Fractures of the humerus in the proximal part. Humeral neck fracture (humeral neck fracture) Anatomical humeral neck

To perform the functions of support, movement and protection, our body has a system that includes bones, muscles, tendons and ligaments. All its parts grow and develop in close interaction. Their structure and properties are studied by the science of anatomy. The humerus is part of the free upper limb and, along with the bones of the forearm and the scapula and clavicle, provides complex mechanical movements of the human arm. In this work, using the example of the humerus, we will study in detail the principles of the musculoskeletal system and find out how its structure is related to the functions it performs.

Features of tubular bones

A triangular or cylindrical shape is characteristic of the components of the skeleton - tubular bones, in which elements such as the epiphyses (edges of the bone) and its body (diaphysis) are distinguished. Three layers - the periosteum, the bone itself and the endosteum - are part of the diaphysis of the humerus. The anatomy of the free upper limb is currently quite well studied. It is known that the epiphyses contain spongy substance, while the central section is represented by bone plates. They form a compact substance. The long shoulder, elbow, and femur have this appearance. The anatomy of the humerus, a photo of which is presented below, indicates that its shape best corresponds to the formation of movable joints with the bones of the upper limb girdle and forearm.

How do tubular bones develop?

During the process of embryonic development, the humerus, together with the entire skeleton, is formed from the middle germ layer - the mesoderm. At the beginning of the fifth week of pregnancy, the fetus has mesenchymal areas called anlages. They grow in length and take the form of humeral tubular bones, the ossification of which continues after the birth of the child. The top of the humerus is covered with periosteum. This is a thin shell consisting of connective tissue and having an extensive network of blood vessels and nerve endings that enter the bone itself and provide its nutrition and innervation. It is located along the entire length of the tubular bone and forms the first layer of the diaphysis. As anatomy science has established, the humerus, covered with periosteum, contains fibers of the elastic protein - collagen, as well as special cells called osteoblasts and osteoclasts. They are grouped near the central channel of Havers. With age, it fills with yellow bone marrow.

Self-healing, repair and growth in thickness of tubular bones in the human skeleton is carried out thanks to the periosteum. The anatomy of the humerus in the middle part of the diaphysis is specific. There is a tuberous surface to which the superficial deltoid muscle is attached. Together with the girdle of the upper limbs and the bones of the shoulder and forearm, it provides lifting and abduction of the elbows and arms up, back and in front.

The significance of the epiphyses of tubular bones

The end parts of the tubular bone of the shoulder are called epiphyses, contain red bone marrow and consist of spongy substance. Its cells produce blood cells - platelets and red blood cells. The epiphyses are covered with periosteum and have bone plates and cords called trabeculae. They are located at an angle to each other and form an internal skeleton in the form of a system of cavities, which are filled with hematopoietic tissue. How to determine the bones at the junction with the scapula and the bones of the forearm is quite complex. The articular surfaces of the humerus have proximal and distal ends. The head of the bone has a convex surface that is covered and fits into the socket of the scapula. A special cartilaginous formation of the scapular cavity - the articular lip - serves as a shock absorber, softening shocks and impacts when the shoulder moves. The capsule of the shoulder joint is attached at one end to the scapula, and at the other to the head of the humerus, descending to its neck. It stabilizes the connection between the shoulder girdle and the free upper limb.

Features of the shoulder and elbow joints

As human anatomy has established, the humerus is part of not only the spherical shoulder joint, but also another one - the complex elbow. It should be noted that the shoulder joint is the most mobile in the human body. This is understandable, since the hand serves as the main instrument of labor operations, and its mobility is associated with adaptation to upright posture and freedom from participation in movement.

The elbow joint consists of three separate joints connected by a common joint capsule. The distal humerus articulates with the ulna to form the trochlear joint. At the same time, the head of the condyle of the humerus enters the fossa of the proximal end of the radius, forming the humeroradial mobile joint.

Additional shoulder structures

The normal anatomy of the humerus includes the greater and lesser apophyses, the tubercles from which the ridges arise. They serve as an attachment point. There is also a groove that serves as a receptacle for the biceps tendon. At the border with the body of the bone, the diaphysis, below the apophyses, the surgical neck is located. It is most vulnerable to traumatic shoulder injuries - dislocations and fractures. In the middle of the body of the bone there is a tuberous area to which the deltoid muscle is attached, and behind it there is a spiral-shaped groove in which the radial nerve is immersed. At the border of the epiphyses and diaphysis there is a region whose rapidly dividing cells determine the growth of the humerus in length.

Humerus dysfunction

The most common injury is a fracture of the shoulder due to a fall or severe mechanical shock. The reason is that the joint does not have real ligaments and is stabilized only by the muscular corset of the upper limb girdle and an auxiliary ligament, which looks like a bundle of collagen fibrils. Soft tissue lesions such as tendinitis and capsulitis are quite common. In the first case, the tendons of the supraspinatus, infraspinatus, and teres minor muscles are damaged. Another disease occurs as a result of inflammatory processes in the joint capsule of the shoulder.

The pathologies are accompanied by tunnel pain in the arm and shoulder, limited mobility of the shoulder joint when raising the arms up, placing them behind the back, or abducting them to the sides. All these symptoms sharply reduce a person’s performance and physical activity.

In this article, we studied the anatomical structure of the humerus and found out its relationship with the functions performed.

- This is a violation of the integrity of the humerus in its upper part, just below the shoulder joint. More often it occurs in elderly and senile women, the cause is a fall on an arm pulled back or pressed to the body. It manifests itself as pain, swelling and limitation of movements in the shoulder joint. Sometimes a bone crunch is detected. To clarify the diagnosis, an x-ray examination is performed. Treatment is usually conservative: anesthesia, reduction and immobilization. If it is impossible to match fragments, an operation is performed.

ICD-10

S42.2 Fracture of the upper end of the humerus

General information

A humeral neck fracture is an injury to the upper end of the humerus. It is more often detected in older women, which is caused not only by osteoporosis, but also by a characteristic restructuring of the metaphysis of the humerus: a decrease in the number of bone beams, an increase in the size of the bone marrow cavities and thinning of the outer wall of the bone in the area of ​​​​the transition of the metaphysis to the diaphysis. A fracture usually occurs as a result of indirect trauma. It may be impacted, accompanied or not accompanied by displacement of fragments.

In most cases, a fracture of the humeral neck is a closed isolated injury; open injuries to this area practically do not occur. With high-energy impacts, combinations with fractures of other limb bones, pelvic fracture, spinal fracture, TBI, rib fractures, blunt abdominal trauma, bladder rupture, kidney damage, etc. are possible. Treatment of humeral neck fractures is carried out by orthopedic traumatologists.

Causes

According to the observations of specialists in the field of traumatology and orthopedics, usually the cause of a fracture of the humeral neck is an indirect injury (a fall on the elbow, shoulder or hand), which causes bending of the bone in combination with pressure on it along the axis. The effect of the applied forces depends on the position of the hand at the time of injury. If the limb is in a neutral position, the fracture line is usually located transversely. The peripheral fragment is embedded in the head, and an impacted fracture is formed. In this case, the longitudinal axis can be preserved, but more often the formation of a more or less pronounced angle, open posteriorly, is observed.

If the shoulder is in the adduction position at the time of injury, the central fragment “goes” into the abduction position and turns outward. In this case, the peripheral fragment rotates inward and moves anteriorly and outward. An adduction fracture occurs, in which the angle between the fragments is open posteriorly and inwardly. If the inner edge of the distal fragment is embedded in the head, an impacted adduction fracture of the surgical neck of the humerus is formed. If penetration does not occur (this is quite rare), damage is formed with complete displacement and separation of fragments.

When the shoulder is abducted at the time of injury, the central fragment “goes” into the adduction position and rotates inward. In this case, the peripheral fragment is pulled forward and upward, rotates inwards and moves anteriorly. The fragments form an angle, open posteriorly and outward. This injury is called an abduction fracture. As in the previous case, with abduction injuries, part of the peripheral fragment is usually embedded in the head of the humerus; complete separation and displacement of the fragments is rarely detected. The most common fractures are abduction fractures.

Pathanatomy

The humerus is a long tubular bone consisting of a diaphysis (middle), two epiphyses (upper and lower) and transition zones between the diaphysis and epiphyses (metaphyses). The upper end of the bone is represented by a spherical articular head, immediately below which there is a natural narrowing - the anatomical neck of the shoulder. Fractures in this area are detected very rarely. Just below the anatomical neck there are two tubercles (places of attachment of muscle tendons) - large and small.

Below the tubercles and above the place of attachment of the pectoralis major muscle there is a conventional boundary between the upper end and the diaphysis of the bone. This border is called the surgical neck of the humerus, and it is in this area that fractures most often occur. The articular capsule of the shoulder joint is attached just above the tuberosities, therefore transtubercle fractures, like fractures of the surgical neck of the shoulder itself, belong to the category of extra-articular injuries. The division of these injuries is very arbitrary; taking into account the general symptoms and principles of treatment, most clinicians combine them into the general group of fractures of the surgical neck of the humerus.

Such fractures usually heal well, and the formation of false joints is extremely rare. However, in the presence of a fairly pronounced displacement and absence of reposition in the long-term period, significant limitation of movements is possible, due to both the consolidation of fragments in the wrong position and the proximity of the ligaments and articular capsule, which are easily involved in the adhesive process. The most unfavorable from the point of view of subsequent limitation of function is an unreduced adduction fracture, after which a pronounced limitation of abduction may occur.

Symptoms of a fracture

Patients with impacted fractures of the humeral neck complain of moderate pain in the joint area, which intensifies with movement. The joint is swollen, and hemorrhages are often detected. Active movements are possible, but limited due to pain. Palpation of the humeral head is painful. In displaced fractures, the symptoms are more pronounced: the rounded shape of the joint is disrupted, some prolongation of the acromion process and retraction in the head area are noticeable.

There is a change in the axis of the shoulder: it runs obliquely, with the central end of the axis directed forward and inward. The elbow is displaced posteriorly and is distant from the body, but there is no fixation of the elbow joint (as in a dislocation), and the symptom of spring resistance is not detected. A shortening of the affected shoulder by 1-2 cm is determined. Active movements are impossible, passive movements are sharply limited due to pain and are sometimes accompanied by bone crunching. During rotational movements, the head does not move with the humerus.

When palpating the surgical neck, sharp local pain occurs. In thin patients with poorly developed muscles in the axilla, the end of the distal bone fragment can be palpated. In some cases, a displaced fragment can compress the neurovascular bundle, which is manifested by cyanosis due to impaired venous outflow, swelling of the limb and a feeling of crawling.

Diagnostics

To clarify the diagnosis, radiography of the shoulder joint is prescribed in two projections: direct and “epaulet” (axial). An “epaulet” shot is performed by moving the shoulder away from the body at an angle of 30-40 degrees. Greater abduction is strictly not recommended, as it may aggravate the displacement of the fragments. In doubtful cases, CT scan of the shoulder joint is used. If compression of the neurovascular bundle is suspected, patients are referred for consultation to neurologists or neurosurgeons and vascular surgeons.

Treatment of a humeral neck fracture

Elderly patients with impacted fractures do not require reduction in most cases. The damaged area is anesthetized with novocaine and a fixing bandage is applied for 6 weeks. If a moderately displaced impacted fracture has been diagnosed in a young or middle-aged person, reduction is indicated. For patients of all ages, reduction is performed for comminuted and non-impacted fractures. Then the limb is immobilized, painkillers and UHF are prescribed. Therapeutic exercises begin from the second day, light movements (slight adduction, abduction and rocking) in the shoulder joint - from the fifth day. Subsequently, the range of movements is gradually increased.

As a means for immobilizing a fracture, depending on the nature of the injury and the age of the patient, a regular scarf bandage (in elderly patients) or a snake scarf, on which the bent arm is suspended, can be used. If necessary, the scarf is supplemented with a roller in the armpit area. In some cases, with impacted adduction fractures with angular displacement and easily displaced non-impacted fractures with complete divergence of the fragments, skeletal traction is performed on an abduction or abduction splint.

Surgical treatment is indicated for significant angular displacement, complete separation of fragments and the impossibility of matching the fragments by closed reduction. The operation is performed in a trauma department under general anesthesia. Typically, an anteromedial incision is used. To hold fragments in adults, osteosynthesis is performed with a plate; in children, fixation with knitting needles is possible. The wound is sutured layer by layer and drained.

In the postoperative period, immobilization is performed using a curved Kremer splint or a bandage with a pad in the armpit. Painkillers and antibiotics are prescribed. From the third day, exercise therapy begins with movements in the fingers, elbow and wrist joints. The sutures are removed on the 10th day, movements in the shoulder joint begin on the 20th day after surgery. The results of surgery are usually good.

Very rarely, with fragmentation of the upper parts of the humerus and aseptic necrosis of the head, endoprosthetics of the shoulder joint is indicated. Depending on the age and physical condition of the patient, it is possible to use unipolar endoprostheses (replacing only the head of the humerus) or total endoprosthetics (replacing both the head and the glenoid cavity of the scapula). If there are contraindications to endoprosthetics, arthrodesis is performed.

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.

Humerus - long bone. It distinguishes between a body and two epiphyses - the upper proximal and lower distal. The body of the humerus, corpus humeri, is rounded in the upper part and triangular in the lower part.

In the lower part of the body, there is a posterior surface, facies posterior, which is limited along the periphery by the lateral and medial edges, margo lateralis et margo medialis; the medial anterior surface, facies anterior medialis, and the lateral anterior surface, facies anterior lateralis, separated by an inconspicuous ridge.

On the medial anterior surface humeral body, slightly below the middle of the body length, there is a nutrient opening, foramen nutricium, which leads into the distally directed nutrient canal, canalis nutricius.

Above the nutrient opening on the lateral anterior surface of the body there is a deltoid tuberosity, tuberositas deltoidea, - the place of attachment, m. deltoideus

On the posterior surface of the body of the humerus, behind the deltoid tuberosity, there is a groove of the radial nerve, sulcus n. radialis. It has a spiral motion and is directed from top to bottom and from inside to outside.

Upper, or proximal, epiphysis, extremitas superior, s. epiphysis proximalis. thickened and bears a hemispherical humeral head, caput humeri, the surface of which faces inwards, upwards and somewhat posteriorly. The periphery of the head is delimited from the rest of the bone by a shallow ring-shaped narrowing - the anatomical neck, collum anatomicum. Below the anatomical neck, on the anterior outer surface of the bone, there are two tubercles: on the outside - the large tubercle, tuberculum majus, and on the inside and slightly in front - the small tubercle, tuberculum minus.

A ridge of the same name stretches down from each tubercle; crest of the greater tubercle, crista tuberculi majoris, and crest of the lesser tubercle, crista tuberculi minoris. Heading down, the ridges reach the upper parts of the body and, together with the tubercles, limit a well-defined intertubercular groove, sulcus intertubercularis, in which the tendon of the long head of the biceps brachii muscle, tendo capitis longi m, lies. bicepitis brachii.
Below the tubercles, at the border of the upper end and the body of the humerus, there is a small narrowing - the surgical neck, collum chirurgicum, which corresponds to the area of ​​the epiphysis.

On the anterior surface of the distal epiphysis of the humerus above the trochlea there is a coronoid fossa, fossa coronoidea, and above the head of the condyle of the humerus there is a radial fossa, fossa radialis, on the posterior surface there is an olecranon fossa, fossa olecrani.

Peripheral parts of the lower end humerus end with the lateral and medial epicondyles, epicondylus lateralis et medialis, from which the muscles of the forearm begin.

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There are fractures of the head, anatomical neck (intra-articular); transtubercular fractures and surgical neck fractures (extra-articular); avulsions of the greater tubercle of the humerus (Fig. 1). The main types of fractures are given in the AO/ASIF UKP.

Rice. 1. Fractures in the proximal part of the humerus: 1 - fractures of the anatomical neck; 2 — transtubercular fractures; 3 — surgical neck fractures

Fractures of the head and anatomical neck of the humerus

Causes: a fall on the elbow or a direct blow to the outer surface of the shoulder joint. When the anatomical neck is fractured, the distal fragment of the humerus usually becomes wedged into the head.

Sometimes the humeral head becomes crushed and deformed. The head can be torn off, with its cartilaginous surface turning towards the distal fragment.

Signs. The shoulder joint is increased in volume due to swelling and hemorrhage. Active movements in the joint are limited or impossible due to pain. Palpation of the shoulder joint area and tapping the elbow are painful. During passive rotation movements, the greater tuberosity moves with the shoulder. With concomitant dislocation of the head, the latter cannot be felt in its place. Clinical signs are less pronounced with an impacted fracture: active movements are possible; with passive movements, the head follows the diaphysis. The diagnosis is confirmed by x-ray; an axial projection is required. Mandatory monitoring of vascular and neurological disorders is necessary.

Treatment. Victims with impacted fractures of the head and anatomical neck of the humerus are treated on an outpatient basis. 20-30 ml of a 1% solution of novocaine is injected into the joint cavity, the arm is immobilized with a plaster splint according to G.I. Turner in the position of abduction (using a roller, pillow) by 45-50°, flexion in the shoulder joint up to 30°, in the elbow - up to 80-90°. Analgesics, sedatives are prescribed, from the 3rd day they begin magnetic therapy, UHF on the shoulder area, from the 7-10th day - active movements in the wrist and elbow and passive movements in the shoulder joint (removable splint!), electrophoresis of novocaine, calcium chloride , UV irradiation, ultrasound, massage.

After 4 weeks the plaster splint is replaced with a scarf bandage, and rehabilitation treatment is intensified. Rehabilitation - up to 5 weeks.

Working capacity is restored after 2-2 1/2 months.

Indications for surgery: impossibility of reduction in unstable fractures with significant displacement of fragments, interposition of soft tissues and fragments between articular surfaces (type A3 and more severe).

Fractures of the surgical neck of the humerus

Causes. Fractures without displacement of fragments are usually impacted or pinched. Fractures with displacement of fragments, depending on their position, are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur when falling with emphasis on the outstretched adducted arm. In this case, the proximal fragment is retracted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward. Abduction fractures occur when falling with emphasis on the outstretched abducted arm. In these cases, the central fragment is adducted and rotated medially, and the peripheral fragment is internally and anteriorly displaced forward and upward. An angle is formed between the fragments, open outward and posteriorly.

Signs. With impacted fractures and non-displaced fractures, local pain is determined, which increases with load along the axis of the limb and rotation of the shoulder; the function of the shoulder joint is possible, but limited. During passive abduction and rotation of the shoulder, the head follows the diaphysis. The x-ray determines the angular displacement of the fragments. In fractures with displaced fragments, the main symptoms are severe pain, dysfunction of the shoulder joint, pathological mobility at the level of the fracture, shortening and disruption of the axis of the shoulder. The nature of the fracture and the degree of displacement of the fragments are clarified radiographically.

Treatment. First aid includes the administration of analgesics (Promedol), immobilization with a transport splint or Deso bandage (Fig. 2), hospitalization in a trauma hospital, where a full examination is carried out, anesthesia of the fracture site, reposition and immobilization of the limb with a splint (for impacted fractures) or a thoracobrachial bandage with mandatory radiographic control after the plaster has dried and after 7-10 days.

Rice. 2. Transport immobilization for fractures of the humerus: a, b - Deso bandage (1-5 - bandage stroke); in — ladder tire

Features of reposition(Fig. 3): for adduction fractures, the assistant raises the patient’s arm forward by 30-45° and abducts it by 90°, bends the elbow joint to 90°, rotates the shoulder outward by 90° and gradually smoothly extends it along the axis of the shoulder. The traumatologist controls the reposition and performs corrective manipulations in the area of ​​the fracture. The traction along the axis of the shoulder should be strong; sometimes for this, an assistant applies counter support with the foot in the area of ​​the armpit. After this, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction to 90-100°, flexion at the elbow joint to 80-90°, extension at the wrist joint to 160°.

Rice. 3. Reposition and retention of fragments of the humerus: a, b - with abduction fractures; c-e - for adduction fractures; e - thoracobrachial bandage; g - treatment according to Kaplan

For abduction fractures, the traumatologist corrects the angular displacement with his hands, then reposition and immobilization are carried out in the same way as for adduction fractures.

The duration of immobilization is from 6 to 8 weeks; from the 5th week, the shoulder joint is released from fixation, leaving the arm on the abduction splint.

Rehabilitation time is 3-4 weeks.

Working capacity is restored after 2-2 1/2 months.

From the first day of immobilization, patients should actively move their fingers and hand. After turning the circular bandage into a sponge bandage (after 4 weeks), passive movements in the elbow joint are allowed (with the help of a healthy arm), and after another week - active ones. At the same time, massage and mechanotherapy are prescribed (for dosed load on the muscles). Patients practice exercise therapy daily under the guidance of a methodologist and independently every 2-3 hours for 20-30 minutes.

After the patient can repeatedly raise his arm above the splint by 30-45° and hold the limb in this position for 20-30 seconds, the abduction splint is removed and full rehabilitation begins. If closed reposition of the fragments fails, then surgical treatment is indicated (Fig. 4).

Rice. 4. Osteosynthesis for a fracture of the surgical neck of the humerus, bone (a) and Ilizarov apparatus (b)

After open reduction, the fragments are fixed with lag screws with a T-shaped plate. If the bone is osteoporotic, then knitting needles and a tightening wire suture are used. Four-part fractures of the head and neck of the humerus (type C2) are an indication for endoprosthetics.

Fractures of the tuberosities of the humerus

Causes. A fracture of the greater tuberosity often occurs with a dislocated shoulder. Its separation with displacement occurs as a result of a reflex contraction of the supraspinatus, infraspinatus and teres minor muscles. An isolated nondisplaced fracture of the greater tuberosity is primarily associated with a direct blow to the shoulder.

Signs. Limited swelling, tenderness and crepitus on palpation. Active abduction and external rotation of the shoulder are impossible, passive movements are sharply painful. The diagnosis is confirmed by x-ray.

Treatment. For fractures of the greater tubercle without displacement after blockade with novocaine, the arm is placed on an abductor pillow and immobilized with a Deso bandage or scarf for 3-4 weeks.

Rehabilitation - 2-3 weeks.

Working capacity is restored after 5-6 weeks.

In case of avulsion fractures with displacement, after anesthesia, reposition is carried out by abduction and external rotation of the shoulder, then the limb is immobilized on an abduction splint or with a plaster cast (Fig. 5).

Rice. 5. Fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - therapeutic immobilization

For large edema and hemarthrosis, it is advisable to continue for 2 weeks. use shoulder traction. Abduction of the arm on the splint is stopped as soon as the patient can freely lift and rotate the shoulder.

Rehabilitation - 2-4 weeks.

Working capacity is restored after 2-2 1/2 months.

Indications for surgery. Intra-articular supra-tubercular fractures with significant displacement of fragments, failed reduction in a fracture of the surgical neck of the humerus, entrapment of the greater tubercle in the joint cavity. Osteosynthesis is performed with a screw or a tightening wire loop (Fig. 6).

Rice. 6. Surgical treatment of a fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - fixation with a screw; c - fixation with wire

Complications are the same as with shoulder dislocations.

Traumatology and orthopedics. N. V. Kornilov