32,Principles of Dislocation Manangment.pptx

Bill

1. P rinciples of Dislocation Management Moderator :Dr.Theodros Assistant professor of Orthopedics and Traumatology Presenter: Dr.Bol Kuol (OSR1) 1 1 1 28 th Dec, 2023 1

2. Outlines Introduction Principles of dislocation Management of; GH joint Elbow joint Hip joint Knee joint Ankle joint Summery References 2

3. Types of Joints Fibrous/ Synarthrosis No movement are permitted E.g. suture,syndesmosis,gomphosis Cartilaginous/ Amphiarthrosis Little movements are permitted E.g. rib cage, symphysis pubis 3

4. Synovial( Diarthrosis ) Movement is free Pivot Hinge Condylar Saddle Plane Ball and Socket 4

5. Definition Dislocation When its articular surfaces are wholly displaced one from the other, so that apposition between them is lost. Subluxation Exists when the articular surfaces are partly displaced but retain some contact with each other . 5

6. Types of dislocation Congenital Acquired 1.Traumatic 2.Pathological e.g TB hip, Septic Arthritis 3.Paralytic e.g Poliomyelitis ,cerebral palsy ,etc. 4.Inflammatory disorders e.g. rheumatoid arthritis NO joint is immune from dislocation 6

7. Most commonly occur in the following joints Shoulder Elbow Hip Knee Ankle Metacarpophalangeal joint Facet Joint dislocation in cervical spine Acromioclavicular joint dislocation 7

8. Complications Acute Injury to peripheral nerve and blood vessels Chronic Unreduced dislocation Recurrent dislocation Traumatic osteoarthritis Joint stiffness Avascular necrosis Myositis ossificans 8

9. Shoulder(GH) Dislocation The glenohumeral joint is inherently unstable Stability provided by glenoid labrum, ligaments and muscles Most common dislocated joint Y oung/athletic patients(recurrence >90% if <25 year old ) Associated with labral tears(<40 year old ) R otator cuff tears(> 40 year old ) G lenoid rim (‘ ’bony Bankart ’’) fracture Hill-Sachs lesion 9

10. Anatomic Classification Based on direction of humeral head Anterior Dislocation Most common Posterior Dislocation often missed Superior Dislocation extremely rare Inferior Dislocation luxatio erecta: abducted arm cannot be lowered (rare) Recurrent Dislocation happen repeatedly 10

11. Anterior Dislocation Most common and more than 90 % Mechanism Direct force anteriorly impact to the posterior shoulder fall on the backward-stretching hand forced abduction and external rotation of the shoulder 11

12. History Trauma/fall Pain Inability to move arm Neurovascular Examination Test axillary nerve function P/E ‘ ’Flattened’ ’shoulder Patient carries affected arm with other hand Empty glenoid fossa, compared with contralateral side Palpable dislocated head(anterior in axilla ) 12

13. Imaging Trauma series AP view LT view Axillary view Scapular Y view overlapping shadow of the humeral head and glenoid fossa Hill-Sachs lesion Bony Bankart lesion Humeral neck # Tuberosity 13

14. Non Operative Closed Reduction Traction and Counter traction Method Most commonly used Axial traction is applied to arm counter traction is applied with sheet wrapped over shoulder Kocher’s Maneuver Traction External rotation Adduction Internal rotation 14

15. Stimson Maneuver Gravity method in prone position Milch Maneuver Patient supine steady downward traction applied at elbow combined with slow gradual external rotation and abduction of limb 15

16. Operative Soft tissue interposition Displaced greater tuberosity fracture > 5mm Glenoid rim #> 5 mm in size Glenoid labrum has been damaged or detached 16

17. Immobilization and Rehabilitation over 30 years of age , stiffness is more of a risk than recurrent dislocation so movements are begun after 1 week . under 30 years , recurrence is more of a risk and so the sling is retained for 3 weeks before mobilizing Complications Recurrent dislocation/instability (esp.in young/<25 y.o) Neurovascular injury (axillary n, musculocutaneous n and axillary a) Rotator cuff tear in older people 17

18. Posterior Shoulder Dislocation commonly missed Rare than anterior shoulder dislocation Mechanism Direct Trauma Blow on the front of the shoulder indirect trauma Electric shock convulsion 18

19. History Trauma/fall Pain Inability to move arm Convulsion Neurovascular Examination Test axillary nerve function P/E Shoulder internally rotated and adduction Palpable mass posterior to the shoulder Flattening of the anterior shoulder Tenderness 19

20. AP VIEW Half Moon Sign Light bulb sign 20

21. Reduction technique The arm is pulled and rotated laterally, while the head of the humerus is pushed forwards . 21

22. Immobilization and Rehabilitation over 30 years of age , stiffness is more of a risk than recurrent dislocation so movements are begun after 1 week . under 30 years , recurrence is more of a risk and so the sling is retained for 3 weeks before mobilizing 22

23. Recurrent dislocation Once a shoulder has been dislocated, this may happen repeatedly. the capsule and labrum have usually been stripped from the margin of the glenoid and the humeral head may be indented In the vast majority of cases recurrence is anterior 23

24. History Dislocation the patient complains that the shoulder ‘ slips out ’ when the arm is lifted into abduction and lateral rotation Physical examination The apprehension test is positive the shoulder is passively manipulated into abduction, extension and lateral rotation . the patient tenses up and resists further movement 24

25. Imaging AP x-ray MRI 25

26. Treatment Anterior dislocation some form of anterior capsular reconstruction is usually successful recurrent posterior dislocation is more difficult and may require soft-tissue reconstruction combined with a bone operation to block abnormal movement at the back of the shoulder 26

27. Elbow Dislocation The elbow is the second most commonly dislocated joint in adults . Acute dislocation of the elbow is almost always reducible by closed methods. most are stable after reduction. Open reduction may be required if fracture fragments in a fracture-dislocation block closed reduction Approximately 20% of dislocations are associated with fractures: “ terrible triad ”=elbow dx with radial head&coronoid fracture Collateral ligaments &anterior capsule are typically torn Mechanism Usually a fall/RTA in elderly and young patient 27

28. History Trauma/fall Inability to move elbow Neurovascular Examination P/E Swelling Deformity Limited /no elbow ROM Good neurovascular exam 28

29. Classification By direction of forearm bones Posterior- posterolateral(>80%)>posteromedial Anterior (rare) Medial Lateral(rare) Divergent(rare) 29

30. Radial Head Subluxation Common in children age group(2-5 years ) Reduction With thumb in antecubital space as a fulcrum The forearm is supinated and flexed 30

31. Imaging XR Elbow series CT To define associated fracture 31

32. Treatment Acute-Closed reduction Prone position Only forearm hangs from the stretcher Gentle downward traction R eduction of the olecranon with the opposite hand 32

33. Operative ORIF( corocoid,radial head ,olecranon ),LCL repair,+/- MCL repair Acute complex elbow dislocation Persistent instability after reduction Open reduction, capsular release, and dynamic hinged elbow fixator Chronic dislocation 33

34. Immobilization Stable Splint in 90 degree of flexion for 7-10 day Unstable Splint for 2-3 week Complications Elbow stiffness and stability Recurrent dislocation Neurovascular injury (Median and ulnar nerves, brachial artery) Secondary osteoarthritis 34

35. Hip Dislocation The hip joint is inherently stable Orthopedic emergency risk of femoral head AVN increases with late/delayed reduction Mechanism of Injury High-energy trauma E.g. MVA, dashboard injury significant fall History Trauma , severe pain, cannot move thigh/hip 35

36. Physical Examination Anterior Dislocation Occurs with the hip in abduction and external rotation Characteristic position of affected limb . Hip flexed, thigh abducted and externally rotated Posterior Dislocation Most common (90%) Axial load through flexed knee( dashboard injury) Femur adducted and internally rotated hip flexed Associated with posterior wall acetabular #,femoral head #,and sciatic nerve injury 36

37. Cont,,,, Central Dislocation This is the least common and difficult of all dislocation of the hip joint Due to direct trauma to greater trochanter fracture of floor of acetabulum Lateral force against adducted femur Always fracture- dislocation 37

38. XR : AP pelvis, femur and knee series CT : R/o fx or bony fragments/ loose bodies post reduction 38

39. Treatment Nonoperative Emergent closed reduction within 6 hours for acute anterior and posterior dislocations Contraindicated in ipsilateral displaced or non –displaced femoral neck fracture 39

40. Operative Open reduction removal of incarcerated fragments Irreducible dislocation Delayed presentation ORIF for Acetabulum fracture Femora head and neck 40

41. Maneuver of Reduction Allis maneuver for posterior Hip Dislocation Patient supine on table, under anesthesia or sedation . Examiner applies firm distal traction at flexed knee to pull head into acetabulum slight rotary motion may also help Assistant fixes pelvis by pressing on anterior superior iliac spine 41

42. Allis Maneuver for Anterior Hip Dislocation Reduction Anterior dislocations reduced using traction and counter-traction Traction is applied in line with the femur with gentle flexion. Along with a lateral push on the inner thigh internal rotation and adduction are used to reduce the hip 42

43. Post-reduction Care For simple dislocation Within 6 hours a brief period of rest for several days to 2 weeks followed by mobilization After 6 hours since the rate of AVS is highest, it may be reasonable to delay full weight bearing for 8 to 12 weeks Most patients can achieve full weight bearing by 6 weeks Dislocations with Associated Fractures The rehabilitation for patients who had associated fractures fixed is determined by the associated injury In the case of posterior wall acetabular fractures or femoral head fractures, active hip motion may be deferred for approximately 6 weeks 43

44. Complications Posttraumatic osteonecrosis (AVN) (reduced risk with early reduction ) 5-40% incidence Increased risk with increased time to reduction sciatic nerve injury (posterior dislocations ) 8 -20% incidence femoral artery/nerve injury (anterior dislocations ) Post traumatic arthritis Up to 20% for simple dislocation, markedly increased with complex dislocation Recurrent dislocations Less than 2 % 44

45. Precautions !!!! 1.Prohibit patients from crossing their legs 2.Bending their hip a 90-degree angle 3.Twisting their hip inward 45

46. Knee Dislocation Frank dislocation of Knee joint is a devastating injury with the potential for limb-threatening complications Many spontaneously reduce, must keep index of suspicion of suspicion for injury Multiple ligaments and other soft tissue are disrupted High incidence of associated fracture and neurovascular injury 46

47. Mechanism of Injury High energy From MVA,fall from a height or dashboard Low energy An athletic injury, routine walking 47

48. Presentation Symptoms History of trauma and deformity of the knee Knee pain Inability to bear weight 48

49. Physical Examination Appearance No obvious deformity 50% spontaneously reduce before arrival to ED Signs of trauma( swelling, effusion, abrasions, ecchymosis ) +/- distal pulses/peroneal nerve function ‘ ’Dimple Sign ’’-buttonholing of medical femoral condyle through the medical capsule Vascular exam To rule out vascular injury both before and after reduction Serial examinations are mandatory Palpate the dorsalis pedis&posterior tibial pulses Neurologic exam Sensory and motor function of peroneal and tibial nerve 49

50. Classification Kennedy classification based on the direction of displacement of the tibia Anterior (30-50%) Most common Due to hyperextension injury Usually involves tear of PCL The highest rate of peroneal nerve injury Posterior( 30-40%) 2 nd most common Due to axial load to flexed knee(dashboard injury) The highest rate of vascular injury (25 %) Highest incidence of a complete tear of popliteal artery 50

51. Lateral(13%) Due to a Varus or valgus force Usually involves tears of both ACL&PCL Medial (3%) Varus or valgus force Usually disrupted PLC and PCL Rotational (4%) Posterolateral is most common rotational dislocation Usually irreducible Buttonholing of femoral condyle through the capsule 51

52. Imaging X-ray Pre-reduction and post reduction (AP&Lt of the Knee) May be normal if spontaneous reduction Look for asymmetric or irregular joint space Look for avulsion Fxs( segond sign -lateral tibial condyle avulsion Fx ) CT Scan Facture identified on post reduction x-ray Findings Tibial eminence, tibial tubercle, and tibial plateau fractures may be seen 52

53. Cont,,,,,,,,,,,,,,,,,,,,,,,,,,,,, MRI Obtain MRI after acute reduction but prior to hardware placement Required to evaluate soft tissue injury ( ligaments, meniscus ) and for surgical planning 53

54. Closed reduction technique Anterio r Traction and anterior translation of femur Posterior Traction,extension,and anterior translation of the tibia Medial/Lateral Traction and medial or lateral translation Rotatory Axial limb traction and rotation in the opposite direction of deformity 54

55. External Fixation Indications Vascular repair Open fracture-dislocation Compartment syndrome Polytrauma patient Open reduction Irreducible knee Vascular injury Open fracture-dislocation Posterolateral dislocation 55

56. Early Ligamentous reconstruction (<3 week) Acute reconstruction has been shown to lead to improved clinical and functional outcomes Complications Vascular compromise 40-50% in anterior or posterior dislocations Stiffness( arthrofibrosis ) most common complication (38 %) Laxity and instability 37% of some instability,redislocation is uncommon Peroneal nerve injury 25% occurrence of a peroneal nerve injury,50% recover partially 56

57. Subtalar Dislocation Accounts for 1% of all dislocations More common in young or middle-aged males 25% may be open especially in lateral dislocation Mechanism Typically result from a high energy Mechanism RTA Fall from height Athletics 57

58. Presentation Severe Pain Gross deformity Foot will be locked in supination with medial dislocation Known as ‘’ acquired clubfoot ‘’ Foot will be locked in supination with lateral dislocation Known as ‘’ acquired flatfoot ’’ 58

59. Anatomic Classification Medical dislocation Most common(65-80%) Due to lateral malleolus acting as strong butrres,preventing dislocation Foot become locked in supination Reduction blocked by peroneal tendon and talonavicular capsule Lateral dislocation More likely to be open Foot become locked in pronation Associated with lateral process ,anterior calcaneus and fibula # Reduction blocked by PT tendon ,FHL,FDL 59

60. Anterior dislocation Rare Posterior dislocation Rare Total dislocation(extruded talus ) Usually open Talus is completely dislocated from ankle and subtalar and talovavicular joints 60

61. Imaging X-ray of ankle( AP&Lt view ) CT scan of ankle Subtalar osteochondral fragment causing subluxation 61

62. Non operative 60-70 % cab be reduced by closed methods short leg cast non-weight bearing cast for 4-6 week Traction counter traction 62

63. Operative reduction Open dislocations Failure of closed reduction 63

64. Post-Op care If joint stable Place in short leg cast with non-weight bearing for 4-6 weeks If joint remains unstable place temporary tranarticular pins or spanning external fixator 64

65. Complications Stiffness Most common complication Post-traumatic arthritis 65

66. Typical deformities in dislocation Shoulde r- Abduction deformities Elbow -Flexion deformities HIP : Anterior :Flexion ,abduction and external rotation deformities . Posterior- Flexion ,adduction and internal rotation deformity Knee - flexion deformity Ankle - Varus deformity 66

67. Summery Principles of dislocation Management Aims Save life Save limb save the function Assessment of condition of the patient for shock and other injuries Assessment of local condition of injured limb (vascular injury, nerve) Resuscitation, if needed Safe transport, this help to minimize complication in injuries to spine (All dislocations associated with fractures should be immobilized immediately ) 67

68. Radiography of the part Reduction of dislocation Closed manipulation Open Immobilization Re-radiography of the part Early physiotherapy For the preservation of the function of the limb Rehabilitation 68

69. Ameseginalehu ! 69

70. References Apley &Solmon’s concise system of orthopaedic &truma -4 th edition Campbell’s Operative Orthopaedics-13 th edition Netter’s Concise Orthopedics anatomy -2 nd edition Othrobullets-Trauma -2021 Rockwood &Green’s fracture in Adults-8 th edition Internet 70