Fracture of the surgical neck of the humerus: causes, symptoms, diagnosis, treatment

Fracture of the surgical neck of the humerus is very common, especially in the elderly.

This fracture is half of all fractures of the humerus.

[1], [2], [3]

What causes a fracture of the surgical neck of the humerus?

There is a fracture of the surgical neck of the humerus, mainly from indirect violence, but is possible with the direct mechanism of injury.

Depending on the mechanism of injury and displacement of fragments, there are differentiation between adduction and abduction fractures.

Adduction fracture is the result of falling on the arm bent and brought into the elbow joint. On the elbow joint is the main action of force. Due to the mobility of the lower ribs, the distal end of the shoulder performs the maximum reduction. The true ribs (especially the standing V-VII) are connected to the sternum and are not so flexible that it creates a fulcrum on the border of the upper third of the shoulder. A lever arises, the continuation of the load on the long shoulder of which should dislocate the head of the shoulder from the outside. A powerful capsular device prevents this, resulting in a fracture in the weak point of the bone - at the level of the surgical neck.

The central fragment is shifted to the outside and to the front, rotated outward due to the mechanism of trauma and traction of the supraspinous, subacute and small round muscles. Peripheral fragment as a result of the mechanism of damage deviates outward and shifts upward under the action of deltoid, biceps and other muscles that are thrown through the joint. Between the fragments an angle is formed that is open to the inside.

Abduction fracture occurs when falling on the assigned arm. It would seem that at a single level of fracture and the action of the same muscles, the displacement of fragments during adduction and abduction fractures should be the same. But the mechanism of injury makes its own adjustments. Simultaneous action of forces in two directions leads to the fact that the peripheral fragment is displaced to the inside and turns its central edge towards the side by its outer edge. As a result, the central fragment somewhat deviates anteriorly and downwards. The peripheral, located inward from it, forms an angle that is open to the outside.

Symptoms of a fracture of the surgical neck of the humerus

Complaints of pain and impaired function in the shoulder joint. The victim supports a broken arm under his elbow.

Diagnosis of fracture of the surgical neck of the humerus

Anamnesis

In the history - a characteristic trauma.

Examination and physical examination

Externally, the shoulder joint is not changed. With abduction fractures with a displacement of fragments, a westing occurs in the place of an angular deformation, simulating a shoulder dislocation. With palpation, pain is identified in the fracture site, and sometimes bone fragments can be felt in thin people.

Active movements in the shoulder joint are extremely limited, passive are possible, but sharply painful. Mark a positive symptom of the axial load. Rotational movements of the humerus are performed in isolation from its head. To determine this, the surgeon puts his fingers of one hand on the large bump of the shoulder of the injured limb of the patient, and the second hand, seizing the elbow joint, produces light rotational movements. The rotation of the shoulder is not transmitted to the head, but takes place at the site of the fracture.

When examining patients with fractures of the surgical neck of the shoulder, one should not forget about the axillary nerve, the branches of which pass along the posterior surface of the humerus in this zone. Their injuries most often lead to the paresis of the deltoid muscle and the loss of skin sensitivity along the outer surface of the upper third of the shoulder, and this leads to the hanging of the limb, overstretching of the muscles and nerve endings, secondary paresis, subluxation of the head of the shoulder.

Laboratory and instrumental research

To clarify the diagnosis and determine the nature of the displacement of fragments, X-rays are performed in a straight and axial projection.

Conservative treatment of a fracture of the surgical neck of the humerus

Patients with punctured fractures of the surgical neck of the shoulder are treated on an outpatient basis. Such a diagnosis can be made only after X-ray in two projections. According to the picture in a direct projection, it is difficult to judge the displacement, since the fragments, entering one after another in the frontal plane, create the illusion of a punctured fracture. In the axial projection, the displacement of fragments along the width and length will be clearly seen.

In the hematoma of the fracture, 20-30 ml of a 1% solution of procaine is injected, having first ascertained whether the patient is suffering from it. For elderly and elderly people, the dose of the injected substance should be reduced to avoid intoxication, which is manifested by the state of intoxication: euphoria, dizziness, pale skin, gait unsteadiness, nausea, vomiting, lowering of blood pressure. In cases of development of intoxication, the patient should subcutaneously inject sodium caffeine-benzonate: 1-2 ml of 10-20% solution.

After the anesthesia of the fracture site, the limb is immobilized with a gypsum longus by GI Turner (from a healthy shoulder-strap to the heads of the metacarpal bones of the injured arm). In the axillary cavity a roller or a wedge-shaped pillow is placed to give the limb some lead. In the position of reduction immobilize the limb is impossible due to the threat of development of stiffness in the shoulder joint. Leaching of the shoulder at 30-50 ° reveals Riedel's pocket (axillary ovorot of the shoulder joint), prevents its adhesion and obliteration, which serves as the prevention of contractures. In addition to the lead, the shoulder is deflected anteriorly, approximately 30 °, the elbow joint is bent at an angle of 90 °, the wrist joint is bent 30 °. Permanent immobilization lasts 3-4 weeks.

Assign analgesics, UHF, static type of exercise for the immobilized limb and active exercises for the brush. After 3-4 weeks, the longe is made detachable and proceeds to therapeutic exercises for the shoulder and elbow joints. On the shoulder area appoint phono and electrophoresis procaine, compounds of calcium, phosphorus, vitamins. Fixation of the limb with a removable gypsum lintage lasts another 3 weeks. The total period of immobilization is 6 weeks.

After this period, they begin rehabilitative treatment: DDT, ozocerite or paraffin application, ultrasound, rhythmic galvanization of the shoulder and forehead muscles, massage of the same areas, laser therapy, exercise therapy and mechanotherapy for upper limb joints, hydrotherapy (baths, pool with LFK in water) , ultraviolet irradiation.

Do not assume that all physical factors can be applied simultaneously. It is rational to prescribe one or two physiotherapy procedures in combination with curative gymnastics. Persons over 50 years of age and having concomitant diseases are treated under the control of arterial pressure, electrocardiography, the general condition of the patient and subjective sensations performed by an outpatient or family doctor.

Workability is restored in 6-8 weeks.

Treatment of fractures of the surgical neck of the shoulder with displacement of the fragments is carried out in a hospital. Most often it is conservative and consists of a closed manual reposition performed in compliance with the basic rules of trauma:

• peripheral fragment is placed along the central;
• Reposition is performed back to the mechanism of injury and displacement of fragments.

Local anesthesia (20-30 ml of 1% solution of procaine at the site of fracture) or general. The patient's position is lying on his back. Through the armpit, a folded sheet is passed, the ends of which are folded over a healthy shoulder-blade. For them one of the assistants carries out a counter-force. The second assistant grabs the lower third of the shoulder and the forearm of the victim. The surgeon makes manipulations directly in the fracture zone and coordinates the actions of the entire brigade participating in the reposition. The first stage is traction along the limb axis (without jerks and rough efforts) for 5-10 min before muscle relaxation. The further stages depend on the type of fracture. As the fractures of the surgical neck are divided into abduction and adduction ones, and the displacement of fragments with them are different, it should be remembered that the directions of displacement of the reponant fragments will be different.

Thus, in the case of an abduction fracture, the fragments are compared by limb traction along the anterior axis and the subsequent reduction of the segment located below the fracture. The surgeon with the thumbs on the outside rests against the central fragment, and the rest covers the upper part of the peripheral fragments and shifts it to the outside. A bean-shaped bead is placed in the armpit. The limb is fixed with a gypsum longus by G.I. Turner.

In the case of an adduction fracture, after traction along the axis, the limb is removed from the outside, anteriorly and rotated outwards. Weaken traction along the axis, after cleavage of fragments, the shoulder gently rotates to the inside. The limb is placed in the outward position of the shoulder outside and anteriorly, respectively at 70 ° and 30 °, bent at the elbow joint by 90-100 °, the forearm is in the middle position between the supination and pronation, the wrist joint is withdrawn by 30 ° of the rear extension. Fixation is performed with a gypsum thoracobrachial bandage or a discharge line. Positive result of the reposition must be confirmed by an X-ray.

The period of immobilization at fractures of the surgical neck of the shoulder after manual repositioning is 6-8 weeks, of which within 5-6 weeks the plaster bandage should be constant, then 1-2 weeks - removable. Workability is restored after 7-10 weeks.

In those cases where the fragments have an oblique fracture line and are easily displaced after comparison, the method of skeletal traction for the elbow process on the TSITO tire was previously used. Currently, the method is almost not in demand due to the unwieldiness of the structure, the inability to use it in the elderly and the availability of more radical and accessible interventions. Sometimes they are used as a sparing method of step-by-step repositioning.

In elderly people, the functional method of treatment according to Dreving-Gorinevskaya is applied in a stationary setting, which is taught to the patient for 3-5 days, then the classes continue to be outpatient. 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 a fracture of the surgical neck of the humerus

Surgical treatment of fractures of the surgical neck of the shoulder consists in an open reposition and fixation of fragments by one of many methods.

The original fixator with thermomechanical memory was offered by scientists of the Siberian Physico-Technical Institute named after VD. Kuznetsov and Novokuznetsk GIDUV. A fixator is made of special alloys in the form of curved structures that not only hold the fragments, but also bring them closer together. In the fragments, holes are drilled. Then, cooling the fixer with chloroethyl, give its parts a shape that is convenient for insertion into the prepared holes. Heating in the tissues to 37 ° C, the metal takes its original form, securing and compensating for the fragments. Osteosynthesis is so stable that it allows you to do without external immobilization.

In other cases, after surgery, a gypsum thoracobrachial bandage is applied. It should be noted that the plaster bandage is acceptable in young people. Since fractures of the surgical neck of the shoulder are more common in older people, the fixation method for them becomes a snake bandage and a wedge-shaped cushion in the armpit. The terms of immobilization and restoration of work capacity are the same as for fractures with a displacement of fragments. Metal fixators are removed 3-4 months after the operation, after making sure that the fracture has cleaved.

Transosseous osteosynthesis according to GA Ilizarov and external fixation devices of other authors has not found wide distribution for the treatment of patients with fractures of the surgical neck of the shoulder. It is used only by individual enthusiasts.

[4], [5], [6], [7],