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Fracture of the surgical neck of the humerus: causes, symptoms, diagnosis, treatment
Last reviewed: 05.07.2025
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[ What causes a fracture of the surgical neck of the humerus?
A fracture of the surgical neck of the humerus occurs mainly due to indirect violence, but is also possible with a direct mechanism of injury.
Depending on the mechanism of injury and displacement of fragments, adduction and abduction fractures are distinguished.
An adduction fracture is the result of a fall on a bent and adducted arm at the elbow joint. The elbow joint bears the brunt of the force. Due to the mobility of the lower ribs, the distal end of the humerus performs maximum adduction. The true ribs (especially the protruding V-VII) are connected to the sternum and are not so flexible, which creates a fulcrum at the border of the upper third of the humerus. A lever is created, the continuation of the load on the long arm of which should dislocate the head of the humerus outward. A powerful capsular apparatus prevents this, resulting in a fracture in a weak spot of the bone - at the level of the surgical neck.
The central fragment is displaced outward and forward, rotated outward due to the mechanism of injury and traction of the supraspinatus, infraspinatus and teres minor muscles. The peripheral fragment, as a result of the mechanism of injury, deviates outward and is displaced upward under the action of the deltoid, biceps and other muscles thrown across the joint. An angle open inward is formed between the fragments.
An abduction fracture occurs when a person falls on an abducted arm. It would seem that with the same fracture level and the same muscles acting, the displacement of fragments in adduction and abduction fractures should be the same. But the mechanism of injury makes its own adjustments. The simultaneous action of forces in two directions leads to the peripheral fragment being displaced inward and its outer edge turning the central fragment towards adduction. As a result, the central fragment deviates slightly forward and downward. The peripheral fragment, located inward from it, forms an angle open outward.
Symptoms of a fracture of the surgical neck of the humerus
Complaints of pain and dysfunction in the shoulder joint. The victim supports the broken arm under the elbow.
Diagnosis of fracture of the surgical neck of the humerus
Anamnesis
The anamnesis shows a characteristic injury.
Inspection and physical examination
Externally, the shoulder joint is not changed. In abduction fractures with displacement of fragments, a depression is formed at the site of the angular deformation, simulating a shoulder dislocation. Palpation reveals pain at the site of the fracture; sometimes bone fragments can be felt in thin people.
Active movements in the shoulder joint are extremely limited, passive ones are possible, but are extremely painful. A positive symptom of axial load is noted. Rotational movements of the humerus are performed in isolation from its head. To determine this, the surgeon places the fingers of one hand on the large tubercle of the shoulder of the patient's injured limb, and with the other hand, grasping the elbow joint, makes light rotational movements. Rotation of the shoulder is not transmitted to the head, but is performed at the site of the fracture.
When examining patients with fractures of the surgical neck of the humerus, one must not forget about the axillary nerve, the branches of which run along the posterior surface of the humerus in this area. Their damage most often leads to paresis of the deltoid muscle and loss of skin sensitivity along the outer surface of the upper third of the shoulder, and this leads to drooping of the limb, overstretching of muscles and nerve endings, secondary paresis, subluxation of the humeral head.
Laboratory and instrumental studies
To clarify the diagnosis and determine the nature of the displacement of fragments, radiography is performed in direct and axial projections.
Conservative treatment of fracture of the surgical neck of the humerus
Patients with impacted fractures of the surgical neck of the humerus are treated on an outpatient basis. Such a diagnosis can only be made after radiography in two projections. It is difficult to judge the displacement from a direct projection image, since the fragments, going one after another in the frontal plane, create the illusion of an impacted fracture. In the axial projection, the displacement of the fragments in width and length will be clearly visible.
20-30 ml of 1% procaine solution is injected into the hematoma of the fracture site, after first finding out whether the patient can tolerate it. For elderly and senile people, the dose of the administered substance should be reduced to avoid intoxication, which manifests itself as a state of intoxication: euphoria, dizziness, pale skin, unsteadiness of gait, nausea, possibly vomiting, decreased blood pressure. In cases of intoxication, the patient should be given caffeine-sodium benzoate subcutaneously: 1-2 ml of a 10-20% solution.
After anesthesia of the fracture site, the limb is immobilized with a plaster splint according to G. I. Turner (from the healthy shoulder to the heads of the metacarpal bones of the injured hand). A bolster or wedge-shaped pillow is placed in the armpit to give the limb some abduction. In the adduction position, the limb cannot be immobilized due to the risk of developing stiffness in the shoulder joint. Abduction of the shoulder by 30-50° opens the Riedel's pocket (axillary inversion of the shoulder joint), prevents its fusion and obliteration, which serves as a prevention of contractures. In addition to abduction, the shoulder is tilted forward, approximately 30°, the elbow joint is flexed at an angle of 90°, the wrist is extended by 30°. Permanent immobilization lasts 3-4 weeks.
Analgesics, UHF, static exercise therapy for the immobilized limb and active exercises for the hand are prescribed. After 3-4 weeks, the splint is made removable and therapeutic exercises for the shoulder and elbow joints are started. Phonophoresis and electrophoresis of procaine, calcium compounds, phosphorus, and vitamins are prescribed for the shoulder area. Fixation of the limb with a removable plaster splint lasts another 3 weeks. The total immobilization period is 6 weeks.
After this period, restorative treatment begins: DDT, ozokerite or paraffin application, ultrasound, rhythmic galvanization of the shoulder and supraclavicular muscles, massage of these same areas, laser therapy, exercise therapy and mechanotherapy for the joints of the upper limb, hydrotherapy (baths, pool with exercise therapy in water), ultraviolet irradiation.
It should not be assumed that all physical factors can be used simultaneously. It is rational to prescribe one or two physiotherapy procedures in combination with therapeutic gymnastics. For people over 50 years of age and those with concomitant diseases, treatment is carried out under the control of blood pressure, electrocardiography, the general condition of the patient and subjective sensations, carried out by an outpatient or family doctor.
Working capacity is restored within 6-8 weeks.
Treatment of fractures of the surgical neck of the humerus with displacement of fragments is carried out in a hospital setting. Most often it is conservative and consists of closed manual repositioning, performed in compliance with the basic rules of traumatology:
- the peripheral fragment is placed on the central one;
- repositioning is performed in the opposite direction to the mechanism of injury and displacement of fragments.
Anesthesia is local (20-30 ml of 1% procaine solution at the fracture site) or general. The patient is positioned on his back. A rolled-up sheet is passed through the armpit, the ends of which are brought together above the healthy shoulder. One of the assistants uses them to provide countertraction. The second assistant grasps the lower third of the shoulder and forearm of the victim. The surgeon performs manipulations directly in the fracture zone and coordinates the actions of the entire team involved in the repositioning. The first stage is traction along the axis of the limb (without jerking or rough force) for 5-10 minutes until the muscles relax. Further stages depend on the type of fracture. S a c a fractures of the surgical neck are divided into abduction and adduction, and the displacement of fragments in them can be different, it should be remembered that the directions of movement of the fragments being repositioned will be different.
Thus, in an abduction fracture, the fragments are aligned by traction of the limb along the axis forward and subsequent adduction of the segment located below the fracture. The surgeon rests his thumbs on the central fragment from the outside, and with the rest of his fingers grasps the upper part of the peripheral fragment and shifts it outward. A bean-shaped roller is placed in the armpit. The limb is fixed with a plaster splint according to G.I. Turner.
In case of adduction fracture after axial traction the limb is abducted outward, forward and rotated outward. The axial traction is relaxed, after the fragments have wedged the shoulder is carefully rotated inward. The limb is placed in the position of shoulder abduction outward and forward, respectively, by 70° and 30°, flexed at the elbow joint by 90-100°, the forearm is in the middle position between supination and pronation, the wrist joint is abducted by 30° of dorsal extension. Fixation is performed with a plaster thoracobrachial bandage or abduction splint. A positive result of repositioning must be confirmed by an X-ray.
The period of immobilization for fractures of the surgical neck of the humerus after manual repositioning is 6-8 weeks, of which the plaster cast should be permanent for 5-6 weeks, then removable for 1-2 weeks. Working capacity is restored after 7-10 weeks.
In cases where the fragments have an oblique fracture line and are easily displaced after alignment, the method of skeletal traction for the olecranon on the CITO splint was previously used. Currently, the method is practically not in demand due to the bulkiness of the structure, the impossibility of use in elderly people and the availability of more radical and accessible interventions. Sometimes it is used as a gentle method of staged repositioning.
In elderly people, the functional method of treatment according to Dreving-Gorinevskaya is used in hospital conditions, which the patient is taught for 3-5 days, then the classes are continued on an outpatient basis. The method is designed for self-regulation of fragments due to muscle relaxation under the influence of the mass of the limb and early movements.
Surgical treatment of fracture of the surgical neck of the humerus
Surgical treatment of fractures of the surgical neck of the humerus consists of open reposition and fixation of fragments using one of many methods.
An original fixator with thermomechanical memory was proposed by scientists from the Siberian Physics and Technology Institute named after V.D. Kuznetsov and the Novokuznetsk State Institute of Advanced Medical Studies. The fixator is made of special alloys in the form of curved structures that not only hold the fragments, but also bring them together. Holes are drilled in the fragments. Then, after cooling the fixator with ethyl chloride, its parts are given a shape convenient for insertion into the prepared holes. After heating in the tissues to 37 ° C, the metal takes its original shape, fastening and compensating the fragments. Osteosynthesis can be so stable that it allows for doing without external immobilization.
In other cases, a plaster thoracobrachial bandage is applied after the operation. It should be noted that a plaster bandage is acceptable for young people. Since fractures of the surgical neck of the humerus are more common in older people, the method of fixation for them is a snake bandage and a wedge-shaped pad in the armpit. The terms of immobilization and restoration of working capacity are the same as for fractures with displacement of fragments. Metal fixators are removed 3-4 months after the operation, after making sure that the fragments have fused.
Transosseous osteosynthesis according to G. A. Ilizarov and external fixation devices of other authors has not found wide application for the treatment of patients with fractures of the surgical neck of the humerus. It is used only by individual enthusiasts.