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Traumatic Dislocation

and common soft


tissue injury
Khor Shu Lin
Maya Athirah
Phang Chin Tong

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.

In congenital dislocation of the hip,


the socket part of the joint, the
acetabulum, loses the mechanical
stimulus for normal growth and
development because the ball part of
the joint, the head of the femur, does
not rest in the joint.
The acetabulum and a large part of
the pelvis develop poorly or not at all,
whereas the femoral head, if it makes
contact higher up on the pelvis, may

Symptoms of dislocation include pain and tenderness


at the site, a sensation of grating or grinding on
attempting to use the part, and inability to use the
part.
Common signs are deformed appearance of the joint,
swelling of surrounding tissue, and discoloration of
the overlying skin.
X-ray examination is useful to indicate the extent of
the injury.
Simple dislocations are treated by returning the
bones to their normal position (reduction) by
manipulation or occasionally by traction.
The joint is then kept immobile until healing is
complete.
Recurrent and congenital dislocations are special
problems that usually require surgical reconstruction
of 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

(i) Acute dislocation


The traumatic dislocation commonly occur in the
shoulder, elbow and hip. The acute dislocation are
further classified according to the direction of
dislocation of the distal bone in relation to the
proximal, e.g. Anterior, posterior
Clinically the acute traumatic dislocation is
diagnosed by the history and findings. There is
acute pain and swelling around the joint. There is
gross deformity at the joint and the bony
landmarks are distorted.

The clinical signs common to all dislocation fall


into two groups:-

The signs denoting the


absence of the articular
end of a bone from its
normal anatomical
position.
Signs denoting the
presence of the
displaced end of the
bone in an abnormal
position

One should look for associated nerve


and vascular injuries. Radiograph
confirm the diagnosis and detect
associated fractures
Management: Acute dislocation of a
joint is an orthopaedic emergency and it
requires immediate reduction under
anaesthasiae. After redction the part
should be immobalized till the soft
tissues like the capsule and ligaments
heal. After about 3-4 weeks the joint is
mobilie=sed by exercise therapy.

(ii) Old Unreduced Dislocation


Patients with unreduced dislocation presents
themselves for treatment weeks to months after
the primary dislocation.
These are difficult problems and need prolonged
treatment.
Treatment: Closed reduction under anaesthesiae
is attempted in cases presenting within 4 weeks.
This should not be done in dislocation more than
6-8 weekss old as there is danger of fracture
during the manipulation. Surgical reduction is
indicated in such cases

(iii) Recurrent Dislocation


When a traumatic dislocation of a joint is followed
by subsequent frequent dislocations by minimal
trauma, it is called recurrent dislocation.
This is particularly common in the shoulder and
patellofemoral joint

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

This is common in: ~ Tuberculosis of the hip when there is a travelling


acetabulum
~ Septic arthritis of the hip of infancy where there is total
destruction of the head of femur

The head of the femur gets dislocated when the joint


capsule is rapidly distended by an effusion of synovial fluid
or pus

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

Painful at the joint and patient tries to avoid


moving it.
Shape of joint is abnormal
Bony landmark is displaced
Characteristic position:
Shoulder- abduction deformities
Elbow- flexion deformities
Hip: Anterior- flexion abduction and internal rotation deformities.
Posterior-flexion, adduction and internal rotation deformity

Knee-flexion deformity
Ankle-varus deformity

Movement is painful and restricted


Apprehension test +ve

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.

Acute: Injury to peripheral nerve and vessels


Chronic: Unreduced dislocation
Recurrent dislocation
Traumatic osteoarthritis
Joint stiffness
Avascular necrosis
Myositis ossificans

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

Subcoracoid (most common)


Subglenoid
Subclavicle
Intrathoracic

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

EAM : Traction, External rotation, Adduction, Medial Rotatio

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

Operative (open reduction)


Indication :

Failed closed reduction


Soft tissue interposition
Greater tuberosity fracture
Displacement >1cm after reduction
Large glenoid rim fracture

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

Posterior Shoulder Dislocation


Mechanism of injury
Direct : direct blow from anterior aspect of shoulder
Indirect** : fall on internally rotated, adducted and
flexed hand

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

Radial Head Fractureeasy to feel at lateral epicondyle


Hand should be examined for signs of neurovascular
damage

Xray
Essential to confirm the presence of a dislocation and to
identify any associated fractures
Note radial head avulsion fracture

Treatment of acute dislocations


Non-operative
reduction and splinting at 90 for 7-10 days followed by
early therapy
Indications : simple stable dislocations
early therapy
supervised (therapist) active and active assist range-ofmotion exercisesafter 1 to 2 weeks
initial range of motion is the stable arc found on
postreduction examination

rehabilitation
proceed with light duty use 2 weeks from injury

reduction splinting in hinged brace at 90 for 2-3 weeks


Indications : simple unstable elbow dislocations
(dislocations with extension)
early range of motion exercises with arm in pronation

Post reduction
Immobilize elbow in molded posterior plaster splint
Splint elbow at 90 degrees flexion (Allows ligament and
capsular healing)
Splint for 3 weeks

Gentle Range of motion afterSplinting


Never force range of motion (worsens injury)
Temporary stiffness is common

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

Treatment for chronic dislocation


Operative
open reduction, capsular release, and dynamic hinged
elbow fixator
Indications : hinged external fixator indicated in chronic
dislocation to protects the reconstruction and allows early
range of motion, but it does not maintain the reduction
approach
posterior utility approach used
technique
concomitantradial head fracture
fix first
ORIF for radial head that can be reconstructed
radial head arthroplastyis indicated for a radial head
fracture that cannot be reconstructed

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 -

depend upon relationship


between femoral head and acetabulum

Posterior
Anterior
Central
Dislocation Dislocation Comminuted
70%

10-15%

/ displaced
farcture of
acetabulum

Posterior Hip DislocationAnterior Hip DislocationCentral Hip Dislocation

Posterior Hip Dislocation


Causes
Car dashboard injury
Fall off weight on back of a stooping miner

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

simple dislocation, with the femoral head lyin


above and behind the acetabulum.

Another patient with


dislocation and an
associated acetabular rim
fracture

Management
Conservative (closed reduction / manipulation under GA)
Classical Watson Jones Method

Bigelows method

Stimsons gravity
method

After treatment, the limb is immobilized in a Thomas


splint for 3 weeks in the position of abduction

Operative (open reduction)


Indications
Failure of closed reduction due to obstruction by bony
fragments or soft tissues; locking fracture fragments;
button holing of femoral head through the capsule
Intra-articular loose fragment not allowing concentrix
reduction
Instability after reduction
Sciatic nerve palsy

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

Vascular injury (superior gluteal artery)


Associated fractured femoral shaft
Late
Avascular necrosis of femoral head (15-20%)
Myositis ossificans
Stiffness
Unreduced dislocation
Secondary osteoarthritis

Anterior Hip Dislocation


Mechanism of injury
Dashboard injury with thigh abducted and external
rotated
Fall from height
Blow to back in squatted position
Causes the neck to impinge on acetabular rim and lever
the femoral head out in front of its socket.
Femoral head will then lie superiorly (type I : pubic) or
inferiorly (type II : obturator)

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

Neurovascular injury (femoral artery, nerve or evein)


Irreducible dislocation
Post traumatic OA
Aseptic necrosis
Reccurent dislocation

Central Hip Dislocation


Mechanism of injury
A fall on the side, or a blow over the greater trochanter,
may force the femoral head medially through the floor of
the acetabulum

It is really a fracture of the acetabulum

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 pulses are present and normal


does not indicate absence of arterial injury
collateral circulation can mask a complete politeal artery
occlusion

measure Ankle-Brachial Index (ABI)


if ABI >0.9
then monitor with serial examination (100% Negative Predictive
Value)

if ABI <0.9
perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery

If pulses are absent or diminished


confirm that the knee joint is reduced or perform
immediate reduction and reassessment
immediate surgical explorationif pulses are still absent
following reduction
ischemia time>8 hourshas amputation rates as high as
86%

if pulses present after reduction then measure ABI then


consider observation vs. angiography

Special test for ligament instability

Investigations

X-ray (AP & lateral view)


Arteriogram
MRI (ligament injuries)
The extent and location of ligament disruption, meniscal tears, and subtle
injuries to the bone, as well as which tears are repairable.

Knee arthroscopy is contraindicated within 2 weeks of


knee dislocations

capsular tears cause fluid extravasations into the leg incompartment


syndrome

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

Operative ( emergent surgical intervention )


indications

vascular injury repair (takes precedence)


open fracture and open dislocation
irreducible dislocation
compartment syndrome

delayedligamentous reconstruction/repair
indications
generally instability will require some kind of ligamentous
repair or fixation

patients can be placed in a knee immobilizer for 6


weeks for initial stabilization
improved outcomes with early treatment(within 3
weeks)
technique
PLC ( recommend early reconstitution )
PCL ( reconstruct prior to ACL reconstruction )

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

Pivot Shift Test


knee fully extended
whilst maintaining
a valgus force, and
the knee is then
gradually flexed, a
palpable reduction
of this subluxation
is felt at 2030
degrees.

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

Palpable gap at the site


of rupture

Bruising comes out a


day or two later.

Sign
s

Calf squeeze test (Thompsons


or Simmonds test)
With the patient prone, if the calf is squeezed

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

Tear of soleus muscle

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.

Ruptures that present


late
reconstruction using
local tendon
substitutes (e.g. flexor
hallucis longus tendon)
or strips of fascia lata

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