SPRAINS AND DISLOCATIONS OF THE SHOULDER BELT Shoulder girdle dislocations are very common during sports. Three types of dislocations maybe 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 mostcommon lesion of the shoulder girdle. ❉ Etiology The acromioclavicular sprain can originate from a direct impact on the joint, but most often itresults from a fall on the shoulder stump, the hand or the elbow. In young subjects the sprainis often less serious (stage 1) than in adults, due to the weakness of the kinetic energyinvolved during the trauma (lower speed and above all lower body mass); the dislocation isexceptional. ❉ Diagnosis . Physical examination The diagnosis is raised during questioning in front of an athletecomplaining about the anterior part of the top of the shoulder. Comparative inspection showsa modification of the scapular relief. The outer end of the clavicle being more or lessprotruding upwards. Even in the case of a "minimum" dislocation (stage I) swellingsecondary 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 passivepalpation looks for abnormal movements in the piano key (between the acromion and theclavicle). The highlighting of this sign affirms the dislocation. If the pain is not too severe theexaminer can also look for an anteroposterior drawer, a sign of a rupture of all the ligamentssupporting the clavicle. If the subject is not examined immediately, a hematoma and/orsignificant edema may develop and interfere with the examination. . Radiologicalexamination The radiographic examination is performed from the front and following Buttin'sinclination. Any passive maneuver aimed at reducing the dislocation should be avoided.Possible associated bone lesions will be looked for. The dynamic examination by traction onthe arm will never be carried out "hot". From clinical and radiological data four stages can bedetermined: ● - 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 onradiography. ● - 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 clinicalexamination and on radiological images. - Stage 4, which corresponds to majordisrepair 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 oralnon-steroidal anti-inflammatory drugs and immobilize the upper limb. Local anti-inflammatoryphysiotherapy and gentle mobilization of the shoulder will be started very early to avoidstiffness. 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'scardiovascular capacity. Before resuming activity, comparative dynamic radiographs(carrying a load in the body axis, abducting the arm to 0°) will verify the absence of surgicalindication. 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 theanatomical integrity of the joint. It will consist of repairing the ligament bracing. In type 3dislocations, ligament repair can be carried out arthroscopically. The intervention will befollowed by a 1 immobilization for three to four weeks, then shoulder rehabilitation (passiveand 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 ajump (ruptures of the costoclavicular and sternoclavicular ligaments are exceptionallysecondary 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 insufficientlymuscular. ❉ 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 beencountered 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 referredfor reduced dislocation on the field. Otherwise the diagnosis is obvious given thedeformation of the shoulder stump and the swelling caused by the anterior sliding of thehead. Gentle palpation 1 finds the humeral head which can be mobilized by passivemovements of the elbow. If nerve and vascular lesions can be easily eliminated ordemonstrated by clinical examination, this is not the case for associated bone lesions whichwill in all cases require an x-ray examination. . X-ray examination reveals the displacementof the humeral head, the type of dislocation (posterior, antero-internal...), and especially theexistence 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 willalways be preceded by a neurological and radiographic examination. Despite the great easeof reducing maneuvers, these techniques will not be practiced on the sports field. The arm isthen 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 cryotherapyseveral days which will often be sufficient to calm the pain. When the arm is released, therehabilitation of the shoulder will aim to regain normal mobility of the joint and on the otherhand to prevent a recurrence by practicing proprioception and bodybuilding techniques. ➢ Recurrent dislocations Recurrent dislocations constitute a complication of scapulohumeral dislocation (see shoulderinstability).