Joints Dislocation PDF

# Joints dislocation ## By - Prof. Dr. Mohamed Abdelhamid ## Professor of Orthopedics and Traumatology ## Shoulder Dislocation - Pain is the main symptom for a shoulder dislocation ## Shoulder Anatomy - Greatest ROM - No inherent bony stability - Relies on soft tissues for stability - Many in...

# Joints dislocation ## By - Prof. Dr. Mohamed Abdelhamid ## Professor of Orthopedics and Traumatology ## Shoulder Dislocation - Pain is the main symptom for a shoulder dislocation ## Shoulder Anatomy - Greatest ROM - No inherent bony stability - Relies on soft tissues for stability - Many injuries involve soft tissues - Rotator cuff, labrum - Little glenoid bone stock ## Rotator Cuff - dynamic stabilizer - Passive muscle tension - Compression of articular surface ## Capsular & GHL - static stabilizer - Ligament tightening ## Classification ### TUBS - Traumatic aetiology - Unidirectional instability - Bankart lesion is the pathology - Surgery is required ### AMBRI - Atraumatic: minor trauma may be present - Multidirectional instability may be present - Bilateral: asymptomatic shoulder is also loose - Rehabilitation is the treatment of choice - Inferior capsular shift: surgery required if conservative measures fail ## Classification of Traumatic disloc. - Anterior - Posterior - Multidirectional ## Pathology - Follows traumatic anterior Dislocation - Glenoid labrum and capsule are avulsed anteriorly - Bankart Lesion - Capsule is stretched anteriorly - Indentation in the posterolateral humeral head ## What causes a dislocated shoulder? - Sports injuries - Accidents, including traffic accidents - Falling on your shoulder or outstretched arm - Seizures and electric shocks, which can cause muscle contractions that pull the arm out of place ## Risk factors - A previous shoulder dislocation - Incidence of 80-90% - High risk is found in athletes involved in sports such as football, rugby, hockey and skiing due to the frequent contact impacts, throwing activities and falls. - Congenital conditions causing loosening of the joints, such as Ehlers-Danlos Syndrome. - Weakness of the muscles around the shoulder and core muscles due to lack of training can predispose to a dislocation. - Incorrect posture and inadequate sporting technique. ## Dislocated shoulder signs and symptoms may include: - Severe shoulder pain - Swelling and bruising of the shoulder or upper arm - Numbness and/or weakness in the arm, neck, hand, or fingers - Trouble moving the arm - Feeling the arm to be out of place - Muscle spasms in your shoulder ## Clinical Picture - **Pain** - Holds injured limb with other hand close to trunk - The shoulder is abducted and the elbow is kept flexed. - Loss of the normal contour of the shoulder - Anterior bulge of head of humerus may be visible or palpable - Empty glenoid socket ## Radiology - X-ray of shoulder showing an arrow pointing at the humeral head - The humeral head is dislocated - The glenoid is clear ## MRI - Two MRI images of the shoulder are shown - One shows the intact rotator cuff. - The second shows the torn rotator cuff. ## Treatment - Nonoperative treatment - Surgical treatment - Rehabilitation ## Nonoperative treatment - Closed reduction is performed usually under anaesthesia in the Emergency Department. - It consists of manual reposition the humeral head in the glenoid. - This is followed by the immobilisation of the shoulder for approximately four weeks, aided by local treatment with ice and/or heat and non-steroidal antiinflammatory drugs (NSAIDs). - At a later stage physiotherapy is recommended. ## Manoeuvers - Traction-countertraction method - Hippocrates method - Stimpson’s technique - Kocher’s technique ## Surgical technique - Illustration of healthy ligament ## Rehabilitation - Physiotherapy is a key form of treatment following a shoulder dislocation whether or not surgery has occurred. - Strengthening the muscles around the shoulder. - Therapy also aims at restoring the range of motion of the shoulder following initial immobilisation. - Physiotherapy consists of a number of approaches: - Use of a sling - Massage - Joint mobilisation - Ice/heat treatment - Physical exercise (pendular movements) - Education in sport and daily activities - Ergonometric postural correction - Return to sport plan ## Prevention - Take care to avoid falls - Wear protective gear when you play contact sports - Exercise regularly to maintain strength and flexibility in your joints and muscles ## Reference - Grays Anatomy for Students 3rd Ed - Moore - Clinically Oriented Anatomy 7th Ed by allmedicalstuff.com - https://medlineplus.gov/dislocatedshoulder.htm - https://www.physio-pedia.com/Shoulder Dislocation - http://pathologies.lexmedicus.com.au/pathologies/shoulder-dislocation-and-luxation ## Dislocation of the elbow - **Posterior dislocation (most common)** - A combination of elbow hyperextension, valgus stress, arm abduction, and forearm supination. - **Anterior dislocation** - A direct force strikes the posterior forearm with the elbow in a flexed position. ## Closed reduction - Illustrations of two different methods of closed reduction ## Dislocations in the wrist - **Lunate dislocation:** - Can cause carpal tunnel syndrome - Usually needs open reduction - Rehabilitation to avoid hand stiffness ## SHOULDER DISLOCATION The shoulder is the most commonly dislocated joint. This is due to the shallowness of the glenoid socket, and the wide range of movement of the shoulder joint. ### Classification: 1. **Anterior Dislocation:** This is the most common type and it occurs as a result of a fall on the hand or an excessive abduction-external rotation. 2. **Posterior Dislocation:** This is a rare type. It occurs due to a marked adduction-internal rotations force. It occurs commonly during a fit of convulsion. 3. **Inferior Dislocation:** This is also a very rare type. ### CLINICAL PICTURE of anterior dislocation 1. Pain is severe. 2. The patient supports the arm with the other hand, and avoids any kind of movement of the arm. 3. Squaring of the shoulder owing to prominence of the acromion, a relative emptiness beneath the acromion posteriorly, and a palpable mass anteriorly. 4. Examine for neurovascular injury. The axillary nerve is the commonest to be injured. Look for contraction of the deltoid muscle when the patient is asked to abduct the shoulder. X-ray in antero-posterior, and axial views are necessary for diagnosis. ## Magnetic resonance imaging (MRI) may be used to identify tears of the rotator cuff, capsule, and glenoid labrum (Bankart's lesion). ## TREATMENT: ### Acute Dislocation: Closed reduction under general anesthesia is necessary. - **Kocher's manipulation:** Traction in abduction and external rotation is followed by adduction and internal rotation. The humeral head if felt slipping back to its normal position. The Ancient Egyptians practiced this technique 3000 years ago. - **Hippocratis' technique:** The surgeon places his bare foot across the axillary folds and onto the chest wall, with gentle internal and external rotation with axial traction on the affected upper extremity. The humeral heads slips back to its normal position. - After reduction the arm is rested on the chest and held there with adhesive strapping for 3 weeks. Thereafter active exercises for mobilisation of the shoulder are encouraged. ### Old Unreduced Dislocation: Closed reduction under general anesthesia should be tried for dislocations less than 6 weeks old. Thereafter, or if it fails, open reduction is indicated. ### Recurrent Dislocation: Surgical treatment is usually indicated. ## COMPLICATIONS: 1. Neurovascular injury of the axillary nerve and rarely the axillary artery. 2. Stiffness if mobilisation is neglected after 3 weeks. ## DISLOCATIONS OF THE ELBOW JOINT Elbow dislocation is a common injury in children and young adults. With the exception of the shoulder, the elbow is the most frequently dislocated joint in the body. ### ANATOMY: - The elbow is a modified hinge joint with a high degree of intrinsic stability owing to joint congruity, opposing tension of triceps and flexors, and ligamentous constraints. - The three separate articulations are: - Ulno-humeral (hinge). - Radio-humeral (rotation). - Proximal radio-ulnar (rotation). ### TYPES OF DISLOCATION: - The most frequent is posterior dislocation of both bones. Next in frequency is lateral dislocation, involving only the radial head. All other dislocations are rare. ### POSTERIOR DISLOCATIONS: *Mechanism of injury:* A fall on the out stretched hand. The force disrupts the medial and lateral collateral ligaments and the anterior capsule. The ulnar, radial and median nerves or the brachial blood vessels are rarely injured. The flexor muscles of the forearm may be extensively lacerate. ### DIAGNOSIS: - A) Clinical Features: There is severe pain, limitation of movements, swelling and ecchymosis. Normally, the tip of olecranon and the medial and lateral epicondyles form an isosceles triangle if the elbow is flexed to right angle. This relationship is disrupted in dislocations of the elbow, but not in supracondylar fractures. The head of the radius can also be palpated posterior to the lateral condyle. - B) Radiographic Evaluation: (Fig.40) to confirm the type of dislocation and any associated fractures fracture of the coronoid process; head of the radius or of the lateral condyle. ## TREATMENT: Urgent closed reduction under general anesthesia. Reduction is achieved by gradual gentle longitudinal traction with the elbow slightly flexed. The hand of the surgeon manipulates the upper radius and ulna and guides them into their normal position. ### AFTER CARE: - The elbow should be fixed at right angle flexion and the forearm in neutral position, in above elbow plaster cast for 3 weeks. Early active exercises should be started after that. - Passive motion, massage, forcible stretching and repeated manipulations should be avoided, to prevent myositis ossificans and elbow stiffness.