Diagnostic Approach and Principle of Management in Dislocation

DR. Hermawan N Rasyid, MD., PhD

Email: hermawan_nr@indo.net.id Department of Orthopaedic and Traumatology Faculty of Medicine Universitas Padjadjaran / Dr. Hasan Sadikin Hospital

JOINT INJURY
Joint injuries are commonly seen in the emergency Joint dissociations can be categorized into three groups depend on degree and type of joint involved

Dislocation Subluxation Diastasis: disruption of the interosseus membrane which is connecting the two joints
Simon R.., Koenigsknecht. Emergency Orthopedics. 1987

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

SUBLUXATION
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.

Simon R.., Koenigsknecht. Emergency Orthopedics. 1987

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

X-Ray Evaluation of Shoulder Problem

Recommended view
Trauma Series:
True Anteroposterior (AP) view in internal & extenal rotation Axillary view Scapular Y view

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

SHOULDER DISLOCATION

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

Trauma Mechanism
Cause: fall on the hand The humerus is driven forward, tearing the capsule or avulsing the glenoid labrum Feature:

The limb must always be tested for nerve & vessel injury.

Support the arm, Which is held abducted and appears too long. The contour is angular, due to prominent of the acromion process and flat of deltoid muscle. Shoulder motion is impossible.

Anterior Shoulder dislocation

Usually also inferior Bankarts Lesion

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

Clinical Picture

Loss of the contour of the shoulder may appear as a step Anterior bulge of head of humerus may be visible or palpable A gap can be palpated above the dislocated head of the humerus

X Ray anterior Dislocation of Shoulder

True AP view

Axillary view

Scapular Y view

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

Axillary Nerve Injury

Also called circumflex nerve It is a branch from posterior cord of Brachial plexus It hooks close round neck of humerus from posterior to anterior It pierces the deep surface of deltoid and supply it and the part of skin over it

Axillary nerve injury

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

Treatment

Reduce

Hold

Exercise

Methods of Reduction of anterior shoulder Dislocation

Hippocrates Method ( A form of anesthesia or pain abolishing is required )

Stimpsons technique ( some sedation and analgesia are used but No anesthesia is required ) Kochers technique is the method used in hospitals under general anesthesia and muscle relaxation

Hippocrates Method

Stimpsons technique

Kochers Technique

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

Ms. E (39 yo)

After reduction

Velpeau bandage

Mr. E (53 y.o)

ELBOW DISLOCATION

Trauma Mechanism
A Fall on the hand may dislocate the elbow. The forearm is push backwards. Feature:

The pts support the forearm with the other hand Deformity if very obvious The elbow is held immobile

Illustration
History: 21 YO fell from tree on his left arm 2 days ago and complains of pain, inability to move the elbow and has numbness in his little finger. Exam: Patients elbow is swollen, painful on movement with marked limitation of range of motion. Pulses normal but decreased sensation over the palmer aspect of the little finger and he can not spread his fingers.

Treatment
Under anaesthesia Pulls on the forearm while the elbow is slightly flexed

REDUCE
With one hand, sideways displacement is corrected, then the elbow is further flexed while the olecranon process is pushed forward with the thumbs.

HOLD

EXERCISE

Held in collar and cuff with the elbow flexed above 90 deg

Complication Early: Nerve injuries; Associated fracture (Radial head, Olecranon fx) Late: Myositis ossificans; Unreduced disloc, recurrent dislocation

HIP DISLOCATION

Trauma Mechanism
Posterior disloc is most common The bent leg is thrust backward, as when a car hits a tree and the passengers knee is struck by the dashboard. Feature:

Short leg and lies adducted, internally rotated and slighlty flexed. Femoral head is palpable in the buttock.

Mr. M (34 y-o)

HIP REDUCTION
Sedation Relaxation, flexion, traction, and rotation Gentle and atraumatic

Bigelow techique

Relocation should be palpable and permit significantly improved ROM. This often requires very deep sedation.

KNEE DISLOCATION

Trauma Mechanism
The knee can only be dislocated by considerable violence, as in road accident. The cruciate ligaments and one or both lateral ligaments are torn. Features:

Severe bruising, swelling and gross deformity. Circulation must be examined because the popliteal artery may b torn or obstructed. Distal snsation must be tested to excluded popliteal nerve injury.

Treatment:
Reduce Hold Exercise

Mr. A (65 yo)

PIPJ DISLOCATION

Hyper-extend the joint, apply traction then flex the joint. Follow with a post reduction x-ray, check for avulsion fracture.

CONCLUSION
Joint dislocation must be reduced immediately in order to prevent avascular necrosis especially for the hip. There are several techniques to reduce the dislocation but choose one that you are familiar with the technique.

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