Multiplanar and posterior shoulder instability

The shoulder joint is the most mobile joint in the human body because it can move in all three planes. The joint itself consists of the articular surface of the scapula (glenoid cavity), the head of the humerus, which absolutely matches the shape of the cavity, and the clavicle. The head of the humerus is held in position by the cartilage cushion that lines the edge of the glenoid cavity and the connective tissue that forms the joint capsule. The muscles and tendons surrounding the joint provide it with stability and strength.

But it is precisely this mobility that is responsible for shoulder dislocations and injuries (due to the fact that the area of ​​contact of the articular surfaces is small). A shoulder dislocation is a instability in which the head of the humerus falls out of the glenoid socket as a result of physical force. Dislocations of the humerus in the shoulder joint are anterior (most common), posterior and inferior (depending on the direction of displacement of the head of the humerus).

Diagnostics.

Diagnosis of a dislocation includes a detailed examination of the patient, palpation of the damaged joint and the appointment of x-rays in two projections of the damaged joint. Using the obtained x-ray, the doctor identifies the type of dislocation, whether there is a fracture, and determines the method of reduction. In more serious cases, the doctor may prescribe computed tomography and magnetic resonance imaging to clarify the diagnosis. If there are serious injuries, consultation with a surgeon is necessary.

Main types.

The classification is quite extensive and is carried out according to various indicators. It is customary to distinguish congenital (with joint dysplasia) and acquired types over time. The latter is divided into:

• Primary traumatic. Accounts for more than 50% of the instability. Occurs when the upper limb is hit, falls on the shoulder, or jerking movements. Athletes are at risk.
• Habitual. Occurs due to unstable joint function. The cause may be an untreated injury (fracture, capsule disruption), as well as connective tissue dysplasia, muscle weakness when there is a load on the joint.

Dislocations are also classified by location:

• 1. Front. One of the most common, accompanied by a displacement to the front of the shoulder. Its consequence is a Bankart injury - a separation of the anterior part of the labrum.
• 3. Rear. Characterized by a backward shift. An uncommon occurrence, it occurs when a person falls on his arms extended forward. As a result, the posterior part of the labrum may become damaged.
• 3. Lower. In this case, the victim is unable to return the limb to its natural position and holds it above the body. The injured part moves downwards.

According to the time that has passed since the injury, dislocations are distinguished:

• Fresh (up to three days).
• Stale (from three days to three weeks).
• Old (more than three weeks old).

The success of subsequent treatment and recovery depends on this indicator.

Treatment of humeral dislocations.

To restore normal functioning of the shoulder joint, the victim must be urgently taken to the traumatology department, where he will receive qualified assistance.

When a shoulder is dislocated, treatment occurs in several stages.

1. Anesthesia (local anesthesia or general anesthesia, determined by the doctor)
2. Reduction of dislocation (conservative or surgical, according to indications)
3. Immobilization (additional fixation of the reduced dislocation using bandages or a plaster cast, duration 3-6 weeks)
4. Taking painkillers and anti-inflammatory medications
5. Rehabilitation

Treatment.

Today there are several main treatment methods:

• 1. In a practical way, when the dislocation is simply reduced. In the clinic this is carried out with preliminary anesthesia.
• 2. Minimally invasive method - using arthroscopy. If it is prescribed, then two miniature incisions are made to the patient under anesthesia; an arthroscope with a camera is inserted through one, and surgical instruments are inserted through the second. A high-quality image is displayed on the screen, which allows you to diagnose the problem and immediately carry out treatment. In case of habitual dislocation, anatomically damaged structures are most accurately diagnosed arthroscopically. After this, the doctor has the opportunity to fix the torn parts of the labrum and ligaments. To do this, there are many different methods and modifications of operations, the choice of which depends on the damage in each individual case. Arthroscopy is a gentle type of intervention, and most patients go home on the day of its procedure.
• 3. Using open surgery. In recent years it has been used rarely and only in the most difficult situations.

After the operation, the limb is subject to immobilization for some time. Then it is necessary to undergo a rehabilitation course, consisting of a set of measures: massage, physiotherapy, magnetic therapy and exercise therapy. The rehabilitation department has a full arsenal of services from the best specialists. Which procedures will be prescribed depends on the characteristics of the injury, as well as the treatment plan.

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Recovery after a dislocated shoulder.

Rehabilitation measures take place in several stages. At the initial stage, in the first week after the injury, the patient is given rest with limitation of any actions in the shoulder joint, cold compresses are used, and the doctor prescribes electrophoresis. It is recommended to lightly warm up the hands and wrists (to prevent future atrophy of the arm muscles). At the next stages, exercises for developing the arm are gradually strengthened (a set of exercises is selected individually for each patient), and various physiotherapeutic procedures are prescribed. By strictly following all the recommendations of your doctor, continuing to do gymnastics to develop the joint and observing basic safety requirements, you can avoid serious consequences (for example, repeated dislocation, etc.)

Publications in the media

Frequency: 50–60% of all dislocations.

Anatomical features of the shoulder joint • The glenoid cavity is 3–4 times smaller than the articular surface of the humeral head • Spherical shape of the humeral head • Thin and extensive articular capsule.

Etiology - trauma • Falling backwards onto an outstretched arm • Falling forward onto an outstretched or abducted arm.

Classification is based on the position of the head of the dislocated humerus • Anterior dislocation - the head of the humerus is displaced anteriorly (98% of all shoulder dislocations) • Posterior dislocation - the head is displaced posteriorly • Inferior dislocation - the head is displaced inferiorly.

Pathomorphology. The joint capsule always ruptures. There are tears or separations of muscle tendons (especially the supraspinatus). In 10–40%, avulsion of the greater tubercle is detected, less often - of the lesser tubercle of the humerus.

Clinical picture • Diffuse pain in the joint area • Lack of active movements, a symptom of springy fixation, the elbow joint is not brought to the body • The shoulder girdle is lowered, the patient’s head is tilted to the injured side. The injured arm is supported by the healthy arm • The arm is abducted, bent at the elbow joint, seems elongated • The axis of the shoulder continues upward and passes through the collarbone (normally through the acromial process of the scapula) • The distance from the acromial process to the lateral condyle of the shoulder is lengthened • The relief of the deltoid muscle is flattened, sharp delineation of the acromion process, retraction of the soft tissues underneath • The head of the humerus is palpated under the coracoid process or in the axilla (easier with rotational movements of the shoulder) • Tension of the muscles surrounding the joint (especially the deltoid) • When the head of the humerus compresses the neurovascular bundle: cyanosis, pallor of the skin, decreased sensitivity, paresthesia, weakened pulse on the radial artery • With a fracture of the surgical neck - the shoulder is shortened and not abducted, there is no symptom of spring fixation, crepitus • Dislocation of the humerus, combined with an impacted fracture of the surgical neck, is difficult to diagnose. During reduction, the fracture may separate.

Diagnosis : X-ray examination in two perpendicular projections.

Treatment

• Anesthesia or local anesthesia 30–40 ml of 1% procaine solution after injection of 1 ml of 1% trimeperidine solution.

• Reduction of dislocation •• The Kocher technique is based on the use of a lever action. They consistently reproduce the movements made by the limb when a dislocation occurs, but in the reverse order. The patient is seated on a chair, the assistant holds the patient with a towel, an 8-shaped loop covering the damaged shoulder joint in the armpit. The surgeon brings the patient's arm bent at the elbow joint, moves it down along the axis of the shoulder, performs external rotation and smoothly moves the shoulder forward and to the midline (reduction often occurs at this moment). The last movement is throwing the forearm onto the healthy forearm with medial rotation of the shoulder •• Dzhanelidze method. The patient lies on his side for 10–20 minutes so that the dislocated arm hangs down freely. After relaxing the muscles, the surgeon grabs the flexed forearm and presses it closer to the elbow, combining pressure with slight rotational movements in the shoulder joint. In this case, reduction occurs.

• After reduction, X-ray control is carried out and the shoulder joint is fixed with a Deso plaster cast for 4 weeks with the simultaneous administration of physiomechanical therapy (UHF, diadynamic currents, then ozokerite, mud applications, massage, exercise therapy).

• For irreducible dislocations - surgical treatment.

ICD-10 • S43.0 Shoulder dislocation

Treatment of shoulder instability

Many cases of posterior and most cases of multiplanar instability can be successfully treated conservatively.

treatment, which consists of changing the nature of activity and general physical therapy aimed at strengthening the muscles and stabilizing the scapula.

To operational

treatment is resorted to when the possibilities of conservative measures have been exhausted and have not brought results. Good results are achieved with arthroscopic fixation of the posterior part of the labrum with various anchors. Arthroscopy is the procedure of choice for chronic posterior shoulder instability

Rehabilitation

Rehabilitation in such patients occurs gradually. Joint stiffness is rare and an overly vigorous rehabilitation program increases the risk of recurrent instability.

For 5 weeks, the patient is prescribed immobilization on an abduction pad in a neutral position. From the 5th fifth week active movements are allowed. From the 8th week, exercises focused on active and actively-accompanied movements begin. Passive movements are not allowed.

From 3 months, isometric exercises and exercises for the shoulder blade begin. The patient gradually regains strength by 4 months. Patients return to a sports regimen without restrictions within 5-6 months.

Shoulder joint – lateral and medial displacement during reverse arthroplasty

function and complication rates through improved prosthetic design, or whether these results are an inevitable consequence of the patient's aging and changing activity levels.

The lateral displacement design also demonstrated significant improvement in outcomes in patients with more than 2 years of follow-up. One of the early criticisms of the design was the higher failure rate of the base plate, but the new base plate design reduced the failure rate to 0.3%. One design was notable for reducing the incidence of mechanical failure, scapular ulceration, and overall complications in short-term outcomes. Medium- and long-term results also led to cautious optimism. In a sample of 94 patients with a 5-year follow-up period, the prosthesis demonstrated a survival rate of 94% and resulted in significantly improved clinical outcomes—comparable to those of the Grammont prosthesis—with a lower scapular usuration rate of 9%. In a subsequent 10-year study of the same cohort, implant survival was 90%, and patients maintained functional improvement but showed reduced motion in all planes compared with short-term follow-up. A study of young, highly active patients (<55 years) with prote lateralization showed significantly improved clinical outcomes over the medium term (mean 60 months) without deterioration. In an intact population, McFarland et al followed 42 patients and found a 2% failure rate at a minimum 2-year follow-up in patients with lateralized RTSA displacement without bone grafting, and patients again had significantly improved outcome rates. Ultimately, both medialized and lateralized implants demonstrated improved clinical outcomes and good long-term survival. Whether long-term decline in movement and function may be due to implant design or patient factors has not yet been determined.

Conclusion

Much information has been published regarding the biomechanical principles, successes, and limitations of medialized and lateralized offset glenosphere designs. In addition, a series of clinical results have also supported the successful use of any type of component in the treatment of shoulder pathology with and without rotator cuff disease in both primary and revision surgery. From what is available in the literature, each implant system has advantages and disadvantages that appear to be inherent to their individual design. Although lateralized glenospheres were initially a source of failure due to poor glenoid engineering, recent developments seem to be succeeding over time and achieving their goals. The biomechanical principles that Paul Grammont described in his medialized design still hold true today, and this design has an impressive track record of good long-term clinical results. More recently, the discussion about glenoid side lateralization has evolved into a more complex discussion about humeral side design with varying angulations from the initial 155 degrees of Grammont to the more anatomical 135 degrees of Frankl. Recent implants have begun to offer options that range between the two extremes, and research has focused on the "ideal" combination of glenoid and humeral side implants to achieve optimal range of motion, stability, and function. Although there currently does not appear to be a single superior component on either the glenoid or humeral side, there is sufficient data to demonstrate the potential risks and benefits of each design. In addition, each patient in practice may require the surgeon to take advantage of different aspects of medialized or lateralized displacement. Overall, there is a long history of both medialized and lateralized designs, and

Types of deviation

The type of pathology depends on the intensity and type of displacement. The joint can deviate in the vertical or horizontal plane (there is also a combined displacement).

There are 3 types of pathology that appear for the following reasons:

• Severe injuries - dislocations or subluxations due to blows and bruises. Displacement occurs, causing rotator cuff instability. Because of this, functionality is impaired and mobility is reduced. Scar tissue gradually forms, which increasingly impairs functionality and leads to the pathology becoming chronic.

• Sprains of the joint capsule - appear due to increased mobility or regular physical activity. This leads to a decrease in the stability of the joint capsule, which in the future will provoke dislocation or subluxation.
• Instability in the horizontal or vertical plane - appears in childhood and represents hyperelasticity. It manifests itself in the form of discomfort during physical activity, as the shoulder joint is greatly displaced.

How is Bankart surgery performed at the CELT clinic?

Posterior and anterior instability of the shoulder joint in the CELT clinic is eliminated arthroscopically and does not require an incision. Through minimal punctures, the length of which does not exceed two centimeters, our specialists insert an arthroscope and special manipulative instruments into the joint.

Arthroscopy allows you to diagnose damage to the joint from the inside. Using manipulators, a new articular labrum is formed from the articular capsule, which is fixed to the bone using special anchors. Anchor clamps are special devices with strong threads and a clamp located at one end. They can be made of metal or absorbable materials.

If ruptures of the articular labrum or periosteal muscle are detected during the operation, they are eliminated.

Literary sources[edit | edit code]

• Brophy RH, Marx RG: Osteoarthritis following shoulder instability. Clin Sports Med 2005;24(1):47.
• Good CR, Macgillivray JD: Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment. CurrOpin Pediatr 2005;17(1):25.
• Kim SH et al: Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med 2004; 32(8): 1849.
• Kim SH et al: Loss of chondrolabral containment of the glenohumeral joint in atraumatic posteroinferior multidirectional instability. J Bone Joint Surg Am 2005;87-A(l):92. *Kirkley A et al: Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Ar-throscopy 2005;21(1):55.
• Krishnan SG et al: A soft tissue attempt to stabilize the multiply operated glenohumeral joint with multidirectional instability. Clin Orthop 2004;(429):256.
• Safran O et al: Posterior humeral avulsion of the gle no-humeral ligament as a cause of posterior shoulder instability. A case report. J Bone Joint Surg Am 2004;86-A( 12):2732.

Treatment of pathology

Treatment begins with conservative methods, which include physical exercises to strengthen the pectoral and latissimus dorsi muscles. Physical therapy should not cause discomfort, as this will only worsen the problem. Additionally, anti-inflammatory and painkillers are prescribed in the presence of acute symptoms. In more than 50% of cases, surgery can be done without surgery.

If it is not possible to achieve a positive result, then surgical treatment is prescribed - open surgery or arthroscopy (minimally invasive method). After the operation, a long recovery is required, which includes exercise therapy, physiotherapy and medication.

Why do they trust us and choose CELT?

The effectiveness of treatment in the multidisciplinary CELT clinic is due to an integrated approach, a thorough diagnostic examination and the use of gentle surgical treatment methods.

Bankart operation is carried out:

• using modern arthroscopic equipment, which eliminates joint depressurization and injury to periarticular tissues;
• with anesthesia selected individually in accordance with the wishes of the patient, which eliminates any discomfort during the intervention;
• experienced specialists who have not only successfully performed dozens of operations in this area and achieved excellent results, but also conduct training courses on arthroscopic shoulder joint surgery for other traumatologists.

In our clinic you can not only perform Bankart surgery, but also receive professional advice from specialists in various fields.

Causes of injury

Common causes of recurrent shoulder dislocation:

1. Features of the structure of the bones of a particular person.

2. Violation of the integrity of the joint due to impacts or sudden movements. A common injury is avulsion of the labrum, which is reconstructed during the Bankart procedure.

3. Complications after injuries arising due to premature physical activity, late consultation with a doctor, improper treatment of primary dislocation, early refusal of immobilization;

4. Formation of scars during the healing of injured tissues surrounding the joint, the appearance of muscle imbalance.