Sprains and Dislocations of the Shoulder Belt

SPRAINS AND DISLOCATIONS OF THE SHOULDER BELT Shoulder girdle dislocations are very common during sports. Three types of dislocations may be of interest to this belt. ➢ Sprain and acromioclavicular dislocation Sprain and acromioclavicular dislocation constitute a group of pathologies that are very common in sports. It is the most common lesion of the shoulder girdle. ❉ Etiology The acromioclavicular sprain can originate from a direct impact on the joint, but most often it results from a fall on the shoulder stump, the hand or the elbow. In young subjects the sprain is often less serious (stage 1) than in adults, due to the weakness of the kinetic energy involved during the trauma (lower speed and above all lower body mass); the dislocation is exceptional. ❉ Diagnosis . Physical examination The diagnosis is raised during questioning in front of an athlete complaining about the anterior part of the top of the shoulder. Comparative inspection shows a modification of the scapular relief. The outer end of the clavicle being more or less protruding upwards. Even in the case of a "minimum" dislocation (stage I) swelling secondary to local edema can give a protruding appearance to the end of the clavicle. Examination reveals an exquisite tender point at the tip of the acromion. Gentle passive palpation looks for abnormal movements in the piano key (between the acromion and the clavicle). The highlighting of this sign affirms the dislocation. If the pain is not too severe the examiner can also look for an anteroposterior drawer, a sign of a rupture of all the ligaments supporting the clavicle. If the subject is not examined immediately, a hematoma and/or significant edema may develop and interfere with the examination. . Radiological examination The radiographic examination is performed from the front and following Buttin's inclination. Any passive maneuver aimed at reducing the dislocation should be avoided. Possible associated bone lesions will be looked for. The dynamic examination by traction on the arm will never be carried out "hot". From clinical and radiological data four stages can be determined: ● ● ● - Stage 1, corresponding to a simple sprain, and whose symptoms are limited to clinical signs, without modification of radiological images - Stage 2, characterized by damage to the capsule and acromioclavicular ligaments. In this case, there may be a moderate piano key and an image of subluxation on radiography. - Stage 3 which combines the lesions described in stage 2 with a rupture of the trapezoid ligaments and conoid. The clavicle appears frankly dislocated on clinical examination and on radiological images. - Stage 4, which corresponds to major disrepair of the means of fixation of the clavicle, at both ligamentous and muscular. ❉ Treatment It will be different depending on the stage diagnosed. . First and second degree dislocations: First, ice the joint, place the athlete on oral non-steroidal anti-inflammatory drugs and immobilize the upper limb. Local anti-inflammatory physiotherapy and gentle mobilization of the shoulder will be started very early to avoid stiffness. Immobilization will be maintained depending on the improvement of clinical signs, between 2 to 3 weeks. During this period, jogging is authorized (if it is painless) to maintain the athlete's cardiovascular capacity. Before resuming activity, comparative dynamic radiographs (carrying a load in the body axis, abducting the arm to 0°) will verify the absence of surgical indication. Resumption of activity will be done with shoulder support for two days. . Third and fourth degree dislocation: Surgical intervention is the only way to restore the anatomical integrity of the joint. It will consist of repairing the ligament bracing. In type 3 dislocations, ligament repair can be carried out arthroscopically. The intervention will be followed by a 1 immobilization for three to four weeks, then shoulder rehabilitation (passive and active mobilization, search for range of motion, weight training). ➢ Sternoclavicular sprain and dislocation ❉ Etiology This is a rare condition in children, mainly found in adolescents. The lesion responds to violent trauma to the sternal manubrium or indirectly to the shoulder stump. ❉ Diagnosis . ● ● Physical examination Clinically, the adolescent consults for pain located next to the sternoclavicular joint. It is not uncommon for a small hematoma to mark this region. The pressure of the finger causes exquisite pain without, however, evidence of a jump (ruptures of the costoclavicular and sternoclavicular ligaments are exceptionally secondary to sports trauma in children). . Radiological examination Perform an x-ray of the clavicle and manubrium to rule out a possible associated fracture. ❉ Treatment . Ice the traumatized area for a few minutes. . The cessation of sporting activity will only be relative depending on the pain felt by the child (in the first days polypnea can awaken pain and limit sporting activity). . In adolescents who have fused their growth plates, ultrasound can be practiced locally. . Surgical intervention is only proposed for total ruptures of the attachment ligaments. ➢ Scapulohumeral dislocation Scapulo-humeral dislocation is more common in adolescents who are still insufficiently muscular. ❉ Etiology The mechanisms responsible for this injury can be a fall on the hand, the arm extended, or a landing on the elbow. Rare cases of posterior dislocation may be encountered due to direct and violent trauma to the shoulder stump. ❉ Diagnosis . Physical examination The clinical diagnosis is sometimes difficult to make due to the pain and edema which quickly accompany this type of trauma. Very often the athlete is referred for reduced dislocation on the field. Otherwise the diagnosis is obvious given the deformation of the shoulder stump and the swelling caused by the anterior sliding of the head. Gentle palpation 1 finds the humeral head which can be mobilized by passive movements of the elbow. If nerve and vascular lesions can be easily eliminated or demonstrated by clinical examination, this is not the case for associated bone lesions which will in all cases require an x-ray examination. . X-ray examination reveals the displacement of the humeral head, the type of dislocation (posterior, antero-internal...), and especially the existence of possible associated lesions (fracture of the tubercle, fracture of the glenoid...). In children, we will systematically check the integrity of the growth plate. ❉ Treatment The reduction, relatively easy when it is early, will be carried out without anesthesia or after an injection of Valium (used as a muscle relaxant). The reduction will always be preceded by a neurological and radiographic examination. Despite the great ease of reducing maneuvers, these techniques will not be practiced on the sports field. The arm is then immobilized for days. An analgesic may be prescribed in case of pain. Gentle, analgesic physiotherapy can be started the next day. It will be accompanied by cryotherapy several days which will often be sufficient to calm the pain. When the arm is released, the rehabilitation of the shoulder will aim to regain normal mobility of the joint and on the other hand to prevent a recurrence by practicing proprioception and bodybuilding techniques. ➢ Recurrent dislocations Recurrent dislocations constitute a complication of scapulohumeral dislocation (see shoulder instability).