SPONSORED

BY

Ehlers-Danlos Society Learning Conference,

December 2018

SPONSORED

BY

Ehlers-Danlos Society Learning Conference,

December 2018

Managing Dislocations

2018 SYDNEY PATIENT DAY

Dr Helen Cohen

Consultant – Rheumatology & Chronic Pain

Royal National Orthopaedic Hospital, UK

http://www.kongyuensing.com/pic/20100705left_hip_dislocation_rabbit_5months_sling_leg_method_toapayohvets_singapore.jpg. Accessed Nov 2018.

Accidents do happen

https://symmetry.physio/blog/Shoulder%20dislocation.jpg. Accessed Nov 2018.

AFP:Getty Imageshttps://i.dailymail.co.uk/i/pix/2016/08/20/15/37181E9300000578-3750383-image-a-18_1471704913914.jpg. Accessed Nov 2018.

Clive Brunskill / Getty Images http://media.coreperformance.com/images/411*308/dislocated-finger2.jpg.. Accessed Nov 2108.

And then there is hypermobility

https://i1.wp.com/media.boingboing.net/wp-content/uploads/2016/08/14089010_1251748584849583_4223014777537261544_n-600x600.jpg?resize=600%2C600. Accessed Nov 2018.

https://mediadrumworld.com/wp-content/uploads/2018/02/MDRUM_Crazy_Contortion-14.jpg. Accessed Nov 2018.

Gokulacandra YouTube Channel https://cdn.doyouyoga.com/wp/2017/01/frog-pose-feet-touching-ground.jpg. Accessed Nov 2018.

Pain and the joints

• In hypermobility

– The joints are bendy

– The ‘proprioception’ (knowing where the joint is in space) is often poor

– The ligaments and tendons are not as supportive

– Some people may have recurrent subluxations & dislocations

http://www.pgwip.org.uk/a-trump-card-for-joint-pain/.Accessed Nov2018.

Pain and the muscles

• Muscle fitness and tone is very important

– Muscle fitness and tone helps to support joints and

compensate for the ligaments & tendons

– Pain often causes less use, so muscles get weaker

– Muscles can be very irritable

– Deconditioning makes the instability worse

– ‘Muscle patterning’ can cause dislocations/subluxations

Muscle coordination

• Around a normal joint – Muscles work together in a smooth coordinated

activity pattern – Some switch on, others relax – Muscle groups cooperate and do not tussle with

each other

https://cdn.80000hours.org/wp-content/uploads/2016/02/Screen-Shot-2016-02-09-at-12.26.20-AM-1024x532.png. Accessed Nov 2018.

Muscle patterning

• Around the hypermobile joint with muscle patterning – Some muscles are over active

– Other muscles are not activating

– The usual smooth coordination between muscles is not working

– This abnormal pattern of muscle activity can pull the joint out of place

Universal. https://cdn.vox-cdn.com/thumbor/-uurDXFMdfxBroh8dKnMLd-EupM=/0x0:1396x606/920x0/filters:focal(0x0:1396x606):format(webp):no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/3859170/manyminions.jpg. Accessed Nov 2018.

Pain and subluxations/dislocations

• ‘Acute’ pain as well as chronic pain

• Joints come out easily; can go in easily

• Muscle spasm will cause pain and prevent relocation

• Stress, panic, anxiety will make spasm much worse – vicious cycle

https://ohmygodlife.com/wp-content/uploads/2017/03/vicious-cycle-1024x764.png. Accessed Nov 2018.

Dislocations/subluxations • Many perceived ‘dislocations’ are subluxations

• You have nosy joints that clunk, click, snap, pop etc

• Not every clunk/snap/pop is a dislocation; most are not

• Do not be afraid of your noisy joints

• Self-management is key

• Common joints: shoulders, hips, knees (patella)

• Hips – exceedingly rare that hips dislocate – More often snapping hip and subluxation

Recurrent dislocators

• Role of muscle patterning particularly in shoulder, hip

• Muscle patterning is the major driver

• Surgery cannot overcome muscle patterning

• RECOGNISE & TREAT EARLY

• Develop a dislocation plan

• Usually does not require aggressive manipulation

• Learn triggers

• Frequent visits to A&E is NOT the answer

• Pain and panic causes

– More stress

– Muscle spasms – pull the joint out of place

– More pain

– Less chance of resolving the dislocation

Dislocation: the pain-stress-panic vicious

cycle

https://images-na.ssl-images-amazon.com/images/I/51ab9y0GviL._SS500.jpg. Accessed Nov 2018.

The Dislocation Plan

The Times; cartoon. http://morlandcartoon.co.uk/wp-content/uploads/2015/03/Boris-Wrestle.jpg. Accessed Nov 2018.

Dislocation plan

• DO NOT PANIC • It is painful, unpleasant, inconvenient, can be

frightening but is NOT life-threatening and usually does NOT cause severe damage

• Support the joint in a comfortable position • Breath normally • Take your pain killers • Relax • Heat; distraction; massage

http://chestofbooks.com/health/general/domestic-hygiene-rational-medicine/Dislocation-of-the-Shoulder.html

Dislocation plan

• Give it time

• When relaxed, use your usual technique

• Treat as any other acute musculoskeletal injury – Rest, ice, compression, elevation

• Caution next 2-3 days

• AVOID prolonged immobilisation

• Careful use of splints, supports

What if it won’t go back?

• Give it more time and revisit your dislocation plan

• Are you as comfortable and relaxed as you can be?

• Is there something someone else can help with?

• Have you used your back-up plan medication?

• If the limb goes cold, discoloured, very numb – may need A&E

https://images-na.ssl-images-amazon.com/images/I/41FxHHkNdjL.jpg. Accessed Nov 2018.

If you have to go to A&E

• Do they know you have hypermobility?

• Had it gone back by the time you got there?

• If you are a regular visitor – have you got an A&E plan?

• Don’t need an xray

• Minimal medication

• Caution ! – Opiates !; Fentanyl lozenges; buccal fentanyl – highly addictive and NOT

appropriate for this

– Gas & air (nitrous oxide) – can also be addictive; if used a lot, can decrease B12

• If you are a regular visitor – you need advice and a good self-managed dislocation plan!

Orthopaedics and atraumatic shoulder instability

• Is the anatomy normal?

• Is the capsule loose?

• Rotator cuff muscles & tendons

• Glenohumeral ligaments

• Is there muscle patterning?

• The Stanmore Triangle

TYPE I Traumatic structural • significant trauma • often a Bankart’s defect • usually unilateral • no abnormal muscle patterning, (ie: your classic sporting injury) TYPE II Atraumatic structural • no trauma • structural damage to the articular surfaces • capsular dysfunction • no abnormal muscle patterning • not uncommonly bilateral, (ie the classic recurrent dislocators when doing normal or sporting activities); congenital or acquired TYPE III Habitual non-structural (muscle patterning) • no trauma • no structural damage to the articular surfaces • capsular dysfunction • abnormal muscle patterning • often bilateral, (ie more complex shoulder with multiple factors)

https://thesports.physio/2013/05/12/shoulder-instability-an-introduction/.

The unstable joint

• Optimise non-surgical treatments

• Surgery to ‘fix’ an unstable joint rarely works

• Surgery should be approached with extreme caution

• High failure rate

• Problems if muscle patterning is not addressed

• What is potential for being worse off?

• Extreme caution with fusing joints – upstream & downstream compensation

• Most hypermobile recurrent dislocators are type II/III

• Surgery is very rarely the answer • Its all physio and getting the muscles working

properly

https://thesports.physio/2013/05/12/shoulder-instability-an-introduction/. Accessed Nov2018.

Dislocation Plan