DISLOCATION
DEFINITION
A joint is dislocated when its articular surfaces are completely displaced, one from the other, so that
all contact between them is lost.
CLASSIFICATION ON THE BASIS OF AETIOLOGY
1. CONGENITAL DISLOCATION
Congenital dislocation is a condition where a joint is dislocated at birth e.g., congenital dislocation
of the hip (CDH).
2. ACQUIRED DISLOCATION
Acquired dislocation may occur at any age.
Types of Acquired Dislocation
a. TRAUMATIC DISLOCATION
Injury is by far the commonest cause of dislocations and sub-luxa tions at almost all joints.
The force required to dislocate a particular joint varies from joint to joint.
DIFFERENT TYPES OF TRAUMATIC DISLOCATIONS
TYPES DEFINITION EXAMPLE
1. ACUTE This is an episode of dislocation where the force of Shoulder dislocation
TRAUMATIC injury is the main contributing factor .
DISLOCATION
2. OLD A traumatic dislocation, not reduced, may present Old posterior
UNREDUCED as an old unreduced dislocation . dislocation of the hip
DISLOCATION
In some joints, proper healing does not occur after Recurrent dislocation
3. RECURRENT the first dislocation. of the shoulder and
DISLOCATION This results in weakness of the supporting patella
structures of the joint so that the joint dislocates
repeatedly, often with trivial trauma.
4. FRACTURE- When a dislocation is associated with a fracture of A dislocation of the
DISLOCATION one or both of the articulating bones, it is called hip is often
fracture dislocation. associated with a
fracture of the lip of
the acetabulum
b. PATHOLOGICAL DISLOCATION
The articulating surfaces forming a joint may be destroyed by an infective or a neoplastic process, or
the ligaments may be damaged due to some disease.
This results in dislocation or subluxation of the joint without any trauma e.g., dislocation of the hip
in septic arthritis.
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PATHOLOGY
Dislocation cannot occur without damage to the protective ligaments or joint capsule.
Usually the capsule and one or more of the reinforcing ligaments are torn
Permitting the articular end of the bone to escape through the rent
Sometimes, the capsule is not torn in its substance but is stripped from one of its bony attachments
Rarely, a ligament may withstand the force of the injury so that instead of ligament rupture, a fragment
of bone at one of its attachments may be chipped off (avulsed).
At the time of dislocation, as movement occurs between the two articulating surfaces
A piece of articular cartilage with or without its underlying bone may be ‘shaved off’
Producing an osteochondral fragment within the joint.
CLINICAL FEATURES
1. Pain
2. Loss of function
3. Deformity
4. Restricted mobility
RADIOLOGICAL EXAMINATION
1. X-ray should always be taken in two planes at right angles to each other
2. CT scan may also be of help.
COMPLICATIONS
EARLY LATE
1. Recurrence 1. Recurrence
2. Myositis Ossificans 2. Osteoarthritis
3. Persistent Instability 3. Avascular Necrosis.
4. Joint Stiffness
TREATMENT
1. ACUTE TRAUMATIC DISLOCATION
urgent reduction of the dislocation by:
a. Conservative methods
A dislocation may be reduced by closed manipulative manoeuvres.
Prolonged traction may be required for reducing some dislocations.
b. Operative methods
Operative reduction in case of:
i. Fracture-dislocation
ii. Old unreduced dislocations
2. RECURRENT DISLOCATIONS
An individual episode is treated like a traumatic dislocation.
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For prevention of recurrences, reconstructive proce -dures are required.
DISLOCATION OF SHOULDER JOINT
DEFINITION
When the head of humerus is displaced and loses contact with the glenoid cavity, the condition is called dislocation of shoulder.
CLASSIFICATION
1. Anterior Dislocation In this injury, the head of the humerus comes out of the
glenoid cavity and lies anteriorly.
I. ACUTE DISLOCATION 2. Posterior Dislocation In this injury, the head of the humerus comes to lie
posteriorly, behind the glenoid.
3. Inferior Dislocation (Luxation Erecta) The head comes to lie in the subglenoid position.
II. RECURRENT
DISLOCATION
I. ACUTE DISLOCATION
1. ANTERIOR DISLOCATION
DEFINITION
In this injury, the head of the humerus comes out of the glenoid cavity and lies anteriorly.
CAUSES
1. Fall on hand with external rotation of shoulder.
2. Violence of the joint with upper arm in abduction.
3. Wide range of movement.
CLASSIFICATION
1. Preglenoid The head lies in front of the glenoid.
2. Subcoracoid The head lies below the coracoid process. Most common type of dislocation.
3. Subclavicular The head lies below the clavicle.
PATHOLOGICAL CHANGES
1. Bankart's lesion Avulsion of a piece of bone from antero-inferior glenoid rim.
2. Hill-Sachs lesion This is a depression on the humeral head in its postero-lateral quadrant.
3. Rounding off of the anterior glenoid rim Occurs in chronic cases as the head dislocates repeatedly over it.
4. Associated injuries Fracture of greater tuberosity
Rotator-cuff tear
Chondral damage
CLINICAL FEATURES
1. Extreme pain and swelling of affected shoulder joint.
2. Pt. resents any movement of shoulder.
3. Arm may not always lie by the side, may be in slight abduction.
DIAGNOSIS
1. Gap under the edge of acromion due to absence of humeral head.
2. On palpation just below the coracoid process, head of humerus may be felt there.
3. Flattened shoulder.
4. Abnormal prominence of acromion due to absence of humeral head.
5. Few tests are performed:`
1. Dugas' Test Inability to touch the opposite shoulder.
2. Hamilton Ruler Test Because of the flattening of the shoulder, it is possible to place a ruler on the lateral side of
the arm. This touches the acromion and lateral condyle of the humerus simultaneously.
3. Callway’s Test Vertical circumference of axilla is increased in comparison to the other side.
4. Bryant’s Test Anterior & posterior folds of axilla are at different levels.
6. X-ray – Trans Lateral View.
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7. CT scan
TREATMENT
1. Reduction under sedation or general anaesthesia
2. Followed by immobilisation of the shoulder in a chest-arm bandage for three weeks.
3. After the bandage is removed, shoulder exercises are begun.
TECHNIQUES OF REDUCTION OF SHOULDER DISLOCATION
This is the most commonly used method.
The steps are as follows:
(i) Traction— with the elbow flexed to a right angle steady traction is applied along the long axis of the
1. KOCHER'S humerus;
MANOEUVRE (ii) External rotation—the arm is rotated externally
(iii) Adduction—the externally rotated arm is adducted by carrying the elbow across the body towards
the midline;
(iv) Internal rotation – the arm is rotated internally so that the hand falls across to the opposite shoulder.
In this method, the surgeon applies a firm and steady pull on the semiabducted arm.
2. HIPPOCRATES
He keeps his foot in the axilla against the chest wall.
MANOEUVRE
The head of the humerus is levered back into position using the foot as a fulcrum.
Manoeuvre is performed without GA.
Pethidine 200 mg is administered.
3. GRAVITATIONAL Pt. lies prone on the table.
TRACTION
Place a sandbag under the clavicle and arm is allowed to hang over the side of table.
Maintain the same position
Shoulder is reduced within an hour
2. POSTERIOR DISLOCATION
CAUSES
1. Due to fall on outstretched hand and internally rotated head.
2. Direct blow on the front of the shoulder.
3. Forced internal rotation of the abducted shoulder.
CLINICAL FEATURES
1. Pain
2. Deformity
3. Local tenderness
INVESTIGATIONS
1. X-Ray – Axial lateral or translateral view
TREATMENT
1. Arm is abducted at 90⁰ and traction is applied
Then externally rotated
On complete reduction, arm is rested in a broad arm sling.
II. RECURRENT DISLOCATION
DEFINITION
When the shoulder dislocates repeatedly with decreasing trauma, the condition is known as recurrent dislocation.
It is usually an anterior dislocation.
CLINICAL FEATURES
1. Dislocation of shoulder with trivial trauma.
2. Self-reduction of shoulder.
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3. Sudden external rotation of shoulder.
TREATMENT
1. Putti-Platt operation 3. Bristow's operation
2. Bankart's operation 4. Arthroscopic Bankart repair
DISLOCATION OF THE ELBOW JOINT
CRITERIA POSTERIOR DISLOCATION ANTERIOR DISLOCATION
DEFINITION Forearm is pushed backwards. Forearm is pushed upwards.
CAUSES 1. Fall on outstretched hand 1. Fall on the elbow
2. Spasm of triceps muscle 2. Associated with fracture of olecranon,
humerus shaft, ulna, radius.
C/F 1. Deformity and swelling of elbow
2. Pt. supports affected elbow with hand ----------------------
INVESTIGATIONS X-Ray X-Ray
TREATMENT Reduction under anaesthesia followed by immobilisation Reduction by traction
in an above-elbow plaster slab for 3 weeks
COMPLICATIONS 1. Joint stiffness
2. Myositis ossificans
3. Median and Ulnar Nerve injury
4. Vascular injury
DISLOCATIONS OF THE HIP JOINT
CLASSIFICATION
I. CONGENITAL DISLOCATION
1. Pathological Dislocation May be seen in TB or RA.
2. Paralytic Dislocation Following poliomyelitis
II. ACQUIRED DISLOCATION a. Anterior Dislocation
3. Traumatic Dislocation b. Posterior Dislocation
c. Central Dislocation
DESCRIPTION OF DISLOCATIONS
CRITERIA POSTERIOR DISLOCATION ANTERIOR DISLOCATION CENTRAL DISLOCATION
The head of the femur is pushed out of This is a rare injury In this common injury, the femoral
the acetabulum posteriorly. head is driven through the medial
DEFINIITON wall of the acetabulum towards the
pelvic cavity.
1. The injury is sustained by violence 1. Legs are forcibly abducted 1. Fall on side or a blow on greater
directed along the shaft of the femur, and externally rotated. trochanter which breaks floor of the
with the hip flexed. 2. Fall from a tree when the acetabulum and drives the head of
2. It requires a moderately severe force to foot gets stuck and the hip femur through the floor of the
dislocate a hip, as often occurs in abducts excessively, or in a acetabulum into the pelvis.
motor accidents. road accident.
CAUSES 3. The occupant of the car is thrown
forwards and his knee strikes against
the dashboard. The force is transmitted
up the femoral shaft, resulting in
posterior dislocation of the hip. It is,
therefore, also known as Dashboard
Injury.
1. REGULAR DISLOCATION 1. PUBIC TYPE
Iliofemoral ligament is placed When the head of fgemur
anteriorly and remains intact when lies in front of pubis.
TYPES the dislocation of hip has taken ---------------------------------------------
place. 2. OBTURATOR TYPE
2. IRREGULAR DISLOCATION When head lies in front of
When iliofemoral ligament is obturator foramen i.e.
completely torn. almost in the perineum.
1. H/O severe trauma followed by pain, 1. The limb is in an attitude of 1. Swelling and bruises in the
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swelling and deformity (flexion, external rotation, flexion, trochanteric region
adduction and internal rotation). abduction.
C/F 2. Shortening of the leg. 2. There may be true
3. One may be able to feel the head of lengthening, with the head
the femur in the gluteal region. palpable in the groin.
CRITERIA POSTERIOR DISLOCATION ANTERIOR DISLOCATION CENTRAL DISLOCATION
X-Ray : Shenton’s Line is distorted. X-Ray : Shenton’s Line is X-Ray:
CT scan distorted. a. shows fracture of floor of
INVESTIGATIONS acetabulum
b. femoral head is displaced
medially into pelvis.
1. Technique of Closed Reduction 1. Reduction : 1. Reduction :
The patient is anaesthetised and placed Same as posterior Under GA, pull thigh strongly
supine on the floor dislocation . and femoral head is levered
Under GA, hip is flexed, outwards by adducting the
An assistant grasps the pelvis firmly abducted, and external thigh.
rotation are corrected by 2. Immobilisation :
The surgeon flexes the hip and knee at a medial rotating and Traction is applied distally and
right angle and exerts an axial pull adducting the hip. laterally for 3 weeks with 15
TREATMENT 2. Immobilisation pounds weight.
Usually one hears a‘sound’ of reduction, Fixed skin traction in a 3. Rehabilition :
after which it becomes possible to move Thomas Splint for 4 After traction has been pulled
the hip freely in all directions weeks and then off, patient may be allowed up
moblisation on bed for with crutches.
The leg is kept in light traction with the hip further 2 weeks before No weight bearing for 8 weeks.
abducted, for 3 weeks. wieght bearing.
2. Immobilisation Skeletal traction for 3
Fixed skin traction in a Thomas weeks through tibial
Splint for 4 weeks and then tubercle
moblisation on bed for further 2
weeks before wieght bearing.
Skeletal traction for 3 weeks
through tibial tubercle
1. Injury to the sciatic nerve 1. Femoral nerve injury 1. Osteoarthrosis
2. Avascular necrosis of the femoral head 2. Obturator nerve injury 2. Hip stiffness
COMPLICATIONS 3. Late OA of hip 3. Avascular necrosis of femoral 3. Myositis ossificans
4. Myositis ossificans head
5. Unreduced dislocation 4. Secondary OA
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