Raiyyan Tahsan

Raiyyan Tahsan
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TC(960).(05).Orthopedics Case No 38. Subluxation

1. Definition / সংজ্ঞা

Subluxation = joint-এর articular surface আংশিকভাবে alignment হারানো, কিন্তু সম্পূর্ণ বিচ্ছিন্ন নয়।

সহজ ভাষায়:
হাড় joint থেকে পুরোপুরি বের হয়নি, কিন্তু ঠিক জায়গায়ও নেই।

Common joints:
Shoulder, patella/knee, elbow, wrist, finger, hip, ankle, temporomandibular joint, cervical spine.

2. Etiology / Causes — কারণসমূহ

A. Trauma-related cause

  • পড়ে যাওয়া, খেলাধুলায় ধাক্কা, accident, মারধর, sudden twisting।
  • Shoulder subluxation সাধারণত arm abduction + external rotation অবস্থায় injury হলে হয়।
  • Patellar subluxation সাধারণত knee twist, valgus force, sudden direction change-এ হয়।

B. Ligament/capsule laxity

  • Joint capsule বা ligament ঢিলা হলে joint বারবার সরে যেতে পারে।
  • Hypermobility, congenital ligament laxity, Ehlers-Danlos-type connective tissue disorder থাকলে ঝুঁকি বেশি।

C. Previous dislocation/subluxation

  • একবার shoulder বা patella subluxation হলে ভবিষ্যতে recurrent instability হতে পারে।
  • Young active patient, athlete, overhead activity করলে recurrence risk বেশি। Primary anterior shoulder dislocation review অনুযায়ী young active patients, বিশেষ করে under 30, recurrent instability-এর ঝুঁকিতে থাকে।

D. Muscle weakness / imbalance

  • Shoulder: rotator cuff ও scapular stabilizer দুর্বল হলে humeral head socket থেকে সরে যেতে পারে।
  • Patella: quadriceps/Vastus medialis obliquus দুর্বল হলে patella lateral দিকে subluxate করতে পারে।
  • Stroke/hemiplegia patient-এ shoulder muscle tone কমে গেলে shoulder subluxation হতে পারে।

E. Structural abnormality

  • Shallow socket, glenoid bone loss, trochlear dysplasia, patella alta, abnormal Q-angle।
  • Shoulder anterior instability-তে Bankart lesion ও Hill-Sachs lesion দেখা যেতে পারে; anterior dislocation review-এ Bankart lesion 73–85% anterior dislocation case-এ উল্লেখ আছে।

F. Seizure / electric shock

  • Posterior shoulder instability/dislocation seizure বা electric shock-এর পরে হতে পারে; MSD Manual posterior shoulder dislocation সন্দেহ করতে বলে যখন seizure/electric shock history থাকে।

3. Pathophysiology — রোগতত্ত্ব

Subluxation হলে joint-এর stabilizing structure ক্ষতিগ্রস্ত হয়:

  • Ligament stretch/tear
  • Joint capsule stretching
  • Labrum injury — shoulder-এ Bankart lesion
  • Cartilage injury
  • Muscle spasm
  • Bone bruise / osteochondral fracture
  • Nerve বা vessel stretch injury

Repeated subluxation হলে joint instability বাড়ে, cartilage ক্ষয় হয়, chronic pain ও osteoarthritis হতে পারে।

4. Symptoms / Clinical Features — লক্ষণসমূহ

প্রধান symptoms

  • Joint pain — movement করলে বাড়ে।
  • Joint “slip করে গেল” বা “বের হয়ে আবার ঢুকে গেল” অনুভূতি।
  • Swelling বা ফুলে যাওয়া।
  • Bruising বা কালশিটে।
  • Joint weakness।
  • Movement limitation।
  • Instability/apprehension — নির্দিষ্ট position-এ রোগী ভয় পায় যে joint আবার বের হয়ে যাবে।
  • Clicking, popping, catching sensation।
  • Muscle spasm।
  • Visible deformity থাকতে পারে, তবে subluxation-এ dislocation-এর মতো সবসময় obvious না-ও হতে পারে।

Red flag symptoms

  • হাত/পা অবশ হয়ে যাওয়া।
  • আঙুল/পায়ের আঙুল ঠান্ডা, নীলচে বা pulse কম।
  • ব্যথা অস্বাভাবিক বেশি।
  • Joint আটকে গেছে, নড়ানো যাচ্ছে না।
  • Open wound।
  • Neck/spine injury suspicion।
  • Recurrent subluxation with weakness.

MSD Manual dislocation injury-তে neurovascular injury—numbness, paresis, poor perfusion—ও compartment syndrome-এর signs দ্রুত evaluate করতে বলে।

5. Clinical Diagnosis — কীভাবে clinically diagnose করবেন

History

  • Injury mechanism: fall, twist, direct blow, sports, seizure।
  • Joint কি বের হয়ে আবার ঢুকেছে?
  • প্রথমবার নাকি recurrent?
  • Previous dislocation/subluxation history।
  • Numbness/weakness আছে কি?
  • Pain location ও severity।
  • Dominant hand, occupation, athlete status।

Examination

  • Inspection: deformity, swelling, bruising।
  • Palpation: joint line tenderness, bony tenderness।
  • Range of motion: active ও passive ROM।
  • Stability test: apprehension test, relocation test, sulcus sign — joint-specific।
  • Neurovascular exam:
    • Pulse
    • Capillary refill
    • Skin temperature/color
    • Sensation
    • Motor power

Important: fracture suspicion থাকলে aggressive stress test করবেন না; radiograph দিয়ে fracture exclude করতে হয়। MSD Manual radiographs দিয়ে dislocation confirm ও fracture assess করার কথা বলে।

6. Investigations — specific test

X-ray — first-line

  • AP view + lateral view।
  • Shoulder হলে: AP, scapular Y view, axillary view।
  • Knee/patella হলে: AP, lateral, sunrise/Merchant view।
  • Finger/toe হলে: AP + lateral + oblique।
  • Reduction করা হলে post-reduction X-ray দরকার।

Radiographs সাধারণত dislocation diagnose ও fracture exclude করতে যথেষ্ট; অন্তত 2 views different planes-এ করার কথা MSD Manual উল্লেখ করেছে।

CT scan

দরকার হয় যদি:

  • Subtle fracture সন্দেহ।
  • Intra-articular fracture।
  • Glenoid bone loss / Hill-Sachs lesion quantify করতে।
  • Complex trauma।

MRI

দরকার হয় যদি:

  • Labral tear suspicion — shoulder Bankart/SLAP।
  • Ligament tear।
  • Tendon injury/rotator cuff tear।
  • Recurrent instability।
  • Osteochondral injury।

MRI soft-tissue pathology যেমন labrum, axillary nerve, shoulder capsule injury দেখতে useful, তবে history/exam essential information দেয়।

Ultrasound

  • Rotator cuff tear।
  • Joint effusion।
  • Dynamic instability assessment কিছু ক্ষেত্রে।

Doppler / CT angiography

  • Pulse absent/weak।
  • Limb cold/pale।
  • Expanding hematoma।
  • Knee dislocation/subluxation with vascular risk।

EMG/NCS

  • Persistent numbness/weakness থাকলে কয়েক সপ্তাহ পরে nerve injury assess করতে।

7. Differential Diagnosis

  • Complete dislocation
  • Fracture
  • Severe sprain
  • Tendon rupture
  • Rotator cuff tear
  • Meniscal injury
  • Ligament tear — ACL/PCL/MCL/LCL
  • Septic arthritis
  • Acute gout/pseudogout
  • Bursitis/tendinitis
  • Cervical radiculopathy — shoulder/arm pain mimic করতে পারে
  • Referred pain

8. Complications — জটিলতা

  • Recurrent subluxation/dislocation।
  • Chronic joint instability।
  • Labral tear — shoulder Bankart lesion।
  • Hill-Sachs lesion।
  • Cartilage damage।
  • Osteochondral fracture।
  • Nerve injury — shoulder-এ axillary nerve।
  • Vascular injury — rare but serious।
  • Frozen shoulder/stiffness — বিশেষ করে বয়স >40।
  • Chronic pain।
  • Early osteoarthritis।
  • Loss of sports/work performance।
  • Compartment syndrome — rare emergency।

Primary anterior shoulder dislocation review-এ post-reduction film, recurrence risk stratification, age/activity level assessment, এবং physiotherapy long-term management হিসেবে উল্লেখ করা হয়েছে।

9. Treatment / Management — guideline-based practical plan

A. Immediate first aid

  • Joint নাড়াচাড়া কমান।
  • Sling/splint দিন।
  • Ice pack 15–20 মিনিট, দিনে 3–5 বার।
  • Limb elevation সম্ভব হলে।
  • Self-reduction করবেন না।
  • Severe pain/deformity/neurovascular symptom হলে ER.

B. Emergency / hospital management

  • Pain control।
  • Neurovascular exam before and after reduction।
  • X-ray before reduction, especially first-time traumatic injury, age >40, severe trauma, bony tenderness।
  • যদি joint এখনও subluxed/dislocated থাকে → trained clinician closed reduction করবেন।
  • Reduction-এর পর X-ray confirmation।
  • Sling/brace immobilization।
  • Orthopaedic follow-up।

MSD Manual shoulder dislocation treatment-এ reduction, sling immobilization, sedative/strong pain-reliever/local anaesthetic ব্যবহারের কথা উল্লেখ করে।

C. Immobilization

  • Shoulder subluxation/dislocation: sling সাধারণত 1–3 সপ্তাহ, বয়স/recurrence risk অনুযায়ী।
  • বয়স >40 হলে prolonged immobilization এড়ানো ভালো—frozen shoulder risk।
  • Patellar subluxation: patellar stabilizing brace + early physiotherapy।

2019 Sports Medicine Open review-এ simple reduction বা surgical stabilization-এর পর internal immobilization 1–3 weeks এবং long-term physiotherapy recommended বলা হয়েছে।

D. Physiotherapy / Rehabilitation

Phase-wise:

  1. Acute phase: pain control, sling, gentle isometric।
  2. ROM phase: pain কমলে gentle active-assisted ROM।
  3. Strength phase: rotator cuff/scapular stabilizer বা quadriceps strengthening।
  4. Proprioception phase: balance, coordination, sports-specific training।
  5. Return to sport/work: pain-free full ROM + strength symmetrical হলে।

E. Surgery indications

  • Recurrent subluxation/dislocation।
  • Young athlete with traumatic anterior shoulder instability।
  • Bankart lesion with recurrent instability।
  • Large bony defect।
  • Associated fracture।
  • Failed physiotherapy।
  • Neurovascular injury।
  • Osteochondral loose body।

10. Pharmacological Management — Bangladesh practice + MedEx-listed brands

এগুলো educational drug list; patient-specific prescription নয়। Kidney disease, liver disease, peptic ulcer, asthma, pregnancy, anticoagulant use, uncontrolled HTN/heart disease থাকলে NSAID/Tramadol এড়াতে বা doctor supervision দরকার।

10.1 Paracetamol — first-line pain relief

  1. Generic name: Paracetamol
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Para-aminophenol derivative; central analgesic
  4. Bangladesh available brand name with mg: Napa 500 mg, Ace 500 mg, Renova 500 mg, Napa Extend 665 mg, Napa One 1000 mg — MedEx-listed examples।
  5. Adult dose: 500–1000 mg every 6–8 hours PRN। Max 4000 mg/day; liver disease/alcohol dependence/low body weight হলে lower max দরকার।
  6. Duration: 2–5 days or as needed short course।
  7. Why used: Mild–moderate pain কমাতে; inflammation কমায় না।
  8. Side effects: Rare rash, allergy; overdose হলে severe liver injury।
  9. Interaction: অন্য paracetamol-containing cold/flu medicine-এর সাথে একসাথে খেলে overdose হয়; long-term/high-dose paracetamol warfarin effect বাড়িয়ে bleeding risk বাড়াতে পারে।

10.2 Ibuprofen — inflammatory pain হলে

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Bangladesh available brand name with mg: Profen 400 mg, Inflam 400 mg, Neurofen 400 mg, Iburex 400 mg, Rapofen 400 mg — MedEx-listed examples।
  5. Adult dose: 400 mg after meal every 8–12 hours PRN।
  6. Duration: 3–5 days; shortest effective duration।
  7. Why used: Pain + swelling/inflammation কমাতে।
  8. Side effects: Gastritis, dyspepsia, GI bleeding, renal function worsening, BP rise, bronchospasm in NSAID-sensitive asthma।
  9. Interaction: Warfarin/anticoagulant, aspirin, steroid, SSRI, ACE inhibitor/ARB, diuretic, lithium, methotrexate-এর সাথে risk বাড়ে; একই সাথে অন্য NSAID যেমন naproxen/diclofenac খাবেন না। NHS ibuprofen guidance-এ anticoagulants, steroids, antidepressants, BP medicine interaction এবং অন্য NSAID একসাথে না নেওয়ার কথা বলা হয়েছে।

10.3 Naproxen sodium — longer acting NSAID

  1. Generic name: Naproxen sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Bangladesh available brand name with mg: Naprosyn 500 mg, Naprox 500 mg, Naproxen 500 mg, Napryn 500 mg, Naxin 500 mg, Naspro 500 mg — MedEx-listed examples।
  5. Adult dose: 250–500 mg every 12 hours after meal; max usually 1000 mg/day।
  6. Duration: 3–5 days for acute injury pain।
  7. Why used: Pain + inflammation; longer duration than ibuprofen।
  8. Side effects: Gastric irritation/ulcer, GI bleed, renal injury, edema, BP rise।
  9. Interaction: Same NSAID interactions—anticoagulant, aspirin, steroid, SSRI, ACEi/ARB, diuretic; do not combine with ibuprofen/diclofenac/etoricoxib.

10.4 Etoricoxib — COX-2 selective NSAID

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Bangladesh available brand name with mg: Recox 60/90/120 mg, Ratirex 90 mg, plus other etoricoxib brands — MedEx-listed examples।
  5. Adult dose: 60–90 mg once daily after meal; acute severe inflammatory painে doctor may use 90–120 mg short course।
  6. Duration: 3–5 days, shortest possible।
  7. Why used: Inflammatory joint pain কমাতে; once-daily সুবিধা।
  8. Side effects: Dyspepsia, edema, hypertension, renal risk; cardiovascular risk বেশি হতে পারে।
  9. Interaction: Anticoagulant, ACEi/ARB, diuretic, lithium, methotrexate; uncontrolled hypertension/ischemic heart disease/stroke history থাকলে avoid/doctor-only।

10.5 Diclofenac gel — topical NSAID

  1. Generic name: Diclofenac sodium topical gel
  2. Therapeutic category: Topical analgesic, anti-inflammatory
  3. Pharmacological class: Topical NSAID
  4. Bangladesh available brand name with mg: Diclofen 1% gel, DicloGel 1% w/w, Diclomol 1% w/w — MedEx-listed examples।
  5. Dose: 2–4 g affected area-তে দিনে 3–4 বার হালকা করে লাগাবেন।
  6. Duration: 5–7 days।
  7. Why used: Local pain/swelling কমাতে; oral NSAID-এর gastric risk তুলনামূলক কম।
  8. Side effects: Skin irritation, rash, burning।
  9. Interaction: Oral NSAID-এর সাথে একসাথে ব্যবহার করলে total NSAID exposure বাড়তে পারে; broken skin/open wound-এ লাগাবেন না।

10.6 Esomeprazole — NSAID gastric protection

  1. Generic name: Esomeprazole
  2. Therapeutic category: Anti-ulcerant, gastric acid suppression
  3. Pharmacological class: Proton pump inhibitor — PPI
  4. Bangladesh available brand name with mg: Maxpro 20 mg, Esoral 20 mg, Esotid 20 mg, Esonix 20/40 mg, Sompraz 20 mg — MedEx-listed examples।
  5. Adult dose: 20 mg once daily, breakfast-এর 30–60 মিনিট আগে।
  6. Duration: NSAID চলাকালীন 3–7 days; high-risk patient হলে doctor decides longer।
  7. Why used: NSAID-induced gastritis/ulcer risk কমাতে।
  8. Side effects: Headache, nausea, abdominal discomfort; long-term useে B12/Mg deficiency, infection risk।
  9. Interaction: Clopidogrel effect কমাতে পারে; warfarin/phenytoin/diazepam interaction possible।

10.7 Tizanidine — muscle spasm থাকলে

  1. Generic name: Tizanidine hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Centrally acting alpha-2 adrenergic agonist
  4. Bangladesh available brand name with mg: Sirdalud 2 mg, Tizadin 2 mg, Relentus 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg — MedEx-listed examples।
  5. Adult dose: 2 mg at night or 2 mg every 8–12 hours if severe spasm; start low।
  6. Duration: 3–5 days।
  7. Why used: Painful muscle spasm কমাতে, reduction/immobilization-এর পরে muscle guarding কমাতে।
  8. Side effects: Drowsiness, dizziness, dry mouth, hypotension, weakness।
  9. Interaction: Ciprofloxacin/fluvoxamine-এর সাথে contraindicated/avoid; alcohol, sedative, benzodiazepine, antihypertensive-এর সাথে sedation/hypotension বাড়ে। MedEx tizanidine painful muscle spasm indication উল্লেখ করে।

10.8 Tramadol — severe painে doctor-only short course

  1. Generic name: Tramadol hydrochloride
  2. Therapeutic category: Analgesic
  3. Pharmacological class: Opioid analgesic; μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
  4. Bangladesh available brand name with mg: Anadol 50 mg, Lucidol 50 mg, Kingdol 50 mg, Trado 50 mg, Utramal 50 mg, Tranal 50 mg, Syndol 50 mg — MedEx-listed examples।
  5. Adult dose: 50 mg every 8–12 hours PRN severe pain; doctor may adjust।
  6. Duration: 1–3 days only; routine mild subluxationে দরকার হয় না।
  7. Why used: Severe acute pain, reduction/post-reduction pain, NSAID contraindicated হলে selected cases।
  8. Side effects: Nausea, vomiting, dizziness, constipation, sedation, dependence, respiratory depression, seizure risk।
  9. Interaction: Alcohol, benzodiazepine, sleeping pill, SSRI/SNRI/MAOI, antipsychotic, other opioid-এর সাথে dangerous sedation/serotonin syndrome/seizure risk। MedEx tramadol 50–100 mg every 4–6 hours dose range উল্লেখ করলেও self-medication করা উচিত নয়।

10.9 Lidocaine injection — ER/procedure use only

  1. Generic name: Lidocaine hydrochloride injection
  2. Therapeutic category: Local anaesthetic
  3. Pharmacological class: Amide local anaesthetic; sodium channel blocker
  4. Bangladesh available brand name with mg: Lidocaine 2% injection, G-Lidocaine 2%, Chemocain 2%, Jasocaine 2% — MedEx-listed examples।
  5. Use: Closed reduction-এর আগে intra-articular/local anaesthesia হিসেবে trained doctor ব্যবহার করতে পারেন।
  6. Why used: Pain কমিয়ে reduction সহজ করা।
  7. Side effects: Local numbness, allergy rare, toxicity হলে seizure/arrhythmia।
  8. Interaction/caution: Adrenaline-containing preparation end-artery area-তে caution; cardiac disease/arrhythmia history থাকলে careful।

11. Bangladesh doctors commonly কী prescribe করেন এবং কেন

Mild subluxation pain

  • Paracetamol 500 mg — pain control।
  • Diclofenac gel 1% — local pain/swelling।
  • Sling/brace + ice + rest — primary treatment।

Moderate pain + swelling

  • Paracetamol + one NSAID only
    উদাহরণ: Ibuprofen অথবা Naproxen অথবা Etoricoxib — একসাথে একাধিক NSAID নয়।
  • Esomeprazole 20 mg — NSAID-related gastric protection, especially gastritis/ulcer risk থাকলে।

Muscle spasm prominent

  • Tizanidine 2 mg night dose — short course, sedation warning সহ।

Severe pain / reduction done

  • Tramadol 50 mg — doctor-only, short course।
  • Lidocaine injection — ER reduction procedure-এ।

Routine use হয় না

  • Antibiotic — open wound/surgery/infection ছাড়া নয়।
  • Steroid — routine acute traumatic subluxationে নয়।
  • Calcium/Vitamin D — subluxation treat করে না; osteoporosis/deficiency থাকলে আলাদা indication।

12. Prevention — কীভাবে প্রতিরোধ করবেন

  • Injury-এর পর proper rehab complete করুন।
  • Early pain কমলেই sports/work-এ full return করবেন না।
  • Shoulder হলে rotator cuff + scapular stabilizer strengthening।
  • Patella হলে quadriceps/VMO + hip abductor strengthening।
  • Warm-up ও stretching করুন।
  • Contact sports-এ protective technique ও brace ব্যবহার।
  • Recurrent subluxation হলে orthopaedic evaluation করুন।
  • Hypermobility থাকলে heavy end-range movement avoid করুন।
  • Return to play/work only when pain-free full ROM + strength symmetrical।

Overview / Summary

Subluxation হলো joint-এর partial dislocation। প্রধান কারণ trauma, ligament laxity, previous dislocation, muscle weakness ও structural abnormality। Diagnosis history, clinical exam, neurovascular assessment এবং X-ray দিয়ে করা হয়; CT/MRI joint-specific complication দেখতে লাগে। চিকিৎসার মূল ভিত্তি হলো protect, immobilize, reduce if needed, pain control, physiotherapy, recurrence prevention। ওষুধ ব্যথা/inflammation/spasm কমায়; joint stability ফিরিয়ে আনে physiotherapy ও প্রয়োজন হলে surgery।

Actionable Plan / Steps

  1. নতুন injury হলে: joint immobilize + ice + ER/orthopaedic evaluation।
  2. X-ray করুন: fracture exclude ও alignment confirm করতে।
  3. Neurovascular check: pulse, sensation, motor power before/after reduction।
  4. Pain control: Paracetamol first; inflammatory pain হলে one NSAID short course; gastric risk হলে PPI।
  5. Physiotherapy: pain কমলে ROM → strengthening → proprioception।
  6. Recurrent হলে: MRI + orthopaedic opinion; Bankart/labral tear বা bony defect থাকলে surgery লাগতে পারে।
  7. Red flag: numbness, weak pulse, severe deformity, open wound, spine injury suspicion হলে emergency.

Reference List

Textbook

  1. Apley & Solomon’s System of Orthopaedics and Trauma, 11th ed. Joint injuries, dislocations and shoulder instability sections.
  2. Rockwood and Green’s Fractures in Adults, 9th ed. Shoulder dislocation/instability and joint injury management chapters.
  3. Campbell’s Operative Orthopaedics, 14th ed. Shoulder instability, Bankart repair, Latarjet procedure sections.

Guideline / Clinical reference

  1. MSD Manual Professional Edition. Overview of Dislocations: neurovascular assessment, imaging, fracture exclusion.
  2. MSD Manual Consumer Version. Shoulder Dislocation: subluxation definition, symptoms, X-ray confirmation, reduction and sling.
  3. NICE BNF, updated 2026: prescribing, dose, interactions and safety principles for analgesics/NSAIDs.
  4. MedEx Bangladesh: Bangladesh available brand names for paracetamol, ibuprofen, naproxen, diclofenac gel, etoricoxib, esomeprazole, tizanidine, tramadol, lidocaine.

Peer-reviewed journal with DOI

  1. Hasebroock AW, Brinkman J, Foster L, Bowens JP. Management of primary anterior shoulder dislocations: a narrative review. Sports Medicine – Open. 2019;5:31. DOI: 10.1186/s40798-019-0203-2.
  2. Whelan DB, Litchfield R, Wambolt E, Dainty KN. External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial. Clinical Orthopaedics and Related Research. 2014;472. DOI: 10.1007/s11999-013-3432-6.

Md.Rafiqul Islam Lipu,Date:-06-06-2026 saturday ,Time:-12-26-49 Pm

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