Fractures of the body of the humerus: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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ICD-10 code
S42.3. Fracture of the body [diaphysis] of the humerus.
[What causes a fracture of the humerus body?
The mechanism of injury can be direct and indirect. In the first case - a blow on the shoulder or shoulder on a solid object, in the second - a fall on the wrist or elbow joint of the withdrawn hand, excessive rotation of the axis.
Symptoms of a fracture of the body of the humerus
Symptoms are identical to any fracture of a long tubular bone: pain, impaired function.
Anamnesis
In the history - an indication of an appropriate injury.
Examination and physical examination
The deformity and shortening of the limb, pathological mobility, crepitation, decrease in the sound conductivity of the bone, a positive symptom of the axial load are characteristic.
Injuries of the shoulder can be accompanied by damage to the neuromuscular bundle, most often with fractures of the diaphysis of the humerus, the radial nerve suffers. Therefore, it is necessary to check skin sensitivity and motor function in the zone of innervation of the radial, ulnar and median nerves.
Laboratory and instrumental research
To clarify the shape of the fracture, the presence of fragments, the degree of displacement of fragments, it is necessary to perform a chest x-ray in two projections.
In fractures of the diaphysis of the shoulder, depending on the level of damage, three types of typical dislocations of fragments are distinguished.
- The first type. The fracture line passes above the place of attachment of the large pectoral muscle. Due to the shortening of the supragastric, subacute and small circular muscles attached to the large tubercle, the central fragment occupies the position of the outward and anterior retraction and is rotated outward. The peripheral fragment is brought to the inside by the force of the large pectoral muscle, pulled upward and under the action of the two-headed and three-headed muscles of the shoulder rotated to the inside (with the elbow elbow) under the influence of the physiological position of the limb - pronation.
- The second type. The fracture line passes below the attachment of the large pectoral muscle, but above the deltoid (middle third of the shoulder). The central fragment of the force of the large pectoral muscle is reduced and moderately rotated to the inside.
- The peripheral fragment is moderately withdrawn to the outside and pulled up due to the contraction of the deltoid muscle and the entire muscular cuff of the shoulder.
- The third type. The fracture line passes below the attachment of the deltoid muscle, which exerts maximum influence on the central fragment, taking it outward and anteriorly. Peripheral fragment is pulled upward as a result of contraction of the muscular cuff of the shoulder.
Treatment of fracture of the humerus body
There are conservative and operative methods of treatment, for each of which there are indications.
Indications for hospitalization
Treatment of diaphyseal fractures of the shoulder is performed in a hospital.
Conservative treatment of fracture of the humerus body
In fractures without displacement of fragments, treatment consists in anesthetizing the fracture site with a 1% procaine solution and applying a gypsum thoracobrachial bandage in a functionally advantageous position. On the 3rd day, UHF, LFK for fingers and wrist joints are prescribed. In the future, medical and physical therapy is conducted, aimed at creating optimal conditions for regeneration. The terms of permanent immobilization are 6-8 weeks, intermittent - 2-3 weeks. After the removal of immobilization, X-ray control is carried out and complex recovery treatment is started. Work is allowed after 9-11 weeks.
In fractures with displacement of fragments, there are two ways of conservative treatment: one-stage reposition and stretching.
Closed, one-stage manual repositioning is performed in those cases where the fracture line is located closer to the metaphysis, has a cross section and there is a guarantee that after the fragments are matched their secondary displacement will not occur. Manipulation is performed under local or general anesthesia, taking into account the displacement of fragments and observance of the basic laws of reposition. The correlated fragments are fixed with a gypsum thoracobrachial bandage, further tactics do not differ from the treatment of patients with fractures of the humerus without displacement of the fragments.
Extension is shown in oblique and helical fractures of the humerus, when the fragments are easily compared, but they are just as easily displaced when the reponant force ceases. The stretching can be skeleton, glue and according to the Caldwell-Ilyin method.
- In case of skeletal traction, the spinal cord is guided through the elbow process perpendicular to its long axis and fixed in a cramp. The limb is laid on the outgoing tire. The cord is attached to the bracket, transferred through the busbar and fixed to a spring or rubber rod, creating a tension force of 3-4 kg. Skeletal traction continues for 3-4 weeks (before the formation of primary, soft calluses), then a gypsum thoracobrachial bandage is applied until the end of the consolidation period.
- Adhesive stretching is used when it is impossible to hold the needle for any reason.
- The Caldwell-Ilyin method has the same indications as the previous two, but it is preferable in persons with injuries or diseases of the chest, respiratory and circulatory organs, since it does not imply the imposition of bulky diverting trunks of gypsum thoracobrachial bandages. The method should be included in the section of disaster medicine as an element of treatment for polytrauma. Apply a circular gypsum bandage from the shoulder joint to the heads of the metacarpal bones with the grafted wire rings in the region of the elbow and the radial surface of the wrist. In the axillary region, put a cotton-gauze roll to give the limb a 30-40 ° lead. The method is based on constant traction.
Permanent immobilization for fractures of the humerus body with a displacement of fragments lasts 8-10 weeks, removable - 4 weeks.
The ability to work is restored in 12-14 weeks.
Surgical treatment of fracture of the humerus body
Surgical treatment of patients with fractures of the diaphysis of the humerus is indicated with damage to the neurovascular bundle, the interposition of soft tissues, open, comminuted or segmental fractures with uncontrolled fragments. The latter include bone fragments that are devoid of points of attachment of muscles.
Operative treatment consists in an open reposition and fixation of fragments by one of the methods: intraosseous, ostal, combined, extra-focal.
Dissect soft tissue, exposing the site of the fracture. The nail is punched into the central fragment until it emerges under the skin above the large tubercle. The skin above the superior end is cut, and the nail is completely driven into the central segment, leaving 0.5-1 cm. The fragments are correlated and retrograde, the nail is pierced from the top downward into the peripheral fragment.
The pin can be inserted into the humerus from other points: from additional incisions in the region of the large tubercle or from the ulnar fossa over the elbow, where the bone is obliquely and parallel to the longitudinal axis drilled before the communication with the medullary canal. Through these holes, after repositioning, a metal nail is pierced, which, while passing along the medullary canals of both fragments, tightly binds them.
In recent years, traumatological hospitals with appropriate equipment use closed intramedullary osteosynthesis of the shoulder in a static or dynamic version. The stem in the bone can be placed from the proximal or distal end.
If they start from the proximal end, a 2-3 cm incision is made, exposing a large tubercle, and a few medial opening of the medullary canal with a cannulated awl along the previously introduced Kirschner's needle to a depth of 6 cm. After preparing the channel (bloom, etc.), the rod is fixed in guide, set the target and injected into the medullary canal with the help of a pusher. Place the distal and then the proximal locking screws (or screw). Detach the rod from the guide. Install a compression or blind screw. Immobilization is not needed.
Cumulative fixation of fragments is carried out with the help of cercles and all kinds of plates. Cerclages are acceptable in oblique and helical fractures with the direction of the fracture line at an acute angle and a large contact area of the fragments. However, this method is not widely used because of the creation of circular "beavers" and bone trophism disorders. Plates are best used in transverse fractures in places with a flat surface, which allows to create a close contact of the fixator and bone.
The technique of binding fragments of a plate is simple: the fragments are compared and fixed by bone support. Overlapping the fracture line, a plate is placed on the bone, holes in the bone are drilled through its holes, and necessarily through both cortical layers. The plate is screwed to the bone, the bone retainers are removed.
Osteosynthesis with plates did not always lead to the desired results, so in the early 50's began a search for their improvement. In the following years self-compression plates of various shapes were developed, with which fragments of any part of the bone can be fixed. There were little-invasive plates, installed from the minimal (length of several centimeters) sections, fastened by screws from point punctures to special guides. Some plates are connected to dynamic screws, they have additional angular stability and completely replaced old plates, beams, cercles, etc. From the use of traumatologists.
Osteosynthesis with modern plates does not require additional external immobilization.
And yet, with fractures with an oblique or spiral long fracture line, multi-lobed and segmental fractures of the shoulder diaphysis, when the surgeon is forced to use more than 6 screws to fix the plate, the threat of operational trauma and complications increases. Therefore, we should agree with surgeons who believe that the use of plates on the shoulder should be in cases where it is impossible to use intramedullary osteosynthesis with external fixation devices. Spinal and core devices of external fixation remain among the most advanced methods of treatment of shoulder fractures.