Shoulder Separation | Michigan Medicine

Topic Overview

What is a shoulder separation?

A shoulder separation is the partial or complete separation of two parts of the shoulder: the collarbone (clavicle) and the end of the shoulder blade (acromion). See a picture of shoulder separation injuries.

The collarbone and the shoulder blade (scapula) are connected by the acromioclavicular (AC) joint, which is held together primarily by the acromioclavicular (AC) and the coracoclavicular (CC) ligaments. In a shoulder separation (also called an acromioclavicular joint injury), these ligaments are partially or completely torn. A shoulder separation is classified according to how severely these ligaments are injured:

• In a type I injury, the AC ligament is partially torn, but the CC ligament is not injured. See a picture of a type I injury.
• In a type II injury, the AC ligament is completely torn, and the CC ligament is either not injured or partially torn. The collarbone is partially separated from the acromion. See a picture of a type II injury.
• In a type III injury, both the AC and CC ligaments are completely torn. The collarbone and the acromion are completely separated. See a picture of a type III injury.

There are three further classifications, types IV through VI, which are uncommon. These types of shoulder separations may involve tearing of the muscle that covers the upper arm and shoulder joint (deltoid muscle) and the one that extends from the back of the head, neck, and upper back across the back of the shoulder (trapezius muscle).

What causes a shoulder separation?

A direct blow to the top of the shoulder or a fall onto the shoulder, such as a fall from a bicycle, can cause a shoulder separation.

What are the symptoms?

Signs and symptoms of a shoulder separation include:

• Pain at the moment the injury occurs.
• Limited movement in the shoulder area (because of pain, not weakness).
• Swelling and bruising.
• Tenderness over the AC joint on top of the shoulder.
• Possible deformity. The outer end of the collarbone may look out of place, or there may be a bump on top of the shoulder.

How is a shoulder separation diagnosed?

A shoulder separation is diagnosed through a medical history, a physical exam, and an X-ray.

Your doctor will check:

• For a deformity or bump.
• The range of motion of your shoulder and other joints.
• Blood flow, by taking your pulse and assessing your skin color and temperature.
• For damage to your nerves or blood vessels.
• The muscle strength of your shoulder and arm.
• For broken shoulder bones or damage to the tendons in the shoulder (rotator cuff tear).

Your doctor will probably X-ray your injured shoulder and possibly your uninjured shoulder to help diagnose the severity of the separation.

How is it treated?

Treatment of a shoulder separation depends on its severity. For a type I or II injury, you support your shoulder with a sling. You typically need the sling until the discomfort decreases (a few days to a week). Early physical therapy to strengthen your shoulder and regain range of motion is important for recovery and to prevent frozen shoulder, a condition that limits shoulder motion (adhesive capsulitis). You can return to normal exercises and activities as your pain and other symptoms go away.

Experts don’t agree on the best treatment for type III injuries. Some doctors treat them with a sling and physical therapy, while others feel surgery may be needed.

Type IV through VI injuries should be evaluated for possible surgery.

To help relieve pain, put ice on the affected area and take nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen. Be safe with medicines. Read and follow all instructions on the label.

Symptoms, Diagnosis, Treatment & Prevention

Overview

What is a separated shoulder?

A separated shoulder occurs when the ligaments between the collarbone (clavicle) and part of the shoulder blade (acromion) are torn. The tear loosens the joint connection between the collarbone and shoulder blade, causing them to separate or move apart from one other. A separated shoulder does not actually involve damage to the main ball-and-socket joint of the shoulder.

Other names for this condition are acromioclavicular joint separation or AC joint separation. These names reflect the medical references for the collarbone (clavicle), and the outer end of the scapula (acromion) that extends over the shoulder joint at its highest point.

Who is affected by a separated shoulder?

A separated shoulder can affect anyone regardless of age, ethnic background, physical health or level of fitness.

Symptoms and Causes

What causes a separated shoulder?

Most shoulder separations are caused by falling directly onto the shoulder with enough force to tear ligaments. Besides falls, car accidents and sports injuries are frequent causes.

What are the symptoms of a separated shoulder?

• Pain at the very top of the shoulder.
• A bump on the top of the shoulder at the end of the collarbone. As a result of torn ligaments, the shoulder blade moves downward from the weight of the arm, causing the top end of the collarbone to protrude up.

Diagnosis and Tests

How is a separated shoulder diagnosed?

• Review of current symptoms and appearance of the injured shoulder.
• Review of medical history.
• A physical examination.
• Imaging tests such as X-rays, ultrasound and MRI (magnetic resonance imaging). The patient may be asked to hold a weight in the hand during these tests to make the injury stand out more on the images that are captured.

After an examination, the doctor can make a determination of the seriousness of the shoulder separation using a scale such as the Rockwood classification of AC joint injuries. This scale ranges from type I (injury limited to an AC ligament sprain; joint still in place) to VI (severe ligament detachment and joint dislocation) injuries. The rating helps determine the appropriate medical response, including the need for surgery, and gives the patient an idea of how long treatment could last and what long-term effects might occur.

Management and Treatment

How is a separated shoulder treated?

Most people will recover from a separated shoulder within two to 12 weeks without surgery. Non-surgical treatments include the following:

• Use of a sling to keep the shoulder in place while healing.
• Ice packs and medications such as ibuprofen, naproxen, aspirin or acetaminophen to reduce pain.
• Physical therapy or an exercise program to strengthen the muscles and ligaments of the shoulder once it has healed. A doctor’s approval should be received before starting a rehabilitation program.
• Avoidance of lifting heavy objects for eight to 12 weeks after the injury has healed.

Surgery may be required in more serious cases (such as a type IV, V or VI injuries on the Rockwood scale) or after determining that non-surgical treatments are not the best option. More serious injuries are indicated when the fingers are numb or cold, arm muscles are weak, or deformity of the shoulder is severe. Surgical treatments include:

• Shaving the end of the collarbone to prevent it from rubbing against the shoulder blade.
• Reattaching torn ligaments to the underside of the collarbone. This surgery can be performed even long after the injury has occurred, but may require a graft tissue to help reconstruct the ligaments if a lot of time has passed since the injury.

What are the complications associated with a separated shoulder?

Although most people regain complete function of the injured shoulder, sometimes a bump or other deformity remains. There may also be continued pain, even in what appears to be a mild shoulder separation. This can be the result of bones rubbing against one another, arthritis, or damage to the cartilage which provides a cushion between bones of the shoulder joint.

Prevention

Can a separated shoulder be prevented?

While there is no sure way to prevent a separated shoulder, it is helpful to be aware of the factors that increase the chances of shoulder injuries. These factors can include:

• Repetitive motions with the shoulder.
• Aging.
• Overuse or straining of the shoulders, particularly in older people.
• Manual labor.
• Participation in sports involving collisions with others or the ground.
• Accidents and falls.

Living With

When should I see a healthcare provider about a separated shoulder?

The presence of any of the following symptoms after a shoulder injury requires medical attention:

• Severe pain.
• Weakness in the arm or fingers.
• Numb or cold fingers.
• Difficulty in moving the arm through a normal range of motion.
• A lump on top of the shoulder, making it look deformed.

Acromioclavicular Joint Separation, Orthosports Orthopaedic Surgeons

This surgery is much more successful when done within 3 weeks of the injury. Although it can be done later, the results of this particular operation may not be as good as if it was done soon after the injury. In long standing and chronic injuries a different operation is usually needed (This is called a Coraco Clavicular Fusion and a bone grafting procedure is required).

Generally speaking anyone who does heavy manual or overhead work should consider having the surgery done soon after the injury. This also applies to throwing or contact athletes.

With most other patients a non operative approach is appropriate on the understanding that you are accepting a small element of risk. That is, if you do not do well with nonoperative treatment, surgery may be needed at a later date. Unfortunately the delayed operation tends not to be as successful as an operation done immediately following the injury.

The Surgical Procedure

The operation takes about 90 minutes and involves the procedure outlined in the diagram above.

You will wake up in the ward in a sling and you will have a drain coming out of your shoulder. You will be given adequate pain killers to keep you comfortable.

The morning after surgery your drain will be removed. A waterproof dressing will be placed on the shoulder and you will be allowed to shower. When showering take the sling off but leave your arm adjacent to your body – do not attempt to lift or rotate the arm – and then put the sling back on after you are dry. Make sure the armpit is as dry as possible because of the risk of a sweat rash or an armpit infection. It is important to sit out of bed and walk around as soon as you are comfortable and able.

You can leave hospital that day if you feel well enough. The sling will need to remain on for at least 3 weeks. The sling must remain on 24 hours a day including at night. The sling only comes off to have a shower and get dressed and on those occasions the arm needs to be kept adjacent to the body.

After 3 weeks the sling is removed and you start gentle movements. You do not do any specific exercises or physiotherapy at this stage because it may compromise the graft.

After about six weeks (if your movements are fine) the sling will be removed and you can move the arm freely. You may be sent for physiotherapy or swimming at this time (but it does depend on your progress). Do NOT get alarmed when you notice that the end of the collarbone rides up by 1 cm. This is a normal occurrence and without this you will not regain full movement.

Full activity, including all sports, can usually be started by 3 months.

Rarely, at about 6 to 9 months the Dacron graft irritates the bone and causes a condition known as “osteolysis”. If this occurs the graft requires removal at about 12 months. By this time the other tissues have compensated for the damaged ligaments the collar bone usually remains stable in its position despite the graft being removed.

Acromioclavicular Joint Separation – Undergraduate Diagnostic Imaging Fundamentals

Case

Acromioclavicular joint dislocation

Clinical:

History – 21 year old female injured her shoulder while wrestling.

Symptoms – This patient complained of a deformed, painful, end of her right collar bone.

Physical – There was swelling and tenderness of the region of the acromioclavicular joint.

DDx:

Acromioclavicular Joint Separation

Clavicle Fracture

Acromion Fracture

Hematoma

Imaging Recommendation

ACR – MSK – Acute Shoulder Pain, Variant 1

Shoulder X-ray

ODIN Link to AC Joint Separation images, Figure 14.2A and B: https://mistr.usask.ca/odin/?caseID=20150209202015857

Figure 14.2A X-ray of the right shoulder, Y-view, with AC joint separation

Figure 14.2B X-ray of the right shoulder, AP, with AC joint separation

Imaging Assessment

Findings:

The lateral clavicle was displaced cranially and the acromioclavicular joint was widened.  The coracoclavicular distance was also widened.

Interpretation:

Acromioclavicular joint dislocation, Type 3.

Diagnosis:

Acromioclavicular joint dislocation

Discussion:

Acromioclavicular joint injuries can be graded on the 6-point Rockwood scale:

Figure 14.3 Acromioclavicular injury classification

X-ray findings may include:

• Minor injuries of this joint space usually involve only the joint capsule and the acromioclavicular ligament.
• With more severe injuries the coracoclavicular ligament may be torn leading to a more displaced clavicle and a wider coracoclavicular distance.
• Severe injuries can involve the coracoclavicular ligament, the deltoid muscle and the trapezius muscle.

Figure 14.2A X-ray of the right shoulder with AC joint separation by Dr. Brent Burbridge MD, FRCPC, University Medical Imaging Consultants, College of Medicine, University of Saskatchewan is used under a CC-BY-NC-SA 4.0 license.

Figure 14.2B X-ray of the right shoulder with AC joint separation by Dr. Brent Burbridge MD, FRCPC, University Medical Imaging Consultants, College of Medicine, University of Saskatchewan is used under a CC-BY-NC-SA 4.0 license.

Figure 14.3 Acromioclavicular injury classification. Courtesy of Dr. Roberto Schubert, Radiopaedia.org, RID: 19124. Originally published at https://radiopaedia.org/cases/rockwood-classification-system-of-acromioclavicular-joint-injuries under a Creative Commons Attribution-Non-commercial-Share Alike 3.0 License.

Shoulder Separation (AC Joint Sprain)

Shoulder Separation (AC Joint Sprain)

Anatomy

The shoulder is a complex, ball-and-socket joint made up of three bones: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head, of the upper arm bone fits into a rounded socket (glenoid) in the shoulder blade. The arm bone is kept centered in the shoulder socket by a combination of muscles and tendons (rotator cuff). The rotator cuff covers the head of the upper arm bone and attaches it to the shoulder blade.

The AC (acromioclavicular) joint is formed where a portion of the scapula (acromion) and the clavicle meet and are held together by tough tissues (ligaments) that act like tethers to keep the bones in place.

Description

A shoulder separation is actually an injury to the AC joint, not the shoulder joint. It is commonly the result of a direct fall onto the shoulder that injures the ligaments that surround and stabilize the AC joint. If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn, causing separation of the collarbone (clavicle) and wingbone (scapula). The scapula moves downward from the weight of the arm, creating a bump or bulge above the shoulder.

Severity can range from a small change in shoulder configuration with mild pain, to a more deforming and painful injury. Even in severe cases, good, pain-free function often returns, however, the greater the deformity the longer it requires to recover.

Diagnosis

A shoulder separation, or AC sprain, often causes a deformity that makes it easy to identify. Where there is less deformity, X-rays and the location of pain can aid in diagnosis. In some cases, asking the patient to hold a weight can increase the deformity so it becomes more obvious on X-rays.

Like other types of ligament injuries, shoulder separations (AC joint sprains) are classified by the degree of severity of the injury.

• Grade 1—Involves stretching/spraining of the joint covering (capsule), with no damage to ligaments connecting the shoulder blade (scapula) and collar bone (clavicle). There may be swelling over the joint but the bump is not permanent. Pain typically lasts for 2-4 weeks, but can be easily reaggravated. Surgery is usually not required.
• Grade 2—Involves tearing of the joint covering (capsule) and stretching (but not tearing) of ligaments connecting the shoulder blade (scapula) and collar bone (clavicle). Frequently results in a small, permanent bump over the top of the shoulder at the AC joint. Initial pain typically lasts 4-6 weeks, however, chronic discomfort at the joint may be experienced when lifting weights or performing other overhead or lifting activities. Surgery is usually not required.
• Grade 3—Involves tearing of the joint covering (capsule) and ligaments connecting the shoulder blade (scapula) and collar bone (clavicle). Causes a mild to moderate permanent bump over the top of the shoulder at the AC joint. Pain typically lasts 4-8 weeks. Surgery is usually not required.
• Grade 4—Defined as a significant posterior displacement, occuring when the clavicle is severely displaced backwards.
• Grade 5—Involves tearing of the joint covering (capsule) and ligaments connecting the shoulder blade (scapula) and collar bone (clavicle), and the end of the collar bone (clavicle) tears through the muscle covering (fascia) above it. Results in a large, permanent bump over the top of the shoulder at the AC joint. Pain typically lasts 4-8 weeks, however chronic discomfort is common. Surgery is frequently recommended.

Nonsurgical Treatment

It is often worthwhile to wait and see if reasonable function will return without requiring surgical treatment. Placing the arm in a sling to hold the shoulder in place as it heals, application of cold packs, and medications are among the most common nonsurgical treatments used to help manage pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or aspirin may provide some relief from symptoms. However, whether using over-the-counter or prescription strength, they must be taken carefully. Using these medications for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.

Surgery

If pain persists after nonsurgical treatment, or if the deformity is severe, your orthopaedic surgeon may recommend trimming back the end of the collarbone so that it does not rub against the acromion. Where there is significant deformity, reconstructing the ligaments that attach to the underside of the collarbone is helpful. This type of surgery works well, even if it is done long after the problem started.

With any surgery, there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.

Recovery

Whether treated conservatively or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength and flexibility. Most people are able to return to near full function after this injury, even if there is a persistent, significant deformity. Some experience continued pain in the area of the AC joint, even with only a mild deformity. This may be due to the development of arthritis, abnormal contact between bone ends when the joint is in motion, or injury to the cartilage found between the bone ends of the joint.

ACL Reconstruction Vail, CO – Dr. Thomas Hackett

An acromioclavicular joint separation (AC separation), or shoulder separation, is a very frequent injury among active people, especially football or hockey players, and cyclists who fall over their handlebars. This injury occurs when the collarbone (clavicle) separates from the shoulder blade (acromion). In most cases, shoulder separation can be remedied without surgery, but there are certain situations where surgery may be necessary.

Overview

Shoulder separation does not refer to a true injury to the shoulder joint. The injury actually involves the acromioclavicular joint where the collarbone and shoulder blade meet. The most common cause of shoulder separation is due to a direct fall onto the shoulder that injures the ligaments surrounding the AC joint. If the impact was severe, the ligaments attaching the collarbone are torn, which causes the separation. This specific injury can range from mild pain to debilitating pain, depending on the severity of the torn ligaments. A mild shoulder separation refers to a sprain of the AC ligament that is unable to move the collarbone and appears normal on x-rays. A more serious shoulder separation involves a tear of AC ligament and a sprain of the coracoclavicular (CC) ligaments, which forces the collarbone out of alignment. In the most severe cases, the impact completely tears both the AC and CC ligaments, which makes the AC joint noticeably out of place.

If the impact was severe, the ligaments attaching the collarbone are torn, which causes the separation. This specific injury can range from mild pain to debilitating pain, depending on the severity of the torn ligaments. A mild shoulder separation refers to a sprain of the AC ligament that is unable to move the collarbone and appears normal on x-rays. A more serious shoulder separation involves a tear of AC ligament and a sprain of the coracoclavicular (CC) ligaments, which forces the collarbone out of alignment. In the most severe cases, the impact completely tears both the AC and CC ligaments, which makes the AC joint noticeably out of place.

Symptoms

Depending on the severity of your condition, symptoms may vary. Here are some common symptoms involved with all cases of shoulder separation:

• Mild, Grade I Separation: tenderness and bruising of the joint, mild pain when moving the arm.
• Moderate, Grade II Separation: moderate to severe pain at the joint, swelling, small bump on top of shoulder, tenderness to the touch.
• Severe, Grade III Separation: pain with any arm motion, cannot support arm by itself, popping sounds, swelling, AC joint is very unstable, bump on the top of the shoulder.

Treatment

During your evaluation, Dr. Hackett may be able to identify a shoulder separation if there is a deformity, or bump on the top of your shoulder. However, X-rays can help the diagnosis and rule out any other injuries you may have. Based on your evaluation in Vail, Colorado, Dr. Hackett will determine a treatment that is best suited for your injury and lifestyle.

Non-Surgical Treatments

In most cases, non-surgical treatments including a sling, ice packs, and medication can be successful in treating shoulder separation. Sometimes, Dr. Hackett may use more complex supports to restrict the joint motion and reduce pain. Physical therapy plays a key role in non-surgical treatments of shoulder separation, which focus on restoring motion and strength to the AC joint. Depending on your natural healing capabilities and the severity of your injury, most patients heal within three months without surgery. In all cases, it’s worthwhile to wait to see how effective non-surgical treatments work for you without resorting to surgical procedures.

Surgical Treatments

Surgery may be necessary for patients that do not respond well to non-surgical treatments. If the pain persists in the AC joint about three months after starting physical therapy, Dr. Hackett may recommend surgery. In some cases, he may recommend surgery earlier if you are a young, active individual, athlete, or laborer who is required to do overhead work.

Distal Clavicle Resection – The most common surgery performed involves restoring the CC ligaments and removing the distal, or shoulder, end of the collarbone (clavicle). Dr. Hackett commonly utilizes a screw or suture loop to stabilize the AC joint. During a distal clavicle resection, about 10 millimeters of the collarbone is removed. Then the AC ligament is transferred from the bottom of the shoulder blade into the removed end of the collarbone to replace the torn ligament.

Physical Therapy

After surgery, patients can expect to wear a sling for about four weeks and lower arm exercises may begin immediately after the two to three weeks immobilization. Most rehabilitation programs will begin after the sling is removed and will at least 6 to 8 weeks to regain full motion of the shoulder.

AC Joint Separation | Brisbane Knee and Shoulder Clinic

What is an AC joint separation?

The shoulder joint is formed at the junction of three bones: the collarbone (clavicle), the shoulder blade (scapula), and the arm bone (humerus). The scapula and clavicle form the socket of the joint, and the humerus has a round head that fits within this socket. The end of the scapula is called the acromion, and the joint between this part of the scapula and clavicle is called the acromioclavicular joint. An acromioclavicular joint separation, or AC joint separation or shoulder separation, occurs when the clavicle separates from the scapula. It is commonly caused by a fall directly on the ‘point’ of the shoulder or by a direct blow received in a contact sport.

Is a shoulder separation the same as a shoulder dislocation?

No! These two injuries are commonly confused, but they are very different conditions. As described above, the shoulder joint is located at the junction of three different bones: the clavicle, the scapula, and the humerus. In a shoulder separation, the junction of the clavicle and scapula is disrupted. In a shoulder dislocation, the humerus (arm bone) is displaced from the socket. Not only are the injuries different in anatomical terms, but the implications for treatment, recovery, and complications are also different.

What causes an AC joint separation?

A shoulder separation is almost always the result of a sudden, traumatic event that can be attributed to a specific incident or action. The two most common descriptions of a shoulder separation are either a direct blow to the shoulder (often seen in football, rugby, or hockey), or a fall on to an outstretched hand (commonly seen after falling off a bicycle or horse).

What are the typical symptoms of AC joint separation?

• Pain and swelling around the joint
• Pain on movement of the arm
• Depending on the grade, a bump may be present on the top of the shoulder where the clavicle ends
• The joint may be very unstable

How is it diagnosed?

The diagnosis of shoulder separation is often quite apparent from hearing a story that is typical of this injury, followed by a simple physical examination. An x-ray should be performed to ensure there is no fracture of these bones. If the diagnosis is unclear, an x-ray while holding a weight in your hand may be helpful. When this type of x-ray is performed, the force of the weight will accentuate any shoulder joint instability and better show the effects of the separated shoulder.

Are all separated shoulders the same?

No. Separated shoulders are graded according to the severity of the injury and the position of the displaced bones and are graded from Type I to VI:

• TypeI – Trauma to the joint ligaments but no severe tearing or fracture. It is commonly referred to as a sprain. Most
  doctors treat this type of injury with anti-inflammatory drugs, pain medication and the placement of the arm
  in a sling or an immobilizer.
• Type II – Complete tearing of the acromioclavicular ligament, as well as a sprain or partial tear of the coracoclavicular ligaments. This often causes a noticeable bump on the shoulder which is permanent. Severe pain and loss of movement are common. Treatment is typically an arm sling, bed rest, ice and heat therapy, and anti-inflammatory drugs. Most people recover full motion of the shoulder and arm within 6 to 8 weeks, often with the assistance of physiotherapy.
• Type III – Both acromioclavicular and coracoclavicular ligaments are torn. A significant bump, resulting in some shoulder deformity, is formed by the end of the clavicle. This bump, caused by the clavicle’s dislocation, is permanent. The clavicle can be moved in and out of place on the shoulder. It may take as long as 12 weeks for the injury to heal and in some cases even longer for shoulder strength and range of motion to feel normal. Physiotherapy can be beneficial.
• Type IV – An unusual injury where the clavicle is pushed behind the AC joint.
• Type V – An exaggerated Type III injury in which the muscle above the AC joint is punctured by the end of the claviclecausing a significant bump over the injury
• Type VI – Exceedingly rare. The clavicle is pushed downwards, and becomes lodged below the corocoid (part of thescapula).

What are the treatment options?

The treatment of the AC joint separation will depend on the grade of the injury. Types I to III are generally treated non-surgically, although a Type III injury may be considered for early surgical intervention. The initial treatment of a separated shoulder consists of controlling the inflammation, and resting the joint. The early steps of treatment should consist of:

• Icing the Injury – The inflammation from a separated shoulder can be controlled with ice placed on the joint every four hours for a period of 15 minutes. Icing can be done for the first several days until the swelling around the joint has subsided.
• Rest – In the acute stage, together with a protective sling and ice, rest can help to reduce the pain and swelling. Resting the joint will help minimize painful symptoms and allow healing to begin.
• Physiotherapy – A rehabilitation program will aim to restore the normal motion and strength to the shoulder. This will begin as soon as tolerated. Returning to sporting activities can occur within 2 to 12 weeks depending on the grade of separation.
• Anti-inflammatory Medications – These medications may assist with the reduction of swelling and pain within the affected shoulder.

Do I need surgery?

Depending on the severity of the joint separation, surgery may be necessary. Surgery is also an option for those AC joint separations that have not responded well to non-operative treatments.

A variety of surgical methods can be considered to stabilise a separated AC joint, and these will be discussed individually with your surgeon.

Common reconstructive surgical techniques today use either a screw or suture loop, and on some occasions an artificial ligament is used.

Several studies have looked at what happens to the AC joint after this injury. It appears that many people, whether they had the joint repaired surgically or not, will need an operation at some time in the future. The injured joint degenerates faster than normal. Over time it becomes arthritic and painful. This process may take years to develop, but sometimes it happens within one or two years.

After Surgery and Rehabilitation

If you don’t need surgery, range-of-motion exercises should be started as pain eases, followed by a program of strengthening. Full recovery can take up to six weeks for Type II separations and up to twelve weeks for Type III separations. Since there is little danger of making the condition worse, you can usually do whatever activities you can tolerate.

After surgery, your surgeon may ask you to wear a sling to support and protect the shoulder for a few days. A physiotherapist will probably direct your recovery program. Physiotherapists usually wait four weeks before starting range-of-motion exercises.

You will usually begin with passive exercises where the shoulder joint is moved but your muscles stay relaxed. Your physiotherapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts six to eight weeks after surgery, once the ligaments have healed.Active range-of-motion exercises help you regain shoulder movement using your own muscle power. You might begin with light isometric strengthening exercises and gradually move onto more active strengthening exercises.

Recovery from shoulder surgery can take some time. You will need to be patient and closely follow your physiotherapy program.

The patient information sheets are intended to provide general information only and are not a substitute for medical advice about your particular condition.

90,000 Tendon ruptures of the biceps of the shoulder – treatment, symptoms, causes, diagnosis

Ruptures of the tendons of the biceps brachii have recently become a fairly common injury. Moreover, up to 90% of cases of ruptures occur in the proximal tendon (long head).

Given the localization relative to the shoulder and elbow joints, the biceps muscle performs a specific function in the activity of the upper limb. In the proximal region, the biceps has 2 tendons that attach to the scapula (tendons of the long and short head of the muscle).The biceps and tendons of this muscle are among the most superficial structures of the hand. As a result, a significant proportion of shoulder injuries and fewer elbow injuries occur in these structures. Tendon rupture usually occurs at the site of attachment to the bone or at the junction of the tendon across the lip. The remaining ruptures of the biceps tendons occur distally in the area of ​​the radial tuberosity or, even less often, in the place of attachment of the short head to the acromion.

Biceps tendon injury is most susceptible to people aged 40-60 years with previous shoulder problems due to certain wear and tear of the tendons.At a younger age, biceps tendon ruptures are possible from injuries from falls, weightlifting, or sports such as football or snowboarding.

The impact of the gap can vary across demographic groups. The main disorders as a result of a proximal biceps rupture are movement restrictions associated with pain in the acute period of injury, and subsequently a decrease in strength during flexion in the shoulder, flexion in the elbow of the forearm and weakness during supination.The distal rupture of the biceps tendon also initially leads to pain, and then a decrease in supination strength, elbow flexion, and grip strength.

Biceps tendon rupture is more common in men than in women, but this difference is mainly due to occupational or household factors. The dominant arm is more prone to rupture due to heavy loads. The age factor is important because at the age of over 40, there are certain degenerative changes in the tendons and, therefore, the strength of the tendons decreases.At a young age, ruptures occur with acute injuries due to various activities.

Symptoms

• Some patients have sudden pain in the front of the shoulder during physical activity. The pain is acute and intense and may be accompanied by a clicking sound or a tearing sensation.
• Other patients may experience recurrent pain during overhead movements or repetitive activities.
• Still others experience intense soreness in the front of the shoulder, which may worsen at night.
• In some patients, the rupture may be almost asymptomatic, and the patient may only notice the appearance of a bulge or induration in the area between the shoulder and elbow. As a rule, such a course is possible with chronic damage to the tendon and after a complete rupture, the pain may disappear. With a distal rupture, there may be similar symptoms, but with localization closer to the elbow.

Reasons

• Proximal biceps tendon rupture is usually caused by chronic inflammation resulting from impingement in the subacromial area and the end result of chronic microtrauma.Repeated injuries often result in tendon wear and tear, with a consequent loss of strength, increasing the risk of rupture even after relatively minor injuries.
• Tendon rupture due to chronic inflammation can occur in rheumatoid arthritis.
• Excessive stress or rapid stress on a tendon, such as in weightlifting, is often the cause of acute tendon rupture.
• Biceps tendon rupture or degeneration is often associated with damage to the rotator cuff in older patients and is often diagnosed during surgery for rotator cuff injuries.This may be due to impingement syndrome.
• Most tears occur at the attachment of tendons to bones proximally and distally:
• Distal tearing of the tendon from the radius is usually caused by chronic irritation, such as chronic ulnar bursitis.
• Acute avulsion is the result of forcible extension of the elbow while in flexion and supination.
• Rare short head biceps tendon ruptures can occur with rapid flexion and adduction of the arm during elbow extension activities.
• Disruption of the physiological mechanisms of regeneration due to the use of medications (eg statins) are also considered to be possible potential factors predisposing to tendon rupture.

Diagnostics

• In most cases, proximal and distal tears can be diagnosed based on medical history and physical examination. The mechanism of injury, the nature of the onset of pain and / or inflammation, and examination findings often lead to a diagnosis.But to verify the diagnosis and exclude possible other diseases, instrumental diagnostic methods can be used.
• Radiography allows the detection of bone abnormalities and makes it possible to obtain only indirect signs of tendon rupture. But radiography allows you to visualize fractures in the shoulder area well.
• Arthrography has until recently been widely used to diagnose injuries in the shoulder, but due to its high invasiveness, the presence of ionizing radiation and a rather low information content, this diagnostic method is currently practically not used.
• Ultrasound The study of shoulder structures is quite informative for the diagnosis of biceps ruptures. But this research method does not allow diagnosing small ruptures or changes of an intra-articular nature. Nevertheless, taking into account the practical harmlessness of painlessness and rather good information content, this research method is widely used in the diagnosis of biceps tendon ruptures.
• Magnetic Resonance Imaging (MRI) is the most informative imaging method that allows diagnosing even small morphological changes in the structures of the shoulder.

Treatment

Treatment of a ruptured biceps tendon is still a matter of debate. Comparison of long-term results of surgical and conservative treatment did not show an obvious advantage of one method over another. But, nevertheless, at present, a certain treatment tactic has been developed, for biceps tendon ruptures, based on an individual approach to each patient.

Surgical methods of treatment (tenodesis and subacromial decompression) are necessary at a young age and in athletes, that is, in cases where strong supination is required.In addition, surgical treatment may be required to address cosmetic problems after a rupture. Surgical methods of treatment mainly use atroscopic techniques that allow restoring the integrity of the ligament with minimal invasion.

Conservative treatment is considered suitable for middle-aged and elderly people and for those who do not require supination force in daily activities. This approach includes unloading and then the use of exercise therapy to strengthen the muscles of the shoulder and elbow.Conservative therapy is quite effective and has no side effects, unlike surgical interventions. Various subsequent studies have shown that with conservative treatment, patients lose up to 20% of their supination strength and this decrease rarely affects daily activity.

Currently, it seems appropriate to use an individual and comprehensive treatment strategy, taking into account the individual characteristics of each patient. Such a strategy is as follows:

• A thorough examination to identify possible pathology of the shoulder and elbow.
• Identification of the risk / benefit ratio of surgical correction, in accordance with the characteristics of each patient (patient’s age, presence of pain syndrome, desire for surgical treatment, patient’s profession, etc.),
• Emphasizing efforts on full-fledged rehabilitation aimed at maximum recovery of functional capabilities, regardless of the results of treatment in the acute period of trauma.

Drug treatment

Anti-inflammatory drugs can be used to reduce inflammation that can predispose to tendon rupture.They can also provide pain relief during the acute phase of injury, when tendons are stressed or partially destroyed. In the acute period, the effect of NSAIDs is higher when combined with rest and cold. For the period of tendon recovery, both in conservative treatment and in the postoperative period, immobilization with the help of orthoses is recommended. During the rehabilitation period, it is possible to use physiotherapy procedures that improve tendon regeneration and improve blood supply to damaged tissues.

LFC . Joint development begins 10-14 after injury (surgery), performing functional exercises with a gradual increase in load over 6-8 weeks. Light loads can be given after 6-8 weeks, but full loads are not recommended for several months, especially with distal biceps ruptures.

90,000 Total instead of shared – Weekend – Kommersant

The new season has shown that gender ambivalence is still at the center of the fashion process and determines everything else in fashion.Moreover, gender ambivalence is only part of a large new clothing concept

Everything is mixed up in the world of fashion and its houses. Someone shows autumn-2021 in January, as was customary before, and someone has already shown it in November; someone showed in November what is called pre-fall, but whether and when there will actually be fall, God knows, and someone will show it also in February – and therefore we will talk here about everyone who showed men’s clothes next fall … The fashion calendar took the form of an ordinary calendar, where the season creeps into the season, outside the window there is even snow and rain, everyone sits at home and looks at the screens of gadgets, like a year ago.And on this groundhog day, guys in dresses, guys in blouses, guys in skirts and guys in high heels appear on these screens. This was literally in every second collection: even those brands that have always clearly distinguished masculine and feminine and have never made any statements about gender transparency, such collections have worked that gender transparency manifests itself in them by itself.

When it all began – in this current format, that is, absolutely openly – in 2015, the very historic red blouse with a fluffy bow that opened the very first men’s show of Alessandro Michele for Gucci, gender mixing seemed to be a challenge – and it was such.A challenge not only to sociocultural conventions, according to which men do not wear blouses with a bow and do not paint their lips, but also to the usual bubbling of marketers that “normal men are conservative, they will never wear anything feminine, all this will only scare them away”. And here we have the FW 2021 season, in which the feminine is in every second men’s collection, in which the feminine dissolves into the masculine and becomes part of the universal.

Such optics divide the whole field of male fashion very clearly.The first are those for whom the division into masculine and feminine is generally irrelevant, because their picture of the world is gender-ambivalent and gender-transparent in its essence. And they most often show their collections together, mixing men’s and women’s bows. Such are, for example, The Row, which have now added men’s outlets to women’s for the first time – but you will not see any difference in men’s and women’s clothing, this is all the same extremely luxurious asceticism and minimalism, and the guys in their lookbook – in jackets with wide shoulders , hats and long straight coats – do not differ from girls.This is Lemair, where the same effect of uniforms both as the basis of aesthetics and as the same style for all genders was emphasized this time not just by mixing men’s and women’s bows, but also by paired outfits. There are no special games with skirts and dresses, but there is aesthetics, within which there is no place for any division – people, any people, either dress like this, because their picture of the world is similar, or not, gender is not important here.

The most indicative here, of course, is Demna Gvasalia, who, having come to Balenciaga, for the first time in the history of the brand began to make men’s collections, and then mixed them with women’s and has been showing everything together for several years.This time, his models looked like characters in a computer game – and everyone was wearing jackboots that imitated medieval knights’ boots, differing only in the presence / absence of a hairpin. The faces of the models were sometimes painted, and sometimes not, regardless of gender, and the final bow, completely stylized as knightly armor, was female. Everything else is a traditional set of large down jackets, furry fur coats, dark trouser suits as if from someone else’s shoulder, belted raincoats, jackets, plaid plaid coats, wide sweatshirts, altered and turned denim and pop art games with a logo – that is, different types of the modern city, who used to take to its streets, but now sit at home like knights in a besieged fortress, and play computer games wrapped in a blanket.

The main character and actually the founding father of a new gender approach in fashion Alessandro Michele showed his Gucci collection in November without any indication of the season. He showed her in the form of a mini-series, directed with Gus Van Sant, the main character / hero of which was an extremely expressive model, devoid of obvious gender characteristics. There were no dresses on men – they were dressed in what is traditionally considered masculine – trousers, shorts, suits – but women (who still got a certain number of dresses) were wearing the same bell-bottomed trousers or mini-shorts.Among the 99 bows of the collection there was also a replica of the same red blouse with a bow, which has definitely gone down in fashion history.

The second in this system are those brands whose men’s and women’s collections are shown separately, but stylistically they are related to each other, have always been transparent and are made under the guidance of the same designer. For example, Prada. In September, the first women’s collection, made jointly by Miuccia Prada and Raf Simons, was shown, now their first men’s collection. She did not have any blouses or dresses, but there was also a lot that was always present in the men’s collections of Rafa – huge parkas, large bombers, massive coarse knit pullovers, all this recognizable oversize, and what Prada always had – double-breasted coats -cocoons, dense textured fabric with a silk surface, sleeves rolled up above the elbow, narrow straight cigarette trousers.Both have always been (and remain after the merger) both in their women’s and in their men’s collections, in the current one gender-open colors have been added – marshmallow pink, baby blue or canary yellow.

Dries Van Noten has been playing a gender game for the second collection in a row, which has not been observed before: long shirts that look like a dress, or, for example, wide ribbons sewn instead of a collar, the ends of which hang loosely on the chest – but could be tied in bow. In general, the Dries Van Noten men’s collection came out excellent, as almost always, with that rare work with proportions, volumes and, in general, a silhouette, which you value so much.There were, for example, suits with wide, high-waisted trousers, reminiscent of the zoot suit aesthetic, the clothing subculture of black musicians in post-war America, paired with narrow blazers like the Beatles in the 1960s. And captivating color combinations – pink, sand and gray-beige taupe or gray-blue and pink-purple mauve.

In general, it is this cell that is most densely populated. From Jil Sander, where Luke and Lucy Meyer wore rubber boots on mint green models paired with a large gray coat and a silver necklace on top of it, to Dolce & Gabbana, where, among hundreds of strictly masculine outlets, there seemed to be everything in the world, even an alien outfit made of gold foil – and there were brightly colored guys.At Rick Owens, models came out in tall platform boots and tall heels, worn with ordinary white panties, and with a naked torso with perfect cubes.

And the last category is brands in which masculine and feminine are clearly separated, have their own aesthetics and their own artistic directors, and these are above all big houses like Dior, Louis Vuitton or Hermes. For example, in Dior, Kim Jones never really flirts with women’s codes, and now he has shown a collection dedicated to such a camp game with an imperial military uniform of the 19th century, where mentics, galloons, plumes, stripes and orders were mounted in modern jackets and jackets, in totally casual looks – either structurally, as part of a silhouette, or decoratively, as a print.At the same time, all these military jackets with stars on the chest were worn by people of color – and, thus, the entire collection could be perceived, among other things, as a not without irony expression on topics related to colonial culture and cultural appropriation, in which fashion is often accused.

Virgil Abloh had even more camp in Louis Vuitton – and quite selective, from sweatshirts made in the form of Manhattan skyscrapers or Notre Dame, to bags in the form of airplanes, buttons in the form of airplanes or silver suitcases in monogram, as if fastened to the wrist models handcuffed.At the same time, the silhouettes themselves were quite classic, perhaps oversized, but no more usual, except again for a series of bows, where instead of trousers there were skirts, but they were also inscribed in a classic silhouette.

Veronique Nishanyan showed her favorite ideal lyceum at Hermes – in the video, the models walked up and down the stairs, and in the final everyone went out into the courtyard for a group photo. The word “ideal” here also refers to the world she created for Hermes, inhabited by impeccable guys in impeccable clothes, where trousers of the same length and width to look fashionable, but with the necessary dose of the indispensable Hermes understatement, and in perfect proportions formal everyday and even subcultural.Well, the color combinations are the most beautiful of which there is no: a pale orange turtleneck with a crushed raspberry-colored jacket or a mouse-gray quilted jacket, worn over something lilac, with cream-colored pants and brown boots.

Fendi’s Menswear collection, made by the design team led by Silvia Venturini-Fendi, had a lot of open color and a lot of quilts – including flared Bermuda shorts that looked almost like skirts, and long sleeves were sewn around the neck of the sweaters. also looked like an ironic allusion to the same pussy bow.And this is one of the coolest collections of the brand in the last few years. But in their haute couture, shown just a week later – and this is the premiere of Kim Jones as the artistic director of women’s collections – there were three men’s exits: a completely strict black suit with transparent shirt cuffs under it, a long dress of a delicate salad color, collected as if of three different pieces, and another black suit made of moire silk imitating marble, with a transparent cloak fluttering over the shoulders.Two of the three models had painted eyes and carnivorous red lips – it was simply impossible to take your eyes off the guys, and all together they were not perceived as a trance show at all, but looked just beautiful, even almost habitually beautiful and natural. And if Kim Jones decided to introduce gender equality into couture and make masculine in it, then couture will only benefit.

If we talk about the future, then his path is the path of aesthetic, ethical and ideological unity. In this bright future, there will be no separate male and separate female aesthetics within the same house, which, in fact, have nothing in common with each other – as can be observed now, when between men’s and women’s collections under one and the same a label can be not only a stylistic abyss, but also a temporary one, as if they were made with a difference of a decade.

Is there still a challenge in gender bias? Do Dolce & Gabbana, Fendi and Balenciaga still have a challenge in the painted faces of men? Loewe wide skirts with sheepskin coats worn over a naked male body? Rather not, because all these gender issues today are only part of another, more important idea – the idea of ​​comfort in its unusually expanded sociocultural meaning.

It unites everything, up to what is commonly called in glossy “trends”: from this point of view, the general fascination with quilted coats and jackets, referring to the British tradition of outdoor, which this time was similar to the TV series about the murders in Midsomer – it also symbolizes the desire for comfort.But now it is not just about comfortable clothes in which you can go for a walk and which does not press or pull. Now, when we are devoured by anxiety for loved ones, for the present and the future, the comfort that we all need is much broader than simple convenience – it has to do with the state of our mind and our soul.

About this comfort Yoon Ahn from the progressive Japanese brand Ambush, who, by the way, has also just shown a collection of men and women, representing an organic unity in which silhouettes with skirts and trousers are equally refined and restrained.Yoon Ahn says he wants to create clothes that are “comfortable and at the same time bring peace of mind.” We will dress in something in which we are calm and happy – and in this way, in particular, we will resist anxiety and sorrow. This is the fashion program for the future.

“Private pioneer” may become a serial

The same characters act in the film, only they have grown up. The doggie Savva, saved by them, has also grown up. “I loved these characters so much that I really didn’t want to part with them,” says director Alexander Karpilovsky.- And then the idea came to continue their story. Now Dimka and Mishka, in love with Karaseva, will go to the sea, to the camp. A pioneer lineup, morning exercises, canteen shifts, an amateur competition, a burning out club, an evening disco … – everyone has their own memories of their pioneer childhood. Will it be interesting for today’s teenagers? Of course, they have changed: they have mobile phones and e-mail … But deep down, they believe in love in the same way, despise meanness and betrayal, dream of adventures and exploits.So it will be a story about first love and growing up, about passions and temptations. “

Final preparations for filming are in progress. In Gelendzhik, two camps were found where the atmosphere and customs of the Soviet era will be reproduced. In addition to Semyon Treskunov, Yegor Klinaev and Anfisa Vistinghausen, already familiar to the audience, Vasily Mishchenko, Sergei Batalov and Ilya Ermolov will play in the film as a pioneer leader – a new, fourth side of the “love triangle”, which will smoothly turn into a “love square” in the course of events.For this unpredictable Karaseva will fall in love with him, and Mishka’s friend will try to help Dimka regain lost love. Although he is not indifferent to this Karaseva himself. The dog Savva will remain, but will fade into the background: when love is raging, the dogs are silent. “Is the plot related to your childhood experiences?” I asked the director. “Of course, – was the answer. – The strongest childhood impressions are the first love, shared or unrequited.”

The project is supported by the Ministry of Culture, but there is not enough money for its completion.”If everyone who liked” Private Pioneers “contributes to its financing even with a minimal amount, then together we will be able to make a good, kind film for teenagers, which are so lacking today!” With such words, Alexander Karpilovsky addresses the audience of his painting “Private Pioneer”. He means the method of crowdfunding – “people’s funding”, when people who are interested in the project can help to implement it with feasible contributions. For this they will receive various bonuses from the film company – from the opportunity to receive a DVD with the film to an invitation to a premiere or even to a shooting in Gelendzhik.This method is widely used in the world, and our film producers, as you can see, are also mastering it – this is how funds were collected, for example, for the film “Panfilov’s 28”. There is an Internet platform boomstarter.ru, on the basis of which everyone can become accomplices in the birth of a new masterpiece: a page dedicated to the film will appear there from September 1. “In my opinion, it’s great when people can participate in what they like,” says Karpilovsky. “Become co-producers, co-creators.” Well, if something goes wrong, and the film never ends, people, the director assures, will receive their contributions back.This is a method that allows art to depend less on the not always kind uncle – government agencies. And, as stated in the poster of the Soviet years: “We believe in friendship fervently, and our motto is:” Shoulder to shoulder! “

The film’s producer Vladimir Yesinov spoke about an even more ambitious idea – to continue the story about these heroes in the future. Let the guys grow up with their time, let them survive the collapse of the USSR and the emergence of Yeltsin’s Russia – and live on the screen, perhaps to this day.Of course, this will already be a television series, but whether any of the TV channels will be interested in a unique project is too early to talk about it.

In Search of the Ideal (Painting by J.E. Schaeffer von Leonhardskoff “Raphael and Fornarina”)

In the collection of the Novosibirsk Art Museum there is a wonderful painting “Raphael and Fornarina” by the Austrian master Johann Evangelist Schaeffer von Leonhardskoff.Looking at him, we seem to be transported to the studio of the renowned painter, become witnesses of his work.

Young, beautiful Raphael turned his enthusiastic gaze on the model. A young girl, picking up a dark red velvet cloak with a fur trim falling from her shoulders with her hand, directs her slightly embarrassed gaze directly at the viewer, drawing him into the space of the canvas. The workshop is plunged into darkness, only at the top you can see a part of the easel, on which a still blank canvas is installed.Although, wait, the contours of the future portrait are already visible there! In Raphael’s hand is a brush, on the tip of which is burning brown paint – burnt sienna, in the other hand – a mushabel, an artistic tool that is almost out of use. This thin wooden stick with a ball at the end rested against the canvas and allowed the hand to not get tired when working on small details.

The simple plot presented in the painting – the creator and his model – is inspired by the special enthusiastic feeling that the young painter Schaeffer von Leonhardskoff experienced when portraying his idol, the great Raphael Santi.This master was the ideal for many artists even centuries after his death. And he occupied a special place in the worldview of the Nazarenes, to which the author of our canvas belonged. It was a group of German and Austrian painters of the early 19th century, whose work had a religious and romantic direction. They got their name from the word “Nazarenes” – the Old Testament Jewish hermits who, like the prophets, served as an example of a selfless, holy life. Fascinated by the ideas of asceticism, the young artists decided to set an example of “truly Christian pious art.”Having moved to Rome and imitating medieval monasteries and art cooperatives, they settled in the cells of the abandoned monastery of San Isidoro, formed a commune with a joint household, ate in the refectory while reading the Bible and “Heart Outpourings” by the German writer – romantic Wilhelm Heinrich Wackenroder. In 1813, all of them who were Protestants converted to Catholicism. Although all Nazarenes were graduates of the Vienna and Munich Academy of Arts, they opposed academism, the rationality of classicism and immorality in contemporary painting.Franz Pforr wrote: “Before, the artist tried to awaken reverent feelings by depicting godly objects and to evoke a spirit of competition by depicting noble deeds, but now what? A certain Venus with Adonis, a bathing Diana – what good can be evoked by such an image? ” “Art must be sincere” – the Nazarenes believed and tried to oppose the outdated canons “truly Christian painting”. The characteristic features of the Nazarene style, in addition to plots related to Christianity or medieval history, are strict composition, emphasized contour and bright colors.They paid special attention to drawing, and they were all excellent draftsmen. The Nazarenes strongly influenced the historical painting of the 19th century, anticipating many creative ideas and views of the neo-romantic trends of the second half of the 19th century: the Pre-Raphaelites, early Alexander Ivanov.

The Nazarenes, inspired by the texts of the romantics, pathetically idealized the image of the Artist-Creator himself. They perceived artistic creativity as a kind of religious occupation. This also influenced their appearance and behavior. The artists wore long hair parted like Christ’s, old German costumes with large cloaks and medieval berets, and their speech was exalted.They fully shared the opinion of Friedrich Schlegel that a modern artist “should be like a medieval master in character, be innocently cordial, pure and immaculate, feeling and thinking.” The most important position of the Nazarene aesthetics was the idea of ​​brotherhood, strong friendship. It is no coincidence that their favorite type of portrait was a group portrait, symbolizing friendship. In Shadov’s painting, images of outstanding masters – the painter Friedrich Wilhelm von Shadov, his brother sculptor Rudolf von Shadov and the Danish sculptor Bertel Thorvaldsen – are complemented by the landscape of Italy, this “holy land” that brought them closer together and inspired them to create beautiful works.

The painting by one of the founders of the movement Friedrich Overbeck “Italy and Germany” was a reflection of the most important principle of the Nazarenes – an attempt to harmoniously combine Italian and German painting of the Middle Ages and the Renaissance. Dark-haired Italy with laurel leaves woven into her hair, dressed in a Renaissance dress, leans towards Germany, dressed in a Gothic outfit, with a myrtle wreath on light long braids. Behind the first lies an idealized Italian landscape that combines trees, mountains and lakes, while the second overlooks a German city dominated by straight, sharp lines.These two female images, full of deep trust and tender affection, in Overbeck’s painting embody the traditions that come from Raphael and Durer. Interestingly, in the 19th century, not only the work of these two titans was considered ideal, but also their life path. This is especially true of Raphael. Michael Brian, in his 1816 Dictionary of Painters and Engravers, wrote of Raphael: “This outstanding artist is widely regarded as the king of painters and is renowned for having a happy combination of talents rarely found among other artists.”The Nazarenes were attracted by the fate of Raphael – even, calm, devoid of falls and always steadily lifting the master to the heights of success. On their canvases, his image appears more than once. Moreover, all life circumstances associated with this artist are mythologized. Riepenhausen’s painting is characteristic, in which the image of the Madonna appears to sleeping Raphael as a kind of mystical vision, a revelation from above. For the Nazarenes, being “Raphael today” becomes the main task, and it is no coincidence that Overbeck was named by his comrades the “new incarnation” of the Italian as the main honorary title.

The title of “Rafaellino”, that is, “little Raphael” was also awarded to the author of our painting, Schaeffer von Leonhardskoff, since he was somewhat younger than the “main” Nazarenes. The image of Raphael for him was a kind of guiding star, ideal, model. Schaeffer von Leonhardskoff, like Raphael, lived a short but eventful life. At the age of fourteen, he participates in the liberation struggle against Napoleon, having risen to the rank of lieutenant. Then – training at the Vienna Academy of Arts, acquaintance with F.Overbeck and F. Pforr. Perceiving from them a passion for Italy, he travels to Venice, Florence, Pisa, lives in Rome, studies the works of Raphael, Perugino, Michelangelo. Adjacent to the Nazarene mug. He writes, draws, giving all of himself to creativity. In 1822, at the age of 27, he died of tuberculosis. Buried in Vienna. There is a living soul behind these meager lines of biography. And painting helps to feel this soul. See the self-portrait of Schaeffer von Leonhardskoff. How it echoes the famous self-portrait of Raphael from the Uffizi! Both artists are young, in their early twenties.We find similarities in the turn of the head, in the long romantic curls of the hairstyle, in the coloristic structure of the paintings, but, most importantly, in the sad and thoughtful look. Internally, the relationship is obvious, and, apparently, the Austrian artist actually felt partly “Rafaellino”.

We meet the same young, heartfelt image of Raphael on our canvas. The artist as a creator, the creator of beautiful worlds – this is one semantic structure of the picture, which is revealed in the image of Raphael directly at work. Another is the relationship between the artist and his muse. Posing for Rafael Fornarina is the artist’s semi-legendary beloved. Reliable evidence of its existence is still the subject of research. In the 18th – 19th centuries, various interpretations of the myth of Raphael and Fornarin were formed, and, moreover, often opposite in meaning.In some, Fornarina acts as an experienced courtesan who used the connection with the brilliant artist for her own selfish purposes and eventually became the cause of his early death. Others talk about the pure and sublime love of two tender hearts. Undoubtedly, the Nazarenes, who deified Raphael, were attracted by just such a romantic story. In the Roman district of Trastavere, on Via San Dorothea, they still show the house at number 20, where, according to legend, Fornarina lived, and that window in which Raphael saw a girl combing her hair.Margarita Luci was the daughter of a baker, so everyone called her “fornarina” – “little baker”. Struck by her beauty, Raphael fell in love, and since then Fornarina has become his permanent model. According to some testimonies, she was his secret wife and after the death of the genius she went to a monastery. As most art critics agree, Fornarina is depicted in the “Portrait of a Young Woman” (1518-1519, Palazzo Barberini, Rome), later rewritten by his pupil Romano and in many respects lost Raphael’s lightness, and she is also a model of “Donna Velata” (1516, Florence, Pitti Gallery).The last portrait is perhaps one of the most captivating in art. In the paintings, a woman’s hairstyle is decorated with a pearl, in which the artist encrypted the name of his beloved: in Latin, “pearl” – “margarita”. We see the features of Fornarina transformed by the genius of Raphael in the famous “Sistine Madonna” (1512, Gallery of Old Masters, Dresden). The heavenly image, captured by Raphael, forever entered the history of painting as the ideal of tenderness and purity. Some of the works of his students are also associated with the name of Raphael’s beloved.For example, a portrait of a woman by Sebastiano del Piombo (Fornarina, 1512, Uffizi, Florence). Perhaps it was this canvas that Leonhardskoff used as a model for his composition. We see correspondences in the arrangement of figures, gestures, clothing, hairstyles and jewelry. It is quite possible that the young painter made copies of Piombo’s paintings during his stay in Florence in 1814 – we find information that he diligently copied Raphael, Perugino, Michelangelo in his biography. But if Sebastiano del Piombo in his work, clearly written from life, is first of all realistic, then Leonhardskof is looking for an ideal and, to solve the image of Fornarina, turns to Raphael himself, for whom his model is more divine than a real woman.

Zh.O.D. works in the same direction. Ingres. He created several versions of Raphael and Fornarina (1814, Harvard University Museum), and it is significant that the time of work on this plot coincides with Ingres’s own marriage to Madeleine Chapelle.In the plot plot of Ingres’s painting, we also see a plot similarity with our work – Raphael, hugging Fornarina posing for him for a portrait, peers into the contours of her image, drawn on a canvas standing next to her on an easel. The girl’s gaze is directed to the viewer. The image of Fornarina Ingres used to create his famous nude – “Big Odalisque” (1814, Louvre, Paris). The same characters are depicted by sculptors Pasquale Romanelli in the light, almost weightless marble group Raphael and Fornarina (mid-19th century, Hermitage, St. Petersburg) and Francesco Vichy (mid-19th century, Museum of Fine Arts, Yekaterinburg).Raphael for these masters is a wonderful refined young man, naturally, with a palette in his hands. He gently bows to Fornarina, who appears before us as a symbol of eternal femininity. Even the jewelry of that time reflected the theme of love of the great painter (Flink. Brooch-cameo “Raphael and Fornarina”, 1880s). The work that belongs to our museum is worthy of a number of works of this circle. Portraying Raphael and his beloved, Johann the Evangelist Schaeffer von Leonhardskof not only embodies in her his delight for Raphael, but also his youthful passionate dreams of finding love and harmony.Dreams that were not destined to come true. A year later, the artist was gone. And the picture continues to live, and painting becomes, despite the time and distance, a conductor of simple human feelings.

90,000 causes, symptoms, diagnosis and treatment

Dislocation is a complete displacement of the articular ends of the bones relative to each other. Pain and gross violation of the joint configuration are observed. Active movements become impossible; when trying to passive movements, spring resistance is determined.The diagnosis is made on the basis of examination and radiographic data. If necessary, CT or MRI is prescribed. Treatment – reduction of dislocation (usually closed). For chronic dislocations, surgery is necessary. After reduction, immobilization and functional treatment (physiotherapy, exercise therapy, massage) are prescribed. The prognosis is usually good.

General

Dislocation is a pathological condition in which the articular surfaces are displaced relative to each other. The distal (distant from the body) part of the limb is considered dislocated.The exception is dislocation of the clavicle (the name indicates the dislocated end of the bone) and dislocation of the vertebra (the overlying vertebra is indicated). Dislocation is a fairly common pathology in traumatology and orthopedics. Traumatic dislocations account for 1.5-3% of the total number of injuries to the musculoskeletal system.

Dislocation

Causes of dislocation

The cause of traumatic dislocation is usually an indirect effect: a blow or fall on an adjacent joint or a distal part of the limb (for example, a dislocation of the shoulder joint can occur when falling on the elbow or forearm), forced muscle contraction, forced flexion and extension of the joint, twisting, traction for the limb.Less commonly, injuries result from direct trauma (hitting or falling onto a joint).

With impacts and ordinary falls, as a rule, an isolated dislocation develops (less often – fracture dislocation). In road accidents, falls from a height and work injuries, a combination of dislocation with other injuries of the musculoskeletal system (fractures of the pelvis, fractures of the spine and extremities), traumatic brain injury, blunt trauma of the abdomen, chest injury and injuries of the genitourinary system can be observed.

Pathology

A joint is a movable connection of two or more bones covered with a synovial membrane, separated by a joint space and connected by a capsule and ligaments. There are several types of joints (ellipsoidal, block-shaped, spherical, saddle-shaped), but, regardless of the shape, all of them are formed by congruent (matching in shape, complementing each other) surfaces.

Due to this structure, during movement, the articular surfaces slide relative to each other, and the joint acts as a hinge.The movement is due to the muscles that attach to the bones above and below the joint. The tense muscle pulls the bone in a specific direction, and the capsule and ligaments keep the articular ends from excessive displacement. With dislocation, there is a mutual displacement of the ends of the bones that form the joint. Surfaces cease to “coincide”, movements become impossible.

To simplify, three main mechanisms of dislocation formation can be distinguished. Traumatic – as a result of increased muscle traction, direct impact or violent impact with indirect injury, the articular ends of the bones are excessively displaced.The impact is too strong, the capsule does not withstand and breaks, ligament rupture is also possible. Pathological – due to various pathological processes, the strength of the capsule and ligaments decreases, they lose the ability to keep the articular ends of the bones in the correct position even with minor influences, therefore, dislocation can occur during normal unforced movements. Congenital – due to anomalies in the development of joint structures (bones, ligaments, capsules), the articular surfaces do not initially coincide or are not held in the correct position.

Classification

Taking into account the degree of displacement, orthopedic traumatologists distinguish complete dislocations, in which the articular ends diverge completely, and subluxations, in which partial contact of the articular surfaces remains.

Taking into account the origin, distinguish:

• Congenital dislocations – arising from malformations of the elements of the joint. The most common is congenital dislocation of the hip joint, less often congenital dislocations of the knee joint and patella.
• Acquired dislocations – resulting from injury or illness. Traumatic dislocations are the most common. The upper limbs suffer 7-8 times more often than the lower ones.

Traumatic dislocations, in turn, are subdivided:

• Taking into account the age of damage: fresh (up to 3 days from the moment of injury), stale (up to 2 weeks from the moment of injury), old (more than 2-3 weeks from the moment of injury).
• With or without violation of the integrity of the skin and underlying soft tissues: open and closed.
• Taking into account the presence or absence of complications: uncomplicated and complicated – accompanied by damage to the nerves or blood vessels, as well as perio – and intraarticular fractures.

Irreducible dislocations are also distinguished – this group includes dislocations with soft tissue interposition that prevents closed reduction, and all chronic dislocations.

In addition, two separate groups of pathological dislocations are distinguished:

• Paralytic dislocation – the cause of development is paralysis of one muscle group, due to which the traction of antagonist muscles prevails.
• Habitual dislocation is a repetitive dislocation that occurs due to the weakness of the capsule, muscles and ligaments and / or changes in the configuration of the articular surfaces. The cause of development is most often the premature onset of movements in the joint after the reduction of acute traumatic dislocation. Less commonly, the habitual dislocation occurs in diseases affecting the bones and ligaments (arthrosis, osteomyelitis, poliomyelitis and some systemic diseases, including hereditary ones).

Symptoms of dislocation

Acute traumatic dislocations are accompanied by intense pain.At the time of injury, a characteristic click or pop is usually heard. The joint is deformed, swollen, bruises may appear on the skin in the affected area. There are no active and passive movements; when trying to passive movements, spring resistance is revealed. Blanching and cooling of the skin is possible below the level of damage. If the nerve trunks are damaged or compressed, the patient complains of numbness, tingling, and decreased sensitivity.

Diagnostics

The diagnosis of dislocation is made on the basis of the clinical picture and X-ray data.In some cases (usually with complicated dislocations), an MRI or CT scan of the joint is prescribed. If there is a suspicion of compression or damage to blood vessels and nerves, the patient is referred for consultation to a vascular surgeon and neurosurgeon. Treatment is carried out in a trauma center or trauma department. The need for hospitalization is determined by the localization of the dislocation, the absence or presence of complications.

Treatment of dislocation

A patient with suspected traumatic dislocation should be taken to a specialized medical center as soon as possible.institution (the best option is within the first 2-3 hours), since subsequently the increasing swelling and reflex muscle tension can make it difficult to reposition. The limb should be fixed using a splint or kerchief, give the patient anesthetic and apply cold to the area of ​​damage. Patients with dislocations of the lower extremities are transported in the supine position, patients with dislocations of the upper extremities – in the sitting position.

Uncomplicated dislocations are subject to closed reduction. Fresh uncomplicated dislocations of small and medium joints are usually reduced under local anesthesia, dislocations of large joints and stale dislocations under general anesthesia.In young children, reduction in all cases is carried out under general anesthesia. For open, complicated and chronic dislocations, open reduction is performed.

Subsequently, rest is prescribed and an immobilization bandage is applied. The term of immobilization is determined by the characteristics and localization of the dislocation. Premature removal of the bandage and early onset of movements in the joint are by no means allowed, as this can lead to the development of habitual dislocation. In the rehabilitation period, exercise therapy, physiotherapy and massage are prescribed.The prognosis is favorable.

Traumatic dislocations

Traumatic dislocation of the shoulder ranks first in terms of prevalence, followed by dislocations of the fingers and elbow joint. Dislocations of the patella and hip joint are somewhat less common.

Traumatic dislocation of the shoulder

The high frequency of pathology is due to the structural features of the joint (the head of the humerus is in contact with the glenoid cavity for a short distance and is mainly held by muscles, ligaments and a special soft tissue formation – the glenoid lip), significant loads and a large volume movements in the joint.When injured, acute pain occurs, there is a feeling that the shoulder is out of place. The shoulder joint looks unnatural: the head of the humerus is not visible, in its place a smoothed surface with a pointed upper edge is visible. The shoulder appears to be drooping. The patient’s hand is usually pressed against the body.

Depending on the direction of displacement of the head, there are three types of dislocations of the shoulder joint: anterior, posterior and lower. Anterior dislocation is the most common (according to various sources, it occurs in 80-95% of cases).The head is displaced forward and is either under the coracoid process of the scapula (in this case, a subclavicular dislocation occurs), or under the clavicle (subclavian dislocation). Usually, anterior dislocations are accompanied by minor damage to the articular lip (cartilaginous ridge, which is a continuation of the glenoid cavity of the scapula and helps the head of the shoulder to stay in the joint). Posterior dislocation develops infrequently (less than 20-5% of cases) and is accompanied by significant damage to the articular lip. Inferior dislocation is very rare.With such damage, the head of the shoulder “goes” down, and the arm is in the raised position until the moment of reduction.

Shoulder X-ray is performed to confirm the diagnosis. CT of the shoulder joint and MRI of the shoulder joint are usually not required, with the exception of suspicions of severe damage to soft tissue structures and fracture dislocations. A slight violation of the blood supply and a slight numbness of the limb are usually caused by compression of the neurovascular bundles and spontaneously disappear after the dislocation is repositioned.Gross sensory disturbances may indicate nerve damage and are an indication for consulting a neurosurgeon.

Reduction of fresh dislocations is usually performed in an emergency room under local anesthesia. A stale dislocation and an unsuccessful first attempt at reduction are indications of reduction under general anesthesia. Usually the Janelidze method is used, less often the Kokher method. After reduction, the arm is fixed for three weeks. During this period, UHF is prescribed to reduce inflammation and exercise therapy (movement of the hand and wrist joint).Then immobilization is stopped, exercises are gradually added to the exercise therapy complex to develop the elbow and shoulder joints. It should be remembered that it takes time for the joint capsule to heal. Unauthorized removal of the bandage too early (even in the absence of pain) can lead to the formation of a habitual dislocation.

Habitual dislocation of the shoulder

Usually occurs after untreated acute traumatic dislocation. Predisposing factors are muscle weakness, increased capsule extensibility, a weakly concave glenoid cavity, and a large spherical head of the shoulder.Habitual shoulder dislocation is accompanied by less intense pain syndrome and can occur even with minor exposures. The frequency of repeated dislocations varies greatly – from 1-2 times a year to several times a month. The cause of development is the failure of the joint capsule. Surgical treatment required. The indication for surgery is 2-3 or more dislocations during the year.

Traumatic dislocations of the phalanges of the fingers

Most often develop when the fingertip is struck with the application of force in the proximal direction.There is a sharp pain and a noticeable visible deformity of the finger in the joint area. Movement is impossible. Increasing edema is noted. X-rays of the hand are done to confirm the diagnosis. Reduction is performed on an outpatient basis under local anesthesia. Then a plaster cast is applied and UHF is prescribed.

Traumatic dislocation of the elbow joint

The cause of the injury is a fall on an outstretched arm or a blow to a bent arm. In the first case, a posterior dislocation occurs, in the second, an anterior one.The injury is accompanied by severe pain and significant soft tissue swelling. In the area of ​​the elbow, a pronounced deformation is revealed, movements are impossible. The radial artery pulse is weakened, and numbness is often observed. In posterior dislocations, the head of the radial bone is palpated in front, in front – in the back.

A distinctive feature of dislocations of the elbow joint is a combination with fractures of the ulna and radius, as well as damage to nerves and blood vessels. X-rays of the elbow joint are taken to confirm the diagnosis.According to the indications, consultations of a neurosurgeon and a vascular surgeon are prescribed. Treatment is carried out in a hospital setting. Treatment tactics depend on the characteristics of the damage. In most cases, closed reduction is performed. If it is impossible to correct the dislocation, match or hold bone fragments (in case of fracture dislocations), a surgical operation is performed.

Traumatic dislocation of the patella

Trauma occurs as a result of falling or hitting the knee at the time of contraction of the quadriceps muscle.Lateral dislocations of the patella develop more often (the patella is displaced inward or outward). Less common are torsional (the patella rotates around the vertical axis) and horizontal (the patella rotates around the horizontal axis and is introduced between the articular surfaces of the bones that form the knee joint) dislocations. The damage is accompanied by severe pain. Deformation occurs, increasing edema appears. The knee is slightly bent, movement is impossible. On palpation, a displaced patella is determined.Hemarthrosis is often observed.

The diagnosis is made on the basis of characteristic symptoms and X-ray data of the knee joint. Reduction is usually not difficult and is performed under local anesthesia. Spontaneous reduction is also possible. With hemarthrosis, joint puncture is performed. After restoring the natural anatomical position of the patella, a splint is applied to the leg for 4-6 weeks. Prescribe UHF, massage and exercise therapy.

Traumatic hip dislocation

Occurs as a result of indirect injury, usually from road accidents and falls from a height.Depending on the location of the femoral head, it can be anterior and posterior. Dislocation of the hip is manifested by sharp pain, swelling, deformation of the affected area, forced position of the limb and shortening of the hip. Movement is impossible. To clarify the diagnosis, an x-ray of the hip joint is performed. Reduction is performed under general anesthesia in a hospital setting. Then skeletal traction is applied for 3-4 weeks, physiotherapy and exercise therapy are prescribed.

Congenital dislocations

The most common is congenital dislocation of the hip.It occurs as a result of underdevelopment of the femoral head and glenoid cavity. More common in girls. Revealed immediately after birth. In infants, it is manifested by limitation of limb abduction, limb shortening and asymmetry of skin folds. Subsequently, lameness occurs, with bilateral dislocation – a duck gait. Diagnosis is confirmed by X-ray, CT of the hip, and MRI of the hip. Treatment begins in the first months of life. Special plaster casts and splints are used.If conservative treatment is ineffective, surgery is recommended until the age of 5 years.

The second most common is congenital patellar dislocation. Compared to hip dislocation, it is a rather rare anomaly. It can be isolated or combined with other malformations of the lower extremities. More common in boys. It is manifested by instability when walking, fatigue and limited movement in the joint. X-ray of the knee joint indicates underdevelopment and displacement of the patella.The dislocation is removed surgically by moving the patella’s own ligament.

If treatment is not carried out, progressive pathological changes develop in the joint in a state of congenital dislocation, severe arthrosis occurs, accompanied by increased limb deformity, impaired support, decrease or loss of working capacity. Therefore, all children with suspicion of such a pathology should be under the supervision of pediatric orthopedists and receive timely and adequate treatment.

90,000 Off someone else’s shoulder. Capital

Maxim Simoroz

Maksim Simoroz on the largest collection of T-shirts in the post-Soviet space, in which famous football players played, the contribution of the bride Ronaldo and Oleg Blokhin’s T-shirt worth $ 4000.

I started collecting T-shirts of famous players in my childhood. As a child, he helped the administrator of the football club “Dynamo” at the dacha, and instead of money as payment he asked to give something that belonged to the players.I was counting on a Dynamo club jersey, but I received an even more valuable copy – a USSR national team jersey. My hobby began with her. Over the next 20 years, I managed to create the largest (about a thousand items) collection in the post-Soviet space. During this time, about 40 thousand T-shirts passed through my hands.

There is a constant rotation of exhibits in my collection: I give T-shirts, change, sell. The most valuable items are my first T-shirt of the USSR national team, Andrey Shevchenko’s T-shirt from the last Euro 2012 match and T-shirts that I myself played in.Yes, once I also played football, and now I play in the team of FC Maestro (the football club of pop, cinema and business stars in Ukraine. – Ed.). I played for the Ukrainian national street football team in Australia, at the FIFA Futsal World Cup in Yakutia in 2006, I was even lucky to play for the England national team. This team could not come to the FIFA Futsal World Cup in Yakutia in full force due to visa problems, so its team was formed from players from other teams, including the national team of Ukraine.

Sometimes my exhibits are bought by other collectors, and for quite decent money.For example, I had about ten jerseys of the USSR national team. One of them, Oleg Blokhin, sold for $ 4000. Of course, money alone is not enough for me to agree to part with such a thing. If the buyer is not a collector, but simply tries to buy a valuable T-shirt for a cheaper price and then resell it, he will not succeed. I can concede even exclusive things to a true connoisseur for a small price. For example, if I have several copies of one T-shirt, the price can start at $ 100.

Recently, it has become more and more difficult to replenish the collection. For example, I set out to collect all the Dynamo Kiev jerseys. To do this, you have to communicate with the old administrators of the club, who have preserved rare, interesting things. There are many people in Kiev who are directly related to football: former and current football players, team administrators, sports officials … Any of them may have rare exhibits. I know a lot of people personally, and if I find something interesting, I usually propose to change.

There are an incredible number of collectors of t-shirts of famous players in the world. Most of them are in Latin America. One day I started to search social networks and add as friends people from abroad who are interested in this topic. At first he began to be friends with Italians. Then Latin Americans began to come out on me. Collections of my online friends often do not exceed one hundred copies. Nevertheless, Latin America has serious collectors, such as “Critter” Ronaldo, who owns one of the largest collections of T-shirts.

Unlike most collectors, I do not hide my wealth and regularly organize special exhibitions and shows. I am engaged in the modeling business: I am looking for new faces, future world stars. Today, aspiring models with whom I collaborate gain experience by participating in the shows of my collection. There are about eight such events a year. Sometimes such a show is a part of some event, sometimes it is an independent presentation. During Euro 2012, for example, at the NSC Olimpiyskiy there was a show of the shirts of all rivals of Kiev Dynamo, and for the team itself I arranged a show of the club’s vintage shirts.

My collection and the modeling business are inextricably linked: thanks to the models, my collection of T-shirts is constantly growing. For example, Alena Osmanova, whose producer I am, having become a top model, participated in the show with Victoria Beckham. I asked her to bring me David’s T-shirt, begging for it from Victoria. This is how his autographed T-shirt appeared in my collection. And during the Miss Ukraine contest, I organized the arrival of the top model Irina Shayk to Kiev. Taking this opportunity, I asked Irina to bring her fiance’s T-shirt and now I have a Cristiano Ronaldo’s T-shirt with his autograph.

People are wondering if I wash T-shirts. If they are beautifully stained, why spoil the picture? Of course, if the match took place in the rain and the shirt is so covered in dirt that neither the name nor the number of the player can be read, it will have to be washed.

The last time the entire collection was shown two years ago, during Euro 2012. Then I arranged a huge exhibition in the Kiev planetarium. In addition to my collection, the collection of Alexei Kokotun was also exhibited there. It was a very large-scale event, during which visitors asked me about the jerseys that “participated” in the iconic matches that real football fans still remember.Many fans of this game have no idea how they can get their hands on a world-class player’s jersey. I’m not talking about a T-shirt bought in a gift shop, but about a real one, taken off, as they say, right after the game. And at our event, they could see hundreds of these T-shirts, each of which has its own story. When at such exhibitions I meet a truly enthusiastic person, I help him in every possible way in finding and purchasing a rare T-shirt. Because I feel a desire to share with people not only knowledge, but also the source of what really interests us.After all, positive emotions, even if shared with strangers, will definitely come back to you.

Shoulder dislocation – Fractura.ru

Shoulder dislocation is one of the most common dislocations. It accounts for more than half of the total number of dislocations in all other joints of the human body. The incidence of dislocation increases significantly with a sports injury, especially in those sports where the load on the shoulder joint is maximum (wrestling, gymnastics, acrobatics, etc.).etc.). Also, dislocation of the shoulder is much more common in men than in women.

This spread of dislocation is explained by the anatomical features and biomechanics of the joint. The joint is spherical in shape, while the articular surface of the humerus is 4-6 times larger than the articular surface of the scapula. To increase the congruence of the articular surfaces around the glenoid cavity of the scapula, there is a fibrocartilaginous ring (glenoid lip), which also softens shocks during movement of the shoulder head and stabilizes the joint.

Movement in the shoulder joint is possible in all planes – this is a huge advantage of the joint over others, but also its huge disadvantage. The capsule of the joint is thin and has several longitudinal thickenings (some authors call them the ligaments of the shoulder joint), it is attached to the articular edge of the scapula and, covering the head of the shoulder, is attached to its anatomical neck. The muscles of the rotator cuff provide true fixation and stabilization of the joint. Fusing tightly with the joint capsule and being in constant tone, they fix the head of the shoulder in the glenoid cavity of the scapula and prevent the joint capsule from gathering into folds and restraining between the articular surfaces.

Contents of the article:

Mechanism of injury

In case of shoulder dislocations, direct and indirect mechanisms of injury are distinguished. Due to the anatomical features of the joint, dislocations due to indirect traumatic effects prevail (80-90% of all dislocations). As a rule, this is a fall on an extended and abducted arm with support on the elbow or palm. Also, dislocation can occur at the moment of “twisting” of the shoulder inward with its sharp extension and when lifting the load on a straight arm with a rotation element.It is extremely rare that a dislocation of the shoulder can occur due to a direct blow to the head of the shoulder from behind or from the front (with anterior or posterior dislocation of the shoulder).

Classification

Distinguish between congenital and acquired shoulder dislocations.

Acquired dislocations are divided into open and closed, as well as:

• Traumatic dislocation of the shoulder (according to A.V. Kaplan):

1. Front:

– Subclavian

– Subcoracoid

– Subcoracoid with a separation of the large tubercle of the humerus

2.Lower (axillary)

3. Rear

• Non-traumatic dislocation of the shoulder:

1. Arbitrary dislocation of the shoulder

2. Chronic pathological dislocation of the shoulder

Distinguish between fresh dislocations – up to 3 days from the moment of injury, stale – up to 3 weeks from the moment of injury and old ones, when more than 3 weeks have passed since the moment of injury.

Also, dislocations are divided into uncomplicated and complicated. Complications can be: damage to the neurovascular bundles passing in the immediate vicinity of the joint; fractures of the bones that form the joint; damage to articular cartilage and ligaments.

Clinic

Appearance of the patient with dislocation of the left humerus

The clinical picture of dislocation of the shoulder is pronounced, accompanied by pain and has some features depending on the type of dislocation. So, with anterior dislocation, the head of the humerus is displaced anteriorly and is easily palpated under the coracoid process of the scapula or under the clavicle. The acromion is easily palpable, and beneath it is determined by the retraction of soft tissues (Lejart’s symptom). Also, the skin folds in the armpit are slightly lower than those on the healthy side (Brent’s symptom).The humerus itself is abducted, and the victim tries to bend his arm at the elbow joint, and holds it with his healthy hand. There is a relative shortening of the shoulder, active movements in the joint are impossible and cause pain, and passive ones are sharply limited, while the person leans forward and sideways towards the injury – this position reduces pain.

With lower shoulder dislocation (also called axillary dislocation), the upper limb is somewhat lengthened due to the fact that the head of the humerus rests against the lower part of the glenoid cavity, and the shoulder itself, like the entire limb as a whole, is set aside.Active movements are also impossible, and passive ones become “springy”.

With a posterior dislocation of the shoulder, the head of the humerus can be displaced posteriorly and downward, where it is fixed under the spine of the scapula, or it can move exactly back and be fixed behind the acromion, then a conventional radiograph in frontal projection may not be sufficient and an additional lateral or oblique projection will be required. The patient’s appearance also has characteristic features: there is a positive Lejard symptom; the shoulder is brought to the chest; flexion in the elbow joint, as well as tilt to the side of injury and springy movements are not typical for this type of dislocation.

Diagnostics

Anterior dislocation of the shoulder

X-ray examination is the leading one in the diagnosis of dislocation of the shoulder. Radiographs should always be taken in two projections perpendicular to each other. Thus, the risk of errors in diagnostics is reduced.

Posterior dislocation of the shoulder

Radiographs do not show damage to soft tissue structures, and therefore, after repositioning of the dislocation, it is necessary to perform ultrasound or MRI of the joint. Dislocations of the shoulder can be accompanied by damage to the rotator cuff, rupture of the “cartilaginous lip” of the glenoid cavity, and rupture of the ligaments holding the joint.

Dislocation of the shoulder can be complicated by damage to the neurovascular bundles located in the joint area, therefore, it is necessary to conduct a study of sensitivity and the presence of active movements distal to the injury, both before and after reduction of the dislocation.

Treatment

The main treatment for dislocations is the reduction of the shoulder head into the glenoid cavity of the scapula and subsequent immobilization of the injured limb. Reduction of the joint is a painful and traumatic process, so it should be performed under conditions of complete anesthesia, preferably with the use of muscle relaxants.The use of conduction anesthesia is possible. When using local anesthetics, it is not always possible to achieve the required level of anesthesia, and therefore the reduction of the dislocation becomes more difficult and the number of complications increases.

Various authors have proposed more than 50 ways to reduce shoulder dislocation. They are conventionally divided into leverage, physiological (based on gradual muscle fatigue by stretching) and jogging, when reduction is achieved by direct pressure on the head of the shoulder.

The most common lever Kocher method is used for fresh and stale anterior dislocations.The method is divided into 4 stages:

1. The doctor, holding the upper limb by the shoulder and wrist joint, flexes it in the elbow joint to 90 ⁰ and, stretching the shoulder along the axis, brings the limb to the trunk.
2. Continuing to stretch the shoulder, the doctor rotates it outward, while bending the limb in the shoulder joint and shifting the elbow to the medial side.
3. Without weakening the traction, the doctor brings the elbow as much as possible anteriorly and medially.
4. From this position, the shoulder, along with the entire limb, is rotated inward (at the moment of repositioning the dislocation, a distinct click is heard).

After the dislocation has been reduced, the upper limb must be immobilized in the abduction position at 30-45 ⁰ . This position is physiological for the joint, and the damaged capsule does not form folds and, as a result, cicatricial adhesions do not form, which interfere with further rehabilitation.

For chronic dislocations, apparatus traction can be used.

Often, dislocations become irreducible when they get between the articular surfaces of soft tissues or bone fragments.If it is impossible to correct the dislocation in a closed way, as well as in the case of chronic dislocations or in the case of a combination of dislocation and fracture of the proximal shoulder, surgical treatment is indicated.

Rehabilitation

All rehabilitation measures must be started after 3-4 weeks of immobilization in the abduction splint (30-45 ⁰ ). You can divide them into:

• physiotherapy;
• medical gymnastics;
• massage;
• use of orthopedic products;
• unconventional methods.

Physiotherapy procedures are absolutely indicated in the recovery period after shoulder dislocation, since they have proven to be safe for the body (excluding individual contraindications). Any physical factors can be used – heat, ultrasound, inductothermy, phonophoresis, laser therapy, massage. All of them are aimed at improving blood supply in damaged tissues, and accordingly accelerate their regeneration.

Immediately after immobilization, various supportive orthoses (braces) or taping of the joint area can be used to reduce pain.It is especially important to use them in the early stages of rehabilitation, when any movements in the shoulder joint cause pain, and muscle strength is reduced due to prolonged immobilization.

Therapeutic exercises can be started immediately after the immobilization phase. It is worth starting with passive movements in the joint, gradually increasing their volume. Pain is the main limiting factor. To reduce it, physiotherapy is performed before gymnastics (ozokerite, phonophoresis, etc.). Do not overly actively perform the exercises – this will not only provoke sharp pain and, as a result, stop the development of the joint, but can also lead to repeated dislocation.Also, do not postpone rehabilitation until the pain sensations disappear completely. The longer the joint remains motionless, the more difficult and painful the subsequent development. Active movements begin with simple exercises that do not imply power loading. And only after the restoration of the full range of active movements is it worth gradually increasing the load on the joint.

Gymnastics should be aimed not only at restoring the range of motion, but also at increasing the strength of the muscles involved in the movement of the joint – this helps to stabilize the joint and prevent dislocation of the shoulder in the future.