Dislocations Flashcards
what is Dislocations ?
- A dislocation is the complete dissociation of the articulating surfaces of a joint
- A subluxation is when the articulating surfaces of a joint remain in partial contact with each other
In a dislocation, a portion of the joint capsule and surrounding ligaments are either completely torn or partially ruptured
Causes of Dislocations
A trauma related sudden twist or wrench of the joint beyond its normal ROM
This can be direct or indirect trauma
Contributing Factors
Pathologies such as RA, paralysis and neuromuscular diseases
Congenital ligamentous laxity or joint malformation
Previous dislocations of the joint
Medical Treatment of Dislocations
Medical treatment involves tractioning the bones that comprise the joint to bring the articulating surfaces back into normal contact-this is called joint reduction
The earlier the joint is reduced after the injury, the easier the procedure will be
If protective muscle spasm has set in, an injection of a muscle relaxant or an anesthetic is used before the joint is reduced
The joint is supported for several weeks to allow the joint capsule and ligaments to heal
Limited pain-free movement and strengthening of the muscles that cross the joint are usually encouraged
Dislocation of Glenohumeral Joint-Anterior dislocation
The most common form of this injury is an anterior dislocation
Also called a subcoracoid dislocation
Mechanism of injury is often excessive abduction and external rotation of the humerus (ex. Tackled from behind while throwing a ball)
Another mechanism of injury is extension of the humerus where the person falls backwards onto his outstretched hand (FOOSH)
The head of the humerus is forced through the inferior portion of the joint capsule where it lodges inferior to the coracoid process
There may be damage to the glenoid labrum (Bankart lesion)
The axillary nerve may be injured
Following reduction, the joint is usually stable if it is held in internal rotation
A sling is used to support the arm
Recurring anterior dislocations may be treated surgically to stabilize the joint
Dislocation of Glenohumeral Joint-Posterior dislocation
Less frequent is a posterior dislocation of the glenohumeral joint
The mechanism of injury is usually flexion, adduction and internal rotation of the humerus (ex. A person falls forward onto his flexed elbow)
Dislocation of Patella
Usually dislocated laterally
Mechanism of injury involves external rotation of the tibia and foot when the knee is flexed
Following reduction, the knee is bandaged for several days
With repeated dislocations, the tibial insertion of the quadriceps may be surgically transposed to a more medial location
Dislocation of Lunate
Dislocates in a palmar direction
Mechanism of injury is usually by a fall on the outstretched hand, forcing the wrist into hyperextension
The radius forces the lunate in a palmar direction, displacing the lunate anteriorly into the wrist between the flexor tendons and the capitate bone
Open reduction may be necessary
After reduction, the wrist is immobilized in 20 degrees of flexion for up to 4 weeks
Dislocation of Elbow
A dislocation of the elbow is usually accompanied by a fracture
The mechanism of injury occurs after a fall on the outstretched hand or in a MVA
The ulna and radius are displaced posteriorly
The elbow is usually immobilized for 3 weeks following reduction
Dislocation of Hip
Uncommon
Mechanism of injury is following a car or motorcycle accident
If the person is seated, the femur is forced posteriorly by a direct impact to the knee
Following reduction, the limb is tractioned for up to 6 weeks
Symptoms Acute
Complete rupture of the joint capsule and surrounding ligaments or an avulsion fracture of the capsular attachments
Snapping or popping noise is heard at the time of injury
Pain is intense and sickening at the time of injury
Joint usually appears deformed before reduction
Marked local edema and heat are evident
Joint is unstable
Bruising is black, blue and red
Decreased ROM at the joint as protective muscle spasm, edema and pain limit movement
Client cannot continue activity
Symptoms
Early Subacute
Joint is unstable
Bruising is black and blue
Hematoma is still present but diminished
Pain, edema and inflammation are still present but reduced
Adhesions are developing around the injury
Because the joint capsule and its supporting ligaments are hypovascular, they heal relatively slowly
Protective muscle spasm diminishes
Muscles crossing the injured joint provide the only stability
The injured joint is taped, splinted or immobilized
ROM is reduced
Symptoms
Late Subacute
Bruising changes to yellow, green and brown
Pain, edema and inflammation are diminishing
Adhesions are maturing around the injury
Protective muscle spasm is replaced by an increased tone in the muscles crossing the joint
Muscles crossing the joint still provide the stability
Affected joint is supported or immobilized
ROM is reduced
Symptoms
Chronic
Pain is local to the joint capsule when the capsule is stressed
Bruising is gone
Adhesions have matured around the injury
HT and TPs are present in muscles crossing the joint and in compensating structures
Full ROM of the joint is restricted
A pocket of chronic edema may remain local to the ligament
Tissue may be cool due to ischemia
Joint may be unstable in the direction the injury occurred unless it is surgically repaired
Muscle weakness or disuse atrophy may be present in muscles crossing the affected joint
Loss of proprioception at the joint
Health History Questions
- What is your overall health history?
- Do you have any contributing conditions that predispose you to ligament injuries?
- Has there been a history of recurrent dislocations?
- When did the injury occur?
- Do you know the mechanism of injury?
- Have you seen any other health care practitioner for this injury?
- Was the joint immobilized or surgically repaired?
- Are you using any supports?
- Are you taking any medication for the dislocation?
- What symptoms are you currently experiencing?
- What aggravates or relieves the pain?
- Is there any edema or bruising?
13.What activities are difficult to complete?
Observations-Acute
Antalgic gait if the dislocation is to a weight bearing joint
Antalgic posture may be present
The affected joint may be supported
The client may have a pained facial expression
Edema is observed at the affected joint and maybe distal
Some redness may be present
Red, black or purple bruising over the injury site
There may be a hematoma
Observations-
Early & Late Subacute
Antalgic gait is still present with dislocations of a weight bearing joint
Antalgic posture will also still occur
Supports for the limb are still present
Edema diminishes from the early to late subacute stage
Bruising over the injury site changes to brown, yellow and green
Hematoma is diminishing if present
Joint capsule and ligaments that were surgically repaired have scars present
Observations-
Chronic
Habituated antalgic gait may be observed with a dislocation of a weight bearing joint
Habituated antalgic posture may be present with an upper limb dislocation
Taping or other supports may be used during activities that stress the joint
There may be some residual chronic edema local to the injury
Scarring following surgery
Palpation-Acute
Heat is present over the injured joint and possibly in the surrounding tissue
Tenderness is present local to the lesion site and refers into the nearby tissue
Texture of the edema is firm
Protective muscle spasm is present in muscles crossing the affected joint
Palpation-Early & Late Subacute
Temperature over the injury site diminishes from the early subacute to the late subacute stage
Tenderness is present local to the injury
Texture of the edema is less firm and adhesions are present as healing progresses
Tone of the muscles crossing the joint changes from spasmodic to tightness and HT
Palpation-Chronic
The injury site may be cool due to ischemia
Point tenderness occurs local to the lesion site
Adhesions local to the joint capsule and injured ligaments
HT and TPs are present local to the injured joint and in the compensating muscles
Testing
Acute, Early & Late Subacute
AF ROM of the proximal and distal joints may be slowly and carefully performed in a pain-free manner
Other testing is CI’d in the acute or subacute stage
Testing
Chronic
The main goal in assessing a dislocated joint before treatment is to determine if the joint is stable or unstable
An AF apprehension test is used if the mechanism of injury is known. The client moves the limb active free towards the position that the joint was in when it dislocated. If the client is unable to perform this action due to apprehension, it is considered a positive for joint instability
If the active free apprehension test is positive, PR testing is not performed because the joint is unstable
Isometric AR testing of the muscles that cross the joint are performed. This will not harm the joint capsule or cause redislocation because the joint is not moving
If the mechanism of injury is unclear, AF ROM is performed on the cardinal planes of motion of the affected joint
If the active free apprehension test is negative, the therapist performs a PR apprehension test, slowly moving the limb towards the position in which the injury occurred. If the client stops the testing due to apprehension that the joint may re-dislocate, this is considered a positive for joint instability. The end feel is empty due to apprehension and the therapist moves to isometric AR testing of the muscles crossing the joint
Testing Protocol for Dislocations
Contraindications
In acute and subacute, testing other than pain-free AF ROM is CI’d to prevent further tissue damage
Avoid removing the protective muscle splinting of acute and early subacute dislocations
Distal circulation techniques are CI’d in the acute and early subacute stages to avoid increasing congestion through the injury site
If the joint is unstable, do not place the limb in the position that the injury occurred
Joint play is CI’d following dislocations where the capsule has not been surgically reduced and the joint is unstable
Frictions are CI’d if the client is taking anti-inflammatories or blood thinners
Avoid heavy hydrotherapy applications applied to the joint in the acute & subacute stages
With dislocations that are casted, avoid hot hydrotherapy applications to the tissue immediately proximal to the cast to prevent congestion
Remedial exercise in the acute stage of a dislocation is CI’d
Before attempting to restore range in the direction that the dislocation occurred, ensure that the majority of strength is regained in the muscles crossing the joint
Where the joint capsule and ligaments have been surgically repaired, full ROM of the affected joint should not be restored in the direction that will stretch the repaired capsule and ligaments
Treatment
Acute
The joint is treated with RICE
Positioning of the client depends primarily on client comfort and on keeping the limb secure so no stress is placed on the injured joint
Hydrotherapy is cold applications
Reduce edema on the injured limb
Maintain local circulation proximal to the injury only
Do not remove protective muscle spasms in muscles that cross the affected joint by overtreating the proximal tissue
On site work is CI’d
Distal work is light stroking and muscle squeezing
Maintain ROM with mid-range PR ROM on the proximal joints that are not crossed by muscles that also cross the dislocated joint
Treatment
Early Subacute
Positioning of the client depends primarily on client comfort and on keeping the limb secure so no stress is placed on the injured joint
Hydrotherapy applications on site are cold/warm contrast
Reduce edema and prevent adhesion formation proximal to the injury
Maintain local circulation proximal to the injury
Reduce but do not remove protective muscle spasm in muscles that cross the affected joint
Reduce TPs
On-site work is now indicated
Maintain ROM with pain-free mid range PR ROM on the proximal joints
Distal techniques are light stroking the muscle squeezing
Treatment
Late Subacute
The limb is elevated without placing stress on the joint
Hydrotherapy applications local to the injury are cold/hot contrast
Reduce remaining edema
Reduce HT and TPs in the entire area
Prevent excess adhesion formation on site
After frictions are performed, only a partial stretch is placed on the muscles and than ice
Maintain ROM with joint play movements in the direction that the dislocation did not occur
Gradually increase ROM with pain-free active assisted ROM and pain-free mid-range PR ROM
Treatment
Chronic
Positioning is for comfort and accessibility to the structures being treated
Hydrotherapy applications proximal to the injury is deep moist heat
Reduce any chronic edema that remains
Reduce HT and TPs to the entire area
Reduce adhesions, stretch and ice
Restore ROM with joint play techniques to the proximal and distal joints and PR ROM to the proximal, affected and distal joints
Increase local circulation
Self-Care
Educate the client on the appropriate hydrotherapy for the stage of healing they are in
Self-massage for the muscles that cross the dislocated joint in the late subacute and chronic stages
Remedial exercise that is appropriate for the stage of healing
Maintain ROM in the acute stage with pain-free AF ROM of the proximal and distal joints
Increase strength in the early subacute stage with pain-free AF ROM of the proximal and distal joints
Increase strength in the late subacute stage with maximal, pain-free AR isometric exercises
Strengthen muscles in the chronic stage
Encourage activity
