Subluxation or dislocation shoulder joint very common domestic injury. Therefore, if not everyone, then as many people as possible should know how to straighten the shoulder on their own or help the victim. Often such injuries occur on vacation, away from medical centers, and have to cope without doctors.

The shoulder joint is the third largest joint of the human skeleton, formed by the scapula and the head of the humerus.

Dislocations are of various nature and severity:

1. Habitual - a dislocation that recurs periodically due to an anatomical disorder, trauma at birth, or as a result of unskilled reduction of a traumatic dislocation;
2. Traumatic dislocation - occurs due to mechanical impact on the joint.

The severity of the injury is determined by:

• Dislocation - when, when the head leaves the humerus, the ligaments, the articular capsule, and often the nearby muscles of the shoulder are damaged;
• Subluxation - a slight separation of the bones of the joint from each other with trauma to the ligament system, but without ruptures of the soft tissues. The danger of subluxation lies in its apparent safety. Often it can be taken simply for a bruise and not seek timely help, which can subsequently adversely affect the health of the joint.

Diagnostics and first aid

Dislocation of any joint is extremely painful and leads to complete immobilization of the limb. The reduction of the dislocation must be done very quickly, literally in the first 5-10 minutes after the head falls out, otherwise the edema and muscle spasm will not allow needed help and further surgery may be required.

Symptoms

Violation shoulder anatomy occurs after a sharp push of an outstretched hand or hard hit on the back in the area of ​​the joint. After the characteristic pop, with which the bone leaves its place, the victim feels a sharp piercing pain.

Visually diagnosed:

• Deformation;
• Hematomas;
• Hollow on the deltoid muscle;
• Immobilization of the arm and rapid swelling of the shoulder;
• The injured shoulder is located below the healthy one;
• The surface of the palms becomes numb or feels tingly.

About a quarter of dislocations are accompanied by bone fractures. In the event of a violation of the blood supply, the hand and forearm of the injured arm will become cold and acquire a bluish tint.

Waiting for the doctor

If it is possible to entrust the reduction of a dislocated shoulder to specialists within 12 hours, then you should not try to do this complicated procedure, it is better to provide first aid to the victim.

For this you need:

1. Fix the hand motionlessly bent at a right angle with a bandage. Any improvised means can act as a bandage - scarves, belts, clothes, bedding. The forearm and elbow are comfortably placed inside the bandage, the ends of which are fixed on the neck in such a way that the forearm is at chest level. This will avoid involuntary movements, fraught with severe pain; and undesirable consequences in case of nerve rupture, vascular damage or bone fracture;
2. Apply cold to the injured area - ice, frozen foods or damp cloth. Due to vasoconstriction, cooling prevents inflammation, reduces bleeding and stops pain syndrome. Ice should be crushed for better adhesion to the surface, poured into a plastic bag and wrapped in a soft, dry cloth so as not to cause harm. skin. Keep the compress on the dislocation for 15-20 minutes per hour;
3. Unbearable pain caused by trauma and muscle spasm can lead to pain shock, so you should offer the victim a pain reliever or muscle relaxant. When choosing a drug, the nature of the injury should be considered. In case of open or internal bleeding, determined by bruising and hematomas, Naproxen and Ibuprofen should be abandoned. These drugs are good painkillers, but thin the blood, increasing bleeding. Also, don't mix medicines without knowing their compatibility.

If the circumstances are such that “saving the drowning is the work of the drowning themselves” and there is nowhere to wait for help, it’s not out of place to know how to straighten the shoulder yourself. But such knowledge should be applied only in the most emergency situations.

How to straighten the shoulder joint yourself

There is a stereotype that the reduction of dislocations is performed by sharp shaking and jerking. This is wrong and dangerous. Even a correctly done procedure can be complicated by additional ruptures of tendons, ligaments, muscle tissue, damage to blood vessels, nerves, life-threatening bleeding and a long loss of consciousness. What can we say about a sharp force impact that will cause more harm than the dislocation itself.

Methods of self-reduction of the shoulder joint

Before undertaking the reduction of the joint, it is necessary to anesthetize and cool it well, otherwise you risk losing consciousness without completing the procedure.

Circular rotation

Do it in a sitting or standing position.

1. Raise the arm bent at the elbow joint to chest level;
2. Without unbending, take to the limit to the side;
3. From this position, lift up so that the palm is above the head.

Movements should be smooth and non-stop.

With the help of the knee

1. Sit on a horizontal platform;
2. Bend your knees and press against the body;
3. Weave your fingers into the lock and put them behind your knees;
4. Slowly leaning back and straightening your knees, try to pull the head of the joint into place.

Either an epic hero or a person placed in a hopeless situation is capable of performing such a manipulation. Much more often around the incident there are other people and the opportunity to receive or provide all possible assistance.

The main thing is that this help should be competent enough and not harm even more.

Reduction of the shoulder joint with an assistant

When you provide assistance to someone and are not sure of the correctness of your actions, you should contact an emergency service employee by phone to clarify the algorithm of actions. Be sure to get the consent of the person you are going to help, warning him that you are not a health worker and cannot be held responsible for unskilled actions.

If you need help, you should try to persuade the person next to you to help. There are not so many people who have had a chance to set someone's hand and, most likely, this proposal will not cause much enthusiasm. It is necessary to calm the person, take full responsibility and manage the process.

The victim should be laid on his back, rest his foot on the armpit of the injured arm, and gently pull the arm itself with increasing effort. Holding the scapular bone with your foot, and extending the arm at an angle of 60-90 degrees, you should feel how the head of the humerus, rounding the scapula, rises to its natural position.

After the shoulder is set, it is necessary to feel the pulse on the injured arm and compare it with the pulse of a healthy one. slowness or complete absence pulse indicates a violation of blood flow, which without urgent medical care may lead to loss of a limb.

If the procedure is successful, a bandage should be applied to fix the unstable joint and take the patient to the nearest hospital. medical institution. In case of failure, the same is true. Only it is necessary to get to the hospital even faster, until the compaction of soft tissues has led to a mandatory surgical operation.

The doctor, having previously taken an x-ray to make sure there are no fractures, will conduct a closed reduction of the shoulder joint. In this case, potent relaxants and anesthetics will be used, up to general anesthesia of necessity.

For those who suffer from the usual form of dislocation, open surgery is recommended to restore the correct functionality of the joint. This operation will identify and eliminate internal causes regular dislocations in order to get rid of them forever and experience a new quality of life.

Recovery of a joint after a dislocation

Successful repositioning of the joint in its original place is not the end, but only the beginning of a long rehabilitation, which can take from three months up to half a year. After 2-4 weeks drug therapy, the patient is prescribed:

• Physiotherapy,
• massages,
• medical gymnastics,
• Swimming and other procedures

Contributing to a speedy recovery, as well as aimed at general development and strengthening the anatomy of the joint to avoid future recurrences. Statistics show that after a traumatic dislocation of the shoulder joint, the risk of developing a habitual dislocation increases significantly, so it is necessary to conscientiously follow all medical recommendations.

The recovery process is regulated by the doctor based on the individual condition of the patient. In general, the reduced and treated shoulder is fully restored, providing normal arm mobility.

findings

1. Never attempt to correct a dislocated shoulder yourself unless it is an emergency;
2. If the situation forced you to make such a decision, perform the procedure as quickly as possible in the first 5-15 minutes after the injury;
3. When you are afraid of the consequences, think about what will happen if the dislocation is not corrected. By comparing the risks, it is easier to choose the less risky option.

The worst case scenario is when alcohol, as an anesthetic, was taken not by the victim, but by the one who provides assistance, and after the procedure no one turned to the doctors.

The human body is inherently unique. Everything in it is thought out to the smallest detail. Each muscle, each cell performs its specific work. And only thanks to this, a person can fully exist. Now I want to talk about what the subscapularis muscle is and what its main function is.

Definition of concepts

Initially, you need to understand the basic terminology. So, what is the subscapularis muscle? According to the medical dictionary, in Latin the name of this part human body sounds like m. subscapularis. It belongs to the belt group. It originates from the anterior surface of the scapula, which is also called the costal. It is attached to a tubercle located on

main function

Why you need a subscapularis is very simple. However, without their fulfillment, a person will not be able to fully live and perform his daily work. So she:

• leads the shoulder to the body of a person;
• helps the shoulder turn inward.

However, its main task is to help stabilize its work during shoulder movements. It is indispensable for the proper operation of the entire shoulder girdle.

Appearance

The subscapularis muscle has a triangular shape, it is flat. Consists of multiple bundles. It is important to note that there are special layers between these bundles, which makes this muscle very unique and unlike others. It also has two layers:

1. Deep. It starts from the costal surface of the scapula. However, it is slightly out of shape with her, as it seems to be slightly displaced.
2. Surface. It is located from the fascia of the subscapular type, where it is securely fastened to the edges of the subscapular fossa.

Feeling (palpation)

In addition to the subscapularis, the so-called rotator ring includes three more: small round, cavitary and supraspinatus. It is because of this that the subscapularis muscle is palpated very, very difficult. Not only is it part of a large complex, it is also located on the front of the shoulder blade. That is, it adheres tightly to chest. Only a specialist can palpate it. To do this, you will have to perform a number of actions:

• The patient should lie either on the stomach or on the back.
• The patient's hand is retracted to the side as much as possible.
• You need to “pass” with your fingers under back wall while feeling for the edge of the shoulder blade.
• Moving medially, you can feel the subscapularis muscle. In this case, it must be pressed against the front wall of the scapula.

Doctors say that the muscle can not always be detected. Much depends on the ability of the patient's scapula to move relative to the chest.

About pain

Damage to the subscapularis muscle is always associated with discomfort. So, a person can feel discomfort not only in the place where it is located. Pain can be concentrated in the area of ​​​​the muscle, it can spread to the entire shoulder blade. But it also happens that discomfort appear even in the wrist area. It is in this place that they are encircling in nature. Also discomfort may be in the case of an attempt to abduct the shoulder to the side or move it outward. Pain can result from the most common causes:

• heavy load on the shoulder when turning inward, especially if the load is regular. This problem, for example, often occurs in crawl swimmers;
• shoulder injuries of various nature can also be the cause.

About problems

What problems might arise if we are talking about this part human body? The first problem is tendopathy of the subscapularis muscle. These are some that occur as a result of insufficient blood supply to the muscles. The cause of tendopathies can also be hereditary pathologies. connective tissue. It should be noted that, for example, with tendinopathy of the subscapularis muscle, pain in a person intensifies at the moments of bringing a spoon to his mouth, combing his hair, and moving his hand behind his back. It should be noted that if the patient often has similar problems relating to the muscles of the shoulder girdle, then he can be diagnosed with "shoulder-shoulder periarthritis". Also, this problem can occur in the case of constant traumatization of the tendons.

About breaks

Rupture of the subscapularis muscle does not occur so often. However, tendopathies that occur as precursors of this problem are most often the cause. Symptoms of a tendon rupture of the subscapularis muscle:

• a sharp increase in pain;
• inability to move freely.

It is also important to note that tears can be either partial or complete, when the tendon is completely detached from the attachment. Of course, the intensity of pain also depends on this. With partial breaks, hand movement may still be preserved (although it will be accompanied painful sensations), while with complete breaks, the arm is completely immobilized.

Diagnostics

Only a doctor can diagnose the problem. This will require an examination of the patient and the collection of anamnesis. Also, the patient will be sent for x-rays. To clarify the extent of damage, you will have to undergo an ultrasound or MRI procedure.

Treatment

How is the subscapularis treated? Most often it is conservative. The main thing at partial break tendons - relieve pain. For this, painkillers, anti-inflammatory drugs can be prescribed. Also, the sore spot is fixed with a tight bandage. A splint may be used for tendon rupture. When the pain goes away and the shoulder returns to normal, doctors prescribe special exercises to develop the joint.

Sometimes surgery is required. This is most often necessary when complete break tendons, or if conservative treatment did not give the desired results.

As surprising as it may be, but modern medicine there is no such thing as a dislocation of the scapula. Specialists mean by this term damage to the humerus in the scapular region or dislocation in the acromioclavicular region. The main characteristic of the dislocation of the scapula is the displacement of the bones relative to each other.

What it is

A dislocation of any joint is an injury in which there is a displacement of the surfaces of the joints. If the connection between the articulating articular surfaces is not completely broken, such a lesion will be called a subluxation. Although dislocation is not considered a serious injury, in most cases it limits the full functioning of the joint, in some cases, patients cannot even move the injured limb.

Causes

It is possible to earn a dislocation of the scapula only by direct mechanical action or with a sharp jerk of the arm forward or upward. Also, such an injury can be obtained when falling from a great height, while the scapular bone will turn and move slightly outward, and its Bottom part pinched between the ribs.

Such damage is almost always accompanied by a strong stretch, but can also lead to a rupture of the muscles located between spinal column and spatula. Motorcyclists and cyclists are at an increased risk of such injuries.

Effects

With illiterate or untimely treatment of the disease, there is a high chance of developing serious complications. Even if the patient has received an incomplete dislocation, after a few months it can turn into a complete one, in which the ligaments, blood capillaries and nerve endings will begin to be damaged.

This complication is dangerous because it can reduce the sensitivity of the affected limb and provoke further joint problems. To protect themselves from re-dislocation, the victim will need to regularly do specially designed exercises even after the end of the rehabilitation course.

The structure of the belt of the upper limbs

The shoulder blades, clavicles, and muscles that provide support and movement for the upper limbs together form the shoulder girdle. The shoulder blade is a steam room flat bone triangular shape. On its back surface there is a bony protrusion called the scapular spine. Its height from the inner to the outer edge gradually increases, and the scapular spine passes into the acromion - a large bone process. Together with the articular end of the clavicle, it participates in the formation of the acromioclavicular joint.

A little lower is the articular cavity. It is a depression that connects to the head of the humerus. Outside, the joint is covered with a capsule and reinforced with ligaments and muscles.

Dislocation of the acromioclavicular joint

This dislocation is most commonly caused by a fall on the shoulder or a blow to the collarbone. The clavicle is connected to the scapula by the acromioclavicular and clavicular-coracoid ligaments. In cases where only the first of them is torn, the dislocation is considered incomplete, and if the integrity of both is violated at the same time, it is considered complete.

If the clavicle is displaced above the acromial process, then such a dislocation is called supracromial. With subacromial dislocation, the outer end of the clavicle is located below the acromion. The latter type of displacement of the articular surfaces of the bones is very rare.

There are a number of signs that are characteristic of complete dislocation of the acromial (scapular) end of the clavicle. A person experiences pain when moving in the shoulder joint, as well as when the doctor probes the acromioclavicular joint. The shoulder girdle on the side of the injury looks shortened. The outer end of the clavicle acts as a step and easily shifts back and forth.

Key sign - important feature dislocation of the collarbone Dislocation of the collarbone: a serious injury. When pressing on the acromial end, it easily returns to its place. But if the clavicle is released, then its outer part, like a key, quickly rises up.

In order to confirm the diagnosis, x-ray examination. The patient must be standing while taking the images. When it is necessary to distinguish complete dislocation from incomplete dislocation, symmetrical radiographs of both acromioclavicular joints are taken.

The dislocation is reduced easily, and after that it is very important to keep the collarbone in the desired position. A variety of bandages are used (often plaster), and a cotton-gauze fixative is applied to the area of ​​the acromioclavicular joint. The period of immobilization (creation of immobility in the joint) is about six weeks.

With old dislocations Dislocation - prevention and treatment and in cases where conservative methods treatments were unsuccessful, surgery is performed. The surgeon from synthetic materials (silk, lavsan, nylon), autotissues (tissues that belong to the patient himself) or allottissues (taken from the body of another person) forms new ligaments. After that, a plaster cast is applied for six weeks.

Shoulder dislocation

Traumatic dislocations of the shoulder usually occur when falling forward on an outstretched or abducted arm. Displacement of the articular surfaces of the humerus and scapula relative to each other can also occur if a person falls back on the outstretched arm.

The head of the humerus can be displaced in different directions relative to the glenoid cavity of the scapula. Depending on this, dislocations are divided into anterior, posterior and lower.

Signs of dislocation appear immediately after the injury that led to its occurrence. The shoulder girdle of the injured arm is lowered, while the patient bows his head in the direction of the injury. A person complains of pain and inability to move in the shoulder joint.

The injured arm appears longer, is flexed at the elbow, and is in an abducted position. In order to create rest of the limb, the patient holds it with a healthy hand.

When probing the area of ​​the joint, the doctor finds that the head of the humerus is in an unusual position. He should also determine if movement and skin sensitivity below the injury is impaired, and check the pulse on the injured arm. This is necessary in order to find out if nerves and blood vessels have been damaged.

Radiography is an important method of examining a patient, with the help of which a final diagnosis is made. The dislocation should not be reduced before this study, as it is necessary to clarify whether there are fractures of the scapula and humerus.

The dislocation must be repaired as soon as the final diagnosis is made. This manipulation is performed under local or general anesthesia. There are many methods by which a dislocated shoulder can be corrected. Dislocated Shoulder - Don't Try to Put Everything in Place. The most famous of them are the methods of Kocher, Hippocrates, Mota, Janelidze, Chaklin, Meshkov.

If between the articular surfaces are soft tissues, then the dislocation is called irreducible, and it cannot be eliminated using conservative methods. In this case, an arthrotomy is performed - opening the cavity of the shoulder joint. The surgeon then removes the obstruction and removes the dislocation.

TRAUMATIC DISTRUCTIONS

Dislocation (luxatio) is the complete separation of the articular ends of two articulating bones with a rupture of the capsule and ligaments. Partial displacement of the articular surfaces is called subluxation (subluxatio).

Dislocations are classified according to the displaced peripheral part of the limb.

There are closed, open, complicated and uncomplicated dislocations and subluxations. The previously used terms "fresh", "stale" and "old" dislocations should be replaced by the term "dislocation" with an indication of the statute of limitations.

With open dislocations, there is a wound communicating with the joint cavity. Complicated dislocations are accompanied by intraarticular or periarticular fractures (fracture dislocations), damage to the main vessels and nerve trunks.

LOCATION OF THE BLADE

Dislocation of the scapula is extremely rare and occurs with forced pulling (traction) by the arm, as well as the impact of a traumatic force directly on the scapula. The scapula is displaced outward, and the lower angle is infringed between the ribs along the posterior axillary line. The rhomboid and serratus muscles are partially damaged.

Symptoms. Pain in the scapula, aggravated by attempting to perform movements. The area of ​​the scapula is deformed, its outlines are unusual. On palpation, it is not possible to determine the vertebral edge of the scapula and its lower angle. The shoulder blade is fixed and motionless.

Treatment. Local anesthesia 40-50 ml of 0.5% novocaine solution. The anesthetic solution is injected under the shoulder blade. The patient is in the prone position. The assistant withdraws and stretches his hand up. The surgeon puts pressure on outer surface shoulder blades. After reduction, immobilization is performed plaster cast Deso for a period of 3 weeks.

TRAUMATOLOGY AND ORTHOPEDICS

Rice. 118. Scheme of the ligamentous apparatus of the clavicular-acromial joint (a),

partial damage to the ligaments (b), complete damage(in)

DISTRUCTION OF THE Clavicle

Dislocation of the acromial end of the clavicle. Dislocation of the acromial end is much more common than dislocation of the sternal end, and occurs as a result of a fall on the shoulder joint or under the influence of a blow. When the upper and loweracromioclavicularligaments form a subluxation of the clavicle. A dislocation develops when there is a rupture andcoracoclavicularligament (rhomboid and trapezoid) (Fig. 118).

Symptoms. Swelling and step-like deformity in the shoulder girdle. When pressing on the protruding end of the clavicle, the deformation is eliminated, when the pressure is stopped, it occurs again (“symptom of the key”).

The diagnosis is confirmed by a roentgenogram in a direct projection with the patient in a vertical position. The acromial end of the clavicle is displaced upward so that its lower contour is at the level of the upper edge of the acromial process or even above it. In case of incomplete displacement of the clavicle, a picture of both clavicles with a load is taken, for which 5 kg weights are fixed to the wrists. In the case of a complete displacement of the articular surfaces, detected under load, the diagnosis of "dislocation" is made.

First aid. A Deso gauze bandage is applied and the victim is sent to the hospital.

Treatment. The dislocation is easy to eliminate, but it is not possible to keep the collarbone in the correct position even with the use of special dressings and splints. There is a relapse of the dislocation. Therefore, conservative methods are effective only for the treatment of subluxations of the acromial end of the clavicle. A Smirnov-Weinstein plaster cast is used, supplemented with a strap-pelot, for a period of 4-5 weeks.

Treatment of dislocations of the acromial end of the clavicle is surgical. Operations aimed at restoring torn ligaments have been proposed, but this is not necessary, since the reduction of the clavicle and its reliable fixation provide cicatricial fusion of damaged ligaments. The most common operation is to reduce the clavicle and fix it with a nail.

It makes no sense to correct dislocations of the clavicle for more than 3 weeks, even in an open way. First, it is a traumatic operation. Secondly, even if it is possible to completely set the clavicle, in the aftermath

As a rule, deforming arthrosis of the acromioclavicular joint develops, pain occurs, mobility is limited and it is necessary to resort to resection of the clavicle. Therefore, in chronic dislocations, an oblique resection of the acromial end of the clavicle is performed so that contact with the acromial process is eliminated and

the end of the clavicle did not survive under the skin.

Dislocation of the sternal end of the clavicle. Dislocation of the sternal end of the clavicle occurs as a result of the action of force on the anterior surface of the shoulder. Anterior dislocations are more common and posterior dislocations are less common.

Symptoms. With dislocation, deformation in the area of ​​the sternoclavicular joint and pain are observed. With an anterior dislocation, there is a subcutaneous protrusion of the end of the clavicle, with a posterior dislocation, there is a retraction. On palpation, the displaced end of the clavicle is determined. The diagnosis is clarified by X-ray examination.

Treatment. Apply a Dezo bandage. The victim is sent to the hospital (hospital) for closed reduction or surgical treatment. The purpose of the operation is to eliminate the displacement of the clavicle and keep it in the correct position for the period of scarring.

Closed reduction is carried out under local anesthesia with 15 ml of 1% novocaine solution. In the patient's sitting position, the assistant rests his knee on the interscapular region and spreads the victim's shoulders. With an anterior dislocation, the surgeon presses on the protruding end of the clavicle. The dislocation is easy to correct, but it is difficult to keep the collarbone. Immobilization is performed with an 8-shaped plaster cast for 5-6 weeks.

In case of unsuccessful reduction, the clavicle is fixed with a 5 cm long screw or with lavsan tape. Operative reduction of the clavicle can also be carried out using a U-shaped transosseous suture.

SHOULDER DISLOCATION

Shoulder dislocation accounts for 50-60% of all traumatic dislocations. The prevalence of dislocation of the shoulder is explained by the anatomical and physiological characteristics of the shoulder joint. This is a highly mobile spherical articulation of bones. The articular cavity of the scapula is elliptical in shape, flattened and in contact with the large round head of the humerus at each moment of movement only in an area not exceeding one quarter of the articular surface. The stability of the articular ends is provided by capsular-ligamentous structures - static stabilizers (articular lip, coraco-brachial, upper, middle and lower glenohumeral ligaments, capsule).

The glenohumeral ligaments contain motor nerve endings.

Mechanoreceptors connected by a reflex arc with the paraarticular muscles. The rotator cuff, as well as the tendon of the long head of the biceps muscle, cause dynamic compression of the

TRAUMATOLOGY AND ORTHOPEDICS

Rice. 119. Classification of shoulder dislocations according to Kaplan:

a - normal joint; o - subclavicular dislocation; c - subclavicular dislocation

with by a margin greater tubercle humerus; g - subclavian; d - axillary;

e - posterior dislocation

dexterity of the shoulder and glenoid cavity and thereby increase the stability of the joint. Thus, the stability of the joint is provided by static and dynamic mechanisms functioning in close relationship.

Classification. Depending on the position of the dislocated head, there are anterior, inferior and posterior dislocations. Anterior dislocation occurs in 75%, inferior in 23%, and posterior in 2% of cases. Anterior dislocations are divided into subcoracoid (75%) and subclavian (10-15%). Among the lower dislocations, axillary (“blocking” or “tense”) dislocation of the shoulder is distinguished (Fig. 119).

Anterior dislocation of the shoulder occurs, as a rule, when falling on an abducted and outstretched arm. As a result of the stop of the large tubercle of the shoulder in the posterior-upper edge of the articular cavity of the scapula and the acromial process, a two-arm lever is formed (the short shoulder is the head and the long one is the entire arm). Length upper limb(about 1 m) is 40 times the radius of the head of the humerus (2.5 cm), so the force on the capsule is 40 times greater than the amount of traumatic force applied to the upper limb. The head of the shoulder acts on the anterior wall of the joint, while the articular lip and joint capsule in the anteroinferior section are stretched and detached from the neck of the scapula (Bankart injury). The impact of the anterior parts of the glenoid cavity of the scapula with the posterior-outer sector of the head of the humerus leads to the formation of an osteochondral fracture of the head (Hill-Sachs injury).

Symptoms. The patient's head and torso are tilted to the injured side. The shoulder is abducted, usually the victim supports it with his hand. Hand movements are extremely painful. The outlines of the shoulder joint are changed: the contours of the acromial joint appear under the skin.

Chapter 8, Traumatic Dislocations

process, and directly below it - retraction. The axis of the shoulder is displaced

medially and passes through the coracoid process or the middle of the clavicle. Passive movements in the joint are impossible due to pain, and when you try to perform them, the springy resistance of the reflex contracted muscles is noted. The head of the humerus is palpated under the coracoid process or under the clavicle. Shoulder when measured from the acromial process to the elbow joint is shortened. With an axillary dislocation, the shoulder is abducted, the head is palpated in the axillary fossa.

Posterior dislocation is rare. It occurs with direct violence. The head is displaced posteriorly and can be located under the acromial process of the scapula or in the infraspinatus fossa.

A displaced head of the shoulder can compress or injure brachial plexus, individual nerve trunks, as well as vessels. More often than others, the axillary nerve is damaged. The complication entails paralysis of the deltoid muscle and anesthesia of the skin of this area. When the shoulder is dislocated, the subscapular, supraspinous, cavitary, and teres minor muscles that attach to the tubercles of the humerus can be damaged. Shoulder dislocations are complicated by a fracture of the large tubercle of the humerus (up to 15%). A fragment of the greater tubercle may remain in place, move anteriorly with the shoulder or under the acromial process, preventing reduction. When a large tubercle is torn off, local pain is determined by palpation, and in more late dates there is an extensive hemorrhage, which is not typical for uncomplicated shoulder dislocations. Sometimes dislocation of the shoulder is combined with a fracture of the surgical neck or head of the humerus.

If a posterior dislocation is suspected, an axial or lateral (transthoracic) x-ray should be taken.

First aid. Apply a ladder splint or a soft bandage Dezo.

Treatment. The reduction of the anterior dislocation of the shoulder is performed under local or general anesthesia. Local anesthesia begins with premedication with 1 ml of a 2% solution of promedol, then 50-70 ml of a 0.5% solution of novocaine is injected into the cavity of the shoulder joint and surrounding tissues.

Reduction is carried out as early as possible. Among different ways shoulder reduction, the most recognized were traction (Dzhanelidze, Mukhin-Mota and Hippocrates) and rotational (Kocher). Using the methods of Janelidze, Mukhina-Mota, it is better to reduce the dislocation of the shoulder, complicated by the separation of a large tubercle. The reduction of such dislocations by the rotational method (Kocher) can lead to its additional displacement (Fig. 120).

1. Janelidze's method. Local anesthesia. The victim is laid on the side where there is a dislocation, with a slight tilt back so that the corner of the table falls on armpit, the angle of the scapula rested securely against the edge of the table, and the patient's head could be comfortably laid on an additional table. It is advisable to attach a load of 3-5 kg ​​to the wrist of a freely hanging limb. In this position, the hand remains for 20 minutes, until the

TRAUMATOLOGY AND ORTHOPEDICS

Rice. 120. Ways to reduce shoulder dislocation:

according to Dzhanelidze (a), Kocher (b), Mukhin-Mot (c), Hippocrates (d)

precise muscle relaxation. The surgeon stands on the side of the patient's face and with his hand (of the same name with the dislocated shoulder) fixes the area of ​​the elbow joint of the dislocated limb, bent at a right angle, and with the other hand grabs the forearm above the wrist joint and gradually stretches down. This usually results in repositioning of the dislocation. In rare cases, it is necessary to resort, in addition to traction, to rotational movements of the shoulder or pressure on the head of the humerus from the axillary fossa.

Chapter 8

2. The Mukhin-Mota method. The victim is laid on his back or seated on a stool. The scapula is fixed with a sheet or towel thrown in the form of a loop over the shoulder and the axillary fossa back. For the ends of the loop crossed on the back, the assistant conducts countertraction. The surgeon grabs the injured limb with one hand above the elbow joint, and with the other hand over the forearm, and performs traction with simultaneous shoulder abduction. When the shoulder is abducted above the horizontal line, the dislocation is usually reduced. If reduction cannot be achieved, the second assistant helps the reduction by pressing on the head with the fingers of his hand while continuing to abduct and stretch the limb.

3. Kocher method. After local anesthesia, the victim is seated on a stool and proceed to reduction. The first moment: the assistant fixes both shoulder girdle with his hands. The surgeon grabs the forearm bent at a right angle with both hands, then, by stretching, brings the shoulder to the chest. The second moment - continuing the extension, the shoulder is rotated outward (this moment must be performed slowly). The third moment - continuing the extension, and leaving the shoulder in the position of external rotation, move its peripheral section to the middle plane of the body. The fourth moment - the limb is rotated inward, throwing the hand over a healthy shoulder girdle. During reduction, it is not recommended to make sudden movements, because when using the shoulder as a lever, a force develops that can cause a fracture in the area of ​​the surgical neck or tear off the tubercle. The latter is especially dangerous in the elderly.

4. Hippocratic method(military field method). The name of the method has been preserved since ancient times. It is used when other methods cannot be applied. In the field, the victim is laid with his back on the ground or floor. The surgeon sits down on the injured side facing him, withdraws his hand and places the heel of his bared leg, the same name with a dislocated shoulder, in the armpit. Then he performs traction with a counter-stop and slowly brings the patient's hand to the body. The surgeon's heel, being the fulcrum of the two-arm lever, pushes the head of the humerus into the articular cavity.

If the reduction of the dislocation is unsuccessful, surgical reduction is resorted to.

After elimination of the dislocation, the joint is immobilized with a Deso plaster bandage for 4 weeks. After the end of the immobilization period, a course of rehabilitation treatment is carried out, which includes passive and active development of movements in the joint, massage, myostimulation. Patients are advised to start physical activity at the household level 3-4 months after the injury. Athletes and persons engaged in heavy physical labor are allowed to perform physical activity at the same level not earlier than in 5-6 months.

Dislocation of the shoulder with a statute of limitations of more than 3 weeks occurs due to an incorrect diagnosis or anatomical obstacle: the tendon of the long head of the biceps muscle, torn off a large tubercle, infringement of the head of the shoulder by the capsule.

TRAUMATOLOGY AND ORTHOPEDICS

It is rare to successfully correct such shoulder dislocations. This is done under anesthesia and carefully enough so as not to damage the neurovascular bundle. If the closed reduction of the dislocation fails, they resort to surgical treatment. Open reduction is completed with temporary fixation with wires or lavsanoplasty.

Habitual dislocation of the shoulder pathological condition, characterized frequent occurrence dislocations without significant traumatic effect on the limb. Approximately 50% of patients with traumatic dislocations are complicated by habitual dislocation of the shoulder. Damage to the elements of the joint that occurs during primary dislocation leads to failure of the anterior part of the capsule and contributes to a violation of the centering of the head of the shoulder and the balance of the muscles of the shoulder girdle. S. A. Novotelnov (1938), when performing chronaxymetry of the muscles of the shoulder joint area in patients, established partial paresis of the deltoid, supraspinatus, and infraspinatus muscles. Repeated dislocations cause even greater stretching and weakening of the capsule and periarticular muscles, and also contribute to additional damage to the articular surfaces.

Symptoms. Shoulder dislocation recurrences occur without significant external influence. In some patients, dislocations occur several times a month or more often. Often, patients adjust the dislocation on their own.

Symptoms of habitual dislocation are caused by a secondary imbalance of the muscles of the shoulder girdle and reflex muscle tension - active stabilizers at the time of the onset of dislocation of the head of the shoulder. Weinstein's symptom consists in limiting the active external rotation of the arm abducted to the horizontal and bent at 90° at the elbow joint. It is determined in the vertical position of the patient against the wall, comparing the movements in the shoulder joints. Babich's symptom is a reflex "muscle control" that causes difficulty in performing passive movements in an unstable shoulder joint. The Iovlev-Karelin "scissors" symptom also occurs due to reflex muscle tension and is manifested by the lagging of the diseased hand from the healthy one while raising the outstretched arms up.

Also apply special methods studies, such as determining the electrical excitability of muscles, electromyography, radiography, ultrasound procedure and arthroscopy.

Electromyographic studies allow us to establish a decrease in the activity of some muscles of the shoulder joint area by 2-3 times. Novotelnov's symptom - a decrease in the electrical excitability of the muscles of the shoulder girdle by faradic and galvanic current (observed with long course disease).

X-rays of the shoulder joint are performed in the following projections: anterior-posterior in the position of internal rotation of the limb (in order to identify an osteochondral defect of the head of the shoulder in the posterior-outer section) and axial. On radiographs, it can be determined

Chapter 8

Rice. 121. Scheme of operation Tkachenko:

a - dissection of the tendon of the subscapularis muscle; b - tendon mobilization

the long head of the biceps brachii and the formation of a split on the head of the humerus; c - transposition of the biceps tendon into the split and its fixation with transosseous sutures; d - suture of the tendon of the subscapularis muscle over the tendon of the biceps muscle

Rice. 122. Scheme of operation Bristow:

a - osteotomy of the coracoid process; b - formation of the bone bed

with a hole in the anterior-lower neck of the scapula

there is a fracture or defect in the bone tissue of the head of the shoulder, in the lower part of the glenoid cavity of the scapula, the “ax-like” shape of the head, osteoporosis in the region of the large tubercle of the humerus.

Ultrasound examination allows assessing the condition of the soft tissue structures of the joint (articular lip, tendons of the rotator cuff and long head of the biceps muscle).

During arthroscopy of the shoulder joint, damage to the “articular lip - ligaments of the capsule” complex, an osteochondral defect of the head of the shoulder and the edge of the glenoid cavity of the scapula are detected.

More than 150 methods have been proposed for the treatment of habitual dislocation of the shoulder. surgical interventions. The most commonly used operations are to create additional ligaments that hold the head of the humerus, in particular tenodesis with transposition and transosseous fixation of the tendon of the long head of the biceps brachii (Tkachenko operation, Fig. 121), or an additional barrier to dislocation by transferring the coracoid process of the scapula (Bristow operation, Fig. 122).