DISLOCATIONS

From Big Medical Encyclopedia

DISLOCATIONS (luxatio, the singular) — the resistant shift of the joint ends of the jointed bones out of limits of their physiological mobility causing dysfunction of a joint.

Fig. 1. The ratio of the joint ends of bones is normal also at dislocation: 1 — norm; 2 and 3 — an incomplete dislocation; 4 — dislocation.

Full V. is characterized by universal loss of contact of joint surfaces of the jointed bones; at incomplete V. (incomplete dislocation) their partial contact, but in inappropriate places (fig. 1) remains. The peripheral bone is considered dislocated, according to the name the cut is designated by V.: at dislocation in a shoulder joint speak about dislocation of a shoulder, in an elbow joint — about dislocation of a forearm etc. At V. clavicles indicate a dislocated segment (sternal or acromial and clavicular). Only V. of a backbone designate on an overlying vertebra.

On an etiological sign of V. divide on traumatic, usual, inborn and pathological.

Traumatic dislocations

Traumatic dislocations meet most often and make 1,5 — 3% of all damages. Their frequency in various joints is not identical that it depends on functionality of joints and them anatomo-fiziol, features. Most often (more than 50% of all V.) V. in the shoulder joint having sharply expressed discrepancy between the size and a form of a head of a shoulder and the joint surface of a shovel that is one of the contributing moments are observed; the hip joint has a deep joint hollow and the strong capsule, powerful sheaves that considerably explains a comparative rarity of V. of a hip.

Traumatic V.'s emergence is most often connected with an indirect injury and the forced violent movement in a joint. At the same time there is a point of support for the two-humeral lever, a long shoulder to-rogo is a vyvikhivayemy part of an extremity, and short — intra joint. Than distalny the moment of force, the more discrepancy between short and long lever arms is enclosed, the easier arises Century.

Traumatic V., as a rule, is followed by a rupture of the capsule of a joint on a big extent, but in mandibular and grudinoklyuchichny joints the capsule at V. is broken off seldom. Injury of ligaments in the form of partial anguishes, stretchings and other small injuries almost always accompanies V.; the complete separation of sheaves most often arises at side V. in blokovidny joints. A consequence of damage of the capsule of a joint and surrounding soft tissues are intra joint hemorrhages from an imbibitsiy synovial membrane that is followed by a pain syndrome and can serve in the subsequent as the reason of deforming arthrosis (see). In some cases V. is followed by damage of large blood vessels and nerves, napr, a popliteal artery at back V. of a shin, an axillary nerve at V. of a shoulder.

Depending on time which passed from the moment of an injury, V. divide on fresh (up to 3 days), stale (to 3 — 4 weeks) and old (more than a month), and depending on a condition of integuments — on closed and opened. Such division of V. has great practical value as for the choice of a method of treatment, and definition of an outcome of an injury.

Especially it is necessary to allocate so-called dislocation-fractures when V. arises along with a change of joint and circumarticular departments of a bone. Most often this type of V. meets in elbow, talocrural, coxofemoral and humeral joints. A dislocation-fracture is also the central dislocation of a hip, at Krom the change of a bottom of an acetabular hollow causes the shift of a head of a hip in a pelvic cavity.

Clinical picture and diagnosis

Fig. 2. Characteristic change of area of the left shoulder joint at dislocation of a shoulder.
Fig. 3. Typical position of the lower extremity at dislocation of a hip: 1 — back and lower; 2 — posterosuperior; 3 — anterosuperior; 4 — anteroinferior.

The great value in V.'s recognition belongs to clarification of the mechanism of an injury. A constant sign of V. is sharp morbidity in the injured joint and disturbance of its function, arising directly at the time of an injury. Change of a shape of a joint is characteristic that allows to make in some cases unmistakably the diagnosis by only outer inspection: the joint gets out of the normal form, its contours are maleficiated, retraction on site of one of the joint ends of bones (fig. 2) is observed; the extremity is in the forced situation typical for separate types of V. (fig. 3), it can be represented shortened or extended. The palpation reveals lack of a head of a bone on the usual place. The active movements in the injured joint almost completely are absent; the passive movements are painful, their volume is sharply limited; the springing resistance is defined.

At establishment of the diagnosis of V. it is necessary to differentiate with a bruise, a rupture of sheaves, inside - and extraarticular changes. V.'s presence is confirmed by X-ray inspection.

Except full V.'s cases, rentgenol. the research reveals as well deviations from a normality of joints at smaller degrees of shift of bones (incomplete dislocations in true joints and stretchings of the copular device in semi-joints, i.e. in synchondroses and syndesmoses).

A technique of a research is usual X-ray analysis. Rentgenol, V.'s symptomatology is evident even in one projection of a research on a sign of discrepancy of provision of joint surfaces in the injured joint. In doubtful cases the comparative research of the joint of the same name of other extremity in identical projective conditions is necessary. At radiodiagnosis, except the fact B. and its character, also the direction and degree of shift of a dislocated bone is considered. At traumatic V. it is always necessary to remember also a possibility of the accompanying change or a separation of a piece of bone substance. Only radiological it is possible to differentiate V. from a dislocation-fracture and from nek-ry intra joint changes (e.g., an anatomic neck of a humeral bone).

Fig. 4. Incomplete dislocation of a humeral bone. The expanded joint crack (roentgenogram) is visible.
Fig. 5. An old dislocation-fracture in a hip joint with formation of a new joint hollow and calcification of soft tissues. Discrepancy of sochlenovny surfaces of a femur and an acetabular hollow (the arrow specified an old acetabular hollow): roentgenogram.
Fig. 6. An incomplete dislocation of foot of a knaruzha at an abduction fracture of both anklebones (roentgenogram).

The main radiological signs at incomplete V. are expansion of a joint crack (fig. 4) and space discrepancy of joint surfaces of bones of the injured joint (fig. 5 and 6), in particular so-called bayonet shaped deformation of a longitudinal axis of an extremity, napr, in a knee joint. The wrong laying investigated and the image of a joint, napr, humeral, in an atipichesky projection can make a false impression of an incomplete dislocation, to-rogo actually is not present.

Fig. 7. An incomplete dislocation V and VI cervical vertebrae (it is specified by an arrow) at an old compression fracture of a body of the VI vertebra (roentgenogram).

Exact recognition of all types of V. and incomplete dislocations in cervical department of a backbone (fig. 7) is especially important, in connection with to-rymi there can be clinical indications to an immediate operative measure.

Treatment

the Pre-medical help at V. shall provide only absolute rest of the injured extremity by imposing transport tire (see) or retentive bandage. In a hospital V.'s treatment includes reposition (repositio), short-term fixing and the subsequent functional therapy.

V.'s elimination is an urgent action, is easier made and yields the best results at fresh V., especially immediately after an injury. In stale cases the closed reposition is successful approximately in 40% of cases. At old V. it in general is impracticable — it is necessary to make open reposition, and sometimes and an arthrectomy.

Achievement of reliable relaxation of muscles of the injured extremity is the cornerstone of all actions for V.'s reposition: the secondary muscular retraction coming after V. strongly holds a dislocated head in vicious situation, interfering with V. Umeniye's elimination to set V. is first of all ability to reliably relax muscles. The rough methods of reposition counted on violent overcoming retraction shall not take place since they are accompanied by considerable traumatization of surrounding fabrics and quite often lead to additional damages of the joint capsule, the joint ends of bones, vessels and nerves.

Fig. 8. A technique of reposition of dislocations of a shoulder and hip on Dzhanelidze's way: 1 and 3 — the first stage (relaxation of the muscles fixing joints in pathological situation); 2 and 4 — the second stage (comparison of the sochlenovny joint ends by rotation of distal fragments of a joint).

Relaxation of muscles can be reached in various ways. At V. in small joints — phalanxes of fingers, a forearm, foot, and also a shoulder at persons with poorly expressed muscles — the good relaxation is provided with local anesthesia of 2% the solution of novocaine entered into a cavity of the injured joint. Depending on V.'s localization introduction of 5 — 20 ml of novocaine is necessary. In some cases relaxation of muscles is reached due to giving of an extremity of special situation as it takes place, e.g., at V.'s reposition of a shoulder and a hip on Dzhanelidze's (fig. 8) way. At stale V., and also in attempts of repeated reposition of V. in large joints all manipulations shall be made under anesthetic, providing a full relaxation and, therefore, the best conditions for reposition.

The set of ways of elimination of V. of various localization (Kokher's ways, the Lexer, Dzhanelidze, Bobrov is offered, etc.) - At good anesthesia and a relaxation the choice of a way of reposition of V. has no essential value. The moment of establishment of a dislocated head according to a joint hollow is determined by characteristic signs — click and recovery of full amplitude of movements in an affected joint. In nek-ry cases, despite a full relaxation of muscles, it is not possible to eliminate V. because of different mechanical obstacles (infringement of sinews or sheaves, parts of the joint capsule). These unreducible V. are subject to operational treatment.

After V.'s reposition the extremity is established in halfbent situation in a joint, a cut is optimum for healing in case of a rupture of the capsule. The extremity needs the acute period of healing of ruptures of the capsule and sheaves in immobilization (see).

It can be carried out in various ways. The most frequent form of an immobilization is the longetny plaster bandage, but also different ways are in certain cases admissible: a soft bandage of Dezo at V. of a shoulder, at V. of a hip skeletal traction (see). Duration of an immobilization after traumatic V. of a shoulder — apprx. 3 weeks, at V. of a hip — to 4 weeks of V. of a clavicle, a shin, feet need longer immobilization (1 — 1,5 month).

The great value in V.'s treatment belongs to functional therapy, duration a cut is defined anatomo-fiziol. features of a joint, type of an injury, age of the patient and his profession. Functional treatment includes remedial gymnastics, massage, physical therapy.

All medical events shall be held under radiological control.

Complications: contractures, the deforming arthrosis, an aseptic necrosis of a head of a hip and habitual dislocation.

Habitual dislocation

Habitual dislocation most often arises in a shoulder joint and is result of the wrong treatment — traumatic reposition, fixing, imperfect or insufficient on terms. At usual V. the vyvikhivaniye of the jointed bones occurs without visible external violence even at the usual movements in connection with existence of weak points in the capsule of a joint on site of the former gap.

Fig. 9. The set habitual dislocation of a humeral bone. Characteristic flattening of a posteroexternal surface of a head of a humeral bone is specified by an arrow (roentgenogram).

So-called usual V. of a humeral bone at the heart of the emergence has anatomic premises, obviously inborn origin since at it a peculiar flattening of a head of a humeral bone (fig. 9), and sometimes and a smoothness of a first line of a joint hollow of a shovel radiographic comes to light.

Treatment, as a rule, operational — a kapsulorafiya (sewing up of the capsule), tendo-, an osteolasty (see. Bone plastics , Plastic surgeries , on muscles, sinews, fastion), etc.

Fig. 10. Congenital dislocation of the left hip (roentgenogram).

Congenital dislocations

Congenital dislocations are result of the wrong pre-natal development with formation of the defective joint ends of the jointed bones. Most often the inborn V. of a hip (fig. 10) found approximately in 0,2 — 0,5% of newborns and occurs at girls 5 — 7 times more often. Unilateral inborn V. is observed 1,5 times more often than bilateral.

Success of treatment of inborn V. is defined in many respects by its early identification.

Radiological recognition of inborn V. demands the accounting of linear and angular indicators of a ratio of a femur with an acetabular hollow from children of early age — Shenton's line, the vertical line of Ombredann, a corner between a horizontal and the plane of a so-called roof of an acetabular hollow (see. Hip joint ).

The head of a hip is underdeveloped, the joint hollow is flattened (roentgenogram).

Fig. 11. Congenital dislocation of a hip at the adult.

Inborn character of V. of a femur at adults is distinguished also on anatomic features of its proximal department (the underdevelopment of a head which is combined with valgus deformation of a neck of a hip and an antetorsiya) and on flattening and expansion of an acetabular hollow (fig. 11).

Diagnosis of congenital dislocation of a hip at newborns allows to begin early treatment and to achieve good results by means of functional methods of treatment (Vilensky's tire, Volkov, CYTO, etc.).

Late detection of congenital dislocation considerably complicates treatment, demands use of operational techniques and yields the worst functional result.

Fig. 12. Pathological dislocation of the left hip at tuberculosis. The affected anonymous bone, an articular head of a femur of N of an outline of an acetabular hollow are visible (the head of a femur is displaced). Roentgenogram.

Pathological dislocations

Pathological dislocations arise more often owing to development in a cavity of a joint or in the joint ends of different bones of pathological processes (fig. 12) leading to a disfiguration of the joint ends of bones (bone and joint tuberculosis, osteomyelitis, etc.), and are followed by similar manifestations with traumatic Century.

Fig. 13. Pathological incomplete dislocations in the I—IV metacarpophalangeal and the I interphalanx joints at polyarthritis (roentgenogram).

Quite often pathological V. and incomplete dislocation are caused by destructions of joint surfaces at mono - and polyarthritises (fig. 13), arthroses.

Pathological V. meet also at sluggish paralyzes of extremities (poliomyelitis), at nek-ry forms neurogenic arthropathies (see). Pathological V.'s treatment is defined by its genesis and comes down to recovery of function of a joint a complex of medical actions (e.g., an arthroplasty with the subsequent recovery therapy at coxarthroses).


Century in separate joints — see articles according to the name of joints: Century of a shoulder — see. Shoulder joint ; Century of a forearm — see. Elbow joint ; Century of a shin — see. Knee joint etc.; Century of fingers of a brush and foot — see. Brush , Foot ; Century of a clavicle — see. Clavicle ; Century of a patella — see. Patella ; Century of a jaw — see. Temporal and mandibular joint .


Bibliography: Babich B. K. Traumatic dislocations and changes, Kiev, 1968, bibliogr.; Barth Lake. Congenital dislocation of a hip and its early conservative treatment, the lane with Wenger., Budapest, 1972; Bogdanov F. R. and Leuven V. N c. Treatment of traumatic dislocations, Works 3rd Vsesoyuz, konf. hir. and travmat. - the orthoitem, page 63, Voronezh, 1969; M. V. Wolves, Ter-Egiazarov G. M. both Yu to and N and G. P. Congenital dislocation of a hip, M., 1972, bibliogr.; Kaplan A. V. The closed injuries of bones and joints, M., 1967, bibliogr.; Kurbatov A. I. Pathological dislocations at burned, Ortop, and travmat., No. 3, page 50, 1968; Maykova-Stroganov V. S. and Rokhlin D. G. Bones and joints in the x-ray image, L., 1957, bibliogr.; Mitelman Yu. N. A radiographic research of large joints at sick ortopedo-herbs-matologicheskoy of clinic, Kiev, 1962, bibliogr.; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1 — 2, M., 1964; Watson-Jones R. Fractures of bones and injury of joints, the lane with English, M., 1972; Farshatov M. N. and Glebov Yu. I. About treatment of compound dislocations of extremities, Vestn. hir., t. 88, No. 4, page 70, 1962; Bruckner H. Frakturen und Luxationen, B., 1974; Pollen A. G. Fractures and dislocations in children, Edinburgh — L., 1973, bibliogr.

Ya. G. Dubrov; S. A. Sviridov (rents.)

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