dislocation and subluxation 3.ppt

Dr. Araib Kaleem
DISLOCATIONS
&
SUBLUXATIONS

JOINT DISLOCATIONS
Definition
 A dislocation is a separation of two bones where
they meet at a joint. A dislocated bone is no longer
in its normal position. A dislocation may also cause
ligament or nerve damage. Dislocations may be
associated with a periarticular fracture
Normal
hip
Dislocated
hip

A subluxation is
an incomplete or partial
dislocation. For example, a
nursemaid's elbow is the
subluxation of the head of the
radius in the elbow.
SUBLUXATION

TRAUMATIC DISLOCATION
• dislocations caused by trauma
to the joint or when an individual
falls on a specific joint
• Great and sudden force applied,
by either a blow or fall, to the
joint can cause the bones in the
joint to be displaced or dislocated
from normal position

DISLOCATION CAUSES
 Dislocations are usually caused by a
sudden impact to the joint. This usually
occurs following a blow, fall, or other
trauma

DISLOCATION SYMPTOMS
 History of injury
 Pain
 Swelling
 Difficulty moving the joint
 Numbness and paresthesias

DISLOCATION SIGNS
 Visibly out-of-place, discolored, or
misshapen joint
 Limited joint movement
 Swollen or bruised
 Intensely painful, especially if you try to
use the joint or bear weight on it or move
it.
 Decreased sensation distal to the joint
 Decreased pulse, cool extremity distal to
the joint

NOMENCLATURE FOR
DISLOCATIONS
 Name the JOINT
 Name the dislocation by the position of
the DISTAL FRAGMENT in relation to
the proximal fragment
 Add FRACTURE to the name if there is
a periarticular fracture.
 Add OPEN if a wound communicates
with the dislocation

RADIOGRAPHS
 Two planes at 90
degrees to each other
 Good quality
 Standard views
 See the entire joint
Dislocated Elbow

TREATMENT
 Reduce the dislocation as soon as possible
 Check Neurovascular function distally
 Take post reduction radiograph
 Immobilize the joint

REDUCTION TECHNIQUE
 Start IV
 Give sedation
 Apply traction force
 Manipulate joint

GENERAL DESCRIPTION & MANAGEMENT
OF DISLOCATION OF SHOULDER JOINT

Shoulder --Anatomy
1. head of humerus
2. scapula
 acromion
 glenoid
 spine
3. glenohumeral joint
4. clavicle (collar bone)
5. acromio-clavicular joint

1. Check neuromuscular status
2. Check basic movement internal/ext
rotation, abduction
3. Palpate acromioclavicular jt
4. Palpate acromion and humeral head
Shoulder--Assessment

 fingers move
 light touch fingers
Shoulder--assessment

1. Check neurovascular status
 fingers move
 pulse/color

1. Check neurovascular
status
 fingers move
 light touch deltoid

1. Check neurovascular status
2. Check basic movement
internal/ext rotation, abduction

3. Palpate acromioclavicular
jt

3. Palpate acromioclavicular jt
4. Palpate acromion and head
of humerus

Dislocation of the Shoulder
 Mostly Anterior > 95 % of dislocations
 Posterior Dislocation occurs < 5 %
 True Inferior dislocation (luxatio erecta) occurs < 1%
 Habitual Non traumatic dislocation may present
as Multi directional dislocation due to
generalized ligamentous laxity and is Painless

Mechanism of anterior shoulder
dislocation
 Usually Indirect fall on Abducted and
extended shoulder
 May be direct when there is a blow on the
shoulder from behind

Clinical Picture
 Patient is in pain
 Holds the injured limb
with other hand close to
the trunk
 The shoulder is
abducted and the elbow
is kept flexed
 There is loss of the
normal contour of the
shoulder

Anterior Dislocation
acromion
humeral head
?
acromion clavicular jt

X Ray anterior Dislocation of
Shoulder

Associated injuries of anterior
Shoulder Dislocation
 Injury to the neuro vascular bundle in
axilla ( rare )
 Injury of the Axillary or Circumflex
Nerve ( Usually stretching leading to
temporary neuropraxia )
 Associated fracture

Management of Anterior Shoulder
Dislocation
 Is an Emergency
 It should be reduced in less than 24 hours
or there may be Avascular Necrosis of
head of humerus
 Following reduction the shoulder should
be immobilised strapped to the trunk for
3-4 weeks and rested in a collar and cuff

SHOULDER REDUCTION
 Sedation
 Apply traction and
counter traction
 Lift humeral head into
the glenoid

Methods of Reduction of
anterior shoulder Dislocation
 Hippocrates Method ( A form of
anesthesia or pain abolishing is required )
 Stimpson’s technique ( some sedation
and analgesia are used but No anesthesia
is required )
 Kocher’s technique is the method used
in hospitals under general anesthesia
and muscle relaxation

Complications of anterior Shoulder
Dislocation : Early
 Neuro vascular injury ( rare )
 Axillary nerve injury
 Associated Fracture of neck of humerus or
greater or lesser tuberosities

Complications of anterior shoulder
Dislocation : Late
 Avascular necrosis of the head of the
Humerus (high risk with delayed
reduction)
 Heterotopic calcification ( used to be
called Myositis Ossificans )
 Recurrent dislocation

Dislocation of the hip joint
Three types of hip dislocation : -
1 . Anterior dislocation ( 10 – 15 %)
2 . Posterior dislocation ( 70 % )
3 . Central dislocation ( rest )

Pipkin Fracture
– I - Posterior dislocation of the hip with
fracture of the femoral head caudal to the
fovea capitis
– II - Posterior dislocation of the hip with
fracture of the femoral head cephalad to the
fovea capitis
– III - Type I and type II with associated
fracture of the femoral neck
– IV - Type I, II, or III with associated fracture
of the acetabulum

Femur bone showing fovea centralis

Clinical features
– Limb shortening
– Flexion , adduction and medial rotation
deformity of the affected limb
– Thigh rest on the contralateral limb
– Head felt in the gluteal region
– Movement of hip decrease
– Feature of sciatic nerve palsy

Feature of sciatic nerve palsy
 SCIATICA or pain localized to the hip,
 PARESIS or PARALYSIS of posterior thigh
muscles and muscles innervated by the
peroneal and tibial nerves,
 sensory loss involving the lateral and
posterior thigh, posterior and lateral leg, and
sole of the foot.
- Pain when sitting, sneezing or coughing
- tingling sensation or numbness down the leg
- Foot drop

Radiology
 X – ray AP and Lateral view of the pelvis
showing both the hip joints
 CT scan and MRI ( for acetabular fracture)

HIP REDUCTION
 Sedation
 Relaxation, flexion,
traction, and
rotation
 Gentle and
atraumatic
Relocation should be palpable and permit significantly
improved ROM. This often requires very deep sedation.

 Closed reduction ( to reduce pain ) : -
 Four methods of closed reduction : -
1 . Stimson`s method : -
– Position : prone , at the edge of the table
– An assistant stabilizes the pelvis
– Physician applies downward pressure on the
calf with one hand while applying external
rotation to the femur.

2 .Allis traction
– Position : supine
– An assistant stabilizes the pelvis
– The physician simultaneously distract (to pull away )
the femur and rocks it medial to lateral .
3 . Bigelow`s method: -
– Physician applied upwards traction on the femur while
an assistant stabilize the pelvis
4 .Classical watson`s – jones method : -
– Limb is brought to the neutral position first then
longitudinal traction in the of femur is given.

After treatment
 After reduction , the patient is put on a skin
traction or immobilised in a Thomas split for 3
weeks .
 Full weight bearing after 6 weeks .
 Indication of open reduction : -
– 1 . Failure of close reduction : due to obstruction by
bony fragments or by soft tissues .
– 2 . Instability after reduction
– 3 . Sciatic nerve palsy

Complications
Early : -
– Sciatic nerve palsy
– Irreducible fracture dislocation
– Missed knee injuries
– Recurrent dislocation
Late : -
– Myositis ossificans
– Avascular necrosis of bone
– Post – traumatic arthritis
– Unreduced posterior dislocation

1. What looks abnormal
2. Patella
3. Fibular head
Knee -- Anatomy

1. What looks abnormal
Knee -- Anatomy

3. Fibular head
Knee -- Anatomy

Knee -- Assessment
What needs urgent attention
What probably needs an x ray

1. Massive swelling
2. Unable to bear weight
3. Neurovascular compromise
4. Infection
5. Getting Worse
Knee -- Assessment
what needs urgent attention
what probably needs an x ray

1. Massive swelling
Knee -- Assessment

1. Massive swelling
– Tibialis posterior pulse
Knee -- Assessment

 Massive swelling
 Unable to bear weight
 Neurovascular compromise
– Tibialis posterior pulse
– Dorsalis pedis pulse
Knee -- Assessment

1. Massive swelling
4. Infection
swollen and also
red and warm
tender
Knee -- Assessment

Massive swelling
Unable to bear weight
Neurovascular compromise
Infection
Getting Worse
If any of these exist,
needs prompt attention !!
does it need an x ray ?
Knee -- Management

Ottawa Knee Rules
X-ray required only with acute knee injury
and one or more of the following:
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex to 90°
Inability to bear weight both immediately and in the
emergency department (4 steps)

Knee Dislocation
 During the acute phase of a patellar injury
or dislocation, the immediate goals are to
reduce inflammation, relieve pain, and
stop activities that place excessive loads
on the patellofemoral joint.

 Acute phase management should apply
the PRICE principle:
 protection of the injured joint,
 relative rest,
 ice,
 compression,
 elevation to control inflammation.

surgical interventions are
reserved for complicated dislocations with
associated fractures
Other options are:
 Patellar bracing
 Patellar taping

Elbow Dislocation
Basics
 History of trauma.
 Posterior dislocation is most common.
 Age group : <20 years of age.
 Rarely, elbow dislocation can occur in
elderly patients after a fall.
 Common site : ulnohumeral joint.

Classification (stimson)
Proximal radioulnar
joint intact:
Posterior (90%):
Proximal radioulnar
joint disrupted :
Anteroposterior
 Radius is anterior
 Ulna is posterior
Medial lateral:
 Radius is lateral
 ulna is medial

Pathophysiology
 The collateral ligaments usually are
ruptured, with injury to the brachialis
muscle and coronoid.

Associated Conditions
 Fracture of the radius
 Fracture of the ulna
 Fracture of the humerus
 Ulnar and median nerve injury
 Brachial artery injury

Cont..
fig : complex dislocation of the elbow . In
addition to dislocation , there are multiple
fracture of the elbow.

Diagnosis
Signs and Symptoms
 The patient presents with :
 pain,
 swelling,
 elbow deformity, and
 inability to move the elbow.

Physical Exam
 Assess the patient's neurovascular status.
– Examine the functions of the radial, median,
and ulnar nerves before reduction.
 The median nerve can be injured at the time of
reduction by becoming entrapped in the joint.
 check nerve function before and after reduction.
– Evaluate the patient for brachial artery injury
before reduction.
 The brachial artery may be trapped in the joint
along with the median nerve.
 Vascular injury is an indication for immediate
surgery.

Exam..
 The upper extremity should be inspected
for other injuries, such as Monteggia
fracture-dislocation[fracture of the ulna
with radial head dislocation].
 Palpate the forearm for increased swelling
or signs of compartment syndrome

Tests
Imaging
 Radiography:
– AP : greater superimposition of distal humerus
with proximal ulna and olecranon is seen.
– lateral views : coronoid process lies posterior to
the condyles of the humerus
 CT (fracture pattern).
 MRI (ligamentous injury).

Treatment
General Measures -
 arm should be immobilized and elevated,
 Cryotherapy
 neurovascular status must be evaluated
before and after reduction.
 rules out associated fractures.
 closed reduction under general anaesthesia.

.
-
 Figure 42
 Performance of lateral pivot shift test,.
 - holds the wrist and the elbow.
 - The forearm is supinated, and a valgus stress
is applied
 - The “snap” noted by the patients can only be
reproduced under general anaesthesia; it occurs
around 40° of elbow flexion.

Con..
 fig
Figure 42 Performance of lateral pivot shift test,.
- holds the wrist and the elbow.
- The forearm is supinated, and a valgus stress is
applied.
- The “snap” noted by the patients can only be
reproduced under general anaesthesia; it occurs around
40° of elbow flexion.

Cont..
 fig
Figure 43 Performance of lateral pivot shift test on a
recumbent patient.
The arm is placed alongside the body, in full internal
rotation.
The forearm is supinated, and axial compression and
valgus stress are applied as the elbow is moved from
the fully extended to a flexed position.

Surgery
 Surgery is indicated for:
– Irreducible dislocation
– Open dislocation
– Neurovascular entrapment
– Complex fracture dislocations

 Open reduction and internal fixation are
recommended for:
– Displaced radial head fractures
– Olecranon fractures
– Supracondylar humerus fractures
 Repair of complex fracture dislocations
should be based on restoring stability to
the elbow.
– by repairing of the coronoid (if possible),
restoration of the radial head or radial head
replacement, or repair of the collateral
ligaments.

Complications
 Neurovascular injury (ulnar – radial –
median )
 Recurrent dislocation
 Arthritis
 Myositis ossificans .

Cont..
 Fig: normal alignment after the elbow has
been reduced.

ELBOW DISLOCATION
 Non surgical treatment
 Surgical treatment

Non-surgical treatment
 It is possible for the elbow to relocate by
itself. This is more likely when there is a
subluxation, rather than a complete
dislocation.
 There are several different methods used
for manual (closed) reduction

 Closed reduction refers to the fact that
the elbow can be put back in joint without
surgery. An open incision is not needed.
 Manual reduction can be done in an
emergency on site
 You would be given medications first to
help with the pain.

Surgical Treatment
 If there is too much swelling, it may be
necessary to delay surgery for a few days
up to a week
 The elbow will be reduced right away and
the arm immobilized while waiting for the
swelling to subside.

 If there has been damage to the bones
and/or ligaments, surgery may be needed
to restore alignment and function
 The type of surgery depends on the
extent of the damage
 Wires, pins, or even an external fixation
device may be needed to hold everything
together until healing occurs

Acromioclavicular Joint
 The acromioclavicular joint, or AC
joint, is a joint at the top of
the shoulder
 It is the junction between
the acromion (part of the scapula that
forms the highest point of the
shoulder) and the clavicle

FUNCTION
 The acromioclavicular joint allows the
ability to raise the arm above the
head
 This joint functions as a pivot point
(although technically it is a gliding
synovial joint), to help with
movement of the scapula resulting in
a greater degree of arm rotation.

 A common injury to the AC joint is
dislocation, often called AC separation
or shoulder separation.
 Acromioclavicular joint dislocation is
particularly common in collision sports
such as ice
hockey, football, Judo, rugby

GRADING & MANAGEMENT OF
ACJ DISLOCATIONS
 Acromioclavicular joint dislocations
are graded from I to VI
 Grading is based upon the degree of
separation of the acromion from the
clavicle with weight applied to the
arm

 Grade I is slight displacement of the
joint, and a badly stretched or partially
torn AC ligament. It has the normal
separation of <4mm
 Grade II is a partial dislocation of the AC
joint with a complete disruption tear of the
AC joint and a partial disruption of
coracoclavicular ligament. The AC gap is
>5mm.

 Grades I and II never require surgery
and heal by themselves, though
physical therapy may be required.

 Grade III is complete disruption of AC
and CC ligaments
 Grade III separations most often do not
require surgery and shoulder function
should return to normal after 16–20
weeks.

 Grades IV-VI are complications on a
'standard' dislocation involving a
displacement of the clavicle, and will
almost always require surgery.

dislocation and subluxation 3.ppt

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