Joint Instability.hen

8/12/2019 Joint Instability.hen

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Joint Instability

Hendradi Khumarga SPOT. FICS


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Definition

Lackof stabilityof a jointor joint prosthesis.

Factorsinvolvedare intra-articulardiseaseand integrityof extra-articular structuressuch as joint capsule,ligaments, and muscles

A very rare syndrome characterized mainly byloose joints. Joint dislocations tend to occurmainly in the shoulders, hips and kneecap.
http://www.mondofacto.com/facts/dictionary?Lackhttp://www.mondofacto.com/facts/dictionary?stabilityhttp://www.mondofacto.com/facts/dictionary?jointhttp://www.mondofacto.com/facts/dictionary?joint+prosthesishttp://www.mondofacto.com/facts/dictionary?Factorshttp://www.mondofacto.com/facts/dictionary?involvedhttp://www.mondofacto.com/facts/dictionary?articularhttp://www.mondofacto.com/facts/dictionary?diseasehttp://www.mondofacto.com/facts/dictionary?integrityhttp://www.mondofacto.com/facts/dictionary?extrahttp://www.mondofacto.com/facts/dictionary?structureshttp://www.mondofacto.com/facts/dictionary?joint+capsulehttp://www.mondofacto.com/facts/dictionary?ligamentshttp://www.mondofacto.com/facts/dictionary?muscleshttp://www.mondofacto.com/facts/dictionary?muscleshttp://www.mondofacto.com/facts/dictionary?ligamentshttp://www.mondofacto.com/facts/dictionary?joint+capsulehttp://www.mondofacto.com/facts/dictionary?structureshttp://www.mondofacto.com/facts/dictionary?extrahttp://www.mondofacto.com/facts/dictionary?integrityhttp://www.mondofacto.com/facts/dictionary?diseasehttp://www.mondofacto.com/facts/dictionary?articularhttp://www.mondofacto.com/facts/dictionary?involvedhttp://www.mondofacto.com/facts/dictionary?Factorshttp://www.mondofacto.com/facts/dictionary?joint+prosthesishttp://www.mondofacto.com/facts/dictionary?jointhttp://www.mondofacto.com/facts/dictionary?stabilityhttp://www.mondofacto.com/facts/dictionary?Lackhttp://www.mondofacto.com/facts/dictionary?Lack


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Joint laxity, familial: Causes and Types

Genetic conditions

Joint conditions Musculoskeletal conditions
http://www.wrongdiagnosis.com/g/genetic/intro.htmhttp://www.wrongdiagnosis.com/r/rheumatic_conditions/intro.htmhttp://www.wrongdiagnosis.com/m/musculoskeletal_conditions/intro.htmhttp://www.wrongdiagnosis.com/m/musculoskeletal_conditions/intro.htmhttp://www.wrongdiagnosis.com/r/rheumatic_conditions/intro.htmhttp://www.wrongdiagnosis.com/g/genetic/intro.htm


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Causes

Familial Cause: Joint laxity, familial

Joint laxity, familial has been identified as tending tooccur in family members. A familial cause may be froma common environmental influence or may be genetic.


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Symptoms of Joint instability syndrome (Joint

laxity, familial)

Loose joints

Dislocated joints Dislocated kneecap

Dislocated shoulder

Dislocated hips
http://www.wrongdiagnosis.com/sym/joint_symptoms.htmhttp://www.wrongdiagnosis.com/s/shoulder_dislocation/intro.htmhttp://www.wrongdiagnosis.com/sym/dislocated_hip.htmhttp://www.wrongdiagnosis.com/sym/dislocated_hip.htmhttp://www.wrongdiagnosis.com/s/shoulder_dislocation/intro.htmhttp://www.wrongdiagnosis.com/sym/joint_symptoms.htm


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Dislocated joints

Joint dislocation, or luxation(Latin: luxatio) [1], occurs when

bones in a jointbecome displaced or misaligned.

It is often caused by a sudden impact to the joint. The ligamentsalways become damaged as a result of a dislocation. A

subluxationis a partial dislocation.
http://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Ligamenthttp://en.wikipedia.org/wiki/Joint


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Epidemiology

Although it is possible for any joint to become subluxed ordislocated, the most common sites it is seen in the human bodyare:

Shoulders

Fingers

Knees (Most likely by accompanied by a fracture)

Elbows (Most likely by accompanied by a fracture)


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Joint dislocation

Classification and external resources

A traumatic dislocation of the tibiotalar jointof the ankle with distal fibularfracture. Open arrow marks the tibiaand the closed arrow marks the talus
http://en.wikipedia.org/wiki/Tibiotalar_jointhttp://en.wikipedia.org/wiki/Fibularhttp://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Talushttp://en.wikipedia.org/wiki/Talushttp://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Fibularhttp://en.wikipedia.org/wiki/Tibiotalar_joint


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Dislocated joints


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Treatment

A dislocated joint usually can only be successfully 'reduced' intoits normal position by a trained medical professional.

Trying to reduce a joint without any training could result inmaking the injury substantially worse.

X-rays are usually taken to confirm a diagnosis and detect any

fractures which may also have occurred at the time ofdislocation.


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Treatment

Once a diagnosis is confirmed, the joint is usually manipulatedback into position. This can be a very painful process, thereforethis is typically done either in A&E under sedationor in anOperating Room under a general anaesthetic.

It is important the joint is reduced as soon as possible, as in thestate of dislocation, the blood supply to the joint (or distalanatomy) may be compromised. This is especially true in the case

of a dislocated ankle, due to the anatomy of the blood supply tothe foot.
http://en.wikipedia.org/wiki/Sedationhttp://en.wikipedia.org/wiki/General_anaesthetichttp://en.wikipedia.org/wiki/General_anaesthetichttp://en.wikipedia.org/wiki/Sedation


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Treatment

Shoulder injuries can also be surgically stabilized, depending on the severity,using arthroscopic surgery.

Some joints are more at risk of becoming dislocated again after an initialinjury. This is due to the weakening of the muscles and ligaments which hold

the joint in place. The shoulder is a prime example of this. Any shoulderdislocation should be followed up with thorough physiotherapy.

There are some medical conditions by where joint dislocations are frequentand spontaneous, such as Ehlers-Danlos syndromeand congenital hipdysplasia.
http://en.wikipedia.org/wiki/Ehlers-Danlos_syndromehttp://en.wikipedia.org/wiki/Hip_dysplasia_(human)http://en.wikipedia.org/wiki/Hip_dysplasia_(human)http://en.wikipedia.org/wiki/Hip_dysplasia_(human)http://en.wikipedia.org/wiki/Hip_dysplasia_(human)http://en.wikipedia.org/wiki/Ehlers-Danlos_syndromehttp://en.wikipedia.org/wiki/Ehlers-Danlos_syndromehttp://en.wikipedia.org/wiki/Ehlers-Danlos_syndrome


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After care

After a dislocation, injured joints are usually held inplace by a splint(for straight joints like fingers and toes)or a bandage(for complex joints like shoulders).

Additionally, the joint muscles, tendons and ligamentsmust also be strengthened. This is usually done througha course of physiotherapy, which will also help reduce

the chances of repeated dislocations of the same joint.
http://en.wikipedia.org/wiki/Splint_(medicine)http://en.wikipedia.org/wiki/Bandagehttp://en.wikipedia.org/wiki/Physiotherapyhttp://en.wikipedia.org/wiki/Physiotherapyhttp://en.wikipedia.org/wiki/Bandagehttp://en.wikipedia.org/wiki/Splint_(medicine)


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Dislocated shoulder

A dislocated shoulderoccurs when the humerusseparatesfrom the scapulaat the glenohumeral joint.

The shoulder joint has the greatest range of motion of any joint

in the body and as a result is particularly susceptible todislocation and subluxation.

Approximately half of major joint dislocationsseen in

emergency departments are of the shoulder.

Partial dislocation of the shoulder is referred to as subluxation.
http://en.wikipedia.org/wiki/Humerushttp://en.wikipedia.org/wiki/Scapulahttp://en.wikipedia.org/wiki/Glenohumeral_jointhttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Joint_dislocationhttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Joint_dislocationhttp://en.wikipedia.org/wiki/Subluxationhttp://en.wikipedia.org/wiki/Glenohumeral_jointhttp://en.wikipedia.org/wiki/Scapulahttp://en.wikipedia.org/wiki/Humerus


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Dislocated shoulder

The left shoulder and acromioclavicular joints, and the proper ligaments ofthe scapula


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Anterior (forward)

Over 95% of shoulder dislocationcases are anterior.

Most anterior dislocations are sub-coracoid. Sub-glenoid; subclavicular;

and, very rarely, intrathoracicorretroperitonealdislocations may occur.

It can result in damage to the axillaryartery.
http://en.wikipedia.org/wiki/Coracoidhttp://en.wikipedia.org/wiki/Glenoidhttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Intrathoracichttp://en.wikipedia.org/wiki/Retroperitonealhttp://en.wikipedia.org/wiki/Axillary_arteryhttp://en.wikipedia.org/wiki/Axillary_arteryhttp://en.wikipedia.org/wiki/Axillary_arteryhttp://en.wikipedia.org/wiki/Axillary_arteryhttp://en.wikipedia.org/wiki/Retroperitonealhttp://en.wikipedia.org/wiki/Intrathoracichttp://en.wikipedia.org/wiki/Claviclehttp://en.wikipedia.org/wiki/Glenoidhttp://en.wikipedia.org/wiki/Coracoid


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Posterior (backward)

Posterior dislocations are occasionally due to electrocutionorseizure and may be caused by strength imbalance of the rotatorcuff muscles.

Posterior dislocations often go unnoticed, especially in an elderlypatient and in the unconscious trauma patient.

An average interval of 1 year was discovered between injury and

diagnosis of posterior dislocation in a series of 40 patients.
http://en.wikipedia.org/wiki/Electric_shockhttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Electric_shock


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Inferior (downward)

Inferior dislocation is the least likely form,occurring in less than 1% of all shoulderdislocation cases.

This condition is also called luxatio erectabecause the arm appears to be permanentlyheld upward or behind the head.

It is caused by a hyper abduction of the armthat forces the humeral head against theacromion.

Inferior dislocations have a highcomplication rate as many vascular,

neurological, tendon, and ligament injuriesare likely to occur from this kind ofdislocation.


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Signs

Significant pain, which can sometimes be felt past the shoulder, along the arm.

Inability to move the arm from its current position, particularly in positionswith the arm reaching away from the body and with the top of the armtwisted toward the back.

Numbness of the arm.

Visibly displaced shoulder. Some dislocations result in the shoulder appearingunusually square.

No bone in the side of the shoulder showing shoulder has become dislocated.


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Treatment

Prompt professional medical treatment should be sought for any suspected dislocationinjury.

Usually, a dislocated shoulder is kept in its current position by use of a splint or sling(however, see below). A pillow between the arm and torso may provide support and

increase comfort. Ice may help reduce pain.

Emergency department care is focused on returning the shoulder to its normalposition via processes known as reduction. Normally, closed reduction, in whichseveral methods are used to manipulate the bone and joint from the outside, is used.

A variety of techniques exist, but some are preferred due to fewer complications oreasier execution.

In cases where closed reduction is not successful, surgical open reduction may beneeded.
http://en.wikipedia.org/wiki/Reduction_(orthopedic_surgery)http://en.wikipedia.org/wiki/Reduction_(orthopedic_surgery)


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Treatment

Following reduction, X-Rayimaging is often used to ensure that the reductionwas successful and there are no fractures. The arm should be kept in a sling orimmobilizer for several days, preferably until orthopedic consultation.

Hippocrates' and Kocher's method are rarely used anymore. Hippocrates usedto place the heel in the axilla and reduce shoulder dislocations. Kocher'smethod if performed patiently and slowly can be performed withoutanesthesia and if done correctly does not cause pain.

Traction is applied on the arm and it is abducted. Then, it is externallyrotated, and the arm is adducted following which it is internally rotated andmaintained in the position with the help of a sling. A chest x-ray should betaken to confirm whether the head of humerus has reduced back into theglenoid cavity.
http://en.wikipedia.org/wiki/X-Rayhttp://en.wikipedia.org/wiki/Hippocrateshttp://en.wikipedia.org/wiki/Hippocrateshttp://en.wikipedia.org/wiki/X-Rayhttp://en.wikipedia.org/wiki/X-Rayhttp://en.wikipedia.org/wiki/X-Ray


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Post-reduction: immobilisation in external versus

internal rotation

For thousands of years, treatment of anterior shoulder dislocation hasincluded immobilisation of the patient's arm in a sling, with the arm placed ininternal rotation (across the body).

However, three studies, one in cadavers and two in patients, suggest that thedetachment of the structures in the front of the shoulder is made worse whenthe shoulder is placed in internal rotation to be seen.

By contrast, the structures are realigned when the arm is placed in externalrotation. New data suggest that if the shoulder is managed non-operativelyand immobilised, it should be immobilised in a position of external rotation.

Another study found that conventional shoulder immobilisation in a slingoffered no benefit


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Surgery

Some cases require non-emergency surgery to repair damage to the tissues surroundingin the shoulder joint and restore shoulder stability.

Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsularligaments, bicepslong head anchor or SLAP lesionand/or to tighten the shouldercapsule.

The time-proven surgical treatment for recurrent anterior instability of the shoulder isa Bankart repair.

When the front of the shoulder socket has been broken or worn, a bone graft may berequired to restore stability [. When the shoulder dislocates posteriorly (out the back), asurgery to reshape the socket may be necessary .

Conversly, there are new procedures that should be investigated as a possiblealternative to open surgery.
http://en.wikipedia.org/wiki/Glenoidal_labrumhttp://en.wikipedia.org/wiki/Capsular_ligamentshttp://en.wikipedia.org/wiki/Capsular_ligamentshttp://en.wikipedia.org/wiki/Biceps_brachii_musclehttp://en.wikipedia.org/wiki/SLAP_tearhttp://en.wikipedia.org/wiki/SLAP_tearhttp://en.wikipedia.org/wiki/Biceps_brachii_musclehttp://en.wikipedia.org/wiki/Capsular_ligamentshttp://en.wikipedia.org/wiki/Capsular_ligamentshttp://en.wikipedia.org/wiki/Glenoidal_labrum


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Kneecap dislocation

Kneecap dislocation occurs when the triangle-shaped bone covering the knee (patella) movesor slides out of place.

The problem usually occurs toward the outsideof the leg.


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Left knee-joint from behind, showing interior ligaments.


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Capsule of right knee-joint (distended). Lateral aspect.


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Patellar dislocation

Dislocation usuallyoccurs as a result ofsudden direction changes

while running and theknee is under stress or itmay occur as a directresult of injury.


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Causes

A dislocated kneecap most often occurs in women. It isusually a result of sudden direction changes whilerunning. This puts the knee under stress.

Dislocation may also occur as a direct result of injury.When it is dislocated, the kneecap may slip sidewaysand around to the outside of the knee.


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Symptoms

Kneecap (patella) moves to the outside of the knee

Knee painand tenderness

Knee swelling

"Sloppy" kneecap -- you can move the kneecap excessively from right to left(hypermobile patella)

The first few times this occurs, you will feel pain and be unable to walk.However, if dislocations continue to occur and are untreated, you may feelless pain and have less immediate disability. This is not a reason to avoidtreatment.

Kneecap dislocation damages your knee joint.


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First Aid

Stabilize (splint) the knee with the leg fully straight (extended), and get medical attention.

Your health care provider will examine the knee, which could confirm that the kneecap isdislocated.

A knee x-rayand, sometimes, MRIs should be done to make sure that the dislocation did not

cause a bone to break or cartilage to be damaged.

If tests show that you have no such damage, your knee will be placed into an immobilizer or castto prevent you from moving it for several weeks (usually about 3 weeks).

After this time, physical therapy can help build back your muscle strength and improve the knee'srange of motion.

If the knee remains unstable, you may need surgery to stabilize the kneecap. This may be doneusing arthroscopicor open surgery.


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Prevention

Use proper techniques when exercising or playingsports. Keep your knee strong and flexible.

Some cases of knee dislocation may not be preventable,especially if anatomic factors make you more likely todislocate your knee.


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Dislocated Hip

Background

Hip dislocations can be classified into congenital and traumatic.

The annual incidence of congenital hip dislocation is approximately 2-4 cases

per 1000 births, and approximately 80-85% of the affected individuals aregirls.

Congenital hip dislocations are commonly the result of femoral head oracetabular dysplasia.


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Pathophysiology

The hip is a modified ball-socket joint. Thefemoral head is situated deep within theacetabular socket, which is further enhancedby a cartilaginous labrum.

The hip is also bolstered by a fibrous jointcapsule, the ischiofemoral ligament, and

many strong muscles of the upper thigh andgluteal region.

Because of this anatomic configuration, thehip is stable, subsequently, a large force isrequired to dislocate the joint.

Since a high force mechanism is required,other life-threatening injuries and fracturesare common.


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Dislocated Hip

Motor vehicle crashes (MVC) account for almost twothirds of traumatic hip dislocations.

Falls from height and sports injuries are also commoncauses of hip dislocations.

The relationship of the femoral head to the acetabulum

is used to classify hip dislocations. The 3 main patternsare posterior, anterior, and central.


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Posterior dislocation

Posterior dislocations compromiseapproximately 80-90% of hipdislocations caused by MVCs.

The femoral head is situated posteriorto the acetabulum.

During a MVC, force is transmitted tothe flexed hip in one of two ways.During rapid deceleration, the kneesstrike the dashboard and transmit theforce through the femur to the hip.

If the leg is extended and the knee islocked, force can be transmitted fromthe floorboard though the entire lowerand upper leg to the hip joint.


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Anterior dislocation

The femoral head is situated anterior to the acetabulum.An anterior dislocation is most commonly caused by a

hyperextension force against an abducted leg that leversthe femoral head out of the acetabulum. Lesscommonly, an anterior force against the posteriorfemoral neck or head can produce this dislocation

pattern.


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Central dislocation

A central dislocation is afracture-dislocation, thefemoral head lies medial to afractured acetabulum.

This is caused by a lateralforce against an adductedfemur seen in side impactMVCs.


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Clinical

A high index of suspicion for hip dislocation must be present wheneverevaluating a patient involved in a major trauma such as an MVC, significantfall, or an athletic injury.

Patients with a hip dislocation will be in severe pain. They may complain ofpain to the lower extremities, back, or pelvic areas.

Patients will have difficulty moving the lower extremity on the affected sideand may complain of numbness or paresthesias.

Frequently, patients will be a victim of multiple trauma and may not pinpointpain to the hip as a result of altered mental status or distracting injuries.

Patients with a total hip replacement may present differently


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Physical

As with any major trauma victim, assessment of theairway, breathing, and circulation are of primaryimportance. During the secondary survey, an

examination of the pelvic girdle and hip aremandatory. Examination should consist of inspection,palpation, active/passive range of motion, and aneurovascular examination.


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Physical

InspectionIsolated anterior and posterior dislocations have classic appearances. In practice, theseappearances may be altered by the presence of fracture-dislocations or other bonyabnormalities along the leg.

Posterior: The hip is flexed, internally rotated, and adducted.

Anterior: The hip is minimally flexed, externally rotated and markedlyabducted

PalpationPalpate the pelvis and lower extremity for any gross bony deformities or step-offs. Inan anterior hip dislocation, the femoral head can occasionally be palpated. Largehematomas may signify vascular injury.

Range of motionPatients with a hip dislocation have severely limited range of motion. Evaluate whatthe patient can do comfortably. Do not forcefully perform range of motion on apatient who cannot tolerate manipulation. Normal, painless rangeof motion virtually excludes hip dislocation.


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Physical

Neurovascular examinationSigns of sciatic nerve injury include the following: Loss of sensation in posterior leg and foot Loss of dorsiflexion (peroneal branch) or plantar flexion (tibial branch) Loss of deep tendon reflexes (DTRs) at the ankle

Signs of femoral nerve injury include the following:Loss of sensation over the thighWeakness of the quadricepsLoss of DTRs at knee

Signs of vascular injury include the following:

HematomaLoss of pulsesPallor


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Treatment

Prehospital Care

Patients with hip dislocation often have associated injuries that may takeprecedence during stabilization, both in the field and in the ED. Attempts toreduce the dislocation in the field are ill advised.

Establish the ABCs with appropriate spinal immobilization.

If hip dislocation is detected in the field, the patient should be placed on abackboard and allowed to assume the leg position that is most comfortable(ie, hip slightly flexed, leg adducted).

The patient should be transported to a level of trauma center appropriate forhis or her overall clinical status.


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Treatment

Emergency Department Care

Patients with hip dislocations often have life-threatening injuries that takeprecedence.

Once life-threatening injuries have been stabilized or ruled out, the hipdislocation can be addressed. A proper neurovascular examination should beperformed. If a neurovascular deficit exists, there is even more urgency toreduce the dislocation.

Appropriate analgesia should be provided. If hemodynamic status permits,intravenous narcotics are usually indicated.

Radiographs to detect hip pathology should be obtained.

Reduction is greatly facilitated by the use ofprocedural sedation. Unlesssufficient sedation and muscle relaxation is achieved, attempts at relocation arefutile.
http://emedicine.medscape.com/article/109695-overviewhttp://emedicine.medscape.com/article/109695-overview


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Treatment

Simple hip dislocations without associated fracture are within the practice scope ofmost emergency physicians. Consider orthopedic consultation if it will not delayrelocation beyond a reasonable amount of time, usually within 6 hours.

Once procedural sedation has been achieved, the hip may be reduced by one ofthe preceding methods.

Reducing a hip usually takes a significant amount of space and resources.

Usually, one person applies traction and one or two people supply counter traction. Anurse or other physician provides sedation.

More than 3 attempts at closed reduction in the ED is not recommended. Theincidence of AVN increases with multiple attempts. If the dislocation cannot bereduced, an emergent CT scan is indicated to visualize any bony or soft tissuefragments that may hinder reduction. Closed reduction may be attempted in theoperating room under general anesthesia. However, a majority of these patients mayrequire open reduction.
http://emedicine.medscape.com/article/823471-diagnosishttp://emedicine.medscape.com/article/823471-diagnosis


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Treatment

Fracture-dislocations or concomitant fractures of the femoral neck usually require the expertise ofan orthopedic specialist. Practice styles vary widely. Some orthopedists make an attempt at closedreduction, whereas others immediately perform an open reduction if a fracture-dislocation exists.

After closed reduction, confirm placement with a repeat radiograph. A repeat neurovascularexamination should be performed and documented as well. A CT scan or MRI of the hip canprovide valuable information about further treatment and prognosis.

If relocation of the hip is successful, immobilize the legs in slight abduction by using a padbetween the legs to prevent adduction until skeletal traction can be instituted.

After reduction, patients with hip dislocation should be admitted to the hospital. Patients will benonambulatory and require a great deal of supportive care. Pain will be significant, even afterreduction, and patients may require parenteral narcotics.

The duration of traction and nonweight-bearing immobilization is controversial. Evidencesuggests that early weight bearing (eg, 2 wk after relocation) may increase the severity of asepticnecrosis when it occurs. Early weight bearing decreases the incidence of other complications (eg,

venous thromboembolism, decubiti), and some studies have found equivalent outcomes withearly and delayed weight bearing.


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Indications for open reduction

Irreducible dislocation (approximately 10% of all

dislocations)

Persistent instability of the joint following reduction (eg,

fracture-dislocation of the posterior acetabulum)

Fracture of the femoral head or shaft

Neurovascular deficits that occur after closed reduction

M di i


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Medication

Administer adequate parenteral analgesia. The emergency physician,consultant, and patient must decide on the most appropriate type and placefor reduction: open versus closed and emergency department versus operatingroom.

If a closed reduction is attempted in the ED, the patient requires procedural

sedation. Procedural sedation policies should be established to define whocan administer medication, who must monitor the patient, the classes anddoses of procedural sedation medications, and the resources on hand forresuscitation.

In addition to airway protection and rescue, the procedural sedation goals

must include pain relief, muscle relaxation, and procedure amnesia.

General anesthesia in the operating room may be required for patients withdislocations that are irreducible by closed means as well as for those withsignificant associated fractures, central dislocations, or associatedneurovascular injury.

M di i


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Medication

Analgesics

Pain control is essential to good-quality patientcare. It ensures patient comfort, promotes

pulmonary toilet, and aids physical therapyregimens. The analgesic must have a rapid onset,predictable action, and be easily titratable.

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Joint Instability.hen