Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Cavus foot deformity in children

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology.

Cavovarus, the most frequent type of cavus foot, presents with

·        an elevated medial longitudinal arch,

·        first ray plantarflexion, and,

·        if rigid, a fixed heel varus.

The cavovarus foot deformity causes an increase in anteromedial ankle joint pressure which may lead to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.

Common causes include

·        progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and

·        NON progressive conditions such as cerebral palsy and poliomyelitis.

A calcaneocavus foot may be seen in

·        poliomyelitis,

·        spinal dysraphism, and

·        peripheral neuropathy.

Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity.

Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment.

·        Standing radiographs of the feet and

·        spine, magnetic resonance imaging, and

·        electrodiagnostic studies

may be useful.

Management goals are to obtain a

1.      plantigrade,

2.      mobile,

3.      pain-free,

4.      stable,

5.      motor-balanced

foot.

Post-operative dynamic measurement of plantar peak pressures and contact area offers limited information about functional and anatomical improvement after surgery.

The heel pressures displays an inverse relationship to ankle power generation.

The amount of correction achieved radiographically does not correlate with pedobarographic measurements.

The increased heel pressure is not addressed by treatment.

Normalization of pressure patterns should be the goal in treating children with symptomatic cavovarus feet.

Although the foot deformity may be completely corrected in neuromuscular disorders, pressure distribution is not normalized, and therefore, symptoms may persist.

Surgical options include

1. soft-tissue and plantar fascia releases for a flexible deformity,

2.      osteotomy (plantar opening wedge, cuneiform bones, Dwyer) for a fixed deformity, and

3.      tendon transfers (modified Jones procedure) to restore muscle balance.

Triple arthrodesis has poorer long-term results than soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity in patients with progressive deformity and sensory impairment.

Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 2 cases

Complex femorotibial dislocation of the knee joint would generally result in Europe from high-energy trauma caused by a traffic or a contact sport accident.

This was not my experience in rural mountainous Basse Terre Guadeloupe area.

Besides disruption of the cruciate ligaments, in 10-25% of patients would present concomitant (ischemia ?) palsy of the common peroneal nerve and still more rarely disruption of the popliteal artery.

The purpose of this short article is to assess outcome in a monocentric consecutive series of two cases of  low energy knee dislocations with total ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.

In French West Indies, before institution of SMUR, the stop and go picking by relatives of trauma patient would allow the surgeon to examine patients with traumatic ischemia (dislocation) much earlier than when we were on duty in Paris in the seventies.

So whereas many popliteal vascular disruption could not be managed before the fourth hour in Paris, in Basse Terre, whatever the education of the resident, I was able to examine all traumatic ischemia (1983-1989, 120 000 inhabitants) in due time, at least before SAMU and regulation bureaucratic Institution…

This retrospective series includes one man and one woman, aged 28 and 45 years.

The left  knee was injured in both.

Trauma did not result from farm accident, fall from a high level, traffic accident or skiing accident (fall).

The woman was 7 months pregnant.

Both were fall victims.

There was no morbid obesity.

Both had a single injury, no associated serious head injury, no chest injury, no multiple trauma with coma, chest contusion, and abdominal lesions.

No patient had  fracture.

No dislocation was open.

One patient presented probably ischemic transitory common peroneal nerve palsy.

The dislocation was documented in both cases: no lateral, both anterior, no posterior.

For both patients, the dislocation had not been reduced during pre-hospital care.

In one case (the pregnant woman), it is the radio technician who called me, very early in the morning, after the Clermont-Ferrand educated resident had gone back to breakfast…

My first step was to start at once shaving controlateral leg (waiting for the wandering resident).

Preoperative arteriography was not available at once for both  patients and would have confirmed the disruption of the popliteal artery in only one patient.

Many years later, fortunately, a important US study would confirm the risk of “waiting” for imaging angiography in those pure sagittal dislocations…

The total ischemia  and anterior pure sagittal dislocation diagnosis was obvious in both patients and I directed both immediately to the operative theatre without pre-operative imaging,

Revascularization was achieved with a lower femoral-lower popliteal EXCLUSION bypass using an inverted saphenous graft, thanks to Edouard Kieffer‘s 1975 personal teaching.

The graft was harvested from the controlateral greater saphenous.

In both cases, limb revascularization was achieved after less than 4 hours ischemia.

Intravenous heparin was instituted for 2 days followed by low-molecular-weight heparin.

The dislocation was secondarily stabilized by a cast in both.

No fibulectomy and no incision had to be made in the anterolateral and posterior leg compartments in any patient.

No revision procedure was necessary because of recurrent ischemia. No thin skin grafts were used (no aponeurotomy surfaces).

Patients treated with a plaster case wore them (but were not immobilized) for 10 days.

Surgical ligament repair was not performed in these two patients.

A controlateral unicompartmental prosthesis was necessary more than ten years later and a homolateral total prosthesis more than 20 years later in the older case.

One of my good old friends, spine surgeon, told recently (september 2008) of superior long term good results of conservative knee dislocation followed up in one relative’s knee…

Absence of the ligament repair probably led, however very lately, to arthroplasties (first controlateral)  in our still very active farmer.

Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in both patients.

No transient acute renal failure required.

Pregnancy ended normally…

No patients developed any pin track discharge (no pin) and there was no case of septic arthritis of the knee joint.

Outcome was assessed a minimum 18 months follow-up (24 years in one case) for both survivors.

Both patients treated by immobilization without a second surgical procedure did not complain of joint instability without any major clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.

An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma.

The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation may be between 4 and 20%.

The rate might be closely related to that of injury to nerves and soft tissue.

Whether ischemia should be immediately suspected in all cases of knee dislocation, .

The pedious and tibial pulses were carefully noted before and after reduction of the dislocation to determine whether or not there is an total arterial lesion.

If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction.

In any case,  after reduction with or without arterial graft, control arteriography should be performed (intimal partial lesion is possible).

Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture.

Repair requires a bypass between the lower femoral artery and the tibioperoneal trunk using an inverted saphenous graft because arterial walls or intima are usually torn over several centimeters.

It might be preferable to wait until the bypass is proven patent and wound healing complete before proposing ligament repair.

This should be done after a precise anatomic work-up to assess each ligament lesion.

Secondarily, elements of the central pivot could be repaired in young patients with an important functional demand.

Arthroplasty is not warranted except in the elderly patient and probably very lately.

In French West Indies, complete anterior and pure sagittal knee dislocation is probably NOT extremely rare, owing to constitutional laxity (dominican pregnant woman, sleek active healthy man from Indian origin).

It might also be in 2009 caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy.

Compression, contusion or disruption of the popliteal artery is not so rarely caused by low energy anterior displacement of the tibia on the femur.

Limb survival may be compromised.

Mandatory emergency restoration of blood supply would possibly modify immediate and subsequent surgical strategies.

There has not however been any study exclusively devoted to double joint and vascular involvement.

This article of mines presents a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single rural center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

Bilateral femoral neck fractures due to transient osteoporosis of pregnancy

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 1. Antero-posterior radiograph of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 2. T1 weighted coronal MRI scan of the pelvis post partum.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Figure 3. Antero-posterior radiograph of the pelvis post fixation with dynamic hip screws.

Transient osteoporosis of pregnancy (TOP)

Transient osteoporosis of pregnancy (TOP) is a rare, idiopathic self-limiting condition typically associated with the third trimester of pregnancy.

It almost always affects a single hip although bilateral presentation and involvement of the knee have been reported [1-3].

TOP usually presents with a sudden, quite severe onset of unilateral groin pain with no history of trauma.

The patient may be unable to walk, or may have an antalgic gait.

Pain is elicited by hip rotation, although a full range of motion is common.

Radiographs are avoided in pregnancy where possible, and are a poor investigation for demonstrating early osteopaenia.

Magnetic Resonance Imaging (MRI) reveals low signal intensity of bone marrow on T1 weighted images, and high signal on T2 weighted images suggestive of bone marrow oedema[4].

The natural history is of resolution of symptoms over the course of 3 to 6 months

Hip fracture secondary to TOP

Hip fracture secondary to TOP is very rare with only 12 reported patients in the literature to date; in two cases the hip fractures were bilateral[2,3,5-8].

The majority of these fractures were caused by a traumatic event.

Atraumatic hip fractures secondary to TOP are even more unusual and are easily overlooked and hence may present to the orthopaedic surgeon at a late stage, making management more challenging.

Musculoskeletal complaints are very common in pregnancy.

The position and weight of the gravid uterus alters the centre of gravity and loading patterns of the axial and appendicular skeleton, whilst hormonal changes lead to joint laxity, and fluid retention may cause neural compression[9].

The majority of musculoskeletal complaints are not serious, and are managed conservatively without a specific diagnosis.

Pregnant women frequently complain of hip or pelvic pain.

The differential diagnosis includes some serious problems that need to be excluded, namely

1. transient osteoporosis,
2. osteonecrosis and
3. pubic symphysiolysis.

Conventionally ionising radiation is avoided during pregnancy although Brodell et al. suggested that in the third trimester of pregnancy the benefits of adequate investigation of hip pain may outweigh the minimal risks[5].

MRI during pregnancy

There is no conclusive evidence that MRI has deleterious effects, however the safety of MRI has yet to be definitively proven[10].

It is in common use in the third trimester of pregnancy where clinically indicated[11] and is generally considered to be safe[12].

MRI has a high sensitivity for diagnosis of occult hip fracture[13] and can reliably distinguish between osteonecrosis and transient osteoporosis[4], making it the investigation of choice for hip pain in the third trimester of pregnancy.

Displaced intracapsular fractures have a high incidence of non-union and avascular necrosis[14].

It has however been shown that the risk of non-union is independent of bone quality[15] therefore in young patients with high value hips internal fixation should be the goal.

References

1.	Lloyd JM, Lewis M, Jones A: Transient osteoporosis of the knee in pregnancy. J Knee Surg 2006, 19:121–123. [PubMed]
2.	Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M: Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Trauma Surg 2008, 128:313–316. [PubMed] [CrossRef]
3.	Munker R, Niedhart C, Niethard FU, Schmidt-Rohlfing B: [Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy]. Z Orthop Ihre Grenzgeb 2007, 145:88–90. [PubMed] [CrossRef]
4.	Takatori Y, Kokubo T, Ninomiya S, Nakamura T, Okutsu I, Kamogawa M: Transient osteoporosis of the hip. Magnetic resonance imaging. Clin Orthop Relat Res 1991, :190–194. [PubMed]
5.	Brodell JD, Burns JE, Heiple KG: Transient osteoporosis of the hip of pregnancy. Two cases complicated by pathological fracture. J Bone Joint Surg Am 1989, 71:1252–1257. [PubMed]
6.	Cohen I, Melamed E, Lipkin A, Robinson D: Transient osteoporosis of pregnancy complicated by a pathologic subcapital hip fracture. J Trauma 2007, 62:1281–1283. [PubMed]
7.	Fokter SK, Vengust V: Displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. A case report. Int Orthop 1997, 21:201–203. [PubMed] [CrossRef]
8.	Wood ML, Larson CM, Dahners LE: Late presentation of a displaced subcapital fracture of the hip in transient osteoporosis of pregnancy. J Orthop Trauma 2003, 17:582–584. [PubMed] [CrossRef]
9.	Smith MW, Marcus PS, Wurtz LD: Orthopedic issues in pregnancy. Obstet Gynecol Surv 2008, 63:103–111. [PubMed] [CrossRef]
10.	Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y: Fast MR imaging in obstetrics. Radiographics 2002, 22:563–580. [PubMed]
11.	De Wilde JP, Rivers AW, Price DL: A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 2005, 87:335–353. [PubMed] [CrossRef]
12.	Garcia-Bournissen F, Shrim A, Koren G: Safety of gadolinium during pregnancy. Can Fam Physician 2006, 52:309–310. [PubMed]
13.	Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R: Early diagnosis of occult hip fractures MRI versus CT scan. Injury 2005, 36:788–792. [PubMed] [CrossRef]
14.	Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE: Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994, 76:15–25. [PubMed]
15.	Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS: Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome? J Bone Joint Surg Br 2005, 87:367–373. [PubMed] [CrossRef]