Dislocation: Causes, Symptoms, Diagnosis, Treatment

Dislocation (luxatio) - persistent displacement of articular ends of articulating bones beyond their physiological mobility with violation of joint function.

The name of the dislocation is received from the damaged joint, or the underlying segment is considered to be dislocated (except for the clavicle and vertebrae). Example: a dislocation in the elbow joint or dislocation of the forearm, but not a dislocation of the elbow joint.

[1], [2]

Epidemiology

Traumatic dislocations are the most common type, accounting for 2-4% of all skeletal injuries and 80-90% of all other dislocations. They occur in all age groups, but mainly in men aged 20-50 years: they account for 60-75% of injuries.

[3], [4], [5], [6], [7], [8], [9], [10], [11]

What causes dislocation?

The cause of dislocations is most often injuries of the indirect mechanism - violent movements that exceed the functionality of the joints. In this case, as a rule, the capsule of the joint is broken, partially the ligamentous apparatus, the surrounding soft tissues are injured.

Symptoms of dislocation

Among the joints of the extremities, the shoulder joint is most prone to dislocation. Damage to the arteries and nerves during dislocation is uncharacteristic, but the risk of their occurrence exists (for example, with dislocations in the knee, elbow joints or dislocation of the hip joint), especially with delayed dislocation of the dislocation.

Traumatic dislocation is accompanied by an extensive rupture of the capsule of the joint, tearing or rupture of the tendons, less often rupture or compression of the vessels and nerves. Clinical manifestations of trauma are typical: pain; edema, bruising, impaired limb function. Characteristic features of this type of damage are: the change in the shape of the joint, its contours are smoothed; In the place of one of the articular ends of the palpation is determined by the occlusion; the attempt of passive movements in the joint causes a sharp increase in pain, a springy resistance is felt.

In clinical practice, the most common dislocations of the hip, and congenital, dislocated shoulder, mostly habitual, subluxation of the head of the radial bone in children with a sudden stretch of the child's hand leading his adult man (dislocation Chassenyaka).

Symptoms of dislocation include pain, swelling, joint deformity and inability to move. The diagnosis is confirmed radiologically. Treatment usually consists of as soon as possible closed repositioning; this requires sedation and analgesia, and sometimes general anesthesia. The condition of blood vessels and nerves is evaluated before and after repositioning. If closed reduction failed, an open surgical treatment is indicated.

Classification

The dislocation is classified as follows:

1. By the origin of the dislocation is divided into: acute traumatic (the first 3 dislocations in the same joint, documented by X-rays); habitual traumatic dislocation after three acute traumatic; congenital, as a consequence of birth trauma; pathological dislocation in diseases and oncoprocesses in the joints.
2. The volume of the dislocation is divided into: full, when a total mismatch of the standing of the articular surfaces is formed; partial (subluxation), when the contact is limited, but preserved.
3. By localization: the lower segment of the limb is indicated (for example, if the shoulder is dislocated in the shoulder joint, the shoulder is dislocated, the forearm is forearm, the hip joint is the hip dislocation, etc. Only the vertebral dislocation is indicated by the overlying vertebra (for example, in the vvicha in the zone the first cervical vertebra diagnosis is defined as a dislocation of the head, with a dislocation between the XII thoracic and I lumbar vertebra - the dislocation of the XII thoracic vertebra).
4. In terms of duration from the moment of injury, the dislocation is divided into: fresh (up to 3 days); stale (up to 3-4 weeks); old (more than a month).
5. For damage to the skin, the dislocation is divided into closed and open.

Especially distinguished are the so-called fractures, when there is a fracture of the bone in the area of the intra-articular capsule and a dislocation (or subluxation of the head of the bone). More often this dislocation is noted in the humerus, ankle, elbow, wrist joints. A fracture in the hip joint can be formed of two types: simple, when there is a fracture of the femoral neck and its dislocation; and central fracture, when there is a fracture of the acetabulum, through which the head of the femur (a fracture of the femur may not be) is wedged into the pelvic cavity.

[12], [13], [14], [15], [16]

Single types of dislocations

Dislocation of the shoulder joint

Dislocation of the shoulder in 95% of patients is anterior. A typical mechanism is the retraction and external rotation of the shoulder. Often there is damage to the axillary nerve or separation of the large tubercle, especially in patients older than 45 years. The acromial process with the dislocation of the shoulder joint protrudes, the head of the humerus shifts anteriorly and downward and is not palpable in its usual place. The sensitivity of the axillary nerve, passing at the lateral margin by the deltoid muscle, is checked. Treatment is usually closed in the correction with sedation, but with the preservation of consciousness. The Mukhina-Mott method is used most often. After restoring the joint immediately immobilized with a bandage or a scarf.

Occasionally observed posterior dislocation - usually undiagnosed trauma, or lower (luxatio erecta). The latter is often accompanied by damage to the brachial plexus and brachial artery.

If the shoulder is dislocated, Pagensteecher's syndrome may occur-the subluxation of the head of the humerus up and in, with the simultaneous detachment of the biceps tendon of the shoulder.

[17], [18], [19], [20], [21], [22]

Dislocations of the elbow joint

A frequent mechanism is the fall on an unbent and withdrawn hand. Dislocations of the elbow joint are common, more characteristic is the posterior type. Concomitant lesions can include fractures, neuritis of the ulnar and median nerves, possibly damage to the brachial artery. The limb is usually bent at a joint angle of about 45 *, the elbow process strongly protrudes and palpable behind the condyle of the humerus and above the line connecting the epicondyle of the humerus; However, it is sometimes difficult to determine the relationship of these anatomical formations due to pronounced edema. Dislocation is usually corrected with a long, accurate traction after sedation and analgesia.

[23], [24], [25]

Subluxation of the head of the radius

In adults, the radius of the radial arm is wider than the neck, which prevents the ray head from penetrating through the tightly encircling neck of the ring-shaped ligament. However, in toddlers (about 2-3 years old), the radial head is not wider than its neck and can easily penetrate the ligament fibers with the formation of subluxation. This can happen with a sharp stretch for the straightened arm at the moment the child falls forward, but most parents do not take this into account. Symptoms may include pain and tenderness in palpation; However, in most cases, children are not able to clearly communicate their complaints and simply protect their hand from movements in the elbow joint (pseudo paralysis). Direct radiographs without pathological changes, some experts believe that they do not need to be performed, except for the suspicion of an alternative diagnosis. The direction can be both diagnostic and therapeutic. The elbow joint is completely unbent and supined, then bent, usually without sedation and analgesia. In children the mobility of the joint is restored in about 20 minutes. Immobilization is not needed.

Dislocation of the proximal interphalangeal joint

A typical dislocation. The dorsal displacement of the middle phalanx arises more often than the ventral phalange, usually with re-opening, sometimes with a shift in the intra-articular structures. Palmar dislocations can be accompanied by rupture of the central portion of the extensor tendon with the formation of a boutonniere type deformation. Such deformation in the dislocation of the proximal interphalangeal joint is common. In case of visible separation of the damaged finger from the others, a lateral radiograph should be performed.

In most cases, they carry out closed reorientation under conductive anesthesia. In the rear dislocation traction along the axis and palmar force is applied, with the palmar one uses a rear force. At the rear dislocation, the splinting is performed with a 15 ° flexion for 3 weeks. After the palmar dislocations are spliced in the extension position for 1-2 weeks. In some cases, rear sprains may require open repositioning.

[26], [27], [28], [29], [30], [31], [32]

Dislocations of the hip joint

In most cases, rear sprains are observed, appear with a pronounced force acting directed posteriorly to the knee, while the hip and knee joints are in the flexion position (for example, impact against the car dashboard). Complications can include damage to the arteries (especially with anterior dislocations) followed by avascular necrosis of the femoral head and damage to the sciatic nerve. Treatment consists in as soon as possible correction with the subsequent bed regimen and immobilization of the joint.

Congenital dislocation of the thigh is characterized by specific symptoms: Allis symptom - with the position of the child on the back with knees bent at the knees, the difference in limb length is revealed; Malgens a symptom - in a position on a healthy side the patient should bend and lead to the torso a sprained hip, then make them rotational movements, while easily groping the dislocated head of the thigh; Marx ("slippage") symptom - when trying to withdraw the bent leg of a child lying on his back, at one point in the lead, the head with a characteristic click enters the cavity, when it is brought back, it again dislocates; Trendelenburg symptom - when supported by a painful leg, the pelvis on the healthy side drops, the gluteal fold is shifted to the top. In a patient lying on the back or on radiographs, you can define the Briant triangle - the line from the anterior superior ostium of the ilium bones is posterior to, perpendicular to it is drawn from the large trochanter top (Briand's line), the hypotenuse of the triangle is the line from the upper to the large trochanter - with congenital dislocation thigh or other pathology of the head and neck of the femur, the triangle becomes not isosceles, but with the shortened Briand line.

[33], [34]

Dislocations of the knee joint (femoral-tibial)

Most of the anterior dislocations are due to over-extension; most of the posterior dislocations arise after direct force action directed posteriorly to the proximal part of the meta-epiphysis of the slightly bent tibia. Many dislocations recover spontaneously before seeking medical help, which can cause a pronounced joint instability later. Damage to the popliteal artery occurs frequently, this should be remembered even in the absence of limb ischemia. Angiography is shown to all patients with dislocation of the knee joint with marked instability. Treatment consists in immediate correction and surgical recovery.

[35], [36], [37],

Lateral patellar dislocation

A frequent mechanism is the contraction of the quadriceps muscle together with flexion and external rotation of the shin. Most patients have an anamnesis of patellofemoral pathology. Many dislocations recover spontaneously before seeking medical help. Treat treatment; the hip moderately bend, gently move the patella to the side with extension of the knee joint. After repositioning impose a cylindrical gypsum bandage on the shin, with indications pass to surgical treatment.

Diagnostics

Diagnosis of the dislocation is refined and documented necessarily X-ray, preferably in two projections, but in the absence of conditions, one is enough. Radiographs are given to the victim's hands or stored in the archive of the hospital, without the right to destroy, they must be issued at the first request. This is necessary to document the diagnosis of a habitual dislocation (more than three times in one joint), in which there are indications for surgical treatment and grounds for release from service in the army, and sometimes for determining disability. Pathological dislocations are formed in degenerative joint diseases: tuberculosis, arthropathy of various genesis, arthrosis, arthritis, mainly when the capsule of the joint is changed.

[38], [39]

Examination and physical examination

The joint is deformed. When palpation reveals a change in the external orientation of the joint, soreness. Active movements in the joint are absent. Attempting to perform passive movements causes severe pain. Determine the symptom of the spring resistance. The latter consists in the fact that the doctor, making passive movements, feels an elastic resistance to movement, and when the effort stops, the limb segment returns to its previous position.

If there is a suspicion of dislocation, it is necessary to check the pulsation of the arteries, skin sensitivity and motor function of the distal limb, as damage to the neurovascular bundle is possible.

[40], [41], [42], [43], [44]

Laboratory and instrumental research

When diagnosing dislocations, it is necessary to conduct an X-ray examination, without it it is impossible to establish the presence of concomitant fractures without bias and cracks in the bones. Otherwise, if you try to reinforce the segment, a fracture and displacement of the fragments may occur.

Treatment of dislocation

First aid

Treatment of fresh dislocations is an emergency measure; It should be started immediately after diagnosis. Help begins with the introduction of painkillers.

[45]

Conservative treatment

After anesthesia, the dislocated segment of the limb is replaced.

The most common dislocation of the shoulder. When examining, in addition to the noted features, it is determined the withering of soft tissues in the upper third of the shoulder, under the acromion. The patient tries to keep a healthy arm damaged, tilts the body in the direction of damage.

The first pre-medical care consists of applying a bandage dressing or Dezo bandage, giving analgesics. The victims are subject to urgent delivery to the hospital, where the doctor, depending on the nature of the injuries, chooses a certain method of correction.

Usually, when a dislocation is introduced, the doctor needs 1-2 helpers. Most often, the dislocation of the shoulder is eliminated by the methods of Kocher, Mota-Mukhina, Hippocrates. When the shoulder is dislocated by the method of Coher, four consecutive stages are distinguished. Stage 1: the surgeon with one hand brush grasps the elbow joint region from the back, the second arm with the forearm in the area of the wrist joint. Bending the arm at an angle of 90 ° in the elbow joint, it pulls along the axis of the shoulder of the injured limb and brings the shoulder to the trunk. Assistant physician should fix the body of the victim and produce a counterweight. Stage II: Without stopping the extension along the axis, the doctor turns the shoulder outward so that the inner surface of the forearm coincides with the frontal surface of the body. Stage III: Without weakening the traction, the surgeon slowly leads the elbow to the midline of the trunk with simultaneous rotation of the arm outward, and often a dislocation is eliminated.

If the reattachment does not occur, proceed to the IV stage: without loosening the traction, the forearm and shoulder quickly turn to the inside and sharply throw back on the healthy side with the expectation that the brush is on a healthy shoulder joint.

The direction of the dislocation is accompanied by a click, and movements in the shoulder joint are possible. In the patient's lying position, before being withdrawn from the anesthesia, the doctor with the helpers apply a soft bandage of Dezo with a small platen in the axillary region.

When the shoulder is dislocated by the Mota-Mukhina method, the damaged foreleg is covered with a towel or folded sheet in such a way that the ends are directed to the healthy side. One assistant holds a pull for the ends of the towel toward the healthy shoulder, and the second - bends the arm at the elbow joint at a right angle and holds the forearm with both hands.

Extension in opposite directions is carried out gradually, avoiding tremors. The doctor probes the displaced head of the shoulder in the armpit and fixes it with his fingers. At the command of the doctor, the assistant makes rotational movements with the shoulder, without stopping the extension. Then the doctor presses his fingers or fist on the head of the shoulder in the upper-internal direction - as a rule, the dislocation is being adjusted.

The method of Hippocrates is used to correct dislocations in elderly patients and when combined with a fracture of the neck of the humerus.

The doctor holds the forearm with both hands and produces a smooth extension of the limb. With the heel of his foot, he presses on the displaced head of the humerus. At the same time, the arm stretching and the load on the head gradually increase. Dislocation of the dislocation requires complete relaxation (relaxation) of the muscles, which is achieved with general anesthesia.

When correcting a traumatic dislocation, the following rules must be observed.

• Manipulation is performed with the use of local or general anesthesia, since only in this case it is possible to achieve complete relaxation of the muscles.
• The dislocated segment is guided as sparingly as possible, without jerks and gross violence.
• After elimination of the dislocation, the limb is immobilized with a plaster bandage.
• After removing the fixing bandage, a course of rehabilitation treatment is carried out (therapeutic gymnastics, physiotherapy, hydrotherapy, mechanotherapy aimed at alleviating the pain syndrome, normalizing blood circulation, increasing the elasticity of soft tissues).

The treatment of stale and (especially) chronic dislocations is decided individually, as the prognosis is far from always successful.

[46], [47], [48], [49], [50], [51], [52], [53], [54], [55],

Surgery

Patients with habitual dislocations should be referred to a hospital for surgical treatment of dislocation.