ACUTE MAJOR DISLOCATIONS

By Dr Muhamad Asif Fahmy

Mentor Dr Fadhil
 Definition
• A dislocation occurs when 2 bones are out of
place at the joint that connects them.
• Symptoms of a dislocated joint:
– Numbness or tingling at the joint or beyond it
– Pain
– Limited range of movement
– Swollen or bruised
– Visibly out of place, discoloured, or misshapen
 3 grades of joint injury:
• Subluxation (partial dislocation)
• Dislocation
• Fracture dislocation
Subluxation
• Partial contact between joint surfaces.
• Seldom need active treatment.
• Normal stability usually returns when the periarticular
tissues have healed.

Acromioclavicular joint subluxation

Dislocation
• No contact between joint surfaces.
• The joints must be reduced and immobilized
until the soft tissue have healed.
• Dislocations may be followed by:
– recurrent dislocation (e.g. recurrrent anterior
shoulder dislocation)
– aseptic necrosis
– chronic instability; or
– osteoarthitis if joint surfaces are damaged.
Fracture dislocation
• Dislocations that are
accompanied by a
fracture around the joint.

Fracture dislocation of the ankle

 DISLOCATION

SHOULDER ELBOW HIP

 SHOULDER DISLOCATION
• In a shoulder dislocation, there is separation
of the humerus from the glenoid of the
scapula at the glenohumeral joint.
• Types of dislocation:
– Anterior dislocation (most common, 95%)
– Posterior dislocation
– Inferior dislocation
ANTERIOR SHOULDER DISLOCATION
• The commonest type
• Usually result from
forced abduction,
external rotation, and
extension.
• E.g. of hx of presenting
complaint:
– Falling on outstretched
hands
 ANTERIOR SHOULDER DISLOCATION

• In anterior dislocations, the humeral head

comes to lie anterior, medial and somewhat
inferior to its normal location and glenoid
fossa.
Scapula Y view
 ANTERIOR SHOULDER DISLOCATION

• Signs:
– A: Absent normal contour of shoulder
– B: Bryant test – anterior axillary fold is at lower level
when compared to the other side
– C: Callaway test – increased axillary girth (diameter)
– D: Duga’s test – with elbow at chest, patient unable
to touch the other shoulder.
– H: Hamilton’s ruler – when tip of acromion and
lateral epicondyle can be joined in a straight line
Duga Test

With the patient seated,

the examiner instructs
the patient to flex the
elbow and reach across
the body, place hand on
opposite shoulder. Then
the examiner pull their
elbow against the
patients’s chest.

Positive test: Inability to

complete the test due to
pain.
 ANTERIOR SHOULDER DISLOCATION

• Diagnosis:
– Shoulder x-ray in AP,lateral, Y view, glenohumeral
view
– Do not attempt reduction before confirming
fracture is safely excluded from x-ray
 ANTERIOR SHOULDER DISLOCATION

• Usually treated with closed reduction and a

period of immobilization to allow adequate
capsular healing.
• Four ways to reduce humeral head:
i. Manipulation under general anaesthesia
ii. Hanging-arm technique
iii. Hippocratic method
iv. Kocher’s method
 MANIPULATION UNDER
GENERAL ANAESTHESIA

If there’s no fracture, the arm can be

pulled gently and the head pushed
back over the lip of the glenoid.

HANGING-ARM TECHNIQUE

To place patient face down on a couch

and allow the arm to hang freely. The
weight of the arm will then achieve
reduction.
 HIPPOCRATIC METHOD

This technique involved laying patient

on the floor, lifting and pulling the arm
upwards and pushing the humeral
head back into position with unbooted
foot.

KOCHER’S METHOD

T – Traction in line of humerus

E – External rotation of humerus
A – Adduction of arm
M – Medial rotation
 POSTERIOR SHOULDER DISLOCATION
• Far less common and
tricky to identify.
• E.g. of hx of
presenting complaint:
– Direct high energy
trauma
– Epileptic seizures
– Electroconvulsive
therapy
 POSTERIOR SHOULDER DISLOCATION

•  The humeral head is forced posteriorly in an

internal rotation while the arm is adducted.
• Posterior dislocation can become recurrent,
particularly if the patient has generalized
ligamentous laxity.
• Treatment: Reduction is easily done by pulling
the arm gently forwards and externally
rotating it, but it’s often unstable.
 Aetiology
1. Trauma
- usually in acute setting

2. Microtrauma
Maybe due to labral tear, erosion of posterior labrum leading to gradually
stretching of capsule
(common in weight lifters)

3. Seizures
- Tetanic muscle contraction pulls the humeral head out

4. Biomechanical forces
- flexed, adducted and internally rotated arm is high risk to develop
posterior dislocations of the shoulder
 Physical examination
Jerk test
- Place arm in 90 degree
abduction, internally
rotated and elbow bent.
Apply and axial force
along axis of humerus and
adduct the arm in a
forward flexion position
- a “clunk” is positive of
posterior subluxation
 POSTERIOR SHOULDER DISLOCATION
• Radiological sign:
LIGHTBULB SIGN
The head of the
humerus in the same
axis as the shaft
producing a light bulb
shape
 Other signs on xray
• Rim sign- widened * Empty anterior glenoid fossa
glenohumeral joint >
6mm
 Resuction Depalma method
- The arm is adducted and internally rotation
with traction
- Medial aspect of the upper arm is pushed
laterally, disengaging the humeral head from
the glenoid fossa
- The arm is then extended
 SHOULDER DISLOCATION
• COMPLICATIONS:
– Shoulder stiffness
– Axillary nerve damage
– Traumatic OA
– Recurrent dislocations
– Unreduced dislocation
 DISLOCATION

SHOULDER ELBOW HIP

 ELBOW DISLOCATION
• Second most common
major joint dislocation
• Posterior elbow
dislocation is more
common than anterior
elbow dislocation
• Posterior dislocations
typically occur
following a fall onto
an extended arm
 ELBOW DISLOCATION
• Simple elbow dislocation: When the radius and
ulna become dissociated from the humerus
without associated fracture. Typically the
radius and ulna move behind the humerus.
• Complex elbow dislocation: This injury is a
simple dislocation combined with a fracture of
the humerus, radius, ulna or a combination of
all three bones.
• In paediatrics, radial head
subluxation is the main cause of
elbow dislocation (pulled
elbow or nursemaid’s elbow).
• Peak incidence in children
aged 2-3 years and generally
affects children younger than
6 years.
• Typically results from a quick
pull on a child’s arm.
 ELBOW DISLOCATION
• For simple elbow dislocation, closed reduction and a brief
period (e.g. <2 weeks) of immobilisation at 90 degrees of
flexion usually suffices.
• Complex dislocations of the elbow require operative
management, consisting reduction of the dislocation,
management of the fracture and repair of surrounding
damaged soft tissues (ORIF).
• They are far more likely to have a poor outcome, including
secondary osteoarthritis, limited range of motion,
instability and recurrent dislocation as well as pain.
 DISLOCATION

SHOULDER ELBOW HIP

 HIP DISLOCATION
• Hip dislocations are an
orthopaedic emergency.
• Posterior hip dislocations
are the most common.
The usual cause is a motor
vehicle accident with the
passenger's knee hitting
the dashboard and forcing
the femoral head out of
the acetabulum
posteriorly.
 HIP DISLOCATION
• Posterior hip dislocation will show:
– FLEXION
– ADDUCTION
– INTERNAL ROTATION
– Deformity with shortening of limb
– Abnormal gluteal bony mass of head of femur
 HIP DISLOCATION
• Radiological signs:
– Femoral head out of
acetabulum
– Lesser trochanter less
prominent
– Broken Shenton’s line
– ASIS shifted upwards
– Associated fractures
 HIP DISLOCATION
• Treatment: Reduction (posterior dislocation)
• Should be done within 6 hours to reduce the
risk of avascular necrosis of head of femur
• Reduction methods:
– Bigelow maneuver
– Allis maneuver
 BIGELOW MANEUVER

FLEX to 90 degrees
ADDUCT
INTERNALLY ROTATED
ONE PRACTITIONER APPLY
LONGITUDINAL DISTRACTION
THE ASSISTANT APPLY PRESSURE TO
THE ASIS

ALLIS MANEUVER

Patient in supine.
Affected hip and knee are flexed in 90
degrees.
In neutral rotation of hip, an upward
traction is applied along the axis of
femur and the same counter traction is
given by holding the pelvis.
 HIP DISLOCATION
• COMPLICATIONS:
– Sciatic nerve injury
– Vascular injury
– Irreducible dislocation
– Recurrent dislocation
– Associated fractures
– AVN (15%)
– Secondary OA
 Resorces
1. Guidelines for House Officers
2. Orthobullets ( shoulder, elbow and hip dislocations)
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649652/ -
Posterior hip dislocation and ipsilateral femoral neck
fracture.
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470057/
- Management of Recent elbow dislocations