intense burn research prove that wound care, nutrition, and hydration are the keys to successful healing regardless of burn size or shape. The Journal of Parenteral and Enteral Nutrition knows a thing or two about nutrition and metabolic support. Evidence-based results for burn care support good nutrition, even for minor burns. A noted improved clinical status and decreased healing times are seen with low-fat nutrition in all types of burn patients. Low-fat nutrition, for example, decreases rates of infection and shortens overall healing times. Fish oil did not show any added clinical benefit. Overall, monitored nutrition during healing times for patients with burns can help modulate cortisol binding globulin and free circulating cortisol after severe stress. (J Parenter Enteral Nutr 1995;19[6]:482.)
A study in the British Journal of Nursing said disregarding nutritional status for burn patients may compromise healing times or prolong the stages of wound healing. Fatty acids are essential for cell structure, and play an active role in the inflammatory process. Increased levels of protein are necessary for collagen formation when the body is attempting to heal, and this also helps prevent wound dehiscence. Some studies show vitamin C also plays a role in the healing process, and it could be an added supplement. Vitamin C deficiencies can also contribute to fragile granulation tissue. Finally, some evidence suggests that low albumin and body mass index (BMI), adequate rest, and even some holistic approaches are essential for healing. (Brit J Nurs 2001;10:[1]:S42.)
Finally, it is well known and accepted that fluid replacement, even for minor burns, is essential to wound healing. Several approaches help determine the needed amounts of fluid resuscitation for burn patients. These rules do not apply just for inpatient admissions. Hospitalization should be considered if you are thinking of aggressive fluid resuscitation management for a patient. The Rule of 9s and the Parkland formula are good standards to review and practice when you are concerned about a burn patient.
Do not forget to tell patients with minor burns to increase fluid intake and avoid dehydration. This should be standard practice for all your burn patients. Encourage a balanced, high-caloric diet free from saturated fats and with increased protein intake over the next 48-72 hours. Also discourage high sodium and sugar intake for the next week. As noted, multivitamin supplementation is still debatable for many ailments, but vitamin C is an organic and inexpensive holistic approach. Be sure to note that aloe and honey are acceptable and affordable forms of topical healing agents, but manufactured creams like Silvadene and bacitracin are still the go-to topical treatments.
Tip of the Week
Having a hard time getting the gauze to wrap around the thumb? Cut a hole in the middle of the gauze wrap, and let it slide over the thumb just like the way you would put a T-shirt on over your head. The gauze remains uninterrupted, and you can continue to wrap the extremity. This will help keep the dressing in place, and doesn’t allow the gauze to roll up over the thumb and expose open skin that could let in bacterial intruders that could cause infection.
Go Green
You opened a pack of sterile gauze, and only used one piece. Your instinct is to just throw away the rest because the patient is leaving and doesn’t need any more gauze for his wound care. Send the extra home with the patient! He can use the nonsterile part on the outer surface of the bulky dressing.

Friday, February 28, 2014
Hand burns from thermal injuries are common chief complaints in the emergency department. Sometimes, 2nd- and 3rd-degree burns may need immediate interventions and warrant special attention. These injuries are painful, and often have associated complications such as permanent scarring, cosmetic issues, prolonged pain, and even infection. ED providers can assist with the primary complications related to blistering of the hand or extremity. Careful follow-up and a detailed discharge plan produce better outcomes and minimize overall complications. Full body/surface burns or circumferential burns should always be seen and evaluated by a local burn center. Burns related to alkaline, gas, fire, poisons, and chemicals may require expert consultation and possible admission to the burn center.
The patient’s burn featured in the photos below occurred about 48 hours before ED arrival. The patient, a chef, accidentally placed his hand on a hot flat-plate grill while cooking in a restaurant. The initial burn surface was not swollen or raised, but it began to swell uncontrollably over 24 hours. The swelling fluid pocket produced significant pain and restriction of the first digit. The patient came to the ED hoping we could drain the site and preserve the soft tissue of his hands.

The American Society for Surgery of the Hand (ASSH) classifies burns into four categories: 1st degree: superficial, redness of skin without blisters; 2nd degree: partial thickness skin damage, blisters present; 3rd degree: full thickness skin damage, skin is white and leathery; and 4th degree: 3rd degree with damage to deeper structures like tendons, joints, and bone. (http://bit.ly/HandBurns.) Classification of burns is also based on three criteria: depth, percentage of total body surface area, and source of the injury (thermal, chemical, electrical, radiation). (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th ed. Philadelphia: Saunders/Elsevier, 2014.) It is important to complete an accurate evaluation of every burn patient in case fluid resuscitation or transfer to a burn center is necessary. More information about how to categorize burns can be found on the American Burn Association website at www.ameriburn.org.
The initial ED management blisters from burns, however, is controversial. It likely doesn’t matter exactly what is done. Traditionally, large blisters are left intact to help with pain relief, and small or broken blisters are debrided when first seen. Blistered skin will eventually have to be removed, and skin grafting may be required. All burns are different in size and shape and healing times may vary, but smaller more manageable wounds are usually watched carefully and not aggressively debrided on initial presentation. The blister in this case, however, warranted drainage. The patient will need to follow up with a plastic surgeon or hand specialist within a day or two. Actual treatment is based on the severity of the burn, potential for complications, and availability of follow-up.
Needle aspiration of blisters should not be performed with overlying skin that has not been debrided for more than a few days because this increases the risk of infection (UpToDate [2014]. “Treatment of Minor Thermal Burns,” http://bit.ly/1powgJT.) Each hand only makes up 2.5 percent of total body surface area, but loss of function and pain from a burn is 100 percent maddening.

Aspiration of the blister two days after the ED presentation with the skin left intact. This flap of skin will need to be debrided in a few days.

The Approach
• Wound care with simple hand washing and cleansing
• Gentle incision and drainage of the site
• Coverage of wound with ointment and bulky dressing
• Splint care and pain control
• Follow-up with plastic surgery or specialist in one to two days
The Procedure
• Medicate the patient appropriately with either PO or IV medications prior to starting any procedure after evaluating the initial burn. Burns are quite painful injuries.
• Instruct the patient to sit on a stretcher while you inspect the burn.
• Consider consulting a hand specialist prior to beginning. Typically, the ED provider can drain burns of this size and caliber (such as the one featured in this photo) at the bedside.
• Clean the area with Betadine or antiseptic. Gentle hand washing is also encouraged prior to treatment.
• Sterile gloves are not necessary, but they are not a bad idea.
• Use an 11-blade scalpel to make a 0.5-1 cm incision at the base of the burn. It is best to make the incision to an area of the burn where flexion or extension is at its least resistant. The incision was made at the base of palm, just distal to the wrist, in this case.
• Note: Local anesthesia is not typically indicated for the initial I&D of a burn. The patient’s skin is the most painful under the burn, and future pain is usually caused by drying or peeling/pruritus of the skin flap that remains over top of the burn. The drainage incision is also small and should not cause significant pain. Do not make a large incision if you are choosing to leave the skin flap in place.
• Slowly allow the fluid pocket to drain into a basin. Do not rush this evacuation. Gently massage the skin to evacuate the fluid. It may take two to five minutes to completely drain the area, depending on the size of the burn.
• We suggest initially leaving the deflated skin in place as a protective cover for the burn once the area is mostly drained and flattened. Complete debridement of the burn with removal of the skin is controversial, but all tissue must be removed eventually. (Roberts & Hedges, 2014.) Discuss your decisions with the patient based on your consult with plastic surgeon on call.
• Cover the area with ointment. Bacitracin and silver sulfadiazine (Silvadene) are fine choices. A thin, moderate layer is used. Silvadene has broad gram-positive and gram-negative antimicrobial spectrum coverage including B-hemolytic strep, Staphylococcus aureus and S. epidermidis. It may also cover pseudomonal infections, so it may be the better choice for diabetic patients or immunocompromised patients. (Roberts & Hedges, 2014.) Antibiotics are not initially given.
• Apply a bulky dressing and splint. Different variations of the thumb spica or radial gutter splint may be used best for palmar burns. Burns to the dorsal surface may do best with a volar splint.
• Give a supply of pain medication because the patient may experience increased pain from the site as the skin dries over the next 24-48 hours. Tell the patient to take pain medication half an hour before dressing changes. (Roberts & Hedges, 2014.) Pruritus is often a common complaint, and can be treated with over-the-counter Benadryl. Warn the patient to return to the ED for complications such as black or ecchymotic changes to the skin or even associated cellulitis or lymphangitis. Stress that the dressing should not be constricting and that the splint needs to be worn for proper healing.
• Remind patients not to soak their hands in water or ice water. This causes further damage to the soft tissue. If the patient arrives at the ED with his hand soaking in a bucket, have him stop immediately.
• Take any jewelry or restrictive clothing off immediately. Rings and bracelets must come off with a ring or jewelry cutter if attempts by the patient fail.
• IV pain medication is often necessary so do not hesitate to medicate these patients quickly and appropriately.
• Cleaning the area with gentle soap and water is necessary to avoid infection.
• The patient should never scrub the area pre- or post-procedure because this will further damage the skin.
• Antibiotic ointments such as bacitracin or Silvadene are acceptable post-burn ointments. Patients should avoid holistic approaches like toothpaste, butter, herbs, or sprays because they can cause further damage to the soft tissue. (Medscape [2014]. “Emergent Management of Burns,”
http://bit.ly/1poP7nX.) Of note, Silvadene is contraindicated for term pregnancy and in newborns because of possible induction of kernicterus. (Roberts & Hedges, 2014.)
• Bulky dressings are helpful, but can often stick to the burn and cause more pain, especially with removal. Review wound care and approaches to dressing changes with the patient prior to leaving. Demonstrate how to apply appropriate layers of bacitracin or Silvadene with appropriate dressings prior to discharge. Gentle, cool water rinses can be used to help with dressing removal at home.
• Elevate the extremity while at home whenever possible (UpToDate.com, 2014.)
Update tetanus as needed.
• You also should consider admission if you think a patient warrants PO antibiotics for potential or existing infection!
• Finally and most importantly, a circumferential burn of any limb can sometimes constrict it like a tourniquet. The constriction must be controlled or “released” with an escharotomy if this occurs. (American Society for Surgery of the Hand, 2014.)
Tip of the Week
We know we said holistic approaches for burn treatments should be avoided, but aloe vera cream may be an inexpensive and useful treatment for smaller burns. Honey may also be used on the burn because it has been proven to provide antibacterial and anti-inflammatory properties. Oral corticosteroids, however, are not useful. There is “no role for topical steroids in the initial treatment of minor burns, as this may increase the risk of infection and impair healing.” (UpToDate, 2014 and Roberts & Hedges, 2014.)

Friday, January 31, 2014

Part 1 in a Series

Wound care and suture repair are two of the most frequently encountered issues in the emergency department. It is the midlevel provider’s job to be familiar with proper wound care and suturing techniques as well as quick and safe treatment of soft tissue skin injuries. You can use various suturing techniques and styles, but it is important to find a few that really work for you, often tailored to the area of injury.

This month, we are focusing on lacerations and puncture wounds to the soft tissue of the face. Future posts will touch on other suturing skills, with some great tips from our plastic surgery friends. More in-depth posts will include videos of nerve blocks to the face, which are incredibly useful for wound repair. We will also touch on nasal, buccal, and ear lacerations as well.

The face has a plentiful blood supply. Primary closure is important for facial lacerations to avoid unnecessary scaring. Sometimes, swelling or extensive facial tissue damage makes primary closure more difficult. Careful wound cleaning of facial lacerations is critical. The soft tissue of the face is not at high risk for infection, but removing foreign bodies and cleansing with antibacterial agents is paramount. All wounds should be cleaned well and closed within a four- to six-hour window. Wounds older than six hours or presenting the day after the injury can be repaired, but a plastics consult may be warranted. (Semers N. Practical Plastic Surgery for Nonsurgeons. Philadelphia: Authors Choice Press, 2007.)

Case Study
Mr. J fell down the stairs of one of Washington, DC’s busy Metro stations. He fell face first, and the frame of his glasses became embedded in his face. Mr. J could not remove them and neither could EMS personnel. The glasses were then tapped to his face to help keep them positioned without ripping his skin further until our providers in the emergency department could complete an evaluation.

The Approach
• Stabilization of foreign body to affected area
• Local anesthesia
• Careful removal of object
• Radiographs and/or CT as needed
• Wound care
• Suture and repair
• Plastics follow-up

The Procedure
• Consult your on-call plastic surgeon if you have any questionable areas of repair.
• Consider early pain management interventions for this procedure. Percocet or Vicodin are good PO choices. IV morphine or Dilaudid may be needed for more extensive injuries and pain. A small dose of Valium or Ativan may also help your patient relax after the emotional and physical pain these injuries can cause. Local anesthesia administered promptly will usually alleviate the need for additional pain control.
• Prep. Wash your hands. This is still the primary way to decrease infection rates for all procedures. It is a good idea to practice sterile technique for the majority of ED procedures. Sterile gloves have not proven to decrease infection rates, despite what your predecessors may have taught you. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition. Philadelphia: Saunders/Elsevier, 2014.) Masks and eye protection should always be donned.
• Anesthetize. Local anesthesia to the site of the laceration can be used before or after removal of the foreign body. Anesthesia may be considered when and if the foreign body is deeply lodged in the skin. The best choice of local anesthesia is buffered lidocaine with epinephrine. The only time lidocaine with epinephrine is contraindicated is when the wound is a flap, raised by the injury. (Semers, 2007.) Plain lidocaine is a better choice for facial flap injuries because you do not want to compromise circulation to the flap.
• Investigate. Inspect the area for any smaller foreign bodies once the larger objects have been removed. Complete removal of all debris, wood, dirt, and objects must be done. Also look for bone involvement. Obvious dead or dark tissue can be removed carefully.
• Clean. Jet lavage is the proper irrigation procedure to use, but excessive spraying can cause further tissue damage. Be gentle but thorough. A mixture of Betadine and normal saline is a good agent for cleansing.
• Note: Antibiotic solutions have not been defined as a standard practice.
• A 20-gauge angiocatheter used at the tip of the irrigation device is good for removing most debris. Copious normal saline or tap water can also be used. DO NOT put an irrigating catheter into a puncture wound; it disseminates foreign material and cause tissue swelling, but rarely provides wound irrigation. A hemostat spread open inside the tract helps to separate a small laceration to facilitate wound irrigation.
• Apply firm pressure with gauze for two to three minutes instead of countless dabs if you have significant bleeding from the injured area after irrigating.
• Inspect and examine the whole face, including an ocular exam if indicated. Tend to eye injuries first, such as a ruptured globe or lid laceration. Ear exams are also important because significant head trauma can cause injury to the middle ear. Check for the presence of a hemotympanum and Battle’s sign, which may indicate a basilar skull fracture. A ruptured TM can be a surgical emergency and cause facial paralysis if the facial nerve has been compromised. Consult ENT if you suspect this issue.
• Never put your finger into a wound to explore what’s inside! Use ONLY your forceps and tweezers and occasionally x-rays to explore ALL wounds.
• Cervical spine injuries may not be obvious because of distracting injuries. A complete CT of the cervical spine and a head CT should be done if the patient has a significant mechanism of injury to the face or neck such as a traumatic fall.
• Complete the necessary radiographs and/or CT imaging of affected areas (i.e., orbits, mandible, etc.).

• Prep for your suture repair once the area is clean and dry. Suture choice: 6.0 or 7.0 nylon thread for soft tissue injuries of the face. Running sutures or simple interrupted are good choices for closure. Mattress suturing is NOT indicated for facial lacerations.
• Repair all flap injuries first.
• Note that sutures on the face are placed slightly closer together, approximately 3 mm apart. (Semers, 2007.)
• Cover closed lacerations with a thin layer of bacitracin or antibiotic ointment.
• Instruct the patient that suture removal must be done in five to seven days to avoid sutures scars.
• Leave the area open to the air or use a dressing. A gauze bandage is indicated if there is an extensive area of injury. Instruct the patient not to wash or disturb the repaired area for at least the first 24 hours (unless following up with plastic surgeon). Then, daily wound care using gentle cleansing of diluted antibacterial soap like Dove or Dial should be initiated. NO scrubbing.
• Note that covering the injury with gauze or a dressing not only serves as protection of the wound but aids patient comfort. They may also help stabilize the affected area if the patient is following up with plastics the following day. They also prevent the wound from drying out, which can cause the patient pain as it heals. Wound coverings also help absorb serosanguineous drainage. (Roberts & Hedges, 2013.)
• Tip: Consider Adaptic, Xeroform, or Aquaflo petrolatum gauze for better coverage.
• Do not use bacitracin after the first 24-48 hours because it keeps the area too moist, and can lead to further scarring or healing complications.
• Tell the patient to elevate his head when sleeping and to avoid heavy lifting, bending, or dangerous activities to minimize facial swelling. (Semers, 2007.)
• Small puncture wounds are best left unsutured. Even more irrigation is required if they are caused by a foreign body. Infection is common if foreign material is left deep within the puncture, but retained material cannot always be appreciated at the first visit. Be sure to warn the patient of this possibility! (We will discuss human, cat, and dog bite puncture wounds in future blog posts.)
• There are no universal standards or treatments for puncture wounds (Roberts & Hedges, 2013), and studies are limited. What is important is ample cleaning of the area. Probing or coring a puncture wound to the face is not suggested. Antibiotic use for puncture wounds to the face is not clearly defined in the literature. High-risk patients (immunocompromised or diabetic patients) may benefit from a short course of antibiotics, but this has yet to be proven.
• Update tetanus as needed.

• Is there any pulsatile bleeding? Be sure to complete your vascular exam and address all issues.
• Is the patient a smoker? This will impair wound healing. Smoking cessation advice is always important in the ED.
• Did you ask the hard, personal questions about HIV, hepatitis, or other immunocompromised status? Always be sure to use universal precautions with all patients, but especially pay attention to those who are immunocompromised. Diabetic patients may also have wound healing issues.
• Was there an injury to the area involving the shoe, clothing, fabric, or other rubber? Bits of material may be imbedded in the wound. It may be required that a puncture in noncosmetic areas be widened into a linear laceration with a scalpel to adequately explore for and remove foreign material.
• Hydrogen peroxide is a very weak antibacterial agent. It is toxic to tissues and red cells. Don’t use it, and be sure to educate your patients on this concept as well.

Tip of the Week
This week we are giving a shout out to Medscape because we know you are all wondering about local anesthesia to the nose! Check out this excellent article by Medscape, and put all your fears to rest: http://bit.ly/1hIMU1K.

Friday, January 03, 2014
Finger dislocations are relatively simple to identify and treat, but ligament and volar plate ruptures are often missed. Radiographs are not always indicated, but are useful in locating the area of injury and noting avulsion fractures. It is important to listen to the patient’s story to identify the mechanism by which the injury occurred because mimicking this mechanism is typically the best way to relocate the joint. Patients typically do not always need local anesthesia or digital block because relocation techniques are quick and can often be done while simply distracting the patient for a second or two. Treatment is dependent on your skill level, comfort, and ability to recognize these injuries.
DIP, PIP, or MCP dislocation can be caused by any kind of significant force to the area such as hyperextenion or flexion, trauma, pressure, or crush injuries. Keep in mind that primarily the IP joints are much more secure than the MCP joints because of the IP joints’ bicondylar arrangement and the fact that the collateral ligaments are tight throughout the entire range of motion. (Medscape, 2014.) Dislocation of any phalanx joint dorsally can cause separation from the volar plate while lateral dislocations can disrupt one or both of the collateral ligaments. Tendon injury and avulsion fractures may also occur.

Figure A. Dorsal dislocation of second phalynx. (Lippincott, Williams & Wilkins, 2001.)

Figure B. Volar dislocation of second phalanx. (Lippincott, Williams & Wilkins, 2001.)

Figure C. (Lippincott, Williams & Wilkins, 2001.)
Figures A, B, and C: Three variants of PIP joint dislocations are depicted. The most common are (A) dorsal and (B) pure volar with central slip rupture, and least common is (C) rotatory subluxation, which is often confused with pure volar dislocation.

Pure dorsal dislocation at the DIP joint is a rare injury. (Lippincott, Williams & Wilkins.)
Let’s take a minute to review the hand anatomy:

Bones and muscles of the hand. (Lippincott, Williams & Wilkins.)

The Approach
• Digital blocks (+/-)
• Radiographs (+/-)
• Traction method of joint reduction
• Laceration repair (if indicated)
The Procedure
• After examining the patient, order appropriate radiographs of the finger, not just the hand. Appropriate views include the AP, lateral, and oblique views. Lateral views of the finger allow the provider to see subtle dislocations or avulsion fractures.
• Have the patient on a stretcher in a comfortable position.
• Digital blocks are not routinely necessary. But if the patient has a laceration, needs extensive wound care, or could benefit from a block, complete this on an as-needed basis. Note: Skin repairs are done after the dislocation is reduced.
• Traction method of joint reduction is used to treat the injury.
• Distract the patient with conversation while holding the injured area. It helps to make eye contact.
• Mimic the path by which the initial injury occurred; that is, slightly exaggerate the deformity that is present.
• Pull the finger forcefully and quickly in the opposite direction as you relocate the finger; that is, push the joint back into position.
• Complete a full range-of-motion exam and neurovascular checks. Check stability.
• Appropriate splinting (see below for a few tips) should also be completed. Splint the finger in a 20-30 degree angle of flexion for two to three weeks. Orthopedic or hand specialist consultation is recommended.
• Be sure to ask about tetanus vaccination if there is a laceration or abrasion.
• Stay tuned for future Procedural Pause blogs on suture techniques over joint spaces!
• PIP joint dislocations need closer follow-up because they are more prone to scarring and heal at a slower rate. Central slip ruptures may also progress to boutonniere deformities.
• Flexion and extension ability and neurovascular checks should be completed after relocation procedures.
• Dorsal PIP dislocations are most common because they occur with bending the finger backward (hyperextension), but beware of volar plate rupture. These may need digital block if injury is extensive. How do you determine if a patient has a volar plate rupture? After completing relocation procedure, the patient will hyperextend with passive and active motion and show laxity.
• Volar PIP dislocations are usually uncommon, but should be splinted with full extension for two to three weeks after relocation of the injury.
• Lateral dislocations usually are resolved prior to arrival to the ED, but are easily relocated if not. Buddy-taping the affected finger with an adjacent finger is recommended if there is a suspected collateral ligament tear.
• Don’t miss DIP dislocations; they can be subtle, especially in the thumb. They require only 10-12 days of immobilization with dorsal splint.
• Mallet finger is NOT a dislocation! It is extension tendon rupture. Use a STACK splint to immobilize this joint and allow the PIP to move freely.
• Does the patient have tenderness of the medial side of the thumb’s MCP? Gamekeeper’s or Skier’s thumb is from rupture of the ulnar collateral ligament in the thumb at the MCP joint, usually from a forceful abduction. You may not be able to identify this injury fully in the ED so close follow-up is recommended if suspected. Check for instability, tenderness, and swelling. Patients will have issues gripping items in the future if this injury is missed.
Be more concerned about and seek consultation for the following:
• Neurovascular compromise
• Associated fractures
• Open joint dislocations
• Ligament or volar plate rupture
• Joint instability
• Inability to easily reduce a dislocation
(Medscape, 2014)
Don’t mess with these! Take a good history.
Hand deformities in rheumatoid arthritis. PA radiograph shows boutonniere deformity of the ring finger, Z-shaped deformity of the thumb, proximal dislocation of the first CMC joint, volar dislocation of the MCP joint of the little finger, and ulnar translocation of the carpus. (Lippincott, Williams & Wilkins.)
Tip of the week: Get friendly with your hand specialist on call, if you are lucky enough to have one available. Often you can send him a quick photo of an x-ray or the finger itself via smart phone and ask for a consult. This way, the specialist can follow up with the patient in his office and already know the story behind the injury.
Go green: Did you know a running faucet uses up to five gallons of water a minute? Of course, it is incredibly important to do appropriate and diligent wound care for patients with hand injuries, but consider using a basin first with soap and water to scrub and clean the hand or affected digit. This is also a great time to sit down to explore and examine the patient’s injury. This also helps create a natural bond with your patient and helps ease tension. This beats making them stand at a sink where the lighting is poor and the splatter effect is even worse!
1. Polansky P, et al. (2014) Finger dislocation joint reduction. Medscape.com. Retrieved Dec. 17, 2014, from
2. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.

Tuesday, December 03, 2013
We finish our shoulder dislocation series by paying our respects to posterior shoulder dislocation. Posterior shoulder dislocations are rare, and account for less than 4-5 percent of all shoulder dislocations, but all ED providers should know how to identify and relocate these injuries. Cases of misdiagnosis and even late diagnosis can occur. Early recognition and appropriate management can save a patient from complicated issues related to the dislocation as well as chronic pain.

Anteroposterior (AP) view, left, of a patient with a posterior dislocation. This dislocation may be difficult to appreciate on an AP view because it is not inferiorly displaced and may appear to be in the glenoid fossa. Note that the space between the glenoid fossa and the humeral head does not look normal. The scapular Y view, right, reveals that a posterior dislocation is present. Note that the humeral head lays posterior to the glenoid fossa rather than being centered over it.
The provider will note on physical exam that patients commonly present with a triad of internal rotation, adduction, and flexion. The physical exam, as always, is key; do not rely on films as your only source of information. You will find it quite difficult and painful if you try to abduct or externally rotate the patient’s arm. Various studies reviewed on UpToDate (2013) show that comparing one shoulder with another is not always resourceful because these injuries present bilaterally depending on the mechanism of injury (examples include seizure, electrical shock, falls).
UpToDate also suggests some useful radiographic clues seen on AP films, one being the light bulb sign, where the humeral head is internally rotated that gives it a circular appearance. It actually looks more like a light bulb (hence the name) than its normal club shape. The space is also widened between the humeral head itself and the anterior glenoid rim, the rim sign. Suspect posterior dislocation if the distance is greater than 6 mm. Finally, the rare trough sign may also be seen with posterior dislocation. This is a fracture of the medial head of the humerus. Note that the AP film may not always give enough information so a Y view is always obtained. The Y view should answer whether it is dislocated.

Posterior shoulder dislocation seen on a scapular Y view, left. The anteroposterior view does not definitively show the dislocation. No superior or inferior displacement of the humeral head is seen because the dislocation is directly posterior. The head of the humerus appears to maintain a normal relationship with the glenoid fossa and the acromion process on superficial observation. Definite abnormalities exist on this film, however. The space between the humeral head and the glenoid fossa is abnormal, and the head and neck are seen end on and resemble a light bulb because of the extreme internal rotation of the humerus. It becomes obvious on the Y view, right, that the humeral head is posteriorly dislocated. It projects posteriorly under the scapular spine rather than in its normal location, centered over the glenoid fossa.

Anteroposterior views comparing posterior dislocation, left, and a normal shoulder joint, right. Posterior shoulder dislocation causes internal rotation of the humeral head, which makes the head appear as a light bulb rather than its normal club-shaped appearance. Note that the space between the articular surface of the humeral head and the anterior glenoid rim is also widened, and the overlap between the head and the fossa is decreased.
The Approach
• Radiographs are always necessary before and after any shoulder dislocation to assess positioning, success, and possible fracture, despite some recommendations to the contrary.
• Pain control and conscious sedation are keys to a successful procedure and happy patient.
• Intra-articular lidocaine injection (combined with other analgesia) can be an important component to relocation (see previous blog on anterior shoulder dislocation for refresher:
• Traction-countertraction for posterior shoulder dislocation.
• Orthopedic follow-up.
Note: Reduction techniques are similar to those used for anterior shoulder dislocation with a twist. Traction techniques are still embraced and are useful. Neurovascular exams and reassessment of your patient remain the same.
The Procedure
• Complete an examination focusing on neurovascular status and visual appearance of the shoulder. Be sure to examine both shoulders. Changes in baseline mental status of patients who sustained a seizure, electrical shock, or trauma may be present, and these patients may not be able to express pain.
Obtain thorough history.
• Obtain complete anteroposterior, lateral (Y), and axillary views of the shoulder. Get ready to complete the relocation procedure if the films are negative for a fracture and you do not suspect nerve or artery injury. Consult orthopedics before proceeding if there are any complications. Note: Elderly patients may also be difficult candidates for relocation, and osteoporotic bones can be fractured with reduction techniques.
• Obtain baseline vitals including oxygen saturation. Continually monitor your patient’s oxygen saturation before and after this procedure. Repeat your neurovascular exam if indicated. Numbness on the outside of the shoulder represents axillary nerve compression, which often subsides after relocation.
• Give proper analgesia. Use IV medications for pain control and keep the patient NPO until you are sure he will not need surgical intervention. Morphine, fentanyl, or Dilaudid are all fine choices.
• Have a sling handy to apply after reduction.
• Go in search of several partners. The bigger, the better because we will be using the weight of our own bodies to help relocate the shoulder. You will be applying traction, internal rotation, and adduction to the affected arm so you will need three people. See last month’s blog for pictures of the reduction.
• Person 1: You. Hold the patient’s forearm (not wrist) and use traction, pulling the shoulder and arm toward you during the procedure.
• Person 2: Assistant 1. Wrap a sheet around the axilla of the patient’s affected arm, and place the patient in a supine position. Wrap the free end of the sheet around your waist. He will simply lean back to apply the countertraction during the maneuver.
• Person 3: Assistant 2. Have another person place his hands behind the affected shoulder and apply upward pressure on the posterior aspect of the humeral head.
• This entire maneuver may take a few attempts and a few minutes. If it has not been successful in less than five minutes, try adjusting points of traction or move to another technique. Don’t forget to give adequate sedation if the patient is starting to wake up.
• Temporarily sling the arm and prep the patient for repeat radiographs if relocation and full ROM is achieved.
• Check films for post-reduction fractures and repeat your neurovascular exam.
• Keep the arm immobilized with the elbow at a 90-degree angle with slight hand pronation. Repeat neurovascular exams after splint is applied.
• Document pre- and post-neurovascular exams.
• Follow up with orthopedics in two to three days.
• PO Vicodin or Percocet for pain control, although ibuprofen is useful for soft tissue swelling.

Apply traction, internal rotation, and adduction to the affected arm. Instruct one assistant to apply countertraction (with a sheet wrapped around the waist) and another assistant to apply anteriorly directed pressure on the posterior aspect of the humeral head.

• Did you miss a rotator cuff injury? Don’t. Have the patient follow up with orthopedics. Rotator cuff injuries are best assessed in a week or two week after injury when the pain and swelling has decreased.
• Did you miss a clavicular fracture? Don’t be distracted by the obvious injury. Look at the entire film before focusing in on the injury itself.
• Don’t want frozen shoulder? Teach your patient the proper exercises to complete once he is in a sling. Usually, a sling is only necessary for two or three weeks.
• Was there a cervical spine injury? How about a radiculopathy? Consider nerve injury, especially for those shoulders that dislocate often. Injury to the axillary nerve will cause a weak or even paralyzed deltoid muscle.
• Arterial injury? The axillary artery can be injured (rare), so be sure to check and recheck neurovascular status. Be sure to monitor the patient for at least one hour after dislocation to reexamine neurovascular status post-reduction because complications such as nerve and artery compromise can occur after your procedure.
Go Green
The next time you suture, you will probably have one of those nice blue towels left over. Rarely do they ever get used during the suturing process and are always thrown in the garbage. Next time, separate it out and save it. It’s great to add to your zombie apocalypse stockpile, especially if you feel the need to wax and polish your car, dust corners of your house, or polish your fine collection of silver teapots. These blue towels are very sturdy, and beat a paper towel any day. And it’s a great burping cloth for your newborns!
1. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.
2. Wheeless CR. (2013). Textbook of Orthopaedics. Retrieved from
www.wheelessonline.com, Oct. 23, 2013.
3. UpToDate (2013). Posterior Shoulder Dislcoation. Retrieved from
www.uptodate.com, Nov. 18, 2013.
About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA, and is Dr. Roberts’ daughter.

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