Joint dislocation (Lat. - luxatio) — it is a complete disconnection of the articular ends of the two bones articulate with rupture of the capsule and ligaments (complete dislocation). Under incomplete dislocation or subluxation, a partial offset understood articular surfaces. If, at the border crossing of the normal movement of the joint capsule and ligaments toil, but still keep the joint surfaces in their normal relationship - a failed or incomplete dislocation is called displacement.
The concept of dislocation can be turned on and the displacement of soft tissues, such as nerve dislocation, dislocation of the tendon. But usually, speaking of dislocation, disconnection mean bone joint.
By the mechanism the origin of the joint dislocation distinguished:
Traumatic joints dislocations
Traumatic dislocations of of the joint to its emergence as the demand conditions predisposing and produce very dislocated. Contributing to the dislocation moments are gender and age. Men who are more engaged in physical labor, dislocations observed 4-5 times more frequently than women, except for the dislocation of the mandible.
Age as well is important: the dislocation occur between the ages of 20 to 60 years. The reasons which in this age of dislocations of form, under the age of 20 years are epiphysiolysis and old people - epiphyseal fractures. The weakness of some places of the joint capsule is not backed by ligaments and muscles, also contributes to the formation of frequent dislocations. Dislocations of "round" of the joints, allowing large volumes of various movements - the most common.
In general, joint dislocations occur every 9-10 less fractures. These figures show a sufficient stability of the articular apparatus of the spine and lower limbs. On the contrary, in the development of bipedal after forelimb became the top and work its load moved into the motor, it is found that with the device osteoarticular mechanism for new targets has sharply decreased, and strength of the upper limb to load its long axis: more of the 90% of the dislocations of the upper limb is obtained mainly in the fall of the brush.
In the mechanism of origin of traumatic dislocation, depending on the anatomical features of the joint, playing the role of the three producing dislocation forces consistently influencing the formation of dislocation:
- External forces, often indirect (dislocated shoulder in the fall of the brush). Due to the movement of the joint, rolling physiological borders, to get quick action lever neravnoplechnogo a foothold - in the bony prominences surrounding the joint, or on its powerful chords, with rupture of the capsule, and the distal end of stepping into the gap torn capsule. Only in the jaw joints pretty much free capsule is stretched, and because of its tensile dislocation can occur without breaking the capsule;
- Direct force like a blow, push, can give only a dislocated by the action of force in the direction in which the distal end is possible to knock out of joint. Here, as with the violence, traction current, dislocation can happen only through the torn ligaments and sometimes - muscle. Generally direct violence often gives a fracture than a dislocation;
- Third producing a dislocation force that helps bring the action arm of the articular surface of contact between them and lock them in a new position is a muscle contraction that puts the limb in a characteristic position, creating the so-called typical dislocation.
What muscle contraction plays an important role in the formation of dislocation can be seen from the fact that in the absence of it, for example, on the body, is not possible to create a typical dislocation so easily, as it happens in vivo. Voltage strictly defined muscle groups, following the rupture of a weak spot bags, - contributes to the formation of the typical dislocation. On the contrary, the vast gaps bags can release the joint ends to locate them in any relation to each other and fixing all pull different for each case will create an atypical muscle sprain. Severe muscle contraction may create their own dislocation, such as epileptic seizures. In terms of the value of muscle contraction in the formation of dislocations becomes clear mounds and detachment. For example, the gap between the greater tuberosity of the humerus back muscles blades marked Turner often accompanies a dislocated shoulder and a moment of complicating it.
Among other complications observed dislocation: injuries, impairment or even passing the gap next to the joint muscles, tendons, blood vessels and nerves. All of these complications are determined by inherent to each of them features:
- pain, neuritis, paresis and hyperesthesia in the compression of the nerves (traumatic neuropathy)
- paralysis and anesthesia in traumatic rupture of nerves (traumatic neuropathy)
- edema and profuse bleeding at rupture of blood vessels
The end of dislocated bones as well as the fracture can disturb the integrity of the skin and give an open dislocation. A bone fracture as a rare complication of dislocation occurs when an external force continues to operate after the dislocation. Sometimes it formed first bone fracture, joint dislocation and then the head.
Diagnosis and symptoms of joint dislocation
Independent pain of dislocation can be very minor. Pain little increase and palpation, and when trying to move, t. To. Undamaged part of the bag and ligaments are strained and sprained arm remains fixed and tense in his new position. This fixation with spring resistance is very characteristic and sharply distinguished from a bone fracture dislocation of the joint end, which is easily obtained in the mobility of the arm, severe tenderness and excessive bleeding.
The insignificant hemorrhage in pure dislocation due to the fact that the distal end is restrained in a torn capsule and compresses the gap torn and bleeding in her vessels.
As a result of the displacement of the articular ends with dislocation of the joint and shape changes can be observed also change the length and direction of the lever depending on the position of the peripheral end, ectopic upwards or downwards, or anterior posterior, medial or lateral from its normal position. Radiographs in the dislocation of the joint confirms it, especially in images in different planes.
Clinical manifestation of joint dislocation
The healing of damaged tissues after dislocation as aseptic damage after all, is so perfect that usually after a reduction of dislocation and light bleeding joint synovitis disappear in 2-3 weeks. But if the gap of the joint capsule was great, but after reduction was not sufficient fixation and healing of the joint capsule prevented the early movement, or if, due to damage to the nerve branches remained the weakening of muscle activity and the patient soon began to hard work - a dislocated joint may be repeated to form habitual dislocation.
If the sprain was not diagnosed or reposition is failed, formed chronic dislocation. In the latter cases, the constant irritation dislocated bone end in a new place is fibro-osseous razrascheniya to form even a bone excavation and new bags around of the articular end, while the old bag zapustevaet. The formation of a new joint subsequently greatly improves the function of the limb. In other cases, especially when complications of bone dislocation detachments mounds and a large margin of the capsule and ligaments, articular ends of the fuse still, completely stopping the function of movement in them. Complicated by dislocations in general is much more likely to leave behind traces in the form of restriction of movements.
The prognosis is quite favorable when fresh, pure dislocation, deteriorates in terms of motor function and complications. When you break the large vessels hemorrhage and injury of nerves at pareticheski state kept for a few weeks, after which the joint function can be restored. Edema of the compression of large vessels and as an indicator of the vasomotor disorder disappears in parallel with the restoration of joint function. And only more severe complications of dislocation as detachments mounds and bone fractures significantly impair the function of the joint. Prognosis worsens particularly if interruption nerve, which may require surgery crosslinking its ends. If you have an open dislocation requires careful adherence to aseptic technique in the treatment.
Traumatic joint dislocations treatment
Treatment of traumatic dislocation is urgently reposition, retention of its immobilization and subsequent mechanotherapy and physiotherapy - to return to its normal joint mobility. The sooner the reduction made in the dislocation, the easier it is doable. Nevpravlenny dislocation leaves man largely incapacitated or unable to fully serve themselves independently. It is difficult to answer the question, what limitations chronic dislocation can still successfully trying to right. There are dislocations with strong bones infringement articular head in a narrow slit or infringement of passing through the joint tendons, which are difficult to vpravimy even in the first 24 hours after the dislocation. But most of the dislocations to the upper limb can try to straighten even a month later, on the lower limbs - 1.5-2 months. At the round joints in this regard it is obtained the best result in the reduction of dislocation.
- During reduction of joint dislocation use of brute force with a short intravenous anesthesia is not required. Reduction of dislocation of the joint takes place on the basis of its anatomical features. When reduction of dislocation of the joint should be to shift the distal end in the opposite direction to the way in which education was going dislocation. This so-called normal way of reduction of dislocation of the joint. In general, as a principle for the successful reduction of dislocation of the joint is necessary to relax the muscles, the capsule hole in it and survived strong ligaments. Being in a tense state, they represent an obstacle to reduction of dislocation of the joint. Muscle relaxation is achieved by short-term intravenous anesthesia, and the joint capsule and ligaments relax to give the final situation in which it can be used as a lever to reposition. Anesthesia and one assistant for protivovytyazheniya enable successful reduction of dislocation is not rough reception. In particular, especially when the actual reduction of dislocation of the joint movements are composed of traction, abduction and rotation (rotation) in both directions.
- After the reduction of joint dislocation - to prevent the recurrence dislocations and a quicker healing fracture of the joint capsule and ligaments - is necessary to immobilize the joint fixing bandage. The duration of immobilization in the dislocation is in the case and from the joint, on the presence of pain:
- with typical dislocation - an average of 10-15 days
- with atypical dislocations with extensive capsule ruptures - from 3 to 6 weeks
- Recovery to normal movement of the joint after reduction of its dislocation is achieved in the next few weeks by:
- therapeutic massage
- warm baths
- passive movements under the supervision and guidance of rehabilitologist
- Physical Therapy (SMC, UHF, IT)
Currently encountered cases of appointment to work too early to relate and dislocations. Sprained limb should be considered workable and without the risk of relapse after a complete disappearance of pain during movement in the joint (in any case no earlier than 1-2 months after its reposition). When chronic dislocations (1-2 months old) must be under intravenous anesthesia techniques to try to shake the rotary joint in all directions - vigorously, but not brutally, trying torn adhesions, and then apply the normal reception reduction.
Nevpravimy chronic dislocation of the joint, if it forms a flexible neoarthrosis, it is better not to try to correct the operational way. Surgical correction of chronic sprains ankylosed - mostly to improve the situation than function - sometimes made using osteotomy, sometimes with a gasket to form neoartroza fascia. Secondary surgery require dislocations of joints, complicated by damage to the major nerve trunks, to restore their continuity, if prolonged use mechanotherapy and physiotherapy does not provide a significant improvement in function.
Excessive bleeding during dislocation, indicating an aggravation of his large vessel rupture or separation hill, does not speak against the possibility in principle structurally unstable reduction. Rotary methods without, however, must be made with great care, and require more prolonged immobilization. Open joint dislocation after reduction requires careful aseptic treatment with drainage in the case of cavity formation festering wounds.
Recurrent or habitual joint dislocation
Habitual dislocations can arise from such conditions, when, after the dislocation of the capsule and ligaments are stretched enough to easily get re-dislocation. This contributes to muscle damage, completely or partially paralyzed due to their tears or damage to nerve branches, they supply as attaching shoulder - in the form of nerve damage axillary branches (axillary nerve, n. Axillaris).
Various aspects, leading to a general weakening of the body as serious infections, poor nutrition may also be predisposing conditions for the formation of habitual dislocation. Most other usual dislocations occur on the shoulder, thumb, knee and lower jaw cup (as mentioned above).
Congenital joint dislocation
Congenital dislocation of his education are still in the embryonic stage. From them it is necessary to distinguish dislocations, resulting in the newborn during childbirth. Congenital dislocation of predominantly found on the hip joint, with a unilateral dislocation occurs twice as often bilateral. The reasons lie in congenital dislocation defect formation and delay the development of the articular surface of the femoral head and pelvis. Regarding the wider pelvis and early bookmark it at the moment girls are predisposing to the formation of congenital dislocation of the hips, which is found in their 7-8 times more often than boys.
Symptoms of congenital hip dislocation are detected after the child starts to get on its feet. The clinical picture of congenital dislocation of the hip following:
- shortening the length of the limb with an emergence of the trochanter up against the Roser-Nelaton line;
- duck gait, especially pronounced in the bilateral dislocation, as a consequence of the installation of the femoral head posterior to the joint, as well as a compensatory phenomenon that - pronounced lordosis of the lumbar spine to tilt the pelvis forward and tilting the upper body backward.
Active motion of the joint is normal, it is often the mobility even more than the norm, except for abduction, which is limited. Often there is the mobility of the head along the length of the thigh with the congenital dislocation.
When the load foot Trendelenburg symptom is observed: the pelvis leaning in a healthy way, and the body - in the patient. This gluteal fold on the healthy leg is below. Trendelenburg symptom is a consequence of the mobility of the hip axis, in the absence of bone fixation head and due to the lack of action gluteal muscle attachment points are close together. In these circumstances, when the load is lowered dislocation of the pelvis in the opposite direction so as on the side of dislocation it loads you are rested in a dislocated hip. Influenced by burdening the joint capsule, following the upward movement of the head, gradually stretched. Leaning over the top edge of the acetabulum, the bag is subsequently glued together to form a kind of hourglass. Therefore bloodless relegation head and install it in the acetabulum is usually limited to a certain height standing head reaching nevpravimogo position to 7-8 years.
Until that time, in the early period, and the sooner, the more likely it is necessary to make attempts at non-surgical reduction. Under anesthesia with the patient on the back, the assistant holds a basin with two hands. This is first necessary to remove obstacles to reposition from shortened muscles. To this effect a bending of the hip and knee length with traction on the hip axis. Clasping his right hand bent knee, the surgeon is now trying to promote head through narrowing of the joint capsule. Traction, abduction and outward rotation of the thigh with his left hand pressure on the greater trochanter head is held on the falling edge of the pit, and squeezed into it through the narrowing of the capsule.
To keep it in place in the "frog" position must be applied a plaster cast or a special fixing thigh brace with the capture of the leg and pelvis, with the pressure immediately above the greater trochanter. Length of stay in the dressing from 2 to 3 months., Followed by a gradual reduction of the limbs, the natural (when walking on crutches) or bandages.
In cases where the specified time for the Conservative missed, later in life, most often between the ages of 15 and 25 years old when shortening great pain and when under load greatly disturbed, often have to resort to palliative surgery, which reduces pain and symptom Trendelenburg and improve gait.
Among the congenital defects of the joint that could lead to dislocation, we should mention the defects of the knee. Congenital dislocation of the shoulder joint are observed and the radial head - often with injury during birth brachial plexus (plexus brachialis). Created defect joint development with the growth progresses until any injury did not cause the patient to pay attention to this defect, which can then doctor misdiagnosed as traumatic dislocation. In other joints, and congenital birth sprains occur very rarely.
Paralytic joint dislocation
Paralytic dislocations arise from a joint dangling when he struck all the muscles and the capsule is stretched greatly - especially under load. But when part of the remaining muscles can contribute to the work of the last dislocation, which in paralysis occurs mainly at round joints - the shoulder and hip. Treatment methods in paralytic dislocations - the creation of arthrodesis (fascia-suspensiya on the shoulder joint when paralytic dislocation of the shoulder, and the use of the method of Koenig on the hip joint).
Pathological joint dislocation
Pathological dislocations are the result of a long stretch of the capsule or exudate or lysis of bone infection in the articular ends, often tubercular character. Offset depends on the load on the affected joint and muscle traction.
When inflammation in the head of the shoulder blade and the strong deltoid muscles pull the shoulder up, and truncal (latissimus dorsi (m. Latissimus dorsi) and pectoral muscle (m. Pectoralis) - in. The result is a displacement of the shoulder upwards and inwards (medially). During coxitis, destroying the acetabulum and the femoral head, the latest in load and without it, thanks to contracture of the lumbar-iliac (m. iliopsoas) and gluteal muscles, moves upward. The muscle contracture knee flexors, extensors are stronger everywhere, taking advantage over quadriceps muscle (m. quadriceps) and, bending the knee at first, then pulls the reins as the shattered end of the tibia posteriorly, forming a posterior subluxation of the knee.
Very often present the clinical picture of pathological dislocation replenished measuring limb standing tall classic point and X-rays, computed tomography (CT) or magnetic resonance imaging (MRI), which presents of the varying degrees of destruction of bone ends and a complete dislocation or subluxation them.
Treatment of pathological dislocation of the joint redressatsiey or permanent traction devices is a different kind of treatment is usually accompanied themselves articular diseases.