What is the optimal management strategy for an adult patient with a dislocated joint and no significant past medical history?

Dislocated Joint Management

Immediate Management Priority

For any adult patient presenting with a dislocated joint, immediate closed reduction under adequate analgesia is the primary goal, ideally performed within 2-4 hours to minimize risk of avascular necrosis, neurovascular compromise, and long-term complications. 1

Pre-Reduction Assessment

Before attempting reduction, document the following critical elements:

• Neurovascular status - Check distal pulses, capillary refill, sensation, and motor function in the affected extremity 1, 2
• Gross deformity and joint position - Note the direction of dislocation 3
• Associated injuries - Palpate for fractures, assess skin integrity for open injuries 3
• Mechanism of injury - High-energy trauma (motor vehicle accident) versus low-energy (fall) dictates imaging urgency 3

Imaging Strategy

Standard Dislocations (Shoulder, Elbow, Finger)

• Obtain radiographs before reduction with minimum two orthogonal views (AP and lateral) to rule out associated fractures 3, 2
• Post-reduction radiographs are mandatory to confirm anatomic alignment 2

High-Risk Dislocations Requiring Vascular Assessment

For knee dislocations specifically, obtain CTA of the lower extremity immediately as vascular injury occurs in approximately 30% of posterior knee dislocations, and popliteal artery injuries require emergent surgical intervention for limb preservation 3

• CTA has replaced conventional angiography as first-line vascular imaging due to similar accuracy with less invasiveness 3
• MRA can be performed simultaneously with MRI if both soft tissue and vascular assessment are needed 3

Reduction Technique

Timing

• Perform reduction as soon as possible after adequate analgesia, ideally within 2-4 hours of injury 1
• Delays beyond 6 hours significantly increase difficulty of closed reduction and risk of complications 1

Analgesia Options

• Procedural sedation (preferred for large joints like hip, knee, shoulder) 1
• Intra-articular lidocaine injection for smaller joints 2
• Regional nerve blocks when available 2

Reduction Method

• Use joint-specific reduction maneuvers appropriate to the dislocation type 1, 2
• If closed reduction fails after 2-3 attempts, do not persist - arrange emergent orthopedic consultation for open reduction 1, 4
• Interposed soft tissue (tendons, capsule) is the most common cause of failed closed reduction 5, 4

Post-Reduction Management

Immediate Post-Reduction Care

• Repeat neurovascular examination and document any changes 1, 2
• Obtain post-reduction radiographs to confirm anatomic reduction 2
• Immobilize the joint in position of stability (joint-specific) 1

Immobilization Duration

• Use rigid immobilization rather than removable splints for any degree of residual instability 6
• Duration varies by joint: typically 1-3 weeks for simple dislocations without fracture 4
• Elbow dislocations have good outcomes with early mobilization after 5-10 days if stable 4

Early Mobilization Protocol

• Begin range-of-motion exercises as soon as stability allows (typically 5-14 days) 4
• Initiate muscle strengthening exercises throughout recovery with continuation for minimum 6 months 6
• Early mobilization prevents stiffness and improves functional outcomes 4

Orthopedic Consultation Requirements

Emergent Consultation (Same Day)

• Knee dislocation (even if spontaneously reduced) - high risk of vascular injury 3, 1
• Posterior sternoclavicular dislocation - risk of mediastinal structure injury 7
• Any dislocation with neurovascular compromise 1
• Failed closed reduction after 2-3 attempts 1
• Open dislocations 5

Urgent Consultation (Within 24-48 Hours)

• All other dislocations after successful closed reduction for definitive management planning 1
• Complex dislocations with associated fractures 3

Critical Pitfalls to Avoid

• Never delay reduction waiting for orthopedic consultation in simple dislocations without vascular compromise - time to reduction directly correlates with outcomes 1
• Never assume knee dislocation is benign even if spontaneously reduced - obtain CTA to rule out popliteal artery injury 3, 1
• Never perform multiple forceful reduction attempts - this increases risk of iatrogenic fracture and soft tissue injury 1
• Never discharge without post-reduction radiographs - occult fractures and incomplete reductions are common 2
• Inadequate immobilization increases risk of redislocation and chronic instability - use rigid splinting 6
• Never skip documentation of pre- and post-reduction neurovascular status - medicolegal and clinical necessity 2