Dislocated shoulder
Under a shoulder dislocation or Schultergelenkluxation (Latin luxatio humeri, luxatio glenohumeralis ) refers to a dislocation ( luxation ) of the shoulder joint. The dislocation of the shoulder is one of the most common dislocations of the large joints. It can be caused by an accident ( traumatic dislocation) or due to the plant ( habitual dislocation). Symptoms include a restriction of movement in the shoulder joint, pain and altered shoulder shape. The therapy is based on the exclusion of fractures by means of X-ray images through a reduction. Surgical therapy may be necessary in case of complications and repeated dislocations.
Molding
Traumatic dislocation is caused by a leverage in force on the extended arm, typically from the front in external rotation and abduction, such as handball players with an outstretched limb or for catching a fall. The initial dislocation usually occurs in young adults. After such trauma recurrent dislocations can occur even at low forces. The reasons are remaining damage to the capsular ligaments, glenoid labrum tear down the ( Bankart lesion), broken bones ( fractures and cartilage, muscle and nerve damage ).
For the habitual dislocation predisposing factors are blamed, although the etiology and pathogenesis are not fully understood. This may be the muscles among other abnormalities of the joint capsule, malformations of the acetabulum, connective tissue ( Ehlers -Danlos syndrome, Marfan's syndrome) or Fehlinnervation. The Erstluxation is directed mostly to the front and occurs predominantly in young patients without adequate trauma.
Following the direction of the dislocation is divided into four different Luxationsformen. The anterior shoulder dislocation (Latin luxatio subcoracoid ) is the most common shoulder dislocation with over 90%. Dislocation backward and downward is called luxatio infraspinata. When luxatio infraglenoidalis or axillary the humeral head is dislocated downwards (Latin caudal ). A rare dislocation is the luxatio erecta in which the humeral head is also dislocated caudally in addition held vertically upward arm.
Symptoms
The shoulder joint is fixed spring, there is a spontaneous movement and pain. The arm is at the leading dislocation usually in abduction and external rotation and is kept with the healthy arm. The shoulder contour is more in shape due to the deltoid muscle is stretched taut over the acromion at caudally displaced upper arm. The socket is empty and the humeral head in the soft tissues usually palpable below the outer clavicle. When damage to the axillary vessels or nerves leads to disturbances of blood circulation, motor and sensory in the arm.
Diagnostics
It is based on the medical history ( mechanism of injury ) and physical examination (Function restriction). In particular, the damage to blood vessels and nerves should be noted and recorded. By X-ray images in different planes, the diagnosis is confirmed and ruled out a fracture. To exclude a Bankart lesion (see below), an MRI scan can be made.
Therapy
As part of the first aid every movement of the arm should be avoided ( immobilization ). A local cooling can alleviate the resulting swelling and pain. Basically should be reminded of an emergency call the emergency services, to carry out a smooth transport and any necessary treatment on the spot.
The Back displacement of the dislocation from the outside without an operation is called a closed reduction and should be done as quickly as possible, because due to muscle tension and swelling of the reduction with increasing duration of dislocation becomes more difficult. If the dislocation nerves ( especially the axillary nerve ) or vessels are clamped, a delayed reduction lead to permanent damage. Basically, a reluctance to immediate emergency reduction is recommended at the scene, as only an x-ray should be made to exclude a concomitant fracture in the guidelines. A blind Repositionsversuch an unidentified bone fracture risk causing additional injuries.
It is therefore recommended in guidelines to make the decision for or against a dependent immediate Repositionsversuch without prior X-ray image in each individual case of certain criteria. Against a Repositionsversuch speaks a short transport time to the nearest appropriate hospital, obtained by bleeding of the arm, got nervous functions and low Repositionserfahrung the helper. A Notfallreposition should be considered during long transport time to the nearest hospital, blood circulation problems, nerve damage with sensory disturbances and experienced helpers on site.
In any case, the patient should receive adequate pain medication to relieve pain, to relieve the pain during transportation or Repositionsversuches. By painkiller and optionally additionally administered sedatives thereby relaxes the muscles, which facilitates reduction. In severe cases, may even be necessary a brief anesthesia with complete muscle relaxation to allow the reduction.
The following manual techniques are in use: When repositioning after Hippocrates, the physician exerts train on the extended arm, while he placed his own foot as an abutment in the patient's axilla. In the reduction by Arlt the train with a chair is carried out as an abutment in the repositioning Kocher the arm (elbow to the body ) by adduction - external rotation - and elevation ( lifting) repositioned using the resulting leverage on the socket. The reduction requires sedation. Subsequently, the joint is for one to three weeks (depending on severity / Luxationsursache etc. ) immobilized in a Gilchrist or Desault Association, but is followed waived in elderly patients due to the risk of shoulder stiffness.
Indications for surgical treatment are a non gelingende closed reduction, complications (vascular / nerve damage, Hill - Sachs lesion, Bankart lesion ) and recurrent dislocations. This can be performed arthroscopically or open depending on the occasion.
Complications
As a Hill-Sachs Delle refers to a bone on humeral head impression. You can by a relining with cancellous bone or a Drehosteotomie ( according to Weber, only rarely applied ) are treated. Under a Bankart lesion is meant the demolition of the cartilaginous glenoid labrum of the inferior glenoid. The treatment consists in an arthroscopic reattachment or reconstruction using a bone graft. Both lesions are risk factors for recurrent occurrence of further dislocations.
In addition, it may lead to the already mentioned injuries of bones, blood vessels and nerves or the rotator cuff.