Joint reductions in ED

As an emergency physician, one of the most gratifying aspects of my job is the immediate relief I can bring to patients in acute distress. Joint dislocations are a common yet harrowing reason patients visit the emergency department (ED). Successfully performing joint reductions not only alleviates excruciating pain but also prevents long-term disability. Here’s a dive into the nuances and methodologies that we, as emergency doctors, employ to manage these cases effectively.

Understanding Joint Dislocations

A joint dislocation occurs when the bones in a joint become separated, often due to trauma. The most frequently encountered dislocations in the ED involve the shoulder, elbow, and hip. Multiple factors influence our approach to management, including the type of joint involved, the duration of the dislocation, and the patient's overall health.

Shoulder Dislocations: A Common Culprit

Shoulder dislocations are particularly prevalent due to the joint's wide range of motion. Anterior shoulder dislocations account for the majority of these cases and typically result from a fall on an outstretched arm. Several techniques are available for reduction, but here are two commonly utilised methods:

1. Stimson Technique: This method involves the patient lying prone with the affected arm hanging over the edge of a bed, and weights are applied to the wrist. Gravity aids in the relocation of the humeral head. This technique is advantageous for its simplicity and minimal requirement for analgesia.

2. External Rotation Method Here, the patient lies supine, and the elbow is flexed at 90 degrees. Gentle external rotation is applied to the arm to guide the humeral head back into the glenoid fossa. This technique is often favored for its high success rate and the comfort it offers to the patient under mild sedation.

Elbow Dislocations: Quick and Careful

Elbow dislocations require prompt attention. The urgency stems from the potential damage to neurovascular structures if the dislocation is left untreated. The reduction usually involves a combination of traction and counter-traction with the patient either seated or lying down. Conscious sedation or, in some cases, general anesthesia may be necessary to facilitate muscle relaxation and ensure patient comfort.

Hip Dislocations: An Orthopedic Emergency

Hip dislocations are less common but represent a true orthopedic emergency due to the risk of avascular necrosis of the femoral head. 

1. Allis Maneuve: This technique involves the patient lying supine, and the physician applies traction in line with the femur while simultaneously performing gentle internal and external rotations. This maneuver often necessitates profound sedation or anesthesia to relax the muscular spasm associated with the dislocation.

2. Captain Morgan Technique: Named after the famous pirate, this method involves the physician placing their knee under the patient's flexed knee while applying an upward and outward force to relocate the femoral head.

Post-Reduction Care

Successful reduction is just the beginning. Post-reduction care involves confirming the alignment with imaging, such as X-rays, immobilizing the joint if necessary, and planning follow-up care. Additionally, it’s paramount to educate the patient on the importance of physiotherapy to restore range of motion and strength while minimising the risk of recurrent dislocations.


Joint reductions in the emergency department are a blend of art and science. The various techniques each have their indications, benefits, and limitations. Mastery of these maneuvers, combined with a compassionate approach to patient care, ensures that we, as emergency physicians, can provide both immediate and long-term relief to those in acute distress.

References:

1. Cunningham, N. J., & Lewis, D. R. (2014). Techniques for the reduction of anterior shoulder dislocation. *Emergency Medicine Journal, 31*(4), 217-222.
2. Kanji, H. D., & Rezaie, S. R. (2019). Managing elbow dislocations in the emergency department. *Practical Neurology, 19*(3), 230-237.
3. Quinn, S. F., & Wallace, R. G. (2020). Emergency management of hip dislocations. *Orthopedic Clinics of North America, 51*(2), 177-187.