Postoperative rehabilitation exercises for old shoulder lock joint dislocation
Wang Weiguo, Department of Orthopaedic Trauma, Jinan Military General Hospital
Shoulder lock joint dislocation is one of the common shoulder injuries, and some of them form old shoulder lock joint dislocation due to various reasons, resulting in shoulder joint dysfunction, which is more difficult to treat. The treatment of old acromioclavicular dislocation with Wolter’s clavicle plate internal fixation is reliable and provides the patients with early functional rehabilitation of the shoulder joint, which is one of the key factors for the success of the operation. From August 2002 to November 2005, we used Wolter plate to treat 18 cases of old acromioclavicular dislocation, and guided 15 of them to perform early functional rehabilitation exercises of the shoulder joint after surgery, with satisfactory results.
1 Clinical data
1.1 General data
There were 15 cases in this group, all of them were III degree dislocation according to Allman’s classification [1], 12 males and 3 females, aged 19-61 years old, average 32 years old. The duration of the disease ranged from 1 to 13 months, with an average of 4 months, including 4 cases of 1 month, 8 cases of 2-4 months, and 3 cases of more than 6 months. Four of them had received external fixation with elastic bandage + shoulder pad, two had received external fixation with clavicle band, and four had undergone internal fixation with incisional repositioning kyphosis, but the deformity recurred at that time or later after removal of fixation; two cases were missed, and three cases had delayed treatment for other reasons. The main symptoms were pain, weakness and limitation of movement of the injured shoulder, accompanied by deformity in appearance, bulging of the external clavicle, and floating sensation when pressing on the external clavicle. x-ray showed separation of the acromioclavicular joint, widening of the rostral-clavicular space, and distal displacement of the clavicle by 1.3 cm to 2.5 cm. three of them had ossification of the rostral-clavicular ligament. The Wolter plate was used for internal fixation of the dislocated shoulder-clavicular joint and repair and reconstruction of the rostral ligament. The affected limb was suspended with a triangular scarf for 1 week after surgery.
1.2 Postoperative rehabilitation exercises
The first stage of rehabilitation exercise (within 3 weeks after surgery): the passive activities of the shoulder joint were the main focus. The active activities of the injured limb’s finger, finger palm, wrist and elbow joints and the passive flexion and extension exercises of the elbow joint were carried out 3 days after surgery. Shoulder joint mobility exercises were started 1 week after surgery. The patient held the affected forearm with the healthy hand and did clockwise and counterclockwise circular movements; the doctor held the upper arm and forearm of the affected limb with both hands and did passive supination, passive external rotation and passive abduction, internal retraction and internal rotation exercises respectively, to the extent that pain appeared, and then slowly returned to the resting position. The shoulder joint muscle strength exercise was started 2 weeks after surgery. The affected limb was flexed at 90°, the affected hand was supported by the healthy hand, and the hand was forced forward to do shoulder forward flexion to exercise the shoulder forward flexion muscle group; the elbow was pushed outward to do abduction action to exercise the abduction muscle group; the elbow was pushed backward to do posterior extension action to exercise the extension muscle group; the shoulder was shrugged at the same time to exercise the scapular lifting muscle group; the scapular was retracted at the same time to exercise the internal scapular muscle group; the affected shoulder Do internal rotation to exercise the internal rotation muscle group; do external rotation of the affected shoulder to exercise the external rotation muscle group.
The second stage of rehabilitation (4-6 weeks after surgery): active shoulder joint activities are the main focus. Continue the pulling exercise of the shoulder joint in all directions, carry out pulley pulling exercise and wall climbing and touching exercise of the affected limb to increase the mobility of the shoulder joint. Perform tension and contraction exercises for the scapular muscles, biceps and triceps. Gradually increase the amount and duration of exercise. Encourage the patient to use the affected hand to perform activities of daily living within the patient’s ability. It can be combined with appropriate local physiotherapy, massage and herbal fumigation for the affected shoulder.
In the seventh week after surgery, increase the intensity of mobility and muscle strength exercise, increase the range of shoulder joint pulling exercise, increase the amount and duration of exercise, participate in sports and perform various activities, but pay attention to self-protection to avoid causing discomfort symptoms.
1.3 Evaluation of efficacy and results
All 15 cases had one-stage healing of the incision. The postoperative follow-up X-ray showed complete repositioning of the acromioclavicular joint. The function of the shoulder joint was completely restored in 4 weeks after surgery in 4 cases with a disease duration of 1 month; in 8 cases with a disease duration of 2-4 months, the function was completely restored in 6-8 weeks after surgery; in 3 cases with a disease duration of 6 months or more, the function of the shoulder joint was mostly restored in 3 months after surgery. The average follow-up period after surgery was 5 to 33 months, with a mean of 13.5 months. In all cases, the appearance and function of the shoulder joint recovered satisfactorily, and no plate fracture or loosening was observed, and no complications such as vascular or nerve injury, osteomyelitis, or joint dysfunction occurred in one case. 6 cases had their internal fixation removed six months after surgery, and the position of the acromioclavicular joint was normal on review after 3 months, and no recurrence of dislocation was observed. According to Lazzcano’s evaluation criteria [2]: 12 cases were excellent and 3 cases were good.
2 Discussion
The purpose of acromioclavicular joint dislocation surgery is to restore the normal anatomy of the joint, rebuild the stable structure of the joint, restore the normal function of the joint, and prevent traumatic arthritis and pain. The advantages of using Wolter plate to treat old severe acromioclavicular dislocation are mainly: ① The hook of the plate through the acromion is designed with smooth surface, which is in line with the characteristics of micro-movement of acromioclavicular joint. ②The strong internal fixation allows for early postoperative rehabilitation exercises for patients with old severe acromioclavicular dislocation, effectively preventing adhesion stiffness of the glenohumeral joint and bringing convenience to clinical care, functional exercises and patients’ life. ③The hook passes under the acromioclavicular joint and bypasses the acromioclavicular joint surface, so that there is no more foreign body interference after the joint restores normal anatomical relationship, allowing an adequate space for the repair and reconstruction of acromioclavicular and rostral ligaments and reducing the occurrence of postoperative traumatic arthritis. Because of the history of delayed treatment or improper treatment after injury, patients have more concerns, so guiding them to carry out reasonable and effective rehabilitation exercises early can play a role that cannot be replaced by surgery.
The focus of postoperative rehabilitation exercises is on range of motion and muscle strength exercises to promote early recovery of shoulder function. In the specific implementation, the exercise intensity in the early stage is reduced and the active contraction of the muscles around the shoulder joint is prohibited to ensure local healing; in the middle and late stages, the exercise of range of motion and muscle strength is gradually strengthened, and the intensity and progress of the exercise are adjusted at the right time to promote the early recovery of the shoulder joint function. Maintaining certain muscle contraction is the best way to promote muscle physiological function, and can effectively prevent the decrease of muscle tone and muscle atrophy caused by the limb being fixed. Local physiotherapy, massage and herbal fumigation of the affected shoulder can relieve local swelling and pain, dilate blood vessels and lymphatic vessels, enhance the flow of blood and lymphatic fluid, promote the dissipation and absorption of bruised and edematous connective tissues, loosen and separate the joint adhesions on the affected side, and improve joint function.
Among the 15 cases in this group, no complications occurred in one case, which indicates that reasonable and effective postoperative rehabilitation exercises play a key role in ensuring the success of surgical treatment. It is necessary to provide good exercise guidance and obtain the cooperation of patients in order to synchronize tissue repair and joint function recovery, reduce complications and joint dysfunction, and achieve satisfactory results.
[References]
[1] Karlsson J,Arnarson H,Sigurjonsson K.Acromioclavicular dislocation treated by coracoacromial ligament transfer.Arch Orthop Trauma Surg,1986,106:8
[2] Huang W H, Fang Y Z, Zhou S F, et al. Reconstruction of acromioclavicular ligament and rostral ligament in the treatment of old acromioclavicular joint dislocation. Chinese Journal of Trauma, 2004, 20(8):485