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DISLOCATIONS FROM THE GROUND UP

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use landmarks on the bony anatomy to describe pattern of injury. condyle head physis ... think about what you want to say and have the films up while describing ... – PowerPoint PPT presentation

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Title: DISLOCATIONS FROM THE GROUND UP


1
DISLOCATIONSFROM THEGROUND UP
  • Herbert Eidt M.D.
  • DeWitt Army Hospital
  • Orthopaedic Surgery Service

2
TALK THE TALK
  • KEEP IT SIMPLE
  • describe what you see on exam and films
  • USE PROPER TERMINOLOGY
  • proximal dorsal
  • distal volar
  • inferior extensor
  • superior flexor
  • medial anterior
  • lateral posterior

3
TALK THE TALK
  • DESCRIBE WHAT YOU SEE
  • avoid terms like
  • Barton's Colles
  • Smiths Monteggia
  • use terms like
  • ulnar radial
  • articular surface

4
TALK THE TALK
  • BE FAMILIAR WITH THE ANATOMY
  • use landmarks on the bony anatomy to describe
    pattern of injury
  • condyle head physis
  • epiphysis metaphysis trochanter diaphysis

5
TALK THE TALK
  • KNOW WHAT YOU WANT TO SAY
  • look at films
  • think about what you want to say and have the
    films up while describing findings
  • measure displacement and angulation beforehand

6
DISLOCATIONS
  • URGENT TO REDUCE
  • EACH JOINT HAS DIFFERENT CONCERNS ASSOCIATED WITH
    DISLOCATION
  • SECRET TO REDUCTION IS ADEQUATE PAIN CONTROL IN
    ALMOST ALL CASES
  • POST REDUCTION XRAYS A MUST TO CONFIRM REDUCTION
    AND RULE OUT FRACTURE

7
DISLOCATIONS
  • FOOT AND ANKLE
  • TOES
  • MIDFOOT
  • LISFRANC
  • HINDFOOT
  • SUBTALAR
  • ANKLE

8
TOE DISLOCATIONS
  • METATARSAL PHALANGEAL
  • Hyperextension injury of great toe
  • More commonly dorsal dislocation
  • Jamming injury of lesser toes
  • More commonly medial or lateral displacement
  • INTER PHALANGEAL
  • Axial load injury
  • More commonly dorsal dislocation

9
TOE DISLOCATIONS
  • OBVIOUS DEFORMITY
  • REDUCE WITH ACCENTUATION OF DEFORMITY AND THEN
    LONGITUDINAL TRACTION WITH PRESSURE ON BASE OF
    DISLOCATED PHALYNX
  • USE METATARSAL BLOCK IF NECESSARY
  • FOOT PLANTARFLEXION WILL RELAX THE FLEXOR
    TENDONS.
  • OPERATIVE INTERVENTION IS REQUIRED AFTER
    REDUCTION IF
  • UNABLE TO REDUCE LIMIT REPEAT ATTEMPTS
  • CREPITUS WITH MOTION
  • UNSTABLE JOINT
  • INTRAARTICULAR LOOSE BODY ON POST REDUCTION XRAY

10
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • COMMON, HIGH ENERGY INJURY
  • OFTEN MISSED
  • HUGE SPECTRUM OF INJURY
  • From mild sprain to fracture/dislocation
  • FORCED DORSIFLEXION MECHANISM

11
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • EVALUATE WITH 3 VIEW WEIGHT BEARING XRAY
  • If pain limits exam, may choose
  • to reevaluate with weight bearing
  • x-ray at later time
  • If suspicious for this injury, keep
  • non-weight bearing and cast
  • until full evaluation possible

12
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • RADIOGRAPHS
  • Look for medial shaft of 2nd MT to align with
    medial border of middle cuneiform on AP
  • Medial shaft of 4th MT should align with medial
    aspect of cuboid on oblique
  • No incongruency of metatarsal-cuneiform
  • Look for fleck sign indicating avulsion of
    Lisfranc ligament
  • Look for compression fracture of cuboid

13
fleck sign
14
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • TYPES OF LISFRANC INJURY
  • TYPE A
  • All five metatarsals displaced
  • homolateral
  • TYPE B
  • One or more articulations intact
  • Medial or lateral displacement
  • TYPE C
  • High energy
  • Divergent
  • High risk for compartment syndrome

15
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • TYPES OF LISFRANC INJURY

16
(No Transcript)
17
TARSALMETATARSAL DISLOCATION (LISFRANC)
  • TREATMENT
  • Swift reduction of deformity
  • Key to improvement of result is accurate
    reduction of displacement
  • Less than 2mm displacement can be treated without
    surgery in non-weight bearing cast

18
SUBTALAR DISLOCATION
19
SUBTALAR DISLOCATION
  • USUALLY MEDIAL
  • Can be lateral, anterior or posterior
  • Medial dislocation can almost always be reduced
    closed
  • Lateral dislocation frequently blocked by
    interposed posterior tibial tendon
  • Look for osteochondral fracture of the talus on
    post reduction films

20
TIBIAL-TALAR
  • USUALLY FRACTURE DISLOCATION
  • POSTERIOR OR ANTERIOR DISLOCATION, SUPERIOR
    MIGRATION WITH DIVERGENCE, LATERAL
    SUBLUXATION

21
TIBIAL-TALAR
  • REDUCTION
  • Pain control is the key conscious sedation
  • Longitudinal traction
  • If joint is not completely reduced think
    interposed posterior tibial tendon
  • If it can be reduced but not maintained, may need
    external fixator
  • MOVE FAST, DONT DELAY REDUCTION.

22
TIBIAL-TALAR
  • CAUTION
  • Check and document neurovascular status before
    and after reduction

23
DISLOCATIONS ABOUT THE KNEE
  • PATELLAR
  • FIBULAR HEAD
  • FEMORAL-TIBIAL

24
PATELLAR DISLOCATION
  • Common injury, especially in younger population
  • Patella dislocates after valgus and external
    rotation force
  • Usually can be easily reduced in the field
  • Lateral dislocation is most common

25
PATELLAR DISLOCATION
  • REDUCTION
  • Extend knee and put medial pressure on patella to
    reduce

26
PROXIMAL FIBULA
  • Anterior-lateral most common
  • Seldom accompanied by nerve injury
  • Posterior-lateral less common
  • Almost always with nerve injury
  • Reduce with direct pressure
  • Protect weight bearing and physical therapy
  • Seldom need surgery unless chronically unstable

27
PROXIMAL FIBULA
28
FEMORAL-TIBIAL
29
FEMORAL-TIBIAL
  • CONCERN FOR NEUROVASCULAR COMPROMISE
  • SHOULD REDUCE AS SOON AS POSSIBLE
  • USUALLY ASSOCIATED WITH MULTILIGAMENTOUS INJURY

30
FEMORAL-TIBIAL
31
FEMORAL-TIBIAL
  • DOCUMENT NEURO STATUS BEFORE AND AFTER REDUCTION
  • CONSIDER ARTERIOGRAM TO EVAL FOR POPLITEAL INJURY
  • ABI CAN BE HELPFUL IN EVALUATION
  • KNEE DISLOCATION WITH SPONTANEOUS REDUCTION CAN
    MASK THE SEVERITY OF THE INJURY
  • GET GOOD EARLY FULL LIGAMENT EXAM TO IDENTIFY
    THOSE AT RISK

32
HIP DISLOCATION
33
HIP DISLOCATION
  • HIGH ENERGY TRAUMA
  • RARE IN SPORTS INJURIES
  • ORTHOPAEDIC EMERGENCY
  • FULL TRAUMA EVALUATION
  • MOST CAN BE REDUCED CLOSED
  • ADDRESS THIS INJURY FIRST ONCE PATIENT STABLE

34
HIP DISLOCATION
  • INITIAL PRESENTATION
  • FLEXED AND INTERNALLY ROTATED AT HIP

35
HIP DISLOCATION
  • ONCE REDUCED, NEEDS FULL XRAY AND CT SCAN

36
HIP DISLOCATION
  • LATE EFFECTS - OSTEONECROSIS

37
HIP DISLOCATION
  • REDUCTION

38
SHOULDER DISLOCATIONS
  • COMMON INJURY IN OUR POPULATION
  • USUALLY ISOLATED INJURY
  • CAN REDUCE IN FIELD IF EARLY, BUT MAY NEED
    SEDATION

39
SHOULDER DISLOCATION
  • ANTERIOR MOST COMMON

40
SHOULDER DISLOCATION
  • Must evaluate with proper x-ray series
  • Glenoid or true AP
  • Scapular Y view
  • Axillary view
  • If too painful may get Velpeau view or CT scan

41
SHOULDER DISLOCATION
  • ASSOCIATED INJURY
  • Labrum tear
  • Axillary nerve neuropraxia
  • Hill Sachs fracture
  • Rotator cuff tear
  • More common in older
  • DO GOOD NEUROVASCULAR EXAM BEFORE AND AFTER
    REDUCTION

42
SHOULDER DISLOCATION
43
SHOULDER DISLOCATION
  • REDUCTION
  • TRACTION
  • COUNTER-
  • TRACTION

44
SHOULDER DISLOCATION
  • REDUCTION
  • GRAVITY
  • AND
  • TRACTION
  • STIMSON

45
SHOULDER DISLOCATION
  • REDUCTION
  • MILCH

46
SHOULDER DISLOCATION
  • EARLY SURGERY VS NONOPERATIVE TREATMENT

47
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