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Dislocation of the interphalangeal joint of a toe is a rare injury, and when it does occur it usually involves the great toe. Dislocation of other toes without fracture is quite rare. We present here a case of dorsal dislocation of the proximal interphalangeal (PIP) joint which was reduced by manipulation.
The so-called locked finger is a rarely reported condition that can be easily recognized when its typical picture is borne in mind: painful locking of a finger, making it impossible to fully extend the metacarpophalangeal joint, and a lateral displacement of the extensor tendon at this level. Radiological findings may include abnormal shape of the metacarpal head, free intra-articular bodies, sesamoid bones at the volar plate level and degenerative changes in the metacarpophalangeal joint. There is consistently a previous history of repeated light manual effort. This condition generally affects men, aged 50 or older. Two of the three cases presented (three of the four affected fingers) were successfully treated by means of gentle manipulation under regional nerve blocking. The patient who refused treatment remains with a painless locked finger 1 year later. There has been no recurrence with either of the two manipulated patients (three fingers).
Twenty-five patients with fractures of the lower leg treated by closed reduction and plaster fixation were examined an average of 7 years and 8 months after trauma. The end result was assessed according to the following: (1) The patient's own opinion; (2) clinical examination including comparing range of motion in knee and ankle in the fractured and non-fractured leg, leg length discrepancy, malrotation of the injured extremity and muscle force analysis; (3) radiological examination. All fractures had healed after a mean of 13.4 weeks. Twelve of the 25 patients had no complaints. Subjective and objective assessment of the end results were in good correlation. Only eight patients had remaining radiological displacement, in only one of which it was severe. The slight remaining malpositionings did not influence the final functional result. The muscle force analysis showed that fractures caused by high-energy trauma also brought permanent reduction of muscular strength to the fractured extremity.
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The juvenile "Tillaux" fracture occurs in a specific age group and may be misinterpreted as a simple sprain if proper examination is not performed. Anatomic reduction is necessary to prevent long term damage to the ankle joint. Computed tomography is of help in the evaluation of adequacy of reduction.
A total of 101 outpatients with acute or sub-acute low-back pain was randomly allocated to one of two treatment groups. One group was given standardised conventional and optimised activating treatment by primary health care teams. The other group received, according to a pragmatic approach, another treatment programme including manipulation, specific mobilisation, muscle stretching, autotraction and cortisone injections. The treatment effect was evaluated by standardised telephone interviews 3, 7, 14, 21 and 90 days after the start of treatment. The two groups were similar in most of the pretrial variables, including age, sex, occupation, education, previous low-back pain problems, previous treatment, sick-leave, findings at the physical examination, quality-of-life score, presence of common symptoms, disability rating and pain score. In the early phase as well as at the 90 days' follow-up, the group receiving manual therapy had significantly less pain, less disability, faster rate of recovery and lower drug consumption, indicating that this type of treatment is superior to conventional treatment.
In cases of dislocation of the shoulder the humeral head almost always dislocates anteriorly. Only rarely does the dislocation result in a posterior position of all or part of the humeral head. The diagnosis of posterior dislocation is not always as easy as the diagnosis of anterior dislocation and for this reason the injury is often missed. Cisternino et al. found that over 50% of patients with posterior dislocation of the shoulder were missed on initial examination. The longer the time between accident and treatment, the more difficult that treatment becomes and the harder it is to achieve a satisfactory functional result. Therefore it is vital to think of this injury in all cases of severe contusion of the shoulder and if there is the slightest suspicion of this injury, the patient must be aggressively investigated to establish the relationship between the humeral head and the glenoid.
We are reporting about a rare case of a bilateral epiphyseal separation of the proximal tibial epiphysis which occurred to a 16 year old male at the time of bileged take-off when somersault diving. The X-rays at admission showed a bilateral proximal tibial epiphyseal separation of Salter-Harris type I on the right side and Salter-Harris type II on the left side. Both epiphyses showed a posterior dislocation. Stable, anatomical position on both sides was achieved by closed reduction under general anaesthesia and fixed by a plaster cast for five weeks. Healing occurred in anatomical position and no redislocation or growth disturbance was observed. The treatment for such separations is usually conservative; the prognosis is very good, provided that an optimal reposition with restoration of the anatomical situation has been achieved.
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This retrospective study reports the evaluation of the surgical treatment of arthrofibrosis of the knee joint. Patients (n = 53) developed arthrofibrosis due to different index operations and various causes. Based on severe preoperative disability, patients of our series can be considered as difficult to treat. Our management concept suggests a step by step, pathology-oriented treatment: if necessary, arthroscopic arthrolysis and gentle manipulation is supported by posterior capsulotomy. To evaluate the results, we assessed the range of motion of the knee joint, the relative gain in range of motion, extension- and flexion-deficit, as well as the Tegner, Lysholm and Flandry score. As a result of arthrolytic surgery, all 53 patients showed statistically significant (P < 0.01) improvement of the above parameters. The mean gain in the range of motion was 73%. To emphasize the importance of the correct timing of arthrolysis, patients were divided into early and late arthrolysis groups. patients with an early arthrolysis obtained a significantly (P < 0.01) greater improvement in the absolute range of motion than those with a later treatment. By the additional procedure of a posterior capsulotomy, the average extension deficit (absolute) was significantly (P < 0.01) more reduced than for patients without this treatment. Our data support an early therapeutic intervention for patients with a large restriction in the range of motion. Patients with an extension deficit after arthroscopic arthrolysis and gentle manipulation will improve with the additional procedure of posterior capsulotomy.
Anterior shoulder dislocations are one of the most common problems seen in an emergency department. Doubtless, immediate reduction is necessary for treatment, a procedure that is extremely rarely accompanied by complications. In these cases early diagnosis and treatment may be limb saving. We report a case with rupture of the arteria subscapularis following reduction of an anterior shoulder dislocation with formation of an axillary hematoma and consecutive paresis of the plexus brachialis. Interdisciplinary operative revision was necessary to remove the hematoma, stop the hemorrhage and for neurolysis of the plexus brachialis. Treatment resulted in a speedy recovery of the patient. Gentle reduction of a dislocated shoulder is a prerequisite for a low complication rate. Contrast-enhanced computed tomography facilitated diagnosis of the hematoma and identification of the bleeding vessel.
Acute shoulder dislocation is a common injury and characterized by an extremely painful lack of motion. The treatment objective after diagnosis is immediate reduction avoiding additional pain and complications. Various techniques have been described for more than 2000 years mostly using traction-countertraction, particularly combined with special positioning and leverage maneuvers. We report a reduction technique which is performed by a single person with the patient sitting on a chair and the physician standing behind him at the affected side. Positioning one fist in the anterior part of the axillary fossa for countertraction but avoiding direct pressure into the axillary fossa, the other hand uses traction grasping the patient's forearm. Only gentle traction is maintained until muscle relaxation is achieved and reduction mostly happens in this moment. Otherwise slow external rotation of the fist placed in the axilla can relieve reduction pushing the humeral head laterally. Additional leverage maneuvers are not necessary. This technique was successful in 98 of 108 (90.7%) patients. Only in 16.3% was premedication (intravenous analgesics) used. In ten patients general anesthesia was required to achieve reduction. No complications occurred in any of the patients. The reported technique allows a gentle and painless reduction of acute anterior shoulder dislocation with a high success rate mostly avoiding premedication.
We reviewed 45 patients on average 14.7 years after surgery for rupture of the anterior cruciate ligament. The aim of the study was to compare the reliability of the Lachman test to evaluation of knee laxity with the KT 1000 arthrometer and the ultrasound-assisted Lachman test. Forty-five knees were examined with the Lachman test: 12 knees showed no sign of instability; 20 had a + positive Lachman test with a hard end point; 6 with a + positive test had no end point and were rated as unstable; a +2 Lachman test was found in 7 knees. With the KT 1000 Arthrometer 44 knees were examined: 30 knees were graded as stable according to the criteria of Daniel; 14 knees were unstable. We used the ultrasound-guided Lachman test in 44 knees. Taking only the side-to-side difference into account, 37 knees were stable and 7 unstable. According to Gruber, a single translation greater than 4 mm is also a sign of instability. Therefore, 12 knees were unstable, although 6 of these knees were rated as stable, taking the side-to-side difference into account. Comparing the two instrument measurements, all knees with ultrasound-rated instability on the basis of side-to-side measurements were also rated as unstable with the KT 1000 arthrometer. Only half of the knees rated as unstable because of a single translation greater than 4 mm with the ultrasound technique were rated as unstable with the KT 1000 arthrometer. Our results show that the accuracy of the Lachman test is as good as the instrument evaluation if the end point is taken into consideration. A positive Lachman test indicating anterior knee laxity is one where the soft end point is as described by Torg et al. Both instrument measurements are accurate in indicating anterior knee laxity, but only if they are used by an experienced examiner. Using the side-to-side measurements, the sensitivity of the KT 1000 arthrometer is higher. If only single translations greater than 4 mm without a significant side-to-side difference with the ultrasound technique are interpreted as anterior knee instability, then some knees will be rated as unstable, although both the clinical and KT 1000 arthrometer examinations prove them to be stable. We believe that only a side-to-side difference with the instrument techniques should be interpreted as knee laxity. Borderline positive measurements should only be used together with the clinical findings. Both instrument measurements can help to improve the quality of the clinical examination if the examiners are inexperienced. If instrument measurements are required, we believe that the ultrasound technique is easy and cheap to perform. Nevertheless, we believe that instrument measurements of anterior knee laxity are not necessary if a thorough clinical examination is performed, taking the end point of the Lachman test into consideration.
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The posterior luxation of the shoulder joint is a rarely reported and often not recognized lesion in the clinical workday. The authors present the first case of a posterior luxation of the shoulder joint in combination with an contralateral anterior shoulder joint fracture dislocation. In that case the authors stress the importance of an exact clinical and radiology diagnostic and the right way to reduce a posterior luxation of the shoulder joint. Finally they draw the readers attention to operative steps to prevent a reluxation of the shoulder joint.
Shoulder dislocation in the newborn is a rare entity. Therefore, a therapeutic regimen does not exist. This retrospective clinical study (1967-2003) includes 9 newborns with 12 dislocations of the shoulder. The data focus in particular on the therapeutic strategy and its success. The position of the joint and its functionality were monitored with a questionnaire. Publications from 1904 to 2003 were reviewed and served for comparison. Results of calculations showed that 0.018-0.07% of newborns suffer from shoulder dislocations. The diagnosis was made on average at the age of 22 days. Our data include four cases each of congenital and paralytic and two cases each of spastic and traumatic shoulder dislocations. All of them were initially treated conservatively, but because of inadequate results one patient finally had to be operated. In the follow-up of 19.4 years, none of them developed a redislocation and all shoulder functions were suitable for daily life. We propose that patients primarily be treated conservatively; however, if therapy fails, surgery has to be performed.