According to our data, habitual dislocation of the shoulder amounts to 2.88% of the pathology of the musculoskeletal system and is more common in highly skilled athletes: pervorazryadnikov, candidates for master of sports of the USSR. Among them, the first place in the incidence of habitual dislocation are sambo (10.3%), followed by representatives of the classic wrestling (7.5%), gymnasts and acrobats (6.7%) and wrestlers (6.5%) .
Symptoms. Athletes who suffer from habitual dislocation of the shoulder, complained of pain in the shoulder joint at rest and during movement (especially abduction of course), to limit the mobility, frequent relapses and the fear of subsequent dislocations, as well as the impossibility of continuing studies chosen sport.
The main clinical symptoms are:
Symptom Weinstein – limitation of external rotation allocated to a right angle shoulder. This symptom is more pronounced in patients with high recurrence rate of dislocation. The athlete proposed to devote both arms to a horizontal line, bent with the hand of the elbow. Producing passive forearm rotation outwards, the doctor reveals its limitations on the affected side.
Symptom Babic is to restrict passive movements of the shoulder joint affected arm due to a protective reflex contraction of the muscles. The patient, for fear of recurrent dislocation, can relax the muscles, which is evident from an examination of passive movements.
Hitrova symptom – "the appearance of diastasis between the humeral head and acromion offshoot sipping at the shoulder down."
Symptom Shtutina-I-«symptom elongation limb" on the side of dislocation.
Symptom Shtutina – II-«reduced resistance reduced": the shoulder on the side of dislocation can not long resist the attempts of the subject to bring it to the body. Its genesis due to lower muscle strength, retaining shoulder abduction (middle and posterior portions of the deltoid, supraspinatus, infraspinatus and teres small).
You should also pay attention to symptoms such as malnutrition muscles of the shoulder girdle and the shoulder; tenderness podklyuvovidnoy area and mezhbugorkovoy groove, limiting shoulder abduction. Some patients can not detect any clinical signs. It should be remembered that one of the reasons that contributed to the habitual dislocation, – damage to the cartilage lip (labrum glenoidale). Early detection of this damage is of great importance for the timely and proper treatment. Labrum glenoidale often called from the edge of the articular surface of the blade in the middle of the type "handle watering can" and appears as a symptom of "clicking". It is identified as follows: the patient is placed on a dressing table or a couch on his back so that his head and body on the same level. The outer edge of the blade of the subject of the joint should be located on the edge of the table. Finiteness bent at the elbow to a right angle, the shoulder is removed from the body to the level of the shoulder girdle and went down. Right hand surgeon covers the ulnar joint, and the left shoulder girdle, so that it is under the thumb I clavicle on the front surface of the shoulder joint medially from the humeral head. In this situation, the surgeon, pressing his right hand on the elbow joint, tries as far as possible to insert the humeral head in the glenoid cavity blade. In this torn labrum glenoidale looming over the head of the humerus. If after this rapid movement put his shoulder to the chest the patient, the "worn" on the head of the humerus labrum glenoidale slips off her. At this point, a hand surgeon and the patient felt a click pereskalzyvanie (M. Sverdlov, 1970). Other types of break labrum glenoidale diagnosed during surgery.
X-ray examination of the shoulder joint can detect the following changes:
fractures anteroinferior acetabulum edge blade;
fractures of large and small tubercles of humerus;
deformation of the head and the greater tubercle (sclerosis, memorization and smoothed contours);
phenomena deforming arthrosis of the articular ends and the shoulder blades;
focal osteoarthritis in the shoulder joint, calcification in the capsule and surrounding tissues, head configuration changes, especially in the lower pole;
sekiroobraznuyu head, etc.
In some cases, X-ray symptoms absent.
Treatment. On treatment of habitual shoulder dislocation in many papers of domestic and foreign authors. At present we know of more than 250 methods of operations and their modifications, but, unfortunately, none of the proposed methods do not provide a complete and permanent cure. According to domestic and foreign authors, the percentage of recurrence after surgical treatment of habitual dislocation of the shoulder is quite high – 0,88-24%.
These techniques can be divided into the following groups:
operations on the shoulder joint capsule, muscle plastic surgery, bone grafting surgery, operations tenodeza, operations tenosuspenzii; combined operations; kozhnoplasticheskie types of operations, operations alloplastic shoulder joint; operation of auto-, homo-, geteroplastiki. In our country the most common operations Weinstein, Rosenstein, Drobotun, Shtutina, Sly Islands and Sverdlov. Foreign operations are recognized Putti – Platt Magnusson, Nicolas and others None of the existing operations now can not be considered radical.
When deciding on the operational methods of treatment of habitual dislocation of the shoulder in athletes, we believe the most acceptable method of YM Sverdlov (1968), which is the most reliable, efficient and provide good functional outcome. It fully complies with the requirements in the postoperative period to musculoskeletal athlete.
The essence of the operation M. Sverdlov is to create two short cords, beginning on the shoulder blade and attaches in the surgical neck humeral bone, creating the conditions for joint stabilization and located on a dislocation of the head, that is, on the front and inside of the upper arm.
Taking as a basis the operation, surgeons clinic № 1 made its modifications developed and implemented the two methods of surgical treatment of habitual dislocation of the shoulder in athletes (VF Bashkirov, VL Safonov). The main objective of the developed techniques – in a more reliable strengthening perednevnutrennego department shoulder and simplification techniques of surgery. The operation is performed under general anesthesia.
Fig. 9 (1, 2, 3, 4, 5, 6). Tendon-muscle plastic two ligaments on the shoulder joint Bashkirov – Safonov.
Method I. Tendons and ligaments of the two muscle plastic shoulder. Skin incision is made at the deltoid-pectoral groove 8-10 cm long, starting at 1 to 1.5 cm down from the coracoid process scapula, and left lateral large subcutaneous Vienna (Fig. 9). Dissection fascia, following the course of the section, bluntly divide and deltoid muscle fibers of the pectoralis muscle and approach the coracoid process and mezhbugorkovoy of the humerus. Revealed tendon sheath of the long head biceps and part of the joint capsule. In the process of allocating the tendon gently freed from adhesions, is put aside and taken taped. Producing moderate external rotation of the shoulder with the retraction of the pectoralis major muscle medially, stands coracoid blades attach a short head of the biceps tendon and coracoid muscles. Aponeurosis of these muscles revealed tendon-muscle flap sizes 7×2, 5×0, 7 cm from the ground at the coracoid process and sewn into a tube with a thin catgut and silk. A defect in the capture of the flap sutured. At the corner of shoulder abduction and 90 ° of external rotation in the neck shoulder bone chisel cut out the U-shaped bone and periosteal flap, the base of the call down, and formed bone trough. Through it (perosseous) spend 2-3 lavsan thread that sews the newly formed band. It is fixed in the bone bed, covered with a top U-shaped bone and periosteal flap with fixation of the latter. Arm placed in neutral. In the lesser tubercle (at the base of its inner surface) is formed bone chisel trough. Tendon of the long head of the biceps is pulled down, shoulder lends itself up and centered in the glenoid cavity blade. Then the tendon is fixed perosseous Dacron sutures in the bone trough in the small protuberance.
Joint capsule is sutured catgut sutures. The wound is sutured in layers tightly.
The proposed operation different operations M. Sverdlov following: first, greatly simplified surgical technique, since the shoulder joint capsule is opened is not always (only suspected to damage the cartilage lip glenoid cavity of scapula), and secondly, not to manipulate the bone mezhbugorkovoy bed furrow, the walls of which the athletes often sclerosal. Fixing the tendon of the long head of the biceps in the bone trough lesser tubercle, in this case do not make the tendon shortening, and immediately create a shorter suspensory ligament of the shoulder and prevent excessive scale movement in the joint. Fixation of the tendon in the bone trough is more robust and reliable.
Method II. Operation U-shaped tendon-muscle plasticity two ligaments in the shoulder joint habitual dislocation of the shoulder. Incision of the skin, allows access to the shoulder joint, tendon sheath opened the long head of the biceps and free from adhesions. Then released coracoid blade. Cutting out and the formation of tendon-muscle flap is exactly the same as in method I. When limb abduction and 65 ° of external rotation and negligible in the small tubercle of humerus, retreating from the inner edge of its base at 1 to 1.5 cm (depending on the degree of stretching of the long head of the biceps tendon), chisel cut out the U-shaped bone and periosteal flap. Formed bone trough, which are stacked two cords formed from the tendon of the long head biceps tendon and a short head and klyuvoplechevoy muscle and fixed in the bone trough perosseous Dacron sutures. Both newly formed ligament catgut sutures are sewn together. Superimposed on top of the U-shaped bone and periosteal flap fixation last silk sutures to the periosteum. Joint capsule is sutured in front catgut. The wound is sutured in layers tightly.
The proposed methodology than simple performance technique has high resistance to dislocation of recurrence, particularly through the creation of two short cords with one point of fixation on a dislocation of the head, as well as biological and physiological compatibility stapled tissue. Operated limb fixed torakobrahialnoy plaster cast for 4 weeks.