Joint Injury

RELEVANT ANATOMY
The factors responsible for the stability of a joint :
The shape of a joint: The shape of the articulating surfaces in themselves may provide great security
against displacement, e.g., the hip joint with its deep socket (the acetabulum) and an almost spherical
ball (the femoral head) is a good design from the
stability viewpoint. On the other hand, the shoulder joint with its shallow socket (the glenoid) and a
large ball (the humeral head) is a poor design and therefore dislocates more easily than the hip joint.
The ligaments: These prevent any abnormal mobility of a joint and are called static stabilisers. The role
of the ligaments in providing stability to a joint is variable. In some joints (e.g., the knee and finger
joints), ligaments form the main stabilising structures, whereas in others (e.g., the hip or shoulder) they
do not play an important role.
The muscles: A strong muscle cover around a joint gives it stability. Muscles also provide a supporting
function to the ligaments by reflexly contracting to protect the ligaments, when the latter come under
harmful stresses. These are, therefore, called the dynamic stabilisers of a joint.
The Joint
Joints are classified structurally, based on their anatomical characteristics,
and functionally, based on the type of movement they permit.
The structural classification of joints is based on two criteria:
(1) synovial cavity
(2) the type of connective tissue that binds the bones together.

Structural Classification Functional Classification

- Fibrous joints: no synovial cavity, and Synarthrosis: An im-movable joint. The
the bones are held together by dense irregular plural is synarthroses.
connective tissue that is rich in collagen fibers. • Amphiarthrosis: A slightly movable
• Cartilaginous joints: no synovial joint. The plural is amphi-arthroses.
cavity and the bones are held together by
• Diarthrosis: A freely
cartilage.
• Synovial joints: have a synovial cavity & movable joint. The plural is diarthroses.
united by the dense irregular All diarthroses are synovial joints. They
connective tissue of an articular capsule, & have a variety of shapes and permit
often byaccessory ligaments several different types of movements.
CARTILAGINOUS JOINTS
SYNOVIAL JOINTS
SYNOVIAL JOINTS
 Joint Injury
Dislocation Subluxation
A joint is dislocated when its articular A joint is subluxated when its articular
surfaces are completely displaced,one from the other, surfaces are only partly displacedand retain some
so that all contact between them is lost contactbetween them.
Clinical manifest
Following an injury the joint is painful and the patient tries at all costs to avoid moving it.
The shape of the joint is abnormal and the bony landmarks may be dis-placed. The limb is often held in
a characteristic position; movement is painful and restricted.

X-rays will usually clinch the diagnosis; they will also show whether there is an associated bony injury
affecting joint stability – i.e. a fracture-dislocation.

Apprehension test If the dislocation is reduced by the time the patient is seen, the joint can be tested by
stressing it as if almost to reproduce the suspected dislocation: the patient develops a sense of
impending disaster and violently resists further manipulation.

Recurrent dislocation If the ligaments and joint margins are damaged, repeated dislocation may occur.
This is seen especially in the shoulder and patellofemoral joint. Habitual (voluntary) dislocation Some
patients acquire the knack of dislocating (or subluxating) the joint by voluntary muscle contraction.
Ligamentous laxity may make this easier, but the habit often betrays a manipulative and neurotic
personality. It is important to recognize this because such patients are seldom helped by operation.
DIAGNOSIS
Clinical examination: In most cases of dislocation, the clinical features are sufficiently striking
and make the diagnosis easy. Never-the less, a dislocation or subluxation is sometimes
overlooked, especially in a multiple injury case, an unconscious patient or in a case where
the bony landmarks are obscured by severe swelling or obesity.

Some dislocations, which are particularly notorious for getting overlooked are:
(i) posterior dislocation of the shoulder especially in an epileptic;
(ii) dislocation of the hip associated with a fracture of the shaft of the femur on the same
side. Some of the salient clinical features of dislocation are as follows:
- Pain: Dislocations are very painful.
- Deformity: In most dislocations the limb attains a classic attitude
- Swelling: It is obvious in the dislocation of a superficial joint
- Loss of movement because of severe pain and muscle spasm and loss of articulation.
- Shortening of the limb occurs in most disloca tions except in anterior dislocation of the
hip where lengthening occurs.
- Telescopy: In this test, it is possible to produce an abnormal to and fro movement in a
dislocated joint
Treatment

The dislocation must be reduced as soon as possible; usually a

general anaesthetic is required, and some-times a muscle
relaxant as well. The joint is then rested or immobilized until
soft-tissue swelling reduces – usually after 2 weeks. Controlled
move-ments then begin in a functional brace; progress with
physiotherapy is monitored. Occasionally surgical
reconstruction for residual instability is called for.
Acute traumatic dislocation Old unreduced dislocations: Recurrent dislocations

Treatment
an urgent reduction of the dislocation
is of paramount importance. Often it is
This often needs
operative reduction. In some cases, if the
An individual episode is
treated like a traumatic dislocation. For
possible to do so by conservative function prevention
methods, although sometimes operative of the dislocated joint is good, nothing of recurrences, reconstructive proce -
reduction may be required. needs to be dures are
a) Conservative methods: A dislocation done. required. These are discussed in the
may be reduced by closed manipulative respective
manoeuvres. Reduction of a dislocated chapters.
joint is one of the most gratifying jobs an
orthopaedic surgeon is called upon to do,
as it produces instant pain relief to the
patient. Prolonged traction may be
required for reducing some dislocations.
b) Operative methods: Operative
reduction may be required in some cases.
Following are some of the indications:
• Failure of closed reduction, often
because the dislocation is detected late.
• Fracture-dislocation: (i) if the fracture
has produced significant incongruity of
the joint surfaces; (ii) a loose piece of
bone is lying within the joint; and (iii) the
dislocation is difficult to maintain by
E.g: Ligament Injury; Meniscus injury
MENISCUS TEARS IN THE YOUNG ADULT
The commonest cause is a sporting injury, when a twisting strain is applied to the flexed, weightbearing
leg. The trapped meniscus commonly splits longitudinally, and its free edge may displace inwards
towards the centre of the joint (bucket-handle tear). This prevents full extension (with physiological
locking of the joint), and if an attempt is made to straighten the knee a painful elastic resistance is felt
(‘springy block to full extension’).
In the case of the medial meniscus, prolonged loss of full extension may lead to stretching and eventual
rupture of the anterior cruciate ligament.
The aim in treating meniscal tears is to correct the mechanical problems that they have created within
the joint, while if at all possible preserving as much of each meniscus as is possible; this, it is thought,
will reduce the risks of instability and the onset of secondary osteoarthritis. In many cases the torn part
of the meniscus (e.g. the handle of a bucket-handle tear) only is excised, but some major meniscal tears
may require total meniscectomy. In peripheral detachments and certain other lesions, particularly those
near the periphery of the meniscus, repair by direct suture or other measures is sometimes attempted.
Many surgical procedures are performed arthroscopically, thereby facilitating early recovery.