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terolateral part of the head is crushed. Rarely, the required.

acromion process levers the head downwards and the With Stimsons technique, the patient is left prone joint dislocates with the arm ESTERNOCLAVICULARwith the arm hanging over the side of the bed. After SUBLUXACION pointing upwards (luxatio erecta); nearly always the arm then drops, bringing 15 or 20 minutes the shoulder may reduce. the head to its subcoracoid position. I n the H ippocratic method, gently increasing trac-

Clinical features
Pain is severe. The patient supports the arm with the opposite hand and is loathe to permit any kind of examination. The lateral outline of the shoulder may be attened and, if the patient is not too muscular, a bulge may be felt just below the clavicle. The arm must always be examined for nerve and vessel injury before reduction is attempted.

too, fails (a very rare occurrence) open redu justied, but great care must be taken not to 1. EXPOSICION: ANTEROPOSTERIOR. the mediastinal structures. After reduction, th tion is applied to the arm with the shoulder in slight abduction,2. DEan assistant appliesDE LA REGION ESTERNOCLAVICULAR DERECHA. while QUE REGION: rm countertraction to the body (a towel slung ders the around 3. GRUPO ETARIO: ADULTO. are braced back with a gure-of-eight b patients chest, under the axilla, is helpful). 4. QUE HUESOS OBSERVA UD.: MANGO DEL ESTERNON CON SU CARILLA ARTICULAR With Kochers method, the elbow is which is worn for 3 weeks. bent to 90

ternoclavicular ANTERIOR ESCAPULOHUMERAL SUBLUXACION dislocation (a) The bump over commonly noclavicular joint may be obvious, thoughEXPOSICION: ANTEROPOSTERIOR. dislocates. This is due to a num this is DE QUE (or, LA ARTICULACION shallowness of to demonstrate on plain x-ray. (b) T omography REGION: DEfactors: the ESCAPULO HUMERAL. the glenoid soc GRUPO ETARIO: ADULTO. still, CT) will show the lesion. extraordinary range of movement; underlying
QUE HUESOS OBSERVA UD.: PARTE DE LA METAFISIS Y EPIFISIS PROX. DEL HUMERO, PARTE DEL CUERPO DE LA ESCAPULA CON SU CAVIDAD GLENOIDEA, APOFISIS (c) CORACOIDES Y ACROMION, SE OBSERVA LA CLAVICULA CON SU ARTICULACION ACROMIOCLAVICULAR, ALGUNAS COSTILLAS (2, 3, 4,5 Y PARTE DE LA 6). TIPO DE ARTICULACION: ENARTROSIS. DONDE ESTA LA LESION: LUXACION ANTERIOR DE LA CABEZA HUMERAL CON RESPECTO A LA CAVIDAD GLENOIDEA. (a) ESTABILIZADORES ESTATICOS: TENSION O RUPTURA (d) LOS LIG. GLENOHUMERALES (SUPRAGLENOSUPRAHUMERAL, (b) DE 24.10 Anterior dislocation of the shoulderPREGLENOSUBHUMERAL), and attening of the contour over SUPRAGLENOPREHUMERAL, (a) The prominent acromion process TROQUITERIANO DISTENDIDO Y TROQUINEANO DEPENDE (+ANTERIOR +TENSO). the deltoid are typical signs. (b) X-ray conrms the diagnosis of anterior dislocation. (c,d) Two methods of reduction. QUIEN FAVORECE ESA POSICION: PECTORAL MAYOR. HILL-SACHS

and held closeCLAVICULAR, EL EXTREMO MDIAL DE LA CLAVICULA CON SU EXTREMO ARTICULAR to the body; no traction should be applied. The arm is slowly rotated 75 degrees laterally, MEDIAL. then the point of the elbow is lifted forwards, and 5. is rotated medially. This technique carnally the arm TIPO DE ARTICULACION: ENCAJE RECIPROCO. ries the risk of nerve, vessel and bone LESION: is not 6. DONDE ESTA LA injury and DIASTASIS EN EL EXTREMO MEDIAL DE LA CLAVICULA CON recommended. SOBREELEVACION sitting on a Another technique has the patient DE LA MISMA CON RESPECTO AL MANGO DEL ESTERNON. X-Ray reduction chairESTABILIZADORES ESTATICOS: DISTENSION DE LA MITAD SUPERIOR DE LAS FIBRAS and with gentle traction of the arm over the back of FIBRAS ANTERIORES Y POSTERIORES, TENSION DEL LIGAMENTO COSTOCLAVICULAR. TheESTERNOCLAVICULARES ANTERIORES, TENSION DE LASthe padded chair the dislocation is anteroposterior x-ray will show the (b) overlapping reduced. shadows of the humeral head and glenoid fossa, with An x-ray is taken to conrm reduction and exclude the head usually lying below and medial to the socket.

DISLOCATION OF THE SHOULDE

Of the large joints, the shoulder is the one th

EXPOSICION: AXIAL. 24.12 Recurrent d DE QUE REGION: ESCAPULOHUMERAL. of the shoulder ( QUE HUESOS OBSERVA UD.: SILUETA EPIFISIS PROXIMAL DEL HUMERO, TORUIN classic x-ray sign is TROQUITER Y CORREDERA BICIPITAL, SILUETA DEL CUERPO, CAVIDAD GLENOIDEA Y sion in the postero APOFISIS CORACOIDES DE LA ESCAPULA. of the humeral hea (PLANO ESCAPULAR ES DE 30 CON RESPECTO AL PLANO FRONTAL) S achs lesion). (b,c) TIPO DE ARTICULACION: ENARTROSIS. showing both the H DONDE ESTA LA LESION: HAY EVIDENCIA DE QUE HUBO LUXACION ANTERIOR ESCAPLO lesion GLENOIDEO HUMERAL POR PRESENTAR FRACTURA AL IMPACTAR CON EL REBORDE and a Banka ANTERIOR. the glenoid rim (arr ESTABILIZADORES ESTATICO: GLENOHUMERALES. ESTABILIZADOR DINAMICO: PECTORAL MAYOR, DELTOIDES FIBRA ANTERIOR.

(b)

(c)

n anterior dislocation tears air occurs spontaneously fole dislocation may not recur; m is detached, or the capsule of the neck of the glenoid, ecurrence is more common. rum occurs particularly in at injur y a bony defect has

a direct blow to the front of the shoulder the outstretched hand.

Clinical f eat ures

The diagnosis is frequently missed par reliance is placed on a single anteropost (which may look almost normal) and par

brachial plexus and axillar y artery.

nd elbow

Clinical features
HILL-SACHS INVERTIDO

The startling picture of a patient with his arm locked EXPOSICION: full CON BRAZO EN should make diagnosis quite in almost AXIAL, abduction ABDUCCION. DE QUE REGION: DE LA easy. The OBSERVA REGIONhumerus may be felt EDL or below DE LA ESCAPULA CON SU CAVIDAD GGLENOIDEA Y head ofUD.: METAFISIS Y EPIFISIS PROXIMAL in HUMERO, PART the ESCAPULO HUMERAL. QUE HUESOS the axilla. AlwaysALGO DE LA TROCLEA. APOFISIS CORACOIDES Y examine for neurovascular damage.
ESTABILIZADORES ESTATICOS: ATRS DE LA ESCPULO HUMERAL NO HAY ESTABILIZADORES ESTATICOS. ESTABILIZADORES DINAMICOS: DELTOIDES FIBRAS POSTERIORES, SUPRAESPINOSO, INFRAESPINOSO Y REDONDO MENOR.

X-ray
BANKART

The humeral shaft is shown in the abducted position 24.12 Recurrent dislocation with the head sitting below EXPOSICION: AXIALI t is importhe glenoid.ESCAPULO HUMERAL. of the shoulder (a) The DE QUE REGION: tant to search for associated fractures of the sign PARTEor LA CAVIDAD GLENOIDEA DE LA ESCAPULA, PARTE DE LA QUE HUESOS x-ray glenoid depresclassic OBERVA UD.: is a DE EPIFISIS PROXIMAL DEL HUMERO, TROQUIN, TROQUITER, CORREDERA BICIPITAL. proximal humerus. sion in the posterosuperior part DONDE ESTA LA LESION: LUXACION ANTERIOR Y AL VOLVERSE A ENCAJAR SE LESIONA EL of the humeral be con- GLENOIDEA. N OTE: True inferior dislocationANTERIORnotLAhead (the Hillmust DE CAVIDAD REBORDE Sachs lesion). (b,c) MRI scans fused with postural downward displacement ofGLENOHUMERALES. ESTABILIZADORS ESTATICOS: the showing both the HillSachs humerus, which results quite commonly from weaklesion and a Bankart lesion of ness and laxity of the musclesthe glenoid rim (arrows). around the shoulder, especially after trauma and shoulder splintage; here
(c)
LUXACION INFERIOR DE HOMBRO EXPOSICION: ANTEROPOSTERIOR DINAMICA 24.14 Inferior dislocation

ars olur; ule id, on. in has he der or is on

a direct blow to the front of shoulder You can a fall on DE QUE REGION: ESCAPULO HUMERAL. of the the shoulder or GRUPO ETARIO: the outstretched hand.see why theADULTO. is condition

Clinical feat ures

ins vial on ved as-

The diagnosis is frequently missed partly because reliance is placed on a single anteroposterior x-ray (which may look almost normal) and partly because those attending to the patient fail to think of it. There are, in fact, several well-marked clinical features. The arm is held in internal rotation and is locked in that position. The front of the shoulder looks at with a prominent coracoid, but swelling may obscure this deformity; seen from above, however, the posterior displacement is usually apparent.

QUE HUESOS OBERVA UD.: DIAFISIS Y EPIFISIS PROXIUMAL DEL HUMERO, CUERPO DE LA called luxatio erecta. The ESCAULA, APOFISIS CORACOIDES, ACROMION, EXTREMO LATERAL DE LA CLAVICULA Y ALGUNAS shaft of the humerus DE LAS COSTILLAS (2, 3, 4 Y 5).points upwards and the ENARTROSIS. TIPO DE ARTICULACION:humeral head is displaced downDONDE STA LA LESION: LA CAVIDAD GLENOIDEA NO SE CORRESPONDE EN DISPOSICION DE LA CABEZA HUMERAL. wards. (LUXACION ANTERIOR O ANTEROINFERIOR ES MAS HABITUAL, INFERIOR MENOR CUANTIA, Y EN MUCHO MAYOR CUANTIA POSTERIORES). ESTABILIZADORES ESTATICOS: CORACOHUMERALES FASCICULO TROQUINEAL Y TROQUITERIAL ESPECIALMENTE EL TROQUITERIAL. 743 ESTBILIZADOR DINAMICO: SUPRAESPINOSO.

X-Ray
I n the anteroposterior lm the humeral head, because

assied according to the direction of dis. H owever, in 90% of cases the radioulnar s displaced posteriorly or posterolaterally, ether with fractures of the restraining bony

with fractures of the restraining bony


LUXACION DE CODO

isThe patientThe bony his forearm (olecranon and epiobvious. supports landmarks with the elbow in slight exion. nless swelling is severe, the deformity condyles) mayUbe palpable and abnormally placed.
is obvious. The bony landmarks (olecranon and epicondyles) may be palpable and abnormally placed.

(b)

24.28 Dislocation of the elbow X-rays showing (a) lateral and (b) posterior displacement.

EXPOSICION: ANTEROPOSTERIOR (IZQ.), SAGITAL (DER.) DE QUE REGION: REGION DE CODO GRUPO ETARIO: ANCIANO? QUE HUESOS OBSERAV UD.: PARTE DE LA DIAFISIS Y EPIFISIS ROXIMAL DEL HUMERO, CABEZA DEL RADIO Y EL CUBITO CRUZADO POR DETRS. IZQ.: PICO DEL OLCERANON, OLECRANON, APOFISI CORONOIDES, ALGO DE LA CABEZA RADIAL. ESTABILIZADORES ESTATICOS: TODOS (LIGAMENTO COLATERAL RADIAL (LATERAL
EXTERNO), LIGAMENTO COLATERAL CUBITAL (LATERAL INTERNO), LIGAMENTO ANULAR.

(a)

(b)

755

(a)

LUXOFRACTURA MONTEGGIA (FRACTURA DE CUBITO Y LUXACIO DE RADIO) 24.28 Dislocation of the elbow X-rays showing (a) lateral and (b) posterior displacement. EXPOSICION: ANTEROPOSTERIOR. DE QUE REGION: COMPLEJO ARTICULAR DEL CODO Y 1/3 SUPERIOR DEL ANTEBRAZO. ESTABILIZADORES ESTTICOS: PRINCIPAL ES EL LIGAMENTO CUADRADO DE DENUCE, LIG. COLATERALES FASC. ANTERIOR, MEDIO Y POSTERIOR SOBRE TODO ANTERIOR Y POSTERIOR, CUERDA DE WEIBRECHT. 755 ESTABILIZADORES DINAMICOS: LOS QUE SE FIJAN EN EL EPICONDILO, EXTENSO SUPINADORES (SEGUNDO RADIEL EXTERNO, EXTENSOR COMUN DE LOS DEDOS, SUPINADOR CORTO

FRACTURA DE GALEAZZI (FRACTURA DE RADIO Y LUXACION CABEZA DE CUBITO) EXPOSICION: ANTEROPOSTERIOR (IZQ.), SAGITAL (DER.) DE QUE REGION: REGION RADIO CARPIANA (MANO) Y 1/3 DISTAL DEL ANTEBRAZO. ESTABILIZADORES ESTATICOS: LIG. RADIO CUBITAL ANTERIOR DISTAL, LIG. RADIO CUBITAL POSTERIOR DISTAL, TAMBIEN HAY COMPROMISO DE LOS FASCICULOS CUBITO CARPIANOS QUE NACEN DEL BORDE ANTERIOR DEL LIG. TRIANGULAR.

FRACTURA SUBLUXACION (BARTON) (a)

(a)
EXPOSICION: SAGITAL. DE QUE REGION: RADIOCARPIANA. ESTABILIZADORES ESTATICOS: LIG. ANTERIOR Y POSTERIOR RAIOCARPIANOS, MEDIAL Y LATERAL. ESTABILIZADORES DINAMICOS: FLEXORES (ANTERIOR), POSTERIORES (EXTENSORES).

Principles of management

Wrist sprain should not be diagn serious injury has been excluded w with apparently trivial injuries, lig times torn and the patient may la instability. I f the x-rays are normal but strongly suggest a carpal injur y, (b) should be applied for 2 weeks, afte rays are repeated. A fracture o (b) (c) (b) (c) (a) LUXACION ESCAFO-SEMILUNAR become more obvious after a few w 25.15 Comminuted fracture ofexclude EXPOSICION: ANTEROPOSTERIOR. 4 Fracture-subluxation (Bartons fracture) negative x-ray not the di Principles of management still doeslunate fossa DE QUE of the volar edge die punchscan or M RI at this stage wil ) The true Bartons fracture is a split REGION: RADIOCARPIANA. bone fragment of the QUE HUESOS OBSERVA UD.: TRAPECIO, TRAPEZOIDE, HUESO must be perfectly reduced a radius be diagnosed unless a more he distal radius with anterior (volar) subluxation of the should not (a,b) GRADE, GANCHOSO, ESCAFOIDE, Wrist sprain SEMILUNAR, PIRAMIDAL, PISIFORME, EPIFISIS DISTAL DEL RADIO Y CUBITOan unnecessar y per has nosis and avoid CON SUS RESPECTIVAS . This has been reduced and held (c) with a small y has beenbeen achieved bycertainty. Even a serious injur excluded with closed reduction APOFISIS ESTILOIDES, METACARPIANOS (1, 2, 3, 4 Y PARTEand5). tion DEL time The wires canf be uset K-wire xation (c). from work. I these rior plate. with apparently trivial injuries, ligaments are someavailable, later develop carpal manipulate the fragment patient shoul times torn and the patient may then the back before x repeatedly until the symptoms sett instability. sis is made. I f the x-rays are normal but the clinical signs sometimes mistaken for a Smiths fracture, but it aclosed The morea splint or plaster d or open reduction strongly suggest carpal K-wiringcommon lesions are injur y,

(b) ers from the latter in that the fracture line runs for 2 weeks, after which time the xshould be applied advisable. (d) rays into the quely across the volar lip of the radiusare repeated. A fracture or dislocation may become more t joint; the distal fragment is displaced anteriorly,obvious after a few weeks, but a second negative x-ray still EXPOSICION: SAGITAL. (c) ying the carpus with it. Because the fragment is does not exclude a serious injur y. A F M INUTED INTRA bone scan or M RI DE QUE REGION: RADIO CARPIANA. at this stage will conrm the diagCOMRACTURED SCAPHOID ll and unsuppor ted, the fractureHUESOSinherently EPIFISIS DISTAL DEL CUBITOperiod SEMILUNAR, -ARTICU is and avoid QUE nosis OBSERVA UD.: an unnecessar y Y RADIO, of immobilizaESCAFOIDES, and time from work. I f these tests are not readilyalm able. Scaphoid fractures account for tion TRAPECIO, FRACTURES IN YOUNG ADULT
ESTABILIZADORES ESTATICOS: LIG. DORSALES, VENTRALES E INTEROSEOS.

The fracture can be easily reduced, but until the symptoms children. aWith diagno- fr repeatedly it is and in settle or rm unstable I n the young adult, a comminuted in as easily re-displaced. I nternal xation, using a sis is made. turealso a high energy injur y. A po is be disruption of the scapho-lu The ll anterior buttr ess plate, is recommended. more common lesionsrotation of the lunate. dorsal are dealt with below. result unless intra-articular congruit (d) ment and length are restored and m RSAL SUBLUXATION as soon as possible. For these patien s is sometimes called a dorsal Bartons fracture. (f) standard must be set than would be FRACTURED SCAPHOID e the line of fracture runs obliquely across the typical osteoporotic fracture. I n addi sal lip of the radius and the carpus Scaphoid fractures account for almost 75 per cent of is carried posposteroanterior rare in the x-rays, (e) all carpal fractures although they areand lateral elderly o orly. often CT scans are useful to show 25.20 Carpal injuries (a,b) Normaland in children. With unstable fractures there may th appearances in also be disruption of the scapho-lunate ligaments and tment The fracture is easier to control than the ment. antero-posterior and lateral x-rays. (c,d) Following a dorsal rotation and theThe simplest option is a manipula of lunate. sprained t is this patient developed persistent pain r Bartons. Iwristreduced closed and the forearm is weakness. X-rays for 6 (c) scapho-lunate dissociation the anatomy is not restored, then an mobilized in a cast showedweeks. I f it re-displaces,
ment
and (d) dorsal rotation of the lunate (the typical DISI pattern). (e,f) This patient, too, had a sprained wrist. The (f) anteroposterior and lateral x-rays show foreshortening of the scaphoid and volar rotation of the lunate (VISI). e d g 25.16

available, then the patient should be although they ar all carpal fractures re-examined

er 5 weeks but a protective splint this period. The K-wires are removed at 6 weeks. should tubercle. accompanied by la 8 weeks because of the risk of(e) This injur y is frequently show an excessivelysev instability. (c) LUXACION SEMILUNAR X -rays EXPOSICION: SAGITAL. compression of the median and thewhich should s nstability can occur. This is treated prior scaphoid nerve, lunate. The DE QUE REGION: RADIOCARPIANA. developing, by using part of thereleased.UD.: EPIFISI DISTAL DEL RADIO Y CUBITO, HUESO GRANDE, SEMILUNAR, cor exor QUE HUESOS OBSERVA foreshortened, with a typical s tendon to reconstruct the ruptured and lateral view, the lunate is tilt palmar ligament of the CMC joint. scaphoid anteriorly (D I SI patter carpo-metacarpal joints are also someCAPHO-LUNATE DISSOCIATION ated, typically when a motorcyclist,S holdTreat ment dlebars, strikes an object and the hand is A wrist sprain may Scapho-lunate instability causesa be followed by persistent pain wards. The hand swells up rapidly and the tenderness over the dorsum just distal t. I f Liste and recurrent discomfor to seen easily missed unless a true lateral x-ray is tubercle. (d) weeks after injur y) the scapho-lu amined. Closed manipulation(f) usually is LUXACION PERI-SEMILUNAR (e) X-rays show an be repaired large gapwith intero excessively directly between and perilunate dislocations. although a K-wire is recommended to EXPOSICION: scaphoid lunate. The scaphoid may app -ray of normal wrist; (c,d) lunateSAGITAL. and the tected by K-wires for 6 weeks dislocation; joint from dislocating again. DE QUE REGION: RADIOCARPIANA. foreshortened, withSEGUNDA FILA HAYcortical ring sign.and a typical LIG. VENTRALES Y DORSALES I n e dislocation. (ENTRE LOS HUESOS DE LA PRIMERA FILA Yweeks. I f seen between 4NO HAY lateral ation Late presentation or INTEROSEOS, PERO HAY LATERALES MEDIALES Y LATRERALES) tilted dorsally and secondary view, the lunate is scaphoid anteriorly (D I SI pattern). eated by joint fusion. H owever, if just the oint is involved, a neat operation is to fuse he fourth to the fth metacarpal and then Treat ment ticular surface of the fth. This will mainScapho-lunate instability causes weakness of the w ent at the fourth CMC, so allowing the and the hand to cup around during grip. recurrent discomfor t. I f seen early (i.e. less tha (f) weeks after injur y) the scapho-lunate ligament sho LUXACION COMPLETA CARPO-METACARPIANA be repaired directly with interosseous sutures, p ocations. EXPOSICION: SAGITAL. tectedDEby REGION: CARPO-METACARPIANA. c,d) lunate dislocation; QUE K-wires for 6 weeks and a cast for 8 QUE f seen between 4 and 24 weeks, DEL weeks. I HUESOS OBSERVA UD.: EPIFISIS DISTAL DEL CUBITO Y RADIO, HUESOS then
CARPO, PRIMER METACARPIANO, FALANGE PROXIMAL Y DISTAL DEL PULGAR, SUMATORIA DE LOS METACARPIANOS Y FALANGES PROXIMAL, MEDIA Y DISTAL. TIPO DE LESION: LUXACION ANTERIOR DE LOS CARPOS. ESTABILIZADORES ESTATICOS: TANTO VENTRALES COMO DORSALES Y COLATERALES.

tenderness over the dorsum ju

(d)

26.8 Carpo-metacarpal dislocation (a) Thumb dislocation. (b) Dislocation of the fourth and fth CMC joints tr eated by closed reduction and K-wires (c). Complete carpo-metacarpal dislocation (d).

793

the fracture, strap the nger to its neighbour and conLUXACION DE LOS DEDOS (SE DIFERENCIA surface of the pha- DEL CONDILO) asal joint joint disloca- distal after aregainingensurePOR LAis nox-ray should be surface or centrate on week to movement. An displacement. joint AP DE SAGITAL there FORMA e; proximal taken can be fractured, he dislocation is easily usually by an angulation force. of permaI f the fracture is displaced, there is a risk 26.9 Finger EXPOSICION: ANTEROPOSTERIOR. tragment to its neighis strapped is not displaced, it is best to disregard nent angular deformity and loss of movement at the DE QUE REGION: METACARPOFALANGICA DEL 1 METACARPIANO.dislocation (a) ements are begun immejoint. The fracture should be anatomically reduced, Metacarpo-phalangeal cture, strap the nger to its neighbourESTATICOS: ESTABILIZADORES and condislocation in the ay show a small ake of either closed or by open operation and xed with ESTABILIZADORES DINAMICOS: thumb occasionally e on regainingthis small K-wires or mini-screws. The nger is splinted for movement. An x-ray should be mar plate avulsion; buttonholes and needs ent must be warned ensure there is then supervised movements are comafter a week to that a few days andno displacement. open reduction; (b,c) d sometimes forever) for menced. interphalangeal e fracture is displaced, there is a risk of permaInjuries of the spine
dislocations are easily reduced (and easily missed if not x-rayed!).

I the is best 27 it can take many monthsf(and sometimes forever) for DYLAR FRACTURE fragment is not displaced, itmenced.to disregard

INT DISLOCATION

ngular deformity and loss of movement at the The fracture should be anatomically reduced, EXPOSICION: SAGITAL. (a) (b) closed or by open operation and xed 26.9 Finger(c) with DE QUE REGION: INTERFALANGICA PROXIMAL DEL 5 MTC. dislocation (a) K-wires or mini-screws. The nger is splinted for Metacarpo-phalangeal ESTABILIZADORES DINAMICOS: FLEXORA. days and then super vised movements are dislocation in the comthumb occasionally d. buttonholes and needs
open reduction; (b,c) interphalangeal dislocations are easily reduced (and easily missed if not x-rayed! ).
EXPOSICION: SAGITAL.

26.9 Finger (b) (c) 27.11 Occipitocervical fusion X-ray showingDE QUE REGION: INTERFALANGICA DISTAL. one of dislocation (a) the devices used for internal xation in occipito-cervical ESTABILIZADORES DINAMICOS: FLEXORA. fusion operations. Metacarpo-phalangeal

dislocation in the thumb occasionally buttonholes and needs Sudden severe load on the top of the head may cause a bursting force which fractures the ring of open reduction; (b,c) the atlas (Jeffersons fracture). There is no encroachment on interphalangeal the neural canal and, usually, no neurological damage. dislocations are easily The fracture is seen on the open-mouth view (if the reduced (and easily lateral masses are spread away from the odontoid peg) missed and the lateral view. A CT scan is particularly helpful if not x-rayed! ).

C1 ring f ract ure

in dening the fracture. I f it is undisplaced, the injury FRACTURA DE JEFFERSON (FRACTURA DEL ARCO ANTERIOR Y POSTERIOR DEL ATLAS) (c)
ESTABILIZADOR ESTATICO: LIG. TRANSVERSO.

27.12 Fracture of C1 ring Jeffersons fracture bursting apart of the lateral masses of C1.

813

is short and lies adducted, internally rotated and slightly exed. H owever, if one of the long bones is e classied according to the diLUXOFRACTURA CERVICAL fractured usually the femur the injur y can easily be head displacement: pos terior (by EXPOSICION: SAGITAL. missed as the limb can adopt almost any position. The DEL CUERPO VERTEBRAL. ariety), anterior and central FRACTURA DEL BORDE SUPERIORx-ray the pelvis in every case of severe (a golden rule is to ESTABILIZADORES ESTATICO: INTERESPINOSO, SUPRAESPINOSO. ced fracture of the acetabulum). injury and, with femoral fractures, to insist on an x-ray that includes both the hip and knee. The lower limb should be examined for signs of sciatic nerve injury CATION (Figure 29.1).

ent, the injury is regarded as a

ury X-ray
I n the anteroposterior lm the femoral head is seen out of its socket and above the acetabulum. A
(c) (d)

ocation, usually occurring in a omeone seated in a truck or car striking the knee against the
(a) LUXACION POSTERIOR DE CADERA(b)

Cervical fracture-dislocation EXPOSICION: ANTEROPOSTERIOR. in the lower cervical spine. (b,c) Stages in th (a) Fracture-dislocation cture-dislocation by skull traction; QUE REGION: COXOFEMORAL. DE (d) subsequent posterior wiring to ensure stability.
QUE HUSOS OBSERVA UD.: ALA ILIACA, CAVIDAD COTILOIDEA, RAMA ISQUIOPUBIANA, AGUJERO OBTURADOR, RAMA HORIZONTAL DEL PUBIS, CABEZA FEMORAL, TROCANTER MAYOR Y ALGO DEL MENOR. TIPO DE LESIN: DESPLAZADA HACIA ARRIBA Y POSTERIOR. ESTABILIZADORESTATICO: LIG. REDONDO. ESTABILIZADOR DINAMICO: PELVITROCANTEREOS.

(b) LUXACION ANTERIOR DE CADERA

(c)

(d)

ion of the hip (a) This is the typical posture in a patient with posterior dislocation: the left hip is 29.3 Anterior hip dislocation (a,b) EXPOSICION: ANTEROPOSTERIOR. ally rotated. (b) The x-ray in this case showed a simple dislocation, with the The usual head lying of an anterior femoral appearance DE QUE REGION: COXOFEMORAL. etabulum. (c) Another patient with dislocation and an associated acetabulardislocation: the hip is only slightly rim fractur e. However, QUE HUESOS OBSERVA UD.: ALA ILIACA, CAVIDAD COTILOIDEA, RAMA ISQUIOPUBIANA, d a CT scan and three-dimensional image reconstruction to appreciate the full extent of the head shows clinically abducted and the AGUJERO OBTURADOR, RAMA HORIZONTAL DEL PUBIS, CABEZA FEMORAL, TROCANTER ury (d). as a prominent lump.
MAYOR Y ALGO DEL MENOR. TIPO DE LESION: DESPLAZADA HACIA ABAJO Y ANTERIOR. ESTABILIZADOR ESTATICO: LIG. REDONDO ESTABILIZADOR DINAMICO:

(b)

(a)

Unreduced dislocation After a few weeks an untreated

dislocation can seldom be reduced by closed manipulation and open reduction is needed. The incidence of stiffness or avascular necrosis is considerably increased and the patient may later need reconstructive surgery.
Osteoarthritis Secondary osteoarthritis is not uncom-

mon and is due to (1) cartilage damage at the time of the dislocation, (2) the presence of retained fragments in the joint or (3) ischaemic necrosis of the femoral head. I n young patients treatment presents a difcult

upwards. Occasionally the leg is abducted almost to a right angle. Seen from the side, the anterior bulge of the dislocated head is unmistakable, especially when the head has moved anteriorly and superiorly. The prominent head is easy to feel, either anteriorly (superior type) or in the groin (inferior type). H ip movements are impossible (Figure 29.3).

X-ray
I n the anteroposterior view the dislocation is usually

will themay for

Treatmentof the joint capsule produces a leak of the Rupture posterior part of the plateau (cruciate ligament

mall s are ding be hed

ntly ment condyle (the Segond fractur e). the (a) (b) (c) Ar teriograpy is not essential if the clinical ully, LUXACION POESTRO LATERAL DE RODILLA assessted. ment of the circulation is normal. The ankle/ brachial EXPOSICION: ANTEROPOSTERIOR (IZQ.), SAGITAL (DER.) rag- arterial pressure index (ratio of systolic pressure at the is a sen- ankle relative to systolic pressure at the elbow)DE QUE REGION: DEL COMPLEJO ARTICULAR DE LA RODILLA. useful measure and should not be less than 0.9, but if HUESOS OBSERVO UD.: EPIFISIS DISTAL DEL FEMUR CON SUS CONDILOS, ROTULA, QUE is EPIFISIS ews, there is any doubt an arteriogram should be obtained ROXIMAL DELA TIBIA CON LOS PLATILLOS TIBIALES Y PARTE DEL PERONE. (Robertson et al., 2006). ESTABILIZADOR ESTATICO: LIG. POSTERO INTERNO. aster it is Treatment ourReduction under anaesthesia is urgent; this is usually ment achieved by pulling directly in the line of the leg, but (d) am- (a) hyperextension must (b) avoided because of the(c) be danger to the popliteal knee (a,b) reduction dislocation; (c,d) anteromedial dislocation. 30.11 Dislocations of the vessels. If Posterolateralis achieved,
LUXACION ANTERO MEDIAL DE RODILLA

tus femoris joint severe bruising gently avulsion), avulsion of the bular styloid or avulsion of may force the femoral he trochanter, haemarthrosis, the prevents and head from displacing Under anaesthesia leading tois aspiratedthe and swelling. This may into full extension. Often the especially the manipulated be the only clue on inspection,fragment if a fragment from the near the edge of the lateral tibial LUXACION CENTRAL DE CADERA dislocated position and the spontaneously. the condyle (the Segond fractur e). falls back intojoint has reduced x-ray shows that Otherwise, Ar fracture is reduced. straightfor the kneethere is gross defor- teriograpy is not essential if the clinical assessthe diagnosis is As long as ward as extends fully, EXPOSICION: ANTEROPOSTERIOR. 29.4 Central disloc small amounts30.11). Theelevation canin the foot mustment of the circulation is normal. The ankle/ brachial mity (Fig. of fragment circulation be accepted. be DEfrag- REGION:pressure index (ratio of systolic pressure at the QUE arterial COXOFEMORAL. (a) The plain x-ray g If there is a block to fullthe popliteal if the bone be torn or examined because extension or artery may QUE HUESOS OBSERVA UD.: ALApressure CAVIDAD COTILOIDEA, RAMA ISQUIOPUBIANA, ankle relative to systolic ILIACA, at the elbow) is a ment remains displaced, operative reduction is essen-as compicture of the displa obstructed. Repeated examination is necessary AGUJERO OBTURADOR, RAMA HORIZONTAL DEL PUBIS, if tial. The fragment often largerathan suspected peroneal measure and should not be less than 0.9, but PUBIS, CABEZA FEMORAL, TROCANTER is useful partment syndrome is also risk. Common (b) a CT scan shows restored to its bed and anchored by small MAYOR Y ALGOis anyMENOR. arteriogram should be obtained screws, there DEL doubt an nerve injury occurs in nearly 20 per cent of cases; distal injury more clearly. (Robertson et al., LIG. REDONDO. taking care to avoid the physis. ESTABILIZADOR ESTATICO:2006). sensation and movement should be tested. After either closed or open reduction, a longESTABILIZADOR DINAMICO: NO HAY, LA LESION ES ESTRUCTURAL. plaster (c) Skeletal traction, cylinder isIapplied with the knee almost straight; it is lms X-ray n addition to the dislocation, the Treatment needs both longitud worn for 6 weeks and then movements are tibial spine or occasionally reveal a fracture of the encourlateral vectors, is an aged. Reduction under anaesthesia is urgent; this is usually posterior part of the plateau (cruciate ligament method of reduction The outcome is usually good and full movement achieved by pulling directly in the line of the leg, but avulsion), avulsion of the bular styloid or avulsion of regained; there may be some residual laxity on exam- hyperextension must be avoided because of the dana fragment from the near the edge ination, but this rarely causes symptoms. of the lateral tibial to the popliteal vessels. If reduction is achieved, ger

EXPOSICION: ANTEROPOSTERIOR (IZQ.), SAGITAL (DER.). DE QUE REGION: DEL COMPLEJO ARTICULAR DE LA RODILLA. QUE HUESOS OBSERVO UD.: EPIFISIS DISTAL DEL FEMUR CON SUS CONDILOS, ROTULA, EPIFISIS ROXIMAL DE LA TIBIA CON LOS PLATILLOS TIBIALES Y PARTE DEL PERONE. ESTABILIZADOR ESTATICO: LIG. ANTERO EXTERNO. ESTABILIZADOR DINAMICO: ISQUIOTIBIALES.

(c)

(d)

dislocation; (c,d) anteromedial dislocation.

ation the symptoms and external rotation of the cylinder whenapplied with the mechanism is signs operatively a padded ankle cast is the though still is caught in a supinated position. Closed reduction when the foot unpleasant. After knee in extension; this can be renewed LUXACION TOTAL DE RODILLA he knee looks normal, but traction (to disimpact the hinged brace is substituted, therefore needs the swelling has subsided. A fracture) and itive. then internal rotationwhich provides control for weightbearing(IZQ.), SAGITAL (DER.). Knee dislocation and EXPOSICION: ANTEROPOSTERIOR and allows of the foot. QUEclosedDEL COMPLEJO ARTICULAR DE30.12 (a,b) This patient wa I f REGION: reduction trauma DE knee movement. Quadriceps exercises are encour-LA RODILLA. with a CON SUS CONDILOS, succeeds, a cast is applied, following the same routine DISTAL DEL FEMUR dislocated knee. After QUE HUESOS OBSERVO UD.: EPIFISIS (c) the x-ray looked satisfacto e aged. ROTULA, EPIFISIS PLATILLOS TIBIALES Y as for undisplaced fractures. Failure of closedROXIMAL DE LA TIBIAEPIFISIS PROXIMAL DEL did not. (d) An art reduction CON SUScirculation PERONE. TUBEROSIDAD ANTERIOR DE LA TIBIA, e showed vascular cut-off just a (sometimes a torn medial ligament is ESTATICO: in ESTABILIZADOR caught had this not been recognized l and tangential (skyline) ESTABILIZADOR DIAMICO: amputation might have been between dislocation, and medial malleolus) or late the talus Complications In an unreduced redisplacement or Recurrent dislocation Patients aterally displaced and tiltedcalls for operative treatment. treated non-operatively Type an associated for also be caused by have a 1520 of cases there is B fractures may a rst-time dislocation abduction; per cent often the lateral aspect of of suffering further dislocations. This depends chance the bula is comminuted (a) (b) (c) (d) and the fracture line more horizontal. Despite accuLUXACIO ROTULIANA e rate reduction (the ankle is adducted and the foot the limb is rested on a back-splint and the circulation Stiffness L oss of movement, due t EXPOSICION: is checked repeatedly during the 48 hours. Because of of the patella SAGITAL (DER.). common problem 30.16 Dislocation often supinated), these injuries are unstable ANTEROPOSTERIOR (IZQ.), (a) DE LA RODILLA. and immobilization, is a DE right patella has dislocatedmore swelling, a plaster cylinder is dangerous. QUE REGION: DEL COMPLEJO ARTICULARtroublesome than instabili even laterally; The QUE HUESOS the poorly controlled in a cast; internal attenedOBSERVO UD.: is typical. DEL FEMUR CON SUS CONDILOS, kn A vascular injur y will need immediatethe xation is there- surgical reconstruction, normal repair and appearance EPIFISIS DISTAL early ROTULA an ante(DESPLAZADA), EPIFISIS ROXIMAL DE LA TIBIA CON SUS PLATILLOS limb is then more conveniently splinted with elusive. fore preferred. (b,c) Anteroposterior and lateral lms of TIBIALES.

rior external xator (Fig. 30.12). I f possible, repair or traumatic dislocation LIG. ALAR MEDIAL Y PATELO MENISCAL. ESTABILIZADOR ESTATICO: reconstruction of the capsule and collateral ligaments of the patella. Displaced undertaken at fractures time this may Weber type C the same The bular fracture is ESTABILIZADOR DIAMICO: should be well above suture or reattachment of the avulsed involve simplethe syndesmosis and frequently there are ACUTE INJURIES OF EXTENS portions to bone in order to enable early movement APPARATUS of the knee with the suppor t of a hinged knee brace. If (b) the direct repair is tenuous, augmentation using (c) 889 FRACTURA DISLOCACION D isruption of the extensor apparatus m tendon grafts may be needed. the quadriceps tendon, at the attach I n general, early reconstructionEXPOSICION:torn ligaof the ANTEROPOSTERIOR. quadriceps tendon to the proximal s ments followed by protected movementREGION: TIBIO PERONEA ASTRAGALINA. of the joint DE QUE patella, through the patella and retin reduces the severity of joint stiffness. The cruciate lig- EPIFISIS DISTAL DE LA TIBIA CON SU APOFISIS ESTILOIDES, QUE HUESOS OBSERVA UD.: sions, at the junction of the patella and t aments can be reconstructed after knee movement has ASTRAGALO. EPIFISIS DISTAL DEL PERONE, ament, in the patellar ligament or at th recovered, usually some 612 months later. Pro- LIG. INTEROSEO. ESTABILIZADOR ESTATICO: the patellar ligament to the tibial tuberc longed cast immobilization (usually 12 weeks) is no patellar ligament is often called the pate longer recommended as it has been shown to be less I n all but direct fractures of the patel good at preserving knee function. nism of injur y is the same: sudden resis of the knee or (essentially the same thing Complicat ions sive exion of the knee while the quad tracting. The patient gives a histor y of s EARL Y stair, catching the foot while running, o Arterial damage Popliteal arter y damage occurs in (c) (d) at a muddy football. nearly 20 per cent of patients and needs immediate The lesion tends to occur at progre repair. D elay and an extended warm ischaemic period acture: in this DanisWeber type B fracture the tibiobular levels with increasing age: adolescents s can result in amputation. e precisely parallel and the width of the joint space is regular fractures of the tibial tubercle; young Nerve is intact but the popliteal nerve laterally with desmosis injury The lateraltalus has movedmay be injured.the people tear the patellar ligament, midd Spontaneous recover y is possible gnifying a deltoid ligament ruptur 20 It if the ner ve is not e. per vital, after reductionfracture theirtissues are weakened by chr is cent of patients those whose patellae; and older peop of completely disrupted about ormal; if beisexpected ligament has prf obably been trapped insteroid medication) suffer acute tears o can it not, the to improve. I ner ve conduction ioning of the talus. (c) Fracturedislocation: in this high bular tendon. studies or clinical examination shows no sign of ceps recovery, a been torn and the talus is displaced and al ligament hastransfer of tibialis posterior tendon throughtilted. the ed before the ankle can be stabilized. (d) Posterior int securinterosseous membrane to the lateral cuneifor m may help restore ankle dorsiexion. RUPTURE OF QUADRICEPS TEND LATE

actur ed, the talus may be displaced upwar ds. The fragment

The patient is usually elderly, may hav

ed for the disruptions that occur at the midfoot efoot junction. Classifying these by direction of efoot dislocation is, however, pointless it is neiFRACTURA DISLOCACION 3 MALEOLO er a guide to treatment nor an indication of outme. These are often high-energy injuries with EXPOSICION: SAGITAL. ensive damage to the whole region QUEthe foot, and DE of REGION: mply to assess the direction of metatarsal displaceent is to miss the complexity of the injur y pattern.

inical f eat ures

M T dislocation or fracturedislocation should ways be suspected in patients with pain and swelling the foot after high-velocity car accidents and falls. nfortunately about 2030 per cent of these injuries e initially missed. Only with severe injur y is there an vious deformity. (d)

for accurate reduction. This can often be achi traction and manipulation under anaesthesia; th tion is then held with percutaneous K-wires or and cast immobilization. The cast is changed few days when swelling has subsided; the new retained, non-weightbearing, for 68 weeks. wires are then removed and rehabilitation e begun. I f closed reduction fails, open reduction is e The key to success is the second TM T joint. T a longitudinal incision, the base of the metatarsal is exposed and the joint manipulat position. Reduction of the remaining parts tarso-metatarsal articulation will not be too d The bones are xed with percutaneous K-w screws and the foot is immobilized as de earlier.

LUXACION TARSO METATARSIANA (COMPROMISO ARTICULACION LISFRANC)

acture the tibiobular EXPOSICION: ANTEROPOSTERIOR. he joint space is regularQUE REGION: METATARSO CUNEIFORME. DE ESTABILIZADOS ESTATICO: LIG. COLATERAL MEDIAL Y COLATERAL LATERAL. moved laterally with the It is vital, after reduction of r obably been trapped in ocation : in this high bular alus is displaced and tilted. stabilized. (d) Posterior upwar ds. The fragment

(a)

(b)

(c)

(d)

29 TM T injuries (a) Dislocation of the TMT joints. (b) X-ray after reduction and stabilization with K-wires. (c) owing a high-energy fracturedislocation involving the TMT joints. These are serious injuries that may be complic compartment syndrome of the foot.