Traumatic dislocation of the clavicle (collar bone). Classification, clinic, treatment.

Dislocations of the clavicle ranked third after the dislocation of the shoulder and forearm and rate from 5 to 15% of all dislocations. The acromial end of the clavicle is most often erupted, rarely the sternal one. Such dislocations is the result from direct and indirect trauma.

Dislocations of the acromial end of the clavicle

The clavicle -acromial joint keeps the arm in a normal position and provides its functionality.

In childhood , this joint is separated by a cartilage disk, which is fixed to the capsule and eventually degenerates, and after 8 years of life may disappear completely. The balance between the scapula and the clavicle is maintained by two separate systems - the upper arm and clavicle joint and the stronger scapular-clavicular joint (conical and trapezoidal ligaments). The particular arrangement of these ligaments and their attachment points prevent the ascending and posterior or anterior dislocation of the clavicle. The cause of dislocation of the acromial end of the clavicle is a fall or a strong impact to the area of the upper arm when the clavicle is raised up and pressed against the ribs. Sometimes there is a dislocation with sudden and strong stretching of the arm or etc.

The injury of the clavicle-acromial joint is rate by 3 types (Fig.). The first type is when the capsule of a joint with partial rupture ("stretching") of the upper arm and clavicular ligaments is stretched, which does not disturb the stability of the joint (15% of cases). The second type is when the components of the joint are severed, but the integrity of the conical and trapezoidal ligament is preserved, which is not shown by a significant shift of the clavicle up and back (34%). The third is a tear of the capsule and all the connection between the clavicle and the scapula (51%), accompanied by rupture and dislocation of the disc, sometimes a rupture of the deltoid and trapezius muscles, as well as a tear fracture of a piece of clavicle or upper arm.

At the first stage,the patient feels slight pain, which is increasing by hand movements. Visually detect slight swelling, and palpation - local pain.In the second stagethere is severe pain, especially when the patient raises his arm above 90 ° (at the moment of rotational movement of the shoulder blade). Clinically, pain, joint swelling and deformity are more pronounced due to some displacement of the acromial end of the clavicle. In non-recent cases, when the clavicle is pressed or diversion of the arm, pathological mobility of its articular end can be determined.

The third degree is recognized by extremely severe pain, which limits the movements of the shoulder and neck, and at the rupture of the trapezius muscle - tilting the head in the opposite direction. The deformation of the joint is visually and palpatorily clearly defined. The articular end of the collarbone is shifted up and back, bulging beneath the skin, a positive symptom of a "key" is expressed - when to fix the reduced arm, when pressing the collarbone, it is lowered and displaced upwards when released.

X-ray examination in the sagittal projection is important in diagnostics, and it is important to make a comparative radiograph of both clavicular-acromial joints in the standing position of the patient without load or with load (3-5 kg). There are conservative and surgical methods of treating injuries to the upper shoulder-clavicle joint, depending on the degree of displacement of the acromial end of the clavicle and the time that has passed after the injury.

The main purpose of conservative treatment is to fix the inserted clavicle by pushing on its acromial end with the simultaneous lifting of the shoulder upwards, at the time of fusion of the ligamentous apparatus of the clavicle-acromial joint (4-6 weeks).

Fresh dislocations are reduced under local anesthesia with a 1% solution of novocaine. At dislocation of the acromial end, the reduced arm is fixed by pushing on the dislocated end, direct it. The arm is fixed on a plaster thoraco-brachial bandage (up to 90 °) bent 20-25 ° and slightly rotated outside the shoulders. Therefore, in the form of the upper arm, a gypsum pilot is modeled, which is fixed to the corset-bandage.

The fixed end of the clavicle can be steadily fixed by the Kirchner needles, transcutaneously drawn through the acromial outgrowth.

Conservative treatment is effective only for injuries of grade I and sometimes grade II.

Surgical treatment is required in all cases of complete dislocation of the clavicle, with failures of conservative treatment and with minor injuries of grade I, if they disturb the patient.

The essence of the operation consists in the management of subluxation or dislocation of the clavicle, restoration of the ligaments and fixation at the time of its fusion.

Traumatic dislocation of the shoulder. Classification, clinic, treatment.

Shoulder dislocations account for 50-60% of all dislocations. This frequency is explained by the anatomical and physiological features of the shoulder joint (spherical joint form, large volume of movements, imbalance of joint surfaces, weakness and small size of the ligaments (ligamentous apparatus), non-coverage of the muscles of the lower part of the joint), the main load on the upper limbs of the human.

Mechanogenesis of dislocation is usually typical as a result of indirect trauma when the shoulder moves beyond the physiologically possible range of motion. The direct mechanism of injury - when the active force knocks the head of the humerus from the joint is uncommon.

Classification of shoulder dislocations:

 

1. Front surfaces:

• arachnid (?);
• subclavian.

2. Anterior:

• axillary.

3. Lower:

• under the joint cavity.

4. Rear surfaces:

• subacromial.

5. Posterior:

• wicked.

Frontal dislocations are more common (70-75% of all dislocations in the shoulder joint).

Clinic and diagnostics.

Already on examination, a noticeable classic arm position and deformation.

At the front dislocations the shoulder is slightly open and bent back, the patient maintains the injured arm by healthy arm in a forced position, and below the acromial process can be seen a decrease in the deltoid muscle, smoothing of the subclavian fossa, sometimes sore.

At lower dislocations the patient holds the forearm and the brush of the affected limb on the head. Palpation, in addition to local pain, can determine the location of the head of the humerus and the elasticity of passive movements. Paresthesia, cyanosis, etc. may occur with compression or damage to the head of the nerve or blood vessels. The pulse on the radial artery is weakened or absent.

The diagnosis of dislocation in the shoulder joint, as well as its morphological features are specified by radiographs made in two projections. Treatment.

Dislocation is managed as soon as possible under local or general anesthesia. The method of control is chosen differentially, depending on the direction of displacement of the head of the humerus.

At the front dislocations of the shoulder is considered the optimal method of fixing by Kocher

In cases (regardless of the nature of the dislocation), when there is a contraindication to anesthesia, as well as in elderly people with atrophied muscles, dislocation is embed under local anesthesia Janelidze.

After the exercise of dislocation, the limb is fixed with a plaster bandage. Check radiography is required. The fixation period is on average 3 weeks, after which appoint an exercise therapy, massage. Disability is 6-7 weeks.

Surgical treatment is carried out in cases of late diagnosed dislocation (2-3 weeks and later), or when it is not immediately possible to correct it due to a head pinch between the posterior edge of the acromion and the fibrous cartilage lip of the joint of the shoulder blade. Also operate in case of pinching of the capsule of the shoulder joint or fragmentation of the lip of the articular depression of the shoulder blade.

Traumatic dislocations of the forearm. Classification, clinic, treatment

Dislocations of the bones of the forearm

Dislocations forearm in frequency in second place after a shoulder dislocation and is 20-30%.

There are the following dislocations of the bones of the forearm:

1. Dislocation of both bones of the forearm:

a) back,

b) front;

2. Isolated dislocation of the radial head in adults;

3. Pronational subluxation of the radial head;

4. Fractures (dislocation of the bones of the forearm with "tear fracture of the process of the shoulder, coronal process, fractures Montage).

Among the different types of dislocations, the posterior-lateral dislocations of both forearm bones and rarely the posterior-median ones are most often (85%), which is caused by the anatomical structure of the joint block. Sometimes they are accompanied by a separation of the overgrowth of the humerus. Rarely are the anterior dislocations of both forearm bones, sometimes with a fracture of the coronal process (processus coronoideus), and extremely rarely - divergent, in which the joint end of the humerus is wedged between the bones of the forearm.

The dislocation pattern depends on the mechanogenesis of the injury. Lateral-lateral dislocations usually occur when falling on the outstretched arm with extension in the elbow. The ulcer (olecranon) rests on the humerus, resulting in a lever and a dislocation with a tear of the capsule in front of the joint. In this defect of the capsule penetrates the joint end of the humerus. Very rarely, a posterior dislocation occurs when striking the back of the lower third of the shoulder with a fixed forearm.

The front dislocations of the forearm are caused by a fall in the excessively curved elbow in the forearm. From the impact at such an angle, the ulnar process jumps over the block of the humerus, the forearm moves or protrudes forward and sideways because it is held by a strong three-headed muscle.

Divergent dislocations occur when falling on a stretched arm with excessive pronation of the forearm. Due to the force exerted on the limb axis, the joint end of the humerus is killed between the bones of the forearm, which diverge after the rupture of the annulus and the intercostal membrane, sometimes with a fracture of the elbow bone.

Symptoms and diagnosis.

Diagnosis of dislocation of the forearm is not complicated. The patient holds the hand in a forced, half-bent position and supports it with a healthy hand. The area of ​​the elbow is swollen and deformed - at the posterior dislocations above the elbow, the recession is visible, the front of the protruding tip of the elbow is not visible, and the elbow hole is smoothed. On palpation, a tensile tendon of the triceps muscle and displaced joint ends are felt. Gitter triangle disturbed or undetected due to large hematoma and tissue swelling.

The limb axis is also broken - lateral deviation of the forearm (cubitus valgus) appears. Active movements in the joint are not possible, and passive - sharply painful and elastic. Neurological disorders are possible with posterior dislocations due to trauma to the ulnar nerve. Stretching of the tissues in front of the joint can cause paralysis of the median and radial nerves, or also artery compression. Diagnosis is made radiographically in two projections, paying attention to whether there is no dislocation of the fracture of the superior bone of the humerus or corolla or elbow.

Treatment.

Dislocation of the forearm is managed under anesthesia, in order to completely relax the muscles and to avoid additional tissue traum a.

To correct the back dislocation of the forearm, the assistant holds the lower third of the forearm and gradually pulls it lengthwise. The surgeon first eliminates lateral displacement, and then grabs the lower thirds of the shoulders with the palms of his hands, which creates a counterbalance, with the first two fingers presses on the top of the ulnar process and directs the dislocation. The moment of control is accompanied by a slight crunch. After the exercise, the assistant flexes the forearm at the elbow to 75-80 ° to avoid any relaxation. The upper limb in this position is fixed with a posterior gypsum ligament - from the humerus to the metacarpophalangeal joints. Make a check radiograph. To correct the forward dislocation of the forearm, the assistant holds and flexes it (to relax the muscles more). At this time, the surgeon pulls the upper third of the forearm with one arm at the axis of the shoulder and moves the lower end of the shoulder forward with the other. After reduction, the posterior gypsum is applied, keeping the forearms slightly bent (100-110 °).

Considering the particular reactivity of the elbow joint, when even after slaughter very quickly develops immobility and contracture, the immobilization period after dislocation management should not exceed 10-12 days. Therefore, the patient is prescribed active development of joint movements, muscle massage. Forced passive development leads to the opposite. Massage of the area of the elbow and thermal procedures that accelerate scarring and the appearance of paraarticular ossifying hematoma are also not recommended. Thermal procedures with a temperature not higher than 40 ° C (paraffin applications) are applied only 3-4 weeks after the injury. Employment is restored in 5-6 weeks.

Surgical treatment. With stiff dislocations of the forearm, when it has already passed 10-14 days, the attempts of management end in failure. In those cases, as well as with outdated dislocations, an open operation should be performed.

Diversionary dislocation of forearm bones.

The divergent dislocation of the forearm bones is extremely rare and occurs when the arm rests when the forearm is restrained. During examination, the forearms are flexed in pronation and appear short. Sharply expressed hematoma and increase in the size of the elbow joint in the anterior-posterior and lateral planes. Forearm movements are not possible. The pal-stator can be touched by the head of the radial bone in the front, and the ulnar process - behind and medially relative to the block of the humerus. Diagnosis is made radiographically in two projections, and it is necessary to capture the area of ​​the diaphysis bones because the dislocation is often accompanied by a fracture of one of them.

Treatment. Dislocation is administered under anesthesia. First, the surgeon manages to dislocate the elbow bone, extending one arm lengthwise, and the other presses the elbow. The forearms are then gradually flexed, supinated ltaneously pressed on the head of the radial bone, which is thus managed. The arm is fixed with a posterior gypsum elbow in the same position of the forearm with a supine and slightly bent, so that no head relaxation occurs. To prevent this, the head of the radial bone is fixed with a Kirchner needle, held transcutaneously posteriorly through the head of the growth of the humerus, plunging it into the bone by 5-6 cm. Check radiography to confirm that the dislocation and fracture of the bone are corrected. If it is not possible to repair the fragments of the bone, then repositioning is not applied. After two weeks, the broken bone is fixed with a spoke or rod apparatus, the fragments are repaired and the needle is removed from the radial head. Appoint to actively and passively develop movements in the elbow. If there was no fracture of the forearm bone, then after 2 weeks the needle is removed and the flexion movements in the elbow begin. After 3 weeks, plaster cast is dropped.If the head of the radial bone fails to correct, indicating that the capsule or annular ligament is trapped, this is a direct indication of the operation. Surgery should be performed 3-4 days after the injury, when the damaged vessels are sealed. In the presence of neurological disorders or circulatory disorders, the operation is carried out immediately. The technique of the operation is no different from that described

Dislocation of the distal end of the ulna (elbow bone) This term refers to the displacement of the head of the ulnar bone (elbow bone) in the distal radial elbow joint in the dorsal or palmar side due to the rupture of the ligaments that connect the elbow to the beam.

In fact, the elbow bone, like the mast, remains in place and does not dislocate, and the radial bone along with the brush erupts due to the rupture of these ligaments.

Therefore, it is a dislocation of the radial bone with a brush with displacement in the dorsal or palmar side. At dislocation towards the palm of the head the elbow bone protrudes on the dorsal surface of the proposed forearm, and this gives reason to consider it dislocated. Sometimes this dislocation may be accompanied by a tear fracture of the pterygoid process of the ulna. There are times when this is interpreted as an isolated fracture of the process, and the rupture of the radiolarian ligaments is not diagnosed. It is extremely rare for the opposite to occur.

Clinical diagnosis is not complicated - the examination shows how the head of the elbow bone. When pressed on it, with a fixed brush, it falls, and when it is released, it pops up again like a key. And the pain is not very sharp.

Treatment. It is necessary to manage a dislocation as follows: under local anesthesia 1% solution of novocaine is pulled by a brush for I-III fingers (and not for IV-V fingers) for the axis of the forearm and it is translated into full suppression with ulnar deviation of the brush, which allows to adapt the torn as much as possible communication apparatus. This is the only way to correct and hold in place not the head of the elbow, but the radial bone and brush. Additionally, it is possible to fix the forearm for 3 weeks with two Kirschner needels, transverse across the area of the radiolar joint. Impose in this position (supination!) Back gypsum tire from the heads of the metacarpal to the middle third of the shoulder for 5-6 weeks. Therefore, they carry out physiotherapy treatment and development of joint movements. Capability is restored 6-7 weeks.Surgical treatment is used for management failures (tissue trapping, etc.) and outdated dislocations.

Doctor	Name	Specialization	Reception time (Sunday)
	Білик Сергій Вікторович	Traumatology and Orthopedics	-