Download RECURRENT DISLOCATION OF SUPERIOR TIBIO

RECURRENT
DISLOCATION
OF
Pitfall
A Diagnostic
The
adolescent
girl
context
of instability
the answers
so often
in Knee Joint
OWEN,
ROBERT
is notoriously
SUPERIOR
THE
an
elusive
JOINT
Derangement
OSWESTRY,
of the knee.
When
one
are vague
and unhelpful.
TIBIO-FIBULAR
ENGLAND
and
attempts
My
“
unreliable
witness,
to analyse
knee gives
her
way
particularly
story
“
;
“
in the
of knee
my knee
trouble
locks in
bed
;
there
is a click
somewhere
in front
;
I get a swelling
which
disappears
are
familiar
remarks.
In spite of the most meticulous
examination
no accurate
diagnosis
is made
and,
worse,
the surgeon
may
be persuaded
into a half-hearted
diagnosis
and indeed
may
operate
with unfortunate
consequences.
Among
the numerous
lesions
that
can cause
confusion
the admittedly
rare
entity
of
“
“
recurrent
“
superior
tibio-fibular
prominence.
Bristow
normal
menisci
were
Parry
Nichols
incidence
that in
joint
(1925)
found
and
Lewis
(1958),
of so-called
loose
4,500 meniscectomy
FIG.
Case
1-In
knee
joint
eight
with
disease.
342
l-Radiographs
reviewing
I
to show
Clinically,
previously,
weakness.
however,
the
young
has
1,723
cases
of
cartilages
in young
errors
in diagnosis
not
meniscectomy,
state
(Fig.
1) and
to
recurrent
therefore
FIG.
the normal
been
on
were
servicemen.
amounted
that can lead to misdiagnosis,
The following
case reports
are
1963 a fifteen-year-old
months
ill-defined
in
“
that
in seventy-five
operations
findings
in seven
other
patients
and normal
operations
that in a list of sixteen
lesions
fibular
head is not mentioned.
Case
dislocation
reported
and the
“
given
sufficient
the knee
doubtful.
thirteen
Again
showed
a high
Smillie
(1962)
stated
183.
It is interesting
dislocation
of
of some interest.
the
2
the dislocated
position
(Fig.
2).
girl presented
after
Her
no
which
family
abnormality
with a vague
history
of a twist to the right
she experienced
episodes
of pain in front
of the
doctor
offered
a diagnosis
of Osgood-Schlatter’s
was found
except
ill-defined
patello-femoral
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RECURRENT
tenderness.
DISLOCATION
Radiographs
diagnosis
including
six months
lesion and
a variety
of diagnoses
a subluxating
patella
the grounds
appearance
Finally
of insecure
of a transient
the joint
tunnel
patellae
of chondromalacia
OF THE
SUPERIOR
and
was
TIBIO-FIBULAR
skyline
made.
views
were
her
subsequent
During
including
early
were mentioned.
osteochondritis
Conservative
343
JOINT
negative
and
visits
dissecans,
management
diagnosis.
On the seventh
month
the knee again
gave way, with the
lump
on the outer
side ; but again
no positive
diagnosis
was made.
locked
(Figs.
tibio-fibular
The
maturity.
over
a lateral
cartilage
was pursued
on
while
the
child
was
in bed,
there
was
associated
pain
on
side, and the incident
was followed
by minor
bruising
anterior
to the right
Diagnosis
was thus established,
in that the fibular
head
could
be displaced
laterally
with ease, and the movement
was accompanied
by pain.
Radiographs
displacement
a tentative
extending
1 and
2).
The
left
fibular
head
was
also
hypermobile
the
lateral
fibular
head.
forwards
and
confirmed
whereas
the
inferior
joints
were stable
clinically
and radiologically.
parents
were advised
that the hypermobile
state
would
resolve
with the
This proved
to be the case.
She can now take part in games
and dancing
onset
with
of
no
disability.
Case 2-In
locking
of
outer
flexed
1964 a girl of sixteen
years presented
with a few
the left knee
associated
with a transient
swelling
side of the joint.
position.
A click
episodes
cartilage
were not
trouble
On
incidents
were usually
triggered
heard
on a few occasions;
there
painful
but
was suggested
“
examination
examination
mechanism.
left fibular
The
was
she
was
off on getting
was no history
they caused
parental
worry
by the referring
doctor.
well
built
with
no
undue
and
ankles
was
Other
in detail
were
told
bandage
indeed
she
operation
generalised
joint
to
normal
to avoid
clinically
while
playing
tennis.
now leads an active
cases-Lately
because
and
hyperflexion
radiologically.
of the
knee,
Operative
to
Over
the past
university
life.
persist
years
two other
cases have appeared
of the short follow-up
period.
treatment
with
three
in my
cure
laxity.
games
Thorough
quadriceps
to dislocate
the
tendon
relaxed
disability
clinics
was not
and
to wear
has
but
are
that is
degree.
5 to 8).
advised
but
a supportive
steadily
too
the
“
or
swelling
has come
back,
forwards
but to a less
the lesion clearly
(Figs.
“
she
an
up from the knee
of injury.
Most
revealed
no incriminating
signs
referable
to the knee
joint
ln the light of previous
experience,
however,
it was found
easy
head
forwards
with
the knee
partially
flexed
and the biceps
(Figs.
3 and 4). The girl responded
with the remark
: The
what happens.”
The right fibular
head could
also be displaced
Radiographs
of the superior
tibio-fibular
joint
demonstrated
The
months’
history
of intermittent
somewhere
on the front
and
decreased;
recent
to report
DISCUSSION
in the
There
are many
reports
of acute
traumatic
dislocation
adult,
nearly
always
involving
fairly severe
deforming
a single case.
and Peterson
Lyle (1925) presented
a comprehensive
(1940)
described
forty
cases.
Lord
parachutists.
Vitt
discussed
this
occurring
in
(1948),
Delaney,
traumatic
adults
MacDonald
condition.
from
moderate
Harrison
head necessitating
formal
reduction;
there
tissues
and,
in consequence,
the diagnosis
fibular
head.
Anterior
dislocation
is thought
the
latter
The
age
of eighteen
is often
50 B,
VOL.
G
occasionally
lesion
under
little
NO.
being associated
discussion
in this
years.
pain.
2, MAY
The
The
1968
episode
quadriceps
Hindenach
lesion
is a full
(1956)
and
(1959)
scale
Stratford
(1959)
described
dislocation
five
of the
in
also
cases
fibular
is disruption
of the capsule
and surrounding
soft
is easy because
of the persisting
swelling
at the
to be twice as common
as posterior
displacement,
with common
paper
occurs
is fleeting
is not
MacNab
and
The
superior
tibio-fibular
joint
N#{233}laton(1874) described
review
ofthe
injury.
MackIm,
Hartmann
and Coutts
(1944)
reported
the injury
and
trauma.
of the
forces.
and
wasted,
peroneal
nerve involvement.
in the young
patient-usually
can
there
occur
without
is no permanent
injury;
before
moreover
swelling
the
there
or effusion
344
R.
FIG.
Case
2-Anterior
(Fig.
3
3) and
FIG.
lateral
(Fig.
dislocated
FIG.
Case
2-Lateral
views
OWEN
4) views
of the knee
FIG.
the head
anteriorly
the fibular
head
forwards.
7
showing
4
showing
of the
fibula
dislocated
in its normal
8
position
(Fig.
7) and
(Fig. 8).
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RECURRENT
to guide
the
the
clinician,
DISLOCATION
and,
as noted,
OF THE
the
SUPERIOR
patient,
usually
localisation
of symptoms.
The tendency
is towards
The purpose
of this paper
is to emphasise
that
always
diagnosis
be in the mind
of the surgeon
during
will save much
in the way of family
possibly
mutilating
TIBIO-FIBULAR
a girl,
can
offer
improvement.
this condition,
examination
worry
and
of the
furthermore
345
JOINT
little
although
help
rare,
young
knee joint.
avoid
unnecessary
towards
should
Early
and
surgery.
SUMMARY
1
.
2.
Two
patients
The
difficulties
with
recurrent
dislocation
in diagnosis
are
of the
head
of the
fibula
are
described.
discussed.
REFERENCES
W.
DELANEY,
R. J.,
Joint.
R.,
Derangement
I. B.,
Medical
and
Joint
Internal
MACDONALD,
Canadian
HARRISON,
and
(1925):
R.
BRISTOW,
J. C.
41-B,
of the
MACNAB,
Association
HINDENACH,
Surgery,
and
Journal,
R. (1959):
Knee-Joint.
I. (1956):
74,
Journal
Simple
of Bone
Dislocation
and Joint
of the
Superior
Surgery,
7, 413.
Tibio-Fibular
906.
Dislocation
of the
Upper
End
of the
Fibula.
Journal
of Bone
I 14.
J. W. (1944):
A Study ofTypical
Parachute
Injuries Occurring
in Two Hundred and
Jumps at the Parachute
School.
Journal
of Bone and Joint Surgery,
26, 547.
LYLE,
H. H. M. (1925):
Traumatic
Luxation
of the Head of the Fibula.
Annals
of Surgery,
82, 635.
MACKLIN,
W. E., HARTMANN,
C. M., and PETERSON,
H. 0. (1940):
Dislocation
of the Head of the Fibula.
Minnesota
Medicine,
23, 649.
NELATON,
A. (1874): Elements
de Pathologie
Cizirurgicale, Deuxi#{232}meedition.
Vol. 3, p. 282.
Paris: Librairie
Germer Bailli#{232}re.
PARRY,
C. B. W., NICHOLS,
P. J. R., and LEWIS,
N. R. (1958): Meniscectomy: A Review of 1,723 Cases.
Annals
C. D.,
LORD,
Fifty
and
COUTFS,
Thousand
of Physical
Medicine,
I.5. (1962):
SMILLIE,
STRATFORD,
Surgery,
B.
C.
41-B,
Vrrr,
R. J. (1948):
VOL.
50 B, NO. 2,
4, 201.
Injuries
(1959):
of the
Simple
Knee
Joint.
Dislocation
Third
of the
edition.
Edinburgh
Superior
and
Tibio-fibular
London:
Joint.
E. & S. Livingstone
Ltd.
Journal
of Bone and Joiizt
120.
Dislocation
MAY
1968
of the
Head
of the Fibula.
Journal
of Bone
and Joint Surgery,
30-A,
1012.