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Joint dislocation

From Wikipedia, the free encyclopedia

Not to be confused with sprain.

Joint dislocation
Other namesLatin: luxatio
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.
SpecialtyOrthopedic surgery Edit this on Wikidata

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 often caused by sudden trauma to the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves.[2] Dislocations can occur in any major joint (shoulder, knees, etc.) or minor joint (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation.[1]

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

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

  • Intense pain
  • Joint instability
  • Deformity of the joint area
  • Reduced muscle strength
  • Bruising or redness of joint area
  • Difficulty moving joint
  • Stiffness

Complications

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Joint dislocations can have associated injuries to surrounding tissues and structures, including muscle strains, ligament and tendon injuries, neurovascular injuries, and fractures. Depending on the location of the dislocation, there are different signs, symptoms and complications to consider.

Shoulder

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  • Vessel and nerve injuries during a shoulder dislocation are rare, but can cause many impairments and requires a longer recovery process.[4]

Knee

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Elbow

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Wrist

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Finger

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Hip

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Foot and Ankle

[edit]

Causes

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Joint dislocations are caused by trauma to the joint or when an individual falls on a specific joint.[5] 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.[6] 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.[7]

Risk Factors

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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.[8] Hypermobility syndrome is an inherited disorder that affects the ligaments around joints.[9] 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.[10] 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.[10]

Risk factors associated with increased risk of first time dislocation

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  • Participation in sports[11]
  • Being male[11]
  • Variations in shape of joint[11]
  • Older Age[11]
  • Joint hypermobility in males[11]

Risk factors associated with recurrent dislocation

[edit]
  • Participation in sports[11]
  • Being a young male[11]
  • History of dislocation with an associated injury[11]
  • Previous dislocation[11]

Diagnosis

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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

Imaging Types

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Standard plain radiographs, usually a minimum of 2-views

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  • Generally, pre- and post-reduction X-rays are recommended. Initial X-ray can confirm the diagnosis as well as evaluate for any concomitant fractures. Post-reduction radiographs confirm successful reduction alignment and can exclude any other bony injuries that may have been caused during the reduction procedure.[12]
  • In certain instances if initial X-rays are normal but injury is suspected, there is possible benefit of stress/weight-bearing views to further assess for disruption of ligamentous structures and/or need for surgical intervention. This may be utilized with AC joint separations.[13]
  • Nomenclature: Joint dislocations are named based on the distal component in relation to the proximal one.[14]

Ultrasound

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  • Ultrasound may be useful in an acute setting, particularly with suspected shoulder dislocations. Although it may not be as accurate in detecting any associated fractures, in one observational study ultrasonography identified 100% of shoulder dislocations, and was 100% sensitive in identifying successful reduction when compared to plain radiographs.[15][16] Ultrasound may also have utility in diagnosing AC joint dislocations.[17]
  • In infants <6 months of age with suspected developmental dysplasia of the hip (congenital hip dislocation), ultrasound is the imaging study of choice as the proximal femoral epiphysis has not significantly ossified at this age.[18]

Cross-sectional imaging (CT or MRI)

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  • Plain films are generally sufficient in making a joint dislocation diagnosis. However, cross-sectional imaging can subsequently be used to better define and evaluate abnormalities that may be missed or not clearly seen on plain X-rays. CT is not commonly used, however it is useful in further analyzing any bony aberrations, and CT angiogram may be utilized if vascular injury is suspected.[19] 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

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Dislocations can either be full, referred to as luxation, or partial, referred to as subluxation. Depending on the type of joint involved (i.e. ball-and-socket, hinge), the dislocation can further be classified by anatomical position.

Prevention

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Avoiding positions and activities that place the joint at risk for dislocation are effective strategies to prevent dislocation.[20] Strengthening exercises targeting muscles surrounding the joint are important to prevent dislocation.[20]

Treatment

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Pain Control

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Pain control is an important component of managing joint dislocations. Joint dislocations can be painful and appropriate pain control is helpful during joint reduction.

Reduction/Repositioning

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X-rays are usually 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.[21] Once a diagnosis is confirmed, the joint is usually manipulated back into position. This can be a very painful process, therefore this is typically done either in the emergency department under sedation or in an operating room under a general anaesthetic.[22] 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.[23]

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.[24] 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 postreduction management before the person can be evaluated at a medical facility.[25] 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).

Surgery

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Surgery is often considered in extensive injuries or after failure of conservative management with strengthening exercises.[20] 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.[21]

Immobilization

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Immobilization is a method of treatment to place the injured arm in a sling or in another immobilizing device in order to keep the joint stable.[25] A 2012 Cochrane review, found no statistically significant difference in healing or long-term joint mobility between simple shoulder dislocations treated conservatively versus surgically.[26]

Physiotherapy

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Additionally, the joint muscles, tendons and ligaments must also be strengthened. This is usually done through a course of physiotherapy, which will also help reduce the chances of repeated dislocations of the same joint.[27] The shoulder is a prime example of this. Any shoulder dislocation should be followed up with thorough physiotherapy.[21] The most common treatment method for a dislocation of the Glenohumeral Joint (GH Joint/Shoulder Joint) is exercise based management.[28] 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.[29]

Prognosis

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Epidemiology

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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:

  • Dislocated shoulder
    • Anterior shoulder dislocation is the most common type of shoulder dislocation, accounting for at least 90% of shoulder dislocations. [4] [30]
    • The incidence rate of anterior shoulder dislocations is roughly 23.1 to 23.9 per 100,000 person-years.[31][32] Young males have a higher incidence rate, roughly four times that of the overall population.[31]
    • Shoulder dislocations account for 45% of all dislocation visits to the emergency room.[4]
    • Anterior shoulder dislocations have a recurrence rate around 39%, with younger age at initial dislocation, male sex, and joint hyperlaxity being risk factors for increased recurrence.[33]
    • Recurrent anterior shoulder dislocations have a higher rate of labrum tears (Bankart lesion) and humerus fractures/dents (Hill-Sachs lesion) compared to initial dislocations.[34]
  • Knee
    • The majority of dislocations (64.5%) are caused by trauma to the knee, with more than half caused by car and motorcycle accidents.[35]
    • The incidence rate of initial patellar dislocations is roughly 32.8 per 100,000 person years.[32]
    • Nearly 41% of knee dislocations have an associated fracture, with the majority of these fractures in one of the legs.[35]
    • Nerve injury occurs in about 15.3% of knee dislocations, while major artery injury occurs in 7.8% of knee dislocations.[35]
    • More than half (53.5%) of knee dislocations have an associated torn meniscus.[35]
    • Tendon rupture occurs up to 13.1% of the time.[35]
  • Elbow
    • The incidence rate of elbow dislocations is 5 to 6 per 100,000 persons per year.[36][32]
    • Posterior dislocations are the most common type of elbow dislocations, comprising 90% of all elbow dislocations.[37]
  • Wrist
    • Lunate and Perilunate dislocations are the most common[38]
  • Finger
    • Interphalangeal (IP) or metacarpophalangeal (MCP) joint dislocations[39]
      • In the United States, men are most likely to sustain a finger dislocation with an incidence rate of 17.8 per 100,000 person-years.[40] Women have an incidence rate of 4.65 per 100,000 person-years.[40] The average age group that sustain a finger dislocation are between 15 and 19 years old.[40]
  • Hip
    • Posterior and anterior dislocation of hip
      • Anterior dislocations are less common than posterior dislocations. 10% of all dislocations are anterior and this is broken down into superior and inferior types.[41] Superior dislocations account for 10% of all anterior dislocations, and inferior dislocations account for 90%.[41] 16-40 year old males are more likely to receive dislocations due to a car accident.[41]
      • When an individual receives a hip dislocation, there is an incidence rate of 95% that they will receive an injury to another part of their body as well.[41]
      • 46–84% of hip dislocations occur secondary to traffic accidents, the remaining percentage is due based on falls, industrial accidents or sporting injury.[33]
  • Foot and Ankle
    • Lisfranc injury is a dislocation or fracture-dislocation injury at the tarsometatarsal joints
    • Subtalar dislocation, or talocalcaneonavicular dislocation, is a simultaneous dislocation of the talar joints at the talocalcaneal and talonavicular levels.[42][43] Subtalar dislocations without associated fractures represent about 1% of all traumatic injuries of the foot and 1-2 % of all dislocations, and they are associated with high energy trauma. Early closed reduction is recommended, otherwise open reduction without further delay.[44]
    • Total talar dislocation is very rare and has very high rates of complications.[45][46]
    • Ankle Sprains primarily occur as a result of tearing the ATFL (anterior talofibular ligament) in the Talocrural Joint. The ATFL tears most easily when the foot is in plantarflexion and inversion.[47]
    • Ankle dislocation without fracture is rare.[48]
[edit]
  • Dislocation of the left index finger
    Dislocation of the left index finger
  • Radiograph of right fifth phalanx bone dislocation
    Radiograph of right fifth phalanx bone dislocation
  • Radiograph of left index finger dislocation
    Radiograph of left index finger dislocation
  • Depiction of reduction of a dislocated spine, ca. 1300
    Depiction of reduction of a dislocated spine, ca. 1300
  • Dislocation of the carpo-metacarpal joint.
    Dislocation of the carpo-metacarpal joint.
  • Radiograph of right fifth phalanx dislocation resulting from bicycle accident
    Radiograph of right fifth phalanx dislocation resulting from bicycle accident
  • Right fifth phalanx dislocation resulting from bicycle accident
    Right fifth phalanx dislocation resulting from bicycle accident
  • Shoulder dislocation before (left) and after (right) being reduced
    Shoulder dislocation before (left) and after (right) being reduced
  • X-ray of ventral dislocation of the radial head. There is calcification of annular ligament, which can be seen as early as 2 weeks after injury.[49]
    X-ray of ventral dislocation of the radial head. There is calcification of annular ligament, which can be seen as early as 2 weeks after injury.[49]
  • X-ray of left elbow posterior joint dislocation without fracture
    X-ray of left elbow posterior joint dislocation without fracture

See also

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References

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  2. ^ Smith RL, Brunolli J (1989). "Shoulder kinesthesia after anterior glenohumeral joint dislocation". Physical Therapy. 69 (2): 106–112. doi:10.1093/ptj/69.2.106. ISSN 0031-9023. PMID 2913578.
  3. ^ a b Skelley NW, McCormick JJ, Smith MV (May 2014). "In-game Management of Common Joint Dislocations". Sports Health. 6 (3): 246–255. doi:10.1177/1941738113499721. PMC 4000468. PMID 24790695.
  4. ^ a b c Khiami F, Gérometta A, Loriaut P (2015). "Management of recent first-time anterior shoulder dislocations". Orthopaedics & Traumatology: Surgery & Research. 101 (1): S51 – S57. doi:10.1016/j.otsr.2014.06.027. PMID 25596982.
  5. ^ Mayo Clinic: Finger Dislocation Joint Reduction
  6. ^ U.S. National Library of Medicine – Dislocation
  7. ^ Pubmed Health: Dislocation – Joint dislocation
  8. ^ "Ehlers-Danlos syndromes | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". web.archive.org. 24 September 2017. Retrieved 16 January 2025.
  9. ^ Ruemper, A. & Watkins, K. (2012). Correlations between general joint hypermobility and joint hypermobility syndrome and injury in contemporary dance students. Journal of Dance Medicine & Science, 16(4): 161–166.
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  26. ^ Taylor F, Sims M, Theis JC, Herbison GP (18 April 2012). Cochrane Bone, Joint and Muscle Trauma Group (ed.). "Interventions for treating acute elbow dislocations in adults". Cochrane Database of Systematic Reviews. 2012 (4): CD007908. doi:10.1002/14651858.CD007908.pub2. PMC 6465046. PMID 22513954.
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  37. ^ Elbow Dislocation
  38. ^ "Carpal dislocations". Archived from the original on 24 December 2014. Retrieved 5 March 2013.
  39. ^ Finger Dislocation Joint Reduction
  40. ^ a b c Golan E, Kang KK, Culbertson M, Choueka J (2016). "The Epidemiology of Finger Dislocations Presenting for Emergency Care Within the United States". HAND. 11 (2): 192–6. doi:10.1177/1558944715627232. PMC 4920528. PMID 27390562.
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  46. ^ For a graphic representation of displacements that may lead to a total talar dislocation see: Robert W. Bucholz (29 March 2012). Rockwood and Green's Fractures in Adults: Two Volumes Plus Integrated Content Website (Rockwood, Green, and Wilkins' Fractures). Lippincott Williams & Wilkins. p. 2061. ISBN 978-1-4511-6144-1.
  47. ^ Ringleb SI, Dhakal A, Anderson CD, Bawab S, Paranjape R (1 October 2011). "Effects of lateral ligament sectioning on the stability of the ankle and subtalar joint". Journal of Orthopaedic Research. 29 (10): 1459–1464. doi:10.1002/jor.21407. ISSN 1554-527X. PMID 21445995.
  48. ^ Wight L, Owen D, Goldbloom D, Knupp M (October 2017). "Pure Ankle Dislocation: A systematic review of the literature and estimation of incidence". Injury (Review). 48 (10): 2027–2034. doi:10.1016/j.injury.2017.08.011. PMID 28826653.
  49. ^ Earwaker J (1992). "Posttraumatic calcification of the annular ligament of the radius". Skeletal Radiol. 21 (3): 149–54. doi:10.1007/BF00242127. PMID 1604339. S2CID 43615869.
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