Acute joint dislocation

Dislocation

• A complete disruption of a joint with no remaining

contact between the articulating surfaces

Subluxation

• A partial disruption of a joint with partial remaining , but

abnormal contact between the articulating surfaces
Anatomy of joint

1) Articular cartilage of bone ends

-smoothness of joint

1) Synovial membrane/ capsule

-synovial fluid for articular nutrition and
lubrication

2) Ligaments
-static stability

3) Tendons and muscles

-dynamic stability
 nereve

tendon

synovium
cartilage

ligament

muscle
 pathology of dislocation

1. Cartilage

• Metabolism of hyaline cartilage disrupted

• Degeneration over a brief period of time
• No regeneration for cartilage defect- filled with fibrosis
• Post-traumatic osteoarthritis
2. Synovial capsule

• Stretching, laceration
• Impaired function– lubrication, nutrition
• Tension– compromised vascularity to the joint, especially
in hip joint
• Haemarthrosis– chronic inflammation
3. Ligaments

• Strain, sprain, rupture

• Relatively avascular tissue- fibrosis
• Slow healing
• Static stability reduced- lead to instability
4. Tendons and muscles

• For dynamic stability

• Stretching, contusion, rupture
• Only partial recovery
• Healed by deep scarring
5. Periarticular fractures

• Avulsion, depression, comminuted fractures

• Intra-articular step-off
• Static stability
• Post-traumatic arthritis
• Instability
The process of healing

• Haematoma
• Acute inflammation
• Proliferation
• Remodeling
• Maturation
 Types of dislocation

1. Acute dislocation
Acute fracture dislocation
2. Open dislocation
3. Old unreduced dislocation- > 3 weeks
4. Recurrent dislocation
5. Habitual dislocation
6. Pathological dislocation
7. Congenital dislocation
 Diagnosis of dislocations

History

• Age
• Timing of injury
• Pain
• Swelling
• Deformity
• Disability
• Mechanism of injury-
high-energy trauma- RTA , fall from height, land slide
low-energy trauma- fall on the hand, blowing

• Neurological symptoms-
-tingling, numbness, weakness
• Distal vascular symptoms-
-pain, pallor
• Associated injuries-
other limbs, joints, head, chest, abdomen
Fall on the hands
Physical examination

• Characteristic deformity
- flexed, adducted and internally rotated hip
- hyperextension of finger joints
• Contour of the joint
- squaring of shoulder
• Distortion of the bony landmarks
- distorted triangle of elbow
Squaring of shoulder

Flexed, adducted, internally rotated hip

• Soft tissue and bony swelling
- bony swelling of radial head
- bony swelling of acromioclavicular joint
• Characteristic tests in each
- emptying sign in hip
- Dugas test in shoulder
• Painful limitation of movements of joints
• Shortening
• Distal neurovascular status
- sensory and motor deficit, color, temperature,
capillary refill

• Vital signs in multiple injured and high energy trauma

• Priority to the life threatening condition

Radiological studies

Radiograph

• To confirm diagnosis
• Proper views
• 2 views, 2 joints, 2 limbs
• See the articular and bony outlines
• Compare in 2 joints
• Direction of displacements
• Associated fractures
Computed tomography

• To assess the bony detail of the joint

• Useful in fracture-dislocations of large joints and spine
- hip, spine, sacroiliac joint
• Plan for treatment
• Conventional or 3 dimensional CT
Magnetic resonance imaging

• To assess the articular defect, damage

• To assess the marrow in hip
• To assess neurological structures in spine

Arthroscopy
Arteriogram
elbow dislocation
Shoulder dislocation
Bilateral hip dislocations

Avascular necrosis
 Treatment

• Orthopedic emergency
• Damage to the articular cartilage, joint capsule,
ligaments and vascularity of bones
• Post-traumatic arthritis
• Reduced as soon as possible
• In emergency room or theater
1. Closed reduction
2. Open reduction
3. Reconstruction- fracture-dislocation
4. Arthrodesis- young, active person
5. Arthroplasty- adult and old age
Closed reduction

• The first for most of uncomplicated cases

• Sedation, intravenous analgesia, general anesthetics
• Muscle relaxants
• Gentle manipulation with proper methods
• To obtain anatomical concentric reduction
• Image intensification aids in reduction
• No repeated manipulations- generally 2-3 times
• Excessive force- additional trauma, iatrogenic
fractures, nerve stretching
• Stability test after reduction
• Check neurological and vascular status before and
after reduction
• Always prepare for open reduction
Shoulder dislocation
Elbow dislocation
 Posterior Dislocation of the Elbow
Methods of Treatment -Closed Reduction
• After the initial examination of the
neurovascular function
• manipulation and reduction are performed
under anesthesia.
• All the methods employ some form of
distraction followed by anterior translation.
• The simplest reduction maneuver requires
gentle countertraction on the humerus by
an assistant
 methods of reduction Pusher Techniques.

The pushers apply a pushing force to the tip of

the olecranon with the thumbs.
the patient lies prone with the elbow flexed and
the forearm hanging over the side of the table
Puller Techniques. The pullers apply a
pulling force directly to the anterior aspect of
the proximal forearm with the elbow at 70°
to 80° of flexion
• surgeon applies distal traction on the
wrist and proximal forearm.
• Medial or lateral displacement is
corrected first, and then distal traction is
continued as the elbow is flexed.
• Downward pressure by the surgeon on
the proximal forearm to disengage the
coronoid from the olecranon fossa may
be helpful.
• Hyperextension should be avoided.
• After reduction, test the stability
 Examination of Stability
after Reduction

• Have patient range motion from full flexion

to extension and look for point of
subluxation or dislocation. Do this
passively if patient can’t cooperate.
• Varus and valgus instability should nearly
always be present do not help guide
treatment.
• Valgus stability reflects relative sparing of
medial structures.
• The x-rays must also be scrutinized
for associated fractures at
1. distal humerus,
2. radial head,
3. coronoid process.
• to admit the patient for 24 hours of
observation if there is any concern
about excessive swelling, vascular
injury, or the risk of compartment
syndrome.
 Simple Elbow Dislocation
Treatment
• No more than 2 weeks
of cast immobilization
• Early active use and
exercises
Hip dislocation
 Classical Appearance
Posterior Hip Dislocation
• Severe pain
• Flexion, internal rotation and
adduction
 Classical Appearance
Anterior Hip Dislocation
• Extreme external rotation,
• Mild flexion and abduction
Physical Examination
• Pain to palpation of hip.
• Pain with attempted motion
of hip.
• Possible neurological
impairment.

THOROUGH EXAM
ESSENTIAL
Radiographic Evaluation
X Ray Pelvic (AP)
• Should allow diagnosis and show
direction of dislocation.
– Femoral head
not centered in acetabulum.
– Femoral head appears
larger (anterior) or smaller (posterior).
• Shenton Line should be
smooth and continuous
Closed reduction
Preferred method
• Closed reduction with
general anaesthesia

• If not feasible,
– Reduction under conscious
sedation
 ALLIS METHOD
• Traction –
countertraction
• Flexion – 70 degree
• Gentle rotation and
slight adduction
• Lateral force to proximal
thigh
CLUNK
STIMSON GRAVITY TECHNIQUE

• Prone
• Affected leg – hanging
off
• Hip flexion - 90
• Knee flexion - 90
• Assistant – immobilize
pelvis
• Surgeon – applied
anteriorly directed
Whistler maneuver

Emergency orthopaedic, 5th edition

Reduced Hip
• Moves more freely
• Patient more comfortable

• Requires testing of stability

• Simply flexing hip to 900
does not sufficiently test
stability
 STABILITY TEST
• Hip flexed to 90o
• If hip remains stable, apply internal
rotation, adduction and posterior
force.
• The amount of flexion, adduction
and internal rotation that is
necessary to cause hip dislocation
should be documented.
• Caution!: Large posterior wall
fractures may make appreciation of
dislocation difficult.
• If hip stable after
reduction, and
reduction congruent.
• Maintain patient comfort.
• ROM precautions (No
Adduction, Internal Rotation).
• No flexion > 60o.
• Early mobilization.
• Touch down weight-bearing for
4-6 weeks.
• Repeat x-rays before allowing
weight-bearing.
ANTERIOR DISLOCATION OF HIP
• Anterior dislocations of the hip are uncommon
and, constitute only 12% of traumatic hip
dislocations
• Anterior dislocations are classified according to
the position assumed by the femoral head:
pubic, obturator, or perineal
• Because of their anterior relationship to the hip,
the femoral vessels and nerve may be injured,
especially with pubic dislocations
• An anterior dislocation usually can be
reduced without surgery
• the dislocation cannot be reduced by
these maneuvers, open reduction is
performed through a Smith-Petersen
approach
 Treatment after reduction
• Temporary period of traction until pain has
subsided
• Extremes of motion should be avoided 4 –
6 weeks to allow capsular and soft tissue
healing
Knee dislocation
Knee dislocation
 Treatment – Closed Reduction
• Should be done EMERGENTLY/URGENTLY with
sufficient muscle relaxation (Don’t apply aggressive
force!)

• Closed Reduction
• In the field
• In ED
• Under general anesthesia if not reducible with
conscious sedation (Rare as the bony anatomy of
the knee is not constrained)

• Direct force against Popliteal fossa &

hyperextension should be AVOIDED
 Closed Reduction Maneuver
POSITION of DISLOCATION
(Tibia relative to Femur)

•Anterior
• Traction & elevation of distal femur
•Posterior
• Traction & extension of proximal tibia
•Lateral / Medial
• Traction & correctional translation
•Rotational
• Traction & correctional derotation
 General Principle
Open reduction for dislocation

Indications

1. No anatomical, concentric reduction obtained

- interposition of soft tissues
2. Stable reduction not obtained- associated
3. Complete nerve injury after reduction
4. Distal circulatory impairment (persistent ischemia) before
and after reduction
Procedure

• Approach to the joint

• Check articular surfaces
• Removal of interposed tissues or osteochondral
fragments
• Restoration of articular congruency
• Maintenance of reduction- POP or fixation
• Reconstruction of joint
• Exploration and repair of vessels and nerves if indicated
 Rehabilitation

• To avoid inevitable stiffness

• Aim for normal, painless, stable joint

Immobilization of the joint

- functional position
- usually, 3 weeks
- splint, cast, brace, traction
- rest for healing of the tissues
- relief of pain
Programmed exercises
- active exercises of distal and proximal joints during
immobilization
- control active, strength and stretch exercise of
affected joint after immobilization

Weight bearing program

- for lower limb joint dislocation
- normal, painless, stable gait
 Complications

1. Vascular injury
• Spasm, laceration, rupture
• e.g. popliteal artery injury in knee dislocation
• Arteriogram
• Exploration

2. nerve injury
• Stretching, contusion or rupture
• Usually neuraprexia
• E.g. Sciatic nerve injury in hip, axillary nerve in
shoulder
• Exploration
3. Skin loss
• In subcutaneous joint, e.g. knee ankle
• Skin laceration, tension and ischemia

4. Ligamentus injuries
5. Periarticular fractures
6. Infection
7. Avascular necrosis
 8. Joint stiffness
9. Recurrent dislocation
10. Post-traumatic arthritis
11. Ectopic ossification (myositis ossificans)
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