Joint Relocation

Part of First Aid

When a joint pops out of its socket and there is no hospital to drive to, knowing how to relocate it can prevent permanent nerve damage and restore function within minutes.

Understanding Dislocations

A dislocation occurs when the bones forming a joint are forced completely out of alignment. The most commonly dislocated joints you will encounter:

Joint	Frequency	Difficulty to Reduce	Risk Level
Shoulder (anterior)	Very common	Moderate	Low-medium
Finger/toe	Common	Easy	Low
Kneecap (patella)	Moderate	Easy-moderate	Low
Elbow	Less common	Difficult	High
Hip	Rare (high force)	Very difficult	Very high

Critical Safety Rules

• Never attempt to reduce a joint if you suspect a fracture at the same site --- deformity with grinding or crepitus means broken bone, not just dislocation.
• Never force a joint. If it does not reduce with steady, gentle traction after two attempts, immobilize it and wait for someone with more experience.
• Elbow and hip reductions carry serious risks of nerve and blood vessel damage. Only attempt these in true survival situations where no other help is coming.

Before You Begin

Assess the injury:

1. Compare the injured side to the uninjured side --- look for obvious deformity, swelling, and abnormal positioning.
2. Check circulation below the joint: feel for a pulse, check skin color and temperature. Cold, pale, or blue skin means a blood vessel may be compressed --- this is urgent.
3. Check nerve function: can the person feel light touch below the injury? Can they wiggle fingers or toes?
4. Document what you find --- if circulation or sensation is compromised, you have roughly 4-6 hours before permanent damage sets in.

Pain management:

• Have the person bite down on a leather strap or folded cloth.
• If you have access to alcohol, a moderate amount (not excessive) can help with pain and muscle relaxation.
• Willow bark tea (containing natural salicin) can reduce pain --- steep a thumb-sized piece of inner bark in hot water for 15 minutes.
• Wait 20-30 minutes after pain management before attempting reduction.

Shoulder Reduction (Anterior Dislocation)

The shoulder is the most commonly dislocated major joint. An anterior dislocation presents with the arm held slightly away from the body, rotated outward, with a visible gap or hollow below the outer tip of the shoulder.

Cunningham Technique (Preferred --- No Traction Needed)

1. Sit the patient upright in a chair or on a log.
2. Have them place their hand of the injured arm on your shoulder (you sit or kneel facing them).
3. Ask them to consciously relax --- this is the most important step. Talk them through slow breathing.
4. With your fingers, massage the muscles in this order, spending 1-2 minutes on each:
   • Trapezius (the muscle running from neck to shoulder tip) --- use firm, circular kneading.
   • Deltoid (the rounded muscle capping the shoulder) --- work the middle portion.
   • Biceps (front of upper arm) --- massage firmly to release spasm.
5. As the muscles relax, gently encourage the patient to slowly sit up straighter and draw their shoulders back.
6. The shoulder will often slide back in with a subtle clunk. The patient will feel immediate relief.

External Rotation Method (Alternative)

1. Patient lies on their back.
2. Hold the elbow at 90 degrees, tucked against their side.
3. Very slowly rotate the forearm outward (externally), moving no faster than 1 degree per second.
4. If the patient tenses up, stop and wait until they relax, then continue.
5. By the time the forearm reaches about 70-90 degrees of external rotation, the shoulder usually reduces.

Stop Immediately If

You feel or hear grinding, the patient reports sudden sharp nerve pain shooting down the arm, or there is new numbness or tingling that was not present before your attempt.

Finger and Toe Reduction

These are the simplest joint reductions and the ones you will perform most often.

1. Grasp the dislocated finger or toe firmly beyond the dislocated joint.
2. Apply steady traction --- pull along the axis of the digit, straight out.
3. While maintaining traction, gently guide the bone back into alignment.
4. You will feel a satisfying pop or click as it seats.
5. Buddy-tape the reduced digit to the adjacent finger or toe for 2-3 weeks using cloth strips.

Kneecap (Patellar) Reduction

The kneecap typically dislocates to the outside of the knee. The person cannot straighten their leg, and you can see and feel the kneecap sitting off to the lateral side.

1. Have the patient lie down and consciously relax their thigh muscles.
2. Slowly straighten the knee by lifting the ankle, extending the leg.
3. As the leg straightens, gently push the kneecap toward the midline (inward).
4. The kneecap will snap back into its groove as the leg reaches near-full extension.
5. Immobilize the knee in a straight position with a splint for 3-4 weeks.

Post-Reduction Care

After any successful reduction:

1. Re-check circulation and nerve function immediately. Compare to your pre-reduction findings.
2. Immobilize the joint using splints, slings, or buddy taping:
   • Shoulder: arm sling holding the elbow at 90 degrees, with a swath (wrap around the torso to prevent rotation). Keep for 2-3 weeks.
   • Fingers: buddy tape for 2-3 weeks.
   • Kneecap: straight-leg splint for 3-4 weeks.
3. Cold therapy: apply cold water-soaked cloths or, if available, ice wrapped in fabric. 20 minutes on, 20 minutes off, for the first 48 hours.
4. Anti-inflammatory: willow bark tea 3 times daily for pain and swelling.
5. Gentle movement after immobilization period: start with small range-of-motion exercises and gradually increase over 2-4 weeks.

Recognizing Complications

Seek additional help or closely monitor if you observe:

• Loss of pulse below the joint after reduction --- the bone may have shifted onto a blood vessel.
• Increasing numbness or weakness in the days following --- nerve compression.
• Inability to reduce after two attempts --- there may be tissue trapped in the joint or an associated fracture.
• Re-dislocation with minimal force --- the joint is unstable and needs prolonged immobilization (4-6 weeks).

Key Takeaways

• Always check circulation and nerve function before and after any reduction attempt.
• Muscle relaxation is more important than force --- most reductions fail because the muscles are in spasm.
• Shoulders and fingers are the most common and safest to reduce in the field.
• Never force a joint --- two gentle attempts maximum, then immobilize and splint.
• Post-reduction immobilization is critical to prevent chronic instability.