Distorsion

DISTORSION, distorsion, sprain, a complex of injuries in the area of a joint, caused by rapid and forceful movement that exceeds physiological limits, without permanent displacement of the articular ends of bones and without damage to them. A. Pare defined D. as the first degree of dislocation. D., like other traumatic injuries, occur more frequently in men than in women. D. rarely occur in childhood, when the ligaments of joints are pliable and elastic. In old people, overstrain of non-pliable ligaments, in addition to damage in soft tissues, often leads to tearing away of the articular ends of bones due to their greater fragility in old age. Predisposing factors for D. are all those pathological processes that change the statics of the joint and reduce the strength of its ligaments: genu valgum, pes planus, atrophies and paralyses of muscles serving a particular joint. These same factors should include previous D., because after this injury the ligaments have less endurance. In the occurrence of D. in individual joints, factors characteristic of each joint play a role. Thus, D. of the ankle joint most often occurs when walking on uneven ground, when the foot turns awkwardly and the center of gravity is immediately transferred from the middle of the joint to the lateral ligaments. If the ligaments cannot bear the weight of the body, their rupture occurs. D. of the elbow joint is most often observed with hyperextension, when the ligaments attached to the coronoid process of the ulna rupture. With a greater degree of violence, the injury ends in a posterior dislocation of the elbow. D. also occurs with movements in the joint that are not characteristic of this joint in normal conditions. Thus, severe injuries to the lateral ligaments of the knee joint, often with destruction of the menisci, can occur with hyperextension combined with rotational movement in the knee joint. D. are most often observed in the ankle joint; next in frequency are the knee joint, wrist, elbow, etc. Joints with extensive movements, such as the shoulder and hip, rarely undergo sprain. The damage observed in D. involves all tissues, starting with the skin and ending with the synovial membrane and the cavity of the joint itself. In the skin and subcutaneous tissue, damage to blood and lymphatic vessels is observed, leading to bruises and sero-hematic infiltrates with signs of edema. Muscles and their tendon insertions are also damaged to a greater or lesser degree, up to rupture, and the tendon sheaths are often stretched by the outpoured blood. Gross violations of large vessels and nerve trunks are usually not encountered due to their great elasticity. The degree and forms of ruptures of ligaments and the joint capsule can be very diverse and can be complicated by damage to cartilage and articular ends of bones. Wide, flattened ligaments usually receive tears. Short, strong ligaments, without rupturing themselves, tear away from their places of attachment, taking with them the periosteum and even pieces of bone. The synovial membrane rarely ruptures, but sometimes, being caught at the moment of injury between the articular ends of bones, it responds to this with a sero-hematic effusion into the joint cavity (hemarthrosis). In severe cases, patho-anatomical changes are so complex that they are not covered by the term distorsion (sprain). Thus, in children, cases of detachment of the attachment of epiphyses have been described—that which Ollier (ОШeg) called entorse juxta-epiphysaire. In the knee joint with D., there may be violations of the integrity of the menisci attached to the joint capsule, ruptures of the cruciate ligaments; in other joints, cases of partial destruction of the cartilaginous covering of the bone ends have been observed. These injuries lead as a rule to hemorrhages into the joint cavity with all the clinical manifestations and consequences of hemarthrosis. The main symptoms of D., common to all joints, are pain, swelling, limitation of movement, and bruises. These symptoms quickly increase in the immediate period after injury. The greatest tenderness is observed at the site of attachment of the ligaments. Extensive bruises should arouse suspicion of the possibility of fracture due to tearing away of the ligaments at their attachment to the articular ends of bones. In all cases, radiological examination should be recommended in order not to miss damage to the bones. Cases with accompanying bone damage should be interpreted as fractures, and not as true distorsions. The prognosis in D. varies depending on the extent and severity of damage to individual elements of the joint. Complete restitutio ad integrum usually does not occur: the ligamentous apparatus of the joint remains less strong, therefore repetitions are possible after even a single D. Hemorrhages into the joint cavity also give an uncertain prognosis, because it is always possible to expect after hemarthrosis the formation of intra-articular adhesions, which can lead to limitation of movement to varying degrees. Tears of the periosteum at the sites of attachment of ligaments often lead to persistent disfigurements of the contour of the bone in this area. Persistent pains are caused by violations of the integrity of the menisci; in this case, conservative treatment is often unsuccessful, and the case ends with the operation of resection of these menisci. Treatment in the first days after injury should consist of rest with the limb in an elevated position. After a few days, massage of the affected area and movements should be begun. Depending on the variety of patho-anatomical changes (condition of cartilage, violation of integrity of menisci, hemorrhage into the joint cavity, etc.), treatment methods should be varied. In most cases, treatment should be conservative. The puncture of the joint recommended for extensive hemarthroses for the purpose of freeing it from the outpoured blood should be performed with great caution under special indications and in an environment guaranteeing complete asepsis.