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JOINT INJURY DONNY BASTIAN BASICS Joint = junction between 2 or more bones Provide segmentation of human skeleton Allow varying degrees of motion 5 distinct types: - syndesmosis - synchondrosis - synostosis - symphysis - synovial...

JOINT INJURY DONNY BASTIAN BASICS Joint = junction between 2 or more bones Provide segmentation of human skeleton Allow varying degrees of motion 5 distinct types: - syndesmosis - synchondrosis - synostosis - symphysis - synovial joints SYNOVIAL JOINTS Joint with smooth, self lubricating, almost frictionless gliding Boundary lubrication by mucin (hyaluronate) in the synovial fluid Synovial membrane - Lines the entire joint, except articular surface - Secrete and absorb mucin (hyaluronate) - Rich of blood vessels, lymphatic vessels and nerve fiber - Synovial fluids: dual functions nourishing the joint surface lubricating  Articular cartilage = hyaline cartilage - Acts as cushion or shock absorber during impact loading - Varies in thickness - Lack of blood vessels, lymphatic vessels and nerve fiber - Has limited ability to heal/regenerate INJURY TO JOINTS Twisting or tilting forces that stretch the ligaments and capsule Greater force 🡪 ligaments tear, bone avulsion Articular cartilage may be damaged if the joint surfaces are compressed or if there is a fracture into the joint Forceful angulation will tear the ligaments rather than crush the bone In older people (porotic bone) the ligaments may hold and the bone on the opposite side of the joint is crushed instead In children there may be a fracture of the physis. LIGAMENTOUS SPRAIN - STRAIN - TEAR Sprain: painful twisting or pulling movement of a joint Strain: - more severe than a sprain, possibly tearing of some fibres - stable joint Complete tear - If the stretching or twisting force is severe enough - unstable joint Torn ligaments heal by weak fibrous scar tissue  Normal healing time of torn ligament varies example: Finger: 3 weeks, knee: 3 months Children heals faster Three degrees of joint instability: 1. Occult joint instability (apparent only when joint is stressed) 2. Subluxation Joint surface lost their normal relationship but still retain some contact 3. Dislocation (luxation) Complete loss of contact of joint surface When accompanied by intraarticular fracture 🡪 fracture-dislocation DIAGNOSIS OF JOINT INJURY A. HISTORY TAKING Chief complaints: pain, unable to move joint Patient usually feels the joint has gone out of place 🡪 proprioceptive sensations Trauma: sport injury, MVA Past incidents: recurrent/habitual Comorbids: epilepsy B. PHYSICAL EXAMINATION General state: Trauma protocol (ATLS) Generalized laxity Ehler-Danlos syndrome  Local state: LOOK: Deformity Swelling, bruising The limb is in a characteristic position Sulcus sign FEEL: vascular: pulse, CRT, O2 saturation nerve: numbness MOVE: unable to move affected joint Special tests for ligament injury: - Varus/valgus stress test: knee, elbow, ankle - Drawer test: knee, ankle - Wait until swelling and pain subside C. RADIOLOGICAL EXAMINATION X-ray: - Specific limb position 🡪 doesn’t need x-ray - AP and lateral view - Bony injury - Stress view - Pre and post reduction Ultrasound: operator dependent CT scan MRI: better modality for soft tissue diagnosis NOMENCLATURE 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 INCIDENCE  SHOULDER Sulcus sign  SHOULDER LUXATIO ERECTA  HIP Flexion, exorotation, abduction  HIP Flexion, endorotation, adduction TREATMENT OF JOINT INJURY A. LIGAMENTOUS INJURY (sprain, strain) Conservative treatment - Stable joint - NSAIDs - P.R.I.C.E until inflammatory phase end - Do no H.A.R.M - Physiotherapy after pain subsides maintain muscle strength better results in the strength of the healed ligament (less fibrosis) P.R.I.C.E. P = Protection: splint, functional brace, crutch R = Rest: light activity, keep the joint move I = Ice: cool pack C = Compression bandage E = Elevation Do no H.A.R.M H = Heating: swelling >> A = Alcohol R = Run: No sport, impact exercise (2-4 weeks) M = Massage Heparin gel/cream …?? MASSAG E  TREATMENT OF JOINT INJURY A. LIGAMENTOUS INJURY (sprain, strain) Operative treatment - Unstable joint - Bony avulsion - Chronic pain - High demand: athlete Primary repair/suture Reconstruction using graft Open surgery vs arthroscopy ORIF if bony avulsion B. Subluxation/Dislocation Treat as emergency Closed reduction - for most uncomplicated dislocation - may general anaesthetic and a muscle relaxant - gentle traction - countertraction  Closed reduction - DO NOT use excessive force - “Clunk” sound - Max. 2 attemps 🡪 if fail, then open reduction - Check neurovascular before and after reduction - Immobilize / Splint 2-3 weeks - Exercise after pain subsides  Open reduction Indication: - Failed closed reduction - Stable reduction can’t be maintained - Neurovascular compromise - Fracture-dislocation with large bony fragment COMPLICATIONS Neurovascular injury Infection (septic arthritis) after open injury or open reduction Avascular necrosis Joint stiffness Post traumatic arthritis Recurrent dislocation Habitual dislocation THANK YOU