Dislocations

Question 1

What are dislocations?

Answer 1

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

Question 2

Causes of Dislocations

Answer 2

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

Question 3

Medical Treatment of Dislocations

Answer 3

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
anaesthetic 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

Question 4

Dislocation of Specific Joints:

Glenohumeral Joint-Anterior dislocation

Answer 4

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

Question 5

Dislocation of Specific Joints:

Glenohumeral Joint-Posterior dislocation

Answer 5

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)

Question 6

Dislocation of Specific Joints:

Patella

Answer 6

● 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

Question 7

Dislocation of Specific Joints:

Lunate

Answer 7

● 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

Question 8

Dislocation of Specific Joints:

Elbow

Answer 8

● 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

Question 9

Dislocation of Specific Joints:

Hip

Answer 9

● 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

Question 10

Symptoms
Acute

Answer 10

● 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

Question 11

Symptoms
Early Subacute

Answer 11

● 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

Question 12

Symptoms
Late Subacute

Answer 12

● 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

Question 13

Symptoms
Chronic

Answer 13

● 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

Question 14

Health History Questions

Answer 14

● 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?
● What activities are difficult to complete?

Question 15

Observations-Acute

Answer 15

● 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

Question 16

Observations
Early & Late Subacute

Answer 16

● 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

Question 17

Observations
Chronic

Answer 17

● 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

Question 18

Palpation-Acute

Answer 18

● 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

Question 19

Palpation-Early & Late Subacute

Answer 19

● 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

Question 20

Palpation-Chronic

Answer 20

● 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

Question 21

Testing
Acute, Early & Late Subacute

Answer 21

● 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

Question 22

Testing
Chronic

Answer 22

● 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

Question 23

Contraindications

Answer 23

● 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

Question 24

Testing Protocol for Dislocations

Answer 24

Question 25

Treatment
Acute

Answer 25

● 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

Question 26

Treatment
Early Subacute

Answer 26

● 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

Question 27

Treatment
Late Subacute

Answer 27

● 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

Question 28

Treatment
Chronic

Answer 28

● 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

Question 29

Self-Care

Answer 29

● 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