Dislocation of the shoulder: causes, symptoms, diagnosis, treatment

Dislocation of the shoulder (dislocation in the shoulder joint) - persistent dissociation of the articular surfaces of the head of the humerus and articular cavity of the scapula as a result of physical violence or pathological process. When the congruence is broken, but the contact of the articulating surfaces is kept, it is said about the subluxation of the shoulder.

ICD-10 code

S43.0. Dislocation of the shoulder joint.

What causes shoulder dislocation?

The mechanism of the injury is mostly indirect: falling on the assigned arm in the position of the anterior or posterior deviation, excessive rotation of the shoulder in the same position, etc.

Anatomy of the shoulder joint

The shoulder joint is formed by the head of the humerus and the articular cavity of the scapula. The articular surfaces are covered with hyaline cartilage. Their contact areas are 3.5: 1 or 4: 1. At the edge of the articular cavity of the scapula is the joint lip, which has a fibrous-cartilaginous structure. From it begins the joint capsule, attached to the anatomical neck of the humerus. The thickness of the capsule is uneven. In the upper part it is thickened due to interlacing joint-brachial and coracoid-brachial ligaments, and in the antero-medial section it is considerably thinned; accordingly, here it is 2-3 times less strong. In the anterior section, the capsule of the joint is attached much lower than the surgical neck, increasing its cavity and forming an axillary volvo (Riedel pocket). The latter allows to maximally withdraw the shoulder, while the vascular-neural bundle approaches the articulating surfaces, which should be remembered during surgical interventions. The bundle includes the nerves of the brachial plexus: the medial cutaneous nerve of the shoulder and forearm, the musculocutaneous nerve, the median, radial, ulnar and axillary nerves. There are also vessels: the axillary artery and the vein with their branches (pectoral, submachular, upper thoracic, anterior and posterior arteries, surrounding the humerus, with the veins accompanying them).

[1], [2]

Symptoms of shoulder dislocation

Patients complain of pain and discontinuation of the functioning of the shoulder joint, which occurred after the trauma. The patient keeps his hand on the side of damage with a healthy hand, trying to fix it in the position of the lead and some deviation anteriorly.

Classification of shoulder dislocation

1. Congenital.
2. Purchased:
   • non-traumatic:
     • arbitrary;
     • pathological (chronic);
   • traumatic:
     • uncomplicated;
     • complicated: open, with damage to the neurovascular bundle, with a rupture of tendons, fractures, pathological repetitive, chronic and habitual dislocations of the shoulder.

Traumatic shoulder dislocations account for 60% of all dislocations. This is explained by the anatomical and physiological features of the joint (the globular head of the humerus and the flat articular cavity of the scapula, the discrepancy in their size, the large joint cavity, the weakness of the ligament-capsular apparatus, especially in the anterior section, peculiar muscles work and a number of other factors contributing to the development of the dislocation).

In relation to the scapula, the forearm dislocations of the shoulder are distinguished (subarachnoid, intubus-like, armpit), lower (subarticular) and posterior (podacromial, subacute). Most often (75%) there are anterior dislocations, underarms account for 24%, for the rest 1%.

[3], [4], [5], [6]

Diagnosis of shoulder dislocation

[7], [8], [9]

Anamnesis

In the history - indication of an injury.

[10], [11], [12], [13], [14],

Examination and physical examination

The shoulder joint is deformed: flattened in the anteroposterior direction, the acromion stands under the skin, under it there is a deviation. All this gives the joint a distinctive appearance.

At palpation, a violation of the external reference points of the proximal part of the shoulder is determined: the head is probed in an unusual place for it, more often inside or outside of the articular cavity of the scapula. Active movements are impossible, and when trying to perform passive movements, a positive symptom of the springing resistance is revealed. Rotational movements of the shoulder are transmitted to an atypically located head. The feeling and determination of the motor function of the shoulder joint is accompanied by pain. Movements in the distal joints of the hand remain in full volume. Movement, as well as skin sensitivity, the surgeon must determine necessarily, since dislocation can be accompanied by damage to the nerves, most often the axillary nerve suffers. It is possible and damage to the main vessels, so you should check the pulsation on the arteries of the limb and compare it with pulsation on the healthy side.

[15], [16]

Laboratory and instrumental research

The main auxiliary method of research with dislocations of the shoulder is radiography. Without it, the final diagnosis can not be made, and the attempt to eliminate the dislocation before radiography should be attributed to medical errors. Without an X-ray, it is not possible to recognize the fractures of the proximal end of the humerus or scapula, and as a result, when manipulating, damage the patient.

Treatment of shoulder dislocation

Conservative treatment of shoulder dislocation

The dislocated segment must be corrected immediately to establish the diagnosis. Anesthesia can be either general or local. Preference should be given to anesthesia. Local anesthesia is provided by injecting into the joint cavity a 1% solution of procaine in an amount of 20-40 ml after a preliminary subcutaneous injection of a solution of morphine or else codeine + morphine + narcotin + papaverine + thebaine is injected.

Shoulder rest without anesthesia should be considered an error. Before eliminating the dislocation, it is necessary to get in touch with the patient: calm him, determine the behavior at the stages of correction, and achieve maximum relaxation of the musculature.

The conductor anesthesia of the brachial plexus is used according to the VA method. Meshkov (1973). Perform it as follows. The patient sits on a chair, leaning on his back, or lies on the dressing table. His head is turned towards the healthy shoulder. For anesthesia, determine the point under the lower edge of the clavicle at the border of its outer and middle thirds above the tip of the probable beak-like process of the scapula, where they make a "lemon crust". Then, perpendicular to the skin surface, the needle is injected to a depth of 2.5-3.5 cm (depending on the severity of the subcutaneous fat and muscle layers of the patient) and 20 ml of 2% or 40 ml of 1% procaine solution is administered.

Research VA. Meshkova showed that the needle in this place can not damage subclavian vessels, and the solution pumped through it is washed by the nerve branches participating in innervation of the capsule and muscles of the shoulder joint.

After the anesthesia is reached, the shoulder is adjusted.

There are more than 50 ways to eliminate shoulder dislocation. All of them can be divided into three groups:

• leverage methods;
• physiological methods based on muscle fatigue traction (traction);
• Methods that involve pushing the head of the humerus into the joint cavity (jogging methods).

It should be noted that this division is very conditional, since in many ways different elements of shoulder reinforcement technique are combined.

The most famous example of the lever principle of shoulder reinforcement is the method of Kocher (1870). The patient sits on a chair. Towels in the form of an 8-shaped loop cover the damaged shoulder joint, creating a counter-pull. The doctor puts his hand, which is of the same name with the dislocated arm of the injured person, on top of the elbow and covers it, while the second hand holds the wrist joint, bending the limb of the patient in the elbow joint at right angles. Then the doctor's actions are composed of four stages, smoothly replacing each other:

• Extension along the limb axis and bringing the shoulder to the trunk;
• continuing the movement of the first stage, the shoulder is rotated outwards by deflecting the forearm in the same direction;
• without changing the achieved position and traction, move the elbow joint anterior and inward, bringing it closer to the midline of the body;
• produce an internal rotation of the shoulder behind the forearm, moving the hand of this hand to a healthy shoulder-strap.

The method of Kocher - one of the most traumatic, it can be used to reinforce the shoulder in young people with anterior dislocations of the shoulder. In older people, it can not be used because of the threat of fracture of the porous shoulder bones and other complications.

Method F.F. Andreeva (1943). The patient lies on the back on the couch. The surgeon, standing at the head, takes the injured hand of the injured person by the forearm bent at right angles and raises it up to the frontal plane, simultaneously producing traction along the axis of the shoulder. The hand is rotated first to the inside, then to the outside and lowered down.

The most numerous should be recognized as a group of methods based on directing the dislocation by stretching. Often, the traction is combined with rotational or rocking movements. The most ancient in this group is the method of Hippocrates (IV century BC). The patient lies on the couch on the back. The doctor puts the heel of his unraveled leg (the same name with the patient's dislocated arm) into the axillary region of the patient. Grabbing the brush of the victim, produces traction along the long axis of the hand with simultaneous gradual reduction and pressure by the heel on the head of the shoulder from the outside and up. When pushing the head, it is repositioned.

Method E.O. Mukhina (1805). The patient lies on his back or sits on a chair. The damaged shoulder joint is covered at the back with a folded sheet, the ends of which are crossed on the patient's chest. The helper uses it to counter. The surgeon smoothly, with increasing force, pulls the shoulder of the patient, gradually withdrawing it to the right angle and simultaneously performing rotational movements (Figure 3-10).

The Method of Mota (1812). The patient lies on the table. The assistant pulls his aching arm up, resting his foot against the injured shoulder, and the surgeon tends to fix the head of the shoulder with his fingers.

There are several methods to eliminate shoulder dislocation, based on traction for damaged legacy. These are the ways of Simon (1896), Hofmeister (1901), AA. Kudryavtsev (1937).

By Simon's method, the patient is placed on the floor on a healthy side. The assistant becomes on the stool and pulls the wrist of the dislocated arm up, and the surgeon tries to fix the head of the humerus with his fingers.

Methods Hofmeister and AA. Kudryavtsev differ in that in the first case, the traction for the limb is made with the help of a load suspended to the hand, and in the second case, using a cord that is thrown over the block.

The most physiological, atraumatic in this group is the method of Yu.S. Dzhanelidze (1922). It is based on the relaxation of the muscle and the traction, the severity of the affected limb. The patient is placed on the dressing table on his side in such a way that the dislocated arm hangs over the edge of the table, and a high table or bedside table is placed under his head.

The trunk of the patient is fixed with rollers, especially in the area of the scapula, and leave it in this position for 20-30 minutes. There is a relaxation of the muscles. The surgeon, having grasped the bent forearm of the patient, produces traction down the arm (outside), followed by rotation outside and inside. Shoulder restraint can be determined by a characteristic click and restoration of movements in the joint.

A small number of methods are based on the direct pushing of the head of the humerus into the joint cavity without the use of traction or with very little stretching.

The method of VD Chaklin (1964). The patient is placed on his back. The surgeon grasping the upper third of the forearm, bent at right angles, somewhat retracts the dislocated arm and extends the axis of the shoulder. At the same time, the other arm, inserted into the armpit, presses on the head of the shoulder, which leads to correction.

The method of VA Meshkov (1973) is classified as non-traumatic, it is convenient in eliminating anterior and (especially) lower dislocations.

After subclavian conductor anesthesia, described earlier, the patient is placed on the table on his back. The assistant takes the dislocated limb upward and anteriorly at an angle of 125-130 ° and holds it in this position, without producing any action for 10-15 minutes with the aim of fatigue and relaxation of the muscles. The surgeon creates a counter-support with one hand due to pressure on the acromion, and the second - pushes the head of the shoulder from the armpit to the top and backwards with anterior dislocations and only upwards - with the lower ones.

The above methods of eliminating the dislocation of the shoulder are not equivalent in technique and popularity, but each of them can restore the anatomy of the joint. True, this does not mean that the surgeon is obliged to apply in his work all the ways and their modifications. It is enough to master the technique of repositioning the head in three to five ways, they will be enough to eliminate any types of traumatic dislocations. It is necessary to choose gentle, atraumatic methods of correction. Worthy of widespread introduction into practice can be considered the methods of Janelidze, Kudryavtsev, Meshkov, Chaklin, Hippocrates, Simon. But they will be successful only if the manipulation is performed carefully and with complete anesthesia.

It should be noted that sometimes, even with the classical execution of the technique, it is not possible to restore the articulation. These are the so-called irreparable dislocations of Meshkov's shoulder. They arise when the tissues hit between the articulating surfaces. Interpont most often are damaged tendons and muscles, the edges of the broken and wrapped joint capsule, the slipped tendon of the long head of the biceps, the bone fragments. In addition, an obstacle may be the torn muscles of the shoulder blade, torn from the large tubercle, welded to the joint capsule and called the rotator cuff by the surgeons.

[17], [18], [19], [20], [21]

Surgical treatment of shoulder dislocation

Irreversible dislocations are considered an indication for surgical treatment of shoulder dislocation - arthrotomy of the shoulder joint, removal of the obstruction, elimination of dislocation and restoration of congruence of the articulating surfaces.

After closed or open reposition of the shoulder, the limb should be immobilized with a gypsum longure on the Turner from the healthy shoulder-strap to the head of the metacarpal bone of the injured limb. The period of immobility, in order to avoid the development of a habitual dislocation of the shoulder, should be at least 4 weeks for young people, for the elderly - 3 weeks. In elderly and elderly people, bandages (instead of gypsum dressings) are used for 10-14 days.

Assign analgesics, UHF on the shoulder joint, exercise therapy of static type and active movements in the joints of the hand.

After the elimination of immobilization, exercise therapy is prescribed for the shoulder joint. Exercises should be passive and active types, aimed at restoring circular movements and leaning of the shoulder. During therapeutic gymnastics, it is necessary to control that the movements of the shoulder and shoulder blades are separated, and in the presence of the shoulder-and-shoulder syndrome (the shoulder moves along with the scapula), the shoulder blade should be fixed by the practitioner's hands. Assign also rhythmic galvanization of shoulder and forehead muscles, procaine electrophoresis, ozocerite, laser beam, magnetotherapy, swimming pool exercises.

Estimated period of incapacity for work

The ability to work is restored in 4-6 weeks.

[22], [23]