TRAUMATIC DISLOCATION

AND SUBLUXATIONS IN
ADULTS (dislocated shoulder,
forearm and hip).
 Traumatic dislocation - the total displacement of the articular
ends of bones, which lost contact with the articular surfaces in the
junction area. Dislocation occurs due to injury, accompanied, as a rule,
break the joint capsule and ligaments. Subluxation called incomplete
displacement of articular surfaces.

Traumatic dislocations are 1.5 - 3% of the total number of all

types of injuries of the musculoskeletal system. Sprains are injuries
severe kind, often requiring hospital treatment. Traumatic dislocations
are commonly observed in middle age, more common in men.
 There are dislocations in most cases as a result of
indirect trauma (fall, focusing on a straightened or bent limb).
Dislocation is also possible due to a sharp sudden muscle
contraction, such as throwing grenades; stone, sudden
movement during the voyage.
Considered to be dislocated distal part of the limb, but
there is an exception: a dislocation of the acromial end of the
clavicle, vertebrae dislocation. These dislocations are called by
proximally-located portion.
There are:
• Fresh,
• chronic,
• irreducible,
• usual,
• indoor and outdoor,
• complicated
• and uncomplicated dislocations and subluxations.
 Fresh dislocation considered in the first 2 days, stale - up
to 3 - 4 weeks; stale usually considered to be dislocated after 4
weeks. Irreducible dislocation are caused by soft tissue
interposition basically torn muscle between the head and the
glenoid cavity. By irreducible also include all chronic sprains.
Irreducible dislocation should reduce a surgically. Routinely refer
constantly recurring sprains that occurred after the initial
dislocation of the joint.

Complicated intra-articular or sprains are accompanied by

periarticular fractures, damage to major vessels, nerve trunks.

The frequency of individual dislocations in the joints

depends on the anatomical structure of the joint, the strength of
the joint capsule and ligaments, muscle strength, the joint nature
and extent of movement in the joint. The joints of the upper
limbs are damaged in 7-8 times more often than the lower.
 When dislocation not only located near the
injured muscle, but vary in length and direction of the
fibers, which causes a marked reflex contraction of
one group of muscles and stretching the other. Very
quickly after the dislocation develops muscle retraction
to warrant a strong fixation dislocated bone in a
vicious position. The more time has passed since the
dislocation, the muscle contraction is more stable and
less reversible. If the rule is not dislocated in time, the
result is inflammation and subsequent hemorrhage
glenoid cavity is filled with scar tissue and bloodless
reduction of dislocation becomes impossible.
Sometimes gradually formed a new joint with new
axes of motion.
 Diagnostics.
The diagnosis of dislocation is established when the following data:
•a history of trauma (fall, sudden movement);
•strong pain; joint deformation field, clearly visible when compared
with the healthy side; forced, characteristic for each type of
dislocation, the position of the limb;
•Changing a sprained limb axis direction with respect to the adjacent
points of identification;
•Changing the length of the limbs (usually shortening, less elongation);
•Lack of active and sharp restriction of passive joint movement;
•«springy fixation", in which an attempt to make certain passive
motion to withdraw the finiteness of the forced position, meets elastic,
springing resistance and it resumes the same position;
•articulate the end, which came with a dislocation of the glenoid
cavity, is felt not in its usual place or not is determined.
 It is important to study the pulse on the affected limb, as well as
the sensitivity of the determination. When dislocations, especially
complicated fractures may damage the neurovascular bundle.
Dislocation should be distinguished from joint injury, damage to
ligaments, fractures inside and outside the joint.
Unlike dislocations in fractures fixing limbs is not observed in the
wrong position, and the mobility in an unusual location. Exceptions are
fractures in conjunction with the dislocation, in which the detected
characteristic of pathological fractures and the mobility is not a typical
symptom of dislocation "springy fixation" in the joint. In these cases, the
correct diagnosis can be made with the X-ray examination.
X-ray examination, which is necessary for suspected dislocated,
allowing accurate diagnosis, to determine the exact position of the
articular ends, to exclude or detect the presence of concomitant fracture
or separation of bone tissue. The first medical assistance in cases of
suspected dislocation is reduced to immobilize the limb, the use of
analgesics and immediate direction of the victim to the trauma hospital.
• Treatment.
In traumatic dislocation is reduced to as early
as possible reposition, preferably under
general anesthesia, the retention reduction of
the articular ends of the bones by immobilizing
the limb and the subsequent recovery of its
function. The need for an early reduction of
dislocation is dictated by the fact that as the
time elapsed from the moment of dislocation,
increases muscle contracture, holding the limb
in a vicious situation, and the more time
passes since the injury, the more difficult to
straighten luxation.
 SHOULDER DISLOCATION
Dislocation of the shoulder is 50 - 60% of all
dislocations. This is explained by the frequency of their
anatomical and physiological characteristics of the
shoulder joint; the surface of the glenoid cavity of the
blade in 3 - 4 times less than the surface of the
humeral head, which has a spherical shape; joint
capsule wide and thin.
Traumatic dislocation of the shoulder joint
occurs more often in indirect trauma (eg fall back on
the exposed arm or elongated forward or assigned to
a hand). When dislocation of the humeral head can be
displaced anteriorly, posteriorly or downward from the
glenoid cavity.
 Depending on the position of a head of a sprained shoulder
distinguished:
•Front;
•Rear;
•lower sprains;
The most common front sprains (98%), and very rarely - back
sprains.

1 2 3
Types front shoulder dislocations.
1 under the coracoid; 2 - within the coracoid; 3 -
subclavian;
 Shoulder dislocation is always accompanied by rupture of the joint
capsule. This may overstrain or completely tear the muscle tendons,
especially the supraspinatus.

Girdle the affected hand is omitted, the patient keeps his head
bowed in the damaged side. He is trying to create peace limbs, gently
supporting her with his good hand. Hand is in the abduction, bent at the
elbow and appears elongated shoulder axis extends upward in the normal
passes through the acromion process of the scapula and at dislocation - in
the collarbone. The distance from the acromion process to the outer
condyle shoulder will be greater than on the healthy side as a result of
lower standing shoulder head shoulder joint area. Normal roundness in the
deltoid muscle at the dislocation disappears at this place is rough flat
surface due to the absence of the head in the glenoid cavity. Above this
surface detectable free acromion process. Active movements are absent or
severely hampered in the joint. When you try to perform passive
movements: to lift the arm of the patient, give or take it, marked "elastic
fixation" shoulder cushioning resistance. The elbow joint is not possible to
give to the body. On palpation determined diffuse tenderness in the joint
area.
 Dislocation of the shoulder is sometimes combined with a
fracture of the surgical neck of the shoulder. At the turn of the
shoulder usually shortened and set aside. In these cases, when you try
to bring the abduction of the shoulder and is not characteristic of the
dislocation of a spring resistance. When motion is determined by the
shoulder crepitus. Much more difficult to clinically diagnose a dislocated
shoulder while impacted fracture of his neck. Early diagnosis of a
fracture to reposition very important, since the separation of impacted
fracture can occur when reposition. Therefore, clinical evaluation is
completed by X-rays in two projections, which clarifies the diagnosis.

Pose a patient with anterior shoulder dislocation.

 Treatment.
When fresh dislocation of the shoulder joint
are beginning to reposition it under
anesthesia in order emergency care.
Sometimes the reduction can be performed
under local anesthesia. For this to reposition
the patient is administered 1 mL of 1%
solution pantopon or morphine. Then spend
anesthesia the shoulder joint by injecting
30-40 ml of a 1% solution of novocaine in
the joint capsule. There are many ways to
reposition the shoulder dislocation.
• Method of Hippocrates -
Cooper. The doctor sits facing the back
of the patient lying on the side of
dislocation and two-handed wrist grabs.
The heel of his bare feet, the same
name of the victim with a sprained
hand, puts in his armpit and presses the
shifted her head, realizing at the same
time stretching on hand axis. Sweep the
head of the humerus in the glenoid
cavity reduce a.
 Kocher method. It is used for
the front dislocations. The patient
is placed on a table at the back, to
a sprained hand went beyond the
edge of the table. The method
consists of four steps carried out
successively.
 1 2

3 4
Stages reposition shoulder dislocation by Kocher.
• First step. A surgeon with one hand holding
the lower third of the forearm sore hand, and the
other, with a sprained heteronymic - arm, which is
bent at a right angle, and gently carries it to the body,
exercising traction on the shoulder axis. Assistant
captures the shoulder girdle (Figure 1).

• Second phase. Not relaxing traction on the shoulder

axis, which is pressed to the body, the surgeon slowly
rotates outwards to shoulder until the upper arm will
not rise to the frontal plane of the body. At the same
time shoulder the head articular surface rotated
forward. Often, when the second phase of reduction of
dislocation occurs at the same time you hear a click
(see Figure 2).
• Third stage. Keeping the position of rotation
outwards and relaxing stretching, gradually begin to
raise the forearm up and down, moving close to the
body of the patient elbow to the middle line and up.
This usually becomes head against a place of rupture
of the bag. Sometimes the head is to the right after
this stage (Figure 3).
• The fourth stage. It starts after a thorough
implementation of the previous phase. The forearm is
used as a lever to rotate inwards sharply. This affected
the brush is moved to the opposite shoulder joint and
forearm are placed on the patient's chest (Figure 4).
At this point, usually it occurs reduction. If it does not
happen, you should not hurry, carefully repeat all the
stages, avoiding rough and sudden movements.
 Method Janelidze.
Once the victim is laid on the table of anesthesia on the
patient side by side so that the edge of the table come in
axilla, and a sprained arm hanging down freely. The head is
placed on a front table. In this position, the patient must be
within 10 - 20 minutes, there was a relaxation to the muscles
of the shoulder girdle. Then proceed to the reduction of
dislocation. The surgeon gets in front of the patient, it
captures bent at the elbow and forearm pushes him closer to
the elbow, combining pressure with small circular movements
of the shoulder joint. This results in reduction of dislocation of
the shoulder. Then applied for 2 - 3 weeks plaster bandage,
fixing his hand to his chest. After reposition should make an
X-ray to make sure that I correct the dislocation and bone
lesions are absent. After 5 - 7 days is prescribed therapeutic
physical training and physical therapy procedures to a speedy
recovery. Employability is restored within 30 - 45 days.
Shoulder dislocation
reduction on Janelidze.
 Method Chaklin. The patient lies on his back.
The doctor sips given the length of the shoulder,
pushing outward shoulder head of the second hand,
introduced in axilla. Method Chaklin less traumatic and
is performed under general anesthesia. Especially this
method is shown in fractures and dislocations of the
shoulder.

Irreducible fresh dislocations. Anatomical

obstruction to reposition can be tendon of the long
head of the biceps muscle afflicted head, or cut off the
greater tuberosity and the infringement of the head
into the cracks break capsules or soft tissue
interposition. Irreducible dislocation can only
straighten surgically.
Chronic sprains.
Unrecognized and incorrectly treated sprains are
accompanied by scar shrinkage of the joint
capsule, numerous splices formed scars, loss of
muscle elasticity. Joint deformation with
inveterate dislocation of the shoulder becomes
more pronounced after the resorption of
hemorrhages and muscle atrophy. The amount
of active and passive movements increases,
sharp pains disappear. However, abduction and
lifting his hands with a fixed blade is not
possible. The method of treatment of chronic
dislocation is the surgical reduction.
 Treatment.
If irreducible and chronic dislocations of the humerus surgery.
The operation is performed under general anesthesia. Position
the patient on the back, shoulders under a pillow. Penetration
into the joint at the shoulder lateral groove. Coracoid process cut
off from the muscles are attached to it and discharged
downwards. In view of the possible marginalization of the head
of the neurovascular bundle anterior surgeon should be
especially careful not to damage the vessel and not to damage
the nerve structures. After sectioning the subscapularis muscle
joint capsule is opened. Cavity him as the head, free from
adhesions and scarring, and then reduce a head in the joint.
Sutured capsule (sometimes When sewing the edge with the
subscapularis to small tubercle), and the coracoid process is
fixed in place. Impose abductor thoraco-brachial bandage. After
8 - 10 days begin passive motion in the shoulder joint.
 DISLOCATION OF THE FOREARM

Dislocation of the elbow in frequency in second place and

constitute 18-27% of all dislocations mostly in young people.
Most often, a dislocation of the forearm occurs during the fall
on an outstretched hand with the elbow hyperextension.
observed:
1. dislocation of both bones of the forearm (posterior,
anterior, outwards, inwards, divergent dislocation)
2. a radius dislocation (anteriorly, posteriorly, laterally)
3. a dislocation of the ulna.

The most common posterior dislocation of both bones of the

forearm (90%) and a dislocated radial bone anteriorly. Other
types of dislocations of the forearm are rare.
 A B

Dislocation of both bones of the forearm.

A - back, B – front
Posterior dislocation of the forearm. Diagnosis is based on the
deformation of the joint. His areas increased in circumference,
painful limb is forced semi-unbent position. Active movements are
not possible. When you try to passive movements there is a spring
resistance. Seen from the front forearm shortened as compared
with the healthy side. The elbow is palpated shoulder epiphysis.
Reduction rear dislocation is preferably carried out under general
anesthesia. The patient is laid on his back on the table. Hand
assigned in the shoulder and bent at the elbow so that the forearm
is in a vertical position. The surgeon places a thumbs up to the
olecranon, pressing down on the patient's shoulder from front to
back, and at the same time pushing forward olecranon. At this
point, the assistant performs traction along the length of the
forearm and elbow flexion. After reposition make an X-ray. Check
the radial pulse. The bent at an acute angle of the elbow is
immobilized posterior plaster splint for 7 days, after which the
prescribed exercise therapy (cautious in the early days and more
active since the 10th day) in combination with heat treatment.
Employability is restored within 20 - 30 days.
Reduction rear dislocation of
forearm
 Anterior dislocation of the forearm. Reposition it
requires flexion of the shoulder and elbow joints. Helper
producing traction length for hand and forearm, it slowly
flexes, while the surgeon by placing the thumb on the
speaker on the back side of the joint end of the humerus, lifts
it anteriorly in the proximal direction while simultaneously
pushing the other fingers forearm back in the distal direction .
Before and after the reduction of dislocation requires
radiological control. Along with the described methodology is
applied and modified. After reposition Assistant extends the
forearm to the obtuse angle. In this position, fix the rear limb
plaster splint with the forearm supinated 10-12 days. On
failure, the manual reposition can be carried out by operative
reduction, but only if there is no ossification around the joint;
if it (ossification occurs very quickly: in 2 weeks) it is better to
produce arthrodesis or arthroplasty of the elbow joint.
Diaplasis anterior dislocation of the forearm
 HIP DISLOCATION

Traumatic dislocation of the hip is about 5% of all dislocations.

There are:
• rear
• front sprains:
rear divided into caudineural or iliac and lowback or sciatic, front -
on the anterior and anteroinferior or obturator. Posterior dislocation
hip - iliac and ischial - there are 3 times more likely to front. Among
dominate iliac posterior dislocations. Traumatic dislocation of the
hip occur mainly in a strong, physically developed people aged 20
to 50 years. The mechanism of posterior dislocation often - indirect
significant violence provided when the thigh is rotated suddenly
sharply inwards and at the same time given. This breaks the head
capsule and is restrained between its edges and muscles; round
ligament is torn completely normally. The femoral head is located
on the outer and rear surfaces of the wing of the ilium; low sciatic
dislocation is behind the head and downward from the acetabulum.
 Hip dislocation is accompanied by severe pain,
inability to stand on the leg after the injury.
Characteristically forced position of the legs, which
depends on the type of dislocation. When she bent
posterior dislocation of the hip joint is shown and rotate
inwards; active movement in hip impossible. Trying to
bring passive limb of the forced position is accompanied by
pain; thus reveals characteristic symptom of dislocation of
the spring resistance. There shortening the legs. Under the
inguinal ligament retraction is determined, and the rear
overhang is sometimes visible and palpable to shift the
head.
For anterior dislocation - the obturator and on pubic
- characterized by limb lengthening. When the obturator
dislocation of the head can be felt on the inside of the hip,
buttocks flattened, the greater trochanter is not defined. X-
ray study adds to the clinical picture.
 Diaplasis hip dislocation should be performed under general
anesthesia. The most common way to reposition dislocated back on
Kocher. The patient lies on his back on a table or on the floor. The
assistant holds the patient's hips with both hands, position on the iliac
crest. The surgeon folds the victim limb at a right angle at the knee
and hip joints and conducts stretching vertically, rotiruya limb inwards.
Very often when reposition clicks.
When you reposition a patient in a manner Dzhanelidze laid on
the table in the stomach so that the injured leg dangling. For a more
robust fixation of the pelvis under the spine enclose two small bag of
sand. Assistant presses both hands to the patient's pelvis these sacs,
thus achieving a strong fixation. If the reduction is made under general
anesthesia, the patient lay on his stomach needed after a deep sleep
comes. The patient remains in this position for 10-20 minutes.
Assistant to the pressure of hands on the sacrum fixes pelvis. The
surgeon stands between the patient table and hanging leg, bend it at
the knee at a right angle and with the abduction and rotation outwards
begins to apply pressure on the popliteal fossa (better than your knee).
The result of these manipulations head is shifted in the acetabulum,
which is accompanied by a clicking sound.
 1 2

3 4
Dislocation of the hip and leg position while. 1 - caudineural iliac
dislocation of the hip; 2 - lowback sciatic dislocation of the hip; 3 - the
anterior pubic dislocation of the hip; 4 - anteroinferior obturator hip
dislocation.
 Reduction in anterior dislocation of the hip joint is carried
out somewhat differently. It is necessary to combine traction on
the length of the limb from the foot in the direction of traction
with a soft loop superimposed on the proximal femur.
After reposition of dislocation the limb must be applied plaster
splint back, fixing the hip, knee and ankle joints. After 30 days,
patients start walking with crutches without a load on the leg for
8 - 10 weeks. Assign physiotherapy. Employability is restored
after 3 months after the reduction. Forecast reposition after hip
dislocation is usually good. Some patients in the future as a
result of impaired blood flow in the femoral head may develop
aseptic necrosis and deforming osteoarthritis. With long-standing
and irreducible dislocation of the hip shows rapid reduction.
However, if the irreducible dislocation is still possible to try to
make the cut after posterioexternal reduction, when it is
expedient to make inveterate dislocation of the joint arthrodesis.
 b
a

Reduction of dislocation femur

Kocher.
a - the position of the patient;
b - reduction rear dislocation; c
c - reduction anterior dislocation.
The numbers indicate the
sequence of stages of
reduction.
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