This document outlines principles of managing common joint dislocations. It discusses the anatomy, mechanisms, clinical presentation, imaging and treatment approaches for dislocations of the shoulder, elbow, hip and knee. For each joint, it describes techniques for closed and open reduction as well as post-reduction care and rehabilitation. Complications of joint dislocations like recurrent instability, stiffness and avascular necrosis are also summarized.

1. Principles of Dislocation Management
Moderator :Dr.Theodros
Assistant professor of Orthopedics and Traumatology
Presenter: Dr.Bol Kuol
(OSR1)
111
28thDec, 2023 1

2. Outlines
Introduction
Principles of dislocation Management of;
 GH joint
 Elbow joint
 Hip joint
 Knee joint
 Ankle joint
Summery
References
2

3. Types of Joints
Fibrous/Synarthrosis
No movement are permitted
E.g. suture,syndesmosis,gomphosis
Cartilaginous/Amphiarthrosis
 Little movements are permitted
E.g. rib cage, symphysis pubis
3

4. Synovial(Diarthrosis )
Movement is free
 Pivot
 Hinge
 Condylar
 Saddle
 Plane
 Ball and Socket
4

5. Definition
Dislocation
When its articular surfaces are wholly displaced one from the other, so that apposition
between them is lost.
Subluxation
Exists when the articular surfaces are partly displaced but retain some contact with each other.
5

6. Types of dislocation
Congenital
Acquired
1.Traumatic
2.Pathological e.g TB hip, Septic Arthritis
3.Paralytic e.g Poliomyelitis ,cerebral palsy ,etc.
4.Inflammatory disorders e.g. rheumatoid arthritis
NO joint is immune from dislocation
6

7. Most commonly occur in the following joints
 Shoulder
 Elbow
 Hip
 Knee
 Ankle
 Metacarpophalangeal joint
 Facet Joint dislocation in cervical spine
 Acromioclavicular joint dislocation
7

8. Complications
Acute
Injury to peripheral nerve and blood vessels
Chronic
Unreduced dislocation
Recurrent dislocation
Traumatic osteoarthritis
Joint stiffness
Avascular necrosis
Myositis ossificans
8

9. Shoulder(GH) Dislocation
 The glenohumeral joint is inherently unstable
 Stability provided by glenoid labrum, ligaments and muscles
 Most common dislocated joint
 Young/athletic patients(recurrence >90% if <25 year old )
Associated with
 labral tears(<40 year old )
 Rotator cuff tears(> 40 year old )
 Glenoid rim (‘’bony Bankart’’) fracture
 Hill-Sachs lesion
9

10. Anatomic Classification
 Based on direction of humeral head
Anterior Dislocation Most common
Posterior Dislocation often missed
Superior Dislocation extremely rare
Inferior Dislocation luxatio erecta: abducted arm cannot be lowered (rare)
 Recurrent Dislocation happen repeatedly
10

11. Anterior Dislocation
Most common and more than 90%
Mechanism
Direct force anteriorly impact to the posterior shoulder
 fall on the backward-stretching hand
forced abduction and external rotation of the shoulder
11

12. History
Trauma/fall
Pain
Inability to move arm
Neurovascular Examination
 Test axillary nerve function
P/E
‘’Flattened’ ’shoulder
Patient carries affected arm with other hand
 Empty glenoid fossa, compared with
contralateral side
Palpable dislocated head(anterior in axilla )
12

13. Imaging
Trauma series
 AP view
 LT view
 Axillary view
 Scapular Y view
overlapping shadow of the humeral head and glenoid fossa
Hill-Sachs lesion
Bony Bankart lesion
Humeral neck #
Tuberosity
13

14. Non Operative
Closed Reduction
Traction and Counter traction Method
Most commonly used
Axial traction is applied to arm
 counter traction is applied with sheet wrapped over shoulder
Kocher’s Maneuver
Traction
External rotation
Adduction
Internal rotation 14

15. Stimson Maneuver
Gravity method in prone position

Milch Maneuver
 Patient supine
steady downward traction applied at elbow
combined with slow
gradual external rotation and abduction of limb
15

16. Operative
Soft tissue interposition
Displaced greater tuberosity fracture > 5mm
Glenoid rim #> 5 mm in size
Glenoid labrum has been damaged or detached
16

17. Immobilization and Rehabilitation
 over 30 years of age, stiffness is more of a risk than recurrent dislocation so
movements are begun after 1 week.
under 30 years, recurrence is more of a risk and so the sling is retained for 3
weeks before mobilizing
Complications
Recurrent dislocation/instability (esp.in young/<25 y.o)
Neurovascular injury (axillary n, musculocutaneous n and axillary a)
Rotator cuff tear in older people
17

18. Posterior Shoulder Dislocation
 commonly missed
Rare than anterior shoulder dislocation
Mechanism
Direct Trauma
 Blow on the front of the shoulder
indirect trauma
 Electric shock
 convulsion
18

19.  History
Trauma/fall
Pain
Inability to move arm
Convulsion
 Neurovascular Examination
 Test axillary nerve function
 P/E
Shoulder internally rotated and
adduction
Palpable mass posterior to the
shoulder
Flattening of the anterior
shoulder
Tenderness
19

20. AP VIEW
Half Moon Sign Light bulb sign
20

21. Reduction technique
The arm is pulled and rotated laterally, while the head of the humerus is pushed forwards.
21

22. Immobilization and Rehabilitation
over 30 years of age, stiffness is more of a risk than recurrent dislocation so
movements are begun after 1 week.
under 30 years, recurrence is more of a risk and so the sling is retained for 3
weeks before mobilizing
22

23. Recurrent dislocation
Once a shoulder has been dislocated, this may happen repeatedly.
the capsule and labrum have usually been stripped from the margin of the
glenoid and the humeral head may be indented
In the vast majority of cases recurrence is anterior
23

24. History
Dislocation
the patient complains that the shoulder ‘slips out’
 when the arm is lifted into abduction and lateral rotation
Physical examination
The apprehension test is positive
 the shoulder is passively manipulated into abduction, extension and lateral rotation.
the patient tenses up and resists further movement
24

25. Imaging
AP x-ray
 MRI
25

26. Treatment
 Anterior dislocation some form of anterior capsular reconstruction is
usually successful
recurrent posterior dislocation
 is more difficult and may require soft-tissue reconstruction combined with a
bone operation to block abnormal movement at the back of the shoulder
26

27. Elbow Dislocation
The elbow is the second most commonly dislocated joint in adults.
 Acute dislocation of the elbow is almost always reducible by closed methods.
 most are stable after reduction.
 Open reduction may be required if fracture fragments in a fracture-dislocation block closed
reduction
Approximately 20% of dislocations are associated with fractures:
 “terrible triad”=elbow dx with radial head&coronoid fracture
Collateral ligaments &anterior capsule are typically torn
Mechanism
Usually a fall/RTA in elderly and young patient
27

28. History
Trauma/fall
Inability to move elbow
 Neurovascular Examination
P/E
Swelling
Deformity
Limited /no elbow ROM
Good neurovascular exam
28

29. Classification
By direction of forearm bones
Posterior-posterolateral(>80%)>posteromedial
Anterior (rare)
Medial
Lateral(rare)
Divergent(rare)
29

30. Radial Head Subluxation
Common in children age group(2-5 years)
Reduction
With thumb in antecubital space as a fulcrum
The forearm is supinated and flexed
30

31. Imaging
 XR
Elbow series
CT
To define associated fracture
31

32. Treatment
Acute-Closed reduction
Prone position
Only forearm hangs from the stretcher
Gentle downward traction
 Reduction of the olecranon with the opposite hand
32

33. Operative
ORIF(corocoid,radial head ,olecranon ),LCL repair,+/- MCL repair
Acute complex elbow dislocation
Persistent instability after reduction
Open reduction, capsular release, and dynamic hinged elbow fixator
Chronic dislocation
33

34. Immobilization
Stable
Splint in 90 degree of flexion for 7-10 day
Unstable
Splint for 2-3 week
Complications
Elbow stiffness and stability
Recurrent dislocation
Neurovascular injury (Median and ulnar nerves, brachial artery)
Secondary osteoarthritis
34

35. Hip Dislocation
The hip joint is inherently stable
 Orthopedic emergency risk of femoral head AVN increases with late/delayed reduction
Mechanism of Injury
High-energy trauma E.g. MVA, dashboard injury
 significant fall
 History
Trauma, severe pain, cannot move thigh/hip
35

36. Physical Examination
 Anterior Dislocation
Occurs with the hip in abduction and
external rotation
Characteristic position of affected limb.
 Hip flexed, thigh abducted and externally
rotated
 Posterior Dislocation
Most common (90%)
Axial load through flexed knee(dashboard
injury)
Femur adducted and internally rotated
 hip flexed
Associated with posterior wall acetabular
#,femoral head #,and sciatic nerve injury
36

37. Cont,,,,
Central Dislocation
This is the least common and difficult of all dislocation of the hip joint
Due to direct trauma to greater trochanter fracture of floor of acetabulum
Lateral force against adducted femur
Always fracture- dislocation
37

38.  XR:
AP pelvis, femur and knee series
CT: R/o fx or bony fragments/ loose bodies
post reduction
38

39. Treatment
Nonoperative
Emergent closed reduction within 6 hours for acute anterior and posterior
dislocations
Contraindicated in ipsilateral displaced or non –displaced femoral neck fracture
39

40. Operative
Open reduction
 removal of incarcerated fragments
 Irreducible dislocation
 Delayed presentation
ORIF for
 Acetabulum fracture
 Femora head and neck
40

41. Maneuver of Reduction
Allis maneuver for posterior Hip Dislocation
Patient supine on table, under anesthesia or sedation.
 Examiner applies firm distal traction at flexed knee to pull head into acetabulum
 slight rotary motion may also help
 Assistant fixes pelvis by pressing on anterior superior iliac spine
41

42. Allis Maneuver for Anterior Hip Dislocation Reduction
Anterior dislocations reduced using traction and counter-traction
Traction is applied in line with the femur with gentle flexion.
Along with a lateral push on the inner thigh
internal rotation and adduction are used to reduce the hip
42

43. Post-reduction Care
For simple dislocation
Within 6 hours a brief period of rest for several days to 2 weeks followed by
mobilization
After 6 hours since the rate of AVS is highest, it may be reasonable to delay full
weight bearing for 8 to 12 weeks
Most patients can achieve full weight bearing by 6 weeks
Dislocations with Associated Fractures
The rehabilitation for patients who had associated fractures fixed is determined by the
associated injury
 In the case of posterior wall acetabular fractures or femoral head fractures, active hip motion
may be deferred for approximately 6 weeks 43

44. Complications
Posttraumatic osteonecrosis (AVN) (reduced risk with early reduction)
5-40% incidence
Increased risk with increased time to reduction
 sciatic nerve injury (posterior dislocations)
8-20% incidence
femoral artery/nerve injury (anterior dislocations)
Post traumatic arthritis
Up to 20% for simple dislocation, markedly increased with complex dislocation
Recurrent dislocations
Less than 2 %
44

45. Precautions !!!!
1.Prohibit patients from crossing their
legs
2.Bending their hip a 90-degree angle
3.Twisting their hip inward
45

46. Knee Dislocation
Frank dislocation of Knee joint is a devastating injury with the potential for limb-threatening
complications
Many spontaneously reduce, must keep index of suspicion of suspicion for injury
Multiple ligaments and other soft tissue are disrupted
High incidence of associated fracture and neurovascular injury
46

47. Mechanism of Injury
High energy
From MVA,fall from a height or dashboard
Low energy
An athletic injury, routine walking
47

48. Presentation
Symptoms
History of trauma and deformity of the knee
Knee pain
Inability to bear weight
48

49. Physical Examination
Appearance
No obvious deformity 50% spontaneously reduce before arrival to ED
Signs of trauma(swelling, effusion, abrasions, ecchymosis)
+/- distal pulses/peroneal nerve function
‘’Dimple Sign’’-buttonholing of medical femoral condyle through the medical capsule
Vascular exam
To rule out vascular injury both before and after reduction
Serial examinations are mandatory
Palpate the dorsalis pedis&posterior tibial pulses
Neurologic exam
Sensory and motor function of peroneal and tibial nerve
49

50. Classification
Kennedy classification based on the direction of displacement of the tibia
Anterior (30-50%)
Most common
Due to hyperextension injury
Usually involves tear of PCL
The highest rate of peroneal nerve injury
Posterior( 30-40%)
2nd most common
Due to axial load to flexed knee(dashboard injury)
The highest rate of vascular injury (25 %)
Highest incidence of a complete tear of popliteal artery
50

51. Lateral(13%)
Due to a Varus or valgus force
Usually involves tears of both ACL&PCL
Medial (3%)
Varus or valgus force
Usually disrupted PLC and PCL
Rotational (4%)
Posterolateral is most common rotational dislocation
Usually irreducible
Buttonholing of femoral condyle through the capsule
51

52. Imaging
X-ray
Pre-reduction and post reduction (AP&Lt of the Knee)
 May be normal if spontaneous reduction
 Look for asymmetric or irregular joint space
 Look for avulsion Fxs(segond sign-lateral tibial condyle avulsion Fx)
CT Scan
Facture identified on post reduction x-ray
Findings
 Tibial eminence, tibial tubercle, and tibial plateau fractures may be seen
52

53. Cont,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MRI
Obtain MRI after acute reduction but prior to hardware placement
Required to evaluate soft tissue injury (ligaments, meniscus) and for surgical planning
53

54. Closed reduction technique
Anterior
 Traction and anterior translation of femur
Posterior
 Traction,extension,and anterior translation of the tibia
Medial/Lateral
 Traction and medial or lateral translation
Rotatory
 Axial limb traction and rotation in the opposite direction of deformity
54

55. External Fixation
Indications
 Vascular repair
 Open fracture-dislocation
 Compartment syndrome
 Polytrauma patient
Open reduction
Irreducible knee
Vascular injury
Open fracture-dislocation
Posterolateral dislocation
55

56. Early Ligamentous reconstruction (<3 week)
Acute reconstruction has been shown to lead to improved clinical and functional
outcomes
Complications
Vascular compromise 40-50% in anterior or posterior dislocations
Stiffness( arthrofibrosis ) most common complication (38 %)
Laxity and instability 37% of some instability,redislocation is uncommon
Peroneal nerve injury 25% occurrence of a peroneal nerve injury,50% recover partially
56

57. Subtalar Dislocation
Accounts for 1% of all dislocations
More common in young or middle-aged males
25% may be open especially in lateral dislocation
Mechanism
Typically result from a high energy Mechanism
 RTA
Fall from height
Athletics
57

58. Presentation
 Severe Pain
Gross deformity
Foot will be locked in supination with medial dislocation
 Known as ‘’ acquired clubfoot ‘’
Foot will be locked in supination with lateral dislocation
 Known as ‘’ acquired flatfoot’’
58

59. Anatomic Classification
Medical dislocation
Most common(65-80%)
Due to lateral malleolus acting as strong butrres,preventing dislocation
Foot become locked in supination
Reduction blocked by peroneal tendon and talonavicular capsule
Lateral dislocation
More likely to be open
Foot become locked in pronation
Associated with lateral process ,anterior calcaneus and fibula #
Reduction blocked by PT tendon ,FHL,FDL
59

60. Anterior dislocation
Rare
Posterior dislocation
Rare
Total dislocation(extruded talus )
Usually open
Talus is completely dislocated from ankle and subtalar and talovavicular joints
60

61. Imaging
X-ray of ankle(AP&Lt view )
CT scan of ankle
 Subtalar osteochondral fragment causing subluxation
61

62. Non operative
60-70 % cab be reduced by closed methods
 short leg cast non-weight bearing cast for 4-6 week
Traction counter traction
62

63. Operative reduction
Open dislocations
Failure of closed reduction
63

64. Post-Op care
If joint stable
 Place in short leg cast with non-weight bearing for 4-6 weeks
If joint remains unstable
 place temporary tranarticular pins or spanning external fixator
64

65. Complications
Stiffness
Most common complication
Post-traumatic arthritis
65

66. Typical deformities in dislocation
Shoulder- Abduction deformities
Elbow-Flexion deformities
HIP:
 Anterior :Flexion ,abduction and external rotation deformities .
 Posterior- Flexion ,adduction and internal rotation deformity
Knee- flexion deformity
Ankle- Varus deformity
66

67. Summery
Principles of dislocation Management
Aims Save life
Save limb
save the function
Assessment of condition of the patient for shock and other injuries
Assessment of local condition of injured limb (vascular injury, nerve)
Resuscitation, if needed
Safe transport, this help to minimize complication in injuries to spine
(All dislocations associated with fractures should be immobilized immediately)
67

68. Radiography of the part
Reduction of dislocation
Closed manipulation
Open
Immobilization
Re-radiography of the part
Early physiotherapy
For the preservation of the function of the limb
Rehabilitation
68

69. Ameseginalehu !
69

70. References
Apley &Solmon’s concise system of orthopaedic &truma -4th edition
Campbell’s Operative Orthopaedics-13th edition
Netter’s Concise Orthopedics anatomy -2nd edition
Othrobullets-Trauma -2021
Rockwood &Green’s fracture in Adults-8th edition
Internet
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