INJURIES TO JOINTS
U.RADHAKRISHNAN.M.P.T
GRADES OF JOINT INJURY
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THREE GRADES OF JOINT INJURY OCCUR
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SUBLUXATION
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DISLOCATION
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FRACTURE DISLOCATION
DISLOCATION
SUBLUXATION
There will be partial contact between Joint
surfaces
 It seldom needs Active treatment
 The normal stability usually returns when
periarticular tissues have healed
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DISLOCATION
Joints have been completely dislocated
 No contact between Joint surfaces
 The Joints must be reduced and immobilized
until the soft tissues have healed.
 COMPLICATIONS:
 Dislocation may be followed by Recurrent
dislocation Eg.In Patella, In Shoulder.
 Aseptic Necrosis
 Chronic instability
 Osteoarthrosis
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FRACTURE DISLOCATION
Dislocation accompanied by Fracture around the
Joint.
 This dislocation heal more soundly than simple
dislocation because bone unite more soundly than
ligament.
 Treatment- Fixation of Bony fragment
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DISLOCATION OF THE SHOULDER
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Shoulder Joint is mechanically unstable.
TYPES OF SHOULDER DISLOCATION:
 1.Anterior Dislocation
 2.Posterior Dislocation
 3.Luxatio erecta,or true Inferior dislocation
 4.Fracture Dislocations
 5. Multidirectional
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ANTERIOR DISLOCATION OF SHOULDER
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It is more commonest pattern
MECHANISM OF DISLOCATION:
Head of Humerus slipping off the front of Glenoid
when the arm is abducted and Externally rotated.
Anterior dislocations damage the attachment of
labrum to the anterior glenoid margin (Bankart
lesion).
There may also be an associated fracture of anterior
glenoid rim (bony Bankart lesion) or disruption of the
glenohumeral ligaments.
A compression fracture of the humeral head
posteriorly (Hill-Sach lesion) or tearing of the
posterior or superior labrum may also be present
CLINICAL FEATURES:
i)The dislocated shoulder has characteristic
 appearance with a prominent humeral head and
a hollow below the acromion.
 ii) Head slips medially when the arm is lowered
 iii) Flatter appearance of Shoulder( Deltoid
muscle weakness)
 iv) Elbow points outwards
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COMPLICATIONS
Damage to circumflex Axillary nerve
 Arterial damage
 Irreducibility
 Joint Stiffness
 Recurrent Dislocation
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MEDICAL MANAGEMENT
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The sooner the dislocated shoulder is reduced, the
easier it usually is to reduce.
There are a number of methods to relocate the
humeral head onto the glenoid cavity. one method is
injection of 10-15 mL of xylocaine into the joint can
reduce pain and muscle spasm and aid reduction
The manoeuvre involves initial slight abduction and
internal de-rotation of the affected arm. This can be
done without applying a great deal of traction.
The shoulder is then immobilised in a sling.
An X-ray should still be performed post-reduction to
rule out any associated fractures.
STIMSON'S TECHNIQUE:
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The patient is placed in a prone position on the bed.
The affected shoulder is supported and the arm is left
to hang over the edge of the bed.
A weight is attached to the elbow/wrist. It is usual to
begin with about 2 kg. Up to 10 kg may be applied.
Gravity stretches the muscles and reduction occurs.
Gentle internal/external humeral rotation may be
applied.
This method may take 15 to 20 minutes.
STIMSON'S TECHNIQUE
POSTERIOR DISLOCATION
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Posterior dislocation is far less common than anterior
dislocation. It occurs either as a result of direct
trauma or due to a fall on the outstretched arm that
is in some degree of internal rotation or adduction.
It may also be caused by a fits of any cause (e.g.
electric shock or epileptic fits).
Inspection of the patient's shoulder may reveal loss of
the normal rounded appearance at the front of the
shoulder. The arm is held in internal rotation and
adduction.
The cardinal sign is limitation of external rotation.
Suspicion of a posterior dislocation should be based on
the mechanism of injury and the presence of pain and
impaired function.
RECURRENT DISLOCATION
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Dislocation of the shoulder is often associated with damage
to the joint capsule (as in Bankart's and Hill-Sachs lesions)
and this can lead to instability and predispose to recurrent
dislocation.
80-94% of patients who have a dislocation under the age of
20 years will have a recurrence of their dislocation
26-48% of those younger than 40 years will have a
recurrence
0-10% of those older than 40 years will have a recurrence]
A single dislocation in a young man who plays contact sport
may well merit referral to an orthopaedic surgeon to assess
stability of the joint with a view to a stabilisation
operation. Two dislocations in a young person certainly
merit referral.
There are several stabilisation procedures, dependent upon
the nature of the lesion.
FURTHER READING & REFERENCES
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Wilson SR et al; Dislocation, Shoulder, eMedicine, Dec 2009
Anterior Instability of the Shoulder, Wheeless' Textbook of Orthopaedics
Shoulder Dislocation: Associated Injuries, Wheeless' Textbook of Orthopaedics
Posterior Shoulder Dislocation/Instability, Wheeless' Textbook of Orthopaedics
Quillen DM, Wuchner M, Hatch RL; Acute shoulder injuries. Am Fam
Physician. 2004 Nov 15;70(10):1947-54.
Bankart Lesion, Wheeless' Textbook of Orthopaedics
Work Up for Shoulder Dislocation, Wheeless' Textbook of Orthopaedics
Mattick A, Wyatt JP; From Hippocrates to the Eskimo - a history of techniques
used to reduce anterior dislocation of the shoulder. J.R.Coll.Surg.Edinb.,
45,October 2000, 312-316
Hovelius L, Augustini BG, Fredin H, et al; Primary anterior dislocation of the
shoulder in young patients. A ten-year prospective study. J Bone Joint Surg
Am. 1996 Nov;78(11):1677-84.
Handoll HH, Almaiyah MA, Rangan A; Surgical versus non-surgical treatment
for acute anterior shoulder dislocation. Cochrane Database Syst Rev.
2004;(1):CD004325.