A shoulder dislocation is a type of injury to the shoulder joint. At first glance, it may seem that a pathology of this kind affects only athletes or people whose lives are associated with heavy and dangerous physical activity. In fact, this point of view is wrong.
Injury, including dislocation, of the articular apparatus of the shoulder is a condition in which the connection of the surfaces of its elements is torn. Even minor loads, a powerful blow, an unsuccessful fall, lifting a heavy load, light exercise, or a game of beach volleyball with friends can cause a dislocation in the shoulder. As a result, the affected person feels severe pain, and the mobility of the joint and limb is significantly limited.
The structure of the shoulder joint, the causes of dislocations
Content:
- The structure of the shoulder joint, the causes of dislocations
- Symptoms and types of shoulder dislocations
- What is a habitual shoulder dislocation?
- Treatment methods for habitual dislocation
- Main types of shoulder surgery
- Indications and process of preparation for surgery
- How the surgical procedure occurs: modern arthroscopy methods
- Basic shoulder joint intervention techniques
- Features of the rehabilitation period
The shoulder joint is a system that connects the upper limb of the human body with the shoulder girdle of the body, namely the scapula.
The spherical head of the humerus, the element that forms the skeleton of the arm, is involved in the formation of the joint. The glenoid cavity articulates with it - the concave zone of the scapula, which looks like a pit with a flat bottom. Along the edge of the circumference of the fossa there is an articular lip formed by cartilage tissue. This element is designed to increase the area of the socket without limiting the mobility of the joint head. In addition, the lip of the joint softens shocks and shocks when the head moves, acting as a shock absorber.
Between the bony edge of the head of the joint, a capsule is attached to the glenoid cavity - it covers the humeral head and ends at the anatomical neck.
From the base of the coracoid process, a dense bundle of fibers is woven into the articular capsule - it plays the role of an additional ligament of the articular surfaces.
Strengthening and maintaining the elements of the joint occurs, for the most part, due to the muscular corset. It would be impractical to tie them together with dense, strong ligaments, since the working mobility of the shoulder is achieved precisely due to the free rotation of the articular head in the cavity on the scapula.
Dislocation means that the normal state of the joint is disrupted, and its elements are in places that do not correspond to their normal location. The structural parts of the joint are displaced, shifted, or even leave their intended place (this mainly concerns the articular head).
The main causes of shoulder dislocation are joint diseases, physical activity, impacts, falls, inflammatory processes, unnatural rotation of the limb.
Symptoms and types of shoulder dislocations
A dislocated shoulder in an acute condition can be easily identified by its manifestations:
- constant pain syndrome;
- swelling in the shoulder area;
- stiffness of the joint, disruption of its motor function;
- loss of sensation in the shoulder and arm;
- if the dislocation is significant, the doctor can feel the deformation of the articular apparatus.
Depending on how exactly the system of joint elements is disrupted, anterior, lower and posterior dislocations are distinguished.
The first of these is considered the most common. With an anterior dislocation, the head of the humerus moves forward, towards the coracoid process or clavicle. A lower dislocation involves a downward displacement of the head, due to which a person cannot lower his arm. A person can receive a posterior type of injury by falling forward onto outstretched arms. In this case, the articular labrum is separated from the socket in the articular apparatus.
Classification of pathology
The TMJ joint is very mobile, all this makes it extremely susceptible to subluxation/dislocation. But we must take into account that subluxation is a partial deviation of the natural position of the head of the jaw, and dislocation is a complete displacement with the exit of this part of the TMJ from the articular fossa.
In addition, the pathology is also divided into unilateral and bilateral displacement, that is, displacement can be observed simultaneously on both sides or only on the right/left. In addition, the disease can develop in an acute or chronic degree. Based on the cause of its occurrence, the disease can be divided into traumatic or habitual dislocation. In the first case, the cause of the disease is external influences and injuries. In the second, the pathology is caused by various diseases.
What is a habitual shoulder dislocation?
For some people who have experienced this unpleasant injury, it becomes common for the joint apparatus to return to normal after treatment. The affected person complies with all the requirements of the rehabilitation period, protects the shoulder from stress, and fulfills all the doctor’s requirements. It seems that the injury is over, recovery has begun, and you can return to a normal lifestyle again.
However, as soon as a person loads the recovered shoulder with his normal life activity, the joint again suffers from dislocation.
If a patient develops a pathology called “habitual shoulder dislocation”, with any load or sudden movement he will experience dislocations after the dislocation has once been cured. The root cause of this condition in most cases is damage to the labrum, due to which the constituent elements of the joint cannot be properly fixed in relation to each other.
Treatment methods for habitual dislocation
The doctor to whom patients with such an injury usually turn is a traumatologist or surgeon. These specialists, after conducting an initial examination and interviewing the patient, determining his condition of habitual dislocation, can prescribe treatment regimens that are based on conservative therapy or surgical intervention.
Conservative treatment is most often ineffective for habitual dislocation. If their number in a patient does not exceed two or three cases, you can try massage courses in combination with a complex of physical therapy. During this type of treatment, measures must be taken to limit abduction and external rotation in the joint.
If conservative methods do not produce results, and dislocations recur, the only effective way to get rid of them is surgery. This method is aimed at eliminating the cause of constantly recurrent dislocation, while maintaining maximum joint mobility. In this way, it is possible to prevent relapses of the pathology.
How to prepare for the procedure
First of all, the patient is examined in order to objectively recognize the fracture and select the optimal treatment method. Typically this examination includes:
- studying the patient’s complaints and collecting anamnesis by the doctor;
- physical examination, palpation, axial load tenderness tests;
- radiography of the wrist bones in 3 projections;
- CT and MRI are used as additional studies if difficulties arise in diagnosing a fracture.
Persons with purulent-inflammatory skin diseases, wounds in the intervention area, or neurotrophic syndrome (Sudeck syndrome) are not allowed to participate in osteosynthesis.
Main types of shoulder surgery
Treatment of pathology includes up to 200 types of surgical intervention in the articular apparatus. In general, all types of operations for habitual shoulder dislocation can be divided into 4 main groups:
- strengthening the joint capsule;
- plastic interventions on muscles and tendons;
- osteoplastic procedures with implantation of grafts;
- mixed types of operations.
Indications and process of preparation for surgery
The appointment of a surgical intervention of this nature is usually preceded by establishing the diagnosis and the number of recurrences of dislocation, examining the condition of the joint and the degree of its damage. Thus, referring a patient for such an operation is possible if several conditions are met:
- the presence of confirmed repeated dislocation of the shoulder joint;
- ineffectiveness of conservative treatment methods.
Accordingly, the indication for surgery is a habitual shoulder dislocation - one that is repeated constantly under any type of load on the joint.
Preparatory activities include passing some tests that are necessary for the doctor to properly plan the use of anesthesia, as well as to select the technique for performing the operation. So, the surgeon can refer the patient to undergo a general blood test, coagulogram and blood biochemistry.
At the time of prescribing the operation, the doctor must have current X-ray or MRI results of the affected joint.
The intervention can take place using several types of anesthesia, namely local or general anesthesia, so the day before, 8-10 hours before, the patient needs to refrain from eating and drinking.
Reasons for the development of the disease
The causes of the pathology are:
- excessive displacement of part of the joint, overcoming the traction of the ligaments;
- weakening of the TMJ, which allows the head to freely come out and move.
These two mechanisms cause the following phenomena:
- mouth opening becomes excessive;
- the joint is exposed to a traumatic effect from the outside;
- it becomes difficult for the patient to bite and chew;
- dislocation develops with any pressure on the joint, even the smallest.
It should be borne in mind that pathology can develop even in completely healthy people. In this case, the cause will be a strong impact on the jaw, injury. Among the reasons for the development of dislocation in the remaining groups are arthritis, severe weakening of the ligaments, and lack of treatment for TMJ subluxation.
How the surgical procedure occurs: modern arthroscopy methods
Whenever possible, joint surgery is performed through arthroscopy. Arthroscopy refers to the surgeon's method of accessing the surgical field. It eliminates the need to make large incisions and, accordingly, significant tissue trauma. In addition, it takes into account the features of the complex structure of the articular apparatus more than classical open surgery.
The operating process looks like this: the patient is secured on a couch or in a special chair. It should take the most comfortable position, and to ensure complete immobility it is additionally secured with bolsters and belts.
After administering anesthesia, the surgeon treats the surgical field in accordance with aseptic requirements. When the anesthesia takes effect, the doctor makes a small incision and through it inserts an arthroscope into the shoulder - a flexible hollow tube with sensitive optics.
In order for the surgeon to have a better view of the field of activity, a sterile fluid is pumped through a tube into the joint, causing it to swell somewhat and make it easier to see. Several small incisions are made to allow instruments and cannulas to be inserted.
Having completed the necessary manipulations, the doctor removes the arthroscope and all his instruments, processes the incisions, and applies sutures or special patches to them.
Features of the procedure
The choice of osteosynthesis technique is made by the doctor, taking into account the location, nature of the fracture and the time that has passed since the injury.
The operation is performed using local or regional anesthesia. The incision for surgical procedures is made on the side of the palm or on the back of the wrist. After this, the surgeon compares the displaced bone fragments and fixes them with a special screw for long-term stabilization. The correct restoration and retention of the bone is monitored using x-rays.
In situations where the scaphoid bone breaks into more than 2 pieces, the use of a bone graft is recommended. It is a synthetic analogue of bone tissue. It is placed around the damaged bone to stimulate healing. The proximal scaphoid fragment is removed if it is less than 4/3 in size and affected by avascular necrosis. In cases of pseudarthrosis, osteoplastic arthrodeses are performed using a graft.
After surgery, the limb is immobilized by applying a plaster splint or orthosis to the area from the heads of the metacarpal bones to the middle third of the forearm for a period of 8-12 weeks.
Basic shoulder joint intervention techniques
Most often, in surgery of the shoulder joints, doctors resort to several methods of intervention, which are named after the surgeons who proposed them - operations according to Seidel, according to Bankart, according to Weinstein, according to Boychev, Andreev, Latarge or Gendeson.
Seidel surgery
This treatment is based on cutting the tendon of the subscapularis muscle - in this way the surgeon achieves intermuscular balance. In addition, this method makes it possible to strengthen the anterior-inferior part of the capsule. It can be exposed by applying a longitudinal excision of the anterior internal humeral surface, from the acromion process to the deltoid muscle.
If the patient has external rotation of the shoulder, an incision is made in the subscapularis muscle in a transverse manner in the area where it attaches to the lesser tubercle of the humerus. A fascial flap from the thigh is taken in sizes up to 10 centimeters in length and up to 3 centimeters in width. This fascia is first fixed to the capsule in the area of the lower pole zone of the joint cavity with one of the ends, and then gradually laid on the capsule from the bottom up and from the inside outwards in an oblique direction. The fascia is fixed to the capsule along its entire length up to the outer upper edge of the dissected deltoid muscle, after which the free end of the tape is brought under the muscle bundle of the fascia and secured in the area of the humeral process of the scapula.
The wound is sutured in layers, and then a diverting plaster is applied to it - in this way it is possible to achieve immobilization of the joint during recovery and recovery.
After about a month and a half, the period of postoperative rehabilitation ends.
Operation Bankart
In this case, the capsule is strengthened by moving the long head of the biceps muscle to the anterior part of the head of the joint. The subscapularis muscle lengthens. This type of surgery is considered minimally invasive and makes it possible to qualitatively strengthen the articular apparatus by re-fixing the damaged lip of the joint. Using special anchors, a new lip is formed from the joint capsule, after which it is fixed to the bone with anchor clamps. Tears of the biceps muscle or the lip itself identified during the operation must be removed.
Weinstein's operation
In the process, the surgeon lengthens the subscapularis muscle and moves the tendon of the long head of the biceps brachii muscle to the anterior surface of the head of the bone. Access for the operation is formed along the groove separating the pectoralis major and deltoid muscles, and they must be moved apart. The deep fascia is subjected to longitudinal excision, after which the short head of the biceps muscle and the coracobrachialis muscle are displaced inward.
The intertubercular groove must be opened - in this way the tendon part is exposed along the length of the head of the biceps muscle. With external rotation of the shoulder, it is thrown over the lesser tubercle towards the inside and placed in front of the humeral head. The upper part of the tendon is fixed in the area of the proximal segment of the excised subscapularis muscle, the lower part is attached to the lesser tubercle. The subscapularis muscle is sutured and lengthened over the used tendon. The wound is sutured and a soft bandage is applied to it. A week later, the doctor removes the stitches, and after that the patient must gradually begin therapeutic exercises.
Surgical intervention according to Boychev
It is produced to create a thickening in the area of the anterior edge of the articular process. Thus, the tendons of the short head of the biceps muscle and the coracobrachialis muscle, as well as the outer region of the pectoralis minor, are cut off from the coracoid process. A tunnel is formed from top to bottom, through which the cut off muscles are passed behind the subscapularis. Next, they are fixed in place, strengthened on the coracoid process.
After suturing, the person must be provided with complete immobilization of the upper limb for 10-12 days.
Andreev's operation
Its essence is similar to the previous operation algorithm, except that the outer part of the pectoralis minor muscle in this case cannot be cut off.
Operation Latarget
It is prescribed if the patient has a loss of the bone lobe of the anterior edge of the glenoid cavity on the scapula. The operation is performed with the movement of the coracoid process and the muscle fixed on it to the anterior-inferior edge of the glenoid cavity. In this place it must be fixed. This way it is possible to replenish the missing bone mass in this place. The Latarge operation is considered one of the most effective - it is successful in 97-98% of cases.
Henderson operation
It is prescribed to form the tendon ligament between the shoulder and the acromion process. The incision in this case has an epaulette-like shape - through it the acromial clavicular joint and deltoid muscle are exposed. After muscle dissection, drilling is performed in the acromion process and the greater humeral tubercle through a canal into which the peroneus longus tendon is inserted. The tendon is taken at a length approximately half its thickness. It is pulled tight and the ends are sewn together. After suturing, it is necessary to ensure complete rest of the limb for 10-12 days.
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Operative orthopedics and traumatology (Boychev B.) – part 14
Atypical operations on the shoulder joint 225
drawn plan. Often it is started as a subsurgical arthrotomy, and after that
it takes one direction or the other depending on the find. Elements,
to be examined are the following: tendons and muscles near the shoulder joint,
mucous bags and bone structures in relation to exostoses. The main types of
the irregularities in these cases are:
1. Excision of adhesions and setting in motion the so-called. “fixed” shoulder.
2. Excision of abnormal calcareous deposits.
3. Restoration of incomplete ruptures of tendons and muscles. 4. Exostosectomy.
Situation of the patient. The patient lies on his healthy side or back
with a pillow under the shoulder blades.
ABOUT PAIN. Local, conduction anesthesia or general.
Technique . The operation is performed in three stages: 1) arthrotomy, 2) exploration and
3) the main stage of the intervention.
A r t r o t o m i . The most suitable in this case is transacromi-
nal access. The incision starts from the posterior edge of the acromion, passes it past and
parallel to the acromioclavicular joint and lead 3-5 cm anteriorly and downward.
The anterior shoulder of the incision is deepened and, reaching the fibers of m. deltoides, penetrate through
them. Here you need to be very careful not to damage p. axillaris or
its ramifications. To avoid this danger, m. deltoides should not be dissected more than 4 cm from its origin. After this, the wound is opened in front of the acro-
mion and supply lig. coracoacromiale, which is dissected and retracted. The wound is wide
They are opened with dilators and the limb is rotated either outward or inward. This gives
the opportunity to examine the entire area around the head, and, if necessary, perform inter-
mischief. If the field is not wide enough, you can separate some of the fibers
m. deltoides from the acromion and pull them down. If this does not provide sufficient
precise opening, which happens when work is carried out in the zenithal part of the joint capsule,
shows the cutting off of the acromion in a plane parallel to the acromioclavicular joint. Fragment together with m. deltoides are retracted outward and downward. If it is necessary to open
joint, it is best to do this by making a longitudinal incision of the capsule along the lig.
coracocapsulare (space between the m. subscapularis and the tendon of the m. supraspinatus).
The further course of the operation depends on the findings.
1. Excision of severe adhesions. In essence, it starts with
pulling moment m. deltoides together with a fragment of the acromion downwards, since when
This manipulation breaks or dissects all adhesions between m. bursa subacro-
mialis etc. deltoides. However, dissection of these adhesions is not sufficient. You need them
cut with a sharp knife or scissors and remove. After this, the lig is dissected. coraco-
acromiale and adhesions in this area are also excised and removed. After release
shoulder from all fusions, it is necessary to try to make all movements, and this is not always easy and safe. You need to be especially careful during abduction and
external rotation of the limb, since if these movements are abused and reduced,
This can cause anterior or subglenoid subluxation of the joint or a neck fracture.
2. Removing limescale deposits. Most often x is found
along the tendon m. supraspinatus under the acromion. Having reached this place, you can
see and feel the rough fibrous shell of calcareous deposits. It was opened
cut longitudinally, open and scrape out lime deposits, and the cavity is washed with a strong stream of saline solution. After this, the fibrous tissues are excised
the walls and both edges of the surgical wound are sutured with separate sutures.
3. Suturing ruptures in the tendon - muscle cuff -
t s (shells) of the shoulder. Meticulous exploration is of great importance for discovering
opening a gap that at first glance may escape attention. For
To properly open deep tears, use an incision along the lig. coracocap-
sulare. The muscle is everted and the location and size of the tear is determined, if it is found -
in its deepest part. After this, the muscle is cut at the level of the rupture and
on the border between m. supraspinatus and t. infraspinatus (behind) make a third incision, which
which is almost parallel to the first (passing campaign lig. coracocapsulare). Here the image
a flap is cut from m. supraspinatus, which is lifted upward and excised fibrously
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