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ISOLATED
ANTERIOR
DISLOCATION
OF
TIBIOFIBULAR
JOINT
PER
FALKENBERG,
From
THE
PROXIMAL
HOLGER
Central
Hospital,
Naestved
Three cases ofisolated
anterior
dislocation
in the proximal
tibiofibularjoint
are presented.
The common
aetiological
frature
was that injury occurred
with the knee in hyperfiexion
and the foot inverted
and extended.
The symptoms
oflocking,
pain and giving way may lead to an erroneous
diagnosis
of meniscal
injury.
Early
diagnosis
in the acute case enabled easy reduction.
In the inveterate
cases, resection
of the head of the fibula
gave complete
relief of symptoms.
Isolated
anterior
dislocation
of the proximal
tibiofibular
joint has rarely been reported,
and may, therefore,
receive
too little attention.
In the literature,
dislocations
in this
joint
have
been
classified
as anterior,
superior
and
posterior, and as subluxations
(Ogden
1974).
A
distinction
has
to
be
made
between
anterior
dislocations
and the other
varieties,
as the aetiology,
treatment,
and complications
are different.
Anterior
dislocations
are more common
than posterior;
superior
ones are uncommon
and never occur in isolation
(Lyle
1925).
In the course of five months
three cases of isolated
anterior
dislocations,
demonstrating
different
stages of
the same
injury,
were treated
in the Department
of
Orthopaedic
Surgery,
Central
Hospital,
Naestved,
Denmark.
CASE
REPORTS
Case 1. A 17-year-old
male motorcyclist
sustained
a hyperfiexion
injury
of the right knee as the result of a road traffic accident.
He experienced
immediate
pain
on the
lateral
aspect
ofthe
knee
and
was
unable
to bear
weight.
Clinical and radiological
investigations
disclosed
a two-centimetre
anterior
dislocation
of the fibular head which was distinctly
tender
palpation
(Figs
1 and
2). There
was
a slight
extension
defect
in the
Case 2 A 25-year-old
man had been injured in a ball game six years
before referral to hospital.
He stated that he fell, landing on his left leg
with the knee in maximal
flexion.
Since then
he had suffered
uncharacteristic
locking episodes
followed by pain laterally in the knee,
which latterly had been increasing
in severity.
Physical examination
revealed prominence
of the fibular head and
an audible “pop” laterally on medial rotation of the flexed knee. There
was definite
tenderness
at the head of the fibula, but there was no
atrophy ofthe quadriceps
or effusion in the knee. Operation
showed the
head of the fibula to be anteriorly
displaced
and movable ; it was
resected.
The
tender.
on
knee
patient
developed
a transient
peroneal
palsy
but was otherwise
free of symptoms
and was still symptom-free
16 months later.
Case
3. A 31-year-old
football
player
complained
of three
years
of
trouble
from his left knee after a fall when jumping
a low hurdle,
landing on his plantar
flexed foot but with his knee flexed. Since then,
he had had periodical
symptoms
of uncharacteristic
locking episodes
and a sensation
of slipping
laterally.
The joint gave way on weightbearing.
He had undergone
five operations
in the course of two and a
halfyears
and was even seen by a psychiatrist.
The medial as well as the
lateral meniscus
had been removed,
as had parts of the fat pad, the
synovial
fold and granulomata
caused by the sutures.
The symptoms
had persisted
despite the operations.
At physical examination
the contours ofthe knee were normal, but
there was laxity of the proximal
tibiofibular
joint which was definitely
At
the
subsequent
resection
of
the
head
diagnosis
was confirmed,
as the head could be displaced
anteriorly.
After operation
the symptoms
disappeared
was still symptom-free
12 months
later.
of
the
fibula
the
one centimetre
and the patient
which was otherwise
of normal mobility
and stability.
There was no
peroneal
palsy. On the same day, closed reduction
was performed,
under
knee
general
anaesthesia,
in 90 degrees
After
one
by forceful
of flexion
week
in a plaster
bandage
with progressive
free of symptoms.
P. Falkenberg,
Department
Gentoste,
MD,
(Figs
cast
increase
Junior
upon
the fibula
with
and
three
weeks
in weight-bearing,
with
an elastic
the patient
Surgery,
MD, Senior Registrar
of Orthopaedic
Surgery,
Copenhagen
Central
County
Hospital,
for reprints
should be sent to Dr H. Nygaard,
Charlottenlund,
Denmark.
© 1983 British
0301-620X/83/3073-0310
310
Editorial
was
Hospital,
Naestved,
Denmark.
Requests
DK-2920
the
4).
Registrar
of Orthopaedic
Denmark.
H. Nygaard,
Department
pressure
3 and
Society
$2.00
of Bone and Joint
18 Johannevej,
Surgery
DISCUSSION
Anterior
dislocations
in the proximal
tibiofibular
joint
are usually
due to hyperfiexion
injuries,
with the foot
inverted
and extended,
so that the fibular head is pressed
anteriorly
and laterally.
This injury is often observed
in
connection
with parachute
jumps and athletic
activities,
but also in road traffic accidents
(Lord and Coutts
1944;
Christensen
1966; Parks
A common
feature
and
Zelko
1973).
of the present
cases was the
mechanism
of trauma.
The injuries were diagnosed
after
differing
periods
ofdelay,
and the case histories
illustrate
the importance
of an early diagnosis.
An acute
dislocation
is easy to reduce,
and the
subsequent
treatment
is brief. In Case 1 the treatment
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ISOLATED
Fig.
Case
1 . Figures
ANTERIOR
1
1 and
DISLOCATION
Fig.
2-Anteroposterior
OF
2
and lateral
view ofan
after closed
reduction
acute anterior
dislocation
ofthe
fibular
and immobilisation
in a plaster
cast.
3 illustrates
of each
other,
the consequences
Several
interpreted
“pop”
laterally
knee
in the
giving
spontaneously
and
of misinterpret-
pain
prominence
; a sensation
or laxity
3 and
4-Radiographs
taken
reducible.
In the last two cases, both diagnosed
late, the fibular
head was resected
as closed
reduction
was no longer
possible.
However,
others
(Dennis
and Rutledge
1958)
have used open reduction
and internal
fixation.
It has
been reported
that internal
fixation
may entail ankylosis
in the proximal
tibiofibularjoint
and osteoarthritis
in the
talocrural
joint.
In addition,
the osteosynthesis
material
may work loose or break during
movements
in the joint
(Dennis
and Rutledge
1958; Ogden
1974).
Isolated
anterior
dislocation
in the proximal
tibiofibular
joint
differs
from superior
as well as posterior
dislocations
both in aetiology
and symptoms,
and it may
be misinterpreted
as meniscal
injury.
surgeons
had, independently
the condition
as meniscal,
and
had
consequently
been
knee ; diffuse
way;
Figures
head and distinct
tenderness
at the site (Sijbrandij
Radiography
may confirm
the diagnosis.
As seen in Case 3, anterior
dislocations
in the
proximal
tibiofibularjoint
may simulate
meniscal
injury,
but the symptoms
differ,
there
being
neither
intraarticular
effusion
nor atrophy
of the quadriceps,
and the
episodes
of locking
are uncharacteristic,
brief
and
unnecessary
arthrotomies
performed.
The symptoms
in the last two cases were identical:
uncharacteristic
episodes
of locking
with an audible
the
head.
1978).
patient
had had symptoms
from the
very beginning,
but these were so mild that he did not get
referred
until six years after the injury.
The clinical
findings
were evident,
and resection
of the fibular
head
relieved
his symptoms.
Case
311
JOINT
fibular
Zelko
1973).
In Case 2 the
ing the symptoms.
TIBIOFIBULAR
Fig. 3
after reduction
consisted
of a short-term
plaster
cast
followed
by an elastic
bandage
(Parks
and Zelko
1973);
but early treatment
may be restricted
to merely an elastic
bandage
and mobilisation
with increasing
weight-bearing (Lord and Coutts
1944). If the closed reduction
is not
stable,
a temporary
Kirschner
wire may be used (Parks
and
THE PROXIMAL
of
of the
REFERENCES
Christensen
S. Dislocation
of upper end of the fibula. Acta Orthop Scand
1966:37:
Dennis
JB, Rutledge BA. Bilateral
recurrent
dislocations
of the superior tibiofibular
Surg[Am]
Lord
1958: 40-A:
CD, Coutts
Surg
JW. A study
Lyle HHM. Traumatic
JA. Subluxation
JC
Si.jbrandij
VOL.
65-B,
joint
with peroneal-nerve
palsy : a case summary.
J Bone
Joint
fifty
jumps
at the
J Bone
Joint
[Am]
1973 :55-A
1146-8.
of typical
parachute
injuries
occurring
in two
hundred
Ann Surg
1925:82:635-9.
and
thousand
parachute
school.
1944:26:547-57.
luxation
Ogden
Parks
107-9.
II, Zelko
of the
RR.
S. Instability
No. 3, MAY
Isolated
ofthe
proximal
acute
of the proximal
1983
head ofthe
fibula.
tibiofibularjoint.
dislocation
C/in
Orthop
of the proximal
tibio-fibularjoint.
Acta
1974:
101 : 192-7.
tibiofibularjoint.
Orthop
Scand
J Bone
1978 :49: 621-6.
Joint
Surg
: 177-80.