Dislocation of the clavicle - Causes, symptoms and treatment. MF.

Dislocation of the clavicle is a common trauma. As a percentage, the incidence of clavicle dislocation is 5% of the total number of injuries of this kind. In this case, the dislocation of the acromial( external) and sternal( inner) ends should be strictly distinguished. But first things first.

Clavicle is a hollow pair of bone of S-shaped form, which is part of the shoulder girdle of the upper limb. Being the first bone in the body, which begins the process of ossification at the embryonic stage of human development and the only joint of the upper limb with the skeleton, it performs a number of important functions. In particular, the support( on the clavicle with a row of muscles attached blade and limb), protective( clavicle covers the cavity between the neck and limb, through which passes several vital anatomical structures) and transport( clavicle serves as a conductor of impulses from the limb to the spine).However, its main task is to provide free movement of the hand. This explains the structure of this bone: the outer, acromial end, together with the scapula attached to it, is bent by the convex part backwards, and the inner, sternal end fastened to the thorax is curved forward.

Dislocation of the acromial end of the clavicle

Symptoms of clavicle dislocation

Dislocation of the clavicle usually occurs by indirect mechanical damage. This can be a fall on the arm or shoulder, or a blow to the upper body. However, in rare cases, spontaneous dislocations of the clavicle can occur( such as were not preceded by direct trauma).

The lion's share of such injuries is caused by the dislocation of the external( acromial) end of the bone. In comparison with it, the dislocation of the inner( sternal) end of the clavicle is diagnosed much less often. And very rarely there is a simultaneous dislocation of both ends.

Dislocation of external( acromial) end of clavicle

The outer, acromial end of the clavicle is connected to the acromial process of the scapula by two ligaments. Depending on whether one of them is damaged or both, a subluxation or a complete dislocation of the clavicle is diagnosed, respectively.

The main symptoms of dislocation of the outer end of the clavicle are painful sensations in the area of ​​the collarbone with the shoulder blade and pain when trying to move the arm or shoulder.

It should be noted that the latter aspect often leads to the fact that, by ignorance, patients often confuse dislocation of the clavicle with a dislocation of the shoulder joint. However, it is quite easy to distinguish one trauma from another, knowing the following symptoms:

A) When the clavicle dislocates, swelling and deformation caused by protrusion of the outer end of the bone( it protrudes upwards and slightly back) is noted. In the case of dislocation of the shoulder joint swelling occurs rarely.
B) The dislocation of the shoulder joint is accompanied by a feeling that the shoulder is out of place, and any attempt to move the limb is accompanied by a sharp bout of pain. If there was a dislocation of the clavicle, the pain has a moderately restrictive character.

Dislocation of internal( sternal) end of clavicle

Unlike external, dislocation of inner, sternal end of clavicle is confused with something else quite difficult. This is explained by the specificity of the joint of the bone with the thorax. Depending on the nature of the injury, the anterolateral, supra- and retrosternal types of dislocations are distinguished. All of them are characterized by pain in the area where the clavicle connects to the sternum, painful sensations with deep breathing, deformity and swelling of the soft tissues, as well as a noticeable shortening of the shoulder-blade from the injured side. If the dislocated bone touches the vessels, which is most often observed with a retrosternal dislocation, externally specific external manifestations( for example, changes in the color of the skin) will be noted.

There are symptoms characteristic of each type of dislocation. Thus, the first, anteromabrasion type of dislocation is most common and is easily determined by protrusion of the inner end of the clavicle forward. In the case of a supracerebral dislocation, the clavicle protrudes forward and upward. For the third type of dislocation, according to its name, there is a westernization of the inner end of the clavicle. The bony dislocation of the inner end of the clavicle is considered to be the most dangerous, since in this case there is a serious risk of damage to important anatomical structures.

Note: for all variants of dislocation of clavicles, a characteristic symptom is that when you press the protruding end of the clavicle, it easily gets in place, but when the pressure stops, it goes back. This phenomenon is called the "key effect".It allows you not to confuse the dislocation of the clavicle with its fracture.

The fact that in the case of a fracture in addition to swelling and deformity, there is a limitation of shoulder mobility, bruising and rupture of soft tissues by shattered bone fragments also helps to avoid confusion. In addition, the displacement at the fracture, in contrast to the dislocation, usually occurs forward and downward. However, to exclude the presence of a crack in the bone, you should do an x-ray.

Attention: in people suffering from obesity, external signs of dislocation of the clavicle may be less noticeable.

First aid for dislocation of clavicle

If there is a suspicion of dislocation of the clavicle, urgently it is necessary to suspend and fix the limb by applying a bandage( both a bandage and a scarf are suitable for this).In this case, a cotton-gauze roll or a piece of cloth rolled into it should be placed in the axillary cavity.

Reduce edema can be applied to the site of the injury cold.

When transporting a victim to a trauma center, you should carefully monitor that it is comfortable. Before arriving at a medical facility, it is not recommended to take strong painkillers( this may interfere with the decision of the correct diagnosis).Exceptions are cases where a person has a low threshold of pain.

Warning: Before administering an analgesic strong-action drug, you should consult your doctor.

Regarding prohibitions, when providing first aid, you should not try to direct the dislocation yourself, as in other cases even medical techniques of dislocation correction can not guarantee 100% of the result. Moreover, the clavicle is located above a number of important structures of the body. Therefore, self-medication can be deadly to health.

Diagnosis of dislocation of clavicle

Diagnosis of dislocation of the clavicle can be by external signs( characteristic bulging of the external or internal end of the bone, pain, swelling of soft tissues).However, in addition to external examination, the doctor is obliged to palpate the injured place and make a radiograph.

In case of dislocation of the outer end of the clavicle, the radiograph makes it much easier to diagnose, since it allows one to consider the position of the external process of the scapula relative to the lower edge of the clavicle: when dislocated, they are located at an angle from each other. If they are located on the same level, the deformation of the outer end is caused not by a dislocation, but by the pathology of the clavicle.

When an internal end of the clavicle is diagnosed, an X-ray is mandatory. It compares both internal joints of the clavicles with the thorax, thereby determining the presence of a dislocation( the projection of the displaced end is noted above normal, and its shadow overlaps the shadow from the vertebrae).

In some cases, the doctor may also prescribe a CT scan of the affected area.

Treatment of dislocation of clavicle

Therapy of dislocation of the clavicle is carried out by both conservative methods and by surgical intervention. Specificity of the procedure is that to fix the bulging end of the clavicle - the task is not difficult. It is much harder to fix and hold it in the right position.

Treatment of dislocation of the outer end of the clavicle is performed using invasive and non-invasive techniques. In most cases, one of the options for conservative treatment is sufficient. But if there is no result at the end of treatment, or if it is unsatisfactory, the doctor can offer surgery.

Elastic bandages

The most common variant of non-invasive treatment of the dislocation of the outer end of the collarbone is the Volkovitch bandage. Before it is applied, the affected area is anesthetized with a dose( 20-30 ml) of a 1% procaine solution and the colleca is inserted. Then, a cotton-gauze roll is inserted into the axilla, and a cotton-gauze peloton is applied to the acromial joint, which is fixed by the patch in the following sequence:
1) in the direction of the back and downward from the external process of the scapula to the shoulder;
2) on the back of the shoulder to the elbow;
3) girth of the elbow fold;
4) along the anterior part of the shoulder to the acromial process of the scapula.

As an analogue to the first option, you can apply the Dezo bandage. Before its superimposition in the armpit, a cotton-gauze roll is also inserted. The dressing is superimposed as follows:

1) Double wrap the chest with a bandage on the arm from the injured collarbone and at hand - from the side of the healthy limb;
2) Transfer the bandage diagonally across the chest, following the axillary region from the side of the intact arm to the forehead from the side of the lesion;
3) Lower the bandage on the back of the shoulder to the elbow fold;
4) Bend the elbow, hold a bandage over the forearm of the limb from the injured side to the armpit basin healthy;
5) Transfer the bandage diagonally along the back, following the axillary region from the side of the intact arm to the forehead from the side of the lesion;
6) Circumfer the foreleg, hold a bandage on the front of the shoulder from the side of the injury, wind it under the elbow, skirting the forearm.
7) Repeat steps 4 - 6 until complete immobilization of the damaged shoulder girdle.

Dezo bandage with dislocation of clavicle

When treating the dislocation of the outer end of the clavicle with elastic bandages, it is recommended to apply cold to the damaged area from the first day of therapy( this will help to eliminate puffiness and stop pain).In the event that the pain does not go away, you should take an anesthetic.

Remember: self-medication is harmful to health, so taking an anesthetic and its type should be discussed with your doctor.

Inelastic bandages

Despite the possibility of using flexible dressings, the best way to fix the clavicle without surgery is the gypsum dressing. As a rule, to apply it, use the technique of Dezo's bandage.

The type and term of wearing this or that type of dressing is determined exclusively by a specialized specialist. On average, the dressing should be from a month to two. Staying in the hospital during this period is not required.

Surgical operation with dislocation of clavicle

Surgical intervention in the treatment of dislocation of the outer end of the clavicle is prescribed only if conservative therapies have failed.

To date, there is a large number of options for invasive therapy of external dislocation. It can be fixation of the clavicle with the help of metal spokes, screws or "buttons", etc.

Fixation of the collarbone with metal spokes is the most budgetary option for surgical treatment of dislocation. But it is ineffective( the ligaments / ligaments connecting the outer end of the clavicle with the acromial process of the scapula remain unreduced).Moreover, after it, frequent cases of recurrence are possible.

Clamping of the collarbone with screws gives a more reliable attachment and significantly reduces the risk of recurrence. However, such a good fixation often entails a limitation and a decrease in mobility of the clavicle, which directly affects the functionality of the limb, whose shoulder belt has been damaged.

Technique locking the collarbone with the buttons is a kind of synthesis of the first and second type of fixation. It is considered quite safe from the point of view of predictions for the postoperative condition and restoration of the limb's labor capacity. But sewing on the buttons leaves a trace. And cases when this variant of invasive therapy of dislocation of the external end causes frequent relapses are also not rare.

Thus, the most effective and safe way is considered plastic ligaments .During this operation, artificial ligament / ligaments are created from synthetic surgical materials and they are replaced by injured structures.

After any type of intervention, the shoulder girdle is fixed with a plaster bandage, which should be worn for 1.5 to 2 months.

Remember: each type of invasive therapy has its own indications, drawbacks and risks. In view of what it is important to find out all the details of this type of therapy from a doctor who prescribes a surgical procedure.

Therapy of dislocation of the inner end of the clavicle practically does not provide for conservative methods of treatment. Of course, one can consider the method of closed repositioning. It is performed in the following order:

1) Pain the affected area with a dose of novocaine;
2) Relax the muscles with a special drug( muscle relaxant);
3) The patient is laid on the table, putting a cotton-gauze roll under his shoulder;
4) Produce a hand tension with a synchronous pressure on the clavicle;
5) Raise the patient from the table and fix the clavicle with a razor-like bandage.

But this method of treatment of internal dislocation is rarely resorted to, since, in most cases, when lifting from the table, the clavicle again leaves the normal position. Thus, the best result is achieved solely by means of invasive damage therapy.

As a rule, before the operation the doctor conducts a closed dislocation of the dislocation, and during the intervention the collarbone is attached to the sternum mechanically by means of spokes, rods, plates or U-shaped transossal sutures. The material and type of attachment depends on the type of dislocation and is prescribed by the doctor. As an option, by analogy with surgical treatment of external dislocation, it is possible to make plasty of ligaments.
After surgery, a defective tire or plaster bandage is applied to the damaged area for a period of 3 to 4 weeks. And the full capacity of the limb is restored in 1.5 - 2 months.

After the end of treatment, both the external and internal ends of the clavicle are re-diagnosed( including X-rays and, if necessary, tomography) and rehabilitation is prescribed.

The full capacity of the limb is restored in 1.5 - 2 months for both conservative and surgical treatment of dislocation.

Important: remember that many indicators depend on the characteristics of each individual organism( pain threshold, ability to regenerate, allergic factor, etc.).Therefore, when the collarbone is dislocated( both acromiologically and sternally), the specialist should find out its type( full / incomplete), type( front / upper / posterior), preferred methods of treatment and methods of anesthesia, the timing of therapy, possible complications, methodsrehabilitation and the timing of the return of efficiency.

Rehabilitation after dislocation of clavicle

Rehabilitation of clavicle dislocation is a complex of restorative procedures that includes a number of specialized physical exercises aimed at restoring the normal functioning of the shoulder girdle and returning limb mobility, therapeutic massage, manual and UHF therapy. He is appointed by a specialist taking into account the type and type of dislocation, the methods of his treatment and the individual characteristics of the patient.

Treatment for dislocation of the clavicle can not be delayed, since after 3 to 4 weeks after the injury the dislocation is considered to be long-lasting. If the dislocation was incomplete, then after a while he practically does not disturb the patient. But the launched full dislocation in the future is accompanied by pain in the area of ​​damage, weakening and lowering the functionality of the limb.

Please note that chronic clavicle dislocations can not be treated with conservative treatment. Their correction is made exclusively through surgical intervention, and the predictions for the success of the operation and its result are significantly reduced, even if the most expensive and innovative therapies are used.

Rev.doctor of traumatologist-orthopedist Savchenko V.R.