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Traumatic Dislocation
and common softtissue injury
Khor Shu Lin
Maya Athirah
Phang Chin Tong
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Dislocation
• Defned as total or complete loss o contact orcongruity o articular suraces o joint
• The most common ones involve a fnger thum!shoulder or hip
• Less common are those o the mandi!le el!o" or#nee$
• Symptoms include loss o motion temporaryparalysis o the joint pain s"elling and sometimes
shoc#$• Dislocations are usually caused !y a !lo" or all
although unusual physical e%ort may also cause one
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Sublaxation
• Defned as an incomplete joint dislocation "ithparts o the articular suraces remaining incontact "ith either a gradual displacement or
partial dislocation "ithin a joint
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Classication of dislocation
Congenital Traumatic
Pathological Paralytic
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Congenital Dislocation
• A congenital dislocation is present at !irth as theresult o deective ormation o the joint$
• A recurrent or ha!itual dislocation &repeateddislocation o the same joint' may !e the result oimproper healing o an old injury or may !enatural as in (dou!le joints) common in fngersand toes "hich are the result o looseligamentation$
• A pathological dislocation occurs as the result o adisease such as Maran*s syndrome "hich"ea#ens the capsule and ligaments a!out the joint$
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• +n congenital dislocation o the hipthe soc#et part o the joint theaceta!ulum loses the mechanicalstimulus or normal gro"th and
development !ecause the !all part othe joint the head o the emur doesnot rest in the joint$
• The aceta!ulum and a large part othe pelvis develop poorly or not at all"hereas the emoral head i it ma#es
contact higher up on the pelvis may
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Traumatic Dislocation
• This usually ollo"s a serious violence$ Theollo"ing are the clinical types o dislocation1-
&i' AcuteDislocation
&ii' 2ld unreduced
dislocation&iii' /ecurrent
dislocation
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(i) Acute dislocation
• The traumatic dislocation commonly occur in theshoulder el!o" and hip$ The acute dislocation areurther classifed according to the direction odislocation o the distal !one in relation to the
pro.imal e$g$ Anterior posterior
• Clinically the acute traumatic dislocation isdiagnosed !y the history and fndings$ There isacute pain and s"elling around the joint$ There is
gross deormity at the joint and the !onylandmar#s are distorted$
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• 2ne should loo# or associated nerve
and vascular injuries$ /adiographconfrm the diagnosis and detectassociated ractures
•Management1 Acute dislocation o a joint is an orthopaedic emergency and itre0uires immediate reduction underanaesthasiae$ Ater redction the part
should !e immo!ali5ed till the sottissues li#e the capsule and ligamentsheal$ Ater a!out 6-7 "ee#s the joint ismo!ilie8sed !y e.ercise therapy$
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(ii) Old Unreduced Dislocation
• Patients "ith unreduced dislocation presentsthemselves or treatment "ee#s to months aterthe primary dislocation$
• These are di9cult pro!lems and need prolongedtreatment$
• Treatment1 Closed reduction under anaesthesiaeis attempted in cases presenting "ithin 7 "ee#s$
This should not !e done in dislocation more than
:-; "ee#ss old as there is danger o ractureduring the manipulation$ Surgical reduction isindicated in such cases
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(iii) Recurrent Dislocation
•
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at!ological Dislocation
• This is caused !y some diseases process and iscommon in the hip joint$ This occur "hen there isdestruction o the head o the emur or e.cessive
distention o the joint capsule• +t can !e divided into destructive and distensive
dislocation
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at!ological Dislocation
Destructive
dislocatio
n
• This is common in1-• = Tu!erculosis o the hip "hen there is a travelling
aceta!ulum• = Septic arthritis o the hip o inancy "here there is total
destruction o the head o emur
Distensiv
edislocation
• The head o the emur gets dislocated "hen the jointcapsule is rapidly distended !y an e%usion o synovial >uidor pus
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aralytic Dislocation
• This occurs "hen there is mar#ed im!alance omuscle po"er
• +t can occur in the hip "henever there is anoveraction o the hip >e.or s and adductors in
certain paralytic conditions• This is al"ays a posterior dislocation
• +n poliomyelitis "hen the hip e.tensors anda!dictors are paralysed the normal adductors and
>e.ors overact and cause dislocation• +n cere!ral palsy the spasm o the adductors and
>oe.ors cause the deslocation
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Clinical features ofDislocation
• Painul at the joint and patient tries to avoidmoving it$
• Shape o joint is a!normal
• ?ony landmar# is displaced
• Characteristic position1Shoulder- a!duction deormities
@l!o"- >e.ion deormities
ip1 Anterior- >e.ion a!duction and internal rotation deormities$Posterior->e.ion adduction and internal rotation deormity
Knee->e.ion deormity
An#le-varus deormity
• Movement is painul and restricted
• Apprehension test Bve
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Recurrent dislocation• Ligaments and joint margin are damaged
repeated dislocation may occur$
• This is seen especially in the shoulder and thepatellaemoral joint$
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"abitual (#oluntary)dislocation
• Some pt ac0uired #nac# o dislocating &orsu!lu.ating' the joint !y voluntary musclecontraction
• Ligamentous la.ity may cause dislocation easier!ut the ha!it oten !etrays a manipulative andneurotic personality
• +t is important to recogni5e this !ecause patientsare seldom helped !y operation
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$n%estigation
• /adiograph o the a%ected part should includeanterior posterior and lateral vie"s andsometimes special vie"s needed$
• CT Scan
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Treatment
• +t is an orthopedic emergency$• /eduction should !e 0uic# and prompt$
• /eduction should al"ays !e under eneralanaesthesia or sedation$
• oint is rested or immo!ili5ed until sot tissuehealing occur ater 6-7 "ee#s
• Physiotherapy
• + ligaments are torn they may have to !e
repaired
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Com&lication
3$ Acute1 +njury to peripheral nerve and vessels
4$ Chronic1 Enreduced dislocation
/ecurrent dislocation
Traumatic osteoarthritis oint sti%ness
Avascular necrosis
Myositis ossifcans
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?y Maya Athirah Fahaya
Dislocation Of S!oulder
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Anatomy
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$ntroduction
• 2 the large joints shoulder is the one that mostcommonly dislocates$ This is due to• Shallo"ness o the glenoid soc#et
• @.traordinary range o movement
• Enderlying condition such as ligamentous la.ity or glenoiddysplasia
• Sheer vulnera!ility o the joint during stressul activities othe upper lim!$
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Classication
Anterior
Dislocation• GHI• ead o humerus
comes out oglenoid cavity
and liesanteriorly$
osterior
Dislocation• HI• ead o humerus
come to lieposteriorly
!ehind theglenoid
'uxatio
recta• ead o humerus
come to lie insu!glenoidposition
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Anterior Dislocation ofS!oulder
• 7 su!types• Su!coracoid &most common'
• Su!glenoid
• Su!clavicle
• +ntrathoracic
• Mechanism o injury• Direct 1 !lo" &most common' rom posterior aspect o the
shoulder pushing head o humerus out o the glenoidcavity
• +ndirect 1 all on outstretched &e.tended' hand "ithshoulder a!ducted and e.ternally rotated$
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• Pathological Changes• ?an#art*s Lesion
• Jlenoid la!rum
• Dislocation causes
stripping o the glenoidla!rum along "ithperiosteum romanterior surace oglenoid and scapular
nec#• ead thus comes to lie
in ront o the scapularnec# in the pouchthere!y created$
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• ill-Sach*s Lesion
• umeral head
• Depression on humeral head in its posterolateral0uadrant caused !y impingement !y the anterioredges o the glenoid on head as its dislocates
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• Clinical eatures• ho all on outstretched hand
• Severe pain arm held ina!duction and e.ternal
rotation• Lost o normal round contour
shape o the a%ected shoulder joint
• Posterior aspect o the a%ected
shoulder is >at• Anterior aspect sho"s ullness
!elo" the clavicle due todisplaced head and can elt !yrotating the arm
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• Apprehension test
• Dugar test
• amilton ruler test
• /egiment !adge test
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• +nvestigations• /adiological e.amination o the shoulder & AP vie"
a.illary vie"'
• Arthrography
• CT scan M/+• Treatment
• Conservative
• /eduction under sedation JA ollo"ed !yimmo!ili5ation o the shoulder in chest arm !andageor 6 "ee#s
• Kocher*s Maneuver
• ippocrates Maneuver
• Stimson*s gravity method
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A 1 Traction .ternal rotation Adduction edial /otati
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• Post reduction• ,-ray to confrm reduction and e.clude racture
• Ater patient ully a"a#e active a!duction is gently testedto e.clude a.illary nerve injury
• /est the arm on sling or 3-4 "ee# and ater that active
movement should !egin$ A!duction and lateral rotationmust !e avoided or at least 6 "ee#s
• 2perative &open reduction'
• +ndication 1
• ailed closed reduction
• Sot tissue interposition• Jreater tu!erosity racture
• Displacement 3cm ater reduction
• Large glenoid rim racture
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• Complication• A.illary nerve injury resulting paralysis o the deltoid and
small areas o anaesthesia over lateral aspect o theshoulder
• /otator cu% tear• Nascular injury &a.illary artery'
• racture dislocation
• /ecurrent dislocation
• Enreduced dislocation
• Traumatic osteoarthritis
• Shoulder sti%ness
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osterior S!oulder Dislocation
• Mechanism o injury• Direct 1 direct !lo" rom anterior aspect o shoulder
• +ndirectOO 1 all on internally rotated adducted and>e.ed hand
• Clinical eatures• Severe pain arm held in a!duction and internal
rotation
• A!duction is restricted
• Loss o normal round contour shape o a%ected
shoulder joint
• ullness in posterior aspect o the a%ected shoulder
• lat anterior aspect
• Prominent coracoid process
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• +nvestigation• /adiological e.amination
• Light !ul! sign
• +nternal rotation o humerus
• /im sign• Nacant glenoid sign
• Through*s sign
• Thransthoracic lateral ,-ray 1 N-shaped rolling line
• Arthrography
• CT scan
• M/+
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• Treatment• Conservative
• The acute dislocation is reduced &usually under generalanaesthesia' !y pulling on the arm "ith the shoulder in
adduction• a e" minutes are allo"ed or the head o the humerus
to disengage and the arm is then gently rotatedlaterally "hile the humeral head is pushed or"ards$
• + reduction eels sta!le the arm is immo!ili5ed in a
sling• other"ise the shoulder is held "idely a!ducted and
laterally rotated in an airplane type splint or 6:"ee#s to allo" the posterior capsule to heal in theshortest position$
• Shoulder movement is regained !y active e.ercises
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Anatomy
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• stability of elbo*• primary sta!ili5ers
• MCL is the main sta!ili5er o the el!o" joint &providesH7I valgus sta!ility "hile osseous articulationprovides 66I'
• ulnohumeral articulation• coronoid1 clinical e.perience suggests HRI intact
coronoid re0uirement or sta!ility "ith or "ithoutligamentous integrity
• olecranon contri!ution to sta!ility inversely correlated
"ith resection amount1 6RI articular surace oolecranon needed or sta!ility
• secondary sta!ili5ers
• radiohumeral articulation &most important'
• capsule1 greatest role in e.tension o el!o"
insignifcant role &3RI' in >e.ion
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$ntroduction• second most common major joint dislocation
- dislocation is usually closed and posterior• Adults + c!ildren
• ec!anism• all on outstretched hand "ith e.tended el!o"
• anatomic morphology o semilunar notch may predisposeto el!o" dislocation
• central angle o semilunar notch is signifcantly larger ingroup o pts "ho had dislocation o the el!o" comparedto normals
•
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• Side-s"ipe injury• occurs typically "hen a car-driver*s el!o" protruding
through the "indo" is struc# !y another vehicle$
• The result is or"ard dislocation "ith ractures o any or
all o the !ones around the el!o" sot-tissue damage&including neurovascular injury' is usually severe$
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Classications
• According to direction o dislocation
• Posterior
• Posterolateral &;RI'
• Posteromedial
• Lateral• Medial
• Divergent
• Simple & dislocation "ithout racture ' Ns Comple. &dislocation "ith ractures'
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• Sim&le dislocation• rupture o capsule rupture o MCL lateral ligaments
rupture o >e.or pronator mass and less commonly injuryto !rachialis muscle
• lateral collateral ligament may !e the essential lesion inrecurrent or persistent insta!ility ollo"ing simpledislocations o the el!o"
• rupture o !rachial artery has !een reported
• Comple. dislocation
• dislocation *, radial !ead frx• frx dislocation *, C' injury (radial head r.
MCL +nsta!ility'
• terrible Triad- (dislocation. cornoid &rocess frx. andradial !ead frx)
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• Clinical eatures• Pt supports orearm "ith el!o" in slight >e.ion
• Enless s"elling is severe the deormity is o!vious
• ?ony landmar# &olecranon and epicondyles' may !e
palpa!le and a!normally placed• @l!o" >e.ed to GR degrees
• Assess alignment o these 6 points at el!o"
• Uormal1 e0uilateral triangle
• Dislocated1 straight line
• /adial ead racture easy to eel at lateral epicondyle• and should !e e.amined or signs o neurovascular
damage
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• ,ray• @ssential to confrm the presence o a dislocation and to
identiy any associated ractures
• Uote radial head avulsion racture
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Treatment o acute dislocations
• Uon-operative
• reduction and splinting at GRV or W-3R days ollo"ed !yearly therapy
• +ndications 1 simple sta!le dislocations
• early therapy
• supervised &therapist' active and active assist range-o-
motion e.ercises ater 3 to 4 "ee#s• initial range o motion is the sta!le arc ound on
postreduction e.amination
• reha!ilitation
• proceed "ith light duty use 4 "ee#s rom injury
• reduction splinting in hinged !race at GRV or 4-6 "ee#s• +ndications 1 simple unsta!le el!o" dislocations
&dislocations "ith e.tension'
• early range o motion e.ercises "ith arm in pronation
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• Post reduction
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• Post reduction
• +mmo!ili5e el!o" in molded posterior plaster splint
• Splint el!o" at GR degrees >e.ion &Allo"s ligament andcapsular healing'
• Splint or 6 "ee#s
• Jentle /ange o motion ater Splinting
• Uever orce range o motion &"orsens injury'
• Temporary sti%ness is common
http://www.fpnotebook.com/Ortho/Procedure/Cstng.htmhttp://www.fpnotebook.com/Ortho/Procedure/Cstng.htm
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• 2perative• 2/+ &coronoid radial head olecranon' LCL repair B-
MCL repair
• +ndications 1 comple. dislocations "ith ractures and
insta!ility• approach
• posterior utility approach used
• radial head
• "hen placing f.ation on the pro.imal radius one must
!e a"are o the Xsae 5oneX or f.ation• GRV arc in the radial head that D2@S U2T articulate
"ith the pro.imal ulna
• the Xsae 5oneX can !e identifed !y its relationship toListerYs tu!ercle and the radial styloid
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Treatment or chronic dislocation
• 2perative• open reduction capsular release and dynamic hinged
el!o" f.ator
• +ndications 1 hinged e.ternal f.ator indicated in chronicdislocation to protects the reconstruction and allo"s early
range o motion !ut it does not maintain the reduction• approach
• posterior utility approach used
• techni0ue
• concomitant radial head racture
• f. frst
• 2/+ or radial head that can !e reconstructed
• radial head arthroplasty is indicated or a radial headracture that cannot !e reconstructed
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• Complications• @arly
• Nascular injury &!rachial artery'
• Uerve injury &median or ulnar nerve'
• Late• Nalgus insta!ility
• Sti%ness
• eterotropic ossifcation
• Enreduced dislocation
• /ecurrent dislocation
• 2steoarthritis
• Loss o terminal e.tension &most common se0uelaeater closed treatment o a simple el!o" dislocation'
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Dislocation Of "i&
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Anatomy
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Classication / de&end u&on relations!i&bet*een femoral !ead and acetabulum
PosteriorDislocation• WRI
AnteriorDislocation• 3R-3HI
Central• Comminuted
displacedarcture oaceta!ulum
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Posterior ip DislocationAnterior ip DislocationCentral ip Dislocation
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osterior "i& Dislocation
• Causes• Car dash!oard injury
• all o% "eight on !ac# o a stooping miner
• Mechanism o injury
• Esually due to !ac#"ard directed orce along "ith theshat o emur in >e.ed hip
• Dislocation may !e pure i the emur more adducted attime o impact and may associated "ith racture i emurslightly a!ducted$
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• Clinical eatures• ho trauma ollo"ed !y pain
s"elling and deormity &>e.ionadduction and medial rotation'
• Short leg
• Jross restriction o movement oa%ected hip
• ead o emur elt as hard massin gluteal region and moves
along "ith emur
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• +nvestigation• ,-ray o hip
• AP vie" 1 emoral head seen out o its soc#et anda!ove the aceta!ulum
• Less promonent lesser trochanter as thigh is internallyrotated
• ?ro#en Shenton*s line
• A !ony chip i aceta!ular hip is ractured
• CT scan
• elps to determine direction o dislocation loose!odies and associated ractures
• M/+
• Eseul to evaluate la!rum cartilage and emoral headvascularity
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simple dislocation "ith the emoral head lyia!ove and !ehind the aceta!ulum$
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Another patient "ithdislocation and anassociated aceta!ular rim
racture
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• Management• Conservative &closed reduction manipulation under JA'
• Classical
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• ?igelo"*s method
• Stimson*s gravitymethod
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• Ater treatment the lim! is immo!ili5ed in a Thomassplint or 6 "ee#s in the position o a!duction
• 2perative &open reduction'
• +ndications
• ailure o closed reduction due to o!struction !y !onyragments or sot tissues loc#ing racture ragments!utton holing o emoral head through the capsule
• +ntra-articular loose ragment not allo"ing concentri.reduction
• +nsta!ility ater reduction
• Sciatic nerve palsy
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• Complications• @arly
• Sciatic nerve palsy &3R-36I'
• Due to stretching o the nerve or entrapment !et"een theragment
• Commonly a%ectes the peroneal division
• Esually neuropra.ia and recovers spontaneously
• Nascular injury &superior gluteal artery'
• Associated ractured emoral shat
• Late
• Avascular necrosis o emoral head &3H-4RI'• Myositis ossifcans
• Sti%ness
• Enreduced dislocation
• Secondary osteoarthritis
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Anterior "i& Dislocation
• Mechanism o injury• Dash!oard injury "ith thigh a!ducted and e.ternal
rotated
• all rom height
• ?lo" to !ac# in s0uatted position• Causes the nec# to impinge on aceta!ular rim and leverthe emoral head out in ront o its soc#et$
• emoral head "ill then lie superiorly &type + 1 pu!ic' orineriorly &type ++ 1 o!turator'
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• Clinical eatures• True length "ith head palpa!le in groin &inerior type' or
anteriorly &superior type'
• Uot short !ecause the attachment o rectus emorisprevents the head rom displacing up"ards$
• Lim! is in attitude o e.ternal rotation a!ducted andslightly >e.ed$
• 2ccasionally the leg a!ducted almost to a right angle
• ip movement are impossi!le
• ,-ray fndings• +n AP vie" 1 dislocation usually o!vious !ut occasionally
head is almost directly in ront o its normal position
• Lateral vie"
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T t t
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• Treatment• Maneuvers employed are similar to those used to reduce
a posterior dislocation e.cept that "hile the >e.ed #nee
is !eing pulled and the hip gently >e.ed up"ards itshould !e #ept adducted
• An assistant then helps !y applying lateral pressure toinside o the thigh
• Point o reduction is usually heard and elt
• Su!se0uent treatment is similar to that employed orposterior dislocation
• Complications• Ueurovascular injury &emoral artery nerve or evein'
• +rreduci!le dislocation• Post traumatic 2A
• Aseptic necrosis
• /eccurent dislocation
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Central "i& Dislocation
• Mechanism o injury• A all on the side or a !lo" over the greater trochanter
may orce the emoral head medially through the >oor othe aceta!ulum
• +t is really a racture o the aceta!ulum
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0nee Dislocation
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Anatomy
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$ntroduction
• /are$ 2rtho emergency• Esually due to high energy injury
• Defned as com&lete dis&lacement o the ti!ia"ith respect to the emur "ith disruption o 1 or
more o the sta!ili5ing ligaments$• Small avulsion ractures rom the ligaments and capsular
insertions may !e present$
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• Mechanism o injury• igh energy
• Esually rom MNA or all rom height
• Commonly a dash!oard injury resulting in a.ial load to>e.ed #nee
• Lo" energy
• 2ten rom athletic injury
• Jenerally has a rotational component
• Mor!id o!esity is a ris# actor
• Pathoanatomy• Associated "ith signifcant sot tissue disruption
• Z o ligaments generally disrupted
Classications / !ased on
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C ass ca o s !ased odirection o displacement o the ti!ia
Anterior•
6R-HRI• dt hypere.tensioninjury
• Esually involvestear o PCL
• Arterial injury is
generally an intimaltear dt traction
Posterior•
4HI• dt a.ial load to>e.ed #nee
• ighest rate ocomplete tear opopliteal
Lateral•
36I• dt valgusdislocations
• Esually involvestears o !oth ACLand PCL
•
ighest rate operoneal nerveinjury
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Medial• Narus orce• Esually disrupted
PLC and PCL
/otational• Posterolateral is
most commonrotational
dislocation• Esually irreduci!le
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• Clinical eatures• ho trauma and deormity o the #nee
• Knee pain and insta!ility
• May present "ith su!tle signs o trauma &s"ellinge%usion a!rasions'
• Xdimple signX - !uttonholing o medial emoral condylethrough medial capsule
• indicative o an irreduci!le posterolateral dislocation
• a contraindication to closed reduction due to ris#s o s#innecrosis
• sta!ility
• diagnosis !ased on insta!ility on e.am &radiographsand gross appearance may !e normal'
• may see recurvatum "hen held in e.tension
• assess ACL PCL MCL LCL and PLC
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• vascular e.am• priority is to rule out vascular injury on e.am !oth
!eore and ater reduction
• serial e.aminations are mandatory
• palpate the dorsalis pedis and posterior ti!ial pulses
• i pulses are present and normal• does not indicate a!sence o arterial injury
• collateral circulation can mas# a complete politeal arteryocclusion
• measure An#le-?rachial +nde. &A?+'
• i A?+ R$G• then monitor "ith serial e.amination &3RRI Uegative Predictive
Nalue'
• i A?+ R$G
• perorm arterial duple. ultrasound or CT angiography
• i arterial injury confrmed then consult vascular surgery
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• + pulses are a!sent or diminished• confrm that the #nee joint is reduced or perorm
immediate reduction and reassessment
• immediate surgical e.ploration i pulses are still a!sentollo"ing reduction
• ischemia time ; hours has amputation rates as high as;:I
• i pulses present ater reduction then measure A?+ thenconsider o!servation vs$ angiography
• Special test or ligament insta!ility
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• +nvestigations• ,-ray &AP lateral vie"'
• Arteriogram
• M/+ &ligament injuries'• The e.tent and location o ligament disruption meniscal tears and su!tle
injuries to the !one as "ell as "hich tears are repaira!le$
• Knee arthroscopy is contraindicated "ithin 4 "ee#s o#nee dislocations
• capsular tears cause >uid e.travasations into the leg in compartmentsyndrome
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• Management• +nitial Treatment & reduce 2nee and re/examine
%ascular status )
• considered an orthopedic emergency
• splint #nee in 4R-6R degrees o >e.ion
• confrm reduction is held "ith repeat radiographs in!racesplint
• vascular consult indicated i
• i arterial injury confrmed !y arterial duple. ultrasound orCT angiography
• pulses are a!sent or diminished ollo"ing reduction
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• Uon-operative• indications
• limited and most cases re0uire surgical sta!ili5ation
• 2perative & emergent surgical inter%ention )
• indications
• vascular injury repair &ta#es precedence'
• open racture and open dislocation
• irreduci!le dislocation
• compartment syndrome
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• delayed ligamentous reconstruction,re&air• indications
• generally insta!ility "ill re0uire some #ind o ligamentousrepair or f.ation
• patients can !e placed in a #nee immo!ili5er or :
"ee#s or initial sta!ili5ation• improved outcomes "ith early treatment &"ithin 6
"ee#s'
• techni0ue
• PLC & recommend early reconstitution '
• PCL & reconstruct prior to ACL reconstruction '
• postoperative
• recommend early mo!ili5ation and unctional !racing
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• Complications• Sti4ness (art!robrosis)
• is most common complication &6;I'
• more common "ith delayed mo!ili5ation
• 'axity and instability &6WI'• eroneal ner%e injury &4HI'
• most common in posterolateral dislocations
• poor results "ith acute su!acute and delayed &6months' nerve e.ploration
• neurolysis and tendon transers are the mainstay otreatment
• #ascular com&romise
• in addition to vessel damage claudication s#inchanges and muscle atrophy can occur
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Dislocation Of atella
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cS&ortsedicineArt!roco&y,sid6787895!tml
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:::
Acute Dislocation
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Acute Dislocation• /esult rom sudden contraction o
0uadriceps "hile the #nee is >e.ed orsemi->e.ed$
• Dislocates laterally
• Clinical eatures• Pain
• S"elling
• Ena!le to straighten the #nee
• Medial condyle&emur' more prominent
• Tenderness &antero-medially'
• Treatment• /eduction- Ender Jen$ anesthesia
• +mmo!ilisation1 cylinder cast[6 "ee#s
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Recurrent Dislocation
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Recurrent Dislocation
• @tiology• Congenital
• Lig$ La.ity
• hypoplasia o lat$ emoral condyle
• lattening o +ntercondylar groove
• Patellar maldevelopment• Primary muscle deect
• Jenu valgum
• Ac0uired• Jenu valgum
• +ne0uality o gro"th o condyle•
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• Pathology
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;irst e&isode
Tear ofca&sule on
medial side of&atella
$f im&ro&er!ealing
ersistentlaxity
Recurrentdislocation
Damage to
contiguoussurface of
&atella < fem5Condyles
;lattening <t!en furt!erdislocation
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• Clinical eatures• M
• 2ten !ilateral
• Acute pain "ith #nee stuc# in >e.ion
• +n dislocated state1
• Nisually o!vious• Tenderness
• S"elling
• ?et"een attac#
• Patella alta
• Jeneral ligament la.ity• Apprehension test Bve
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• +nvestigations• ,-ray
• Dislocation
• igh-riding patella
• 2ther anatomical a!normality
• M/+
• CT scan
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• Treatment• Conservative
• \uads e.ercise
• USA+DS
• 2perative
• Camphell 2peration• Jold"ait operation
• auser*s operation
• Patellectomy
• Muscle release "ith N-F ]-plasty
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"abitual Dislocation
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"abitual Dislocation
• @verytime #nee is >e.ed it dislocates laterally• Present in early childhood
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ARTR$ORCRUC$AT
'$=A>T TARPhang Chin Tong
Anatomy
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Anatomy
$ntroduction
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$ntroduction
• Can withstand
approximately 400
pounds of force
• Common injuryparticularly in sports (3%
of all athletic injuries)
• Associated "ith MCL meniscus tear &all 68 Terri!le Triad'
• More common in women
ales %s ;emales
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ales %s ;emales
ec!anism of injury
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ec!anism of injury
• Can occur "ithoutcontact
• valgus or
hypere.tension orce to#nee
Clinical ;eatures
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Clinical ;eatures
• istory o a (pop) at the time o injury andimmediate &ie e" hours' s"elling and e%usion atthe #nee
• Patients complain o the #nee (giving out) during
t"isting
Clincal Test
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Clincal Test
Anterior dra*ertest
• #nee at GRV and thehamstrings rela.edgrasp the top o thepatients leg and tryto shit it or"ards
and !ac#"ards&displaced Hmm'
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'ac!man Test• #nee >e.ed to 4RV
one hand atlaterally sta!ili5esthe distal emurand the other handgrasps the pro.imal
ti!ia medially$ Thepro.imal ti!ia ispulled or"ard
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i%ot S!ift Test• #nee ully e.tended
"hilst maintaininga valgus orce andthe #nee is thengradually >e.ed apalpa!le reduction
o this su!lu.ationis elt at 4R6Rdegrees$
$n%estigations
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$n%estigations
• ,-ray1 plain .-ray and stress flms &to rule outSegond ^'
• M/+ confrm diagnosis
• Athroscopy
Di4erential Diagnosis
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Di4erential Diagnosis
• Chronic ACL tear• Avulsion o the ti!ial insertion in adolescents
• Multiligamentous injury to the #nee
Treatment
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Treatment
• Conservative management - modifcation oactivities that produce insta!ility splint crutches unctional !racing
• Surgical repair reconstruction &2pen
endosopic'
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AC"$''ST>DO>
RUTURPhang Chin Tong
Anatomy
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Anatomy
• connects the cal muscle &gastrocnemius' to theheel !one &calcaneus'$
• just !elo" the s#in at the !ac# o the an#le
;unction
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;unction
gastrocnemiusmuscle &in thecal' contracts
&shortens'
tendon moves topoint the ootdo"n"ards
&plantar>e.ions'
$ntroduction
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$ntroduction
Partial or complete tear o theachilles tendon$
Common in men !et"een theages o 6R and HR years&X"ee#end "arriors)'Most commonly occurs in sportsre0uiring an e.plosive push-o%1s0uash !adminton oot!alltennis net!all$
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About ? cmabo%e t!e
tendoninsertion ontot!e calcaneum
(%ascular*aters!ed))
Ty&ical sitefor ru&ture-
ec!anism of Ru&ture
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ec!anism of Ru&ture
Sudden orcedplantar >e.ion o the
oot
Ene.pecteddorsi>e.ion o the
oot
Niolent dorsi>e.ion oa plantar >e.ed oot$
2ther mechanisms1direct trauma
attrition o thetendon as a result olongstanding
peritenonitis "ith or"ithout tendinosis$
Poor musclet th d
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/is#
actors
strength and>e.i!ility
ailure to"arm up and
stretch !eoresport
Previousinjury or
tendinitis
Corticosteroid
injection
Clinical ;eatures
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Clinical ;eatures
• A ripping or popping sensation is elt and otenheard at the !ac# o the heel$
• Loo#ed round to see "ho had hit them over the!ac# o the heel the pain and collapse are so
sudden$
xamination
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xamination
Plantar>e.ion o theoot usually inhi!ited
and "ea#
Palpa!le gap at the siteo rupture
?ruising comes out aday or t"o later$
Signs
Calf s@ueee test (T!om&sonBsor SimmondBs test)
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or Simmond s test)
•
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$n%estigation
• Ultrasound scans must !e used to confrm orreute the diagnosis$
Di4erential diagnosis
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Di4erential diagnosis
Incomplete tear
• Complete rupture
mista#en or partialtear dt• + complete rupture is
not seen "ithin 47hours the gap isdi9cult to eel
• Patient may !y then!e a!le to stand ontiptoe &just' !y usinghis or her long toe>e.ors$
Tear of soleus muscle
• A tear at the
musculotendinous junction causes painand tenderness hal"ayup the cal$
• This recovers "ith theaid o physiotherapyand raising the heel othe shoe$
Treatment
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Treatment
• Conservative• Plaster cast or special !oot is
applied "ith the oot ine0uinus
• /eha!ilitation andphysiotherapy "ithin 7:"ee#s$
• Shoe "ith a raised heel should!e "orn or a urther :;
"ee#s• _/e-rupture rate* a!out 3R I
• Surgical• 2perative repair isassociated "ith
• /is#s• "ound healing
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associated "ith• earlier return to unction
• !etter tendon and calmuscle strength
• a lo"er re-rupture rate$
• Supported reha!ilitation
and physiotherapy are
commenced early&"ithin a "ee# or t"o orepair'
• "ound healingpro!lems
• sural nerve neuroma$
• /uptures that presentlate• reconstruction using
local tendonsu!stitutes &e$g$ >e.orhallucis longus tendon'or strips o ascia lata
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T!an2s
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