Rupture of the rotator cuff of the shoulder: causes, symptoms, diagnosis, treatment

ICD-10 code

S46.0. Trauma of the tendon of the rotator cuff of the shoulder.

What causes a rupture of the rotator cuff of the shoulder?

The rupture of the tendons that are part of the rotator cuff of the shoulder, as a rule, is a complication of shoulder dislocation. Most often, the tendons of all three muscles are damaged at the same time, but isolated ruptures of the tendons of the supraspinous muscle or only the subacute and small round muscles are possible.

Anatomy of the rotator cuff of the shoulder

The rotator cuff of the shoulder is understood as the anterior part of the capsule of the shoulder joint, into which the sinews of the supraspinous, subacute and small round muscles are intertwined. The latter are attached to the side facets of the large tubercle of the humerus. Such anatomical proximity of fixation of muscles allowed traumatologists to unite them into one group (rotator cuff of the shoulder), although they are different in functions: the supraspinatus removes the shoulder anteriorly and outwardly, the subacute and small round muscles - the shoulder rotators outwards.

[1], [2], [3]

Symptoms of rupture of the rotator cuff of the shoulder

To reveal the rupture of the rotator cuff of the shoulder at early stages is difficult, as the clinical picture is veiled by the symptoms of shoulder dislocation and subsequent immobilization with a plaster bandage. Usually patients are treated after prolonged rehabilitation treatment, which does not lead to success.

Patients complain of impaired shoulder joint function, pain, fatigue and a feeling of discomfort in it.

Diagnosis of rupture of the rotator cuff of the shoulder

Anamnesis

In the anamnesis - a dislocation of the shoulder with subsequent long unsuccessful treatment.

Examination and physical examination

Palpation is determined by soreness in the region of the large tubercle. Especially characterized by movement disorders - can not withdraw the shoulder. When trying to perform this movement, the hand is actively withdrawn from the body by 20-30 °, and then pulled upward along with the shoulder (Leclerc's symptom). The amount of passive movements is complete, but if you take your shoulder and do not hold it, the hand falls (a symptom of the falling arm). In addition, with a passive retraction of the shoulder, there appears a symptom of a painful obstacle to the passage of the shoulder by the horizontal level, which arises from the reduction of the podkromialnogo space.

It should be noted that when the torso is tilted forward, the patient actively withdraws the shoulder anteriorly and out to 90 ° or more. Normally, with the vertical position of the human body, shoulder withdrawal is performed as follows: contracting, the supraspinatory muscle presses the head of the shoulder to the articular cavity, creating a support, and then the deltoid muscle acts on the long arm of the humerus. When the tendon of the subacute muscle breaks, the shoulder joint does not close, the contraction of the deltoid muscle leads to a displacement of the head of the shoulder upward, i.e. In the position of subluxation, because the axes of the humerus and articular cavity do not coincide. When the trunk is tilted, these axes are combined, the contraction of the deltoid muscle can close the shoulder joint and keep the limb in a horizontal position.

In the later stages of the trauma, a symptom of the "frozen shoulder" may appear, when the passive removal of it becomes impossible due to the obliteration of Riedel's pocket.

A.F. Krasnov and V.F. Miroshnichenko (1990) revealed and patogenetically substantiated a new symptom characteristic of rupture of the rotator cuff of the shoulder, a symptom of the "falling flag of the chess clock". Check it as follows: the patient is asked to actively or passively (supporting the elbow with a healthy hand) to take an arm to the front to the horizontal level, occupying the middle position between supination and pronation. Then bend his arm at the elbow joint to a 90 ° angle. In this position, the forearm does not hold and falls to the medial side (like a flag of a chess clock with time pressure), rotating the shoulder inward. The reason is the absence of antagonists to the internal rotators and the inability to hold the shoulder weighted by the bent forearm, in a position intermediate between supination and pronation.

Laboratory and instrumental research

In contrast arthrography of the shoulder joint, the cuff rupture is characterized by the filling of the contrasting substance with a podkarmialnoy bag, which normally does not communicate with the joint, and the decrease or disappearance of the podkromialnogo space.

Differential diagnosis of rupture of the rotator cuff of the shoulder

The rupture of the rotator cuff should be differentiated from axillary nerve damage, which is indicated by atony and atrophy of the deltoid muscle and loss of skin sensitivity along the outer surface of the upper third of the arm.

[4], [5], [6]

Treatment of rupture of the rotator cuff of the shoulder

Surgical treatment of rupture of the rotator cuff of the shoulder

Treatment of this pathology is only prompt. The most commonly used is the "saber" incision proposed by Codman, running from the middle of the shoulder blade and parallel to it through the acromion down to 5-6 cm. Trapezoidal muscle and acromion are traversed, deltoid muscle is stratified, the fibrous plate covering the supine muscle is dissected, and the podkromialnuyu bag, reaching rotational cuff of the shoulder. In fresh cases, the shoulder is removed and the tightened suture material is sewn by the tightened ends of the tendons. The wound is sewn layer by layer, including the acromion, which is fastened with two silk sutures. The limb is fixed with a gypsum thoracobrachial bandage for 4-6 weeks in a functionally advantageous position.

It should be noted that surgical interventions with rupture of the rotator cuff of the shoulder are variable and depend on the type of damage, its prescription and secondary changes in the area of damage.

In the early stages of the trauma, especially when the tendons are torn from the tubercles, the intervention can be performed from anterior anterior access without dissection or resection of the acromion. In the late stages, when there is degeneration of the tendons, their shortening and coarsening with coarse scars with surrounding tissues, it is not possible to sew them. They resort to the plastic operations of Debeir (the movement of the adnation of the supraspinous muscle) and Pat-Gutalier (simultaneous movement of the supraspinous, subacute and small round muscles), which allows to eliminate the defect of the rotator cuff of the shoulder.

Estimated period of incapacity for work

The ability to work is usually restored 3-4 months after the operation.