LaPrade RF, Gilbert TJ, Bollom TS, Wentorf F, Chaljub G. The magnetic resonance imaging appearance of individual structures of the posterolateral knee. Dr. Robert F. LaPrade operated on my right knee in May of 2010. Joint subluxation is common in adolescents, typically girls, and results from hypermobility of the joint, in which symptoms can decrease with skeletal maturity.2 Some studies have shown that congenital dislocation of the knee can also be associated with atraumatic superior dislocation of the proximal tibiofibular joint.1 Rule out lateral meniscus tear. The Proximal Tibiofibular Joint: A Biomechanical Analysis of the This helps us to confirm that the patient does have instability of the proximal tibiofibular joint which may require surgery. The common peroneal nerve (CPN) is visualized and protected throughout the case. The chief function of the proximal tibiofibular joint is to dissipate some of the forces on the lower leg such as torsional stresses on the ankle, lateral tibial bending movements, and tensile weight bearing. PMID: 28339288. Comparison with the contralateral knee is useful to determine adequate tightness. doi: 10.1016/j.eats.2017.09.003. The anterior ligament is composed of three to four bundles and is further reinforced by the anterior aponeurosis arising from the long head of the biceps femoris tendon (BFT).3,4 The posterior ligament is generally composed of three bundles and significantly weaker than the anterior ligament (Figure 3).5 The inherent joint stability is also directly related to the inclination of the articular-surface which is classically defined as horizontal or oblique. Proximal tibiofibular joint dislocation - Radiopaedia Morrison T.D., Shaer J.A., Little J.E. If one obtains the diagnosis soon after injury (acutely), immobilization of the knee in extension for a few weeks to try to get the posterior injured ligaments to heal is reasonable. History and physical examination are very important for diagnosis. Bookshelf Thank you for choosing Dr. LaPrade as your healthcare provider. A fibular bone bruise (asterisk) is present near the attachment of the posterior ligament. April 25, 2013 - Appointment with Dr. Lyman, MD-Lyman Knee Clinic, Coeur D'Alene, ID. I am 5-months post surgery, and am doing great, stationary biking and exercising every day, no pain.You know you are seeing the best when you find out he has written over 500 medical journal articles - among many other accomplishments. Reconstructive procedures are recommended for patients whose source of pain is instability in the joint as opposed to arthritis. The integrity of the ankle and functional status of the peroneal nerve should also be assessed during the physical examination, because of the association of nerve, syndesmotic ligament, and interosseous membrane damage with this injury. 43 year-old male with lateral knee pain status-post snowboarding injury. Klaunick G. Recurrent idiopathic anterolateral dislocation of the proximal tibiofibular joint: case report and literature review. The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. Because the joint is relatively inherently stable because of its bony anatomy when the knee is out straight, most cases of proximal tibiofibular joint instability occur when the knee is bent. After 6 weeks postoperatively, patients may start to use a stationary bike with low resistance. This is because there are no muscles that can control the joint for most activities of daily living. Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. Flexing the knee to 90 degrees to relax the lateral collateral ligament and biceps femoris tendon, then moving the fibular head anteriorly and posteriorly, can test instability of the joint. Epub 2017 Mar 21. 2016 May-Jun;40(3):470-6. doi: 10.1016/j.clinimag.2015.12.011. Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. Taping of the proximal tibiofibular joint, in a reverse direction to pull it away from the tendency to anterolateral subluxation, can be very effective at obtaining a validated clinical response in a patient who has injuries to this joint. Injury to the proximal tibiofibular joint can lead to lateral knee pain and instability owing to chronic rupture of the posterior tibiofibular ligament. Sequential axial (9A) and coronal (9B) fat-suppressed proton density-weighted images demonstrate a 20 mm avulsion fracture of the fibular head (red arrows) medial to the styloid at the posterior tibiofibular ligament insertion (blue arrows). Copyright 2017 Arthroscopy Association of North America. Chapter Synopsis PMID: 32061975. Knee Surg Sports Traumatol Arthrosc. Okubo A, Kajikawa Y, Nakajima S, Watanabe N, Yotsumoto T, Oshima Y, Iizawa N, Majima T. SICOT J. We anticipate that our patients will return back to full activities about 4-5 months after surgery, following the rehabilitation program. The drill sleeve is applied to the lateral aspect of the fibular head, avoiding the insertions of the FCL and the BFT. Burke CJ, Grimm LJ, Boyle MJ, Moorman CT 3rd, Hash TW 2nd. Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. Report of two cases. Anterolateral dislocation commonly stems from injury to the anterior and posterior capsular ligaments, and commonly the lateral collateral ligament.1,2 The common cause of traumatic anterolateral dislocation is a fall on a flexed knee, or a violent twisting motion during an athletic activity.3 The hyperflexed knee results in relaxation of the biceps femoris tendon and the lateral collateral ligament, and the violent twisting of the body creates a torque that pushes the fibular head laterally to the edge of the lateral tibial metaphysis.1,2 The forced plantar flexion and ankle inversion forces the laterally displaced fibular head anteriorly.1, The early recognition of instability in the proximal tibiofibular joint is necessary to optimize management of the injury and to avoid potential misdiagnosis. All other clinical possibilities should be ruled out before a diagnosis is made. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic Internal Fixation With a Suture Button. History of Traumatic Injury In acute cases, we have found that immobilization in a brace in full extension for 3 weeks is often very effective to allow the posterior proximal tibiofibular joint ligament tear to scar in sufficiently such that there is no instability. Evaluation of the joint, the supporting ligaments, and the common peroneal nerve should be assessed alongside evaluation of the posterolateral corner. Tibiofibular joints: Anatomy, movements | Kenhub 1997 Jul-Aug;25(4):439-43. doi: 10.1177/036354659702500404. It often appears striated due to the presence of multiple bundles, and it is located just caudal to the anterior arm of the short head of the biceps femoris tendon. AJR Am J Roentgenol. Improved outcomes can be expected after surgical treatment of PTFJ instability. Epub 2017 Mar 24. PMC A slightly curved lateral incision over the fibular head is made. AP weightbearing radiographs of both knees and lateral radiograph of the right knee in a 31-year-old female who fell while skiing. Level IV, systematic review of level IV studies. All I can say is Dr. La Prade did an amazing job and I am not limited in any of my activites. PMID: 20440223. Epub 2005 Dec 22. Traumatic dislocations of the proximal tibiofibular joint are uncommon and are normally caused by high-energy injury or a fall on a twisted knee. Plain radiographs should be taken from anteroposterior, lateral, and oblique (45 to 60 degrees internal rotation of the knee) views, with comparison views from the contralateral knee, or from the preinjury knee if possible.5 When a diagnosis is suspected but not clearly established by plain radiographs, axial computed tomography has been found to be the most accurate imaging modality for detection of injury of the proximal tibiofibular joint.6 Magnetic resonance imaging (MRI) can also confirm a diagnosis of recent dislocation, based on the presence of pericapsular edema of the joint and edema of the soleus at its fibular origin of the popliteus muscle, but this finding is often absent in chronic and atraumatic cases.7, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Management of Proximal Tibiofibular Instability. Instability of the proximal tibiofibular joint occurs when the ligaments which provide stability to this joint are injured. In acute cases, we have found that immobilization in a brace in full extension for 3 weeks is often very effective to allow the posterior proximal tibiofibular joint ligament tear to scar in sufficiently such that there is no instability. Resnick D, Newell JD, Guerra J Jr, Danzig LA, Niwayama G, Goergen TG. Fibular resection during an arthrodesis procedure can decrease ankle pain and instability after surgery. In this regard, it is recommended that the strengths of grafts chosen for proximal tibiofibular reconstructions meet or exceed these values. Recent traumatic anterolateral proximal tibiofibular joint dislocation. [Chronic instability of the proximal tibio-fibular articulation: hemi-long biceps ligamentoplasty by the Weinert and Giachino technique. Reconstruction using the biceps femoris tendon16 and iliotibial band17 autograft have been detailed, and LaPrade has also described a technique to reconstruct solely the posterior ligaments (Figure 12).18,19 Reconstruction of the anterior and posterior ligaments utilizing hamstring grafts has been described by Kobbe et al.20 and Morrison et al.21 More recently, multiple technique papers have described PTFJ stabilization without reconstruction.22,23. PMID: 4837930. Repair with bicortical suspension device restores proximal tibiofibular joint motion. Gross anatomy Articulation fibula: flat facet of the fibular head Atraumatic proximal tibiofibular joint subluxation is the more common presentation of proximal tibiofibular joint instability. At the time of clinical evaluation, patients report lateral knee pain or instability which invokes a broad differential diagnosis. Clinical and Surgical Pitfalls 2700 Vikings Circle Treatment is prompt closed reduction with unstable injuries requiring surgical pinning versus soft tissue reconstruction. The reconstructive procedure is recommended for patients whose pain is a result of joint instability. We have found it to be very effective at restoring stability to this joint and not resulting in joint overconstraint. Common considerations include lateral meniscus pathology, FCL injury/PLC instability, biceps tendonitis, and distal iliotibial band friction syndrome. Proximal Tibiofibular Joint Instability | Knee Specialist | Minnesota Dr. La Prade had just moved to Vail and I was his 2nd patient @ The Steadman Clinic. PMID: 4837931. Atraumatic subluxation is thought to result from injury to the anterior ligament and to the anterior capsule of the joint, and it can be associated with Ehlers-Danlos syndrome, muscular dystrophy, and generalized laxity.1 Subluxation typically occurs in patients who have no history of inciting trauma but may have generalized ligamentous laxity; the condition is not commonly bilateral. Dr LaPrade performed a deep root repair to my meniscus, which saved me from a knee replacement at this time. I was life flighted to MCR in Loveland, CO. My orthopedic injuries were severe, but totally missesd by the orthopedic team at Poudre. The reconstructive procedure is recommended for patients whose pain is a result of joint instability. The diagnosis of joint instability can be confirmed by steroid and local anesthetic injection into the joint under fluoroscopic guidance, if pain is relieved. Injury to the proximal tibiofibular joint can lead to lateral knee pain and instability owing to chronic rupture of the posterior tibiofibular ligament. During significant trauma, traumatic dislocations of the tibiofibular joint are commonly missed, so the physical examination of this joint is a significant part of the comprehensive knee examination. The tibiofibular joints are a set of articulations that unite the tibia and fibula. You may also needAnatomic Acromioclavicular Joint ReconstructionArthroscopic Lateral Retinacular Release and Lateral Retinacular LengtheningArthroscopic and Open Management of Scapulothoracic DisordersMedial Patellofemoral Ligament Reconstruction and Repair for Patellar InstabilityManagement of Pectoralis Major Muscle InjuriesCombined Anterior Cruciate Ligament Reconstruction and High Tibial OsteotomyPosterolateral Corner ReconstructionPatient Positioning, Portal Placement, and Normal Arthroscopic Anatomy 2017 Jul;45(8):1888-1892. doi: 10.1177/0363546517697288. Ogden JA. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic Atraumatic dislocation of the proximal tibiofibular joint is easily misdiagnosed when there is no clinical suspicion of the injury, owing to its association with a wide range of symptoms that mirror many common knee injuries. Displacement of the fibular head in relation to the tibiavisible or palpable deformity. Pessoa P, Alves-da-Silva T, Guerra-Pinto F. Knee Surg Sports Traumatol Arthrosc. The anterior tibiofibular ligament (green arrow) is edematous but in continuity. Limit patients to passive flexion until 6 weeks to reduce the stress that is applied to the reconstructed ligaments (prevent biceps femoris from pulling on the fibular head). Although many patients do not note symptoms during daily activities, symptoms may develop during activities that require sudden changes in direction. Proximal Tibiofibular Joint Instability and Treatment - PubMed Sequential axial (1A), coronal (1B), and sagittal (1C) fat-suppressed proton density-weighted images are provided through the proximal tibiofibular joint. Only gold members can continue reading. LaPrade RF, Hamilton CD. The treatment of proximal tibiofibular joint instability usually depends upon whether it is an acute or chronic injury. The relative avascularity of the area of the proximal tibiofibular joint prevents the presentation of knee effusion with an isolated injury, but there may be a prominent lateral mass. A proximal tib-fib dislocation is a disruption of the proximal tibia-fibula joint associated with high energy open fractures of the tibia and peroneal nerve injury. Anatomic reconstruction of chronic symptomatic anterolateral proximal tibiofibular joint instability. Instability of the Proximal Tibiofibular Joint : JAAOS - Journal of the The most common traumatic dislocations are in an anterolateral direction, followed by posteromedial and superior dislocations. Resecting and protecting the peroneal nerve during surgery can prevent peroneal nerve palsy. Proximal Tibiofibular Joint Instability and Treatment Approaches: A Systematic Review of the Literature Authors: Bradley M. Kruckeberg Mayo Clinic - Rochester Mark Cinque Stanford Medicine. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Proximal Tib-Fib Dislocation. The implant is pulled through, flipping the medial button on the outside of the anteromedial cortex. Axial images from superior to inferior demonstrate soft tissue edema surrounding the proximal tibiofibular joint. Anatomy of the proximal tibiofibular joint. The proximal tibiofibular joint (PTJF) can be injured with the structures in the lateral aspect of the knee in a multi-ligament knee injury (MLKI) patient. Both the anterior and posterior ligaments may be torn however the posterior ligament is weaker and more often torn (Figures 6-8). Knee Surgery, Sports Traumatology, Arthroscopy, 18(11), 1452-1455 . What is your diagnosis? Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. 55 year-old female status-post fibular head dislocation with stable reduction but lateral-sided laxity. Although many patients do not note symptoms during daily activities, symptoms may develop during activities that require sudden changes in direction. 2019 Feb;27(2):412-418. doi: 10.1007/s00167-018-5061-9. A more definitive way to validate a diagnosis of proximal tibiofibular joint instability is with a taping program of the joint. Bone marrow contusions along both sides of the joint may or may not be present, and fractures are less common (Figures 9 and 10). Is stability of the proximal tibiofibular joint important in the multiligament-injured knee? ABSTRACT The drill is advanced through all 4 cortices. Epub 2018 Jul 23. A closed reduction should be attempted in patients with acute dislocation. In some cases, the posterior ligament will be notably absent, but given how small the ligaments are, chronic disruption and subsequent scarring may mask the underlying pathology and therefore isolated asymmetric osteoarthritis of the PTFJ may be the only clue.12. This answers all my questions! 2014 Sep;472(9):2691-7. doi: 10.1007/s11999-014-3574-1. The fibular head lies in an angled groove behind the lateral tibial ridge, which helps to prevent anterior fibular movement with knee flexion [7]. Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. Proximal tibiofibular ligament reconstruction, specifically biceps rerouting and anatomic graft reconstruction, leads to improved outcomes with low complication rates. Hey - if he is good enough for Olympic and professional athletes..he's good enough for me! PMID: 10750995. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic PMID: 28321475. Instability of the proximal tibiofibular joint occurs when the ligaments which provide stability to this joint are injured. The treatment of proximal tibiofibular joint instability depends upon the time of presentation. 2000 Mar-Apr;28(2):191-9. doi: 10.1177/03635465000280020901. Nate Kopydlowski and Jon K. Sekiya The integrity of the proximal tibiofibular joint is best visualized through plain radiographs. Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. 13C: Preoperative physical exam video demonstrating gross PTFJ instability (13A), intra-operative physical exam video demonstrating resolution of instability following PTFJ reconstruction utilizing suture button with TightRope fixation (13B), and an AP postoperative radiograph demonstrating restoration of anatomic alignment (compare with preoperative radiograph Figure 4). 1974 Jun;(101):192-7. MeSH Physical Examination Techniques The drill guide is directed in a posteroanterior direction toward the anteromedial aspect of the proximal tibia, making sure to avoid the MCL and pes anserinus. I am so glad I did! PMID: 29881700; PMCID: PMC5989917. eCollection 2023 Jan. Mediterr J Rheumatol. Clin Orthop Relat Res. Dislocation of the proximal tibiofibular joint is a very uncommon condition that is easily misdiagnosed without clinical suspicion of the injury. In the past, chronic instability was treated with arthrodesis or fibular head resection; however, complications related to altered knee and ankle biomechanics rendered these options less desirable.13,14,15, As knee ligament reconstruction surgery has developed, various techniques to reconstruct the ligaments have been described. more common with horseback riding and parachuting, posterior hip dislocation (flexed knee and hip), proximal fibula articulates with a facet of the lateral cortex of the tibia, distinct from the articulation of the knee, joint is strengthened by anterior and posterior ligaments of the fibular head, symptoms can mimic a lateral meniscal tear, comparison views of the contralateral knee are essential, clearly identifies the presence or absence of dislocation, pressure over the fibular head opposite to the direction of dislocation, extension vs. early range of motion (controversial), commonly successful with minimal disadvantages, chronic dislocation with chronic pain and symptomatic instability, rarely occurs and is usually minimally symptomatic, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Proximal Tibiofibular Joint Ganglion Cysts, Pre-Participation Physical Exam in Athlete, Concussions (Mild Traumatic Brain Injury). If one has a chronic proximal tibiofibular joint injury, we prefer to trial taping to validate that the symptoms of the proximal tibiofibular joint injury are improved with the taping program. Dislocation of the proximal tibiofibular joint is a very uncommon condition that is easily misdiagnosed without clinical suspicion of the injury. Atraumatic instability is more common and often misdiagnosed. I could not bear weight on my right side though I tried repeatedly, but finally I went and got an MRI and one of the orthopedic surgeons that I worked with was shocked when he saw the MRI result. Rev Chir Orthop Reparatrice Appar Mot. Rev Chir Orthop Reparatrice Appar Mot. The anterior sagittal image demonstrates the normal anterior ligament (green arrow) and the relationship between the anterior ligament, the FCL (yellow arrow), the anterior arm of the short head of the BF tendon (purple arrow), and the anterior arm of the long head of the BF tendon (orange arrow). The TightRope needle is then passed through to the anteromedial aspect of the tibia until it exits the skin medially. Traumatic dislocations commonly cause pain along the lateral knee that radiates into the region of the iliotibial band and the patellofemoral joint and is increased with palpation of the prominent fibular head and ankle motion. Isolated traumatic instability of the proximal TFJ is an uncommon and underrecognized injury. We recommend joint reconstruction to repair the proximal tibiofibular joint, which will retain the functional anatomy and rotation of the joint, over arthrodesis, especially in children and athletes. The clinical presentation of joint injury can range from common idiopathic subluxation with no history of trauma, to less common high-energy traumatic dislocations that may be associated with long bone fracture. Axial fat-suppressed proton density weighted image at the PTFJ demonstrates marked soft tissue edema surrounding the joint with intact anterior (green arrow) and posterior (blue arrow) PTFJ ligaments. The arthrodesis procedure is recommended for patients in whom the correction of joint instability would not relieve pain, such as patients with proximal tibiofibular joint arthritis. Proximal Tibiofibular Joint: An Often-Forgotten Cause of Lateral Knee Clinical Presentation McNamara WJ, Matson AP, Mickelson DT, Moorman CT 3rd. However, on a true lateral radiograph, the fibular head should intersect a line created by the posteromedial portion of the lateral tibial condyle and anterior or posterior displacement of the fibular head will disrupt this relationship.9 In cases of transient traumatic dislocation, anatomic alignment may be within normal limits and therefore normal radiographic alignment does not exclude the possibility of recent dislocation or instability. Would you like email updates of new search results? 2010 Nov;18(11):1452-5. doi: 10.1007/s00167-010-1049-9. The BFT, FCL, and nerve are inspected, and the wound is closed in layers. Diagnosis requires careful assessment of radiographs of the knee and tibia (often missed injury). Are you experiencing proximal tibiofibular joint instability? All nonsurgical therapies should be attempted before surgical intervention. Because the joint is relatively inherently stable because of its bony anatomy when the knee is out straight, most cases of proximal tibiofibular joint instability occur when the knee is bent. The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. The posterior ligament (blue arrow) is edematous, the midportion of the ligament is abnormally thinned on the axial, coronal, and sagittal images, and the tibial insertion is torn on the posterior-most coronal image. Espregueira-Mendes JD, da Silva MV. Axial (5A), coronal (5B) and sagittal (5C) fat-suppressed proton density-weighted images demonstrate the anterior (green arrows) and posterior (blue arrows) PTFJ ligaments. Atraumatic proximal tibiofibular joint subluxation is the more common presentation of proximal tibiofibular joint instability. Early diagnosis of this injury can prevent further injuries to the joint that are harder to treat, such as chronic or fixed subluxation. Arthroscopy. Related All nonsurgical therapies should be attempted before surgical intervention. Apropos of 3 cases]. Once a diagnosis of PTFJ instability is confirmed, a standard diagnostic arthroscopy is performed through 2 portals. Bilateral, atraumatic, proximal tibiofibular joint instability. Proximal tibiofibular dislocation is commonly missed initially when high-energy trauma results in other traumatic fractures as well, such as injury to the tibial plateau or shaft, injury to the ipsilateral femoral head or shaft, ankle fracture, or knee dislocation. Reconstruction is recommended to maintain correct anatomic function and rotation of the joint. In both acute and chronic injuries, evaluation of the common peroneal nerve is also essential (Figure 11). Dirim B, Wangwinyuvirat M, Frank A, Cink V, Pretterklieber ML, Pastore D, Resnick D. Communication between the proximal tibiofibular joint and knee via the subpopliteal recess: MR arthrography with histologic correlation and stratigraphic dissection. Chronic instability is commonly the result of untreated or misdiagnosed subluxation of the PTFJ. The diagnosis of proximal tibiofibular joint instability is almost always based on a thorough clinical exam. Patients often report symptoms such as knee instability and giving way during these activities, as well as clicking and popping during daily activities. Bethesda, MD 20894, Web Policies Concurrent surgical treatment of posterolateral corner (PLC) and PTFJ instability poses technical challenges due to the limited working space . Proximal tibiofibular dislocation is commonly missed initially when high-energy trauma results in other traumatic fractures as well, such as injury to the tibial plateau or shaft, injury to the ipsilateral femoral head or shaft, ankle fracture, or knee dislocation.1,2, Atraumatic dislocation of the proximal tibiofibular joint is easily misdiagnosed when there is no clinical suspicion of the injury, owing to its association with a wide range of symptoms that mirror many common knee injuries. 1 The TFJ is stabilized by 3 broad ligaments forming a fibrous capsule, 3 2 posterior proximal tibiofibular ligament and 1 stronger anterior tibiofibular ligament. Surgical treatment discussion and videos courtesy of Jonathan A. Godin, MBA, MD, The Steadman Clinic and Steadman Philippon Research Institute. Most patient histories do not reveal any mechanism of injury to the proximal tibiofibular joint, and symptoms of lateral knee pain can be very misleading. A chronically injured CPN may appear atrophic with abnormally increased T2 signal as well as an abnormal contour due to surrounding scar tissue which often effaces the normal perineural fat. History of Atraumatic Injury Atraumatic dislocation of the proximal tibiofibular joint is easily misdiagnosed when there is no clinical suspicion of the injury, owing to its association with a wide range of symptoms that mirror many common knee injuries. During significant trauma, traumatic dislocations of the tibiofibular joint are commonly missed, so the physical examination of this joint is a significant part of the comprehensive knee examination. On the AP radiograph, the fibula should overlap the lateral margin of the lateral tibial condyle and lateral displacement will widen the interosseous space. Clin Orthop Relat Res. Proximal tibiofibular joint dislocation and instability is an easily overlooked cause of lateral knee pain. The clinical presentation of joint injury can range from common idiopathic subluxation with no history of trauma, to less common high-energy traumatic dislocations that may be associated with long bone fracture.
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