Dislocation of the acromial end of the clavicle is a fairly common injury. It is known that Hippocrates was the first to separate the concepts of “shoulder dislocation” and “dislocation of the acromial end of the clavicle,” which before him were considered the same injury. Of course, from a layman's point of view, these two problems at first glance are not different from each other and are perceived simply as a “shoulder injury” or the expression “knocked out shoulder” is often heard. We specifically made such a philological digression so that you understand that injuries to the shoulder joint and adjacent structures are a separate and very complex area in traumatology. For example, one of the best medical books devoted only to the shoulder joint and its surrounding structures is a two-volume book with 1704 pages! Therefore, in case of injuries to this area, it is extremely important to be treated by a competent specialist.
A little anatomy
The clavicle is a small, S-shaped curved tubular bone, which at one end connects to the sternum (sternoclavicular joint) and at the other end to the acromial process of the scapula (acromioclavicular joint). Traditionally, the clavicle is divided into three parts: the sternal end, the diaphysis (middle part) and the acromial end.
The main injuries to the collarbone are fractures and dislocations. Since the clavicle has two ends (acromial and clavicular), dislocations can occur at both the acromial and sternal ends. More often there are dislocations of the acromial end. Several ligaments are attached to the collarbone, which connect it to the scapula.
Causes of shoulder bruises
External impact on internal structures leads to traumatic injury. Bruises in the shoulder area occur after falls, blows and collisions. The severity of the injury depends on the type, mass and speed of the traumatic agent, as well as the size of the area affected.
When a bruise occurs, the following structures may be damaged:
- Subcutaneous fat and skin
- Muscles and tendons
- Bone and joint structures
- Nerves and small vessels
With bruises of the shoulder area, a fracture of the shoulder and collarbone is often observed. In this case, complete or partial destruction of anatomical bone structures occurs. Most often, a shoulder injury occurs due to a fall. It is not uncommon to receive this injury in car accidents.
A mild and superficial bruise of the clavicle and shoulder is accompanied by damage to small vascular structures and subcutaneous fat. In this case, small vessels can be destroyed, which is accompanied by the appearance of bruises, which in external symptoms resemble petechiae - hemorrhage 1-2 mm in diameter.
A bruise of the scapula, shoulder and shoulder girdle is often accompanied by the following symptoms:
- Ecchymoses are bruises or hemorrhages that are significant bleeding under the skin. The fatty tissue is saturated with blood, but large accumulations of biological fluid are not observed. In some cases, impregnation of muscle structures or skin is noted. With severe bruises, blood accumulates in the area of subcutaneous fat, which leads to the formation of hematomas.
- Bruises are recognized after bruises on days 2-3 and look like blue-purple spots. Gradually, the internal accumulations dissolve, and the color of the bruises becomes blue-green and then yellow. With severe injuries, the bruises resolve only after 12-16 days.
- Swelling and pain - discomfort and pain occurs when the nerve endings located in the soft tissues are damaged. Unpleasant symptoms also appear with the development of swelling, against the background of compression of the nerve endings. In this case, it hurts to raise your arm, but the upper limb does not lose its natural functions.
- Inflammation of a joint or soft tissue is a response to destruction or damage to internal tissues or structures. The inflammatory process is accompanied by the expansion of small vascular structures and leads to their increased permeability. This is accompanied by increased blood flow, after which swelling occurs.
Sprains and bruises in the shoulder girdle are accompanied by fractures of the collarbone and scapula. In this case, complete or partial damage to the anatomical structures is observed. In this case, the hand on the side of the injury is not raised. A fracture is accompanied by severe pain and swelling. Pathological mobility and crepitus (crunching of bone fragments) occurs. The functions of the articular structures are also impaired, and shortening of the shoulder is noted. The injured limb stops moving, so the victim holds it with his healthy hand.
Simple bruises of the shoulder, in which there are no fractures or dislocations, are accompanied by minor damage to the peripheral nerve structures. This is accompanied by mild pain, numbness and a tingling sensation. There may be impairment of motor functions and paleness or redness of the skin in the area of damage. When fractures occur, nerves are usually damaged.
Why does clavicle dislocation occur?
A classic example of an injury in which the acromial end of the clavicle is dislocated is a fall on the shoulder. In this case, the ligaments connecting the collarbone and scapula are torn, and after this, the collarbone moves upward under the influence of muscle traction.
Of course, since there are several ligaments attached to the collarbone, various options for their rupture are possible. For example, only the capsule of the acromioclavicular joint may rupture - in this case, dislocation will not occur or there will be subluxation, since other ligaments will hold the collarbone. If other ligaments (conical and trapezoidal ligaments) are torn, the clavicle will dislocate.
Dislocation of the acromial end of the clavicle: on the left – incomplete (subluxation), the coracoclavicular ligament is intact; on the right - complete, the conical and trapezoid ligaments, which form a single coracoclavicular ligament, are torn.
We have described the simplest classification, but in reality everything is much more complicated. Among specialists involved in the treatment of shoulder injuries, it is customary to use the Rockwood classification, which distinguishes six types of dislocation.
Bruised collarbone in a child
When children receive injuries to the collarbone, a bruise appears in the damaged area. If mobility is maintained in the shoulder joint, then there is no dislocation. To prevent swelling and bruising from increasing in size, you should quickly apply ice or something cold to the skin (even frozen food from the refrigerator will do).
After providing such first aid, the child should go to a traumatologist, who should check whether the vessels are damaged and whether blood has accumulated in the joint. In the latter case, it should be pumped out, since it will not resolve on its own and will interfere with the normal functioning of the entire shoulder joint.
Symptoms of dislocation of the acromial end of the clavicle
Immediately after the injury, pain occurs in the shoulder girdle. If the dislocation is complete, then the collarbone sticks out, and, in some cases, it is possible to identify the symptom of a piano key: when you press on the collarbone, it is set instead (sinks down), but if you stop the pressure, it will immediately dislocate again. The absence of a key sign does not mean that everything is fine with the collarbone. Firstly, this symptom is not always easy to check due to the fact that in some patients pressing on the collarbone causes severe pain. Secondly, swelling occurs several hours after the injury. Thirdly, in obese people the collarbone may generally be poorly contoured.
When the acromial end of the clavicle is dislocated, the function of the arm is impaired - most often it is impossible to raise the arm above the shoulder or move the arm to the side.
A bruise appears around the collarbone (it is mistakenly called a hematoma, but in fact it is just a bruise - the subcutaneous fat is saturated with blood from the torn ligaments). Over the course of several days or even weeks, this bruise may increase in size and “slide” down.
The pain usually decreases within a few days, but we advise you not to wait, but to consult a doctor immediately.
How dangerous is a collarbone injury?
A bruise of the shoulder joint of the clavicle, at first glance, seems to be a harmless injury, unlike, say, bruises of internal organs, the consequences of which can cause internal bleeding, but this is not so. In some cases, the following complications may develop when the collarbone is damaged:
Blood accumulates in the joint after severe injury. There are many vessels in the joint capsule that can tear when bruised. With hemarthrosis, the joint enlarges, the contours smooth out, and the patient experiences an increase in pain. This complication can develop on the first day after injury.
A complication occurs when excessive fluid is released into the joint cavity. This occurs as a result of inflammatory changes in the joint after receiving a bruise. During treatment, the doctor performs a puncture of the joint, extracting a yellowish liquid.
Diagnosis of dislocation of the acromial end of the clavicle
The diagnosis of dislocation of the acromial end of the clavicle is sometimes very simple and everything is obvious upon examination, and sometimes you have to solve a whole puzzle. The most optimal and common diagnostic method is radiography. It is worth saying that, just as there are no identical people, there are no identical collarbones. Most often, the cause of a false diagnosis is the individual characteristics of the acromioclavicular joint.
Therefore, it is advisable to perform an x-ray of not one shoulder, but two at once - which will allow us to assess the normal structure of the opposite clavicle.
In doubtful cases, functional radiography is sometimes performed - a weight is placed in the arm, which pulls it down and the dislocation becomes more obvious.
Epidemiology
Clavicle injuries account for approximately 4% to 10% of bone trauma cases seen in emergency departments.
The vast majority of patients report a direct fall on the arm or a direct blow, most often occurring during outdoor activities. Men are injured more often than women by a ratio of 2:1 and usually at a younger age (on average 30 years versus 39).
More than 2/3 of fractures are localized in the middle third of the clavicle. Fractures of the sternal part account for about 2%, the rest involve the acromial end.
Clavicle injuries are usually treated conservatively with over one hundred existing modalities, most of which involve immobilization in a scarf until pain is relieved .
However, complications of conservative treatment (eg, shortening, deformation and malunion with pain and functional impairment), as well as the advent of new fixation methods and implants, have renewed interest in surgical fixation of clavicle fractures.
Treatment of dislocation of the acromial end of the clavicle
The optimal treatment method depends on the type of dislocation. Previously, in the vast majority of cases, conservative treatment was used, that is, they did not operate. The essence of this treatment was that for several weeks the patient was shackled in bulky and heavy devices that realigned and held the collarbone in the desired position.
Now conservative treatment is indicated for incomplete dislocations (subluxations), i.e. with type 1 or 2 dislocation according to Rockwood. In this case, a light, aesthetic and comfortable sling bandage is sufficient, which is worn for 3-5 weeks, depending on the type of damage to the capsule of the acromioclavicular joint. Next, a control X-ray is performed and a decision is made about rehabilitation - the bandage is removed and physical exercises begin.
On the first day after the injury, cold is applied, which reduces swelling and pain. Immobilization with a sling bandage in itself will significantly reduce the pain, but if it remains, you don’t need to endure it, tell your doctor about it and he will prescribe painkillers.
Subsequently, according to the doctor's decision, the sling bandage can be replaced with tape, which allows you to use the arm, but holds the collarbone. The tape bandage should only be applied by a specialist. For type I injuries, the tape bandage can be used from the very beginning.
First aid for a broken collarbone
Competent assistance to the victim in the first minutes after a collarbone fracture can improve treatment results and significantly shorten the recovery period. First you need to take care of calling an ambulance, after which you should:
- Give the injured person pain relief. The effect of tablets begins 15-30 minutes after administration, and solutions administered intravenously have an anesthetic effect 5-10 minutes after entering the blood;
- carry out immobilization , that is, apply a temporary bandage to reduce the mobility of the damaged area (8-shaped bandage; Delbe rings; scarf bandage; Deso bandage). At home, it is enough to apply a bandage.
- After fixing the injured collarbone, you can reduce the level of swelling by applying a cold compress . Crushed ice in a bag is ideal for these purposes.
Surgical treatment of dislocation of the acromial end of the clavicle
Before we talk about operations, we need to talk about why to operate at all. As we have already noted, with types 1 and 2 of dislocation, conservative treatment is indicated, since there is nothing to be done to operate (with rare exceptions) - the collarbone is already in place. But with type 3 dislocation, when the collarbone is completely pushed up, it is necessary to consider the possibility of surgery. Of course you can - what will happen if you don’t operate? The pain will go away with rest, the hematoma will resolve.
But the following problems are possible:
- Pain on exercise
- Decreased arm strength
An unreduced collarbone will stick out all the time, which is not only a cosmetic problem, but can also limit movement, in particular, the following may occur:
- Limitation of arm abduction, i.e. the arm often cannot be raised above the shoulder.
All these problems can lead to poor posture.
For some, all these possible consequences do not pose any problem at all, since there are people with extremely small physical needs. In any case, the operation to correct the clavicle is not aimed at saving life, so it is necessary to consider the advisability of surgical treatment based on the profession, lifestyle and needs of the patient.
In general, maximum recovery for complete dislocation of the acromial end of the clavicle (types 3, 4, 5 and 6 of dislocations) is possible only with surgical treatment, during which the clavicle is reduced and fixed.
A number of recent scientific studies have shown that for athletes and people with high physical demands, it is advisable not just surgical treatment, but the earliest possible surgical treatment, which allows to obtain the best results.
In most cases, the operation is performed under general anesthesia.
Doctors practice quite a large number of surgical options, but we will focus only on the most minimally traumatic and modern methods. They are the ones that are used in our clinic for surgical assistance.
Degree of injury
The clinical picture of injury to the shoulder girdle has different intensity of manifestation:
- Grade 1 - it hurts to raise your arm for 3-4 days. The presence of abrasions and other minor damage is possible.
- Grade 2 – hematomas and swelling are present. There is redness on the skin on the side of the injury. There is acute pain that does not subside even with complete immobility of the limb.
- Grade 3 – there is obvious redness of the skin. Tendons and muscle structures. Complications such as shoulder dislocation occur.
- Grade 4 – there is a pronounced bruise on the shoulder and there is a complete loss of motor functions. In this case, it is difficult to independently determine whether it is a bruise or a fracture. The hematoma can be large and even reach the elbow. Treatment takes at least 2-3 weeks.
Read also: Sprained ankle
Diagnostics
The clavicle is one of the few bones that can be palpated along its entire length. Hematoma, deformity, threatened skin perforation, or unusual mobility are easily identified .
X-ray examination usually includes anteroposterior and 30° oblique projections with the tube tilted cranially . However, if the decision regarding surgical treatment is influenced by shortening of the clavicle , the caudal 15 posteroanterior view is more reliable for comparing differences with the healthy side. Regardless of the cause of the injury, evaluation of clavicle injuries also includes examination of the vessels and nerves of both extremities.
First aid in hospital
Preparation for surgery is only necessary in severe cases. Although most clavicle fractures are hairline fractures, in some cases the break is severe enough to require surgery—about 5-10% of cases. Surgery is definitely necessary if the broken collarbone is diagnosed as a compound fracture. This means that the bone has broken into several fragments, there has been a tear in the skin, or parts of the collarbone are displaced. Surgery involves rearranging the bone fragments and holding them in place with special metal plates, pins or screws. The collarbone usually breaks in the middle, as opposed to the ends, which are attached to the sternum. Because there is rarely fat on the collarbone, you will likely be able to see and feel the hardware through the skin.
Plates and screws are usually not removed from the bone after healing unless they cause significant discomfort. Often the broken part becomes stronger after surgery compared to the uninjured side.
Due to its anatomical position, a cracked collarbone cannot be cast like a broken limb. Instead, a special hanging mitt or figure-of-eight splint is usually used for support and comfort immediately after the injury if it is a simple hairline fracture, or after surgery if it is a complex fracture. A figure eight splint is wrapped around both shoulders and the base of the neck to support the injured shoulder in an up and back position.
Sometimes more of the material is wrapped around the webbing to keep it closer to your body. You will need to wear the sling continuously until there is pain when moving your arms, this takes two to four weeks for children or four to eight weeks for adults. Slings come in different sizes, including those that are suitable for small children, because it is they who most often break the collarbone - this is the result of a fall on an outstretched hand.
Intramedullary osteosynthesis of the clavicle
Rigid rods or thick wires are not recommended for use due to the risk of implant migration and damage to adjacent neurovascular formations. However, titanium elastic rods have opened new perspectives for percutaneous intramedullary fixation (elastic stable intramedullary osteosynthesis/ESIN) of the clavicle. The patient is placed in a supine position on an X-ray transparent table .
A 2-cm incision is made above the sternal end of the clavicle, and a hole is made in the anterior cortical layer with a 2/5 mm drill. The insertion point is then widened with an awl in a slightly lateral direction. A titanium elastic 2.0-3.5 mm rod (TEN) is inserted with twisting movements and, under the control of an image intensifier, is passed through the fracture zone.
In approximately 50% of cases, closed reduction fails . The fragments are then exposed with a 2-cm incision above the fracture, allowing direct exposure and reduction. The end of the TEN is passed as far as possible laterally without perforating the cortex. After this, the medial end of the rod is cut off and it must be immersed subcutaneously. New rounded end caps prevent back migration of the rod. Immobilization in the postoperative period is not necessary.
When using this method for comminuted fractures, shoulder abduction is limited to 90° for the first three weeks. Removal of the hardware is not mandatory, but can be done after 8 months (at least) from the old sternal approach. The first results of this method are promising, with good pain relief and significant improvement in shoulder function.
Patients with concomitant lower extremity injuries are able to walk with crutches within the first week. Possible complications include painful skin irritation from the protruding end of the rod (6%).
In a comparative study, the nonunion rate was lower and the cosmetic and functional results were better than with conservative treatment. Secondary shortening may occur, therefore, for comminuted fractures, osteosynthesis with a plate remains preferable .
Why should you turn to Scandinavian traumatologists?
Patients with fractures and other traumatic injuries choose the Scandinavia clinic rather than state emergency rooms because:
- We have traumatologists with more than 5 years of experience who can conduct a full diagnosis and select treatment to restore your condition in the shortest possible time;
- The clinic is equipped with modern X-ray machines and tomographs, which allows all necessary studies to be carried out in one place.
For patients who are indicated for osteosynthesis, we have equipped a comfortable hospital with television and Wi-Fi in the clinic. We also accept nonresident citizens: you can find out more by calling the clinic.
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Classification
Allman distinguishes three sections in the clavicle: group I is the middle third, groups II and III are the outer and medial thirds . For each group there are three subgroups :
- “a” - unbiased,
- “b” - shifted,
- “c” - comminuted types of fractures.
The OTA classification distinguishes the medial end, diaphysis and lateral end . nine subgroups in the diaphysis , similar to the subgroups of the Muller-AO classification for fractures of long tubular bones, in which the clavicle is designated code 15 .