Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Threatened limb or skin
A dislocated joint with absent perfusion, progressive neurological loss, an open wound or severe skin tenting needs immediate controlled reduction and specialist help.
Action: Document neurovascular status, provide analgesia, call orthopaedics, reduce urgently when indicated, and obtain the required imaging as soon as it can be done without harmful delay.
Synopsis
Use imaging to confirm dislocation direction, detect associated fracture and verify reduction while allowing immediate treatment when neurovascular or skin viability is threatened.
Before imaging or reduction, record joint position, wounds, distal pulse, refill and the named motor and sensory nerve functions at risk.
Obtain orthogonal views that demonstrate the joint above and below relevant fractures; direction cannot be trusted from one projection.
When perfusion or skin is threatened, controlled emergency reduction takes priority over routine pre-reduction films, with imaging immediately afterwards.
Key red flags
A cool or pulseless limb, expanding haematoma or abnormal perfusion after knee dislocation requires urgent vascular assessment even if alignment has spontaneously returned.
Open dislocation, skin necrosis risk or an irreducible joint needs immediate orthopaedic management and should not undergo repeated forceful attempts.
Posterior shoulder dislocation is commonly missed on an AP view, especially after seizure or electric shock; obtain an orthogonal view.
Post-reduction new nerve deficit, loss of pulse, persistent incongruence or a trapped fracture fragment requires immediate reassessment and escalation.
Posterior shoulder dislocation
Internal rotation after seizure with a light-bulb appearance on AP imaging is suspicious, but an axillary or scapular-Y projection confirms direction.
Knee dislocation pattern
Gross multidirectional instability or periarticular avulsions may indicate a spontaneously reduced dislocation with popliteal artery risk despite a palpable pulse.
Investigation priorities
01
Pre-reduction radiographsFirst step
Confirm direction and identify fractures before manipulation when the limb and skin are not immediately threatened.
Management branches
Stable jointImage before reduction
A dislocation is suspected and distal perfusion and skin remain satisfactory.
Document wounds, pulses, refill and named peripheral nerve functions before analgesia and manipulation.
Obtain adequate orthogonal views and identify direction, fracture, impaction and any barrier to closed reduction.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
NICE NG38 non-complex fractures recommendationsCurrent national recommendations checked 13 September 2026; neurovascular assessment, reduction and imaging context for non-complex fracture care.
AO Surgery Reference orthopaedic traumaAO Foundation current anatomical reference checked 13 September 2026; joint-specific fracture-dislocation patterns and imaging context.
BOAST peripheral nerve injuryCurrent BOA professional standard checked 13 September 2026; assessment, documentation and escalation of traumatic peripheral nerve deficits.
BOASt arterial injuries associated with musculoskeletal traumaPublished June 2026 by BOA/BAPRAS/Vascular Society; patients with arterial injury associated with musculoskeletal trauma. Requires documented arterial examination, urgent realignment and splintage of a pulseless deformed limb, repeat arterial examination and CTA when injury remains suspected; excludes paediatric supracondylar fractures.