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Joints Dislocations for Orthopaedic Examinations
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Joints Dislocations for Orthopaedic Examinations
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Language: EN.
Segment:0 .
OK, guys, we start now, we start from cervical spine dislocations, OK, so we it's not in the order of how it comes, it's in the order of the human body. So I'm starting from top and going down bottom. Cervical spine dislocations or fascia, joint dislocations are quite common exam scenarios. The controversy in there in that particular situation is when to reduce, how to reduce and to do MI or not to do MRI scan.
So remember these buzzwords. But to begin with, someone will show you an X-ray of lateral cervical spine where they will be asking you to comment on what is wrong and then they will ask you to proceed. So in this particular x-rays, these this is only few places in Farsi assault where you describe x-rays properly for 30 40 seconds, because first of all, there is lot to say there.
You need to comment about these spinal lines, these spinal laminar, anterior posterior spanners, process lines and all the rest. You need to describe the soft tissue shadow. You need to describe the percentage of slipping and you need to show them that you are. You are ready to take on this particular topic. OK, so so basically describe the next phase. Take your time.
Don't forgot. Don't forget to talk about atlas, OK and come straight to the meet. If you think it's more than 50% dislocation, talk about bilateral. If it's 25 percent, it's a unilateral. One thing why unilateral is important. Unilateral is important because it's most frequently mixed cervical spine injury on plane X-rays.
It leads to 25% and it associated with one already bilateral comes with. Generally with significant spinal cord injury or signs of spinal cord injury. Now the treatment algorithm, it shouldn't be an alien to you. Everyone knows about this treatment algorithm. It is pretty much a pretty much available every involves books or almost all books.
This I have taken it up from Miller. But you can get it from all tablets. You can get it from barnosky, which you need to. First of all, as I have said. Talk about atlas, but then make sure patient if the patient is alert. If he's alert, you assess the neurovascular deficit so he not only needs to be alert, he needs to be within his within a good frame of mind.
So if he's drunk or something, then he goes straight into the MRI scanner. Yes, depending on what his GCS is, how much neurology he have, if he is alert, then whether he have neurological deficit or not, if he have neurological deficit, then you try imaging close reduction, obviously within the UK setting. This is one of the Bose guidelines and we touch base at that stage.
We say that we're going to discuss it with the spinal injury unit, the nearest spinal injury unit, but in the same sentence without breaking it. However, the principle of management are or how, as Sean always say, however, the overhead we need as it's a dislocation, we need to reduce it closed emergent. Whether it's successful or not successful. You then subsequently get MRI scan and take it further.
See more radical. Remember the buzzwords more radical. Spinal cord injury and imaging. From here, the controversy starts, they will definitely ask you, why do you want mri? You want MRI, try to open reduction or surgical stabilization. Why? because it will dictate your treatment.
If there is disk herniation, you will do anterior first and then posterior. If there is no discrimination, you can simply do posterior. So if you have an MRI scan, it will. It will tell you what to do. It also demonstrates disk herniation extent of the PLL injury, and you can classify it. And it will sometimes show Milo Malaysia as well, if it's being done up, if the dislocation is chronic, but acute dislocations generally show edema, but no signal changes for signal changes to appear, it takes around 12 hours or more.
Now, if the patient is in a late mental condition with more radical, petty and unilateral dislocations, unilateral dislocations are generally difficult to reduce. Why they are difficult to reduce because. Because the ligaments are already intact, the PLL is intact, bilateral PLL is not intact and PLL is torn and it's easy to reduce, but it is difficult to then stabilize it.
So you, you have to have you have to have this answer in your armory. You have to say you have to say if it is unilateral and if there is no neurological deficit, I will do it in a controlled environment in theaters. And will do it with sequential adding of weight and and subsequently keep on checking the neurology of the patient technique, as I say, is there a gradual increase axilo traction addition of which component of cervical flexion can facilitate reduction?
So you put some sort of rolled towel underneath the neck and then you gradually? Provides traction and severe neurological examination. Radiograph keep on taking on the lateral X-rays and abort if neurological exam words or obtain MRI scan following. Praise, I think we've come before is I understand the key principles are this. Obviously, I've discussed this with someone who has experience in doing it.
But these are the key principles that I believe that. And again, you've got to remember that person testing you has probably less knowledge about this than you are. It's not going to be a spinal surgeon asking you this question. But they will, as answer says, they'll probably have a script in terms of key words of what they want you to say.
But yeah, I to say what you've said it, it does scare me like it does for us. And Understanding the principles, I think, is key and everything you said. I can't, you know, a lot more about it than I do. And worth. They may say it's not working with this. So any maneuver, you know, and if you're bluffing because I don't think my person, if you're going to say I haven't done this before, say I would not attempt any maneuver, I would discuss again with my spinel colleagues.
But my understanding is this and this? Yeah, no, that's what we said. There is a Bose guideline for spinal cord injury, guys. So you always say I will ring the National spinal injury unit or the nearest spinal injury unit. I will take that advice. And there is a strong likelihood that they're going to get the patient across to them blue light within the next 30 minutes.
However, the principle of treatment don't stop for them to say can imagine your spinal surgeon won't stop for them to bring up this because that's making examiner talk unnecessary. And in this exam, if the examiners talk less you, you talk more. It means you're going through anyway. As we go back to the presentation, there is quite a lot to cover.
So we are on this slide guy. So over there, we discuss the closed reduction. If you go to further management part, you're lucky. You then take a deep breath because now if they're describing, if you're describing approach, describing in length and properly because you're gaining marks, OK, if they ask you the anterior approach because of the intervertebral disc, you need to take the disk out so that you don't damage the cord as you reduce it positively.
You tell about the anterior approach. Don't just start rattling the approach out till the steps. WHO checklist patient positioning image intensifier your position, images on the images in front of you and all the rest of it. You know that and have a post-op protocol in your head. So have a post-op protocol as to what sort of rehab protocol you will use following this sort of extensive surgery.
Generally? generally. Spinal surgeon says soft color for six weeks because in soft color only for comfort it's not. It has nothing to do with stabilization. It just so that the other people are aware of that. The patient has got an extensive neck surgery and it also stops neck being sore and all the rest of it. So and then you throw a few referrals, if a few references, if you are lucky and if you're reaching there.
Vaccaro is a big name and Ricardo is another big name, and he always, he always classify, quantify these injuries. So if you can remember one name in spine, remember Mercado Mercado change the concept of spinal injury management. It has updated everything, and Vaccaro is the main man these days. OK, I'm going to end the spine bit here.
The other. Dislocation what you get. Is is shoulder dislocations, shoulder dislocations as you come down from neck, shoulder dislocations are not uncommon over here again. You need to describe the x-rays as it says. We have Saab, Saab has a question while thought is working on this.
What's your question, sir? So why can't we? Yeah Hello. Why can't we do MRI in every joint dislocation? You can. You can. Why can't we say that actually, this is a first joint dislocation, whether it's a 25% is a unique capital or it's a bypass, which is more than 50% I would do an MRI scan as my first port of call and to this will have a very huge bearing on my management planning to do an MRI scan once I got I can.
I'm sure that this can be arranged, but the patient is alert oriented or not. It would give me a sense of security to reduce this more comfortably, and if there's any changes happen, I would be to the MRI and after that, we do not say that. Yeah, I think it's a valid question. It's a valid question. See, there is no right or wrong answer to it, and it was the reason why there is a discussion about MRI scan or whether you should do it or knot is because the MRI scans are not available in every trust.
So you're not in every hospital, not in the emergency settings like this, necessarily. So they really try to say, do you need an MRI scan? And you will say my absolute indications for MRI scan of our patients with altered consciousness or neurology. OK that's your axilo if you can justify why you're going to do an MRI scan. That's fine.
But they will try to push you to see when you're going with, they tell you there's no MRI scan available. Your response is no. In these situations, I will always get an MRI scan no matter what. No but I in the see in the controversy part, I wrote how you can defend MRI scan. So, so you you perform MRI scan prior to open reduction or any surgical stabilization it valuable in demonstrating this herniation extent of possible ligament injury.
So it quantifying the injury as well. It it is telling you whether the spinal cord has been compressed or there is established. Milo Malaysia never performed closed reduction in patients with mental status changes and when 26% of patients who fail towards reduction, you then go and get MRI scan so you can get MRI. MRI scan is an essential. No, I'm sorry.
I'm not disagreeing. What I'm saying is the examiner would try and push you to say in a situation where you don't need an MRI scan, which situations would you? So the second dislocation that comes, I hope it works now. The second dislocation that comes is a shoulder dislocation. Again, in shoulder dislocation, please take your time 2021, 30 seconds to describe the shoulder that will give you formulate a time to formulate an answer as well.
When you're looking at the shoulder shoulder x-rays, and these are the key things you need to know, as it says on the normal shoulder behavior. Whenever someone shows you the shoulder x-rays think dislocation, things, subluxation and things like so like and and you all know what I meant by dislocation, subluxation and electricity. Now, the most common shoulder dislocation that comes in the exam and generally, they ask, is traumatic anterior shoulder instability over here you need to talk about.
Are you you know what it is, this is and most of the time it is a sometimes it is posterior and inferior is extremely common. Again, age of the patient makes a huge difference in diagnosing and age of the patient also make a huge difference in terms of what other pathology you will find. So if it's more than 40, you can have rotator cuff tear, but if it's more than 60 reductase are extremely common.
Generally, the shoulder dislocation when it comes and it's acute and traumatic, it's a young individual. It's a young individual whose age is less than 20. And because that's a highest risk of rare dislocation age, where you can have either a bony Bankart lesion or a hill slap lesion or just a soft tissue Bankart lesion, which you have to then take the Bible down to how to repair and what will be the surgical techniques.
Basically, when you see a shoulder, remember to talk about all the anatomical landmarks. Remember to talk about the trauma series x-ray, so you need three views for shoulder. Remember to talk about the age of the patient because that has a very. A strong association with what associated injury patient could have. And remember about all the other associations that can have a bed with a dislocation, so bony Bangkok, a hill sac defect, a greater tuberosity fracture, greater tuberosity fracture can occur in elderly people, and its significant is that the rotator cuff is gone.
The lesser tuberosity fracture? Remember posterior dislocation if you see lesser tuberosity fracture its posterior dislocation unless proven otherwise in a shoulder. So nerve injury 5% which everyone knows which nerve. It's axilo ulnar nerve please test the axillary nerve as of everything. You need to. You need to start again with Atlas.
Hi energy, low energy described the X-rays. Remember, the age factor described the ask for three views and and this again, any dislocation acute reduction plus minus in mobilization within the A&E setting. Someone has to give patient adequate sedation and someone has to maintain the OA. These days, the area and sedation part get done by any colleague, senior consultant or all the same level as a few.
And then you relocate them, followed by some sort of physiotherapy, but a management of first time dislocations again. They ask these dislocations because there is controversy about it. Controversy is how would you treat it? So if it's a first dislocation, some people still like to treat it non operatively. But generally, as a general rule of thumb, if you ask a shoulder surgeon and for the exam purposes particularly, I will keep my indications for surgical management.
If it's a dislocation happens in a patient who's aged less than 20, it's a male who plays contact sports, have some degree of hyper electricity and had glenoid bone loss of more than a 20 to 25. Then you need to have a further bony augmentation or a bony block to that if you reach following this, if you reach the surgical management part, then you are on safe grounds.
Shoulder is not my best topic, but the say then if you are discussing this, you are actually passing the exam. OK, so I have deliberately didn't describe the surgical management of shoulder dislocations because, you know, if you're reaching up until they're then, then you are on the safe grounds and surgical stabilization will subsequently been described or as by Kashif at a later stage as a hot seat wiwa.
And he will then he will then be asking people as to. A how to augment what is traject procedure, what are capsular shift? What what are the benefits of doing it. So quickly? Can you do it also so quickly or you're doing it open or not? So I'm going to finish the shoulder dislocation here and go move on to the hip dislocation. But is anyone has to add anything from the mentors?
Sorry regarding this shoulder dislocation, so you need to bring the best and best guidelines, which are the dislocations are divided according to age, but less than 20 five, 25 to 40 and more than 40 because treatment is completely different for these three groups. But they are divided less than 25 35 to 40 and then more than 40. Less than 35.
As you mentioned, they are young adults. These patients need to be seen by shoulder surgeon within six weeks, and ideally they should do the Mr. program to see whether they need surgical management and between 25 to 40 and then more than 40 more. More than 40 likely they may have enough care. And again, these may be a surgical candidates 25 to 40 years in between group B will immobilize and then reassess.
OK, I think that's a very, very nice shot. So you need to bring the best guidelines in the shoulder dislocation. So that when you are quoting the literature, you are getting the marks. And there is a very, very good algorithm by the base and dislocation. What you have in the exam is the hip dislocation. Always remember on hip dislocation, you should not waste any time on the X-rays.
It's a hip dislocation. You talk about hip dislocation. The minute you talk about hip dislocation, you need to move fast as there is lot to discuss and hip dislocation. It can be an Atlas topic only. Yes, so you're talking about Atlas. It's generally fall from a motorbike or motor vehicle accident, which is a dashboard injury.
So when you are going through the Atlas principal resuscitation position of the limb, you have documented about the sciatic nerve provided patient analgesia. You then start talking about the initial manage the radiographs before going on to radiograph. You can actually comment on what the position of the limits and that can tell you whether it's anterior or posterior 90% of time.
If it's coming, the exam is posterior dislocation dislocation like any dislocation. In this dislocation on the X rays, you need to comment on three things. Any loose fragment. Any concomitant head microfracture or ipsilateral fracture and dislocation. Generally, its posterior. But when you call it.
A4, the venue, when you see the X-rays and you and you need to say that clinically, I will see the patient to make sure to comment more, whether it's in tier or posterior. However, the mechanism of injury, the dashboard or motor vehicle accident is consistent with posterior dislocation. You move forward. There is generally posterior.
As I said, it's 90% why they bring posterior in because it comes with positive all of acetabulum fracture, the femoral head fractures that can be sciatic nerve injuries associated with it up 20% 20% So documentation of sciatic nerve is very important. Pre and post dislocation a pre and post for post operative documentation and pre post relocation documentation and relocation documentation come into an ABC lateral knee injuries that comes up to 25% And examine the knee.
For any associated injury or instability. But that doesn't take precedence. That doesn't take priority. The priority is to relocate the dislocation. Up as far as what x-rays do you want within the sitting, you just have an ape hip that should do and then most dislocation, you reduce it. Most dislocation, you reduce it with manual inline traction while you are talking about reduction.
Please mention that I am aware of the fact that there is a chance that I may bring the loose fragment or the order, the posterior lip fracture within the. Acetabulum, and if that's the case, then it becomes an emergency and you are required to open it. So be wary of it and say it, but I think there is no clear answer here as well. Some people say I will talk to the stability injury unit and and transfer the patient across.
However, the principle of management is whoever is reducing the patient. Whoever is reducing the hip is reducing in a controlled environment. Indicators have all. Of course, all options open in case if it doesn't reduce you, you reduce it open, and if there is an incarcerated fragment within the joint, you take it out or if it's a big enough chunk, you are ready to do the open reduction internal fixation posterior.
So, so you need to touch base with all these. You need to say all these things as you are discussing hip dislocation. When you when you talk about hip dislocation, you talk about femoral head fracture, as you talk about femoral head fracture, you say about you say come in something about Pipkin classification reason being that has to do with the vascular supply of the femoral head and the higher go into the classification, the more it is risk with avian incidence.
I think type 1 and 2 are associated with femoral neck fracture. And if there is a female neck fracture, then the incidence of avian is higher as we move down. So, so again, why? Why they want to know about the femoral head microfracture or contralateral or ipsilateral femur fracture because of the complications of vascular necrosis, because of the development of osteoarthritis secondary to incarcerated or small fragments within the articular joint.
And sometimes, if it's a big enough chunk of the indentation you can, you can actually needs to repair it as well, like you repair it elsewhere in the knee or anywhere else. So, so these are important topics in terms of nutshell, if you see a hip X-ray or a hip dislocation X-ray doctors talk about the mechanism of injury dashboard and you used to talk about me, talk about the posterior leg injury.
Talk about one attempted reduction within any setting that. What I will say and talk about transferring the patient across to a stable unit for further management in terms of possible open internal fixation. Fixation of that, depending on the stability and talk about imaging post reduction, it is very important to have a CT scan post reduction in that. So if you're saying all these things, you are on safe grounds.
Everything else, you're just aware of it. You're aware of the Pipkin classification. You are aware of the femoral head blood supply, which is so important. You need to know and and you are aware of approaches. So, so again, in a nutshell, once you have the typekit classification, you have the blood supply. You have gold about the extra capsule, ascending cervical branches and ligament tees and all the rest.
You have told about the blood supply. You have talked about the fragment and you have done a single image, single attempted reduction in any under deep sedation. You then you are on the safe ground, you assess postproduction, you transfer images to the hip unit or a regular unit, and then they will ask you to talk about approaches. If you are talking about approaches again, you are lucky and and you are on the safe ground.
So that's for the open the so you need to plan. So where is the fracture, where there is a wall fracture, Austria column fracture? Then you will go for the posterior approach to the anterior wall or anterior skull fracture. You will go for anterior approach it be type of complex type of fracture, then you can use a dual approach. It depends.
What are you going to achieve, which side you are fixing? I think that's the answer, yeah, depends how you assess where, yeah, dislocation and the fracture. But generally, generally it's the posterior liberal. Yeah, so if it is still a fracture are opposed to a skull fracture, you go with posterior approach, posterior approach. Yeah, that's what our bullet says as well. Yeah, I think that's a very reasonable yeah, because I worked in St. George's with the Martin burger and then I worked in Birmingham as well, which is a major trauma center.
And we have hip and pelvic surgeons to surgeons. So I work both of them. So that is general approach. Yeah, so, so so basically, the approach what you are using is, is the policy approach. Anyone else have to say anything or we move on to me. They keep asking the question about is it required my attitude to this and I think everyone. I'm sure everyone agrees with.
If you've reduced the hip, you need something to establish if there's a fragment in the joint or not. There is no other way of knowing if you've left a fragment in the jaw going to be mentioned that. So there is no discussion about CT scan, it must be done. Yes OK, so coming down to the last common dislocation is the knee dislocation, which so these are the four general dislocations that we asked if the knee dislocation comes, you know what they're going to ask.
It's about the it's about the vascular. It's about the reduction and it's about the posterior approach to the knee. And it's about whether you put the X Fick's first before the repair or you, you just put the pins. So there is no right or wrong answers, but you need to be aware of all that knee dislocations again for a short tutorial five minutes. Knee dislocations generally can be of two type high energy.
If they are high energy, they are motor vehicle accident, commonly dashboard injury, low energy athletic injury or in a morbidly obese patient. I have seen in a morbidly obese patient with very low rotational component and the knee dislocate. If the need is look, it's generally it means. A three to four ligaments are disrupted, vascular injury in all dislocations are 5% to 15% And in 40% to 50% in posterior dislocations, nerve injury is around 25% And fractures are around 60% concomitant.
It can be either femoral canal or tibial tibial canal fracture. OK, so the classification system, you don't need to know the very comprehensive Shannon classification system, although it's very, very, very, very simple. However, you just need to know shandwick four means all four ligaments are gone. 3 is either a medial collateral or lateral collateral.
So three ligaments ACL, PCL, either of the medial or lateral collateral is gone. And if it's three medial, it is related with vascular injury. If it's posterior, which are 25% of a normal class of normal dislocations. It is associated with arterial injury. If it's anterior, which is the most common, 50% arterial injury are not as common. Why does the arterial injury happens?
Because that's everyone asks this question, and they ask me, is it not because it has something to do with the artery? It's because of tethering of the artery in the popliteal fossa, approximately the fibrous channel in the adductor heights, titrate and distally, the fibrous channel in the soldier's muscle. So if you know this answer this question was been asked directly to me and you can then move forward.
The classic controversy here is the measurement of the ankle brachial pressure index. Even the Miller has given this chart and it says about if. If the ankle brachial beclin pressure index is more than zero point nine, you can do serial neurovascular check and do not do any vascular examination or any arterial gum or things like that, or duplex scan. However, some people like to say duplex scan.
They are not wrong. Whoever, say whatever. Just have a system to defend yourself. I will always say because of its high association to vascular injury, I will have a very low threshold of having a vascular scan in form of a duplex ultrasound scan. It is no it's relatively safe investigation. And why? Why don't we have it all?
The risk is, is if you move forward from this point, you are coming to the treatment part. And if you come to the treatment, then you are on the safe ground for its treatment. Initial management, all dislocation. It is not. This dislocation is no different than any other dislocation. What we have discussed in lesion management involves immediate reduction and repetition of the documented neuromuscular examination.
Definitive treatment is always operative. Surgical indications include emergency surgical indication includes popliteal artery injury. It is related with compartment syndrome. Open dislocation irreducible dislocation. Irreducible dislocation. I have shown you the picture when you see a when you see a pattern of the skin on the side, I don't know where it is going now.
Yes, over here when you see a puckering of the side and it means that it has buttonholed through the knee. It has gotten hold to the knee capsule and it's very unlikely that it's going to reduce itself or it's going to reduce close. So then you have to start thinking about open reduction and and however, the absolute indication of a surgical reduction is when you have a vascular injury, when you have a vascular injury.
This is another classic answer. What would you do? You call for the vascular surgeon. You discuss the posterior approach while the vascular surgeon on the way. And I will say I will put the pins before, put the patient semi lateral and put the pins before and don't bite the external fixator. As the vascular surgeon put the Shenton and repair the artery, I will tighten the external fixator and then reposition the patient to the front.
After that, there is a controversy whether you will do a port for electric physio Tommy's or not, and some people actually like doing prophylactic physio Tommy irrespective of whatever the compartment pressure is. However trauma surgeons just go by their gut feeling if they see the leg is very sore, they do. A leg is very swollen. They do the prophylactic to me and some don't do it and wait for.
But but I wouldn't go to the physio to me, but I will say I will assess it and on case by case basis. However, in most cases, which I have seen with arterial injury, they do prophylactic physio and they do, but they do put the x-rays beforehand. They don't fight it because the initial arterial graft or arterial bypass or whatever the vascular surgeon put, it's very it's very unable to do any pressure and/or any movement.
And if you move it, they start leaking again because they use fine suture to suture it. The other thing to say here is remember, remember the posterior approach, because that is another classic exam question where they say the post, where they say, OK, the vascular surgeon is on its way. Can you please describe the posterior approach? Remember the posterior approach? I didn't put it on to keep, you know, to discuss it.
So when it comes to need a knee dislocation, remember three things motor whether it's high energy or low energy. Remember whether there is any skin changes suggestive of button holing through the capsule? Remember whether there is any arterial injury or not? Talk about enter brachial pressure index and weepies or abbeys. Talk about 0.9. Remember point nine?
But I will get a vascular open muscular study done. However, people very strongly sometimes say against it. As the new Miller says there is no need if the ABI is more than nine, but it's up to you whatever you want to see, then move on to the controversy of putting the X Fick's first and urgent reduction as normal. And if you are reaching the approach level and X fixed level, you are passing so.
And even so, it's a shame to effect because you need to preserve or you need to. Maintain the vascular supply distally, so you do the shunt first pins and the next fix. Unless you are avascular surgeon, a. Good so because if you have a viable question, you. Yeah is it ready? Yeah Yeah. So our next candidate.
Segment:0 .
OK, guys, we start now, we start from cervical spine dislocations, OK, so we it's not in the order of how it comes, it's in the order of the human body. So I'm starting from top and going down bottom. Cervical spine dislocations or fascia, joint dislocations are quite common exam scenarios. The controversy in there in that particular situation is when to reduce, how to reduce and to do MI or not to do MRI scan.
So remember these buzzwords. But to begin with, someone will show you an X-ray of lateral cervical spine where they will be asking you to comment on what is wrong and then they will ask you to proceed. So in this particular x-rays, these this is only few places in Farsi assault where you describe x-rays properly for 30 40 seconds, because first of all, there is lot to say there.
You need to comment about these spinal lines, these spinal laminar, anterior posterior spanners, process lines and all the rest. You need to describe the soft tissue shadow. You need to describe the percentage of slipping and you need to show them that you are. You are ready to take on this particular topic. OK, so so basically describe the next phase. Take your time.
Don't forgot. Don't forget to talk about atlas, OK and come straight to the meet. If you think it's more than 50% dislocation, talk about bilateral. If it's 25 percent, it's a unilateral. One thing why unilateral is important. Unilateral is important because it's most frequently mixed cervical spine injury on plane X-rays.
It leads to 25% and it associated with one already bilateral comes with. Generally with significant spinal cord injury or signs of spinal cord injury. Now the treatment algorithm, it shouldn't be an alien to you. Everyone knows about this treatment algorithm. It is pretty much a pretty much available every involves books or almost all books.
This I have taken it up from Miller. But you can get it from all tablets. You can get it from barnosky, which you need to. First of all, as I have said. Talk about atlas, but then make sure patient if the patient is alert. If he's alert, you assess the neurovascular deficit so he not only needs to be alert, he needs to be within his within a good frame of mind.
So if he's drunk or something, then he goes straight into the MRI scanner. Yes, depending on what his GCS is, how much neurology he have, if he is alert, then whether he have neurological deficit or not, if he have neurological deficit, then you try imaging close reduction, obviously within the UK setting. This is one of the Bose guidelines and we touch base at that stage.
We say that we're going to discuss it with the spinal injury unit, the nearest spinal injury unit, but in the same sentence without breaking it. However, the principle of management are or how, as Sean always say, however, the overhead we need as it's a dislocation, we need to reduce it closed emergent. Whether it's successful or not successful. You then subsequently get MRI scan and take it further.
See more radical. Remember the buzzwords more radical. Spinal cord injury and imaging. From here, the controversy starts, they will definitely ask you, why do you want mri? You want MRI, try to open reduction or surgical stabilization. Why? because it will dictate your treatment.
If there is disk herniation, you will do anterior first and then posterior. If there is no discrimination, you can simply do posterior. So if you have an MRI scan, it will. It will tell you what to do. It also demonstrates disk herniation extent of the PLL injury, and you can classify it. And it will sometimes show Milo Malaysia as well, if it's being done up, if the dislocation is chronic, but acute dislocations generally show edema, but no signal changes for signal changes to appear, it takes around 12 hours or more.
Now, if the patient is in a late mental condition with more radical, petty and unilateral dislocations, unilateral dislocations are generally difficult to reduce. Why they are difficult to reduce because. Because the ligaments are already intact, the PLL is intact, bilateral PLL is not intact and PLL is torn and it's easy to reduce, but it is difficult to then stabilize it.
So you, you have to have you have to have this answer in your armory. You have to say you have to say if it is unilateral and if there is no neurological deficit, I will do it in a controlled environment in theaters. And will do it with sequential adding of weight and and subsequently keep on checking the neurology of the patient technique, as I say, is there a gradual increase axilo traction addition of which component of cervical flexion can facilitate reduction?
So you put some sort of rolled towel underneath the neck and then you gradually? Provides traction and severe neurological examination. Radiograph keep on taking on the lateral X-rays and abort if neurological exam words or obtain MRI scan following. Praise, I think we've come before is I understand the key principles are this. Obviously, I've discussed this with someone who has experience in doing it.
But these are the key principles that I believe that. And again, you've got to remember that person testing you has probably less knowledge about this than you are. It's not going to be a spinal surgeon asking you this question. But they will, as answer says, they'll probably have a script in terms of key words of what they want you to say.
But yeah, I to say what you've said it, it does scare me like it does for us. And Understanding the principles, I think, is key and everything you said. I can't, you know, a lot more about it than I do. And worth. They may say it's not working with this. So any maneuver, you know, and if you're bluffing because I don't think my person, if you're going to say I haven't done this before, say I would not attempt any maneuver, I would discuss again with my spinel colleagues.
But my understanding is this and this? Yeah, no, that's what we said. There is a Bose guideline for spinal cord injury, guys. So you always say I will ring the National spinal injury unit or the nearest spinal injury unit. I will take that advice. And there is a strong likelihood that they're going to get the patient across to them blue light within the next 30 minutes.
However, the principle of treatment don't stop for them to say can imagine your spinal surgeon won't stop for them to bring up this because that's making examiner talk unnecessary. And in this exam, if the examiners talk less you, you talk more. It means you're going through anyway. As we go back to the presentation, there is quite a lot to cover.
So we are on this slide guy. So over there, we discuss the closed reduction. If you go to further management part, you're lucky. You then take a deep breath because now if they're describing, if you're describing approach, describing in length and properly because you're gaining marks, OK, if they ask you the anterior approach because of the intervertebral disc, you need to take the disk out so that you don't damage the cord as you reduce it positively.
You tell about the anterior approach. Don't just start rattling the approach out till the steps. WHO checklist patient positioning image intensifier your position, images on the images in front of you and all the rest of it. You know that and have a post-op protocol in your head. So have a post-op protocol as to what sort of rehab protocol you will use following this sort of extensive surgery.
Generally? generally. Spinal surgeon says soft color for six weeks because in soft color only for comfort it's not. It has nothing to do with stabilization. It just so that the other people are aware of that. The patient has got an extensive neck surgery and it also stops neck being sore and all the rest of it. So and then you throw a few referrals, if a few references, if you are lucky and if you're reaching there.
Vaccaro is a big name and Ricardo is another big name, and he always, he always classify, quantify these injuries. So if you can remember one name in spine, remember Mercado Mercado change the concept of spinal injury management. It has updated everything, and Vaccaro is the main man these days. OK, I'm going to end the spine bit here.
The other. Dislocation what you get. Is is shoulder dislocations, shoulder dislocations as you come down from neck, shoulder dislocations are not uncommon over here again. You need to describe the x-rays as it says. We have Saab, Saab has a question while thought is working on this.
What's your question, sir? So why can't we? Yeah Hello. Why can't we do MRI in every joint dislocation? You can. You can. Why can't we say that actually, this is a first joint dislocation, whether it's a 25% is a unique capital or it's a bypass, which is more than 50% I would do an MRI scan as my first port of call and to this will have a very huge bearing on my management planning to do an MRI scan once I got I can.
I'm sure that this can be arranged, but the patient is alert oriented or not. It would give me a sense of security to reduce this more comfortably, and if there's any changes happen, I would be to the MRI and after that, we do not say that. Yeah, I think it's a valid question. It's a valid question. See, there is no right or wrong answer to it, and it was the reason why there is a discussion about MRI scan or whether you should do it or knot is because the MRI scans are not available in every trust.
So you're not in every hospital, not in the emergency settings like this, necessarily. So they really try to say, do you need an MRI scan? And you will say my absolute indications for MRI scan of our patients with altered consciousness or neurology. OK that's your axilo if you can justify why you're going to do an MRI scan. That's fine.
But they will try to push you to see when you're going with, they tell you there's no MRI scan available. Your response is no. In these situations, I will always get an MRI scan no matter what. No but I in the see in the controversy part, I wrote how you can defend MRI scan. So, so you you perform MRI scan prior to open reduction or any surgical stabilization it valuable in demonstrating this herniation extent of possible ligament injury.
So it quantifying the injury as well. It it is telling you whether the spinal cord has been compressed or there is established. Milo Malaysia never performed closed reduction in patients with mental status changes and when 26% of patients who fail towards reduction, you then go and get MRI scan so you can get MRI. MRI scan is an essential. No, I'm sorry.
I'm not disagreeing. What I'm saying is the examiner would try and push you to say in a situation where you don't need an MRI scan, which situations would you? So the second dislocation that comes, I hope it works now. The second dislocation that comes is a shoulder dislocation. Again, in shoulder dislocation, please take your time 2021, 30 seconds to describe the shoulder that will give you formulate a time to formulate an answer as well.
When you're looking at the shoulder shoulder x-rays, and these are the key things you need to know, as it says on the normal shoulder behavior. Whenever someone shows you the shoulder x-rays think dislocation, things, subluxation and things like so like and and you all know what I meant by dislocation, subluxation and electricity. Now, the most common shoulder dislocation that comes in the exam and generally, they ask, is traumatic anterior shoulder instability over here you need to talk about.
Are you you know what it is, this is and most of the time it is a sometimes it is posterior and inferior is extremely common. Again, age of the patient makes a huge difference in diagnosing and age of the patient also make a huge difference in terms of what other pathology you will find. So if it's more than 40, you can have rotator cuff tear, but if it's more than 60 reductase are extremely common.
Generally, the shoulder dislocation when it comes and it's acute and traumatic, it's a young individual. It's a young individual whose age is less than 20. And because that's a highest risk of rare dislocation age, where you can have either a bony Bankart lesion or a hill slap lesion or just a soft tissue Bankart lesion, which you have to then take the Bible down to how to repair and what will be the surgical techniques.
Basically, when you see a shoulder, remember to talk about all the anatomical landmarks. Remember to talk about the trauma series x-ray, so you need three views for shoulder. Remember to talk about the age of the patient because that has a very. A strong association with what associated injury patient could have. And remember about all the other associations that can have a bed with a dislocation, so bony Bangkok, a hill sac defect, a greater tuberosity fracture, greater tuberosity fracture can occur in elderly people, and its significant is that the rotator cuff is gone.
The lesser tuberosity fracture? Remember posterior dislocation if you see lesser tuberosity fracture its posterior dislocation unless proven otherwise in a shoulder. So nerve injury 5% which everyone knows which nerve. It's axilo ulnar nerve please test the axillary nerve as of everything. You need to. You need to start again with Atlas.
Hi energy, low energy described the X-rays. Remember, the age factor described the ask for three views and and this again, any dislocation acute reduction plus minus in mobilization within the A&E setting. Someone has to give patient adequate sedation and someone has to maintain the OA. These days, the area and sedation part get done by any colleague, senior consultant or all the same level as a few.
And then you relocate them, followed by some sort of physiotherapy, but a management of first time dislocations again. They ask these dislocations because there is controversy about it. Controversy is how would you treat it? So if it's a first dislocation, some people still like to treat it non operatively. But generally, as a general rule of thumb, if you ask a shoulder surgeon and for the exam purposes particularly, I will keep my indications for surgical management.
If it's a dislocation happens in a patient who's aged less than 20, it's a male who plays contact sports, have some degree of hyper electricity and had glenoid bone loss of more than a 20 to 25. Then you need to have a further bony augmentation or a bony block to that if you reach following this, if you reach the surgical management part, then you are on safe grounds.
Shoulder is not my best topic, but the say then if you are discussing this, you are actually passing the exam. OK, so I have deliberately didn't describe the surgical management of shoulder dislocations because, you know, if you're reaching up until they're then, then you are on the safe grounds and surgical stabilization will subsequently been described or as by Kashif at a later stage as a hot seat wiwa.
And he will then he will then be asking people as to. A how to augment what is traject procedure, what are capsular shift? What what are the benefits of doing it. So quickly? Can you do it also so quickly or you're doing it open or not? So I'm going to finish the shoulder dislocation here and go move on to the hip dislocation. But is anyone has to add anything from the mentors?
Sorry regarding this shoulder dislocation, so you need to bring the best and best guidelines, which are the dislocations are divided according to age, but less than 20 five, 25 to 40 and more than 40 because treatment is completely different for these three groups. But they are divided less than 25 35 to 40 and then more than 40. Less than 35.
As you mentioned, they are young adults. These patients need to be seen by shoulder surgeon within six weeks, and ideally they should do the Mr. program to see whether they need surgical management and between 25 to 40 and then more than 40 more. More than 40 likely they may have enough care. And again, these may be a surgical candidates 25 to 40 years in between group B will immobilize and then reassess.
OK, I think that's a very, very nice shot. So you need to bring the best guidelines in the shoulder dislocation. So that when you are quoting the literature, you are getting the marks. And there is a very, very good algorithm by the base and dislocation. What you have in the exam is the hip dislocation. Always remember on hip dislocation, you should not waste any time on the X-rays.
It's a hip dislocation. You talk about hip dislocation. The minute you talk about hip dislocation, you need to move fast as there is lot to discuss and hip dislocation. It can be an Atlas topic only. Yes, so you're talking about Atlas. It's generally fall from a motorbike or motor vehicle accident, which is a dashboard injury.
So when you are going through the Atlas principal resuscitation position of the limb, you have documented about the sciatic nerve provided patient analgesia. You then start talking about the initial manage the radiographs before going on to radiograph. You can actually comment on what the position of the limits and that can tell you whether it's anterior or posterior 90% of time.
If it's coming, the exam is posterior dislocation dislocation like any dislocation. In this dislocation on the X rays, you need to comment on three things. Any loose fragment. Any concomitant head microfracture or ipsilateral fracture and dislocation. Generally, its posterior. But when you call it.
A4, the venue, when you see the X-rays and you and you need to say that clinically, I will see the patient to make sure to comment more, whether it's in tier or posterior. However, the mechanism of injury, the dashboard or motor vehicle accident is consistent with posterior dislocation. You move forward. There is generally posterior.
As I said, it's 90% why they bring posterior in because it comes with positive all of acetabulum fracture, the femoral head fractures that can be sciatic nerve injuries associated with it up 20% 20% So documentation of sciatic nerve is very important. Pre and post dislocation a pre and post for post operative documentation and pre post relocation documentation and relocation documentation come into an ABC lateral knee injuries that comes up to 25% And examine the knee.
For any associated injury or instability. But that doesn't take precedence. That doesn't take priority. The priority is to relocate the dislocation. Up as far as what x-rays do you want within the sitting, you just have an ape hip that should do and then most dislocation, you reduce it. Most dislocation, you reduce it with manual inline traction while you are talking about reduction.
Please mention that I am aware of the fact that there is a chance that I may bring the loose fragment or the order, the posterior lip fracture within the. Acetabulum, and if that's the case, then it becomes an emergency and you are required to open it. So be wary of it and say it, but I think there is no clear answer here as well. Some people say I will talk to the stability injury unit and and transfer the patient across.
However, the principle of management is whoever is reducing the patient. Whoever is reducing the hip is reducing in a controlled environment. Indicators have all. Of course, all options open in case if it doesn't reduce you, you reduce it open, and if there is an incarcerated fragment within the joint, you take it out or if it's a big enough chunk, you are ready to do the open reduction internal fixation posterior.
So, so you need to touch base with all these. You need to say all these things as you are discussing hip dislocation. When you when you talk about hip dislocation, you talk about femoral head fracture, as you talk about femoral head fracture, you say about you say come in something about Pipkin classification reason being that has to do with the vascular supply of the femoral head and the higher go into the classification, the more it is risk with avian incidence.
I think type 1 and 2 are associated with femoral neck fracture. And if there is a female neck fracture, then the incidence of avian is higher as we move down. So, so again, why? Why they want to know about the femoral head microfracture or contralateral or ipsilateral femur fracture because of the complications of vascular necrosis, because of the development of osteoarthritis secondary to incarcerated or small fragments within the articular joint.
And sometimes, if it's a big enough chunk of the indentation you can, you can actually needs to repair it as well, like you repair it elsewhere in the knee or anywhere else. So, so these are important topics in terms of nutshell, if you see a hip X-ray or a hip dislocation X-ray doctors talk about the mechanism of injury dashboard and you used to talk about me, talk about the posterior leg injury.
Talk about one attempted reduction within any setting that. What I will say and talk about transferring the patient across to a stable unit for further management in terms of possible open internal fixation. Fixation of that, depending on the stability and talk about imaging post reduction, it is very important to have a CT scan post reduction in that. So if you're saying all these things, you are on safe grounds.
Everything else, you're just aware of it. You're aware of the Pipkin classification. You are aware of the femoral head blood supply, which is so important. You need to know and and you are aware of approaches. So, so again, in a nutshell, once you have the typekit classification, you have the blood supply. You have gold about the extra capsule, ascending cervical branches and ligament tees and all the rest.
You have told about the blood supply. You have talked about the fragment and you have done a single image, single attempted reduction in any under deep sedation. You then you are on the safe ground, you assess postproduction, you transfer images to the hip unit or a regular unit, and then they will ask you to talk about approaches. If you are talking about approaches again, you are lucky and and you are on the safe ground.
So that's for the open the so you need to plan. So where is the fracture, where there is a wall fracture, Austria column fracture? Then you will go for the posterior approach to the anterior wall or anterior skull fracture. You will go for anterior approach it be type of complex type of fracture, then you can use a dual approach. It depends.
What are you going to achieve, which side you are fixing? I think that's the answer, yeah, depends how you assess where, yeah, dislocation and the fracture. But generally, generally it's the posterior liberal. Yeah, so if it is still a fracture are opposed to a skull fracture, you go with posterior approach, posterior approach. Yeah, that's what our bullet says as well. Yeah, I think that's a very reasonable yeah, because I worked in St. George's with the Martin burger and then I worked in Birmingham as well, which is a major trauma center.
And we have hip and pelvic surgeons to surgeons. So I work both of them. So that is general approach. Yeah, so, so so basically, the approach what you are using is, is the policy approach. Anyone else have to say anything or we move on to me. They keep asking the question about is it required my attitude to this and I think everyone. I'm sure everyone agrees with.
If you've reduced the hip, you need something to establish if there's a fragment in the joint or not. There is no other way of knowing if you've left a fragment in the jaw going to be mentioned that. So there is no discussion about CT scan, it must be done. Yes OK, so coming down to the last common dislocation is the knee dislocation, which so these are the four general dislocations that we asked if the knee dislocation comes, you know what they're going to ask.
It's about the it's about the vascular. It's about the reduction and it's about the posterior approach to the knee. And it's about whether you put the X Fick's first before the repair or you, you just put the pins. So there is no right or wrong answers, but you need to be aware of all that knee dislocations again for a short tutorial five minutes. Knee dislocations generally can be of two type high energy.
If they are high energy, they are motor vehicle accident, commonly dashboard injury, low energy athletic injury or in a morbidly obese patient. I have seen in a morbidly obese patient with very low rotational component and the knee dislocate. If the need is look, it's generally it means. A three to four ligaments are disrupted, vascular injury in all dislocations are 5% to 15% And in 40% to 50% in posterior dislocations, nerve injury is around 25% And fractures are around 60% concomitant.
It can be either femoral canal or tibial tibial canal fracture. OK, so the classification system, you don't need to know the very comprehensive Shannon classification system, although it's very, very, very, very simple. However, you just need to know shandwick four means all four ligaments are gone. 3 is either a medial collateral or lateral collateral.
So three ligaments ACL, PCL, either of the medial or lateral collateral is gone. And if it's three medial, it is related with vascular injury. If it's posterior, which are 25% of a normal class of normal dislocations. It is associated with arterial injury. If it's anterior, which is the most common, 50% arterial injury are not as common. Why does the arterial injury happens?
Because that's everyone asks this question, and they ask me, is it not because it has something to do with the artery? It's because of tethering of the artery in the popliteal fossa, approximately the fibrous channel in the adductor heights, titrate and distally, the fibrous channel in the soldier's muscle. So if you know this answer this question was been asked directly to me and you can then move forward.
The classic controversy here is the measurement of the ankle brachial pressure index. Even the Miller has given this chart and it says about if. If the ankle brachial beclin pressure index is more than zero point nine, you can do serial neurovascular check and do not do any vascular examination or any arterial gum or things like that, or duplex scan. However, some people like to say duplex scan.
They are not wrong. Whoever, say whatever. Just have a system to defend yourself. I will always say because of its high association to vascular injury, I will have a very low threshold of having a vascular scan in form of a duplex ultrasound scan. It is no it's relatively safe investigation. And why? Why don't we have it all?
The risk is, is if you move forward from this point, you are coming to the treatment part. And if you come to the treatment, then you are on the safe ground for its treatment. Initial management, all dislocation. It is not. This dislocation is no different than any other dislocation. What we have discussed in lesion management involves immediate reduction and repetition of the documented neuromuscular examination.
Definitive treatment is always operative. Surgical indications include emergency surgical indication includes popliteal artery injury. It is related with compartment syndrome. Open dislocation irreducible dislocation. Irreducible dislocation. I have shown you the picture when you see a when you see a pattern of the skin on the side, I don't know where it is going now.
Yes, over here when you see a puckering of the side and it means that it has buttonholed through the knee. It has gotten hold to the knee capsule and it's very unlikely that it's going to reduce itself or it's going to reduce close. So then you have to start thinking about open reduction and and however, the absolute indication of a surgical reduction is when you have a vascular injury, when you have a vascular injury.
This is another classic answer. What would you do? You call for the vascular surgeon. You discuss the posterior approach while the vascular surgeon on the way. And I will say I will put the pins before, put the patient semi lateral and put the pins before and don't bite the external fixator. As the vascular surgeon put the Shenton and repair the artery, I will tighten the external fixator and then reposition the patient to the front.
After that, there is a controversy whether you will do a port for electric physio Tommy's or not, and some people actually like doing prophylactic physio Tommy irrespective of whatever the compartment pressure is. However trauma surgeons just go by their gut feeling if they see the leg is very sore, they do. A leg is very swollen. They do the prophylactic to me and some don't do it and wait for.
But but I wouldn't go to the physio to me, but I will say I will assess it and on case by case basis. However, in most cases, which I have seen with arterial injury, they do prophylactic physio and they do, but they do put the x-rays beforehand. They don't fight it because the initial arterial graft or arterial bypass or whatever the vascular surgeon put, it's very it's very unable to do any pressure and/or any movement.
And if you move it, they start leaking again because they use fine suture to suture it. The other thing to say here is remember, remember the posterior approach, because that is another classic exam question where they say the post, where they say, OK, the vascular surgeon is on its way. Can you please describe the posterior approach? Remember the posterior approach? I didn't put it on to keep, you know, to discuss it.
So when it comes to need a knee dislocation, remember three things motor whether it's high energy or low energy. Remember whether there is any skin changes suggestive of button holing through the capsule? Remember whether there is any arterial injury or not? Talk about enter brachial pressure index and weepies or abbeys. Talk about 0.9. Remember point nine?
But I will get a vascular open muscular study done. However, people very strongly sometimes say against it. As the new Miller says there is no need if the ABI is more than nine, but it's up to you whatever you want to see, then move on to the controversy of putting the X Fick's first and urgent reduction as normal. And if you are reaching the approach level and X fixed level, you are passing so.
And even so, it's a shame to effect because you need to preserve or you need to. Maintain the vascular supply distally, so you do the shunt first pins and the next fix. Unless you are avascular surgeon, a. Good so because if you have a viable question, you. Yeah is it ready? Yeah Yeah. So our next candidate.
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