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PubMed2005

Traumatic atlanto-occipital dislocation in children.

BACKGROUND: Traumatic atlanto-occipital dislocation in children and adolescents is a rare and often fatal injury. Although historically most reported cases have been fatal, the advent of modern prehospital care has led to an increase in survival following this injury. As a consequence, some patients may achieve or maintain satisfactory neurologic function following early intervention, stabilization, and definitive management. We analyzed the data on children and adolescents in whom traumatic atlanto-occipital dislocation had been treated with modern resuscitation techniques at our institution. METHODS: Atlanto-occipital dislocation is defined as disruption of the ligaments and other supporting soft tissues as indicated by displacement in either a transverse or vertical direction. With use of the Trauma Registry database at our institution, we identified sixteen such injuries that had occurred between 1986 and 2003. The hospital charts, clinic notes, and radiographs were reviewed. A careful neurological evaluation was performed for all of the survivors at the time of the latest follow-up. RESULTS: The mean age of the sixteen patients at the time of the injury was 7.6 years. The mechanisms of injury were diverse. The mean Glasgow Coma Scale score was 7.4 points. Eleven of the sixteen patients underwent intubation in the field, two were intubated in the emergency department, and three were not intubated. Eight of the sixteen patients were declared dead on arrival in the emergency department. The eight surviving patients initially were immobilized with either a halo vest or another orthosis. All patients except one received intravenous steroids in the emergency department. Three of the patients who survived the initial injury subsequently died while undergoing neurosurgical procedures for the treatment of extensive intracranial injuries. Four of the remaining five survivors underwent occiput-C2 fusion, and one was managed with a Minerva cast. At the time of the final follow-up, at a mean of 4.2 years after the injury, one patient was neurologically normal, three had mild spastic hemiparesis and were very functional, and one had spastic quadriplegia and was ventilator-dependent. CONCLUSIONS: Prompt recognition and treatment of traumatic atlanto-occipital dislocation in children and adolescents can result in improved survival. Early diagnosis, prompt intubation, early and adequate immobilization of the head and neck, and the use of intravenous steroids appear to facilitate survival. We recommend arthrodesis from the occiput to C2 (or the nearest adjacent intact and stable vertebra caudad to C2) for all children who survive a traumatic atlanto-occipital dislocation, particularly those with an incomplete spinal cord injury.

Adolescent↗

PubMed2005

Knee injury in patients experiencing a high-energy traumatic ipsilateral hip dislocation.

BACKGROUND: Traumatic hip dislocation results from the dissipation of a large amount of energy about the hip joint. Clinically, these forces often are first transmitted through the knee en route to the hip. It is therefore logical to look for coexistent ipsilateral knee injury in patients with a traumatic hip dislocation. METHODS: Over a one-year period, we prospectively evaluated the ipsilateral knee of all patients who had a traumatic hip dislocation on the basis of a standardized history, physical examination, and magnetic resonance imaging. RESULTS: Twenty-one (75%) of the twenty-eight knees were painful. Twenty-five (89%) of the twenty-eight knees had visible evidence of soft-tissue injury on inspection. Magnetic resonance imaging revealed evidence of some abnormality in twenty-five (93%) of twenty-seven knees, with effusion (37%), bone bruise (33%), and meniscal tear (30%) being the most common findings. CONCLUSIONS: The present study provides evidence of a high rate of associated ipsilateral knee injuries in patients with a traumatic hip dislocation. Bone bruises may provide a plausible explanation for persistent knee pain following a traumatic hip dislocation. The liberal use of magnetic resonance imaging is recommended for the evaluation of these patients in order to detect injuries that may not be discoverable on the basis of a history and physical examination alone.

Accidents, Traffic↗

PubMed1977

Voluntary glenohumeral dislocation.

Voluntary dislocation of the shoulder is a rare condition with radiographic findings similar to traumatic dislocation. Although these dislocations may be anterior, the majority are posterior. Three cases of spontaneous dislocation are described. While two of these cases had previous trauma to the joint, it is possible that there is no causal relationship. Voluntary dislocations are usually elicited in abduction and extension; frontal and axillary views are most helpful in demonstrating glenohumeral subluxations.

Adolescent↗

PubMed1986

Hyperextension dislocation of the cervical spine.

The purpose of this report is to describe hyperextension dislocation of the cervical spine and to illustrate its often subtle radiographic features. An analysis of the lateral cervical spine radiographs in 20 patients with hyperextension dislocation of the cervical spine revealed the combination of diffuse prevertebral soft-tissue widening together with normally aligned cervical vertebrae in all patients with this injury. In six (30%) of 20 patients, this combination of findings was the only radiographic sign. The precise level of dislocation was indicated by a thin, transversely oriented avulsion fracture fragment arising from the anterior aspect of the inferior end-plate of the dislocated vertebra in 13 (65%) of 20 patients, by a vacuum defect in the intervertebral disk subjacent to the dislocated vertebra in three (15%), by a widened intervertebral disk space in three (15%), and by comminuted fracture of the spinous process in one (5%). Clinically, all 20 patients had facial trauma and all had some manifestation of the acute central cervical spinal cord syndrome.

Adolescent↗

PubMed1987

CT patterns of facet fracture dislocations in the thoracolumbar region.

Thoracolumbar facets are not as commonly dislocated as are those of the cervical spine. It is, however, crucial to make an early and accurate diagnosis of thoracolumbar facet dislocation since the injury may be unstable and require reduction and internal fixation. This paper presents three major CT patterns of thoracolumbar facet fracture dislocation. The first represents anterior subluxation of the vertebral body with anteriorly locked facets. The second is a lateral vertebral body subluxation with laterally locked facets. The third is an acute kyphosis with little vertebral body subluxation but superiorly dislocated facets. Since the vertebral body subluxation may be missed on axial CT images, these facet-dislocation patterns should be recognized by identifying the paired superior and inferior facets and establishing their congruency. Identification of the facets is accomplished by their orientation with respect to the vertebral body (superior facets are directed posteromedially and inferior facets are directed anterolaterally) as well as by the shape of the articular surface (superior facet articular surface is concave, inferior facet articular surface is flat or convex).

Fractures, Bone↗

PubMed1990

CT detection of cortical fracture of the femoral head associated with posterior hip dislocation.

Posterior dislocation of the femoral head is a common injury in automobile accidents and is frequently associated with fractures of the posterior acetabular rim. Fractures of the anterior cortex of the femoral head have not been described. One hundred sixty-four cases of posterior hip dislocation presenting consecutively to our shock trauma unit and emergency department during a 3-year period were evaluated with plain film radiology and CT. In 21 cases (13%), CT showed an anterior cortical fracture of the femoral head that could not be seen on plain radiographs. This injury is similar to the Hill-Sachs lesion of the humerus that results from anterior dislocation. The anterior cortical fracture was associated with fractures of the posterior acetabulum in 18 cases (86%). The anterior fracture is caused by impaction of the anterior femoral head against the posterior acetabular rim at the time of dislocation. We conclude that anterior cortical fracture of the femoral head is a common accompaniment to posterior acetabular dislocation.

Femoral Fractures↗

PubMed1988

Breech position, delivery route and congenital hip dislocation.

The purpose of this study was to investigate whether the mode of delivery for fetuses in breech presentation in any way influenced the frequency of congenital hip dislocation. In 13,559 singleton births 583 fetuses were in breech position, and the cesarean section rate was 39.1%. Eighty-three infants were born with congenital hip dislocation, 11 of whom had been in breech position. Of these 11, cesarean section was required in 5 cases. There was no difference in frequency of congenital hip dislocation between fetuses in breech presentation delivered by cesarean section vs. by the vaginal route. The frequency of breech presentation in congenital hip dislocation was 13.3%. Including 7 external versions, the rate was 21.7%. Female to male ratio was 4:1. The frequency of congenital hip dislocations in infants born in vertex presentation was 5.5 per mille and for infants born in breech presentation it was 18.9 per mille.

Breech Presentation↗

PubMed1978

Lateral dislocation of the patella following Marmor and Guepar arthroplasty of the knee.

The follow-up of 50 knees treated with the modular Marmor prosthesis and 50 with the Guepar hinge joint included tangential radiography of the femoro-patellar joint. After Marmor arthroplasty lateral patellar dislocation was found in seven knees, in six causing pain. After Guepar arthroplasty lateral patellar dislocation was found in 32 knees, but pain was present in only three. There was only a questionable correlation between pre-existing valgus deformity and postoperative lateral patellar dislocation, and an external rotation deformity of the lower leg was found in only five cases after Guepar arthroplasty. Thus, neither phenomenon could explain the high incidence of lateral patellar dislocation in the Guepar series. These dislocations must be assumed to be due to the unphysiological strain on the extensor apparatus inherent in this type of prosthesis.

Adolescent↗

PubMed1992

Incidence of dislocation after hip arthroplasty. Comparison of different registration methods in 408 cases.

We studied four different methods of registration of dislocations after total hip arthroplasty (THA) carried out at Malmö General Hospital during 1979-1988. Established registers failed to incorporate more than half of the dislocations and approximately one third of the patients, compared with a manual retrospective review of the original operating cords and the patient files. In 22 percent of the cases the first dislocation occurred more than one year postoperatively. Therefore different studies must use similar methods of registration concerning all details about dislocations in order to allow an adequate comparison of THA dislocation parameters.

Hip Joint↗

PubMed1991

Stabilization of traumatic atlanto-occipital dislocation. Case report.

Traumatic atlanto-occipital dislocation is most often fatal. Consequently, there are only scattered case reports of patients surviving this injury, and treatment modalities are anecdotal and varied. The case of an 18-year-old woman who suffered an anterior atlanto-occipital dislocation as the result of a motor-vehicle accident is presented. Rigid posterior fixation and complete reduction of the dislocation were achieved using an anatomically contoured steel loop secured to the occiput and cervical vertebrae. The addition of cancellous bone to the graft afforded long-term stability. This operative treatment provided anatomical realignment of the dislocation and allowed early mobilization of the patient with the use of aggressive rehabilitation. Previously reported cases of patients surviving anterior atlanto-occipital dislocation are reviewed. The use of cervical traction, halo bracing, and operative stabilization is discussed.

Accidents, Traffic↗

PubMed2000

Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition.

OBJECT: Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition. METHODS: Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms. CONCLUSIONS: Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.

Adolescent↗

PubMed2002

Traumatic thoracic spinal fracture dislocation with minimal or no cord injury. Report of four cases and review of the literature.

OBJECT: Thoracic fracture dislocations reportedly lead to complete paraplegia in 80% of cases. It is rare for these dislocations not to cause neurological deficits, as evidenced by the mere 11 well-documented neurologically intact cases in the English-language literature. METHODS: The authors report four cases of thoracic fracture dislocation that remained neurologically intact and discuss 11 other previously published well-documented cases. Overall there were 10 men and five women with a mean age of 34 years (range 17-66 years). Mechanisms of injury included car crash in six, motorcycle crash in seven, plane crash in one, and fall from a horse in one. On admission, neurological deficits were absent in 11 patients, intercostal neuralgia was present in two, and mild lower-extremity weakness/numbness was demonstrated in two. All suffered significant thoracic pain, with 14 patients having sustained rib fractures and eight a hemothorax. The levels of dislocation were T3-4 in two, T5-6 in four, T6-7 in four, T7-8 in two, T8-9 in one, and T9-10 in two. All suffered some degree of lateral translation (mean 12 mm, range 3-27 mm). There were six cases of well-documented anterior subluxation in addition to translation (mean 12 mm, range 4-23 mm), and all involved some degree of fracture imploding of one vertebral body (VB) into an adjacent VB. There were six cases of burst fracture with translation (mean kyphotic angle 38 degrees, range 28-50 degrees). Bilateral pedicle shear fractures were present in all 15 cases at the site of subluxation, thus separating the anterior from the posterior elements and preserving the spinal canal. Only two of the 15 patients suffered complete spondylolisthesis. Five patients underwent successful nonoperative management with prolonged bed rest; at follow-up examination, neurological status remained normal in all five, lesions were radiographically unchanged in three, and there was less subluxation but not anatomical alignment in two. Ten patients underwent successful internal fixation via anterior approaches (two cases), posterior approaches (five cases), and combined approaches (three cases). Neurological status either improved to normal or remained normal except in one case with persistent intercostal neuralgia. Surgery resulted in no change in alignment in three, improved but not anatomical alignment in 11, and normal alignment in one patient. All patients ambulated unassisted by 6 months. CONCLUSIONS: In cases in which bilateral pedicle fractures occur at the site of significant thoracic subluxation and/or translation, preservation of the spinal canal and spinal cord neurological function can rarely occur when both the lamina and spinal cord do not dislocate along with the anterior VBs. In these instances, perfect anatomical reduction may require forces that unnecessarily put neurological function at risk and the results appear to justify internal fixation with some or no reduction of deformity.

Adult↗

PubMed1993

Dislocation following THA: comparison of two acetabular component designs.

One hundred ninety-seven consecutive primary cemented total hip arthroplasties using 22 mm heads were evaluated for the rate of dislocation. All surgery was performed by one surgeon through a posterior approach. A Charnley type femoral component was used in each case. Patients were divided into three groups based on the acetabular component used. Group I had 60 Charnley HPW cups implanted between January 1985 and December 1986; group II had 70 Tibac cups implanted between January 1987 and August 1987; and group III had 67 Charnley HPW cups implanted between September 1987 and February 1988. The groups were similar with regards to age, sex, original diagnosis, and surgical technique. There was a total of 11 dislocations (5.6%), of which 8 (11.4%) occurred in group II (Tibac cup). Furthermore, 6 patients (3%) developed recurrent hip dislocations, 5 (7.1%) of which were from group II. Group II had a statistically significant increase in the dislocation rate (P < .05). The authors conclude that the dislocation rate with the 22 mm Tibac cup is unacceptably high and that the design of the Charnley cup affords greater stability to the artificial hip joint than the hemispherical design of the Tibac cup.

Adult↗

PubMedDate not supplied

Traumatic dislocation of the hip joint--pattern and management in a tropical African population.

Traumatic dislocation of the hip is an orthopaedic emergency for which early reduction is indicated. This article describe our experience of the pattern and choice of management of traumatic dislocation of the hip joint in a tropical African population. Majority of the dislocation (87%) were Thompson and Epstein's grades I and II which were easily managed by closed reduction following the administration of titrated intravenous analgesic and intravenous diazepam. This treatment option is cheap and readily administrable to avoid undue delays in the management of this orthopaedic emergency. All the close reduction were carried out in the accident and emergency room except for one patient with bilateral posterior hip dislocation who had his reduction on the ward. Early diagnosis and treatment of traumatic hip dislocation are essential to reduce the morbidities that are commonly associated with delay in reduction.

Adolescent↗

PubMed2003

Experiences in diagnosis and treatment of hip dislocation and dysplasia in populations screened by the ultrasound method of Graf.

Ultrasound investigation of the hip according to Graf is performed, whenever possible, as a routine screening test for hip dysplasia and dislocation in neonates. However, in spite of screening, hip dysplasia and/or dislocation is identified in a number of children after the third month of life only. The present study presents an analysis of reasons and causes. Between August 1999 and July 2001 children aged between six months and five years were documented, in whom the diagnosis of hip dysplasia or dislocation was made, despite normal ultrasound findings at primary investigation and who required non operative or operative treatment by a specialist surgeon working in Switzerland in paediatric orthopaedics. The study included 26 children (17 girls / 9 boys). Hip dysplasia and/or dislocation was diagnosed between the age of 6 days and 41 months. Twelve children had to be excluded from the sample (n = 26), four were infants who had basic neurological disorders or multiple anomalies and there were eight children from abroad whose original documentation could not be obtained. Analysis of the remaining 14 children showed that 43% were misdiagnosed (n = 6) and a treatment error occurred in 36% (n = 5) of cases. One child presented with a teratogenic hip dislocation. In two other infants with normal primary ultrasound findings, hip dysplasia was identified radiographically once the child started to walk. Delayed diagnosis can be the result of technical errors or misinterpretation. The six patients meeting the criteria of misinterpretation can be expressed as a rate of 0.04% of all births. However, even if the disorder is correctly diagnosed, its identification and treatment may be inadequate or fail to produce the desired results. This was the case for five of the children, that is, for a rate of 0.03% of births.

Bone Diseases, Developmental↗

PubMed1989

Screening for congenital dislocation of the hip by child-health nurses in Western Australia.

The child-health nurse screening programme for the presence of congenital dislocation of the hip in Western Australia was evaluated by the use of data that were collected as a routine from the Congenital Malformations Registry, the records of child-health nurses and the Hospital Morbidity System. The programme performed well operationally, with a sensitivity of 68.5%, a specificity of 98.8%, and a positive predictive value of 15.1%. Of the children who were born in the study period (1981-1983), 450 children were diagnosed with congenital dislocation of the hip, and 46 (10.2%) of these children required 104 hospital admissions for the treatment of their dislocation. Of the children whose hips were found to be dislocated in screening (those who were screened as "true-positive" cases), 10.1% were hospitalized, whereas 16.1% of those children who were missed by screening (who screened as "false negative") required hospitalization (95% confidence interval [CI] for the difference in proportions, -7.8% to 19.9%). A comparison of the measures of hospitalization was made between the children who were found to be "true positive" on screening and the children whose dislocation was diagnosed in the hospitals of their birth--a group that generally is considered to show the best outcome. A somewhat-higher proportion of children who were screened as "true positive" required an open surgical procedure (5.0% of children compared with 2.8% of children; 95% CI for the difference, -2.1% to 6.5%). The differences in the other measures of hospitalization between the two groups were small.

Child↗

PubMedDate not supplied

Lateral subtalar joint dislocation: a case with calcaneal fracture.

Subtalar joint dislocation is a relatively rare injury, with lateral dislocation occurring less frequently than medial dislocation. Associated fractures alter the treatment plan and the prognosis, but they are often missed on plain film radiographs. A brief review of the anatomy, pathomechanics, treatment, prognosis, and complications of subtalar joint dislocation is presented. An interesting case of lateral subtalar joint dislocation with an associated calcaneal fracture not evident on plain film radiographs but delineated with computed tomography is presented.

Calcaneus↗

PubMedDate not supplied

Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children.

Recurrent dislocation of the patella is more common in girls than in boys. Although several predisposing factors may exist, patellar dislocation is most commonly associated with familial ligamentous laxity. Many surgical repairs have been described to stabilize the patella. We have found the semitendinosus transfer to the patella to result in a predictable, stable patellofemoral joint without risk of injury to the proximal tibial physis. Between January 1990 and December 1997, 29 children have been treated at the Children's Hospital of Eastern Ontario with a semitendinosus transfer for recurrent dislocation of the patella. Seven children were excluded from the study because of insufficient follow-up; consequently this series consisted of 22 children. Four children underwent bilateral repairs, hence 26 knees that have been operated on with this procedure were included in this study. There were three boys and 19 girls, with an average age at surgery of 14 years and 4 months, ranging from 8 years and 11 months to 17 years and 10 months. The average length of follow-up was 3 years and 2 months, ranging between 2 years and 7 years and 4 months. All children had experienced greater than three episodes of recurrent dislocation of the patella. Pain consistent with patellofemoral syndrome or chondromalacia was present in 17 of 26 knees. On clinical examination, 10 knees exhibited marked ligamentous laxity. There were nine positive patellar apprehension tests, and eight patellae were hypermobile. All children were treated with a semitendinosus transfer to the patella with concomitant tightening of the medial retinaculum and a lateral retinacular release. On long-term follow-up, 23 of the 26 knees (88%) were asymptomatic, and the child had returned to regular activities. Each child completed the Lysholm and the subjective component of the Zarins-Rowe questionnaire to determine the subjective results of the repair procedure. Three children complained of patellofemoral symptoms. One child experienced recurrence of the patellar dislocation, and one child developed medical patellar subluxation.

Adolescent↗