Dislocations of the Upper Limb

What are Dislocations of the Upper Limb?

Traumatic dislocation of the humeral head in children is rare. It is observed mainly in the older age group. The damage mechanism that leads to dislocation of the humeral head in adults in childhood causes traumatic epiphysiolysis or osteoepiphysiolysis. This is facilitated by greater elasticity and strength of the capsule-ligamentous apparatus in children. The most typical displacement of the humeral head in children with traumatic dislocation is the lower axillary.

Diagnosis of Dislocation of the Upper Limb

The diagnosis is not difficult. It should be differentiated from a fracture in the proximal end of the humerus. X-ray examination clarifies the diagnosis. Reduction of the traumatic dislocation is carried out according to the method of Kocher or Janelidze. The experience of treating children with this pathology shows that the restoration of joint congruency often occurs before the completion of all the moments of reduction. The term of immobilization is up to 2 weeks. Exercise therapy and physiotherapy are recommended until complete rehabilitation. When playing sports for the next 3 months, wrestling and jumping with emphasis on hands are excluded. Subject to all terms of rehabilitation rehabilitation is not observed.

The complexity of the anatomical structure of the elbow joint, consisting of the articulation of the humerus, ulna and radius, as well as the peculiarity of the capsule-ligamentous apparatus create the prerequisites for the occurrence of various dislocations of the forearm bones. These injuries take first place among all dislocations encountered in childhood. Dislocations are accompanied by significant damage to the capsule-ligamentous apparatus and are often combined with a fracture of the forearm bones, fragments of the epicondyles of the humerus. Increasing edema and bone displacement can lead to compression of blood vessels and nerves and serious consequences. Highlight the most characteristic damage:

  • dislocation of both bones of the forearm;
  • isolated dislocation of the radial head and subluxation of the same bone;
  • fracture of the scapula dislocation with a concomitant fracture of the ulna in the proximal metaepiphysis, with epiphysiolysis or osteoepiphysiolysis of the radial head or with a fracture of the radial neck with displacement of the head, fracture of the head of the condyle of the humerus, Montage type injuries.

The posterior or posterior dislocation of the bones of the forearm occurs as a result of a fall on the arm extended and extended in the elbow joint. Due to the sharp over-extension in the elbow joint, the bones of the forearm are displaced posteriorly or posteriorly and outwardly, and the humerus distally tears the joint bag and is displaced anteriorly.

On palpation of the elbow joint in the elbow, it is possible to feel the protruding articular end of the humerus, and in the case of posterior dislocation, the radius head is clearly defined. A good differential diagnostic clinical sign is the definition of the Gunter triangle and the Marx sign.

Treatment for Upper Limb Dislocation

One should always bear in mind the possibility of a fracture of the humerus in the area of ​​the distal metaepiphysis. A trans-alkaline fracture of the humerus is often mistaken for a traumatic dislocation of the bones of the forearm and make unsuccessful attempts to reposition, which further injure the paraarticular tissues, contribute to an increase in edema and hemorrhage. With dislocation of the bones of the forearm without separation of the bone tissue, as a rule, there is no hemorrhage in the soft tissue in the elbow joint. On radiographs, special attention is paid to the medial epicondyle of the humerus, which, when the bones of the forearm are dislocated, often moves along the apophysial line and, when the joint capsule ruptures, can invade the joint cavity. After reduction (or self-regulation), the bone fragment can be impaired in the shoulder-elbow joint, which usually leads to joint stiffness.

Perhaps the earliest possible simultaneous reduction of dislocation of the bones of the forearm under conduction anesthesia or general anesthesia. Receptions of the most characteristic posterior-external dislocation of the forearm bones in children are as follows (according to A.V. Itinsky). With one hand, the traumatologist covers the lower third of the shoulder and gropes with his thumb for the head of the radius. The other hand covers the forearm in the lower third and traces along the length, rotates and puts the forearm to the maximum supination position. Reduction is carried out without much physical violence, quickly, without flexion or extension of the forearm. After reduction, movements in the elbow joint become possible almost in full. With the remaining subluxation, a characteristic springing resistance is revealed when trying to bend or unbend the forearm. After the dislocation is repaired, a control x-ray examination is performed (before applying the plaster cast!) In order to identify a possible separation fracture with an infringement of the bone fragment in the joint cavity, as well as to restore the congruence of the articular surfaces. Then impose the posterior plaster cast from the heads of the metacarpal bones to the upper third of the shoulder in the mid-physiological position for a period of 7 days. In the recovery period, several recommendations should be observed: thermal procedures should be moderate, physiotherapy exercises should be carried out without pain, massage of the elbow joint area is contraindicated. Parents of the child should be warned about the length of the recovery period.

Subluxation of the radial head is found exclusively in children of preschool age. It is also called “dislocation from stretching” or “painful pronation of young children.” Damage is observed mainly in children aged 1 year to 3 years. In the future, the frequency of this damage decreases sharply, and in children over 6 years old is an exception.

The reason that causes a subluxation of the radial head is usually a movement in which the child’s arm, in an extended position, undergoes a sharp extension of the wrist or lower end of the forearm along the longitudinal axis of the limb more often upward, sometimes forward. From the anamnesis, it is possible to establish that the child stumbled or slipped, and the adult who led him, most often holding his left hand, pulled it to keep the child from falling. Sometimes this stretching of the arm occurs during the game, when it, holding both hands, is rotated around itself, or when putting on and removing the narrow sleeve. In some cases, adults indicate that the arm has cracked.

The mechanism of this damage can be represented as follows: a sharp pull on the arm along the longitudinal axis of the limb leads to the fact that the head of the radial bone partially slides out of the as yet underdeveloped annular ligament, in which it is infringed. S. D. Ternovsky pointed out such age-related anatomical features of the ligamentous apparatus and musculoskeletal system in children under 3 years of age, such as the later development of the outer part of the distal condyle of the humerus, muscle weakness and thinness of the joint bag. In addition, the joint capsule between the humerus and the radial head is wider and forms a fold that extends into the joint cavity. These anatomical features undoubtedly contribute to a subluxation of the radial head in young children.

Whatever the cause of the damage, the child cries out in pain, after which he immediately stops moving his hand and holds it since then in a forced position, stretching along the body, slightly bending at the elbow joint.

The mechanism of injury and the clinical picture are always typical. The child’s hand hangs along the body, like a paralyzed one, in a position of slight flexion in the elbow joint and pronation. Rotational movements are especially painful. On palpation, it is sometimes possible to determine the most painful point, which is localized in the projection of the radial head. On radiographs of the elbow joint pathological changes are not detected.

Directing a subluxation of the radial head in the first day after the injury is easy and without prior anesthesia. The forearm is carefully transferred to the bending position at right angles in the elbow joint, which is painful for the child, they grab the patient’s hand with the same hand, fixing the wrist, and grasp the elbow with the other hand and, slightly pressing the control finger on the radial head, make the movement complete supination. In this case, the child experiences some pain, and the finger of the adjuster feels a click or a slight crunch. The child immediately calms down and literally after a few minutes begins to freely use his hand as healthy. In some cases, the reduction fails immediately and this technique has to be repeated 2-3 times. There is no need for immobilization.

Traumatic dislocation of the phalanges of the fingers in children is relatively rare. Damage occurs as a result of excessive extension of the fingers. Most often, children experience a dislocation in the metacarpophalangeal joint of the first finger of the hand. With complete dislocation, active and passive movements are absent; with incomplete displacement, limitation of movements and moderate deformation are noted. The diagnosis is specified after radiography. Repositioning an uncomplicated dislocation is usually straightforward. With the interposition of the tendon of the long flexor of the first finger and pinching it between the head of the metacarpal bone and the proximal phalanx of the finger, surgical intervention may be required.