4. Basic Principles managment of dislocation.pptx
- 1. Basic principles of dislocation management By Dagim M(OSR1) Moderator Dr Geletaw Tessema (consultant Arthroplasty,orthopedic surgeon ) Date Dec 12/2019 AAU
- 2. Outline of presentation Introduction to joints Large joint dislocations and Management Shoulder dislocation Elbow dislocation Hip dislocation Knee dislocation Ankle dislocation
- 3. joints Structure determines Function vs function determines structure
- 4. Joint • Joint-connection made between bones in body which link skeletal system in to functional whole. • Function of joints holds skeletal system together allows mobility and flexibility
- 7. Functional • Synarthrosis suture,syndesmosis&gomphosis • Amphiarthrosis rib cage,vertebral joint,syphesis pubis • diarthrosis/(synovial)
- 11. Stability of joints articulating surface ligaments surrounding muscles
- 12. dislocations Definition Dislocation is a complete displacement of the articular surface of joint. Joints are no longer in contact. Subluxation is an incomplete displacement. Recurrent dislocation – repeated dislocation of a joint usually due to damage to the ligaments and joint margin
- 13. Causes of dislocation and subluxation Traumatic Congenital pathological/spontaneous Voluntary
- 14. Gleno-humeral joint dislocation 50% of all dislocations ; reason Wide range of motion Shallow glenoid cavity Weak ligaments thin and lax capsule Glenoid cavity to head ratio 1:3
- 15. Anterior dislocation • Mechanisms • Indirect forces fall on extended arm • Direct fall on superior or lateral shoulder arm adducted • Direct, anteriorly directed impact to the posterior shoulder
- 16. Clinical feature • Most common 90% • Patient carries the affected arm with the other arm abducted • Deformed shoulder contour
- 17. • Empty glenoid fossa , comparison with contralateral side • Palpable dislocated head (anterior in axilla • Injury to axillay nerve , artery • Rotator cuff tear??
- 19. imaging • Trauma series of the affected shoulder • AP, • scapular y • axillary
- 20. • MRI with arthrography gold standared • C scan • U/S
- 21. Non operative: closed reduction • Hippocratic&Traction-countertraction
- 22. Stimson & Milch technique:
- 23. Post reduction care • Immobilization • 3 wks , age >30yrs 1wk • Aggressive occupational therapy
- 24. Operative • Soft tissue interposition. • Displaced greater tuberosity fracture>5mm • Glenoid rim fracture >5 mm in size. • Selective repair in the acute period (e.g., in young athletes
- 25. Posterior dislocation • Less common and difficult to diagnose • Mechanisms indirect trauma fall down electric shock,convelsion direct trauma
- 26. C/m • shoulder internal rotation and adduction • palpable mass posterior to the shoulder • flattening of the anterior shoulder
- 28. imaging AP x-ray signs-less sensitive Axillary view better CT scan
- 29. AP x-ray-Light bulb sign,half moon sign
- 30. AP x-ray-Rim sign,trough line sign
- 32. Post reduction care • immobilization • for 3 wks,age >30yrs for 1week • Shoulder exercise
- 33. operative • Failed closed reduction • Associated humeral neck # • Significant glenoid defect • Reverse hill-sachs defect 20-40%humeral head involvement >40% humeral head involvement • Significant displaced lesser tuberosity # • Recurrent instability
- 34. Associated boney injuries to GHJD • Reverse hill sachs lesion • Bank art lesion • Tuberosity # • Humeral neck#
- 35. Elbow dislocation • Posterior dislocation is most common
- 36. Mechanism of injury Posterior dislocation fall onto an outstretched hand or elbow Anterior dislocation direct force strikes the posterior forearm with the elbow in flexed position
- 37. classification • Simple versus complex • According to the direction of displacement • Posterior Posterolateral Posteromedial • Lateral • Medial • Anterior
- 38. classfication
- 39. C/F • Painful,swollen, and deformed elbow • Restriction of mov’t • Imaging • AP and Lateral elbow x-ray
- 40. rx • Non operative Traction, flexion, and direct manual push
- 41. • After reduction elbow should put at complete range of motion(ROM) • NV exam • Control x-ray , • splint should be removed after 1wk &pt should start gently exercise • broad arm sling for 6wk
- 42. Operative rx • Un stable after reduction • terrible triad of the elbow #-dislocation
- 43. Hip dislocation
- 44. mechanisms Almost always due to high-energy trauma. Most commonly involve MVA falls from heights, industrial accidents sporting injuries.
- 45. Type of Dislocation depends on • Direction of applied force • Position of hip at time of injury • Strength of patient’s bone
- 46. Posterior dislocation Dash board injury Fall on sole of the foot The greater trochanter C/M severe pain with the hip in a position of flexion, internal rotation and adduction Most common
- 48. • Thompson and Epstein classification of posterior hip dislocations
- 49. Anterior dislocation • Relates a history of • direct blow to the posterior aspect of the hip • application of great force to abducted or externally rotated leg • External rotation and abduction of the hip
- 50. • Epstein classification of anterior hip dislocations
- 51. X-ray Evidence • Femoral head Size • Greater and lesser trochanters • Femoral neck • Shentons line • Rotation of femoral shaft
- 52. AP Pelvis X-Ray
- 53. rx • Closed Reduction • Should done emergently • in the operating room • NB: Regardless of the direction of the dislocation, the reduction is attempted by traction in line with the femur and gentle rotation
- 55. Stimson maneuver
- 56. Bigelow
- 58. Indications for open reduction • Dislocation irreducible by closed means. • Nonconcentric reduction. • Fracture of the acetabulum or femoral head requiring excision or ORIF. • Ipsilateral femoral neck fracture
- 59. Post care • Closed Reduction short periods of bed rest 2wks Full weight bearing 6wks • with # rxed by ORIF femoral head/acetabular # femural neck #
- 61. • Traumatic knee dislocation is an uncommon injury that may be limb-threatening; it should therefore be treated as an orthopaedic emergency
- 65. • Schenck Classification – anatomic system done using MRI Utility of Anatomic Classification It requires the surgeon to focus on what is torn. It directs treatment to what is injured. It leads to accurate discussion of injuries among clinicians
- 66. • Schenck classification I – ACL/PCL II – ACL & PCL IIIM – ACL, PCL & MCL IIIL – ACL, PCL & LCL IV – ACL, PCL, PMC & LC l) V –Fracture-dislocation C - Arterial injury N - Nerve injury
- 67. Clinical features • Symptoms • History of trauma • Mechanism of injury • Patients description of spontaneous knee reduction • Knee pain
- 68. P/E • Swelling • hemarthrosis • Deformity • Medial Skin dimpling sign • Neuro-vascular exam
- 69. Vascular examination arterial injury varies with the type of dislocation usually by traction, resulting in an intimal tear or complete arterial tears • Check DP/PT pulses and capillary refill) in any patient with a proven or suspected knee dislocation • Pulse absent • Pulse present
- 71. imaging • immediate reduction is recommended before radiographic evaluation • X-ray • MRI • Indications: all knee dislocations and equivalents
- 72. closed reduction • Anterior: Axial limb traction is combined with lifting of the distal femur. • Posterior: Axial limb traction is combined with extension and lifting of the proximal tibia. • Medial/lateral: Axial limb traction is combined with lateral/medial translation of the tibia.
- 73. Post reduction • X-ray • Evaluate NVS • MRI • Immobilize for 3 wks
- 74. External fixation • This approach is better for the grossly unstable knee. • Protects vascular repair. • Permits skin care for open injuries
- 75. Emergent operative interventions • Vascular repair • Open Fractures • Open dislocations • Compartment syndrome • Failed reduction with vascular compromise
- 76. • points in vascular repairs • Ex fix should be applied first • Any damaged segment should be excised & grafted • Fasciotomy should always be done after vascular repair
- 77. Rx for torn ligaments a Early Repair vs Reconstruction B Early Reconstruction (± Repair). 10-14 days displaced meniscal tear an extensive medial-sided disruption C staged protocols 2-6wks D Delayed Reconstruction after 3wks
- 78. Ankle dislocation • Abnormal separation b/n bones of ankle • Commonly fracture-dislocation • Open injuries common
- 79. Subtalar dislocation • dislocation of the talus at talo calcaneal and talo navicular joints • It most commonly occurs in young men • total talar dislocation
- 80. mech • Fall from height • Athletics • RTA • Inversion of the foot,medial subtalar(85%) • eversion produces a lateral subtalar dislocation.
- 81. c/m • Medial most common • followed by lateral • Severe pain • Gross deformity • Foot locked in supination with medial D&locked pronation with lateral D
- 82. imaging • AP, Lateral& mortise view • X-rays should not delay reduction if NV compromise or skin tenting present • CT scan
- 84. rx • Closed reduction • soft tissues rx • ORIF .
- 85. post • Pain Mx, • Reduce, splint, • Post-reduction films
- 86. summery • Acute dislocations should be reduced as soon as possible. • during reduction traction should be continuous, not jerking • Immediate reduction of an acute dislocation does not guarantee a satisfactory result, AVN post traumatic arthritis, Recurrence ectopic ossification nerve injury
- 87. Google