closed reductions on Peds in the ER

  1. Is it standard to manipulate a closed elbow reduction 3 times? And can this cause additional damage to the fracture site as well as surrounding ligaments and nerves?
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  2. 20 Comments

  3. by   ang75
    Yes. I have seen it done mult times. I have also asked about tissue damage. The answer I rec'd is that orthopods have been trained in the anatomy of a joint. (I asked the smart alek) It is very rare for kids to receive tendon,lig injuries serious enough to cause comp. If this was an elbow dc then the tens and ligs were already stressed anyway. How old was the pt? Was this nursemaids? Or older child?
  4. by   traumaRUs
    Was the child properly sedated?
  5. by   got2luvnights
    Quote from ang75
    Yes. I have seen it done mult times. I have also asked about tissue damage. The answer I rec'd is that orthopods have been trained in the anatomy of a joint. (I asked the smart alek) It is very rare for kids to receive tendon,lig injuries serious enough to cause comp. If this was an elbow dc then the tens and ligs were already stressed anyway. How old was the pt? Was this nursemaids? Or older child?
    I was not clear on have you seen closed reductions repeated several times? The patient was 9yr. It was a radial head fracture with posterior dislocation. The patient was a transfer for surgery however the ER decided to close reduce which took almost 3 hours this resulted in persistant subluxation and joint widening as well as significant displacement of the radial head and neck. The patient ended up in the OR for 3 more hours. I cannot help but think that when a reduction cannot be confirmed on the first try that the ortho resident doing the reduction should have suspected that the patient may have a loose body in the joint. Since they did find bone chips in the joint and the reduction went on for hours could this have caused additional damage to the radial neck and surrounding tissues?
  6. by   got2luvnights
    Quote from traumaRUs
    Was the child properly sedated?
    The 9yr child had been put into conscious sedation however he was moaning, tearing up and raising off the table many times. It was not a good scene. This was my first time to see this procedure and hope that any in the future go much easier.
  7. by   z's playa
    Sounds awful. Kind of like a scene from M.A.S.H. :uhoh21:
  8. by   ang75
    That sounds way wrong. We have a policy, 2 attempts (whether Beir block or whatever) it doesn't go in the patient goes under. That's way tooooooo traumatic-not just for the child. It's bugging the heck out of you too, right?

    In my earlier post, I have seen mult. attempts at relocation in one "visit" these are usually frequent dislocators and have next to nothing left for ligaments in that joint. I have one guy with a semi-monthly shoulder that doesn't even want sedation anymore. He is so used to it. That and when you have that much disruption in a joint, its toast anyhow. He needs the OR. Hope I cleared up My earlier post.
  9. by   got2luvnights
    Quote from ang75
    That sounds way wrong. We have a policy, 2 attempts (whether Beir block or whatever) it doesn't go in the patient goes under. That's way tooooooo traumatic-not just for the child. It's bugging the heck out of you too, right?

    In my earlier post, I have seen mult. attempts at relocation in one "visit" these are usually frequent dislocators and have next to nothing left for ligaments in that joint. I have one guy with a semi-monthly shoulder that doesn't even want sedation anymore. He is so used to it. That and when you have that much disruption in a joint, its toast anyhow. He needs the OR. Hope I cleared up My earlier post.
    Yes thank you what has been your experience in the time frame for a NORMAL reduction to take place?
  10. by   ang75
    Well, after IV's monitor and sedation are all on board (depending on what procedure is being done-conscious sedation or beir block) rarely more than 5 minutes. Kids may take 1-2 minutes longer, but not much. Just because their joints are still funky and underdeveloped etc. I believe I have seen only a handful of closed reductions in the ER take more than 5 minutes. If it is proving to be difficult, we will often send them to the OR for still a plan of closed reduction. A patient being totally under vs. conscious sedation can make all of the difference in the world to get muscles to totally relax to ease reduction. It's still a first choice over open reduction. Just remember, ICE< ICE< ICE! Keeping the swelling in dislocated joint down to minimum can make thinigs sooooooo much easier. The more it swells, the less room the doc has to reduce it which can make it take longer, require more sedation poss even OR. How swollen was your 9 yr old?
  11. by   got2luvnights
    Quote from ang75
    Well, after IV's monitor and sedation are all on board (depending on what procedure is being done-conscious sedation or beir block) rarely more than 5 minutes. Kids may take 1-2 minutes longer, but not much. Just because their joints are still funky and underdeveloped etc. I believe I have seen only a handful of closed reductions in the ER take more than 5 minutes. If it is proving to be difficult, we will often send them to the OR for still a plan of closed reduction. A patient being totally under vs. conscious sedation can make all of the difference in the world to get muscles to totally relax to ease reduction. It's still a first choice over open reduction. Just remember, ICE< ICE< ICE! Keeping the swelling in dislocated joint down to minimum can make thinigs sooooooo much easier. The more it swells, the less room the doc has to reduce it which can make it take longer, require more sedation poss even OR. How swollen was your 9 yr old?
    By the time patient was trasnfered our facility 5hrs had passed MSO4 had been given 3x a cloth splint applied and no ice was applied. The elbow was grossly swollen and deformed. Drugs were given to induce conscious sedation and the 3hr reduction began. I think this kiddo should have been taken directly to the OR.
  12. by   got2luvnights
    Quote from traumaRUs
    Was the child properly sedated?
    TraumaRUs,
    I would have to say no because of all the moaning, crying out for mom and raising off the table many times. The whole procedure in the ER was very long and exhausting. Stat x-rays were called in 3x. What a mess!
  13. by   ang75
    I'm with ya sister. Think about how that kid is gonna be the next time he/she has to go to ER, docs office whatever? No offense, but pt is gonna fight.

    The swelling (majority of it) must have come from the repeated unsuccessful manipulation. Elbow fx's and dc's usually do not swell that much. Poor kid. :angryfire
    Sorry you had to be the one to witness it. I worked as an ortho first assist for a few yrs and that would never have happened with the group I worked with. I am sorry it happened at all. Was it reduced at all by the time pt was transported? Did the swelling get bad enough that DNV's were comprimised? Out of all of the docs that I have come across in my yrs, orthos can sometimes be the worst. (and sometimes kind of weird) Example of the weird? The group I was 1st assist for, barked, barked barked and occasionally bit. I used to be so timid around them. One day after 5 back to back very long surgeries, I got barked at for nothing and finally bit back. 4 surgeries later when our shift was over, they took me out for shots of tequila for "finally growing a spine". Now, I did drink their money, but still called em all names in my head-still do.
    Quote from srichards
    By the time patient was trasnfered our facility 5hrs had passed MSO4 had been given 3x a cloth splint applied and no ice was applied. The elbow was grossly swollen and deformed. Drugs were given to induce conscious sedation and the 3hr reduction began. I think this kiddo should have been taken directly to the OR.
  14. by   got2luvnights
    Quote from ang75
    I'm with ya sister. Think about how that kid is gonna be the next time he/she has to go to ER, docs office whatever? No offense, but pt is gonna fight.

    The swelling (majority of it) must have come from the repeated unsuccessful manipulation. Elbow fx's and dc's usually do not swell that much. Poor kid. :angryfire
    Sorry you had to be the one to witness it. I worked as an ortho first assist for a few yrs and that would never have happened with the group I worked with. I am sorry it happened at all. Was it reduced at all by the time pt was transported? Did the swelling get bad enough that DNV's were comprimised? Out of all of the docs that I have come across in my yrs, orthos can sometimes be the worst. (and sometimes kind of weird) Example of the weird? The group I was 1st assist for, barked, barked barked and occasionally bit. I used to be so timid around them. One day after 5 back to back very long surgeries, I got barked at for nothing and finally bit back. 4 surgeries later when our shift was over, they took me out for shots of tequila for "finally growing a spine". Now, I did drink their money, but still called em all names in my head-still do.
    ang75 The child had all sensation before reduction 1 day postop child lost feeling in ring and small finger and cast had to be split but did nothing for numbness and little for swelling. The patient was only x-rayed splinted and given pain meds before transported to our ER.
    Last edit by got2luvnights on May 19, '04 : Reason: left out information

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