Post on 12-Aug-2020
SPONSORED
BY
Ehlers-Danlos Society Learning Conference,
December 2018
SPONSORED
BY
Ehlers-Danlos Society Learning Conference,
December 2018
Managing Dislocations
2018 SYDNEY PATIENT DAY
Dr Helen Cohen
Consultant – Rheumatology & Chronic Pain
Royal National Orthopaedic Hospital, UK
http://www.kongyuensing.com/pic/20100705left_hip_dislocation_rabbit_5months_sling_leg_method_toapayohvets_singapore.jpg. Accessed Nov 2018.
Accidents do happen
https://symmetry.physio/blog/Shoulder%20dislocation.jpg. Accessed Nov 2018.
AFP:Getty Imageshttps://i.dailymail.co.uk/i/pix/2016/08/20/15/37181E9300000578-3750383-image-a-18_1471704913914.jpg. Accessed Nov 2018.
Clive Brunskill / Getty Images http://media.coreperformance.com/images/411*308/dislocated-finger2.jpg.. Accessed Nov 2108.
And then there is hypermobility
https://i1.wp.com/media.boingboing.net/wp-content/uploads/2016/08/14089010_1251748584849583_4223014777537261544_n-600x600.jpg?resize=600%2C600. Accessed Nov 2018.
https://mediadrumworld.com/wp-content/uploads/2018/02/MDRUM_Crazy_Contortion-14.jpg. Accessed Nov 2018.
Gokulacandra YouTube Channel https://cdn.doyouyoga.com/wp/2017/01/frog-pose-feet-touching-ground.jpg. Accessed Nov 2018.
Pain and the joints
• In hypermobility
– The joints are bendy
– The ‘proprioception’ (knowing where the joint is in space) is often poor
– The ligaments and tendons are not as supportive
– Some people may have recurrent subluxations & dislocations
http://www.pgwip.org.uk/a-trump-card-for-joint-pain/.Accessed Nov2018.
Pain and the muscles
• Muscle fitness and tone is very important
– Muscle fitness and tone helps to support joints and
compensate for the ligaments & tendons
– Pain often causes less use, so muscles get weaker
– Muscles can be very irritable
– Deconditioning makes the instability worse
– ‘Muscle patterning’ can cause dislocations/subluxations
Muscle coordination
• Around a normal joint – Muscles work together in a smooth coordinated
activity pattern – Some switch on, others relax – Muscle groups cooperate and do not tussle with
each other
https://cdn.80000hours.org/wp-content/uploads/2016/02/Screen-Shot-2016-02-09-at-12.26.20-AM-1024x532.png. Accessed Nov 2018.
Muscle patterning
• Around the hypermobile joint with muscle patterning – Some muscles are over active
– Other muscles are not activating
– The usual smooth coordination between muscles is not working
– This abnormal pattern of muscle activity can pull the joint out of place
Universal. https://cdn.vox-cdn.com/thumbor/-uurDXFMdfxBroh8dKnMLd-EupM=/0x0:1396x606/920x0/filters:focal(0x0:1396x606):format(webp):no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/3859170/manyminions.jpg. Accessed Nov 2018.
Pain and subluxations/dislocations
• ‘Acute’ pain as well as chronic pain
• Joints come out easily; can go in easily
• Muscle spasm will cause pain and prevent relocation
• Stress, panic, anxiety will make spasm much worse – vicious cycle
https://ohmygodlife.com/wp-content/uploads/2017/03/vicious-cycle-1024x764.png. Accessed Nov 2018.
Dislocations/subluxations • Many perceived ‘dislocations’ are subluxations
• You have nosy joints that clunk, click, snap, pop etc
• Not every clunk/snap/pop is a dislocation; most are not
• Do not be afraid of your noisy joints
• Self-management is key
• Common joints: shoulders, hips, knees (patella)
• Hips – exceedingly rare that hips dislocate – More often snapping hip and subluxation
Recurrent dislocators
• Role of muscle patterning particularly in shoulder, hip
• Muscle patterning is the major driver
• Surgery cannot overcome muscle patterning
• RECOGNISE & TREAT EARLY
• Develop a dislocation plan
• Usually does not require aggressive manipulation
• Learn triggers
• Frequent visits to A&E is NOT the answer
• Pain and panic causes
– More stress
– Muscle spasms – pull the joint out of place
– More pain
– Less chance of resolving the dislocation
Dislocation: the pain-stress-panic vicious
cycle
https://images-na.ssl-images-amazon.com/images/I/51ab9y0GviL._SS500.jpg. Accessed Nov 2018.
The Dislocation Plan
The Times; cartoon. http://morlandcartoon.co.uk/wp-content/uploads/2015/03/Boris-Wrestle.jpg. Accessed Nov 2018.
Dislocation plan
• DO NOT PANIC • It is painful, unpleasant, inconvenient, can be
frightening but is NOT life-threatening and usually does NOT cause severe damage
• Support the joint in a comfortable position • Breath normally • Take your pain killers • Relax • Heat; distraction; massage
http://chestofbooks.com/health/general/domestic-hygiene-rational-medicine/Dislocation-of-the-Shoulder.html
Dislocation plan
• Give it time
• When relaxed, use your usual technique
• Treat as any other acute musculoskeletal injury – Rest, ice, compression, elevation
• Caution next 2-3 days
• AVOID prolonged immobilisation
• Careful use of splints, supports
What if it won’t go back?
• Give it more time and revisit your dislocation plan
• Are you as comfortable and relaxed as you can be?
• Is there something someone else can help with?
• Have you used your back-up plan medication?
• If the limb goes cold, discoloured, very numb – may need A&E
https://images-na.ssl-images-amazon.com/images/I/41FxHHkNdjL.jpg. Accessed Nov 2018.
If you have to go to A&E
• Do they know you have hypermobility?
• Had it gone back by the time you got there?
• If you are a regular visitor – have you got an A&E plan?
• Don’t need an xray
• Minimal medication
• Caution ! – Opiates !; Fentanyl lozenges; buccal fentanyl – highly addictive and NOT
appropriate for this
– Gas & air (nitrous oxide) – can also be addictive; if used a lot, can decrease B12
• If you are a regular visitor – you need advice and a good self-managed dislocation plan!
Orthopaedics and atraumatic shoulder instability
• Is the anatomy normal?
• Is the capsule loose?
• Rotator cuff muscles & tendons
• Glenohumeral ligaments
• Is there muscle patterning?
• The Stanmore Triangle
TYPE I Traumatic structural • significant trauma • often a Bankart’s defect • usually unilateral • no abnormal muscle patterning, (ie: your classic sporting injury) TYPE II Atraumatic structural • no trauma • structural damage to the articular surfaces • capsular dysfunction • no abnormal muscle patterning • not uncommonly bilateral, (ie the classic recurrent dislocators when doing normal or sporting activities); congenital or acquired TYPE III Habitual non-structural (muscle patterning) • no trauma • no structural damage to the articular surfaces • capsular dysfunction • abnormal muscle patterning • often bilateral, (ie more complex shoulder with multiple factors)
https://thesports.physio/2013/05/12/shoulder-instability-an-introduction/.
The unstable joint
• Optimise non-surgical treatments
• Surgery to ‘fix’ an unstable joint rarely works
• Surgery should be approached with extreme caution
• High failure rate
• Problems if muscle patterning is not addressed
• What is potential for being worse off?
• Extreme caution with fusing joints – upstream & downstream compensation
• Most hypermobile recurrent dislocators are type II/III
• Surgery is very rarely the answer • Its all physio and getting the muscles working
properly
https://thesports.physio/2013/05/12/shoulder-instability-an-introduction/. Accessed Nov2018.
Dislocation Plan