Fracture of the humerus in a child: fracture of the supracondylar bone, fractures of the head of the condyle of the humerus. Structure and injuries of the humerus Fracture of the condyle of the humerus with displacement

Transcondylar fracture and epiphysiolysis of the lower epiphysis of the humerus

A transcondylar (extensor and flexion) fracture is an intra-articular fracture. It occurs when falling on an elbow bent at an acute angle. The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence (G. M. Ter-Egiazarov, 1975).

Symptoms and recognition. There is swelling in the area of ​​the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. The symptoms are uncharacteristic, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Treatment . Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

In adults, transcondylar fractures are treated in the same way as supracondylar fractures.

Intercondylar fractures of the humerus

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be like

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of ​​the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed. Without radiographs taken in two projections, it is impossible to have an accurate idea of ​​the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle of 90-100°, and the forearm is fixed in an average position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped on the 18-21st day and they begin dosed movements in the elbow joint, gradually increasing in volume, using a removable splint at first. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

In children, a single-stage reduction is usually performed under anesthesia, followed by fixation with a plaster splint. The hand is suspended on a scarf. The elbow joint is immobilized at an angle of 100°. Movement in the elbow joint begins in children with displaced fractures after 10 days.

If reposition is unsuccessful, skeletal traction is indicated for the upper part of the ulnar spine with compression of the condyles for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults.

Surgical treatment. It is proven if the reduction of fragments using the described method fails or there are symptoms of a disorder of the innervation and blood circulation of the limb. The operation is performed under anesthesia. The incision is made longitudinally along

the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought above the skin (so that they can be easily removed) or left under the skin (Fig. 59). You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children – after 10 days.

In case of improperly healed fractures, severe limitation of movements, ankylosis of the elbow joint, especially in a functionally disadvantageous position, arthroplasty is performed in adults. In children, resection of the elbow joint and arthroplasty are not indicated due to possible growth arrest of the limb. Surgery should be delayed until adulthood. In elderly and senile patients with intra-articular fractures, they are limited to placing the limb in a functionally advantageous position and functional treatment.

Fracture of the lateral condyle of the humerus

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The head of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (90-180°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.

Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of ​​the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; Without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. Cause

The point is that although the ossification nucleus of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Treatment . Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle of 90-100°.

Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

puts his hand on the inner surface of the patient’s elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded. The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The piece is gradually bent to a right angle; After this, the surgeon compresses the condyles again and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is fixed in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks. In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

Surgical reduction is performed under intraosseous and local anesthesia or general anesthesia. An incision is made along the outer posterior surface of the humeral condyle (it must be borne in mind that the radial nerve is located more anteriorly). Blood clots and soft tissue embedded in the fragment bed are removed.

To avoid avascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.

In most cases, the fragment is easily reduced when the elbow is extended and, if the elbow is then bent, it is held in place. The fragment can also be fixed by passing a catgut suture through soft tissue or through holes drilled with a drill or awl in the fragment and the humerus. In adults, the fragment can be fixed with a bone pin, wire, thin metal nail or screw. After this, the wound is sutured tightly and a plaster cast is applied to the shoulder and forearm, bent at the elbow joint. The forearm is given a position intermediate between pronation and supination. In adults, the plaster cast is removed after 3-4 weeks, and in children, the splint is removed after 2 weeks. Further treatment is the same as for fractures without displacement or after manual reduction.

A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, etc.) observed good results after removal of the lateral condyle for chronic fractures with limited movement. However, you should, if possible, avoid removing the lateral condyle of the shoulder, not only in fresh, but also in old cases, and strive to set the fragment. When the dislocated lateral condyle is unreduced, or after its removal, valgus elbow develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overextension, permanent trauma and even pinching. In cases where symptoms of secondary damage to the ulnar nerve appear, there may be indications for moving it from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the internal condyle of the humerus

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through

olecranon to condyle; in this case, the olecranon process is broken first, and not the internal condyle of the shoulder. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until the age of 10-12 and, therefore, has great elasticity, which resists the force of a fall on the elbow.

Symptoms and recognition. There is hemorrhage, swelling in the area of ​​the elbow joint, pain when pressing on the internal condyle, crepitus and other usual symptoms that were mentioned when describing fractures of the external condyles, but they are determined from the inside. The forearm can be adducted at the elbow joint, which cannot be done normally and with other fractures of the humeral condyles. 42 43

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Forearm injuries

Distal humerus fractures

Causes. Supracondylar (extra-articular) fractures are divided into extension ones, which occur when falling on an outstretched arm, and flexion ones, which occur when falling on a sharply bent elbow. Intra-articular fractures include transcondylar fractures, T- and V-shaped condylar fractures, and a fracture of the head of the humeral condyle (Fig. 46).

Signs: deformation of the elbow joint and the lower third of the shoulder, the forearm is bent, the anteroposterior size of the lower third of the shoulder is increased, the olecranon is displaced posteriorly and upward, and there is retraction of the skin above it. A hard protrusion (the upper end of the peripheral or lower end of the central fragment of the humerus) is palpated in front above the elbow bend. Movement in the elbow joint is painful. V.O. Marx’s symptom is positive (violation of the perpendicularity of the intersection of the shoulder axis with the line connecting the epicondyles of the shoulder - Fig. 47). In intra-articular fractures, in addition to deformation, pathological mobility and crepitus of fragments are determined. These fractures should be differentiated from forearm dislocations. Monitoring the integrity of the brachial artery and peripheral nerves is mandatory! The final nature of the damage is determined by radiographs.

46. Options fractures distal metaepiphysis humerus bones.

1, 4 - lateral And medial fractures condyle ;

2 -fracture heads condyle; 3, 5-V- And T-shaped fractures ;

6, 7 - extensor And flexion supracondylar fractures; 8 -transcondylar fracture

47. Sign V.O. Marx. a-c normal ; b-pri supradisylar fracture brachial bones.

48.Reposition fragments at supracondylar fractures brachial bones. a-pri flexion fractures ; b-pri extensor fractures.

Treatment. First aid - transport immobilization of the limb with a splint or scarf, administration of analgesics. Reposition of fragments in supracondylar fractures is carried out after anesthesia by strong traction along the axis of the shoulder (for 5-6 minutes) and additional pressure on the distal fragment: for extension fractures anteriorly and inwardly, for flexion fractures - posteriorly and inwardly (the forearm should be in the position pronation). After reposition, the limb is fixed with a posterior plaster splint (from the metacarpophalangeal joints to the upper third of the shoulder), the forearm is bent to 70° (for extension fractures) or up to 110° (for flexion fractures - Fig. 48).

The hand is placed on the abductor splint. If the reposition is unsuccessful (x-ray control!), then skeletal traction is applied to the olecranon process. The period of immobilization with a plaster splint is 4-5 weeks. Rehabilitation - 4-6 weeks. Working capacity is restored after 2/2-3 months. With these fractures, there is a risk of damage to the brachial artery with subsequent disruption of muscle nutrition, which leads to the development of ischemic Volkmann contracture.

The use of external fixation devices has significantly increased the possibilities of closed reduction of fragments and rehabilitation of victims (Fig. 49). Strong fixation is ensured by external osteosynthesis (Fig. 50).

In case of an intra-articular fracture without displacement of the fragments, a plaster splint is applied to the posterior surface of the limb in a position of flexion at the elbow joint at an angle of 90-100°. The forearm is in an average physiological position. The period of immobilization is 3-4 weeks, then functional treatment (4-6 weeks). Working capacity is restored after 2-2*/2 months.

When fragments are displaced, skeletal traction is applied to the olecranon process on an abduction splint. After eliminating the displacement along the length, the fragments are compressed and a U-shaped splint is applied along the outer and inner surfaces of the shoulder through the elbow joint, without removing traction. The latter is stopped after 4-5 weeks, immobilization - 8-10 weeks, rehabilitation - 5-7 weeks. Working capacity is restored after 21/2-3 months. The use of external fixation devices reduces the time required to restore working capacity by 1-1*/2 months (Fig. 51).

Open reduction of fragments is indicated when there is a violation of blood circulation in the limb and its innervation. To fix fragments, rods, knitting needles, screws, bolts, and external fixation devices are used. The limb is fixed with a posterior plaster splint for 4-6 weeks. Rehabilitation - 3-4 weeks. Working capacity is restored after 21/2-3 months.

49. Outer osteosynthesis at fractures condyles brachial bones.

50. Interior osteosynthesis at fractures condyles brachial bones.

51. Outer osteosynthesis intra-articular fractures brachial bones.

FRACTURES OF THE HUMERAL CONDYLE IN ADOLESCENTS observed when falling on the hand of the abducted hand. The lateral part of the condyle is most often damaged.

Signs: hemorrhages and swelling in the elbow joint; movement and palpation are painful. Huther's triangle is broken. The diagnosis is confirmed by X-ray examination.

Treatment. If there is no displacement of the fragments, the limb is immobilized with a splint for 3-4 weeks in the position of flexion of the forearm to 90°. Rehabilitation - 2-4 weeks. When the lateral fragment of the condyle is displaced, after anesthesia, traction is performed along the axis of the shoulder and the forearm is deflected inward. The traumatologist sets it by applying pressure to the fragment. When repositioning the medial fragment, the forearm is deviated outward. A control radiograph is taken in a plaster splint. If closed reduction fails, then surgical treatment is resorted to, fixing the fragments with a knitting needle or screw. The limb is fixed with a posterior plaster splint for 2-3 weeks, then exercise therapy. The metal retainer is removed after 5-6 weeks. Rehabilitation is accelerated with the use of external fixation devices.

FRACTURES OF THE MEDIAL EPICONYLE.

Causes: falling onto an outstretched arm with outward deviation of the forearm, dislocation of the forearm (the torn epicondyle can become pinched in the joint during reduction of the dislocation).

Signs: local swelling, pain on palpation, limited joint function, violation of the isosceles of Huter's triangle, radiography helps to clarify the diagnosis.

Treatment the same as for a condyle fracture.

FRACTURE OF THE HEAD OF THE HUMERAL CONDYLE.

Causes: falling on an outstretched arm, while the head of the radial bone moves upward and injures the condyle of the shoulder.

Signs: swelling, hematoma in the area of ​​the external epicondyle, limitation of movements. A large fragment can be felt in the area of ​​the ulnar fossa. Radiographs in two projections are of decisive importance in diagnosis.

Treatment. The elbow joint is hyperextended and stretched with varus adduction of the forearm. The traumatologist sets the fragment by pressing it with two thumbs downwards and backwards. The forearm is then flexed to 90° and the limb is immobilized in a posterior plaster cast for 4 to 6 weeks. Control radiography is required. Rehabilitation - 4-6 weeks. Working capacity is restored after 3-4 months.

Surgical treatment is indicated for unresolved displacement, when small fragments blocking the joint are torn off.

A large fragment is fixed with a knitting needle for 4-6 weeks. Loose small fragments are removed.

During the period of restoration of the function of the elbow joint, local thermal procedures and active massage are contraindicated (they contribute to the formation of calcifications that limit mobility). Gymnastics, mechanotherapy, sodium chloride or thiosulfate electrophoresis, and underwater massage are indicated.

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Humeral shaft fracturesForearm injuries

Anatomically, the humerus is part of the upper limb - from the elbow to the shoulder joint. Knowing where each of its elements is located is useful for the overall development and understanding of the mechanics of the human body. The structure, development, and possible injuries of this critical structure are described below.

When studying the structure of the humerus, we distinguish: the central part of the body (diaphysis), proximal (upper) and distal (lower) epiphyses, where ossification (ossification) occurs last, metaphyses, small epiphyseal tubercles - apophyses.

On the upper epiphysis there is a weakly defined anatomical neck, which passes into the head of the humerus. The lateral part of the pommel of the bone is marked by a large tubercle - one of the apophyses to which the muscles are attached. In front of the upper epiphysis there is a small tubercle that performs the same function. Between the proximal end of the bone and the body, the surgical neck of the humerus stands out, which is especially vulnerable to injury due to a sharp change in the cross-sectional area.

The cross-section changes from one epiphysis to another. Round at the upper epiphysis, towards the lower it becomes triangular. The body of the bone is relatively smooth; an intertubercular groove begins on its anterior surface near the head. It is located between the two apophyses and spirally deviates to the medial side. Almost in the middle of the height of the bone, somewhat closer to the upper part, a smoothed deltoid tuberosity protrudes - the place of attachment of the corresponding muscle. In the trilateral area near the distal epiphysis, posterior and anterior edges are distinguished - medial and lateral.

The distal epiphysis has a complex shape. On the sides there are protrusions - condyles (internal and external), easily detectable by touch. Between them there is a so-called block - a formation of a complex shape. In front there is a spherical capitate elevation. These parts have evolved to contact the radius and ulna bones. The epicondyles are protrusions on the condyles that are used to attach muscle tissue.

The upper epiphysis together with the scapular cavity make up a spherical and extremely mobile shoulder joint, responsible for the rotational movements of the arm. The upper limb carries out actions within approximately a hemisphere, in which it is assisted by the bones of the shoulder girdle - the collarbone and scapula.

The distal epiphysis is part of the complex elbow joint. The connection of the shoulder lever with the two bones of the forearm (radius and ulna) forms two of the three simple joints of this system - the humeroulnar and humeroradial joints. In this area, flexion-extension movements and slight rotation of the forearm relative to the shoulder are possible.

Functions

The humerus is essentially a lever. Anatomy predetermines its active participation in the movements of the upper limb, increasing their range. Partially when walking, it compensates for the periodic shift of the body’s center of gravity to maintain balance. It can play a supporting role and take on part of the load while climbing flights of stairs, playing sports, or in certain body positions. Most of the movements involve the forearm and shoulder girdle.

Development

Ossification of this cartilage structure is completed only upon reaching 20-23 years of age. Anatomy studies performed using x-rays show the following picture of ossification of the shoulder.

1. The point of the medial region of the head of the humerus originates in the womb or in the first year of life.
2. The lateral part of the upper epiphysis and the greater apophysis acquire their own ossification centers by 2-3 years.
3. The lesser tubercle is one of the rudiments of osteogenesis of the humerus and begins to harden at the age of 3 to 4 years in young children.
4. At about 4-6 years the head becomes completely ossified.
5. By the age of 20-23, osteogenesis of the humerus is completed.

Damage

The mobility of the shoulder joints explains the frequency of injury to individual areas of the shoulder. Fractures of bone formations can occur when exposed to significant force. The surgical neck of the bone often suffers, being an area of ​​stress concentration due to mechanical stress. Joint pain can signal a variety of problems. For example, glenohumeral periarthritis - inflammation of the shoulder joint - can be considered as a likely sign of neck osteochondrosis.

The displacement of bones in a joint relative to each other, which is not eliminated due to the elasticity of the supporting tissues, is called a dislocation. It is not always possible to differentiate a dislocation from a fracture without medical equipment. This phenomenon may be accompanied by a fracture of the humeral neck or breaking off of the greater tubercle. Reducing a dislocation on your own, without the appropriate knowledge and experience, is strictly not recommended.

A transcondylar (extensor and flexion) fracture is an intra-articular fracture. It occurs when falling on an elbow bent at an acute angle. The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence (G. M. Ter-Egiazarov, 1975).

Symptoms and recognition. There is swelling in the area of ​​the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. The symptoms are uncharacteristic, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Treatment . Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

In adults, transcondylar fractures are treated in the same way as supracondylar fractures.

Intercondylar fractures of the humerus

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be like

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of ​​the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed. Without radiographs taken in two projections, it is impossible to have an accurate idea of ​​the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle of 90-100°, and the forearm is fixed in an average position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped on the 18-21st day and they begin dosed movements in the elbow joint, gradually increasing in volume, using a removable splint at first. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

In children, a single-stage reduction is usually performed under anesthesia, followed by fixation with a plaster splint. The hand is suspended on a scarf. The elbow joint is immobilized at an angle of 100°. Movement in the elbow joint begins in children with displaced fractures after 10 days.

If reposition is unsuccessful, skeletal traction is indicated for the upper part of the ulnar spine with compression of the condyles for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults.

Surgical treatment. It is proven if the reduction of fragments using the described method fails or there are symptoms of a disorder of the innervation and blood circulation of the limb. The operation is performed under anesthesia. The incision is made longitudinally along

the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought above the skin (so that they can be easily removed) or left under the skin (Fig. 59). You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children – after 10 days.

In case of improperly healed fractures, severe limitation of movements, ankylosis of the elbow joint, especially in a functionally disadvantageous position, arthroplasty is performed in adults. In children, resection of the elbow joint and arthroplasty are not indicated due to possible growth arrest of the limb. Surgery should be delayed until adulthood. In elderly and senile patients with intra-articular fractures, they are limited to placing the limb in a functionally advantageous position and functional treatment.

Fracture of the lateral condyle of the humerus

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The head of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (90-180°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.

Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of ​​the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; Without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. Cause

The point is that although the ossification nucleus of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Treatment . Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle of 90-100°.

Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence.

Symptoms and recognition.

There is swelling in the area of ​​the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited.

Symptoms are uncommon, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be of either flexion or extension type. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition.

When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of ​​the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed.

Without radiographs taken in two projections, it is impossible to have an accurate idea of ​​the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle, and the forearm is fixed in an intermediate position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. By eliminating the displacement of fragments along the length of their compression between the palms and the application of a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position.

The traction is stopped the next day and they begin measured, gradually increasing in volume movements in the elbow joint, using initially a removable splint. Treatment can be carried out; on the same day or the next, the diverged condyles of the humerus are brought together by also using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

If reposition is unsuccessful, skeletal traction on the upper part of the ulna with compression of the condyles is indicated for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults. Surgical treatment.

A longitudinal incision is made in the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought out above the skin (so that they can be easily removed) or left under the skin (Fig.).

You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children after 10 days.

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The hollow of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block.

Rice. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and from the inside, outwards and upwards and always penetrates into the joint.

Symptoms and recognition.

A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of ​​the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful.

When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. The reason is that although the ossification nucleus of the external condyle is visible in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle°.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. The assistant places his hand on the inner surface of the patient's elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded.

The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The elbow is gradually bent to a right angle, after which the surgeon again compresses the condyles and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks.

In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

In order to avoid non-vascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through the olecranon process to the condyle, and the olecranon process breaks first, and not the internal condyle of the humerus. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until the age of 10-12 and, therefore, has great elasticity, which resists the force of a fall on the elbow.

Symptoms and recognition.

There is hemorrhage, swelling in the area of ​​the elbow joint, pain when pressing on the internal condyle, crepitus and other usual symptoms that were mentioned when describing fractures of the external condyles, but they are determined from the inside. The forearm can be adducted at the elbow joint, which cannot be done normally and with other fractures of the humeral condyles.

Fractures of the internal condyle in adults are treated with skeletal traction on the upper part of the olecranon process on an abductor splint for a day, and subsequently with a removable splint and movements in the elbow joint. For this purpose, you can use knitting needles with thrust pads, as well as the Volkov-Oganesyan articulated compression-distraction apparatus.

Fracture of the capitate eminence of the humerus

Damage to the capitate eminence of the humerus can be isolated or combined with a fracture of the head of the radius and other intra-articular fractures. The mechanism of isolated fracture is associated with a fall on an outstretched arm. The head of the radius, moving upward and anteriorly, injures the articular surface of the capitate eminence articulating with it. Damage to it may be limited to depression of the cartilage in a limited area of ​​the articular surface or separation of a small cartilaginous plate or bone fragment covered with cartilage. In some cases, a significant part of the capitate eminence and the adjacent articular block are broken off. The fragment moves anteriorly and upward.

Symptoms and recognition.

In case of an isolated injury with the formation of a small osteochondral fragment and a fracture of a significant part of the capitate eminence, pain and hematoma are localized in the area of ​​the lateral condyle. A larger fragment that has shifted anteriorly and upward can sometimes be felt in the elbow area. Movement in the elbow joint is limited and painful. For recognition, radiographs taken in anteroposterior and lateral projections are crucial. In some cases, small free fragments, often elliptical in shape, can be detected on an x-ray taken after introducing air into the elbow joint. A defect in the outer part of the capitate eminence, if the fragment is small, is sometimes not detected on an x-ray. Damage to the articular cartilage is observed more often in combination with a fracture of the radial head. This combination is found mainly during operations for fractures of the head of the radial bone. If a small plate or osteocartilaginous fragment has separated from the capitate eminence, then when flexing and rotating the forearm, a free fragment between the articular surface of the head of the radius and the capitate eminence may occur, impeding movement, in the manner of entrapment of an articular muscle. This makes it easier to recognize damage to the capitate eminence.

If the fact of a fall on an outstretched arm is established and pain is noted when flexing and rotating the forearm, and the radiograph excludes a fracture, isolated damage to the cartilage of the capitate eminence of the shoulder can be suspected.

Isolated cartilage damage in the early stages after injury, as a rule, is not recognized. Only long-term pain, blockade of the elbow joint, limitation of movements, pain during extension and rotation of the forearm that arose after a fall on an outstretched arm, and, finally, an x-ray taken some time after the injury indicate the development of osteochondritis dissecans in the area of ​​the articular surface of the capitate eminence and suggest that vascular necrosis is a consequence of cartilage contusion.

A fracture of a significant part of the capitate eminence with anterior and upward displacement of the fragment in most cases can be reduced manually.

Rice. Fracture of the capitate eminence with displacement (a). Surgical reduction and transarticular osteosynthesis with a wire (b).

A ml of 1% novocaine solution is injected into the fracture area. The patient lies on the table, the arm is extended at the elbow joint. The assistant grabs the forearm above the hand and stretches the elbow joint. The flexion surface of the arm should be facing upward. The surgeon places the bent leg on a stool, places his knee under the patient’s elbow and presses the fragment with two thumbs downwards and backwards into its bed. Then bend the elbow to a right angle and apply a plaster cast to the shoulder and forearm in a pronated position. In some cases, the fragment is better retained when the elbow is fully extended. If the control x-ray shows good alignment of the fragments, the plaster cast is left in this position for 3-4 weeks, after which movements in the elbow joint begin. Full restoration of function occurs only after 3-4 months.

The time frame for restoration of working capacity depends on the patient’s profession and on which arm is injured - the right or left. These periods range from 2-4 months. If a control radiograph shows that the fragment could not be reduced, surgical reduction is indicated rather than removal of the fragment, since in the latter case the function of the joint often suffers. In children, the fragment is fixed to the bed with catgut sutures, and in adults, with 1-2 knitting needles, which are passed transarticularly - from the extensor surface through the external condyle into the reduced fragment of the capitate eminence into the radius (Fig.). The ends of the needles remain above the surface of the skin. The needles are removed after 2-3 weeks. In case of developed osteochondritis dissecans (Konig's disease) and repeated blockades, surgical removal of the separated section of cartilage is indicated.

Fracture and apophysiolysis of the internal epicondyle of the humerus

A fracture of the internal epicondyle occurs mainly with a sudden and strong abduction of the extended forearm. In this case, the internal collateral ligament is greatly strained and tears off the epicondyle, which usually moves downward. In adolescence, with this mechanism, the epicondyle is separated along the apophyseal cartilaginous line.

This fracture is classified as periarticular. In some cases, the elbow joint bursa ruptures. Sometimes the epicondyle, torn off and connected to the internal collateral ligament, is pinched between the articular surfaces of the olecranon process and the shoulder trochlea and can pull the ulnar nerve with it.

A fracture can also occur with direct severe contusion of the internal epicondyle, which is sometimes accompanied by damage to the ulnar nerve located in the groove behind the epicondyle. Avulsions of the internal epicondyle are also observed with dislocations of the elbow joint.

Symptoms and recognition.

In the area of ​​the internal epicondyle, limited hematoma and swelling are visible, and pain is localized here. If the swelling is small, it is possible to palpate the movable fragment. Active and passive movements in the absence of hemorrhage in the elbow joint are possible and not very painful. When a fragment is pinched between the articular surfaces of the olecranon and the shoulder block, movement in the elbow joint is impossible and causes sharp pain. It is characteristic that against the normal forearm it is possible to abduct and give the elbow a valgus position. As soon as abduction stops, the forearm returns to its previous position. To recognize a fracture, radiographs in two projections are of great importance. The examination needs to determine whether there is damage to the ulnar nerve.

For fractures or separation of the internal epicondyle along the apophyseal line without displacement and with displacement to the level of the joint space, a plaster cast is used, which fixes the elbow joint at a right angle, and the forearm in a position intermediate between pronation and supination. The bandage is removed alternately and movements in the elbow joint are prescribed. The prognosis is good even with displacement of the internal epicondyle. Working capacity is restored after 4-6 weeks.

If the internal epicondyle is pinched in the elbow joint, urgent surgical treatment is indicated. Sometimes it is possible to remove the fragment from the joint when the shoulder is abducted without resorting to surgery. But such a reduction is not advisable, since the ulnar nerve can be injured, and this is an extremely serious complication.

The operation should be performed immediately as soon as the insertion of the internal epicondyle into the elbow joint is recognized based on clinical and radiological studies. The intervention is performed under intraosseous, local or general anesthesia. An incision is made on the inside of the elbow joint. It must be remembered that the ulnar nerve runs somewhat posteriorly. After longitudinal dissection of the deep fascia and spreading the wound with hooks, the site of the epicondyle tear is exposed and it is discovered that the epicondyle, together with the soft tissues, has penetrated into the elbow joint. By expanding the inner part of the joint space by abducting the forearm, it is easy to pull the epicondyle with the soft tissues attached to it from the joint. The internal epicondyle is sutured to the bed by passing two catgut sutures through the soft tissue. It is better to move the ulnar nerve anterior to the internal epicondyle (normally it is located in the groove behind) - this prevents subsequent trauma to the nerve in the rough posterior groove and its compression in the ossifying soft tissues. The wound is sutured tightly and a plaster cast is applied to hold the elbow at a right angle. The bandage is removed after 3 weeks and movements in the elbow joint are prescribed. Working capacity is restored after 6-7 weeks.

Rice. Infringement of the external epicondyle in the elbow joint together with the muscles attached to it before (a) and after (b) surgery.

Fracture and apophysiolysis of the lateral epicondyle of the humerus

A fracture of the external epicondyle is observed much less frequently than the internal one, occasionally in young people. Occurs when there is a sudden strong adduction of the forearm in an extended position. More often, the external tank ligament is torn off along with a small bone plate from the external epicondyle of the shoulder. Avulsions of the lateral epicondyle with varying degrees of displacement are observed, including pinching between the articular surfaces of the lateral condyle of the humerus and the head of the radius.

Symptoms and recognition.

The signs are the same as for a fracture of the internal epicondyle, but they are localized in the area of ​​the external epicondyle. When the external epicondyle is torn off, the forearm in the elbow joint can be adducted, giving it a varus position, which immediately levels out as soon as the adduction stops. When the lateral epicondyle is displaced into the joint, a blockade is observed. X-ray examination, especially an anteroposterior radiograph, is of great importance for recognition.

For fractures of the lateral epicondyle without displacement or with slight displacement, apply a superior plaster cast, and in children, a splint is applied to the elbow joint bent at a right angle. Then movements in the elbow joint are prescribed. Working capacity is restored after 4-5 weeks.

The operation is performed under local anesthesia. An incision is made externally above the epicondyle area. If the epicondyle is significantly displaced, suturing the fragment to the bed is indicated. In cases of entrapment of the lateral epicondyle in the elbow joint, the fragment is removed from the joint along with the muscles attached to it and sutured to the site of the avulsion (Fig.).

The largest medical portal dedicated to damage to the human body

The article talks about a fracture of the shoulder in the condyle area. Methods of treatment and rehabilitation after injury are described. Transcondylar fracture of the humerus is not observed very often by traumatologists. Most cases of injury occur in childhood. Due to the anatomical features of the structure, the injury leads to the development of complications.

Structural features

The condyles of the humerus are located in its distal section, part of the elbow joint. There are two condyles - medial and lateral. The area of ​​bone between them is thinned, which creates the preconditions for the formation of a fracture.

Here are the attachment points for the muscles of the shoulder and forearm, blood vessels and nerves. Damage to them during a fracture leads to the development of complications. The video in this article talks about the structure of the elbow joint.

Causes and types of injury

Transcondylar fractures occur due to excessive extension or flexion of the limb. An extensor fracture of the right humerus is observed much more often than others.

The main cause of occurrence is a fall on an arm that is bent or hyperextended at the elbow. A frequently occurring fracture in children is explained by the characteristics of the bone tissue and its weakest strength in this area. Also, children are more active and can get injured during outdoor games.

The incidence of this fracture in childhood is so high that it is considered a fracture in a typical location. Such an injury is intra-articular, since this entire area is located in the cavity of the elbow joint.

Manifestations

What is a transcondylar fracture from a clinical point of view? Manifestations of injury are not always specific and it is necessary to distinguish it from a dislocation or severe bruise.

The deformity of the limb is not always noticeable; it is masked by pronounced swelling and a growing hematoma in the elbow area. If the fracture is flexion in nature, the limb looks longer compared to a healthy one. Conversely, if the injury occurs as a result of hyperextension of the arm, the limb is relatively shortened.

The broken section of the bone rises up and rotates due to muscle traction - this is how a displaced fracture is formed. Because of this, the position of the shoulder does not correspond to the position of the forearm. With palpation and attempts to move, there is an increase in pain in the elbow area. Pathological mobility in lateral directions is observed.

Such a fracture without displacement is quite rare. It can usually be observed in children with poorly developed arm muscles.

Fractures can be closed or open. The first option is more common.

Injury with displacement is fraught with the development of complications in the form of damage to nerves and blood vessels, as well as muscle separation.

Diagnostics

It is not always possible to determine a closed displacement injury by visual examination. Dislocation in the elbow joint is characterized by similar symptoms.

To clarify the diagnosis, X-ray examination is used. The picture is taken in two projections. The doctor evaluates the fracture line and the extent of bone damage. If necessary, a comparative photograph of a healthy elbow joint is taken.

Treatment

The victim must be taken to a medical facility for diagnosis and follow-up measures. For transportation, it is necessary to immobilize the limb. It is carried out using ladder splints or a bandage. Adequate pain relief is provided.

Basic treatment

If the fracture is incomplete and there is no displacement, it can be treated on an outpatient basis. The limb is covered with plaster for a period of 4 weeks. In the presence of displacement or complex fractures, inpatient treatment using various techniques is indicated.

Table. Treatment methods:

Important! Restoration of movements in the limb with surgical intervention occurs much faster than with conservative treatment.

Rehabilitation treatment

The injury is subject to mandatory rehabilitation. These measures are aimed at preventing complications and restoring motor function.

Rehabilitation treatment consists of:

• taking medications;
• physiotherapeutic procedures;
• massage and therapeutic exercises;
• proper nutrition.

The patient is prescribed a nutritious diet high in protein and calcium. These substances are necessary for bone tissue restoration and fracture healing.

The same goal is pursued by the prescription of medications.

They are used to make the patient feel better and prevent complications associated with damage to bones and cartilage:

1. Anti-inflammatory drugs. Prescribed to relieve pain and eliminate swelling. Used in the form of tablets and ointments - Ibuprofen, Ketonal.
2. Chondroprotectors. With intra-articular fractures, cartilage damage is inevitable, so drugs are prescribed to restore them - Artra, Teraflex, Chondroxide. They can also be taken orally and applied to the damaged area.
3. Calcium preparations. This is the main element of bone tissue, so such drugs are prescribed for any fracture. The instructions provide for their oral administration - Calcium-D3-Nycomed, Kalcemin.
4. B vitamins. Protect nerve fibers from damage, stimulate the restoration of muscles and ligaments. Taken orally or as intramuscular injections - Combilipen, Milgamma.

You can purchase medicines at a pharmacy; the price varies depending on the manufacturer. Physiotherapeutic procedures begin on the 2-3rd day of treatment, provided that the body temperature is normal.

They use techniques such as:

• electrophoresis of drugs;
• magnetic therapy;
• paraffin applications;
• diadynamic currents.

A plaster cast makes these manipulations difficult. In order not to refuse physical treatment, a small hole is cut in the plaster through which the procedures are carried out. Physiotherapy helps improve microcirculation in the damaged area, relieves pain and reduces swelling.

Massage and therapeutic exercises are the basis of rehabilitation treatment for fractures. These methods are aimed at restoring motor function of the limb. They also need to be started on the second or third day. At first the load is minimal.

The massage is carried out with light stroking movements, therapeutic exercises consist of passive movements of the limb. As callus forms, the volume of exercise increases.

A transcondylar fracture of the humerus heals completely in most cases. There are no motor dysfunctions. Subsequently, the development of elbow arthrosis and impaired sensitivity of the limb is possible.

Intercondylar fracture of the humerus

A transcondylar (extensor and flexion) fracture is an intra-articular fracture. It occurs when falling on an elbow bent at an acute angle. The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence (G. M. Ter-Egiazarov, 1975).

Symptoms and recognition. There is swelling in the area of ​​the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. The symptoms are uncharacteristic, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Treatment. Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for a day. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

In adults, transcondylar fractures are treated in the same way as supracondylar fractures.

Intercondylar fractures of the humerus

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be like

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of ​​the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed. Without radiographs taken in two projections, it is impossible to have an accurate idea of ​​the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle, and the forearm is fixed in an intermediate position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped the next day and they begin measured, gradually increasing in volume movements in the elbow joint, using initially a removable splint. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

In children, a single-stage reduction is usually performed under anesthesia, followed by fixation with a plaster splint. The hand is suspended on a scarf. The elbow joint is immobilized at an angle of 100°. Movement in the elbow joint begins in children with displaced fractures after 10 days.

If reposition is unsuccessful, skeletal traction is indicated for the upper part of the ulnar spine with compression of the condyles for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults.

Surgical treatment. It is proven if the reduction of fragments using the described method fails or there are symptoms of a disorder of the innervation and blood circulation of the limb. The operation is performed under anesthesia. The incision is made longitudinally along

the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought above the skin (so that they can be easily removed) or left under the skin (Fig. 59). You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children – after 10 days.

In case of improperly healed fractures, severe limitation of movements, ankylosis of the elbow joint, especially in a functionally disadvantageous position, arthroplasty is performed in adults. In children, resection of the elbow joint and arthroplasty are not indicated due to possible growth arrest of the limb. Surgery should be delayed until adulthood. In elderly and senile patients with intra-articular fractures, they are limited to placing the limb in a functionally advantageous position and functional treatment.

Fracture of the lateral condyle of the humerus

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The head of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.

Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of ​​the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; Without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. Cause

The point is that although the ossification nucleus of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Treatment. Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle°.

Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

puts his hand on the inner surface of the patient’s elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded. The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The piece is gradually bent to a right angle; After this, the surgeon compresses the condyles again and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is fixed in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks. In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

Surgical reduction is performed under intraosseous and local anesthesia or general anesthesia. An incision is made along the outer posterior surface of the humeral condyle (it must be borne in mind that the radial nerve is located more anteriorly). Blood clots and soft tissue embedded in the fragment bed are removed.

To avoid avascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.

In most cases, the fragment is easily reduced when the elbow is extended and, if the elbow is then bent, it is held in place. The fragment can also be fixed by passing a catgut suture through soft tissue or through holes drilled with a drill or awl in the fragment and the humerus. In adults, the fragment can be fixed with a bone pin, wire, thin metal nail or screw. After this, the wound is sutured tightly and a plaster cast is applied to the shoulder and forearm, bent at the elbow joint. The forearm is given a position intermediate between pronation and supination. In adults, the plaster cast is removed after 3-4 weeks, and in children, the splint is removed after 2 weeks. Further treatment is the same as for fractures without displacement or after manual reduction.

A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, etc.) observed good results after removal of the lateral condyle for chronic fractures with limited movement. However, you should, if possible, avoid removing the lateral condyle of the shoulder, not only in fresh, but also in old cases, and strive to set the fragment. When the dislocated lateral condyle is unreduced, or after its removal, valgus elbow develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overextension, permanent trauma and even pinching. In cases where symptoms of secondary damage to the ulnar nerve appear, there may be indications for moving it from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the internal condyle of the humerus

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through

olecranon to condyle; in this case, the olecranon process is broken first, and not the internal condyle of the shoulder. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until adulthood and, therefore, has great elasticity, which resists the force of a fall on the elbow.

Transcondylar fracture of the humerus

This fracture is classified as intra-articular. The fracture plane passes over or through the epiphysis and has a transverse direction.

In cases where the fracture passes through the epiphyseal line, it takes on the character of epiphyolysis.

Causes

There are extensor transcondylar fractures, resulting from a fall on an extended arm at the elbow joint, and flexion fractures, resulting from a fall on the elbow.

Symptoms

The area of ​​the elbow joint is increased in volume, deformed, and the contours of the joint are unevenly expanded. The forearm is bent at the elbow joint and appears shortened, the function of the elbow joint is impaired.

On palpation - pain in the upper part of the elbow joint, a positive symptom of fluctuation.

With flexion fractures, the area of ​​the elbow joint is increased in volume, deformed due to the anterior or anterolateral part of the joint, the function is impaired, the forearm appears elongated, the contour of the olecranon process is smoothed, a positive symptom of fluctuation, Huter’s triangle and Marx’s sign are disrupted.

Passive movements in the elbow joint are sharply limited, aggravate the pain, and crepitus of the fragments is detected. The clinical picture resembles an anterior traumatic dislocation of the forearm.

Differential diagnosis

It does not present any difficulties, since traumatic dislocations are very rare in children, there are no symptoms pathognomonic for dislocations - elastic mobility, and the above-mentioned reliable symptoms of a fracture come to the fore.

Urgent Care

Treatment

Conservative - closed simultaneous comparison of fragments is carried out as for fractures above the condyles of the humerus, taking into account the type of fracture (extension or bending), immobilization lasts 3-4 weeks.

With transcondylar fractures, trauma to the ulnar nerve (bruise, pinching, compression) is possible. With bruises and slight pinching of the ulnar nerve, victims complain of paresthesia in the innervation zone of the fifth and half of the fourth fingers, and when compressed, a decrease or absence of sensitivity in the innervation zone.