There are not many situations in general medicine where a doctor can affect an instant cure, and the patient will call them a “miracle worker.” Most patient visits end with a prescription or two or some instructions along with the admonition, “You’ll feel better in a few days.” One exception to this rule: dislocations. A simple dislocation happens when the end of a bone is pulled out of its socket (or niche) and is left lying beside the joint. Most such dislocations do not involve fractures or tearing of the ligament. With the muscles intact, the remedy requires pulling the bone a bit farther out of the joint, after which the intact muscles will pull it back into place. This “medical miracle” classically involves the reduction (repair) of a radial head dislocation in a young child or toddler (the bone in the forearm, below the elbow). Sometimes called “nursemaid’s elbow,” the injury is often caused when a child and adult are walking holding hands. If danger presents itself — like an automobile or a bicycle or an aggressive dog —the adult will yank the child’s arm to get them out of danger, often inadvertently causing a dislocation. The subsequent call to our office involves a very worried parent whose child has a “paralyzed” arm. “My child has had a stroke!” a parent will shout into the phone. But a stroke is very unusual in this age group. Over my three-plus decades in practice, I have treated one five-year-old who had experienced a stroke (never say never in medicine). My treatment protocol starts with offering the child a treat of some sort (lollipop, sticker, or small toy) in front of the parent. (It is important that the parent is convinced of the cure and can stop worrying about “the stroke” before leaving my office). The small treat is presented to the child’s affected arm, which he will not move, of course — but the child will attempt to grasp it with his “good” arm. Next, I will sit down or kneel beside the child and, ever so gently, feel the paralyzed hand or wrist, gradually moving the thumb of my left hand over the head of the radius bone just below the elbow. With my right hand, I gently supinate (turn palm upward) the child’s forearm, and, if done correctly, I will feel a slight click under my left thumb. I then let go of the child and re-offer the toy/bauble to the affected arm, and the child moves the arm to grasp it. The child is happy with the treat, and the parent is exhilarated, praising me with terms like “miracle-worker” or “wizard!” My introduction to dislocation took place many years before, when I was 11 or 12 and playing touch football in the street in front of my house. I caught the football wrong and felt discomfort in my thumb. When I looked at it, I screamed — the thumb was bent backward and looked like it was coming out of the index finger joint. It was distorted and ugly and very scary. Was my thumb going to fall off? My screams were so pitiful that the father of one of my playmates came out of his house. I offered him a look. He grabbed the thumb, yanked, and it went back into place. I thanked him profusely for saving me from certain amputation. By the way, can you imagine a parent doing that today without a signed release, X-rays, and an ambulance? Fast forward 30 years to an opportunity for payback. One Saturday, there was a knock at my back door. There stood Brian, a 25-year-old neighbor/parishioner with a dislocated thumb. I knew he had no insurance, so I just reached out and reduced it. He was happy and grateful, and I was quite satisfied to have paid off my debt from childhood. Would you believe it — the next day, he showed up with a bouquet of flowers that cost at least $75.00 (150-percent of my usual fee)! Other joints, such as the shoulder, hips, and knees, can dislocate, but it is not a common occurrence. It is unusual enough (like feeling an enlarged spleen) that you immediately look around for a student or an intern to show it to. During my residency, a sailor came in with an anterior shoulder dislocation. It was classic. I was so excited I paused to corral a couple of interns to see it. Once they arrived, I asked the patient to remove his T-shirt so we could have a better view of the injury. Unfortunately for us, as he removed the shirt, he reduced the dislocation. When joint ligaments are stretched, recurrent dislocations can occur, and sometimes those patients learn how to reduce it themselves. My most challenging case was a posterior hip dislocation in a young Ensign at a U.S. Navy base in Newfoundland. The man had been out for dinner at a restaurant on the Trans-Canada Highway, where he had consumed large amounts of food and liquor. Driving back to the base, he ran off the road, overturning the car several times. The ambulance brought him to our hospital quite bloodied about the head and face but also with a dislocated hip. His full stomach and blood alcohol level dissuaded our nurse anesthetist from attempting general anesthesia. I had never seen a hip dislocation before, and neither had any of my staff (pediatrician, flight surgeon, general surgeon, and internist). I did recall an old movie starring June Allyson as a young female intern trying to prove herself as capable as any male. When she had a patient with a shoulder dislocation, she put him on the floor, and she sat on the floor beside him. She put her foot into his armpit, then pulled with both her arms as hard as she could. The arm popped in. My mind raced to figure out how we could do something similar. In current treatment for shoulder dislocation, often the arm would be suspended from an IV stand, and IV pain meds would be given slowly. Gradually, the weight of the rest of the body would distract the joint, allowing reduction. In the room, I spied a large, rusted hook protruding from the ceiling. We tested it for security using ropes against our body weights. Satisfied with that, we laid him out on his back, then tied a rope to his foot and ran it up over the hook. With an IV dripping Demerol, we gradually hoisted him up by his foot. Halfway up to the ceiling, his leg gave a sort of a shudder, and the hip snapped into place. We were all very pleased and excited by our success. You can bet the trip home that night went via the officer’s club. Medical school presents a full curriculum, but it can’t cover everything. Therefore, the wise doctor will not hesitate to incorporate lessons from childhood football and old black-and-white movies. My experience: Using every possible resource benefits our patients. Source
