Historic perspectives of treatment algorithms in knee dislocation.

Knee dislocation remains a devastating injury with many complications. It necessitates prompt diagnosis, reduction if needed, and emergent repair of any vascular injury. Serial physical examinations and frequent use of arteriograms are necessary to avoid late vascular complications. Many authors are concerned that normal pulses, normal Doppler signals, and normal ABIs have preceded late ischemia and documented intimal tear, demonstrated by arteriography. More recently, other authors have challenged the gold standard of mandatory arteriography by describing studies in which physical examination was 100% accurate in diagnosing patients without operative vascular injury. If pedal pulses, Doppler signals, or ABIs are asymmetric before or after reduction then either immediate operative exploration or arteriography should be performed. If the initial physical examination is normal, serial examinations are used in the hospital to check for late artery thrombosis. Opponents of mandatory arteriography point to a 5% false-negative rate, high cost, and an 8% complication rate, such as contrast allergy, pseudoaneurysm, local hematoma, and arteriovenous fistula. Today a consensus is that repair and reconstruction of the PCL and posterolateral corner injuries are the primary concerns in the multiple-ligament injured knee after dislocation. The ACL may be repaired later if instability persists, but some investigators believe it should not be repaired acutely, thereby avoiding increased surgical trauma and possible stiffness. Recently one of the goals of ligamentous repair and reconstruction has been to provide stability with the least invasive surgical technique to avoid postoperative stiffness. Recent treatments have focused on early arthroscopic-assisted allograft reconstruction of the ACL and PCL. Allograft provides a less invasive means of graft support than autograft. Early, limited range of motion in a brace helps to maintain flexion and extension.

Shoulder dislocations in patients older than 40 years of age.

Shoulder dislocations in patients over 40 years of age are common and are frequently associated with serious injuries to adjacent structures. Associated injuries such as brachial plexus injury, rotator cuff tear, axillary artery injury, fractures about the shoulder, and recurrent dislocation can make shoulder dislocations challenging problems for the clinician. Early diagnosis and treatment of associated injuries and treatment complications are the mainstays in prevention of morbidity and, even, mortality.