Fracture Dislocations


Fracture–dislocation,  a severe injury in which both fracture and dislocation take place simultaneously. Frequently, a loose piece of bone remains jammed between the ends of the dislocated bones and may have to be removed surgically before the dislocation can be reduced. Immobilization must be longer than in a simple dislocation to permit healing of the fracture; chances for permanent stiffness or disability are greater than in uncomplicated dislocation or fracture.



Lisfranc Fracture Dislocation Treatment & Management

Medical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, though associated fractures in the surrounding bone may be present (eg, metatarsal [MT] fracture). An athlete with a stable Lisfranc injury usually cannot compete for the remainder of the season. Early return to high-level activity can lead to chronic pain and progressive arthropathy. Therefore, athletes should be given special consideration.

Initial treatment should consist of a well-molded nonweightbearing short leg cast worn for a minimum of 6 weeks. Advancement of ambulation depends on resolution of symptoms. Because many of these injuries initially present with midfoot edema that may help stabilize damaged tissues, all stable injuries should be reexamined approximately 2 weeks after injury. Weightbearing radiographs should be obtained at 4-6 weeks to ensure continued anatomic alignment.

After 6 weeks, progressive weightbearing can be allowed in a well-molded cast, advancing as comfort allows. When full weightbearing in a cast is comfortable, the patient can be advanced to a supportive shoe and reconditioning. The patient can be advanced to an accommodative orthotic with a contoured carbon shank so as to minimize midfoot stress.

Combined closed reduction and casting has no role in the treatment of unstable injuries. Constantly maintaining reduction with casting alone has proved too difficult. In addition, interposing soft tissues can impede closed reduction. For example, the anterior tibial tendon can block reduction of a lateral Lisfranc dislocation; similarly, the peroneus brevis tendon can block a medial dislocation reduction.

joint dislocation, or luxation,[1] occurs when there is an abnormal separation in the joint, where two or more bones meet.[2] A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligamentstendonsmuscles, and nerves.[3] Dislocations can occur in any joint major (shoulder, knees, etc.) or minor (toes, fingers, etc.). The most common joint dislocation is a shoulder dislocation.[2]

Causes


Joint dislocations are caused by trauma to the joint or when an individual falls on a specific joint.[4] 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 normal position.[5] 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.[6]

Some individuals are prone to dislocations due to congenital conditions, such as hypermobility syndrome. Hypermobility syndrome is genetically inherited disorder that is thought to affect the encoding of the connective tissue protein’s collagen in the ligament of joints.[7] The loosened or stretched ligaments in the joint provide little stability and allow for the joint to be easily dislocated.[2]

Symptoms


The following symptoms are common with any type of dislocation.[2]

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

Treatment

A dislocated joint usually can only be successfully 'reduced' into its normal position by a trained medical professional. Trying to reduce a joint without any training could substantially worsen the injury.[8]

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.[9]

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.[10]

It is important the joint is reduced as soon as possible, as in the state of dislocation, the blood supply to the joint (or distal anatomy) may be compromised. This is especially true in the case of a dislocated ankle, due to the anatomy of the blood supply to the foot.[11]

Shoulder injuries can also be surgically stabilized, depending on the severity, using arthroscopic surgery.[9]

Some joints are more at risk of becoming dislocated again after an initial injury. This is due to the weakening of the muscles and ligaments which hold the joint in place. The shoulder is a prime example of this. Any shoulder dislocation should be followed up with thorough physiotherapy.[9]

After care

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). 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.[12]

Epidemiology

Each joint in the body can be dislocated, however, there are common sites where most dislocations occur. The most commonly dislocated is the shoulder joint.[13] The most common type of shoulder dislocation is anterior dislocation, which occurs 95% of the time.[13] The next most common shoulder dislocation is posterior dislocation, which only occurs 3% of the time. Other common areas for dislocations include the following:



References

Dislocations. Lucile Packard Children’s Hospital at Stanford. 

Smith, R. L., & Brunolli, J. J. (1990). Shoulder kinesthesia after anterior glenohumeral joint dislocation. Journal Of Orthopaedic & Sports Physical Therapy, 11(11), 507-513.

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.

Bankart, A. (2004). The pathology and treatment of recurrent dislocation of the shoulder-joint. Acta Orthop Belg. 70: 515-519

Dias, J., Steingold, R., Richardson, R., Tesfayohannes, B., Gregg, P. (1987). The conservative treatment of acromioclavicular dislocation. British Editorial Society of Bone and Joint Surgery. 69(5): 719-722.

Holdsworth, F. (1970). Fractures, dislocations, and fracture dislocations of the spine. The Journal of Bone and Joint Surgery. 52 (8): 1534-1551.

Ganz, R., Gill, T., Gautier, E., Ganz, K., Krugel, N., Berlemann, U. (2001). Surgical dislocation of the adult hip. The Journal of Bone and Joint Surgery. 83(8): 1119-1124.

Itoi, E., Hatakeyama, Y., Kido, T., Sato, T., Minagawa, H., Wakabayashi, I., Kobayashi, M. (2003). Journal of Shoulder and Elbow Surgery. 12(5): 413-415.
Comments