Seminar 5 - Traumatic Dislocation and Common Soft Tissue Injury_2

8/17/2019 Seminar 5 - Traumatic Dislocation and Common Soft Tissue Injury_2

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Traumatic Dislocation

and common softtissue injury

Khor Shu Lin

Maya Athirah

Phang Chin Tong


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Dislocation

• Defned as total or complete loss o contact orcongruity o articular suraces o joint

• The most common ones involve a fnger thum!shoulder or hip

• Less common are those o the mandi!le el!o" or#nee$

• Symptoms include loss o motion temporaryparalysis o the joint pain s"elling and sometimes

shoc#$• Dislocations are usually caused !y a !lo" or all

although unusual physical e%ort may also cause one


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Sublaxation

• Defned as an incomplete joint dislocation "ithparts o the articular suraces remaining incontact "ith either a gradual displacement or

partial dislocation "ithin a joint


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Classication of dislocation

Congenital Traumatic

Pathological Paralytic


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Congenital Dislocation

• A congenital dislocation is present at !irth as theresult o deective ormation o the joint$

• A recurrent or ha!itual dislocation &repeateddislocation o the same joint' may !e the result oimproper healing o an old injury or may !enatural as in (dou!le joints) common in fngersand toes "hich are the result o looseligamentation$

• A pathological dislocation occurs as the result o adisease such as Maran*s syndrome "hich"ea#ens the capsule and ligaments a!out the joint$


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• +n congenital dislocation o the hipthe soc#et part o the joint theaceta!ulum loses the mechanicalstimulus or normal gro"th and

development !ecause the !all part othe joint the head o the emur doesnot rest in the joint$

• The aceta!ulum and a large part othe pelvis develop poorly or not at all"hereas the emoral head i it ma#es

contact higher up on the pelvis may


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Traumatic Dislocation

• This usually ollo"s a serious violence$ Theollo"ing are the clinical types o dislocation1-

&i' AcuteDislocation

&ii' 2ld unreduced

dislocation&iii' /ecurrent

dislocation


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(i) Acute dislocation

• The traumatic dislocation commonly occur in theshoulder el!o" and hip$ The acute dislocation areurther classifed according to the direction odislocation o the distal !one in relation to the

pro.imal e$g$ Anterior posterior

• Clinically the acute traumatic dislocation isdiagnosed !y the history and fndings$ There isacute pain and s"elling around the joint$ There is

gross deormity at the joint and the !onylandmar#s are distorted$


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• 2ne should loo# or associated nerve

and vascular injuries$ /adiographconfrm the diagnosis and detectassociated ractures

•Management1 Acute dislocation o a joint is an orthopaedic emergency and itre0uires immediate reduction underanaesthasiae$ Ater redction the part

should !e immo!ali5ed till the sottissues li#e the capsule and ligamentsheal$ Ater a!out 6-7 "ee#s the joint ismo!ilie8sed !y e.ercise therapy$


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(ii) Old Unreduced Dislocation

• Patients "ith unreduced dislocation presentsthemselves or treatment "ee#s to months aterthe primary dislocation$

• These are di9cult pro!lems and need prolongedtreatment$

• Treatment1 Closed reduction under anaesthesiaeis attempted in cases presenting "ithin 7 "ee#s$

This should not !e done in dislocation more than

:-; "ee#ss old as there is danger o ractureduring the manipulation$ Surgical reduction isindicated in such cases


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(iii) Recurrent Dislocation

•


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at!ological Dislocation

• This is caused !y some diseases process and iscommon in the hip joint$ This occur "hen there isdestruction o the head o the emur or e.cessive

distention o the joint capsule• +t can !e divided into destructive and distensive

dislocation


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at!ological Dislocation

Destructive

dislocatio

n

• This is common in1-• = Tu!erculosis o the hip "hen there is a travelling

aceta!ulum• = Septic arthritis o the hip o inancy "here there is total

destruction o the head o emur

Distensiv

edislocation

• The head o the emur gets dislocated "hen the jointcapsule is rapidly distended !y an e%usion o synovial >uidor pus


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aralytic Dislocation

• This occurs "hen there is mar#ed im!alance omuscle po"er

• +t can occur in the hip "henever there is anoveraction o the hip >e.or s and adductors in

certain paralytic conditions• This is al"ays a posterior dislocation

• +n poliomyelitis "hen the hip e.tensors anda!dictors are paralysed the normal adductors and

>e.ors overact and cause dislocation• +n cere!ral palsy the spasm o the adductors and

>oe.ors cause the deslocation


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Clinical features ofDislocation

• Painul at the joint and patient tries to avoidmoving it$

• Shape o joint is a!normal

• ?ony landmar# is displaced

• Characteristic position1Shoulder- a!duction deormities

@l!o"- >e.ion deormities

ip1 Anterior- >e.ion a!duction and internal rotation deormities$Posterior->e.ion adduction and internal rotation deormity

Knee->e.ion deormity

An#le-varus deormity

• Movement is painul and restricted

• Apprehension test Bve


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Recurrent dislocation• Ligaments and joint margin are damaged

repeated dislocation may occur$

• This is seen especially in the shoulder and thepatellaemoral joint$


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"abitual (#oluntary)dislocation

• Some pt ac0uired #nac# o dislocating &orsu!lu.ating' the joint !y voluntary musclecontraction

• Ligamentous la.ity may cause dislocation easier!ut the ha!it oten !etrays a manipulative andneurotic personality

• +t is important to recogni5e this !ecause patientsare seldom helped !y operation


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$n%estigation

• /adiograph o the a%ected part should includeanterior posterior and lateral vie"s andsometimes special vie"s needed$

• CT Scan


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Treatment

• +t is an orthopedic emergency$• /eduction should !e 0uic# and prompt$

• /eduction should al"ays !e under eneralanaesthesia or sedation$

• oint is rested or immo!ili5ed until sot tissuehealing occur ater 6-7 "ee#s

• Physiotherapy

• + ligaments are torn they may have to !e

repaired


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Com&lication

3$ Acute1 +njury to peripheral nerve and vessels

4$ Chronic1 Enreduced dislocation

/ecurrent dislocation

Traumatic osteoarthritis oint sti%ness

Avascular necrosis

Myositis ossifcans


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?y Maya Athirah Fahaya

Dislocation Of S!oulder


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Anatomy


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$ntroduction

• 2 the large joints shoulder is the one that mostcommonly dislocates$ This is due to• Shallo"ness o the glenoid soc#et

• @.traordinary range o movement

• Enderlying condition such as ligamentous la.ity or glenoiddysplasia

• Sheer vulnera!ility o the joint during stressul activities othe upper lim!$


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Classication

Anterior

Dislocation• GHI• ead o humerus

comes out oglenoid cavity

and liesanteriorly$

osterior

Dislocation• HI• ead o humerus

come to lieposteriorly

!ehind theglenoid

'uxatio

recta• ead o humerus

come to lie insu!glenoidposition


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Anterior Dislocation ofS!oulder

• 7 su!types• Su!coracoid &most common'

• Su!glenoid

• Su!clavicle

• +ntrathoracic

• Mechanism o injury• Direct 1 !lo" &most common' rom posterior aspect o the

shoulder pushing head o humerus out o the glenoidcavity

• +ndirect 1 all on outstretched &e.tended' hand "ithshoulder a!ducted and e.ternally rotated$


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• Pathological Changes• ?an#art*s Lesion

• Jlenoid la!rum

• Dislocation causes

stripping o the glenoidla!rum along "ithperiosteum romanterior surace oglenoid and scapular

nec#• ead thus comes to lie

in ront o the scapularnec# in the pouchthere!y created$


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• ill-Sach*s Lesion

• umeral head

• Depression on humeral head in its posterolateral0uadrant caused !y impingement !y the anterioredges o the glenoid on head as its dislocates


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• Clinical eatures• ho all on outstretched hand

• Severe pain arm held ina!duction and e.ternal

rotation• Lost o normal round contour

shape o the a%ected shoulder joint

• Posterior aspect o the a%ected

shoulder is >at• Anterior aspect sho"s ullness

!elo" the clavicle due todisplaced head and can elt !yrotating the arm


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• Apprehension test

• Dugar test

• amilton ruler test

• /egiment !adge test


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• +nvestigations• /adiological e.amination o the shoulder & AP vie"

a.illary vie"'

• Arthrography

• CT scan M/+• Treatment

• Conservative

• /eduction under sedation JA ollo"ed !yimmo!ili5ation o the shoulder in chest arm !andageor 6 "ee#s

• Kocher*s Maneuver

• ippocrates Maneuver

• Stimson*s gravity method


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A 1 Traction .ternal rotation Adduction edial /otati


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• Post reduction• ,-ray to confrm reduction and e.clude racture

• Ater patient ully a"a#e active a!duction is gently testedto e.clude a.illary nerve injury

• /est the arm on sling or 3-4 "ee# and ater that active

movement should !egin$ A!duction and lateral rotationmust !e avoided or at least 6 "ee#s

• 2perative &open reduction'

• +ndication 1

• ailed closed reduction

• Sot tissue interposition• Jreater tu!erosity racture

• Displacement 3cm ater reduction

• Large glenoid rim racture


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• Complication• A.illary nerve injury resulting paralysis o the deltoid and

small areas o anaesthesia over lateral aspect o theshoulder

• /otator cu% tear• Nascular injury &a.illary artery'

• racture dislocation

• /ecurrent dislocation

• Enreduced dislocation

• Traumatic osteoarthritis

• Shoulder sti%ness


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osterior S!oulder Dislocation

• Mechanism o injury• Direct 1 direct !lo" rom anterior aspect o shoulder

• +ndirectOO 1 all on internally rotated adducted and>e.ed hand

• Clinical eatures• Severe pain arm held in a!duction and internal

rotation

• A!duction is restricted

• Loss o normal round contour shape o a%ected

shoulder joint

• ullness in posterior aspect o the a%ected shoulder

• lat anterior aspect

• Prominent coracoid process


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• +nvestigation• /adiological e.amination

• Light !ul! sign

• +nternal rotation o humerus

• /im sign• Nacant glenoid sign

• Through*s sign

• Thransthoracic lateral ,-ray 1 N-shaped rolling line

• Arthrography

• CT scan

• M/+


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• Treatment• Conservative

• The acute dislocation is reduced &usually under generalanaesthesia' !y pulling on the arm "ith the shoulder in

adduction• a e" minutes are allo"ed or the head o the humerus

to disengage and the arm is then gently rotatedlaterally "hile the humeral head is pushed or"ards$

• + reduction eels sta!le the arm is immo!ili5ed in a

sling• other"ise the shoulder is held "idely a!ducted and

laterally rotated in an airplane type splint or 6:"ee#s to allo" the posterior capsule to heal in theshortest position$

• Shoulder movement is regained !y active e.ercises


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Anatomy


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• stability of elbo*• primary sta!ili5ers

• MCL is the main sta!ili5er o the el!o" joint &providesH7I valgus sta!ility "hile osseous articulationprovides 66I'

• ulnohumeral articulation• coronoid1 clinical e.perience suggests HRI intact

coronoid re0uirement or sta!ility "ith or "ithoutligamentous integrity

• olecranon contri!ution to sta!ility inversely correlated

"ith resection amount1 6RI articular surace oolecranon needed or sta!ility

• secondary sta!ili5ers

• radiohumeral articulation &most important'

• capsule1 greatest role in e.tension o el!o"

insignifcant role &3RI' in >e.ion


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$ntroduction• second most common major joint dislocation

- dislocation is usually closed and posterior• Adults + c!ildren

• ec!anism• all on outstretched hand "ith e.tended el!o"

• anatomic morphology o semilunar notch may predisposeto el!o" dislocation

• central angle o semilunar notch is signifcantly larger ingroup o pts "ho had dislocation o the el!o" comparedto normals

•


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• Side-s"ipe injury• occurs typically "hen a car-driver*s el!o" protruding

through the "indo" is struc# !y another vehicle$

• The result is or"ard dislocation "ith ractures o any or

all o the !ones around the el!o" sot-tissue damage&including neurovascular injury' is usually severe$


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Classications

• According to direction o dislocation

• Posterior

• Posterolateral &;RI'

• Posteromedial

• Lateral• Medial

• Divergent

• Simple & dislocation "ithout racture ' Ns Comple. &dislocation "ith ractures'


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• Sim&le dislocation• rupture o capsule rupture o MCL lateral ligaments

rupture o >e.or pronator mass and less commonly injuryto !rachialis muscle

• lateral collateral ligament may !e the essential lesion inrecurrent or persistent insta!ility ollo"ing simpledislocations o the el!o"

• rupture o !rachial artery has !een reported

• Comple. dislocation

• dislocation *, radial !ead frx• frx dislocation *, C' injury (radial head r.

MCL +nsta!ility'

• terrible Triad- (dislocation. cornoid &rocess frx. andradial !ead frx)


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• Clinical eatures• Pt supports orearm "ith el!o" in slight >e.ion

• Enless s"elling is severe the deormity is o!vious

• ?ony landmar# &olecranon and epicondyles' may !e

palpa!le and a!normally placed• @l!o" >e.ed to GR degrees

• Assess alignment o these 6 points at el!o"

• Uormal1 e0uilateral triangle

• Dislocated1 straight line

• /adial ead racture easy to eel at lateral epicondyle• and should !e e.amined or signs o neurovascular

damage


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• ,ray• @ssential to confrm the presence o a dislocation and to

identiy any associated ractures

• Uote radial head avulsion racture


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Treatment o acute dislocations

• Uon-operative

• reduction and splinting at GRV or W-3R days ollo"ed !yearly therapy

• +ndications 1 simple sta!le dislocations

• early therapy

• supervised &therapist' active and active assist range-o-

motion e.ercises ater 3 to 4 "ee#s• initial range o motion is the sta!le arc ound on

postreduction e.amination

• reha!ilitation

• proceed "ith light duty use 4 "ee#s rom injury

• reduction splinting in hinged !race at GRV or 4-6 "ee#s• +ndications 1 simple unsta!le el!o" dislocations

&dislocations "ith e.tension'

• early range o motion e.ercises "ith arm in pronation


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• Post reduction


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• Post reduction

• +mmo!ili5e el!o" in molded posterior plaster splint

• Splint el!o" at GR degrees >e.ion &Allo"s ligament andcapsular healing'

• Splint or 6 "ee#s

• Jentle /ange o motion ater Splinting

• Uever orce range o motion &"orsens injury'

• Temporary sti%ness is common

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• 2perative• 2/+ &coronoid radial head olecranon' LCL repair B-

MCL repair

• +ndications 1 comple. dislocations "ith ractures and

insta!ility• approach

• posterior utility approach used

• radial head

• "hen placing f.ation on the pro.imal radius one must

!e a"are o the Xsae 5oneX or f.ation• GRV arc in the radial head that D2@S U2T articulate

"ith the pro.imal ulna

• the Xsae 5oneX can !e identifed !y its relationship toListerYs tu!ercle and the radial styloid


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Treatment or chronic dislocation

• 2perative• open reduction capsular release and dynamic hinged

el!o" f.ator

• +ndications 1 hinged e.ternal f.ator indicated in chronicdislocation to protects the reconstruction and allo"s early

range o motion !ut it does not maintain the reduction• approach

• posterior utility approach used

• techni0ue

• concomitant radial head racture

• f. frst

• 2/+ or radial head that can !e reconstructed

• radial head arthroplasty is indicated or a radial headracture that cannot !e reconstructed


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• Complications• @arly

• Nascular injury &!rachial artery'

• Uerve injury &median or ulnar nerve'

• Late• Nalgus insta!ility

• Sti%ness

• eterotropic ossifcation


• /ecurrent dislocation

• 2steoarthritis

• Loss o terminal e.tension &most common se0uelaeater closed treatment o a simple el!o" dislocation'


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Dislocation Of "i&


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Anatomy


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Classication / de&end u&on relations!i&bet*een femoral !ead and acetabulum

PosteriorDislocation• WRI

AnteriorDislocation• 3R-3HI

Central• Comminuted

displacedarcture oaceta!ulum


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Posterior ip DislocationAnterior ip DislocationCentral ip Dislocation


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osterior "i& Dislocation

• Causes• Car dash!oard injury

• all o% "eight on !ac# o a stooping miner

• Mechanism o injury

• Esually due to !ac#"ard directed orce along "ith theshat o emur in >e.ed hip

• Dislocation may !e pure i the emur more adducted attime o impact and may associated "ith racture i emurslightly a!ducted$


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• Clinical eatures• ho trauma ollo"ed !y pain

s"elling and deormity &>e.ionadduction and medial rotation'

• Short leg

• Jross restriction o movement oa%ected hip

• ead o emur elt as hard massin gluteal region and moves

along "ith emur


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• +nvestigation• ,-ray o hip

• AP vie" 1 emoral head seen out o its soc#et anda!ove the aceta!ulum

• Less promonent lesser trochanter as thigh is internallyrotated

• ?ro#en Shenton*s line

• A !ony chip i aceta!ular hip is ractured

• CT scan

• elps to determine direction o dislocation loose!odies and associated ractures

• M/+

• Eseul to evaluate la!rum cartilage and emoral headvascularity


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simple dislocation "ith the emoral head lyia!ove and !ehind the aceta!ulum$


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Another patient "ithdislocation and anassociated aceta!ular rim

racture


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• Management• Conservative &closed reduction manipulation under JA'

• Classical


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• ?igelo"*s method

• Stimson*s gravitymethod


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• Ater treatment the lim! is immo!ili5ed in a Thomassplint or 6 "ee#s in the position o a!duction

• 2perative &open reduction'

• +ndications

• ailure o closed reduction due to o!struction !y !onyragments or sot tissues loc#ing racture ragments!utton holing o emoral head through the capsule

• +ntra-articular loose ragment not allo"ing concentri.reduction

• +nsta!ility ater reduction

• Sciatic nerve palsy


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• Complications• @arly

• Sciatic nerve palsy &3R-36I'

• Due to stretching o the nerve or entrapment !et"een theragment

• Commonly a%ectes the peroneal division

• Esually neuropra.ia and recovers spontaneously

• Nascular injury &superior gluteal artery'

• Associated ractured emoral shat

• Late

• Avascular necrosis o emoral head &3H-4RI'• Myositis ossifcans

• Sti%ness


• Secondary osteoarthritis


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Anterior "i& Dislocation

• Mechanism o injury• Dash!oard injury "ith thigh a!ducted and e.ternal

rotated

• all rom height

• ?lo" to !ac# in s0uatted position• Causes the nec# to impinge on aceta!ular rim and leverthe emoral head out in ront o its soc#et$

• emoral head "ill then lie superiorly &type + 1 pu!ic' orineriorly &type ++ 1 o!turator'


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• Clinical eatures• True length "ith head palpa!le in groin &inerior type' or

anteriorly &superior type'

• Uot short !ecause the attachment o rectus emorisprevents the head rom displacing up"ards$

• Lim! is in attitude o e.ternal rotation a!ducted andslightly >e.ed$

• 2ccasionally the leg a!ducted almost to a right angle

• ip movement are impossi!le

• ,-ray fndings• +n AP vie" 1 dislocation usually o!vious !ut occasionally

head is almost directly in ront o its normal position

• Lateral vie"


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T t t


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• Treatment• Maneuvers employed are similar to those used to reduce

a posterior dislocation e.cept that "hile the >e.ed #nee

is !eing pulled and the hip gently >e.ed up"ards itshould !e #ept adducted

• An assistant then helps !y applying lateral pressure toinside o the thigh

• Point o reduction is usually heard and elt

• Su!se0uent treatment is similar to that employed orposterior dislocation

• Complications• Ueurovascular injury &emoral artery nerve or evein'

• +rreduci!le dislocation• Post traumatic 2A

• Aseptic necrosis

• /eccurent dislocation


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Central "i& Dislocation

• Mechanism o injury• A all on the side or a !lo" over the greater trochanter

may orce the emoral head medially through the >oor othe aceta!ulum

• +t is really a racture o the aceta!ulum


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0nee Dislocation


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Anatomy


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$ntroduction

• /are$ 2rtho emergency• Esually due to high energy injury

• Defned as com&lete dis&lacement o the ti!ia"ith respect to the emur "ith disruption o 1 or

more o the sta!ili5ing ligaments$• Small avulsion ractures rom the ligaments and capsular

insertions may !e present$


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• Mechanism o injury• igh energy

• Esually rom MNA or all rom height

• Commonly a dash!oard injury resulting in a.ial load to>e.ed #nee

• Lo" energy

• 2ten rom athletic injury

• Jenerally has a rotational component

• Mor!id o!esity is a ris# actor

• Pathoanatomy• Associated "ith signifcant sot tissue disruption

• Z o ligaments generally disrupted

Classications / !ased on


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C ass ca o s !ased odirection o displacement o the ti!ia

Anterior•

6R-HRI• dt hypere.tensioninjury

• Esually involvestear o PCL

• Arterial injury is

generally an intimaltear dt traction

Posterior•

4HI• dt a.ial load to>e.ed #nee

• ighest rate ocomplete tear opopliteal

Lateral•

36I• dt valgusdislocations

• Esually involvestears o !oth ACLand PCL

•

ighest rate operoneal nerveinjury


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Medial• Narus orce• Esually disrupted

PLC and PCL

/otational• Posterolateral is

most commonrotational

dislocation• Esually irreduci!le


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• Clinical eatures• ho trauma and deormity o the #nee

• Knee pain and insta!ility

• May present "ith su!tle signs o trauma &s"ellinge%usion a!rasions'

• Xdimple signX - !uttonholing o medial emoral condylethrough medial capsule

• indicative o an irreduci!le posterolateral dislocation

• a contraindication to closed reduction due to ris#s o s#innecrosis

• sta!ility

• diagnosis !ased on insta!ility on e.am &radiographsand gross appearance may !e normal'

• may see recurvatum "hen held in e.tension

• assess ACL PCL MCL LCL and PLC


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• vascular e.am• priority is to rule out vascular injury on e.am !oth

!eore and ater reduction

• serial e.aminations are mandatory

• palpate the dorsalis pedis and posterior ti!ial pulses

• i pulses are present and normal• does not indicate a!sence o arterial injury

• collateral circulation can mas# a complete politeal arteryocclusion

• measure An#le-?rachial +nde. &A?+'

• i A?+ R$G• then monitor "ith serial e.amination &3RRI Uegative Predictive

Nalue'

• i A?+ R$G

• perorm arterial duple. ultrasound or CT angiography

• i arterial injury confrmed then consult vascular surgery


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• + pulses are a!sent or diminished• confrm that the #nee joint is reduced or perorm

immediate reduction and reassessment

• immediate surgical e.ploration i pulses are still a!sentollo"ing reduction

• ischemia time ; hours has amputation rates as high as;:I

• i pulses present ater reduction then measure A?+ thenconsider o!servation vs$ angiography

• Special test or ligament insta!ility


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• +nvestigations• ,-ray &AP lateral vie"'

• Arteriogram

• M/+ &ligament injuries'• The e.tent and location o ligament disruption meniscal tears and su!tle

injuries to the !one as "ell as "hich tears are repaira!le$

• Knee arthroscopy is contraindicated "ithin 4 "ee#s o#nee dislocations

• capsular tears cause >uid e.travasations into the leg in compartmentsyndrome


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• Management• +nitial Treatment & reduce 2nee and re/examine

%ascular status )

• considered an orthopedic emergency

• splint #nee in 4R-6R degrees o >e.ion

• confrm reduction is held "ith repeat radiographs in!racesplint

• vascular consult indicated i

• i arterial injury confrmed !y arterial duple. ultrasound orCT angiography

• pulses are a!sent or diminished ollo"ing reduction


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• Uon-operative• indications

• limited and most cases re0uire surgical sta!ili5ation

• 2perative & emergent surgical inter%ention )

• indications

• vascular injury repair &ta#es precedence'

• open racture and open dislocation

• irreduci!le dislocation

• compartment syndrome


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• delayed ligamentous reconstruction,re&air• indications

• generally insta!ility "ill re0uire some #ind o ligamentousrepair or f.ation

• patients can !e placed in a #nee immo!ili5er or :

"ee#s or initial sta!ili5ation• improved outcomes "ith early treatment &"ithin 6

"ee#s'

• techni0ue

• PLC & recommend early reconstitution '

• PCL & reconstruct prior to ACL reconstruction '

• postoperative

• recommend early mo!ili5ation and unctional !racing


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• Complications• Sti4ness (art!robrosis)

• is most common complication &6;I'

• more common "ith delayed mo!ili5ation

• 'axity and instability &6WI'• eroneal ner%e injury &4HI'

• most common in posterolateral dislocations

• poor results "ith acute su!acute and delayed &6months' nerve e.ploration

• neurolysis and tendon transers are the mainstay otreatment

• #ascular com&romise

• in addition to vessel damage claudication s#inchanges and muscle atrophy can occur


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Dislocation Of atella

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:::

Acute Dislocation


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Acute Dislocation• /esult rom sudden contraction o

0uadriceps "hile the #nee is >e.ed orsemi->e.ed$

• Dislocates laterally

• Clinical eatures• Pain

• S"elling

• Ena!le to straighten the #nee

• Medial condyle&emur' more prominent

• Tenderness &antero-medially'

• Treatment• /eduction- Ender Jen$ anesthesia

• +mmo!ilisation1 cylinder cast[6 "ee#s


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Recurrent Dislocation


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Recurrent Dislocation

• @tiology• Congenital

• Lig$ La.ity

• hypoplasia o lat$ emoral condyle

• lattening o +ntercondylar groove

• Patellar maldevelopment• Primary muscle deect

• Jenu valgum

• Ac0uired• Jenu valgum

• +ne0uality o gro"th o condyle•


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• Pathology


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;irst e&isode

Tear ofca&sule on

medial side of&atella

$f im&ro&er!ealing

ersistentlaxity

Recurrentdislocation

Damage to

contiguoussurface of

&atella < fem5Condyles

;lattening <t!en furt!erdislocation


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• Clinical eatures• M

• 2ten !ilateral

• Acute pain "ith #nee stuc# in >e.ion

• +n dislocated state1

• Nisually o!vious• Tenderness

• S"elling

• ?et"een attac#

• Patella alta

• Jeneral ligament la.ity• Apprehension test Bve


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• +nvestigations• ,-ray

• Dislocation

• igh-riding patella

• 2ther anatomical a!normality

• M/+

• CT scan


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• Treatment• Conservative

• \uads e.ercise

• USA+DS

• 2perative

• Camphell 2peration• Jold"ait operation

• auser*s operation

• Patellectomy

• Muscle release "ith N-F ]-plasty


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"abitual Dislocation


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"abitual Dislocation

• @verytime #nee is >e.ed it dislocates laterally• Present in early childhood


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ARTR$ORCRUC$AT

'$=A>T TARPhang Chin Tong

Anatomy


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Anatomy

$ntroduction


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$ntroduction

• Can withstand

approximately 400

pounds of force

• Common injuryparticularly in sports (3%

of all athletic injuries)

• Associated "ith MCL meniscus tear &all 68 Terri!le Triad'

• More common in women

ales %s ;emales


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ales %s ;emales

ec!anism of injury


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ec!anism of injury

• Can occur "ithoutcontact

• valgus or

hypere.tension orce to#nee

Clinical ;eatures


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Clinical ;eatures

• istory o a (pop) at the time o injury andimmediate &ie e" hours' s"elling and e%usion atthe #nee

• Patients complain o the #nee (giving out) during

t"isting

Clincal Test


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Clincal Test

Anterior dra*ertest

• #nee at GRV and thehamstrings rela.edgrasp the top o thepatients leg and tryto shit it or"ards

and !ac#"ards&displaced Hmm'


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'ac!man Test• #nee >e.ed to 4RV

one hand atlaterally sta!ili5esthe distal emurand the other handgrasps the pro.imal

ti!ia medially$ Thepro.imal ti!ia ispulled or"ard


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i%ot S!ift Test• #nee ully e.tended

"hilst maintaininga valgus orce andthe #nee is thengradually >e.ed apalpa!le reduction

o this su!lu.ationis elt at 4R6Rdegrees$

$n%estigations


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$n%estigations

• ,-ray1 plain .-ray and stress flms &to rule outSegond ^'

• M/+ confrm diagnosis

• Athroscopy

Di4erential Diagnosis


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Di4erential Diagnosis

• Chronic ACL tear• Avulsion o the ti!ial insertion in adolescents

• Multiligamentous injury to the #nee

Treatment


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Treatment

• Conservative management - modifcation oactivities that produce insta!ility splint crutches unctional !racing

• Surgical repair reconstruction &2pen

endosopic'


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AC"$''ST>DO>

RUTURPhang Chin Tong

Anatomy


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Anatomy

• connects the cal muscle &gastrocnemius' to theheel !one &calcaneus'$

• just !elo" the s#in at the !ac# o the an#le

;unction


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;unction

gastrocnemiusmuscle &in thecal' contracts

&shortens'

tendon moves topoint the ootdo"n"ards

&plantar>e.ions'

$ntroduction


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$ntroduction

Partial or complete tear o theachilles tendon$

Common in men !et"een theages o 6R and HR years&X"ee#end "arriors)'Most commonly occurs in sportsre0uiring an e.plosive push-o%1s0uash !adminton oot!alltennis net!all$


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About ? cmabo%e t!e

tendoninsertion ontot!e calcaneum

(%ascular*aters!ed))

Ty&ical sitefor ru&ture-

ec!anism of Ru&ture


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ec!anism of Ru&ture

Sudden orcedplantar >e.ion o the

oot

Ene.pecteddorsi>e.ion o the

oot

Niolent dorsi>e.ion oa plantar >e.ed oot$

2ther mechanisms1direct trauma

attrition o thetendon as a result olongstanding

peritenonitis "ith or"ithout tendinosis$

Poor musclet th d


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/is#

actors

strength and>e.i!ility

ailure to"arm up and

stretch !eoresport

Previousinjury or

tendinitis

Corticosteroid

injection

Clinical ;eatures


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Clinical ;eatures

• A ripping or popping sensation is elt and otenheard at the !ac# o the heel$

• Loo#ed round to see "ho had hit them over the!ac# o the heel the pain and collapse are so

sudden$

xamination


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xamination

Plantar>e.ion o theoot usually inhi!ited

and "ea#

Palpa!le gap at the siteo rupture

?ruising comes out aday or t"o later$

Signs

Calf s@ueee test (T!om&sonBsor SimmondBs test)


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or Simmond s test)

•


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$n%estigation

• Ultrasound scans must !e used to confrm orreute the diagnosis$

Di4erential diagnosis


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Di4erential diagnosis

Incomplete tear

• Complete rupture

mista#en or partialtear dt• + complete rupture is

not seen "ithin 47hours the gap isdi9cult to eel

• Patient may !y then!e a!le to stand ontiptoe &just' !y usinghis or her long toe>e.ors$

Tear of soleus muscle

• A tear at the

musculotendinous junction causes painand tenderness hal"ayup the cal$

• This recovers "ith theaid o physiotherapyand raising the heel othe shoe$

Treatment


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Treatment

• Conservative• Plaster cast or special !oot is

applied "ith the oot ine0uinus

• /eha!ilitation andphysiotherapy "ithin 7:"ee#s$

• Shoe "ith a raised heel should!e "orn or a urther :;

"ee#s• _/e-rupture rate* a!out 3R I

• Surgical• 2perative repair isassociated "ith

• /is#s• "ound healing


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associated "ith• earlier return to unction

• !etter tendon and calmuscle strength

• a lo"er re-rupture rate$

• Supported reha!ilitation

and physiotherapy are

commenced early&"ithin a "ee# or t"o orepair'

• "ound healingpro!lems

• sural nerve neuroma$

• /uptures that presentlate• reconstruction using

local tendonsu!stitutes &e$g$ >e.orhallucis longus tendon'or strips o ascia lata


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T!an2s

Documents

Seminar 5 - Traumatic Dislocation and Common Soft Tissue Injury_2