Joint dislocation

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Joint dislocation
Other names Latin: luxatio
Ankledislocation.JPG
A traumatic dislocation of the tibiotarsal joint of the ankle with distal fibular fracture. Open arrow marks the tibia and the closed arrow marks the talus.
Specialty Orthopedic surgery   OOjs UI icon edit-ltr-progressive.svg

A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. [1] A partial dislocation is referred to as a subluxation. Dislocations are commonly caused by sudden trauma to the joint like during a car accident or fall. A joint dislocation can damage the surrounding ligaments, tendons, muscles, and nerves. [2] Dislocations can occur in any major joint (shoulder, knees, hips) or minor joint (toes, fingers). The most common joint dislocation is a shoulder dislocation. [1]

Contents

The treatment for joint dislocation is usually by closed reduction, that is, skilled manipulation to return the bones to their normal position. Only trained medical professionals should perform reductions since the manipulation can cause injury to the surrounding soft tissue, nerves, or vascular structures. [3]

Signs and Symptoms

The following symptoms are common with any type of dislocation. [1]

Complications

Joint dislocations can have associated injuries to surrounding tissues and structures, including muscle strains, ligament and tendon injuries, neurovascular injuries, and fractures. [4] [5] [6] [7] Depending on the location of the dislocation, there are different complications to consider.

In the shoulder, vessel and nerve injuries are rare, but can cause many impairments and requires a longer recovery process. [4] Knee dislocations are rare, but can be complicated by injuries to arteries and nerves, leading to limb-threatening complications. [5] Degenerative changes following injury to the wrist are common, with many developing arthritis. [6] Persistent nerve pain years after the initial trauma is not uncommon. [6] Most finger dislocations occur in the middle of the finger (PIP) and are complicated by ligamentous injury (volar plate). [7] Since most dislocations involving the joint near the fingertip (DIP joint) are due to trauma, there is often an associated fracture or tissue injury. [7] Hip dislocations are at risk for osteonecrosis of the femoral head, femoral head fractures, the development of osteoarthritis, and sciatic nerve injury. [8] [9] Given the strength of ligaments in the foot and ankle, ankle dislocation-fractures can occur. [10]

Causes

Joint dislocations are caused by trauma to the joint or when an individual falls on a specific joint. [11] Great and sudden force applied, by either a blow or fall, to the joint can cause the bones in the joint to be displaced or dislocated from their normal position. [12] With each dislocation, the ligaments keeping the bones fixed in the correct position can be damaged or loosened, making it easier for the joint to be dislocated in the future. [13]

Risk Factors

A variety of risk factors can predispose individuals to joint dislocation. They can vary depending on location of the joint. Genetic factors and underlying medical conditions can further increase risk. Genetic conditions, such as hypermobility syndrome and Ehlers-Danlos Syndrome put individuals at increased risk for dislocations. [14] Hypermobility syndrome is an inherited disorder that affects the ligaments around joints. [15] The loosened or stretched ligaments in the joint provide less stability and allow for the joint to dislocate more easily. Dislocation can also occur because of conditions such as Rheumatoid arthritis. [16] In Rheumatoid arthritis the production of synovial fluid decreases, gradually causing pain, swollen joints, and stiffness. A forceful push causes friction and can dislocate the joint. Notably, joint instability in the neck is a potential complication of rheumatoid arthritis. [16]

Participation in sports, being male, variations in the shape of the joint, being older, and joint hypermobility in males are risk factors associated with an increased risk of first time dislocation. [17] Risk factors for recurrent dislocation include participation in sports, being a young male, a history of a previous dislocation with an associated injury, and any history of previous dislocation. [17]

Diagnosis

Initial evaluation of a suspected joint dislocation begins with a thorough patient history, including mechanism of injury, and physical examination. Special attention should be focused on the neurovascular exam both before and after reduction, as injury to these structures may occur during the injury or during the reduction process. [3] Imaging studies are frequently obtained to assist with diagnosis and to determine the extent of injury.

Radiograph of right fifth finger dislocation Dislocated Finger XRay.png
Radiograph of right fifth finger dislocation

Imaging Types

X-ray, usually a minimum of 2-views

  • Generally, pre- and post-reduction X-rays are taken. Initial X-ray can confirm the dislocation and evaluate for any fractures. Post-reduction x-rays confirm successful joint alignment and can identify any injuries that may have been caused during the reduction procedure. [18]
  • If initial X-rays are normal but additional injury is suspected, there may be a benefit of obtaining stress/weight-bearing views to look for injury to ligamentous structures and/or need for surgical intervention. One example is with AC joint separations. [19]

Ultrasound

  • Ultrasound may be useful in an acute setting, and is a bedside test that can be performed in the Emergency Department. Ultrasound accuracy is dependent on user ability and experience. Ultrasound is nearly as effective as x-ray in detecting shoulder dislocations. [20] [21] Ultrasound may also have utility in diagnosing AC joint dislocations. [22]
  • In infants <6 months of age with suspected developmental dysplasia of the hip (congenital hip dislocation), ultrasound is the imaging study of choice. This is due to the lack of ossification at this age, which will not be apparent on x-rays. [23]

Cross-sectional imaging (CT or MRI)

  • X-rays are generally sufficient in confirming a joint dislocation. However, additional imaging can be used to better define and evaluate abnormalities that may be missed or unclear on plain X-rays. CT and MRI are not routinely used for simple dislocation, however CT is useful in certain cases such as hip dislocation where an occult femoral neck fracture is suspected . [24] CT angiogram may be used if vascular injury is suspected. [24] In addition to improved visualization of bony abnormalities, MRI permits for a more detailed inspection of the joint-supporting structures in order to assess for ligamentous and other soft tissue injury.

Classification

Dislocations can either be full, referred to as luxation, or partial, referred to as subluxation. Simple dislocations are dislocations without an associated fracture, while complex dislocations have an associated fracture. [24] Depending on the type of joint involved (i.e. ball-and-socket, hinge), the dislocation can further be classified by anatomical position, such as an anterior hip dislocation. [24] Joint dislocations are named based on the distal component in relation to the proximal one. [25]

Prevention

Preventing joint dislocations can be difficult since most are caused by an unexpected injury. If participating in activities such as contact sports, where there is a risk for dislocation, wearing appropriate protective equipment can be helpful. Similarly, avoiding positions that place the joint in a vulnerable position can reduce the risk of experiencing a dislocation. Strengthening the muscles surrounding joints can effectively reduce the risk of a joint dislocation and recurrent dislocations. [11]

Treatment

Non-operative

Reduction/Repositioning

X-rays are taken to confirm a diagnosis and detect any fractures which may also have occurred at the time of dislocation. A dislocation is easily seen on an X-ray. [26] Once X-rays are taken, the joint is usually manipulated back into position. This can be a very painful process. This is typically done either in the emergency department under sedation or in an operating room under a general anaesthetic. [27] A dislocated joint should be reduced into its normal position only by a trained medical professional. Trying to reduce a joint without any training could worsen the injury. [28]

It is important to reduce the joint as soon as possible. Delaying reduction can compromise the blood supply to the joint. This is especially true in the case of a dislocated ankle, due to the anatomy of the blood supply to the foot. [29] On field reduction is crucial for joint dislocations. As they are extremely common in sports events, managing them correctly at the game at the time of injury, can reduce long term issues. They require prompt evaluation, diagnosis, reduction, and post-reduction management before the person can be evaluated at a medical facility. [30] After a dislocation, injured joints are usually held in place by a splint (for straight joints like fingers and toes) or a bandage (for complex joints like shoulders).

Immobilization

Immobilization is a method of treatment to place the injured joint in a sling or in another immobilizing device in order to keep the joint stable. [30] A 2012 Cochrane review, found no statistically significant difference in healing or long-term joint mobility between simple shoulder dislocations treated conservatively versus surgically. [31] Shorter immobilization periods are encouraged, with the goal of return to increased range-of-motion activities as soon as possible. [32] [33] Shorter immobilization periods is linked to increased ranges of motion in some joints. [33]

Rehabilitation

Muscles, tendons and ligaments around the joint should be strengthened. This is usually done through a course of physical therapy, which will also help reduce the chances of repeated dislocations of the same joint [34] The most common treatment method for a dislocation of the Glenohumeral Joint (GH Joint/Shoulder Joint) is exercise based management. [35] For glenohumeral instability, the therapeutic program depends on specific characteristics of the instability pattern, severity, recurrence and direction with adaptations made based on the needs of the patient. In general, the therapeutic program should focus on restoration of strength, normalization of range of motion and optimization of flexibility and muscular performance. Throughout all stages of the rehabilitation program, it is important to take all related joints and structures into consideration. [36]

Operative

Surgery is often considered in extensive injuries or after failure of conservative management with strengthening exercises. [11] The need for surgery will depend on the location of the dislocation and the extent of the injury. Shoulder injuries can also be surgically stabilized, depending on the severity, using arthroscopic surgery. [26]

Prognosis

Prognosis varies depending on the location and extent of the dislocation. The prognosis of a shoulder dislocation is dependent on various factors including age, strength, connective tissue health and severity of the injury causing the dislocation. [24] There is a good prognosis in simple elbow dislocations in younger people. Older people report more pain and stiffness on average. [24] Wrist dislocations are often difficult to manage due to the difficulty in healing the small bones in the wrist. [24] Finger displacement towards the back of the hand is often irreducible due to associated injuries, while finger displacement towards the palm of the hand is more readily reducible. [24] Overall, recovering from a joint dislocation can range from a few weeks to months, depending on the severity of the injury. [11]

Epidemiology

Each joint in the body can be dislocated, however, there are common sites where most dislocations occur. The most common dislocated parts of the body are discussed as follows:

See also

Related Research Articles

A subluxation is an incomplete or partial dislocation of a joint or organ. According to the World Health Organization, a subluxation is a "significant structural displacement" and is therefore visible on static imaging studies, such as X-rays. Unlike real subluxations, the pseudoscientific concept of a chiropractic "vertebral subluxation" may or may not be visible on x-rays.

<span class="mw-page-title-main">Shoulder problem</span> Medical condition

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. An open fracture is a bone fracture where the broken bone breaks through the skin. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture. Most bone fractures require urgent medical attention to prevent further injury.

<span class="mw-page-title-main">Joint replacement</span> Orthopedic surgery to replace a joint

Joint replacement is a procedure of orthopedic surgery known also as arthroplasty, in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. Joint replacement surgery is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.

<span class="mw-page-title-main">Ankle fracture</span> Medical condition

An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.

<span class="mw-page-title-main">Hip dislocation</span> Orthopedic injury

A hip dislocation is when the thighbone (femur) separates from the hip bone (pelvis). Specifically it is when the ball–shaped head of the femur separates from its cup–shaped socket in the hip bone, known as the acetabulum. The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints. With that, dislocation would require significant force which typically results from significant trauma such as from a motor vehicle collision or from a fall from elevation. Hip dislocations can also occur following a hip replacement or from a developmental abnormality known as hip dysplasia.

<span class="mw-page-title-main">Separated shoulder</span> Medical condition

A separated shoulder, also known as acromioclavicular joint injury, is a common injury to the acromioclavicular joint. The AC joint is located at the outer end of the clavicle where it attaches to the acromion of the scapula. Symptoms include non-radiating pain which may make it difficult to move the shoulder. The presence of swelling or bruising and a deformity in the shoulder is also common depending on how severe the dislocation is.

<span class="mw-page-title-main">Dislocated shoulder</span> Injury

A dislocated shoulder is a condition in which the head of the humerus is detached from the glenoid fossa. Symptoms include shoulder pain and instability. Complications may include a Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve.

<span class="mw-page-title-main">Calcaneal fracture</span> Medical condition

A calcaneal fracture is a break of the calcaneus. Symptoms may include pain, bruising, trouble walking, and deformity of the heel. It may be associated with breaks of the hip or back.

<span class="mw-page-title-main">Jammed finger</span> Medical condition

Jammed finger is a common term used to describe various types of finger joint injuries. It happens from a forceful impact originating at the tip of the finger directed towards the base. This type of directional force is called axial loading. It occurs most often when the finger is fully extended. This kind of impact can stretch or strain the ligaments in the joint beyond their normal limits. The severity of damage to the finger increases with the amount of force on the fingertip. In severe cases, injury to bone may occur. When experiencing a jammed finger, the extent of injury is not always obvious and one should be evaluated by a medical professional. Toes may become jammed as well, with similar results.

<span class="mw-page-title-main">Musculoskeletal injury</span> Damage of muscular or skeletal systems

Musculoskeletal injury refers to damage of muscular or skeletal systems, which is usually due to a strenuous activity and includes damage to skeletal muscles, bones, tendons, joints, ligaments, and other affected soft tissues. In one study, roughly 25% of approximately 6300 adults received a musculoskeletal injury of some sort within 12 months—of which 83% were activity-related. Musculoskeletal injury spans into a large variety of medical specialties including orthopedic surgery, sports medicine, emergency medicine and rheumatology.

<span class="mw-page-title-main">Elbow</span> Joint between the upper and lower parts of the arm

The elbow is the region between the upper arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa, and the lateral and the medial epicondyles of the humerus. The elbow joint is a hinge joint between the arm and the forearm; more specifically between the humerus in the upper arm and the radius and ulna in the forearm which allows the forearm and hand to be moved towards and away from the body. The term elbow is specifically used for humans and other primates, and in other vertebrates it is not used. In those cases, forelimb plus joint is used.

<span class="mw-page-title-main">Patellar dislocation</span> Medical condition

A patellar dislocation is a knee injury in which the patella (kneecap) slips out of its normal position. Often the knee is partly bent, painful and swollen. The patella is also often felt and seen out of place. Complications may include a patella fracture or arthritis.

<span class="mw-page-title-main">Medial patellofemoral ligament</span> Ligament of the knee

The medial patellofemoral ligament (MPFL) is one of several ligaments on the medial aspect of the knee. It originates in the superomedial aspect of the patella and inserts in the space between the adductor tubercle and the medial femoral epicondyle. The ligament itself extends from the femur to the superomedial patella, and its shape is similar to a trapezoid. It keeps the patella in place, but its main function is to prevent lateral displacement of the patella.

<span class="mw-page-title-main">Femoral fracture</span> Broken femur, at shaft or distally

A femoral fracture is a bone fracture that involves the femur. They are typically sustained in high-impact trauma, such as car crashes, due to the large amount of force needed to break the bone. Fractures of the diaphysis, or middle of the femur, are managed differently from those at the head, neck, and trochanter; those are conventionally called hip fractures. Thus, mentions of femoral fracture in medicine usually refer implicitly to femoral fractures at the shaft or distally.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

The treatment of broken bones and dislocated joints can be traced as far back as the Ancient Greeks. Hippocrates is credited with a method of reduction of a dislocated shoulder. 16th century Spanish texts talk about the Aztecs use of reduction of fractures using fir branches. The modern discipline of orthopaedics in trauma care developed during the course of World War I, but it was not until after World War II that orthopaedics became the dominant field treating fractures in much of the world. Today, the discipline encompasses conditions such as bone fractures and bone loss, as well as spinal pathology and joint disease.

<span class="mw-page-title-main">Proximal humerus fracture</span> Break of the upper part of the bone of the arm

A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus). Symptoms include pain, swelling, and a decreased ability to move the shoulder. Complications may include axillary nerve or axillary artery injury.

<span class="mw-page-title-main">Knee dislocation</span> Medical condition

A knee dislocation is an injury in which there is disruption of the knee joint between the tibia and the femur. Symptoms include pain and instability of the knee. Complications may include injury to an artery, most commonly the popliteal artery behind the knee, or compartment syndrome.

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