INJURIES TO JOINTS U.RADHAKRISHNAN.M.P.T

GRADES OF JOINT INJURY THREE GRADES OF JOINT INJURY OCCUR SUBLUXATION DISLOCATION FRACTURE DISLOCATION

DISLOCATION

SUBLUXATION There will be partial contact between Joint surfaces It seldom needs Active treatment The normal stability usually returns when periarticular tissues have healed

dislocation Joints have been completely dislocated No contact between Joint surfaces The Joints must be reduced and immobilized until the soft tissues have healed. COMPLICATIONS: Dislocation may be followed by Recurrent dislocation Eg.In Patella, In Shoulder. Aseptic Necrosis Chronic instability Osteoarthrosis

Fracture dislocation Dislocation accompanied by Fracture around the Joint. This dislocation heal more soundly than simple dislocation because bone unite more soundly than ligament. Treatment- Fixation of Bony fragment

Dislocation of the shoulder Shoulder Joint is mechanically unstable. TYPES OF SHOULDER DISLOCATION: 1.Anterior Dislocation 2.Posterior Dislocation 3.Luxatio erecta,or true Inferior dislocation 4.Fracture Dislocations 5. Multidirectional

Anterior dislocation of shoulder It is more commonest pattern MECHANISM OF DISLOCATION: Head of Humerus slipping off the front of Glenoid when the arm is abducted and Externally rotated. Anterior dislocations damage the attachment of labrum to the anterior glenoid margin (Bankart lesion). There may also be an associated fracture of anterior glenoid rim (bony Bankart lesion) or disruption of the glenohumeral ligaments. A compression fracture of the humeral head posteriorly (Hill-Sach lesion) or tearing of the posterior or superior labrum may also be present

CLINICAL FEATURES: i)The dislocated shoulder has characteristic appearance with a prominent humeral head and a hollow below the acromion. ii) Head slips medially when the arm is lowered iii) Flatter appearance of Shoulder( Deltoid muscle weakness) iv) Elbow points outwards

complications Damage to circumflex Axillary nerve Arterial damage Irreducibility Joint Stiffness Recurrent Dislocation

Medical management The sooner the dislocated shoulder is reduced, the easier it usually is to reduce. There are a number of methods to relocate the humeral head onto the glenoid cavity. one method is injection of 10-15 mL of xylocaine into the joint can reduce pain and muscle spasm and aid reduction The manoeuvre involves initial slight abduction and internal de-rotation of the affected arm. This can be done without applying a great deal of traction. The shoulder is then immobilised in a sling. An X-ray should still be performed post-reduction to rule out any associated fractures.

Stimson's technique: The patient is placed in a prone position on the bed. The affected shoulder is supported and the arm is left to hang over the edge of the bed. A weight is attached to the elbow/wrist. It is usual to begin with about 2 kg. Up to 10 kg may be applied. Gravity stretches the muscles and reduction occurs. Gentle internal/external humeral rotation may be applied. This method may take 15 to 20 minutes.

Stimson's technique

Posterior dislocation Posterior dislocation is far less common than anterior dislocation. It occurs either as a result of direct trauma or due to a fall on the outstretched arm that is in some degree of internal rotation or adduction. It may also be caused by a fits of any cause (e.g. electric shock or epileptic fits). Inspection of the patient's shoulder may reveal loss of the normal rounded appearance at the front of the shoulder. The arm is held in internal rotation and adduction. The cardinal sign is limitation of external rotation. Suspicion of a posterior dislocation should be based on the mechanism of injury and the presence of pain and impaired function.

Recurrent dislocation Dislocation of the shoulder is often associated with damage to the joint capsule (as in Bankart's and Hill-Sachs lesions) and this can lead to instability and predispose to recurrent dislocation. 80-94% of patients who have a dislocation under the age of 20 years will have a recurrence of their dislocation 26-48% of those younger than 40 years will have a recurrence 0-10% of those older than 40 years will have a recurrence] A single dislocation in a young man who plays contact sport may well merit referral to an orthopaedic surgeon to assess stability of the joint with a view to a stabilisation operation. Two dislocations in a young person certainly merit referral. There are several stabilisation procedures, dependent upon the nature of the lesion.

Further reading & references Wilson SR et al; Dislocation, Shoulder, eMedicine, Dec 2009 Anterior Instability of the Shoulder, Wheeless' Textbook of Orthopaedics Shoulder Dislocation: Associated Injuries, Wheeless' Textbook of Orthopaedics Posterior Shoulder Dislocation/Instability, Wheeless' Textbook of Orthopaedics Quillen DM, Wuchner M, Hatch RL; Acute shoulder injuries. Am Fam Physician. 2004 Nov 15;70(10):1947-54. Bankart Lesion, Wheeless' Textbook of Orthopaedics Work Up for Shoulder Dislocation, Wheeless' Textbook of Orthopaedics Mattick A, Wyatt JP; From Hippocrates to the Eskimo - a history of techniques used to reduce anterior dislocation of the shoulder. J.R.Coll.Surg.Edinb., 45,October 2000, 312-316 Hovelius L, Augustini BG, Fredin H, et al; Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996 Nov;78(11):1677-84. Handoll HH, Almaiyah MA, Rangan A; Surgical versus non-surgical treatment for acute anterior shoulder dislocation. Cochrane Database Syst Rev. 2004;(1):CD004325.