Shoulder dislocation: first aid, reduction and treatment of habitual dislocation in Tashkent

Why does the shoulder dislocate?

The shoulder joint can be thought of as a golf ball resting on a tee: the head of the humerus is large, and the socket of the scapula is shallow and almost flat. They are held together not by bones, but by soft structures - a cartilaginous lip along the edge of the cavity, which deepens it by about one and a half times, an articular capsule with ligaments and the muscles of the rotator cuff. As long as these structures are intact, the shoulder is stable even under heavy loads. When the hand is sharply pulled back and outward - when falling on an abducted hand, when throwing, in a fight - the capsule and lip cannot withstand it, and the head slides forward.

• Falling on an abducted and outwardly turned arm is the most common mechanism
• Contact sports: wrestling, martial arts, handball, volleyball, basketball
• A sharp throw or blow to the outstretched hand
• Road traffic injury
• Congenital excessive joint mobility and connective tissue weakness
• Seizure or electric shock is a rare cause of posterior dislocation that is often missed

What does a dislocation look like?

The moment of dislocation is usually unmistakable: extreme pain, a feeling that the arm has come out of the socket, and the inability to move it. The person supports the injured hand with a healthy one and presses it to the body or, conversely, holds it slightly abducted. The contour of the shoulder changes: the round line of the deltoid muscle disappears, the shoulder becomes angular, and a recess appears under the outer edge of the scapula - this is where the head used to be.

• Sharp pain that gets worse with the slightest attempt to move your arm
• Loss of the rounded contour of the shoulder, visible step under the acromion
• Forced hand position that a person cannot change
• Spring resistance: the doctor feels that the hand returns to its previous position
• Sensation of shortening or, conversely, lengthening of the arm
• Sometimes - numbness along the outer surface of the shoulder

An important detail: in older people, the clinical picture is blurred, and the dislocation is often combined with a fracture of the greater tubercle or neck of the humerus. If, after reduction, a person over forty-five years old cannot raise his arm independently, it is not “just painful” - this is how a tear of the rotator cuff manifests itself, which in this age group accompanies dislocation very often and requires separate treatment.

First aid and why you can’t adjust it yourself

The only correct task before arriving at the clinic is to do no harm. The hand needs to be fixed in the position in which it is most comfortable, cold applied and the person taken to a traumatologist as quickly as possible. All known reduction techniques that are shown in films and videos are performed in a hospital, under anesthesia and only after an X-ray.

1. Зафиксируйте руку косынкой или широкой повязкой в том положении, которое человек принял сам, не пытаясь его исправить.
2. Приложите холод через ткань на 15–20 минут.
3. Снимите с руки кольца и часы — отёк нарастает быстро.
4. Не давайте есть и пить: возможно, потребуется наркоз.
5. Доставьте пострадавшего в clinicsу как можно быстрее, лучше в первые часы.
6. Не тяните, не дёргайте и не вращайте руку.

Reposition and what happens next

In the clinic, the dislocation is reduced under pain relief - local, intravenous or under anesthesia, depending on the age of the injury and muscle tension. There are several gentle techniques in which the head returns to its place with almost no effort if the muscles are relaxed. Immediately after the reduction, a control photograph is taken: it confirms that the head is positioned correctly and that there is no fracture that was not visible before.

1. Вправление под обезболиванием, максимально бережно и без рывков.
2. Контрольный рентген после вправления — обязательный этап.
3. Проверка чувствительности кожи плеча и силы мышц: подмышечный нерв страдает нередко, и это нужно зафиксировать сразу.
4. Иммобилизация повязкой или ортезом. Срок зависит от возраста: у молодых обычно около 3 недель, у пожилых иммобилизация короче, чтобы не получить контрактуру сустава.
5. МРТ или КТ через некоторое время после травмы — для оценки хрящевой губы, костного дефекта впадины и состояния вращательной манжеты.
6. Повторный осмотр через 2–3 недели с проверкой силы отведения руки — именно тогда становится ясно, не пропущен ли разрыв вращательной манжеты.
7. Реабилитация с постепенным восстановлением объёма движений и силы мышц-стабилизаторов.

Immobilization is not endless. In people over forty years of age, prolonged fixation is more dangerous than the dislocation itself: the shoulder quickly becomes stiff, and a persistent limitation of movements develops, which is more difficult to treat than instability. Therefore, in this age group they return to careful movements early.

Habitual dislocation: why the shoulder starts to fly out

The main problem with a dislocated shoulder is not the episode itself, but what happens next. During the first dislocation, the cartilaginous labrum is torn from the anterior edge of the glenoid cavity - this injury is called a Bankart injury. At the same time, a depressed defect from the edge of the socket remains on the back of the humeral head - a Hill-Sachs lesion. If the lip does not grow back, the front edge of the cavity remains without a limiter, and each subsequent dislocation occurs from less and less effort: first during sports, then when trying to put on a jacket, then in sleep.

Long before the first repeated dislocation, a characteristic premonition appears: a person raises his arm back and up - stretch to the top shelf, swing, turn around on the bed - and inside there is a feeling that the shoulder is about to pop out. He instinctively stops moving. This condition is called apprehension, and it almost always means that the anterior barrier of the joint has been destroyed. It is at this stage, and not after the fifth dislocation, that a conversation with an orthopedist is most useful: as long as the edge of the cavity is intact, restoring stability is technically easier, and the result is more reliable.

• Age at the time of the first dislocation is the strongest factor: in adolescents and young people under 20–25 years of age, the risk of recurrence is very high, after 40 years of age it is noticeably lower
• Contact sports and working with raised arms
• Congenital joint hypermobility
• Bone defect of the anterior edge of the glenoid after several dislocations
• Refusal to rehab after the first episode
• Self-reduction for repeated dislocations, aggravating the damage

With each new dislocation, the edge of the cavity is erased, the defect grows, and at some point, simply restoring the lip is not enough. Therefore, the modern approach is not to wait for the tenth episode: for a young athlete, surgery is often discussed after the first dislocation, and after the second or third it becomes the main option.

Surgery and rehabilitation

There are two main options, and the choice between them depends not on preference, but on whether there is a bone defect in the cavity. Arthroscopic Bankart surgery is performed through punctures: the torn cartilaginous lip is returned to its place and fixed with anchors, restoring the anterior barrier. When the edge of the cavity is already destroyed, there is nothing to sew the lip to, and then a Latarget operation is performed - moving a bone fragment with attached muscles to the anterior edge of the cavity, which creates both a bone support and additional support.

1. Первые недели после операции — фиксация в ортезе, движения по разрешённому врачом объёму.
2. Затем — постепенное восстановление подвижности, в первую очередь наружной ротации, самой уязвимой после пластики.
3. Next — силовая работа с мышцами вращательной манжеты и стабилизаторами лопатки.
4. Возвращение к бытовой активности обычно в течение 1,5–3 месяцев, к контактному спорту — не раньше 5–6 месяцев и по функциональным тестам, а не по календарю.
5. При консервативном ведении после первого вывиха акцент делают на тех же мышцах: сильная манжета и правильная работа лопатки реально снижают риск рецидива.

There is another participant that is hardly talked about - the shoulder blade. The shoulder joint rests on it, and if the shoulder blade is not pressed to the chest and does not rotate in time when raising the arm, the entire load is transferred to the capsule and ligaments. Therefore, in a competent recovery program, exercises on the serratus anterior and lower trapezius muscles take up no less space than working on the shoulder itself. This also explains why endless lateral raises of dumbbells do not solve the problem of instability: they load the deltoid muscle, which does not hold the head in the socket.