Vascular epiphyseal changes in congenital dislocation of the hip; results in adults compared with results in coxa plana and in congenital dislocation without vascular changes.
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Adult↗
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[Results of surgical treatment in dislocated lenses. I. Aspiration of dislocated lenses in children and in young persons (author's transl)].
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Adolescent↗
[Value of internal fixation in the treatment of dislocations and fractures-dislocations of the cervical spine].
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Adult↗
Late dislocation after total hip arthroplasty.
BACKGROUND: Some patients have a dislocation for the first time many years after a total hip arthroplasty, but little is known about the risk factors and outcomes associated with late dislocation. The purposes of this study were (1) to determine the prevalence of late dislocation after total hip arthroplasty, (2) to characterize demographic and other factors associated with such late dislocations, and (3) to report the outcomes of such late dislocations. METHODS: Between 1969 and 1995, 19,680 primary total hip arthroplasties were performed in 15,964 patients at our institution. According to a prospective surveillance protocol, the patients were followed routinely at regular intervals and were specifically queried at each time-point about whether (and, if so, when) the hip had dislocated. First dislocations that occurred five years or more after the operation were defined as late dislocations. RESULTS: Five hundred and thirteen (2.6%) of the 19,680 hips dislocated. Of the 513 hips, 165 (0.8% of the entire cohort; 32% of the dislocated hips) first dislocated five or more years after the primary arthroplasty. The median time until the occurrence of these late dislocations was 11.3 years (range, five to 24.9 years) after the operation. Late dislocation was more frequent than early dislocation in women (p = 0.03), and late dislocation was associated with a younger age at the time of the primary total hip arthroplasty (median, sixty-three years) than was early dislocation (median, sixty-seven years) (p = 0.02). Clinical factors associated with late dislocation included previous subluxations without dislocation in twenty patients, a substantial episode of trauma in eleven patients, and onset of marked cognitive or motor neurologic impairment in eleven patients. Radiographically, the late dislocation occurred in association with polyethylene wear of >2 mm in eighteen hips, with implant loosening with migration or a change in position in eight, and with initial malposition of the acetabular implant (anteversion of <0 degrees or >30 degrees or abduction of >55 degrees) in thirty. Late dislocation recurred in ninety (55%) of the 165 hips and was treated with a reoperation in fifty-five hips (33% of the hips with late dislocation; 61% of the hips with recurrent dislocation). CONCLUSIONS: Late dislocation is more common than was previously thought. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. Late dislocation can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurologic decline, an episode of trauma, or polyethylene wear), or it can occur in association with any combination of these factors. The likelihood of the first late dislocation recurring is high.
Adolescent↗
[Arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint].
PURPOSE OF THE STUDY: The authors present their experience with arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint in young patients. MATERIAL: In up to 80% of patients younger than 25 years, traumatic dislocation of the glenohumeral joint is associated with its recurrence within one year of treatment even in well performed conservative therapy. Repeated dislocations gradually damage the joint and eventually result in the development of arthritis. The articular capsule becomes loose, glenoid surface is reduced and cartilage of the humeral head is affected. Repeated dislocation, reduction and immobilization are causes of patients' discomfort as well as morbidity. For these reasons, the stabilization of recurrent dislocations of the glenohumeral joint is performed by an open procedure or, most recently, arthroscopic method. Arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint is an invasive yet gentle method that permits an exact reconstruction of the injured articular capsule and provides good conditions for complete healing of the affected tissues. METHOD: In order to prevent dislocations from recurring, we offered to perform minimal invasive arthroscopic stabilization in 30 patients who had undergone reduction of a primary dislocation of the glenohumeral joint in the 1999/2001 period. Of these, 18 (45%) accepted this offer. In 11 men and 7 women (average age, 22 years) 12 right and six left glenohumeral joints were treated arthroscopically with the use of absorbable or non-absorbable sutures. The procedure was performed at 2 to 7 days after injury and reduction. The joint was immobilized in an elastic Desault bandage for 6 weeks, but with exercising the elbow. From the 4th postoperative week, the glenohumeral joint was passively exercised in the sagittal plane, but abduction and external rotation were avoided. From the 7th week on, the joint was exercised to achieve its full range of motion. RESULTS: The patients were followed up for 12 to 26 months. No repeated dislocation occurred. The range of motion comparable with the contralateral healthy joint was achieved in all patients by 12 weeks after surgery. One patient with a combined injury involving fracture of the first lumbar vertebra with signs of articular fibrosis underwent redress of the glenohumeral joint under general anesthesia at 6 weeks after arthroscopy. All patients returned to their previous everyday life, working and sports activities. DISCUSSION: Arthroscopic stabilization of the glenohumeral joint is an invasive though gentle method which, when exactly performed and followed by adequate postoperative rehabilitation, can considerably or even completely reduce recurrence of joint dislocation. Its disadvantages include costs of surgery and hospital stay, and a risk of potential intra- or post-operative complications. The statistical evaluation of primary dislocations in young patients showed that, in 80% of them, recurrent dislocations would probably require surgical treatment. In addition, a joint suffering from repeated dislocation may develop lesions to such an extent that dislocation may continue to recur even after surgical treatment; this happens in about 10% of the cases. Our estimate was that only 20% of the patients with primary traumatic dislocation (ruptured articular capsule) would not be in need of further repair. However, it was impossible to determine who they would be. Our results, i. e., the absence of recurrent dislocations, suggest a way of reducing the recurrence of dislocations following a primary injury of the glenohumeral joint. CONCLUSIONS: Arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint in young patients (under 25 or maximally 30 years of age) is the method that allows us, invasively but with a good outcome, to reduce a high number of post-traumatic dislocations and to return sporting and/or manually working subjects to their previous way of life.
Adult↗
[New varieties of lateral metatarsophalangeal dislocations of the great toe].
PURPOSE OF THE STUDY: We report seven cases of traumatic dislocation of the great toe, detailing the anatomy, the mechanism of injury and the radiographic diagnosis. We propose an additional classification based on three hereto unreported cases. MATERIAL AND METHODS: Between october 1994 and october 1997, we treated seven patients with traumatic dislocation of the first metatarso-phalangeal joint of the great toe. There were six men and one woman, mean age 35 years (range 24 - 44 years). Dislocation was caused by motor vehicle accidents in four cases and by falls in three. Diagnosis was made on anteroposterior, lateral and medial oblique radiographs. According to Jahss' classification, there was one type I and three type IIB dislocations. There was also one open lateral dislocation and two dorsomedial dislocations. Only these dorsomedial dislocations required open reduction, done via a dorsal approach. Mean follow-up was 17.5 months (range 9 - 24 months) in six cases. One patient was lost to follow-up. The outcome was good in six cases and poor in one (dorsomedial dislocation). DISCUSSION: Dislocation of the first metatarso-phalangeal joint of the great toe is an uncommon injury. In 1980, Jahss reported two cases and reviewed three others described in the literature. He proposed three types of dislocation based on the feasibility of closed reduction (type I, II and IIB). In 1991, Copeland and Kanat reported a unique case in which there was an association of IIA and IIB lesions. They proposed an addition to the classification (type IIC). In 1994, Garcia Mata et al. reported another case which had not been described by Jahss and proposed another addition. All dislocations reported to date have been sagittal dislocations. Pathological alteration of the collateral ligaments has not been previously reported. In our experience, we have seen one case of open lateral dislocation due, at surgical exploration, to medial ligament rupture and two cases of dorsomedial dislocation due, at surgical exploration, to lateral ligament rupture. CONCLUSION: We propose another additional classification with pure lateral dislocation (type III) and dorso-lateral dislocation (type IL or IIL+), which are related to the formerly described variants.
Accidental Falls↗
[Therapy of traumatic anterior shoulder dislocation: current status of therapy in Germany. Are there scientifically verified therapy concepts?].
There are no generally accepted concepts for the treatment of traumatic anterior shoulder dislocation. The objective of this study was to ascertain the current treatment for traumatic shoulder dislocations in German hospitals and to compare this with the data reported in the literature. A total of 210 orthopedic surgery departments were asked for their treatment strategy in an anonymous country-wide survey; 103 questionnaires (49%) were returned for evaluation. Additional imaging (ultrasound, CT, MRI) beyond the routine X-rays is performed in 82% of clinics for primary shoulder dislocation (94% in recurrent dislocation). A young, athletic patient (< 30 years old) would be operated on for a primary traumatic shoulder dislocation in 73% of hospitals (98% in recurrent dislocation). In contrast, a patient of the same age, with a moderate level of sporting activity would be treated conservatively in 67% of cases (14% in recurrent dislocation). Similarly, for an active, middle-aged patient with a demanding job, 74% of responses favored conservative treatment after a primary dislocation and 6% after a recurrent dislocation. Older patients (> 65 years old) are usually treated conservatively after a primary or recurrent shoulder dislocation (99%, 69%). For a primary shoulder dislocation the most popular surgical reconstruction is a Bankart repair (75%). For recurrent shoulder dislocation several different operative techniques are seen (Bankart 29%, T-shift 26%, Putti-Platt 8%, Eden-Lange-Hybbinette 22%, Weber osteotomy 13%). Based on our literature review, we found: (1) The clinical examination of both shoulders is important to diagnose hyperlaxity; (2) Routine CT or MRI is not necessary for primary traumatic shoulder dislocations; (3) A young, athletic patient should undergo surgical reconstruction after a primary shoulder dislocation; (4) The operation of choice for primary and recurrent dislocation is the Bankart repair; (5) There is no sufficient evidence that an arthroscopic Bankart repair is as good as an open procedure; (6) There are limited indications for other operative techniques, as they are associated with a higher recurrence and arthrosis rate.
Adolescent↗
Gas bubbles in the hip joint on CT: an indication of recent dislocation.
OBJECTIVE: The purpose of this study was to determine if gas bubbles in the hip joint seen on CT scans after trauma are reliable indicators of recent (< 48 hr) hip dislocation. We believe that the gas seen in the hip joint represents intracapsular nitrogen bubbles that result from the vacuum created by forcible distraction associated with traumatic dislocation. MATERIALS AND METHODS: CT scans of 79 consecutive patients with pelvic injury were reviewed retrospectively. We noted the number and position of intracapsular gas bubbles, presence of joint effusion, soft-tissue injury, and associated fractures or dislocations. Intracapsular gas bubbles were defined as round areas of low attenuation, in an intracapsular position, that on visual inspection were equivalent to air. Seventy-three of 79 patients were imaged within 48 hr of injury. Most patients had been involved in a motor vehicle collision or were pedestrians struck by a motor vehicle. Fifteen patients had hip dislocation, including one patient with bilateral dislocation. Fifty-five patients had pelvic fractures without hip dislocation, and nine patients had soft-tissue injury without fracture or dislocation. Fourteen of 16 dislocations had been reduced at the time of scanning. RESULTS: Gas bubbles were seen in the hip joint on CT scans in 13 (81%) of the 16 dislocated hips, including 12 (92%) of 13 dislocations in patients scanned within 4 hr of admission. Bubbles were present in 11 (79%) of 14 hip joints that had dislocations reduced at the time of scanning and in both hip joints that remained dislocated. Most bubbles were located anterior to the femoral neck; however, bubbles were also seen posteriorly. Bubble size (1-3 mm) and number (1-7) varied. Only two (3%) of 64 patients without dislocation had intracapsular gas bubbles; one had been shot and the other had extensive soft-tissue emphysema. CONCLUSION: In the absence of penetrating trauma, intracapsular gas bubbles on CT are reliable indicators of recent hip dislocation and may be the only objective finding of this injury.
Accidents, Traffic↗
Management of dislocated intraocular implants.
Implant dislocation may occur in the absence of appropriate capsular or zonular support (PCIOL) (11,35,53) or following traumatic injury to anterior ocular tissues (ACIOL). (11,19,20) Other factors (e.g., advanced patient age, high myopia, previous vitrectomy, pseudoexfoliation syndrome, and certain connective tissue disorders) also may predispose implant dislocation. (9,52) Although reported for all types of IOLs, implant dislocation is becoming more manageable because of the advancement of surgical techniques. A dislocated ACIOL or PCIOL may be explanted, exchanged, or repositioned. (11,48,71) Repositioning the dislocated PCIOL in the ciliary sulcus with modern vitreoretinal techniques provides an optimal environment for visual recovery. (11,71) Implant repositioning techniques generally may be categorized into the external or the internal approaches. (8,11) The former involves external suturing methods for a primary or secondary implant in the absence of adequate capsular or zonular support (15,16,31,42,56,60,61,64,66,73,76) and the latter is achieved through modern pars plana techniques. 8,11,62,69) Recently, several implant repositioning methods gaining increasing acceptance include the scleral loop fixation, (45) the snare approach, (43) the use of the 25-gauge implant forceps, (13) temporary haptic externalization, (8,11,36,71) and the use of perfluorocarbon liquids. (1,28,40,41,44) The temporary haptic externalization method combines the best features of the external and the internal approaches, avoids complex intraocular maneuvers, and allows precise scleral fixation of the dislocated IOL on a consistent basis. (8,11,71) Endoscopy provides the surgeon with optimal viewing of the anterior retropupillary anatomy that is often difficult to appreciate (e.g., capsular-zonular complex, ciliary sulcus, anterior retina, and vitreous base). (6,11) As a result, precise haptic placement is possible during the repositioning process. (6,11) However, a three-dimensional birds-eye view is lacking, and there may be a steep learning curve with endoscopy. (11) Certain characteristics of a silicone plate implant may enhance implant dislocation. (11,33,34,46,49,58) Capsular contraction following an Nd:YAG posterior capsulotomv may result in a posterior dislocation of the silicone plate implant. (11,33,34,46,49,50,58) Special techniques are available for the retrieval of the slippery dislocated silicone plate implant from the retinal surface without causing injury. (33,58) Repositioning the plate implant anterior to capsular remnants or in the ciliary sulcus may lead to recurrent dislocation, and its removal is frequently the best option. (11) Placing a second implant in the presence of a disLocated implant is ill advised because subsequent surgical management becomes more complex. (11) Surgical options include removing the dislocated implant through a Limbal or pars plana incision with special techniques, (74,75) repositioning the dislocated implant after removing the second implant," and explanting both implants. (11) Considering the increased morbidities and complications associated with the management of double implants, the surgeon should avoid the placement of a second implant in the setting of a dislocated implant. (11)
Cataract Extraction↗
Dislocation multi-junctions and strain hardening.
At the microscopic scale, the strength of a crystal derives from the motion, multiplication and interaction of distinctive line defects called dislocations. First proposed theoretically in 1934 (refs 1-3) to explain low magnitudes of crystal strength observed experimentally, the existence of dislocations was confirmed two decades later. Much of the research in dislocation physics has since focused on dislocation interactions and their role in strain hardening, a common phenomenon in which continued deformation increases a crystal's strength. The existing theory relates strain hardening to pair-wise dislocation reactions in which two intersecting dislocations form junctions that tie the dislocations together. Here we report that interactions among three dislocations result in the formation of unusual elements of dislocation network topology, termed 'multi-junctions'. We first predict the existence of multi-junctions using dislocation dynamics and atomistic simulations and then confirm their existence by transmission electron microscopy experiments in single-crystal molybdenum. In large-scale dislocation dynamics simulations, multi-junctions present very strong, nearly indestructible, obstacles to dislocation motion and furnish new sources for dislocation multiplication, thereby playing an essential role in the evolution of dislocation microstructure and strength of deforming crystals. Simulation analyses conclude that multi-junctions are responsible for the strong orientation dependence of strain hardening in body-centred cubic crystals.
Journal Article↗
Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases.
UNLABELLED: The objective of this study was to determine the mechanisms of injury and pattern of associated foot and ankle injuries and systemic injuries associated with subtalar dislocations, and, correlate these data with the radiographic and clinical/functional outcome of patients after subtalar dislocation. RESULTS: Twenty-five patients with a subtalar dislocation were identified over a seven year period. The mean patient age was 38 years. Males (n=19) comprised 76% of patients, with a mean age of 36 years. High energy mechanisms (motor vehicle accidents, falls) accounted for 68% of subtalar dislocations. Although high energy mechanisms showed a strong trend toward open subtalar dislocations, the association was not statistically significant (p=0.0573, Fisher's exact test). Closed dislocations predominated (75%). Left and right-sided dislocations were nearly equally distributed, even among motor vehicle accidents. Medial dislocations predominated (65%): these were not influenced by mechanism of injury and did not result in statistically lower AOFAS ankle/hindfoot scores. Subtalar dislocation was irreducible (requiring open reduction) in 32%, with higher energy mechanisms of injury being statistically associated with an irreducible subtalar dislocation (p=0.0261, Fisher's exact test). Block to reduction was evenly distributed among soft tissue elements (posterior tibial tendon, flexor hallucis longus tendon, capsule, extensor retinaculum) and osseous elements. Eighty-eight percent of patients incurred concomitant injuries to the foot and ankle (95% of which were closed injuries), namely, the ankle and talus. Systemic injuries occurred in 88% of patients. At a mean follow-up of five years, the mean AOFAS score of the subtalar dislocation side was significantly lower (mean=71 vs. 93, p=0.0007, unpaired Student's t-test). No statistical relation was found between the number of associated extremity injuries and AOFAS score (Spearman correlation coefficient, r=(-)0.236, p=0.331). Radiographic follow-up demonstrated 89% of ankles with radiographic changes (31% symptomatic); however, the majority of these patients (61%) had an associated ankle injury. The subtalar joint demonstrated radiographic changes in 89% of patients, with 63% being symptomatic; 75% of patients with subtalar joint changes incurred a fracture about the subtalar joint at the time of dislocation. Four patients went on to subtalar fusion at an average of 8.8 months post-dislocation. The midfoot showed radiographic changes in 72% of patients, with only 15% of these patients being symptomatic. All patients with midfoot symptoms were well controlled by nonsurgical measures.
Adolescent↗
The treatment of unreduced dislocation of the shoulder. A review of 12 cases.
The clinical and radiographic features and the results of treatment are analysed in 12 cases of shoulder dislocation (5 anterior and 7 posterior) in which the dislocation had been present for periods ranging from 3 weeks to 6 months. The follow-up ranged from 9 months to 16 years. Anterior dislocations are easily diagnosed on anteroposterior radiographs. Posterior dislocations may be suspected clinically because of the position of the limb in internal rotation and loss of external rotation, but can easily be missed on A.P. films, which show only a flattened appearance of the humeral head. A definite diagnosis is obtained only with a lateral (axillary) projection. All the anterior dislocations in our series were uncomplicated, but 4 of the posterior dislocations were associated with fractures of the humeral head and/or the greater tuberosity. Two of the 5 anterior dislocations were treated with physiotherapy and remedial exercises alone, while 2 were successfully reduced by manipulation; in the only patient submitted to surgery, ablation of the humeral head was performed. Results were excellent in one of the 2 patients treated with physiokinesitherapy where dislocation had been reduced spontaneously (the only such case described in the literature), and in one of the two cases submitted to nonoperative reduction of the dislocation. Results were good in the second patient subjected to nonoperative reduction and in the patient operated on. All 7 cases of posterior dislocation were treated surgically: in 3 cases the dislocation was reduced, in one the humeral head was removed, in one a partial shoulder prosthesis was applied, and in 2 cases the whole of the proximal extremity of the humerus was resected. In the latter 2 cases the results were poor and fair respectively, while in the remaining cases the results were good. The best surgical treatment of inveterate dislocations is reduction of the dislocation, which in the posterior forms requires a wide antero-supero-posterior approach. The alternative to surgical reduction is the application of a shoulder prosthesis, the result of which (as in resection of the humeral head) is related to the integrity of the greater tuberosity and the rotator cuff.
Adult↗
[Differential therapy of traumatically-induced persistent posterior shoulder dislocation. Review of the literature].
Three-hundred and twenty-nine cases of posterior dislocation of the shoulder documented in 300 articles published in the international literature are reviewed. They included 130 cases in which the duration of the dislocation was longer than 6 weeks and the dislocation could be classified as persistent primary dislocation. This group is the second largest group following that with acute primary dislocation. The mechanism of injury may be direct or indirect force: trauma, convulsions or electrocution are usually responsible for this type of dislocation, which often persists for longer than 6 weeks. Anatomically, 97.5% of dislocations are classified as subacromial. Posterior dislocation of the shoulder is commonly misdiagnosed on plain antero-posterior radiographs, and in over 50% of cases the diagnosis was missed on first examination. The typical signs of primary traumatic posterior dislocation of the shoulder are described. Management of persistent traumatic posterior dislocation of the shoulder depends on the size of the anterior Hill-Sachs lesion, the precipitating mechanism and the duration of dislocation. The results of 109 surgically and 24 conservatively treated dislocations of this type that have been published in the international literature are reviewed. Closed reduction is indicated in carefully selected cases with an anterior Hill-Sachs lesion under 15% of the size of humeral head (measured in the axillary view) that has been dislocation for less than 2 months. In most due to convulsions there was a distinct anterior Hill-Sachs lesion, which led to recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)
Arthroplasty↗
Carpal bone dislocations: an analysis of twenty cases with relative emphasis on the role of crushing mechanisms.
Twenty cases of carpal bone dislocation were encountered during a 7-year period, with an average of 27 months of follow-up. There were ten types of dislocation in this series; the most common type was transscaphoid perilunate dislocation which was seen in nine cases. In addition, there were two scaphoid subluxations; one volar lunate dislocation; one dorsal perilunate dislocation; one scaphoid perilunate dislocation; one hamate and pisiform dislocation; one transhamate pisiform dislocation; one trapezoid dislocation with dislocation of carpometacarpal joints two to five; one dislocation of the trapezium, trapezoid, and carpometacarpal joints two to four; and two trapezium periscapholunate dislocations. Methods of treatment included open reduction, closed reduction, proximal row carpectomy, total wrist arthrodesis, and excision of the lunate. In this series, the patterns of dislocation were different for crushing injuries and dorsiflexion injuries. The clinical results associated with the soft-tissue injuries of the ipsilateral hand were mostly caused by crushing forces. Although carpal instabilities were noted, there was no significant correlation between the clinical and roentgenographic results in some of our cases. Best results invariably relied on a stable anatomic reduction and an adequate period of immobilization. Poor results were demonstrated in the cases with incomplete initial reduction, secondary degenerative arthrosis, or nonunion.
Adult↗
Chiari I malformation associated with atlanto-axial dislocation: focussing on the anterior cervico-medullary compression.
BACKGROUND: Chiari I malformation with atlantoaxial dislocation may cause both posterior and anterior cervicomedullary compression. We studied the clinicoradiological features and surgical outcome in patients having Chiari I malformation with atlantoaxial dislocation. METHOD: Thirty-nine patients with Chiari I malformation with atlanto-axial dislocation underwent preoperative and follow-up neurological status assessment. In Chiari I malformation with reducible atlanto-axial dislocation (n = 11), a direct posterior stabilization was done. In Chiari I malformation with irreducible atlanto-axial dislocation (n = 28), a single stage transoral decompression with posterior stabilization and/or posterior decompression and duraplasty were done in 18 patients. In 10 patients, only posterior decompression and/or posterior stabilization was performed. Seven among the latter patients subsequently deteriorated and required transoral decompression. Comparison of mean neurological status scores of patients with Chiari I malformation with irreducible atlanto-axial dislocation who underwent single stage transoral decompression with posterior stabilization versus the posterior procedure alone was done using T-test and proportional significance also calculated. FINDINGS: Patients with Chiari I malformation with atlanto-axial dislocation have a high incidence of long tract signs and sphincteric disturbances with a decrease in the mean foramen magnum diameter. The mean neurological status scores of patients with Chiari I malformation with irreducible atlanto-axial dislocation who underwent single stage transoral decompression with posterior stabilization were significantly better than those patients who underwent the posterior procedure alone. The latter patients also showed significant clinical improvement following transoral decompression. In the presence of Chiari I malformation with reducible atlanto-axial dislocation, reduction and stabilization of atlanto-axial dislocation resulted in neurological improvement. The follow up neurological status scores of these patients improved after surgical intervention even in the presence of poor preoperative grades. CONCLUSIONS: Patients with Chiari I malformation should be investigated for the presence of atlanto-axial dislocation. In case atlantoaxial dislocation coexists, priority must be given to relieving anterior cervicomedullary compression.
Adolescent↗
[Radiocarpal dislocation: twelve cases and a review of the literature].
PURPOSE OF THE STUDY: Radiocarpal dislocation is an uncommon entity in traumatology. Proper management depends on the type of dislocation and the presence of concomitant injury. The purpose of this study was to detail the pathogenesis of radiocarpal dislocation and describe its complications and treatment. MATERIAL AND METHODS: Twelve radiocarpal dislocations were reviewed retrospectively. Nine were associated with multiple trauma. For this review, physical examination was performed to determine the functional status, presence of pain, joint motion, and grip force. The Green and O'Brien score as modified by Cooney was used to assess function. Grip force was measured with a Jamar dynamometer and weighted by the non-dominant/dominant ratio. Dumontier and Moneim classifications were used to define different types of radiocarpal dislocation. Radiological evaluation was based on anteroposterior (ulnar and radial inclination) and lateral views of the wrist. RESULTS: Dorsal displacement was observed for nine dislocations. All were associated with fractures (eleven fractures of the lateral cuneal process and eight fractures of the styloid process). Other associated injuries were distal radioulnar dislocation and intracarpal sprains (two scapholunate and two lunotriquetral). There were three median nerve compressions which all regressed without sequelae. Ten patients were treated by styloradial osteosynthesis alone and two patients by capsule-ligament suture via an anterior approach. Pinning was used to stabilize the two lunotriquetral injuries and the one neglected radioulnar dislocation. RESULTS: At last follow-up (mean 46.2 months), the overall functional outcome was satisfactory. The Green and O'Brien (modified by Cooney) score was excellent for one patient, fair for eight, and mediocre for three (75% satisfactory results). Distal radioulnar degeneration developed in the patient who had a neglected radioulnar dislocation. Three cases of radiocarpal degeneration were observed in patients with neglected scapholunate sprains whose wrist was symptomatic at last follow-up. DISCUSSION: Radiocarpal dislocation is associated with intracarpal fracture and/or injury. Intracarpal injury must be treated in order to limit the risk of future degeneration. Pure radiocarpal dislocation (or in association with a minimal fracture of the styloid) should be treated surgically, irrespective of the approach, in order to achieve capsule-ligament suture. Other radiocarpal dislocations can be simply reduced with osteosynthesis of associated fractures. Intracarpal and/or distal radioulnar lesions must be stabilized. Osteosynthesis or capsule-ligament suture must be achieved to obtain a satisfactory clinical result.
Adult↗
[Dislocation of the proximal tibio-fibular joint due to severe leg and knee trauma].
PURPOSE OF THE STUDY: Dislocation of the proximal tibio-fibular joint is a rare lesion generally described in athletes. In our experience, high-energy trauma in traffic accident victims was a frequent cause. Dislocation of the proximal tibio-fibular joint is generally described as anterolateral, posteromedial, superior, or subluxation. We describe an inferior form of dislocation. MATERIALS AND METHOD: The study population included eight men aged 21-55 years (mean 31 years). One patient had bilateral dislocation. There were four superior, one posterior, and four inferior dislocations. All patients also had an associated fracture of the tibia which was an open fracture in eight cases. Five patients suffered a lesion to the common fibular nerve. Three had tibial nerve involvement in a context of inferior disclocation. The lateral collateral ligament was torn in six cases. The central pivot was involved in four. Two patients had an avulsion of the patellar ligament on the tibial tuberosity. Five patients had vessel damage. Three required emergency amputation. Two patients (one superior and one inferior dislocation) underwent emergency bypass surgery but required below-knee amputation later due to persistent ischemia. All dislocations, excepting the one case of complete fibular avulsion and one emergency above knee amputation were treated by transarticular screw fixation of the proximal tibio-fibular joint. RESULTS: Mean follow-up was 5.8 years (1-9 years). At last follow-up, there were no cases of instability or pain in the proximal tibio-fibular joint. The patient with an initial neurapraxia in territory of the common fibular nerve recovered totally. The five amputated patients had prostheses and walked without crutches. DISCUSSION: Dislocation of the proximal tibio-fibuilar joint is a rare entity, but the frequency is probably underestimated. The dislocation can go unrecognized in patients with multiple injuries. Careful search should nevertheless be undertaken due to the risk of secondary involvement of the common fibular nerve. The Harrisson and Hindenach classification, inspired by the Lyle classification, does not mention inferior dislocation of the proximal tibio-fibular joint, a recently described entity. Our series included dislocations resulting from high-energy trauma associated with numerous ligament, nerve, and vessel injuries. In this context, dislocation of the proximal tibio-fibular joint constitutes an epiphenomenon.
Adult↗
Dislocation of the hips in children with bilateral spastic cerebral palsy, 1985-2000.
The aim of this study was to assess the rate of hip dislocation at different ages in children with bilateral spastic cerebral palsy attending special schools in southern Derbyshire, UK, between 1985 and 2000. The medical notes of 110 individuals (68 males, 42 females) were obtained. They were divided into four groups according to the Gross Motor Function Classification System (GMFCS). We determined whether or not their hips were dislocated at the ages of 5, 10, and 15 years, and the kind of surgery performed in each case. The percentage of individuals with one or both hips dislocated increased with age and with severity of disease. Of those in GMFCS Level II (n=18), none had dislocations; Level III (n=16), none had dislocations at ages 5 and 10, but 11% had by the age of 15; Level IV (n=35), 8% had dislocations by age 5, 19% by age 10, and 30% by age 15; Level V (n=41), 22% had dislocations by age 5, 48% by age 10, and 50% by age 15. Forty-two per cent of individuals with hip dislocation had not had previous preventive surgery. Twenty-one per cent of hips operated on still proceeded to dislocation. We conclude that there was a high rate of hip dislocation, especially in GMFCS groups Levels IV and V, and that this often occurred very early. Preventive surgery avoided dislocation in many children. However, orthopaedic referral was often not made before dislocation was discovered, or the referral was made too late for surgery on soft tissue to be successful. These results may be compared with those from current programmes of hip management, involving radiological surveillance and early use of conservative and surgical interventions.
Adolescent↗