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Posterior Dislocation of Shoulder – Presentation and Treatment

September 28, 2008 By 2 Comments

Anteroposterior view of shoulder revealing posterior dislocation

Anteroposterior view of shoulder revealing posterior dislocation

Posterior dislocation is rarer as compared to anterior dislocation. When it occurs damage to the structures is much more owing to the force required for disruption of the joint.

These patients present with pain and deformity. The patients have much more pain than those with acute traumatic anterior dislocations.

After the clinical examination and xrays the diagnosis can be reached at with certainty. A greater damage to the glenoid and humeral head may be evident on xrays.

Careful note is made of associated fractures, including the extent of the impression fracture of the anteromedial humeral head.

Closed reduction should be caried out as soon as possible.

Because of associated muscle spasms, the reduction may not be achievable with sedation and muscle relaxants. [Read more...]

Popularity: 5% [?]

Filed Under: Dislocations, Shoulder Girdle Injuries Tagged With: , , ,

Recurrent Lateral Dislocation of Patella – Presentation

September 26, 2008 By Leave a Comment

Recurrent Lateral Subluxation

The typical patient is a teenage girl who becomes physically active in exercises or sports. The presenting complaint is pain in the knee in around or behind the patella especially on flexion.

There may be symptoms of giving way of knee and a swellingmight be present in the knee.  Locking and popping of the knee may also be present.

A grating sensation might occur when there is  chondromalacia.

Recurrent Dislocation

The dislocation is precipitated by sudden contraction of the quadriceps muscle  when  tibia is  in lateral rotation and the knee is in extension or slight flexion.

Diagnosis of acute dislocation is almost straightforward.

However, patient of recurrent dislocation is usually seen  between the episodes.

With knees flexed to 90 degrees, the posture of the patella will be lateral. In complete extension of the knee the patella slips medially and relocates in the femoral intercondylar groove. On flexion it is  again displaced laterally.

Apprehension test

While attempting to displace the patella laterally with the knee flexed 30 degrees and the quadriceps relaxed,exert latrally directed pressure with both thumbs pressing on the medial side of the patella.

Patient becomes fearful and uncomfortable when the patella reaches the point of maximum displacement and will resist and seize the examiner’s hand and straighten her knee to replace the patella in its relatively normal position.

This is referred to as Fairbank’s apprehension test.

Note: Try to do this test with knee extended and the sense of apprehension is not elicited. this happens because the patella moves readily on the flat condylar and supracondylar surface of the femur and not across the highest point of the lateral condyle.

Other findings that may be noted during examination are  limited  excursion of the patella medially with the knee in extension. The lateral soft tissue might be taut.

Tenderness may be elicited on compression of the patella and palpation over the medial retinaculum.

Knee defrmities like genu valgum and lateral torsional deformity of the tibia are usually present.

The patellar tendon may insert laterally with abnormal increase of the Q angle.

In case of high riding patella, the tendon may be elongated with a high-riding patella.  Hamstring spasm and knee swelling may be present

Popularity: 3% [?]

Filed Under: Dislocations Tagged With: , , ,

Recurrent Subluxation or Dislocation of the Patella – The Causes

September 26, 2008 By Leave a Comment

Recurrent dislocation of the patella is not a common entity. When it does occur, displacement is almost always lateral.

It may be congenital, developmental, or post-traumatic.

In contrast, recurrent subluxation of the patella is quite common. It is more common in females.

A familial tendency has been noted in recurrent subluxation of the patella.

Following causes have been thought of contributing to recurrent dislocation of patella

Ligaments Laxity

Laxity of the medial capsule of the knee is a definite factor. In children with diseases that cause ligamentous laxity (e.g. osteogenesis imperfecta, arachnodactyly, or the “Ehlers-Danlos syndrome), lateral dislocation is more common.

Lateral Patellar Soft Tissue Contracture

The lateral patellar retinaculum and patellofemoral ligament are taut. The vastus lateralis may be contracted, hypertrophied, and inserted low.

The iliotibial tract, a thickened strip of fascia lata may abnormally insert on lateral border of the patella. When the knee is flexed, it axis of iloitibial tract passes behind knee and contributes to subluxation of patella.

Muscular Imbalance

Atrophy, weakness, or a high oblique insertion of the vastus medialis is a factor in most patients. The vastus medialis is a dynamic medial stabilizer of the patella.

Malalignment of the Lower Limb

Lateral tibiofibular torsion, and genu valgum will displace the insertion of the patellar ligament laterally and cause valgus position of the quadriceps mechanism.

Q angle is the angle formed between the patellar tendon with a vertical line extended distally from the center of the inferior pole of the patella. Its value can  provide guide to the rotatory-angular forces.

Patella Alta

This is a high riding patella. In this the normal buttressing effect of the lateral femoral condyle, which serves to check the tendency to lateral patellar displacement, will be lost.

Injury

A traumatic lateral dislocation inadequately treated will result in stretching and weakening of the medial capsule of the knee and insufficiency of the vastus medialis, predisposing to recurrent lateral subluxation.

Popularity: 4% [?]

Filed Under: Dislocations Tagged With: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Recurrent Momentary Lateral Subluxation of the Tibiofemoral Joint

September 23, 2008 By Leave a Comment

This entity was first reported by Beals in 1978. In this condition there is  painful, spontaneous, audible popping  of one or both knees. This occurs in infants and children and the causative factor is lateral displacement of the tibiofemoral joint.

It appears to be caused by an isolated contraction of the biceps femoris muscle in association with capsular laxity.

Radiograms in the anteroposterior projection will show lateral subluxation of the tibiofemoral joint.

The proximal tibiofibular articulation is normal.

Treatment

Part-time splinting of the knee in extension will provide symptomatic relief of the painful, irritable knee. A conservative, nonsurgical approach to management should be followed

As the child gets older and the joint capsular hyperlaxity diminishes, the episodes of involuntary subluxation cease.

Popularity: 1% [?]

Filed Under: Pediatric Disorders Tagged With: , , , , , , ,

Treatment of Discoid Meniscus

September 21, 2008 By Leave a Comment

The menisci in the knee joint are required for

  • Compensation of incongruity between the femur and tibia
  • In the distribution of joint pressure
  • Shock absorber, for stabilization of the knee, in provision of rotation, in spreading of synovial fluid, and in nutrition of articular cartilage.

An intact meniscus transmits 70 to 90 percent of the total load across the knee joint. Therefore, it is desirable to preserve the meniscus whenever possible.

A conservative nonoperative method of management is recommended In the treatment of discoid meniscus  if pain and functional disability are minimal.

SIlent discoid menisci  require no treatment. however, they should be kept under observation.

Conservative measures

  • Immobilization of the knee
  • Restriction of physical activity
  • Progressive exercises for the quadriceps.

Operative Measures

If the knee locking persists their is functional disability or pain partial or complete excision of the discoid meniscus is indicated.

Diagnostic arthroscopy is carried out to know the pathologic changes and the type of discoid meniscus.

Partial resection of the discoid meniscus is preferred when it is of the complete or incomplete type with minimal tearing and slight degeneration

Excision of the entire meniscus is performed when it is of the Wrisberg type  or when it is torn and there is marked degenerations.

Popularity: 2% [?]

Filed Under: Joints Tagged With: , , , , , , , , , , , ,

Clinical Features and Imaging Findings of Discoid Meniscus

September 20, 2008 By Leave a Comment

The mere presence of a disc-shaped cartilage does not cause any problem.  Rather, the condition condition is often asymptomatic in infancy and early childhood.

By the sixth or eighth year of life the child may complain of following in the affected knee.

  • Snapping
  • Click
  • Giving way
  • Catching

Symptoms may be precipitated by a recent injury, especially in the adolescent.

On examination

  • Fullness may be detected in the lateral parapatellar area at the joint line.
  • Loud “clunk” is audible during the last 15 to 20 degrees of extension of the flexed knee.

The clunk is produced by the lateromedial movement of the semilunar cartilage.

On extension of the knee joint, the lateral meniscus does not remain in place under the lateral femoral condyle because it is not fixed posteriorly to the tibia, but is dislocated medially onto the intercondylar space by the pull of the short meniscofemoral ligament.

During flexion the ligament relaxes, and the lateral meniscus is replaced in its usual position by the contracting popliteus and coronary ligaments.

  • Atrophy of the thigh, joint effusion, and synovial thickening are significantly absent.
  • Unless connected with an injury, there is no functional disability.

Forced hyperextension of the knee may elicit pain on the lateral aspect of the joint.

Differential Diagnosis

Other causes of snapping of knee can be

  • Meniscall cyst
  • Congenital subluxation of the tibiofemoral joint
  • Abnormal movement of the popliteus tendon
  • Snapping of the tendons about the knee
  • Subluxation or dislocation of the proximal tibiofibular joint or of the patellofemoral joint.

Radiographic Imaging

Xrays

Increase in lateral joint space may be found on plain xray  if discoid meniscus is thick. Flattening of the lateral femoral condyleand cupping of the lateral aspect of the tibial plateau are other features

Magnetic resonance imaging

It will clearly depict the configuration of the menisci and is the ivestigation of choice.

Contrast arthrography

About 10 ml of a water soluble contrast agent  is injected into the infra-patellar synovial space through a lateral approach and anteroposterior, lateral oblique, medial oblique, poseroanterior, and lateral views are taken.

The diagnosis of discoid meniscus is made when the meniscus can be demonstrated extending to the intercondylar notch separating the cartilages of the lateral femoral condyle and lateral tibial plateau.

Popularity: 3% [?]

Filed Under: Joints, Musculoskeletal Anatomy Tagged With: , , , , , , , , , ,

Acute Anterior Dislocation of Shoulder – Treatment

September 20, 2008 By Leave a Comment

Like any other dislocation acute dislocations of the glenohumeral  or shoulder joint should be reduced as quickly and gently as possible. There are many advantages of early reduction of shoulder dislocation.

  • Eliminates the stretch and compression of neurovascular structures
  • Reduces amount of muscle spasm that must be overcome to effect reduction
  • Prevents further insult to  humeral head  and glenoid labrum

If patient reports within short time, some dislocations can be reduced without medication especially in thinly built patients. Reduction is difficult without medications if patient is very muscular , dislocation is of a long standing duration, the dislocation is locked in soft tissue. [Read more...]

Popularity: 1% [?]

Filed Under: Fractures-Dislocations, Shoulder Girdle Injuries, Sports Injuries Tagged With: , , , , ,

Acute Dislocation of Shoulder – Clinical Presentation

September 19, 2008 By Leave a Comment

There would be history of trauma to shoulder and patient would present with severe pain in the shoulder.
The shoulder would be held in position of typical attitude depending on direction of dislocation.

Anterior Dislocation

The physical examination is almost diagnostic.

Muscles are in spasm because there is an attempt to  stabilize the joint. The head of humerus may be palpable anteriorly especially in case of thin patients. The glenoid area appears  hollow. The attitude of uper limb is abduction and external rotation at the shoulder.

Patient is unable to perform adduction and internal rotation (Duga’s Test).

A detailed examinaton to look for neural and vascular injury should be done. Axillary nerve is a commonly injured nerve in anterior dislocaion of shoulder, therefore should be always looked for.

Posterior Dislocation

The shoulder is held in the traditional sling position of adduction and internal rotation. The classic features of a posterior dislocation include:

  • Limited external rotation of the shoulder
  • Limited elevation of the arm – often to less than 90 degrees
  • Posterior prominence and rounding of the shoulde
  • Flattening of the anterior aspect of the shoulder
  • Prominence of the coracoid process

In both kind of injuries treatment is reduction of the dislocation preferably closed

Popularity: 1% [?]

Filed Under: Shoulder Girdle Injuries, Sports Injuries Tagged With: , , , , ,

Radiographic Studies In Shoulder Dislocation

September 16, 2008 By Leave a Comment

Radiography is a very important aid in making and confirming diagnosis of shoulder dislocation. It also helps to find if any associated injuries.

To make a wholesome diagnosis of the injury, the physician needs to know the following

  • Direction of the dislocation
  • Existence of associated fractures
  • Difficulty if any in the reduction

Following views are used around the shoulder [Read more...]

Popularity: 1% [?]

Filed Under: Shoulder Girdle Injuries Tagged With: , , , ,

Acute Dislocation of Shoulder – Mechanism of Injury

September 15, 2008 By Leave a Comment

The shoulder joint is formed by four articulations

  • Sternoclavicular joint
  • Acromioclavicular Joint
  • Glenohumeral joint
  • Scapulothoracic joint

All of these joints work together  for smooth functioning of the shoulder.

Acute traumatic dislocation of shoulder is quite a common injury. The normal shoulder can become unstable as a result of trauma. Although the shoulder can be dislocated by direct trauma such as a blow directed at the proximal humerus, indirect force is the most common cause of shoulder sprain, subluxation, or dislocation. [Read more...]

Popularity: 2% [?]

Filed Under: Shoulder Girdle Injuries Tagged With: , , , , ,
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