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Dislocation
Defined as total or complete loss of contact or
congruity of articular surfaces of joint
The most common ones involve a finger, thumb,
shoulder, or hip
Less common are those of the mandible, elbow, or
knee.
Symptoms include loss of motion, temporary
paralysis of the joint, pain, swelling, and sometimes
shock.
Dislocations are usually caused by a blow or fall,
although unusual physical effort may also cause one
Sublaxation
Defined as an incomplete joint dislocation with
parts of the articular surfaces remaining in
contact, with either a gradual displacement or
partial dislocation within a joint
Classification of dislocation
Congenital
Traumatic
Pathologic
al
Paralytic
Congenital Dislocation
A congenital dislocation is present at birth as the
result of defective formation of the joint.
A recurrent, or habitual, dislocation (repeated
dislocation of the same joint) may be the result of
improper healing of an old injury or may be
natural, as in double joints, common in fingers
and toes, which are the result of loose
ligamentation.
A pathological dislocation occurs as the result of a
disease, such as Marfans syndrome, which
weakens the capsule and ligaments about the
joint.
Traumatic Dislocation
This usually follows a serious violence. The
following are the clinical types of dislocation:-
(i) Acute
Dislocation
(ii) Old unreduced
dislocation
(iii) Recurrent
dislocation
Pathological Dislocation
This is caused by some diseases process and is
common in the hip joint. This occur when there is
destruction of the head of the femur or excessive
distention of the joint capsule
It can be divided into destructive and distensive
dislocation
Pathological Dislocation
Destructi
ve
dislocatio
n
Distensiv
e
dislocatio
n
Paralytic Dislocation
This occurs when there is marked imbalance of
muscle power
It can occur in the hip whenever there is an
overaction of the hip flexor s and adductors, in
certain paralytic conditions
This is always a posterior dislocation
In poliomyelitis, when the hip extensors and
abdictors are paralysed, the normal adductors and
flexors overact and cause dislocation
In cerebral palsy, the spasm of the adductors and
floexors cause the deslocation
Clinical features of
Dislocation
Knee-flexion deformity
Ankle-varus deformity
Recurrent dislocation
Ligaments and joint margin are damaged,
repeated dislocation may occur.
This is seen especially in the shoulder and the
patellafemoral joint.
Habitual (Voluntary)
dislocation
Some pt acquired knack of dislocating (or
subluxating) the joint by voluntary muscle
contraction
Ligamentous laxity may cause dislocation easier
but the habit often betrays a manipulative and
neurotic personality
It is important to recognize this because patients
are seldom helped by operation
Investigation
Radiograph of the affected part should include
anterior posterior and lateral views and
sometimes special views needed.
CT Scan
Treatment
It is an orthopedic emergency.
Reduction should be quick and prompt.
Reduction should always be under eneral
anaesthesia or sedation.
Joint is rested or immobilized until soft tissue
healing occur after 3-4 weeks
Physiotherapy
If ligaments are torn, they may have to be
repaired
Complication
1.
2.
Dislocation Of Shoulder
By Maya Athirah Yahaya
Anatomy
Introduction
Of the large joints, shoulder is the one that most
commonly dislocates. This is due to
Shallowness of the glenoid socket
Extraordinary range of movement
Underlying condition such as ligamentous laxity or glenoid
dysplasia
Sheer vulnerability of the joint during stressful activities of
the upper limb.
Classification
Anterior
Dislocation
Posterior
Dislocation
Luxatio
Erecta
95%
Head of humerus
comes out of
glenoid cavity
and lies
anteriorly.
5%
Head of humerus
come to lie
posteriorly
behind the
glenoid
Head of humerus
come to lie in
subglenoid
position
Anterior Dislocation of
Shoulder
4 subtypes
Mechanism of injury
Direct : blow (most common) from posterior aspect of the
shoulder pushing head of humerus out of the glenoid
cavity
Indirect : fall on outstretched (extended) hand with
shoulder abducted and externally rotated.
Pathological Changes
Bankarts Lesion
Glenoid labrum
Dislocation causes
stripping of the glenoid
labrum along with
periosteum from
anterior surface of
glenoid and scapular
neck
Head thus comes to lie
in front of the scapular
neck, in the pouch
thereby created.
Hill-Sachs Lesion
Humeral head
Depression on humeral head in its posterolateral
quadrant caused by impingement by the anterior
edges of the glenoid on head as its dislocates
Clinical Features
h/o fall on outstretched hand
Severe pain , arm held in
abduction and external
rotation
Lost of normal round contour
shape of the affected shoulder
joint
Posterior aspect of the affected
shoulder is flat
Anterior aspect shows fullness
below the clavicle due to
displaced head and can felt by
rotating the arm
Apprehension test
Dugar test
Hamilton ruler test
Regiment badge test
Investigations
Radiological examination of the shoulder ( AP view,
axillary view)
Arthrography
CT scan / MRI
Treatment
Conservative
Reduction under sedation / GA followed by
immobilization of the shoulder in chest arm bandage
for 3 weeks
Kochers Maneuver
Hippocrates Maneuver
Stimsons gravity method
Post reduction
X-ray to confirm reduction and exclude fracture
After patient fully awake, active abduction is gently tested
to exclude axillary nerve injury
Rest the arm on sling for 1-2 week and after that active
movement should begin. Abduction and lateral rotation
must be avoided for at least 3 weeks
Complication
Axillary nerve injury resulting paralysis of the deltoid and
small areas of anaesthesia over lateral aspect of the
shoulder
Rotator cuff tear
Vascular injury (axillary artery)
Fracture dislocation
Recurrent dislocation
Unreduced dislocation
Traumatic osteoarthritis
Shoulder stiffness
Clinical features
Severe pain, arm held in abduction and internal
rotation
Abduction is restricted
Loss of normal round contour shape of affected
shoulder joint
Fullness in posterior aspect of the affected shoulder
Flat anterior aspect
Prominent coracoid process
Investigation
Radiological examination
Light bulb sign
Internal rotation of humerus
Rim sign
Vacant glenoid sign
Throughs sign
Thransthoracic lateral X-ray : V-shaped rolling line
Arthrography
CT scan
MRI
Treatment
Conservative
The acute dislocation is reduced (usually under general
anaesthesia) by pulling on the arm with the shoulder in
adduction
a few minutes are allowed for the head of the humerus
to disengage and the arm is then gently rotated
laterally while the humeral head is pushed forwards.
If reduction feels stable the arm is immobilized in a
sling;
otherwise the shoulder is held widely abducted and
laterally rotated in an airplane type splint for 36
weeks to allow the posterior capsule to heal in the
shortest position.
Shoulder movement is regained by active exercises
Elbow Dislocation
Anatomy
stability of elbow
primary stabilizers
MCLis the main stabilizer of the elbow joint (provides
54% valgus stability, while osseous articulation
provides 33%);
ulnohumeral articulation
coronoid: clinical experience suggests 50% intact
coronoid requirement for stability with or without
ligamentous integrity
olecranon contribution to stability inversely correlated
with resection amount: >30% articular surface of
olecranon needed for stability
secondary stabilizers
radiohumeral articulation (most important)
capsule: greatest role in extension of elbow,
insignificant role (<10%) in flexion
Introduction
second most common major joint dislocation;
- dislocation is usually closed and posterior;
Adults > children
Mechanism
Fall on outstretched hand with extended elbow
anatomic morphology of semilunar notch may predispose
to elbow dislocation;
central angle of semilunar notch is significantly larger in
group of pts who had dislocation of the elbow compared
to normals
Side-swipe injury
occurs, typically, when a car-drivers elbow, protruding
through the window, is struck by another vehicle.
The result is forward dislocation with fractures of any or
all of the bones around the elbow; soft-tissue damage
(including neurovascular injury) is usually severe.
Classifications
According to direction of dislocation
Posterior
Posterolateral (80%)
Posteromedial
Lateral
Medial
Divergent
Simple ( dislocation without fracture ) Vs Complex
(dislocation with fractures)
Simple dislocation
rupture of capsule, rupture ofMCL, lateral ligaments,
rupture of flexor pronator mass and less commonly, injury
to brachialis muscle
lateral collateral ligamentmay be the essential lesion in
recurrent or persistent instability following simple
dislocations of the elbow
rupture of brachial artery has been reported;
Complex dislocation
dislocation w/ radial head frx
frx dislocation w/ MCL injury (radial head frx
&MCLInstability)
terrible Triad: (dislocation, cornoid process frx, and
radial head frx)
Clinical features
Pt supports forearm with elbow in slight flexion
Unless swelling is severe, the deformity is obvious
Bony landmark (olecranon and epicondyles) may be
palpable and abnormally placed
Elbowflexed to 90 degrees
Assess alignment of these 3 points at elbow
Normal: equilateral triangle
Dislocated: straight line
Xray
Essential to confirm the presence of a dislocation and to
identify any associated fractures
Note radial head avulsion fracture
rehabilitation
proceed with light duty use 2 weeks from injury
Post reduction
Immobilize elbow in molded posterior plaster splint
Splint elbow at 90 degrees flexion (Allows ligament and
capsular healing)
Splint for 3 weeks
Operative
ORIF (coronoid, radial head, olecranon) , LCL repair, +/MCL repair
Indications : complex dislocations with fractures and
instability
approach
posterior utility approach used
radial head
when placing fixation on the proximal radius, one must
be aware of the "safe zone" for fixation
90 arcin the radial head that DOES NOT articulate
with the proximal ulna
the "safe zone" can be identified by its relationship to
Lister's tubercle and the radial styloid
Complications
Early
Vascular injury (brachial artery)
Nerve injury (median or ulnar nerve)
Late
Valgus instability
Stiffness
Heterotropic ossification
Unreduced dislocation
Recurrent dislocation
Osteoarthritis
Loss of terminal extension (most common sequelae
after closed treatment of a simple elbow dislocation)
Dislocation Of Hip
Anatomy
Classification -
Posterior
Anterior
Central
Dislocation Dislocation Comminuted
70%
10-15%
/ displaced
farcture of
acetabulum
Mechanism of injury
Usually due to backward directed force along with the
shaft of femur in flexed hip
Dislocation may be pure if the femur more adducted at
time of impact and may associated with fracture if femur
slightly abducted.
Clinical features
h/o trauma followed by pain,
swelling, and deformity (flexion,
adduction and medial rotation)
Short leg
Gross restriction of movement of
affected hip
Head of femur felt as hard mass
in gluteal region and moves
along with femur
Investigation
X-ray of hip
AP view : femoral head seen out of its socket and
above the acetabulum
Less promonent lesser trochanter, as thigh is internally
rotated
Broken Shentons line
A bony chip if acetabular hip is fractured
CT scan
Helps to determine direction of dislocation, loose
bodies, and associated fractures
MRI
Useful to evaluate labrum, cartilage and femoral head
vascularity
Management
Conservative (closed reduction / manipulation under GA)
Classical Watson Jones Method
Bigelows method
Stimsons gravity
method
Complications
Early
Sciatic nerve palsy (10-13%)
Due to stretching of the nerve or entrapment between the
fragment
Commonly affectes the peroneal division
Usually neuropraxia and recovers spontaneously
Clinical features
True length, with head palpable in groin (inferior type) or
anteriorly (superior type)
Not short, because the attachment of rectus femoris
prevents the head from displacing upwards.
Limb is in attitude of external rotation, abducted and
slightly flexed.
Occasionally the leg abducted almost to a right angle
Hip movement are impossible
X-ray findings
In AP view : dislocation usually obvious, but occasionally
head is almost directly in front of its normal position
Lateral view
Treatment
Maneuvers employed are similar to those used to reduce
a posterior dislocation, except that while the flexed knee
is being pulled and the hip gently flexed upwards, it
should be kept adducted
An assistant then helps by applying lateral pressure to
inside of the thigh
Point of reduction is usually heard and felt
Subsequent treatment is similar to that employed for
posterior dislocation
Complications
Knee Dislocation
Anatomy
Introduction
Rare. Ortho emergency
Usually due to high energy injury
Defined as complete displacement of the tibia
with respect to the femur, with disruption of 3 or
more of the stabilizing ligaments.
Small avulsion fractures from the ligaments and capsular
insertions may be present.
Mechanism of injury
High energy
Usually from MVA or fall from height
Commonly a dashboard injury resulting in axial load to
flexed knee
Low energy
Often from athletic injury
Generally has a rotational component
Morbid obesity is a risk factor
Pathoanatomy
Associated with significant soft tissue disruption
of ligaments generally disrupted
Classifications - based on
direction of displacement of the tibia
Anterior
Posterior
30-50%
25%
d/t axial load to
d/t hyperextension
injury
flexed knee
Highest rate of
Usually involves
tear of PCL
complete tear of
popliteal
Arterial injury is
generally an intimal
tear d/t traction
Lateral
13%
d/t valgus
dislocations
Usually involves
tears of both ACL
and PCL
Highest rate of
peroneal nerve
injury
Medial
Rotational
Varus force
Usually disrupted
PLC and PCL
Posterolateral is
most common
rotational
dislocation
Usually irreducible
Clinical features
h/o trauma and deformity of the knee
Knee pain and instability
May present with subtle signs of trauma (swelling,
effusion, abrasions)
"dimple sign"- buttonholing of medial femoral condyle
through medial capsule
indicative of an irreducible posterolateral dislocation
acontraindication to closed reductiondue to risks of skin
necrosis
stability
diagnosis based oninstability on exam(radiographs
and gross appearance may be normal)
may see recurvatum when held in extension
assess ACL, PCL, MCL, LCL, and PLC
vascular exam
priority is to rule out vascular injury on exam both
before and after reduction
serial examinations are mandatory
palpate the dorsalis pedis and posterior tibial pulses
if ABI <0.9
perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery
Investigations
Management
Initial Treatment ( reduce knee andre-examine
vascular status )
considered anorthopedic emergency
splint knee in 20-30 degrees of flexion
confirm reduction is held with repeat radiographs in
brace/splint
vascular consult indicated if
if arterial injury confirmed byarterial duplex ultrasound or
CT angiography
pulses are absent or diminished following reduction
Non-operative
indications
limited and most cases require surgical stabilization
delayedligamentous reconstruction/repair
indications
generally instability will require some kind of ligamentous
repair or fixation
postoperative
recommend early mobilization and functional bracing
Complications
Stiffness (arthrofibrosis)
is most common complication (38%)
more common with delayed mobilization
Laxity and instability(37%)
Peroneal nerve injury(25%)
most common in posterolateral dislocations
poor results with acute, subacute, and delayed (>3
months) nerve exploration
neurolysis and tendon transfers are the mainstay of
treatment
Vascular compromise
in addition to vessel damage, claudication, skin
changes, and muscle atrophy can occur
Dislocation Of Patella
http://www.msdlatinamerica.com/ebooks/PracticalOrthopaedi
cSportsMedicineArthrocopy/sid510108.html
***
Acute Dislocation
Result from sudden contraction of
quadriceps while the knee is flexed or
semi-flexed.
Dislocates laterally
Clinical features
Pain
Swelling
Unable to straighten the knee
Medial condyle(Femur) more prominent
Tenderness (antero-medially)
Treatment
Reduction- Under Gen. anesthesia
Immobilisation: cylinder cast3 weeks
Recurrent Dislocation
Etiology
Congenital
Lig. Laxity
hypoplasia of lat. Femoral condyle
Flattening of Intercondylar groove
Patellar maldevelopment
Primary muscle defect
Genu valgum
Acquired
Genu valgum
Inequality of growth of condyle
Weakness of Quads
Contracture
fibrosis
Pathology
First episode
Tear of
capsule on
medial side of
patella
If improper
healing
Damage to
contiguous
surface of
patella & fem.
Condyles
Recurrent
dislocation
Persistent
laxity
Flattening &
then further
dislocation
Clinical features
F>M
Often bilateral
Acute pain with knee stuck in flexion
In dislocated state:
Visually obvious
Tenderness
Swelling
Between attack
Patella alta
General ligament laxity
Apprehension test +ve
Investigations
X-ray
Dislocation
High-riding patella
Other anatomical abnormality
MRI
CT scan
Treatment
Conservative
Quads exercise
NSAIDS
Operative
Camphell Operation
Goldwait operation
Hausers operation
Patellectomy
Muscle release with V-Y Z-plasty
Habitual Dislocation
Everytime knee is flexed, it dislocates laterally
Present in early childhood
ARTERIOR
CRUCIATE
LIGAMENT TEAR
Phang Chin Tong
Anatomy
Introduction
Can withstand
approximately 400
pounds of force
Common injury
particularly in sports (3%
of all athletic injuries)
Associated with MCL
& meniscus tear (all 3
= Terrible Triad)
More common in women
Males
vs Females
Mechanism of injury
Can occur without
contact
valgus or
hyperextension force to
knee
Clinical Features
History of a pop at the time of injury and
immediate (ie, few hours) swelling and effusion at
the knee
Patients complain of the knee giving out during
twisting
Clincal Test
Anterior drawer
test
knee at 90 and the
hamstrings relaxed,
grasp the top of the
patients leg and try
to shift it forwards
and backwards
(displaced > 5mm)
Lachman Test
knee flexed to 20,
one hand at
laterally stabilizes
the distal femur,
and the other hand
grasps the proximal
tibia medially. The
proximal tibia is
pulled forward
Investigations
X-ray: plain x-ray and stress films (to rule out
Segond #)
MRI confirm diagnosis
Athroscopy
Differential Diagnosis
Chronic ACL tear
Avulsion of the tibial insertion in adolescents
Multiligamentous injury to the knee
Treatment
Conservative management - modification of
activities that produce instability, splint &
crutches, functional bracing
Surgical repair reconstruction (Open &
endosopic)
ACHILLES
TENDON
RUPTURE
Phang Chin Tong
Anatomy
connects the calf muscle (gastrocnemius) to the
heel bone (calcaneus).
just below the skin at the back of the ankle
Function
gastrocnemius
muscle (in the
calf) contracts
(shortens)
tendon moves to
point the foot
downwards
(plantarflexions)
Introduction
Partial or complete tear of the
achilles tendon.
Common in men between the
ages of 30 and 50 years
("weekend warriors)
Most commonly occurs in sports
requiring an explosive push-off:
squash, badminton, football,
tennis, netball.
Typical site
for rupture:
About 4 cm
above the
tendon
insertion onto
the calcaneum
(vascular
watershed))
Mechanism of Rupture
Sudden forced
plantar flexion of the
foot
Unexpected
dorsiflexion of the
foot
Violent dorsiflexion of
a plantar flexed foot.
Other mechanisms:
direct trauma &
attrition of the
tendon as a result of
longstanding
peritenonitis with or
without tendinosis.
Poor muscle
strength and
flexibility
Corticosteroid
injection
Risk
factors
Previous
injury or
tendinitis
Failure to
warm up and
stretch before
sport
Clinical Features
A ripping or popping sensation is felt, and often
heard, at the back of the heel.
Looked round to see who had hit them over the
back of the heel, the pain and collapse are so
sudden.
Examination
Plantarflexion of the
foot usually inhibited
and weak
Sign
s
Tendon is
ruptured:
the foot
remains
still.
Normally:
foot will
plantarfle
x
involuntari
ly;
Investigation
Ultrasound scans must be used to confirm or
refute the diagnosis.
Differential diagnosis
Incomplete tear
Complete rupture
mistaken for partial
tear d/t
If complete rupture is
not seen within 24
hours, the gap is
difficult to feel
Patient may by then
be able to stand on
tiptoe (just), by using
his or her long toe
flexors.
A tear at the
musculotendinous
junction causes pain
and tenderness halfway
up the calf.
This recovers with the
aid of physiotherapy
and raising the heel of
the shoe.
Treatment
Conservative
Plaster cast or special boot is
applied with the foot in
equinus;
Rehabilitation and
physiotherapy within 46
weeks.
Shoe with a raised heel should
be worn for a further 68
weeks
Re-rupture rate about 10 %
Surgical
Operative repair is
associated with
earlier return to function
better tendon and calf
muscle strength
a lower re-rupture rate.
Supported rehabilitation
and physiotherapy are
commenced early
(within a week or two of
repair)
Risks
wound healing
problems
sural nerve neuroma.
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