Orthopedic Care and Consultation
Sixteen years male got injured due to fall of building and had anterior dislocation of right hip. Following photograph was taken before reduction maneuver was done.
It shows flexed and externally rotated right hip.
Clinical Photograph Shows A Flexed and Externally Rotated Hip
Here is the xray of the patient showing anterior dislocation. [Read more...]
In few case the dislocation of elbow might tend to become recurrent. It can either be acute or chronic.
Acute Recurrent Dislocation
This usually occurs when elbow suffers a serious trauma. This can occur in either of following situations
If it is due to soft tissue incompetency, the recurrence of the dislocation can be prevented by incrasng the flexion of the elbow when given a supporting splint and increasing the duration of the splint. Increased duration helps to regain the muscle tension and competence back. [Read more...]
These are rarer and unusual forms of dislocations of elbow.
Medial Dislocation of Elbow
Medial and lateral dislocations present with a widening of elbow. However, the relative lengths of the arm and forearm are not changed much.
The patient presents with typical symptoms of pain swelling and the diagnosis should be suspected if mediolateral widening of elbow is present.
Anteroposterior and lateral views are sufficient to make the diagnosis.
In the anteroposterior x-ray, a pure medial or lateral dislocation shows the greater sigmoid notch of the ulna in the plane of the distal humerus
The clinical diagnosis can be difficult in some cases especially in some patients of lateral dislocations with considerable swelling. [Read more...]
A dislocated elbow is considered neglected if it has been lying unreduced for three weeks or more. However, the chance for closed reduction is low even with traction if elbow has not been reduced for seven days.
There are many problems with a neglected elbow. Longer the elbow remains dislocated, more severe are the changes.
When the elbow remains out , the soft tissue starts getting contracted. This involves joint capsules, ligaments and other structures. This leads to contracture of the joint. In addition, there is shortening of triceps fibers leading to contractures of the triceps muscle. [Read more...]
The dislocation of the shoulder requires a sufficient amount of trauma to occur. The same trauma can cause injury to structures around the shoulder joint and lead to immediate and long term complications
Bony Complications
Fracture of humeral head is called Hill Sachs lesion. [Read more...]
The treatment of patellofemoral joint subluxation depends on the following factors.
A rough guide to management of this condition is as follow [Read more...]
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...]
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
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.
First case report of posterior dislocation of the sternoclavicular joint was describd by Rodrigues in 1843.
Injuries to the sternoclavicular joint are rare injuries. They could be anterior or posterior. Anterior dislocations are best treated nonoperatively and posterior dislocations, which is life threatening should be promptly diagnosed and reduced. Special x-rays are usually required to make the diagnosis and the computed tomography scan will present the clearest findings of the fracture or dislocation.
Mechanism of Injury
Either direct or indirect force can produce a dislocation of the sternoclavicular joint. Because the sternoclavicular joint is subject to practically every motion of the upper extremity and the joint is small and incongruous but the ligamentous supporting structure is strong and designed to make the joint less dislocatable.
A traumatic dislocation of the sternoclavicular joint usually occurs only after tremendous forces, either direct or indirect, have been applied to the shoulder.
Direct Injury
When a force is applied directly to the anteromedial aspect of the clavicle, the clavicle is pushed posteriorly behind the sternum and into the mediastinum. Anatomically, it is essentially impossible for a direct force to produce an anterior sternoclavicular dislocation.
Indirect Force
A force act indirectly on the sternoclavicular joint from the anterolateral or posterolateral aspects of the shoulder. This is the most common mechanism of injury to the sternoclavicular joint.
If the shoulder is compressed and rolled forward, an ipsilateral posterior dislocation results. if the shoulder is compressed and rolled backward, an ipsilateral anterior dislocation results.
One of the most common causes of injury is a pile-on in a football game. A player falls on the ground, landing on the lateral shoulder; before he can get out of the way, several players pile on top of his opposite shoulder, which applies significant compressive force on the clavicle down toward the sternum.
Other types of indirect forces that can produce sternoclavicular dislocation are
The most common cause of dislocation of the sternoclavicular joint is vehicular accidents folllowed by sports.
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