Diagnostic Approach and Principle of Management in Dislocation

DR. Hermawan N Rasyid, MD., PhD
Email: hermawan_nr@indo.net.id Department of Orthopaedic and Traumatology Faculty of Medicine Universitas Padjadjaran / Dr. Hasan Sadikin Hospital

Joint injuries are commonly seen in the emergency  Joint dissociations can be categorized into three groups depend on degree and type of joint involved

– Dislocation – Subluxation – Diastasis: disruption of the interosseus membrane which is connecting the two joints
Simon R.., Koenigsknecht. Emergency Orthopedics. 1987


 A dislocation is a separation of two bones where they meet at a joint. A dislocated bone is no longer in its normal position. A dislocation may also cause ligament or nerve damage. Dislocations may be associated with a periarticular fracture

Normal hip

Dislocated hip

For example.SUBLUXATION A subluxation is an incomplete or partial dislocation. . a nursemaid's elbow is the subluxation of the head of the radius in the elbow.

1987 . Koenigsknecht...Simon R. Emergency Orthopedics.

This usually occurs following a blow. or other trauma .DISLOCATION CAUSES  Dislocations are usually caused by a sudden impact to the joint. fall.

DISLOCATION SYMPTOMS History of injury  Pain  Swelling  Difficulty moving the joint  Numbness and paresthesias  .

Visibly out-of-place, discolored, or misshapen joint  Limited joint movement  Swollen or bruised  Intensely painful, especially if you try to use the joint or bear weight on it or move it.  Decreased sensation distal to the joint  Decreased pulse, cool extremity distal to the joint

Name the JOINT  Name the dislocation by the position of the DISTAL FRAGMENT in relation to the proximal fragment  Add FRACTURE to the name if there is a periarticular fracture.  Add OPEN if a wound communicates with the dislocation

Two planes at 90 degrees to each other  Good quality  Standard views  See the entire joint

Dislocated Elbow

X-Ray Evaluation of Shoulder Problem  Recommended view – Trauma Series:  True Anteroposterior (AP) view in internal & extenal rotation  Axillary view  Scapular Y view .

TREATMENT Reduce the dislocation as soon as possible  Check Neurovascular function distally  Take post reduction radiograph  Immobilize the joint  .

REDUCTION TECHNIQUE Start IV  Give sedation  Apply traction force  Manipulate joint  .


Dislocation of the Shoulder    Mostly Anterior > 95 % of dislocations Posterior Dislocation occurs < 5 % True Inferior dislocation (luxatio erecta) occurs < 1%  Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized ligamentous laxity and is Painless .

Mechanism of anterior shoulder dislocation  Usually Indirect fall on Abducted and extended shoulder  May be direct when there is a blow on the shoulder from behind .

Which is held abducted and appears too long. – Shoulder motion is impossible. – Support the arm. . tearing the capsule or avulsing the glenoid labrum  Feature:   The limb must always be tested for nerve & vessel injury. due to prominent of the acromion process and flat of deltoid muscle.Trauma Mechanism Cause: fall on the hand  The humerus is driven forward. – The contour is angular.

Anterior Shoulder dislocation  Usually also inferior Bankart’s Lesion  .

Clinical Picture Patient is in pain  Holds the injured limb with other hand close to the trunk  The shoulder is abducted and the elbow is kept flexed  There is loss of the normal contour of the shoulder  .

Clinical Picture  Loss of the contour of the shoulder may appear as a step Anterior bulge of head of humerus may be visible or palpable A gap can be palpated above the dislocated head of the humerus   .

X Ray anterior Dislocation of Shoulder .

True AP view .

Axillary view .

Scapular Y view .

Associated injuries of anterior Shoulder Dislocation  Injury to the neuro vascular bundle in axilla ( rare ) Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) Associated fracture   .

Axillary Nerve Injury Also called circumflex nerve  It is a branch from posterior cord of Brachial plexus  It hooks close round neck of humerus from posterior to anterior  It pierces the deep surface of deltoid and supply it and the part of skin over it  .

Axillary nerve injury .

Management of Anterior Shoulder Dislocation Is an Emergency  It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus  Following reduction the shoulder should be immobilised strapped to the trunk for 3-4 weeks and rested in a collar and cuff  .

Treatment Reduce Hold Exercise .

Methods of Reduction of anterior shoulder Dislocation  Hippocrates Method ( A form of anesthesia or pain abolishing is required ) Stimpson’s technique ( some sedation and analgesia are used but No anesthesia is required )  Kocher’s technique is the method used in hospitals under general anesthesia and muscle relaxation  .

Hippocrates Method .

Stimpson’s technique .

Kocher’s Technique .

Complications of anterior Shoulder Dislocation : Early  Neuro vascular injury ( rare ) Axillary nerve injury Associated Fracture of neck of humerus or greater or lesser tuberosities   .

Complications of anterior shoulder Dislocation : Late Avascular necrosis of the head of the Humerus (high risk with delayed reduction)  Heterotopic calcification ( used to be called Myositis Ossificans )   Recurrent dislocation .

E (39 yo) .Ms.

After reduction Velpeau bandage .

o) . E (53 y.Mr.





 Feature:  – The pts support the forearm with the other hand – Deformity if very obvious – The elbow is held immobile .Trauma Mechanism A Fall on the hand may dislocate the elbow. The forearm is push backwards.

. Pulses normal but decreased sensation over the palmer aspect of the little finger and he can not spread his fingers. painful on movement with marked limitation of range of motion.Illustration History: 21 YO fell from tree on his left arm 2 days ago and complains of pain. Exam: Patients elbow is swollen. inability to move the elbow and has numbness in his little finger.


then the elbow is further flexed while the olecranon process is pushed forward with the thumbs. Treatment – Under anaesthesia – Pulls on the forearm while the elbow is slightly flexed  REDUCE – With one hand. sideways displacement is corrected. .

 HOLD  EXERCISE – Held in collar and cuff with the elbow flexed above 90 deg Complication Early: Nerve injuries. recurrent dislocation . Associated fracture (Radial head. Olecranon fx) Late: Myositis ossificans. Unreduced disloc.


Trauma Mechanism Posterior disloc is most common  The bent leg is thrust backward.  Feature:  – Short leg and lies adducted. internally rotated and slighlty flexed. – Femoral head is palpable in the buttock. . as when a car hits a tree and the passenger’s knee is struck by the dashboard.

M (34 y-o) .Mr.


flexion. and rotation  Gentle and atraumatic  Bigelow techique Relocation should be palpable and permit significantly improved ROM.HIP REDUCTION Sedation  Relaxation. traction. This often requires very deep sedation. .




 The cruciate ligaments and one or both lateral ligaments are torn.  Features:  – Severe bruising. – Circulation must be examined because the popliteal artery may b torn or obstructed. . swelling and gross deformity. as in road accident.Trauma Mechanism The knee can only be dislocated by considerable violence. – Distal snsation must be tested to excluded popliteal nerve injury.


 Treatment: – Reduce – Hold – Exercise .

Mr. A (65 yo) .


. check for avulsion fracture. Follow with a post reduction x-ray.PIPJ DISLOCATION Hyper-extend the joint. apply traction then flex the joint.

 There are several techniques to reduce the dislocation but choose one that you are familiar with the technique.  .CONCLUSION Joint dislocation must be reduced immediately in order to prevent avascular necrosis especially for the hip.


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