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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.