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DISLOCATIONS FROM THE GROUND UP

DISLOCATIONS FROM THE GROUND UP. Herbert Eidt M.D. DeWitt Army Hospital Orthopaedic Surgery Service. 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

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DISLOCATIONS FROM THE GROUND UP

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  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. 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 TARSALMETATARSAL DISLOCATION (LISFRANC)

  15. TARSALMETATARSAL DISLOCATION (LISFRANC) • TYPES OF LISFRANC INJURY

  16. 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

  17. SUBTALAR DISLOCATION

  18. 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

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

  20. 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, DON’T DELAY REDUCTION.

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

  22. DISLOCATIONS ABOUT THE KNEE • PATELLAR • FIBULAR HEAD • FEMORAL-TIBIAL

  23. 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

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

  25. 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

  26. PROXIMAL FIBULA

  27. FEMORAL-TIBIAL

  28. FEMORAL-TIBIAL • CONCERN FOR NEUROVASCULAR COMPROMISE • SHOULD REDUCE AS SOON AS POSSIBLE • USUALLY ASSOCIATED WITH MULTILIGAMENTOUS INJURY

  29. FEMORAL-TIBIAL

  30. 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

  31. HIP DISLOCATION

  32. 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

  33. INITIAL PRESENTATION FLEXED AND INTERNALLY ROTATED AT HIP HIP DISLOCATION

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

  35. HIP DISLOCATION • LATE EFFECTS - OSTEONECROSIS

  36. HIP DISLOCATION • REDUCTION

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

  38. SHOULDER DISLOCATION • ANTERIOR MOST COMMON

  39. 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

  40. 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

  41. SHOULDER DISLOCATION

  42. SHOULDER DISLOCATION • REDUCTION • TRACTION COUNTER- TRACTION

  43. SHOULDER DISLOCATION • REDUCTION • GRAVITY AND TRACTION STIMSON

  44. SHOULDER DISLOCATION • REDUCTION • MILCH

  45. SHOULDER DISLOCATION • EARLY SURGERY VS NONOPERATIVE TREATMENT

  46. QUESTIONS?

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