The structure of the shoulder joint. Structure of the humerus Humerus characteristics

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Types of humerus fractures and principles of treatment

The humerus is quite long, and a fracture can occur in any part of it:

• anatomical neck of the shoulder (intra-articular fracture);
• surgical neck of the shoulder (extra-articular fracture);
• humeral diaphysis (main part of the bone);
• distal section (closer to the elbow).

Fractures of the surgical neck of the humerus are especially dangerous, as they can lead to damage to the neurovascular bundle, and therefore to hemorrhage and possible paresis in the future.

Treatment of a humerus fracture is usually conservative (reposition of the fragments, casting and observation), but in some cases surgery may be required. The start of treatment usually coincides with the rehabilitation period.

The main goal of rehabilitation is to restore full range of motion. The set of exercises is adjusted by the attending physician and physical therapy doctor individually for each patient. Exercise therapy promotes muscle relaxation, correct alignment of bone fragments, reduces pain, and activates the processes of regeneration and adaptation.

Immobilization stage (first 3 weeks after fracture)

The entire complex should be performed 6-8 times a day for 30 minutes (6-10 repetitions for each exercise). Starting position – standing with a forward bend.

• Breathing exercises.
• The hand must be in a bandage at all times (except for activities).
• Active movements (rotation, flexion/extension, pronation/supination) in the elbow, wrist joints, and hands stimulate blood circulation in the arm, reducing swelling and reducing the risk of blood clots.
• Rotate your arms clockwise and counterclockwise.
• Pendulum-like movements of the hands. This exercise is great for relieving pain at any time. It is enough to remove the sore arm from the bandage and, in a standing position, bending forward, make several pendulum-like swings with the relaxed limb.
• Abduction and adduction of the arm or just the elbow to the body.
• Clap in front of the chest and then behind the back.
• Crossing your arms in front of your chest.
• Torso twists with hands clasped in front of the chest.

Physical treatments include cryotherapy to reduce pain, swelling and inflammation.

The patient receives a list of exercises upon discharge home. It is necessary to continue practicing, otherwise it will be impossible to restore the mobility of your hand.

Functional stage (3-6 weeks)

During this period, the fracture is already considered healed, which is confirmed by x-rays. The goal of rehabilitation at this stage is to restore the previous range of passive and active movements. The set of exercises expands, but the starting position remains the same. The patient should strive for gradual extension and perform exercises while standing without bending forward. Frequency of exercises – 4-6 times a day, up to 6-10 repetitions.

• Raise your arm straight in front of you.
• Active use of block exercise machines: raising and lowering the sore limb, raising the arms to the sides.
• Swing your arms forward, backward, to the sides. Starting position - standing with a slight bend forward.
• Retraction of the arms behind the back with squeezing of the shoulder blades. Starting position – arms in front of the chest, elbows bent.
• Water procedures. While visiting the pool, you should perform exercises that imitate breaststroke and freestyle swimming, crossing your arms in front of your chest, and various movements of your limbs. Staying in water puts additional stress on the muscles, which improves blood circulation in them and increases the effectiveness of training.

Physiotherapy includes magnet, massage, balneotherapy. Courses of 10-12 procedures.

Training stage (7-8 weeks)

It is believed that by this time the patient had almost completely restored the functionality of the injured arm and shoulder. Exercises are performed to strengthen muscles and fully restore range of motion. Training should take place 3-4 times a day for 10-12 repetitions.

• Raise your arm straight in front of you. Starting position: standing straight.
• Exercises for abduction, adduction, pronation, supination, arm rotation. Hanging on a bar or wall bars, hand rests and push-ups, manipulations with medicine balls and dumbbells weighing no more than 5 kg. It is necessary to continue physical therapy to strengthen the deltoid muscle and rotator cuff, which are the muscular framework for the shoulder joint. It should be borne in mind that exercises that require a large load should not be prescribed to elderly patients.
• Stretching exercises. “Walking” with your fingers up and to the sides along the wall, placing a towel or gymnastic stick behind your back. The listed manipulations make it possible to achieve complete restoration of mobility in all directions.
• Swimming pool – swimming in a comfortable style.

Physiotherapy still includes magnet, massage, balneotherapy.

With a rationally selected rehabilitation scheme, the patient’s full recovery occurs within 2-3 months. Only after this it is necessary to perform exercises designed to develop physical strength, stretching, and endurance. You need to take vitamin complexes and special supplements, and also make sure that there is enough calcium in your food (dairy products).

Video “Rehabilitation after a humerus fracture”

Fractures of the humerus in the proximal part

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 2-21/2 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 inward, and the peripheral fragment is inward 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); c - ladder bus

Features of reposition (Fig. 3): for adduction fractures, the assistant lifts 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-d - 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.

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 is able to 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 rehabilitation begins in full. 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 2-21/2 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

The shoulder is the proximal (closest to the torso) segment of the upper limb. The upper border of the shoulder is the line connecting the lower edges of the pectoralis major and latissimus dorsi muscles; lower - a horizontal line passing above the condyles of the shoulder. Two vertical lines drawn upward from the condyles of the shoulder conditionally divide the shoulder into anterior and posterior surfaces.

External and internal grooves are visible on the anterior surface of the shoulder. The bony base of the shoulder is the humerus (Fig. 1). Numerous muscles are attached to it (Fig. 3).

Rice. 1. Humerus: 1 - head; 2 - anatomical neck; 3 - small tubercle; 4 - surgical neck; 5 and 6 - crest of the lesser and greater tubercle; 7 - coronoid fossa; 8 and 11 - internal and external epicondyle; 9 - block; 10 - capitate eminence of the humerus; 12 - radial fossa; 13 - groove of the radial nerve; 14 - deltoid tuberosity; 15 - greater tubercle; 16 - groove of the ulnar nerve; 17 - ulnar fossa.

Rice. 2. Fascial sheaths of the shoulder: 1 - sheath of the coracobrachialis muscle; 2-radial nerve; 3 - musculocutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - sheath of the triceps brachii muscle; 7 - sheath of the brachial muscle; 8 - sheath of the biceps brachii muscle. Rice. 3. Places of origin and attachment of muscles on the humerus, right front (i), back (b) and side (c): 1 - supraspinatus; 2 - subscapular; 3 - wide (back); 4 - large round; 5 - coraco-humeral; 6 - shoulder; 7 - round, rotating the palm inward; 8 - flexor carpi radialis, superficial flexor carpi, palmaris longus; 9 - short radial extensor carpi; 10 - extensor carpi radialis longus; 11 - brachioradial; 12 - deltoid; 13 - greater sternum; 14 - infraspinatus; 15 - small round; 16 and 17 - triceps brachii muscle (16 - lateral, 17 - medial head); 18 - muscle that rotates the palm outward; 19 - elbow; 20 - extensor of the small finger; 21 - extensor of the fingers.

The shoulder muscles are divided into 2 groups: the anterior group consists of flexors - biceps, brachialis, coracobrachialis, and the posterior group - triceps, extensor. The brachial artery, running underneath, accompanied by two veins and the median nerve, is located in the internal groove of the shoulder. The projection line of the artery on the skin of the shoulder is drawn from the deepest point to the middle of the cubital fossa. The radial nerve passes through the canal formed by the bone and triceps muscle. The ulnar nerve goes around the medial epicondyle, located in the groove of the same name (Fig. 2).

Closed shoulder injuries. Fractures of the head and anatomical neck of the humerus are intra-articular. Without them, it is not always possible to distinguish from, and a combination of these fractures with dislocation is possible.

A fracture of the tuberosity of the humerus is recognized only radiographically. A diaphysis fracture is usually diagnosed without difficulty, but is required to determine the shape of the fragments and the nature of their displacement. A supracondylar fracture of the humerus is often complex, T-shaped or V-shaped, so that the peripheral fragment is divided in two, which can only be recognized on an x-ray. Simultaneous dislocation of the elbow is also possible.

With a diaphyseal fracture of the shoulder, the traction of the deltoid muscle displaces the central fragment, moving it away from the body. The closer to the broken bone the greater the displacement. When a surgical neck is fractured, the peripheral fragment is often driven into the central one, which is determined on the image and is most favorable for healing of the fracture. With a supracondylar fracture, the triceps muscle pulls the peripheral fragment backwards and upwards, and the central fragment moves anteriorly and downwards (towards the ulnar fossa), which can compress and even injure the brachial artery.

First aid for closed fractures of the shoulder comes down to immobilizing the limb with a wire splint from the shoulder blade to the hand (the elbow is bent at a right angle) and fixing it to the body. If the diaphysis is broken and there is a sharp deformity, you should try to eliminate it by gently traction on the elbow and bent forearm. With low (supracondylar) and high shoulder fractures, attempts at reposition are dangerous; in the first case, they threaten to damage the artery, in the second, they can disrupt the impaction, if any. After immobilization, the victim is urgently sent to a trauma center for x-ray examination, reposition and further inpatient treatment. It is carried out, depending on the characteristics of the fracture, either in a plaster thoracobrachial bandage, or by traction (see) on an abduction splint. For an impacted neck fracture, none of this is required; the arm is fixed to the body with a soft bandage, placing a cushion under the arm, and after a few days therapeutic exercises begin. Uncomplicated closed shoulder fractures heal in 8-12 weeks.

Shoulder diseases. Of the purulent processes, the most important is acute hematogenous osteomyelitis (see). After an injury, a muscle hernia may develop, most often a hernia of the biceps muscle (see Muscles, pathology). Among the malignant neoplasms, there are those that require amputation of the shoulder.

Shoulder (brachium) is the proximal segment of the upper limb. The upper border of the shoulder is a line connecting the lower edges of the pectoralis major and latissimus dorsi muscles, the lower border is a line passing two transverse fingers above the condyles of the humerus.

Anatomy. The skin of the shoulder is easily mobile, it is loosely connected to the underlying tissues. On the skin of the lateral surfaces of the shoulder, internal and external grooves (sulcus bicipitalis medialis et lateralis) are visible, separating the anterior and posterior muscle groups. The fascia of the shoulder (fascia brachii) forms a sheath for muscles and neurovascular bundles. The medial and lateral intermuscular septa (septum intermusculare laterale et mediale) extend from the fascia deep to the humerus, forming the anterior and posterior muscle containers, or beds. In the anterior muscle bed there are two muscles - biceps and brachialis (m. biceps brachii et m. brachialis), in the rear - triceps (m. triceps). In the upper third of the shoulder there is a bed for the coracobrachial and deltoid muscles (m. coracobrachialis et m. deltoideus), and in the lower third there is a bed for the brachialis muscle (m. brachialis). Under the fascia proper of the shoulder, in addition to the muscles, there is also the main neurovascular bundle of the limb (Fig. 1).

Rice. 1. fascial receptacles of the shoulder (diagram according to A. V. Vishnevsky): 1 - sheath of the coracobrachialis muscle; 2 - radial nerve; 3 - musculocutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - sheath of the triceps brachii muscle; 7 - sheath of the brachial muscle; 8 - sheath of the biceps brachii muscle.

Rice. 2. Right humerus in front (left) and back (right): 1 - caput humeri; 2 - collum anatomicum; 3 - tuberculum minus; 4 - coilum chirurgicum; 5 - crista tuberculi minoris; 6 - crista tuberculi majoris; 7 - foramen nutricium; 8 - facies ant.; 9 - margo med.; 10 - fossa coronoidea; 11 - epicondylus med.; 12 - trochlea humeri; 13 - capitulum humeri; 14 - epicondylus lat.; 15 - fossa radialis; 16 - sulcus n. radialis; 17 - margo lat.; 18 - tuberositas deltoidea; 19 - tuberculum majus; 20 - sulcus n. ulnaris; 21 - fossa olecrani; 22 - facies post.

On the anterior-inner surface of the shoulder, two main venous superficial trunks of the limb pass over the proper fascia - the radial and ulnar saphenous veins. The radial saphenous vein (v. cephalica) runs outward from the biceps muscle along the external groove, at the top it flows into the axillary vein. The ulnar saphenous vein (v. basilica) runs along the internal groove only in the lower half of the shoulder, - the internal cutaneous nerve of the shoulder (n. cutaneus brachii medialis) (color table, Fig. 1-4).

The muscles of the anterior shoulder region belong to the group of flexors: the coracobrachialis muscle and the biceps muscle, which has two heads - short and long; fibrous sprain of the biceps muscle (aponeurosis m. bicipitis brachii) is woven into the fascia of the forearm. Beneath the biceps muscle lies the brachialis muscle. All these three muscles are innervated by the musculocutaneous nerve (n. musculocutaneus). The brachioradialis muscle begins on the outer and anteromedial surfaces of the lower half of the humerus.

Rice. 1 - 4. Vessels and nerves of the right shoulder.
Rice. 1 and 2. Superficial (Fig. 1) and deep (Fig. 2) vessels and nerves of the anterior surface of the shoulder.
Rice. 3 and 4. Superficial (Fig. 3) and deep (Fig. 4) vessels and nerves of the posterior surface of the shoulder. 1 - skin with subcutaneous fatty tissue; 2 - fascia brachii; 3 - n. cutaneus brachii med.; 4 - n. cutaneus antebrachii med.; 5 - v. basilica; 6 - v. medlana cublti; 7 - n. cutaneus antebrachii lat.; 8 - v. cephalica; 9 - m. pectoralis major; 10 - n. radialis; 11 - m. coracobrachialis; 12 - a. et v. brachlales; 13 - n. medianus; 14 - n. musculocutaneus; 15 - n. ulnaris; 16 - aponeurosis m. bicipitis brachii; 17 - m. brachialis; 18 - m. biceps brachii; 19 - a. et v. profunda brachii; 20 - m. deltoldeus; 21 - n. cutaneus brachii post.; 22 - n. cutaneus antebrachii post.; 23 - n. cutaneus brachii lat.; 24 - caput lat. m. trlcipitis brachii (cut); 25 - caput longum m. tricipitls brachii.

The main arterial trunk of the shoulder - the brachial artery (a. brachialis) - is a continuation of the axillary artery (a. axillaris) and runs along the medial side of the shoulder along the edge of the biceps muscle along the projection line from the top of the axillary fossa to the middle of the cubital fossa. Two accompanying veins (vv. brachiales) run along the sides of the artery, anastomosing with each other (color. Fig. 1). In the upper third of the shoulder, outside the artery, lies the median nerve (n. medianus), which crosses the artery in the middle of the shoulder and then goes from its inside. The deep brachial artery (a. profunda brachii) arises from the upper part of the brachial artery. The nutrient artery of the humerus (a. nutrica humeri) departs directly from the brachial artery or from one of its muscular branches, which penetrates the bone through the nutrient foramen.

Rice. 1. Cross cuts of the shoulder made at different levels.

On the posterior-outer surface of the shoulder in the posterior osteo-fibrous bed there is a triceps muscle that extends the forearm and consists of three heads - long, medial and external (caput longum, mediale et laterale). The triceps muscle is innervated by the radial nerve. The main artery of the posterior section is the deep artery of the shoulder, running back and down between the external and internal heads of the triceps muscle and enveloping the humerus posteriorly with the radial nerve. In the posterior bed there are two main nerve trunks: radial (n. radialis) and ulnar (n. ulnaris). The latter is located superiorly posteriorly and internally from the brachial artery and median nerve and only in the middle third of the shoulder enters the posterior bed. Like the median nerve, the ulnar nerve does not give branches to the shoulder (see Brachial plexus).

The humerus (humerus, os brachii) is a long tubular bone (Fig. 2). On its outer surface there is a deltoid tuberosity (tuberositas deltoidea), where the deltoid muscle is attached, and on the posterior surface there is a groove of the radial nerve (sulcus nervi radialis). The upper end of the humerus is thickened. There is a distinction between the head of the humerus (caput humeri) and the anatomical neck (collum anatomicum). The small narrowing between the body and the upper end is called the surgical neck (collum chirurgicum). At the upper end of the bone there are two tubercles: a large one on the outside and a small one in front (tuberculum inajus et minus). The lower end of the humerus is flattened in the anteroposterior direction. Outwardly and inwardly, it has easily palpable protrusions under the skin - the epicondyles (epicondylus medialis et lateralis) - the origin of most of the muscles of the forearm. Between the epicondyles is the articular surface. Its medial segment (trochlea humeri) has the shape of a block and articulates with the ulna; lateral - head (capitulum humeri) - spherical and serves for articulation with the ray. Above the trochlea in front is the coronoid fossa (fossa coronoidea), behind - the ulnar fossa (fossa olecrani). All these formations of the medial segment of the distal end of the bone are combined under the general name “condyle of the humerus” (condylus humeri).

The proximal border of the shoulder is the lower edge of m. pectoralis major in front and latissimus dorsi in back. The distal border is a circular line above both condyles of the humerus.

The humerus is divided into a proximal, distal end and diaphysis. The proximal end has a hemispherical head. Its smooth spherical surface faces inward, upward and somewhat backward. It is limited on the periphery by a grooved narrowing of the head - the anatomical neck. Outward and anterior to the head there are two tubercles: the lateral greater tubercle (tuberculum majus) and the lesser tubercle (tuberculum minus), which is located more medially and anteriorly. Below, the tubercles turn into scallops of the same name. The tubercles and scallops are the site of muscle attachment.

Between these tubercles and ridges there is an intertubercular groove. Below the tubercles, corresponding to the zone of the epiphyseal cartilage, a conditional boundary is determined between the upper end and the body of the humerus. This place is somewhat narrowed and is called the “surgical neck”.

On the anterior outer surface of the body of the humerus, below the crest of the tuberculum majoris, there is a deltoid tuberosity. At the level of this tuberosity, a groove runs along the posterior surface of the humerus in the form of a spiral from top to bottom and from inside to outside (sulcus nervi radialis).

The body of the humerus is triangular in the lower part; here three surfaces are distinguished: posterior, anterior medial and anterior lateral. The last two surfaces pass into one another without sharp boundaries and border the rear surface with well-defined edges - outer and inner.

The distal end of the bone is flattened anteroposteriorly and expanded laterally. The outer and inner edges end in well-defined tubercles. One of them, the smaller one, facing laterally, is the lateral epicondyle, the other, the larger one, is the medial epicondyle. On the posterior surface of the medial epicondyle there is a groove for the ulnar nerve.

Below the lateral epicondyle there is a capitate eminence, the smooth articular surface of which, having a spherical shape, is oriented partly downward, partly forward. Above the capitate eminence is the radial fossa.

Medial to the capitate eminence is the block of the humerus (trochleae humeri), through which the humerus articulates with the ulna. In front above the trochlea there is a coronoid fossa, and behind there is a rather deep ulnar fossa. Both fossae correspond to the processes of the same name of the ulna. The area of ​​bone separating the ulnar fossa from the coronoid fossa is significantly thinned and consists of almost two layers of cortical bone.

The biceps brachii muscle (m. biceps brachii) is located closer to the surface than the others and consists of two heads: a long one, starting from the tuberculum supraglenoidale scapulae, and a short one, extending from the processus coracoideus scapulae. Distally, the muscle attaches to the tubercle of the radius. M. coracobrachialis originates from the coracoid process of the scapula, is located medial and deeper than the short head of the biceps muscle and is attached to the medial surface of the bone. M. brachialis originates on the anterior surface of the humerus, lies immediately beneath the biceps muscle, and inserts distally on the tuberosity of the ulna.

The extensors include the triceps brachii muscle (m. triceps brachii). The long head of the triceps muscle begins from the tuberculum infraglenoidae scapulae, and the radial and ulnar heads begin from the posterior surface of the humerus. Below, the muscle is attached by the wide aponeurotic tendon to the olecranon process.

The elbow muscle (m. anconeus) is located superficially. It is small and triangular in shape. The muscle originates from the lateral epicondyle of the humerus and the collateral ligament of the radius. Its fibers diverge, lie fan-shaped on the bursa of the elbow joint, partially woven into it, and are attached to the crest of the dorsal surface of the ulna in its upper part. N. musculocutaneus, perforating m. coracobrachialis, passes medially between m. brachialis etc. biceps. In the proximal part of the shoulder it is located outside the artery, in the middle it crosses it, and in the distal part it passes medial to the artery.

Blood supply is provided by a. brachialis and its branches: aa.circumflexae humeri anterior and posterior, etc. The extensors are innervated by the p. radialis. It passes at the top of the shoulder behind a. axillaris, and below is included in canalis humeromuscularis along with a. and v. profunda brachii, which are located medially from the nerve.

The nerve encircles the bone in a spiral manner, descending in the upper part between the long and medial heads of the triceps muscle, and towards the middle of the shoulder it passes under the oblique fibers of the lateral head. In the distal third of the shoulder, the nerve is located between mm. brachialis and brachioradialis.

Rice. 1. Humerus (humerus).

A-front view; B-rear view.

A. 1 - greater tubercle of the humerus; 2 - anatomical neck of the humerus; 3 - head of the humerus; 4 - lesser tubercle of the humerus; 5 - intertubercular groove; 6 - crest of the lesser tubercle; 7 - crest of the greater tubercle; 8 - deltoid tuberosity of the humerus; 9 - body of the humerus; 10 - anteromedial surface; 11 - medial edge of the humerus; 12 - coronoid fossa; 13 - medial epicondyle; 14 - block of the humerus; 15 - head of the condyle of the humerus; 16 - lateral epicondyle; 17 - radial fossa; 18 - anterolateral surface.

B. 1 - head of the humerus; 2 - anatomical neck; 3 - greater tubercle; 4 - surgical neck of the humerus; 5 - deltoid tuberosity; 6 - groove of the radial nerve; 7 - lateral edge of the humerus; 8 - fossa of the olecranon process; 9 - lateral epicondyle of the humerus; 10 - block of the humerus; 11 - groove of the ulnar nerve; 12 - medial epicondyle of the humerus; 13 - medial edge of the humerus.

A common injury among fractures of the proximal end of the humerus is surgical neck fractures.

They make up 32-37% of all fractures of the humerus and are observed in people of older age groups, due to anatomical features.

The surgical neck is the zone of the metaphysis of the humerus, the place of transition of the diaphysis into the epiphysis.

In this area, the cortical layer becomes significantly thinner. Bone has a spongy structure. In addition, in older people, involutive degenerative-dystrophic processes and osteoporosis progress, which cause a significant decrease in bone strength.

The mechanism of surgical neck fractures is predominantly indirect. Fractures most often occur as a result of a fall on an abducted or adducted arm.

The mechanical force acting along the axis of the shoulder is concentrated under the head, that is, in the region of the metaphysis, with which it rests against the edge of the articular surface of the scapula.

Two types of fracture occur. If a person falls on an adducted shoulder, actuators occur, adduction fractures, and in case of a fall on an abducted hand - retractable, abduction.

Classification

Surgical neck fractures are:

• no offset;
• driven in;
• with displacement of fragments;
• fracture-dislocations.

Symptoms

Pain appears in the shoulder joint, and arm function is lost. The injured arm is bent at the elbow joint and pressed to the body with the healthy arm, the body is tilted towards the injured arm.

The shoulder appears shortened, there is swelling in the upper third, hemorrhage along the anterior-inner surface. With the above adduction fractures, the distal fragment is displaced outward and a deformation of the shoulder occurs in the upper third with an angle open inwards and backwards, the axis of the shoulder is deviated outward.

On palpation, the intensity of pain is at the height of the deformity; it is aggravated when pressing along the axis of the shoulder. Passive movements are limited, exacerbating pain. It turns out there is pathological mobility in the upper third of the shoulder.

Symptoms of abduction, abduction, and surgical neck fractures of the humerus

Shoulder pain, dysfunction, swelling and hemorrhage along the anterior-inner surface of the shoulder, in the upper third there is deformation with an angle open outward and back, as a result of displacement of the distal fragment inward, pathological mobility in the upper third of the shoulder. The axis of the shoulder is shifted inward.

For non-displaced fractures

The shoulder axis is not disturbed. Noteworthy is swelling in the upper third of the shoulder, hemorrhage along the anteromedial surface, significant local pain on palpation, aggravated by pressure along the axis of the shoulder. With impacted fragments, limited active movements of the hand are possible.

Certain diagnostic difficulties arise when differentiating bruises of the shoulder joint and non-displaced surgical neck fractures.

For bruises

A slight limitation of active movements in the shoulder joint is noted; diffuse pain and hemorrhage are localized directly in the area of ​​action of the traumatic factor.

Whereas in non-displaced surgical neck fractures, pain is localized along the perimeter of the humerus, and hemorrhage appears along the anteromedial surface of the upper and middle third of the shoulder.

In the case of a bruise, there is no pain with axial loads on the humerus, and in case of non-displaced surgical neck fractures or impacted fractures, this symptom is always positive.

For fractures of the head and anatomical neck of the humerus

As a rule, hemarthrosis, displacement of the shoulder axis, deformation and pathological mobility occur.

With fractures of the surgical neck, there is no hemarthrosis; typical deformities occur in the upper third of the shoulder with a displacement of the shoulder axis, and there is pathological mobility.

For traumatic shoulder dislocations

There is an epaulette-type deformation of the shoulder joint, a fixed corresponding position of the shoulder - the victim seems to be carrying the injured arm - a positive pathognomonic symptom for dislocations - elastic mobility.

Traumatic dislocations are observed more often in young people, while surgical neck fractures occur more often in older and elderly people.

X-ray examination in two projections allows you to establish an accurate diagnosis.

Urgent Care

It consists of anesthesia (1.0 g of a 2% promedol solution is injected under the skin), transport immobilization (metal ladder splints or a scarf bandage).

Treatment

Non-displaced and impacted fractures

They are treated conservatively. A posterior plaster splint is applied from the edge of the opposite scapula to the wrist joint, and the hand is placed on a wedge-shaped pillow for a period of 3 weeks.

After the immobilization is removed, rehabilitation is prescribed. Working capacity is restored after 1-2 months for people doing non-physical work and after 2.5-3 months for people doing physical work.

With offset

Closed simultaneous comparison of fragments with subsequent immobilization of the limb with a plaster splint and its placement on a wedge-shaped pillow or abductor splints from TSITO, Vinogradov is shown.

Method of closed reduction of drive (adduction) fractures of the surgical neck of the humerus:

Anesthesia is carried out with 30-40 cubic cm of 1% novocaine solution, which is injected into the hematoma. After 3-5 minutes, pain relief occurs. The victim sits on a chair with the back resting. For weakened victims and children, reposition is carried out in a supine position.

The assistant folds the towel in half or three times (depending on the width of the towel) and stands behind the victim. Then he takes a folded towel or a special flannel belt and moves it across the front surface of the shoulder joint, grabs both ends, tightens and fixes the shoulder joint.

The surgeon stands in front of the victim, with one hand grabs the victim’s forearm and bends the arm at the elbow joint, and with the other - the shoulder above the elbow joint and slowly, without jerking with increasing force, carries out traction along the axis of the shoulder and gradually performs anterior deviation with retraction, depending on the displacement of the fragments , 40-60° from the midline of the body.

In this position, the fragments are compared.

For abduction fractures

After eliminating the contraction along the length, the shoulder is transferred to a position of anterior deviation at an angle of 40° and brought to the midline of the body so that the deformity is completely eliminated and the axis of the shoulder is restored. In this position, immobilization is carried out with a plaster splint or abductor splints from CITO, Vinogradov.

In cases where immediate comparison of fragments is contraindicated for victims (shock, concussion, etc.), skeletal traction of the olecranon is used.

Surgical intervention

If it is impossible to achieve reposition using the closed method or skeletal traction, surgical treatment is indicated. As noted by K.M. Klimov (back in 1949), One of the reasons for the failure of repositioning of fragments is interposition of the tendon of the long head of the biceps brachii muscle.

Open reduction is performed under general anesthesia or conduction anesthesia.

The Mezoniev-Boden or Chaklin approaches are used to dissect the skin and subcutaneous fat. Hemostasis is performed. The main vein is mobilized and pulled medially with a blunt hook.

Next, the gap between the deltoid and pectoralis major muscles is bluntly separated, the deltoid muscle is pulled outward with wide hooks, and the pectoralis major muscle is pulled inward and go to the fracture site. Blood clots are removed from the fracture planes of the proximal fragment and the proximal end of the distal fragment.

The latter is grabbed with a single-pronged hook, brought out into the wound, and open comparison of fragments and osteosynthesis with a plate, screw or knitting needles are performed. The wound is sutured in layers and a deep posterior plaster splint is applied to the limb from the edge of the opposite scapula to the wrist joint. The hand is placed on a wedge-shaped pillow.

When a fracture of the surgical neck is combined with a fracture of the greater tubercle, then after comparison and synthesis the latter is sutured to the humerus transosseously with silk or nylon threads.

The shoulder refers to the long tubular bones of humans. The anatomy is simple and is determined by a number of functions performed. On its surface there are anatomical formations, such as the head, medial condyle, as well as tubercles and pits, which serve as attachment points for muscles and ligaments. The humerus functions as a lever. Fractures are very dangerous, because due to damage to the bone marrow canal, a fat embolism can develop or a vessel may become blocked.

Most often, the shoulder suffers as a result of fractures in the area of ​​the anatomical neck.

Structure and anatomy

At the top of the bone there is a round formation - the head, which is an integral part of the joint. It is separated from the rest of the bone by a narrow groove. It is called the anatomical neck. It is in this part that fractures most often occur. Behind it is the place of attachment of the main muscles of the shoulder, represented by two tubercles - large and small, as well as ridges. The lesser tubercle is located in front of the shoulder. There is a tuberosity in the middle of the bone. This is where the deltoid muscle attaches. On the side of the elbow, the humerus ends with 2 epicondyles, between which there is an articular surface. The medial condyle is much larger than the lateral one. There are also 2 recesses located here - the olecranon process or ulnar fossa and the radial one.

Functions of the humerus

The shoulder structure is actually a lever and increases the range of motion of the upper limb. In addition, the bone is involved in maintaining balance when the center of gravity shifts while walking. This element determines the correct support of a person on his hands when climbing stairs and in other specific body positions.

Damage: causes and symptoms

Dislocation of the shoulder and elbow joint is common and is associated with high mobility of the upper limb. There are anterior, posterior and inferior displacement. If damaged, it becomes difficult to move the limb, pain is felt, and swelling is visualized. When a nerve is pinched, the skin becomes numb. Dislocations are distinguished as new and old. At the same time, a protrusion of the greater tubercle or a fracture of the neck may occur. The shoulder is swollen, painful, there is noticeable hemorrhage, sensitivity in the arm and fingers is lost.

A fracture of the humerus occurs due to significant force. This happens when you fall backward on your elbows or forward on your outstretched arms. Bone fracture occurs in anatomically weak areas. These include:

• anatomical and surgical neck;
• condyle area;
• area of ​​the head of the humerus;
• the middle of the bone.

Immediately after the injury, the patient feels a sharp pain in the arm, as well as the inability to perform actions with it. The exact amount of movement lost depends on the immediate location of the injury. After some time, severe swelling of the shoulder is observed, and bruising and bruising may develop. In this case, the limb is significantly deformed.

Diseases

A common disease is the introduction of infection into the bone marrow through the blood. Damage to the shoulder occurs because this bone is tubular and has an abundant blood supply. As a result of the development of this disease, bone tissue can decompose, and then pathological fractures form (without the participation of strong external influences). In addition, arthritis of the shoulder and elbow joints may develop.