Treatment of a fracture of the greater tubercle of the humerus. Humeral tubercle fracture

Shoulder tubercle fracture- a common injury that occurs as a result of a strong blow to the shoulder, when falling on a straight or bent limb. Fractures can be either isolated or combined with injuries of the proximal humerus, dislocations of the head of the shoulder.

Pathological damage to the lesser tubercle of the shoulder occurs in only 2% of patients. In other cases, isolated fractures of the large tubercle are diagnosed.

Shoulder tubercle fracture requires immediate professional diagnosis. In the absence of medical treatment or as a result of failure to follow the recommendations and instructions of the doctor The patient has the following complications:

Violation of the process of fusion of fragments as a result of untimely or insufficiently strong fixation of the limb. To restore the functionality of the shoulder joint, doctors resort to surgical method treatment - metal osteosynthesis.
Injury to the biceps (long head of the biceps brachii) by fragments. The motor activity of the limb is impaired, a pronounced pain syndrome, increased inflammation of the muscle fibers.
Progression of ossification of the fibers that attach directly to the tubercle of the shoulder. To eliminate complications, laser therapy or surgical treatment is used.
The development of arthrosis is a disease that affects cartilage tissue.
Lifelong limitation of movement in the joint.

REFERENCE: Metalloostiosynthesis - an operation to connect bone fragments with metal devices.

Origin mechanism

The large and small tubercles are located directly under the neck - in the upper part of the humerus. Microfibres are attached to the tubercles muscle tissue. When the tubercle is fractured, deformation and loss of mobility of the shoulder joint are diagnosed.

main reason fracture - direct blow. When falling on the arm, an excessive contraction of the muscles of the shoulder girdle occurs - a complete separation of the shoulder tubercle and its displacement upwards are diagnosed.

Types of shoulder tubercle injuries:

production- builders, miners, workers at factories fall into the risk group;
sports - a dislocation or fracture occurs when lifting a heavy weight, during wrestling;
household - occurs when falling at home (slipping on a wet floor);
age - diagnosed mainly in older people due to atrophy of the surrounding muscle tissue;
shoulder injury as a result of an accident.

IMPORTANT! In case of dislocation of the shoulder, it is not recommended to self-set the head of the humerus. Wrong actions lead to injury to the tubercle of the shoulder.

There are two groups of tubercle fracture:

fracture of a large tubercle;
fracture of the small tubercle.

The greater tubercle is the most frequently injured anterior dislocation shoulder joint. Specialists distinguish three types of damage to the large tubercle:

fracture with separation without displacement;
displaced avulsion fracture;
contusion.

Fracture of the greater tubercle without displacement determined as a result of a weak impact, which allows the fragment to remain in the box. Most often, a periosteal rupture is diagnosed.

Fracture with displacement- a consequence of a strong blow or fall, as a result of which an active muscle contraction occurred. The appearance of muscle traction contributes to the removal of a fragment of the tubercle up.

Contusion fracture characterized by the formation of numerous fragments and their depression into the head of the shoulder. The fragments are immersed in the bone tissue of the shoulder, which makes it difficult to diagnose by palpation.

Fracture of the greater tubercle occurs closed and open. An open fracture is diagnosed skin, but bone extends beyond the epithelium.

IMPORTANT! With an open contusion fracture, you should immediately contact a traumatologist and begin treatment to reduce the risk of developing purulent inflammation of the bone tissue.

With a fracture of the small tubercle, an intense contraction of the subscapularis muscle occurs. This pathology is associated with with posterior dislocation shoulder or neck injury without displacement.

Symptoms

When the tubercle is fractured, a sharp severe pain is noted, which increases with palpation. Pain is diagnosed with external and internal rotation (rotational movements of the shoulder). On palpation, a specific crunch appears. The joint area swells, as a result of subcutaneous hemorrhage, hematomas appear.

Signs:

External and internal rotation of the shoulder

sharp pain in the shoulder joint;
the occurrence of edema and hematomas;
violation of rotation of the shoulder;
the appearance of a specific crunch when moving;
in the case of an open fracture, a wound occurs, in the bottom of which muscle tissue and damaged bone are visible;
with a fracture with dislocation, an unnatural position of the limb is noted.

With a fracture of the large tubercle, the patient cannot perform circular movements of the shoulder joint outward. If a small tubercle is damaged, there is difficulty in moving the shoulder inwards.

Useful video

In this video, you will learn how to correctly identify a shoulder injury using the rotation test. Recommendations of the manual therapist Anton Epifanov.

Conservative therapy

Conservative treatment is prescribed for a fracture without displacement or if the fragments (as a result of immobilization) are compared. Fracture without displacement the doctor prescribes the use of an orthosis, bandage or scarf to fix the arm. The scarf is removed after 2-3 weeks.

Rules for fixing a limb with a scarf:

bend your arm at a right angle;
abduct the shoulder joint and place a wedge-shaped pillow;
put the limb on the scarf.

The main goal of treating a displaced fracture- approximation of a fragment of the tubercle to the shoulder and fixation of the limb.

The hand should be in this position

By virtue of anatomical structure shoulder joint, it is quite difficult to restore the adaptation of the tubercle with the bed of the humerus and the tendon tension. However, some doctors (to avoid surgery) use technique for approaching the shoulder to the fragment. To do this, the shoulder must be abducted 90°, rotated 60°, and flexed anteriorly 40°. In this position, the fragment of the tubercle is located next to the bed from which it was torn out. The arm is fixed with a splint or plaster cast for 3-4 months. After immobilization of the limb, it is recommended to perform intensive exercises with the fingers and hand.

Operation

Surgery assigned in cases where it is not possible to compare fragments in a closed way. Operational correction also indicated in situations where a fracture of the tubercle is combined with trauma to the neck of the humerus, joint capsule, rupture of the ligaments of the shoulder.

If fragments can be compared, then surgeons fix them with metal plates (metal osteosynthesis). In the case when it is impossible to compare the fragments, they are removed, and the injured tendons are attached to the nearest part of the humerus. The minimum period of limb immobilization is 1 month.

NOTE! Metal structures must be removed no later than half a year after the operation. Otherwise, the patient develops metallosis leading to complete destruction of the bone.

First aid

After a shoulder injury and a specific shooting pain, the patient needs to be given first aid and call medical staff.

Necessary actions:

fix (immobilize) the limb;
attach a cooling bag "Snowball" or ice wrapped in a towel to the shoulder;
give the patient an anesthetic (Nise, Nimesil, Nurofen, Solpadein).

Recovery after a fracture of a large and small tubercle

To shorten the rehabilitation period, accelerate the regeneration of bone and muscle tissue, doctors prescribe procedures that help restore the functionality of the shoulder joint:

therapeutic exercises (LFK);
manual therapy;
use of an orthosis for the shoulder joint;
physiotherapy.

exercise therapy

Doctors are allowed to start active exercises with a fracture of the tubercle of the shoulder without displacement on the 3rd day after the bruise (impact). If a patient has been diagnosed with a displaced fracture or has undergone surgery, then physical therapy can only be done after the joint is released from the plaster or bandage (4–5 weeks after the injury).

To recover from a fracture and dislocation of the shoulder with a detachment of the large tubercle, the patient must perform the following exercises:

moving the arm back and forth like a pendulum;
circular movements;
intense bending of the fingers into a fist;
flexion and extension of the arm in the elbow joint;
alternately raising and lowering the arms and shoulders.

The patient performs these exercises at least 2 times per knock for 6-10 repetitions. The rehabilitation course is 2 weeks.

After the complete disappearance of the pain syndrome, the patient is allowed to exercise in gym. First, the patient performs exercises with the ball (lift the ball up, to the sides). Then - extensor and circular movements, alternately raising and lowering the shoulder with dumbbells of 2 kg. (weight gradually increase).

Video with exercises

From the video you will learn the correct technique for performing exercises aimed at restoring the motor activity of the shoulder joint.

Physiotherapy

Physiotherapy is aimed at normalizing blood circulation in the injured limb, accelerating metabolism, reducing muscle spasm and improving muscle performance.

Physiotherapy:

electromagnet therapy;
applications with ozocerite;
laser therapy;
infrared irradiation;
iontophoresis.

How much sick leave

Approximate terms of temporary disability:

closed fracture without displacement - 35–45 days;
closed fracture with displacement - 55–65 days;
open fracture without displacement - 130–140 days;
closed fracture without displacement - 135-145 days.

Results

A fracture of the large or small tubercle of the shoulder is a dangerous pathology, the untimely treatment of which can lead to to lifelong loss of motor activity of the shoulder joint . To protect yourself from negative consequences, you must follow the following rules:

contact a traumatologist who will prescribe the appropriate treatment;
perform gymnastic exercises aimed at improving the functionality of the shoulder joint;
massage the damaged area using;
take chondroprotectors and which help to accelerate tissue regeneration and enhance immune protection body (relevant for open fractures).

A fracture of the greater tubercle of the humerus is a rather insidious injury. The clinical picture in most cases is mild, the patient may not see a doctor for a long time. Delayed assistance leads to improper fusion of fragments, the development of contractures, the occurrence chronic pain in the joint. Also, the detachment of the large tubercle is often combined with a dislocation of the head of the humerus, which can cause diagnostic errors.

An avulsion fracture of the greater tubercle of the humerus occurs under the action of a direct force (impact) or due to excessive muscle contraction during a fall on an extended or bent limb.

A direct blow to the shoulder, as a rule, leads to severe complications. At the same time, the scapula, collarbone, neck or body of the humerus can be damaged.

When falling on a bent or outstretched arm, a sharp contraction of the muscles of the shoulder girdle occurs. As a result, there is a complete detachment of the large tubercle and its upward displacement. If the traumatic force was small, only the cortical layer of the bone is damaged.

Fractures can be of the following nature:

domestic. Slippery bathroom floors, spilled water, or scattered children's toys are common causes of falls;
sports. During gym classes, heavy lifting or martial arts lessons, the risk of injury is much higher;
industrial. The risk group includes builders, miners, people who work in industries with large moving mechanisms. Failure to comply with safety rules, neglect of means personal protection, lack of helmets or gloves increases the chances of injury;
fractures due to road traffic accidents are the most dangerous.

Note! Fracture of the greater tubercle can occur during attempts to set the head of the humerus in case of dislocation. Therefore, all manipulations should be carried out only by an experienced doctor.

The main types of fractures

The choice of tactics for treating a patient depends on the type of injury, location of fragments, and the general condition of the patient. Depending on the mechanism of damage, the following types of injuries are distinguished:

a fracture of the large tubercle of the humerus without displacement occurs due to a slight blow or fall. Fragment remains on same place, which greatly simplifies the treatment;
a displaced fracture is caused by contraction of the muscles of the shoulder that attach to the greater tuberosity. As a result, the bone fragment moves upward;
impacted injuries have a poor clinical picture. The patient may be disturbed by aching pain in the shoulder for several months. Crepitus, limited mobility are optional symptoms for this fracture. Under the action of great force, the fragment is driven into the humerus, therefore, fragments may not be detected during palpation. An X-ray examination is necessary to confirm the diagnosis.

During the initial examination of the patient, it is necessary to assess the integrity of the skin. The first aid algorithm will depend on this. There are the following types of fractures:

at closed injuries the outcome is more favorable, treatment and rehabilitation, as a rule, take less time;
an open fracture is rare, mainly during an accident. In this case, it is necessary to stop the bleeding, cover the wound with a sterile bandage to prevent infection, and take the victim to the hospital as soon as possible.

Symptoms

Clinically, it is difficult to distinguish a fracture of the tubercle from other injuries of the proximal humerus. To avoid diagnostic errors, all trauma patients should be referred for X-ray examination.

Main complaints:

Pain is a mandatory symptom of a fracture. Unpleasant sensations reach a maximum at the time of injury, then decrease slightly. Any movements, attempts to fix or bend the arm lead to increased pain;
swelling indicates an inflammatory reaction. Due to increased vascular permeability, plasma enters the intercellular space. As a result, the shoulder looks swollen, increases in volume;
when capillaries break, small hemorrhages occur on the skin. If a large vessel is damaged, a hematoma is observed;
the upper limb is slightly bent and brought to the body. In this position, the pain decreases;
on palpation, a kind of crunch (crepitus) may occur due to friction of fragments against each other;
since muscles are attached to the large tubercle, which are responsible for external rotation and abduction of the shoulder, it is these movements that are impossible due to severe pain.

Diagnostic methods

In case of injuries, examination and collection of complaints plays only an auxiliary role. Sometimes it is impossible to distinguish a fracture of the tubercle of the shoulder without displacement from a crack or sprain without an X-ray examination. Therefore, to make a diagnosis, the doctor must receive images of the shoulder in several projections. If the fragment is lyzed, it may not be seen on a conventional radiograph.

Note! The most accurate diagnostic method is computed or magnetic resonance imaging. Using the above methods, the doctor can assess the condition of the ligaments, capsule, muscles or joint space.

First aid

If a person complains about severe pain in the area of the shoulder joint, limitation of movements, it is necessary to call ambulance or take the victim to the emergency room. Before the doctor arrives, it is necessary to monitor the patient's condition, eliminate all life-threatening factors.

First aid includes the following steps:

if the fracture is open, the bleeding must be stopped. In most cases, it is enough to apply a pressure bandage or tourniquet above the injury site. It is recommended to record the time of the manipulation;
to prevent infection from entering the body, you need to wash the wound with antiseptics and apply a sterile bandage;
the upper limb should be fixed in the most comfortable position: the arm is bent at the elbow joint, the hand is brought to the chest. For immobilization, improvised means are used;
to reduce swelling, pain, it is recommended to apply an ice pack to the injury site;
The main complaint of a person with a fracture is pain. To prevent the development of traumatic shock, it is necessary to conduct adequate anesthesia. At home, these can be tablet preparations: Ibuprofen, Nurofen, Ketanov, Nise;
The next step is to wait for the doctor.

An important condition in the provision of first aid is not to harm the victim. Therefore, it is necessary to adhere simple rules:

it is forbidden to set the shoulder joint in its unnatural position;
it is not recommended to change the position of the limbs. If the arm is turned outward, it cannot be returned to its original position. Such manipulation can lead to damage to muscles, ligaments, blood vessels and nerves;
increased pain syndrome is the main sign that first aid was provided incorrectly;
The ice pack must be removed periodically for a few minutes to prevent frostbite.

Treatment

In the hospital, the patient is given adequate anesthesia. To date, the most widely used solution of novocaine. After conducting a sensitivity test, the doctor injects the medicine into the area of \u200b\u200bthe shoulder joint. After a few minutes, the patient feels numbness, the pain decreases.

The choice of the method of patient management is determined by the doctor after a thorough examination, evaluation of the results of x-ray examination. Doctor takes note the following factors:

type of fracture;
the number of fragments;
the presence of displacement;
patient's age;
accompanying illnesses;
the degree of damage to muscles, tendons, capsules.

Conservative treatment of a fracture of the shoulder joint is most effective in isolated injuries without displacement. After anesthesia, the traumatologist bends the arm at the elbow joint, slightly moves it away from the body, placing a special pillow under it. In this position, the limb is fixed for a month. If you follow all the recommendations of the doctor, the ability to work is restored after 6-8 weeks.

Surgical treatment is indicated for displacement of fragments, multi-comminuted fracture, damage to the capsule or ligaments. Also, the operation is assigned if conservative treatment was ineffective.

The procedure is called osteosynthesis. After anesthesia, all fragments are fixed with pins, screws or plates. With a multi-comminuted fracture, it is impossible to collect all the fragments, therefore they are removed, and the ligaments and muscles are attached to the humerus.

Note! Metal plates should be removed after a maximum of 5-6 months. Long-term presence of foreign objects in the body leads to the development of metallosis.

Rehabilitation

To fully restore the function of the damaged limb, you need to follow all the doctor's prescriptions. The main rule is regularity. Single sessions of physiotherapy exercises or massage sessions will be ineffective.

Many are interested in how much the fracture heals. It all depends on the type of damage, age of the patient, concomitant diseases. In uncomplicated cases, the ability to work is restored after 5-6 weeks. If there is a displacement or damage to the tendons, muscles, capsule, then rehabilitation takes 2-3 months.

To the most effective methods Recovery after a fracture includes physiotherapy exercises, massage, physiotherapy, good nutrition.

Physical exercise

The upper limb is immobilized for a long time, as a result, blood circulation and lymphatic outflow worsen, and muscle weakness develops. To prevent the above changes, it is necessary to engage in physical therapy. Exercises are allowed to be performed within a few days after the injury. You can develop a hand after a fracture of a large tubercle both at home and in the exercise therapy room.

Note! All exercises are prescribed by a doctor. The load should increase gradually, it is forbidden to immediately use the damaged joint.

The main tasks of physiotherapy exercises:

improvement of microcirculation. Due to muscle contraction, blood flow increases, more oxygen, nutrients and trace elements enter the injury site;
elimination of lymphatic stagnation;
increased muscle tone;
restoration of full range of motion in the joint.

The first stage lasts 10-14 days. To avoid re-displacement of fragments, the doctor prescribes exercises that involve nearby joints. This can be flexion of the hand, rotational movements in the wrist and elbow joint. It is also recommended to slightly take the shoulder to the side. During physical therapy, there should be no pain. If any exercise causes pain, it should be excluded from the program.

At the second stage, the load increases. It is allowed to perform rotational, flexion movements in the shoulder joint. The most effective are exercises using sports equipment: gymnastic sticks, balls, hoops. It is necessary to slowly raise the ball in front of you, wind it up behind your head, roll it over your back. Doctors recommend visiting special rooms for physiotherapy exercises.

Rehabilitation after a fracture of the large tubercle of the humerus can take several months. In the third period, the regime expands. Patients are allowed to hang on the bar, play tennis, basketball, and swim.

Massage should be performed by a qualified specialist, not cause discomfort. Regular visits to a massage therapist can significantly reduce the duration of sick leave, restore limb function faster. During the session, blood flow improves, muscles relax, and metabolism normalizes. For massage to be effective, you must follow simple rules:

before starting the procedure, it is recommended to examine the skin. The patient should not have wounds, bedsores, irritation;
the intensity of movements is increased gradually. You should start with stroking to warm up the muscles, increase blood flow;
during the massage, it is forbidden to touch the damaged area. This can lead to damage to the nerves, blood vessels, increased pain;
movements begin with the fingertips, gradually moving towards the shoulder;
rehabilitation after a fracture of the tubercle of the humerus without displacement is a long process. Therefore, massage should be carried out regularly. Doctors recommend at least 8 sessions to achieve the result.

Possible Complications

Complications in most cases occur when first aid is not provided in time. The most common ones are listed below:

rupture of the biceps brachii. During a fracture, muscle fibers can be damaged by bone fragments. Treatment in this case is operational;
nonunion of fragments can be caused by several reasons: non-compliance by the patient with the doctor's recommendations, poor fixation of fragments, insufficient reposition;

the occurrence of contractures or post-traumatic arthrosis is associated with an insufficiently active period of rehabilitation. The patient may complain that his shoulder hurts for a long time, the range of motion in the joint is limited even six months after the fracture.

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Physiotherapy treatment

The goal of physiotherapy is to improve the flow and circulation of blood, stimulate the processes of metabolism and recovery in tissues. The following procedures are assigned:

Electromagnetotherapy;
infrared irradiation;
Iontophoresis;
Ultrasound;
Ozokerite;
Laser therapy in a stimulating dose.

Highly desirable for recovery after a fracture of the tubercle of the humerus spa treatment where balneotherapy (mineral baths) and pelotherapy (mineral mud), thalassotherapy (sea bathing) are used.

Massotherapy

Massage has excellent restorative properties. It normalizes blood circulation and metabolism, eliminates muscle contractures and increases their contractility, promotes the resorption of edema of congestion in the joint and limb.

Massage is prescribed immediately after immobilization is removed provided that there are no abrasions, bedsores, diaper rash and other damage on the skin. The basic rules of massage are:

Massage is shown not only of the entire limb, but also of the shoulder girdle, collar zone and even the back. It can be done throughout the rehabilitation for 10-15 sessions with breaks.

Possible complications of a fracture and their prevention

With a fracture of the large tubercle of the shoulder, the most common complications are:

Injury to the long head of the biceps brachii (biceps). Damage occurs at the time of injury. Muscle fibers pass in the groove between the large and small tubercles of the shoulder and, in case of fractures with displacement, are injured by fragments. Surgical treatment (muscle stitching);
Non-union of the tubercle and its fragments - occurs due to insufficient reposition or poor fixation of the limb. At the same time, it is impossible to restore the function, therefore, surgical treatment is metal osteosynthesis;
The formation of ossifying myositis is the deposition of calcium, the ossification of muscle fibers attached to the tubercle. Surgical treatment, initial stage possible elimination with laser therapy;
Development of post-traumatic arthrosis and contracture of the shoulder joint. Osteoarthritis of the shoulder joint - damage to cartilage, bone growths, is always the result of insufficient rehabilitation. It is treated conservatively, prevention consists in professional rehabilitation treatment after a fracture.

Fracture of the greater tubercle of the humerus is uncommon, but can cause many problems. Timely professional treatment and high-quality rehabilitation will ensure complete restoration of joint function and quality of life.

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

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

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 is usually wedged into the head.

Sometimes the head of the shoulder is crushed and deformed. The detachment of the head is possible, while it unfolds with a cartilaginous surface to the distal fragment.

Signs. The shoulder joint is enlarged due to edema and hemorrhage. Active movements in the joint are limited or impossible due to pain. Palpation of the shoulder joint and tapping on the elbow are painful. With passive rotational movements, the large tubercle moves with the shoulder. With concomitant dislocation of the head, the latter is not palpable in its place. Clinical signs less pronounced with an impacted fracture: active movements are possible, with passive movements, the head follows the diaphysis. The diagnosis is clarified radiographically, a snapshot in the axial projection is required. Mandatory monitoring of vascular and neurological disorders is required.

Treatment. Patients with impacted fractures of the head and anatomical neck of the shoulder 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. up to 80-90°. Analgesics, sedatives are prescribed, magnetotherapy, UHF on the shoulder area are started from the 3rd day, active movements in the wrist and elbow and passive ones in the shoulder joint (removable splint!), electrophoresis of novocaine, calcium chloride are started from the 7-10th day , UV, ultrasound, massage.

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

Ability to work is restored after 2-2 1/2 months.

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

Fractures of the surgical neck of the humerus

Causes. Fractures without displacement of fragments, as a rule, are driven in or hammered together. Fractures with displacement of fragments, depending on their position, are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur during a fall with an emphasis on an 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 during a fall with an emphasis on an outstretched abducted arm. In these cases, the central fragment is adducted and rotated inwardly, while the peripheral fragment is inwardly and anteriorly displaced forward and upward. An angle is formed between the fragments, open outwards and backwards.

Signs. With impacted fractures and fractures without displacement, 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. With passive abduction and rotation of the shoulder, the head follows the diaphysis. On the radiograph, the angular displacement of the fragments is determined. In fractures with displacement of fragments, the main symptoms are severe pain, dysfunction of the shoulder joint, pathological mobility at the level of the fracture, shortening and violation of the axis of the shoulder. The nature of the fracture and the degree of displacement of the fragments are specified radiographically.

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

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

Features of reposition(Fig. 3): in case of adduction fractures, the assistant raises the patient’s arm forward by 30–45° and abducts it by 90°, flexes the elbow joint up to 90°, rotates the shoulder outward by 90° and gradually extends smoothly 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 the assistant counterstops with the foot in the area of \u200b\u200bthe armpit. After that, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction up to 90-100°, flexion in the elbow joint up to 80-90°, extension in the wrist joint up to 160°.

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

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

The terms of immobilization are from 6 to 8 weeks, from the 5th week the shoulder joint is released from fixation, leaving the hand on the abduction splint.

Terms of rehabilitation - 3-4 weeks.

Ability to work is restored after 2-2 1/2 months.

From the first day of immobilization, patients should actively move their fingers and hand. After the transformation of the circular bandage into a prolongation one (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 a dosed load on the muscles). Exercise therapy patients are engaged 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 s, the abductor splint is removed and rehabilitation begins in full. If the closed reposition of the fragments fails, then surgical treatment is indicated (Fig. 4).

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

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

Fractures of the tubercles of the humerus

Causes. A fracture of the greater tubercle often occurs when the shoulder is dislocated. Its detachment with displacement occurs as a result of reflex contraction of the supraspinatus, infraspinatus and small round muscles. An isolated fracture of the greater tubercle without displacement is mainly 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 radiographically.

Treatment. In case of fractures of the large tubercle without displacement after blockade with novocaine, the hand is placed on the abducting pillow and immobilized with a Dezo bandage or scarf for 3-4 weeks.

Rehabilitation - 2-3 weeks.

Ability to work 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 the abduction splint or plaster cast (Fig. 5).

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

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

Rehabilitation - 2-4 weeks.

Ability to work is restored after 2-2 1/2 months.

indications for surgery. Intra-articular supra-tubercular fractures with significant displacement of fragments, failed reposition in case of a fracture of the surgical neck of the shoulder, infringement of a large 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 — fragment displacement; b - fixation with a screw; c - fixation with wire

Complications are the same as with shoulder dislocations.

Traumatology and orthopedics. N. V. Kornilov

A fracture of the greater tubercle of the humerus does not always attract the attention it deserves, which is necessary in order to fully and correctly carry out its treatment. This diagnosis is established in 15% of patients with a shoulder injury. Despite this, the diagnosis of trauma has great importance to prevent the patient's disability due to violations of important motor functions of the shoulder joint. Depending on the severity of the injury, it can be closed or open. There is also a fracture of the humerus without displacement and with it.

Causes

Causes of injury can be:

fall on hand
damage associated with active sports activities and physical activity;
car crashes;
straight swipe in the shoulder area;
an injury resulting from atrophy of the surrounding muscle tissue, often found in the elderly.

With these injuries, an isolated fracture of a larger tubercle may occur or, in combination with it, a dislocation of the shoulder joint.

Medicine knows several of its types:

detachable;
squeezing, resulting from a bruise.

An avulsion fracture of the tubercle of the humerus is characterized by separation of a fragment of the cortical layer, the consequence of which may be a complete fracture. In some cases, it can cause incorrect or unsuccessful reposition - the compilation of fragments of a damaged bone, or when trying to reduce a dislocation.

The second type of fracture occurs when a fall on the arm or shoulder is the result of a direct injury (when a blow occurs precisely in the shoulder area).

Symptoms

Signs of a fracture may include:

sharp pain;
limitation in the movement of the shoulder joint;
swelling in soft tissues;
characteristic sound (crunch) when moving;
increased pain on palpation and pressure;
the appearance of hematomas and subcutaneous hemorrhages;
with an avulsion fracture, it is not possible to move the shoulder inward.

Diagnostics

The patient is diagnosed based on:

descriptions in the medical history;
patient complaints;
visual inspection;
diagnostic methods.

The X-ray examination of the patient is difficult. Radiologists do not see the fracture due to possible displacement of the bone, and they, in some cases, mistake it for a shadow from bone deposits. For accurate diagnosis, it is possible to use a computer or nuclear resonance tomograph.

Trauma treatment

Determining the presence of an injury is, in principle, a simple process. It is important here not to miss the details and to accurately determine the degree of complexity of the fracture and the type of displacement. To eliminate acute pain in a patient and start treatment, it is necessary to perform anesthesia, both local and general. Only after achieving the effect, you can proceed to the next stage (immobilization). It passes with the help of an abduction splint and a bandage, as well as using a special wedge-shaped pillow that abducts the arm 70-80º to the side.

In this case, the purpose of immobilization is:

the possibility of relaxing the muscles of the hand;
the ability to naturally restore fragments of fragments;
reduction or elimination of severe pain.

An injured patient is unable to work for a long period of 2 to 3 months. With some indications for surgical treatment of a patient, in rather complex cases, an operation is possible to reposition and fasten bone fragments with the help of bolts, plates, etc. In the presence of small fragments that cannot be restored, they are removed and the soft tissues are cleaned.

Due to a violation of the treatment mechanism, incorrect or inaccurate diagnosis, the following consequences are possible after a fracture of the large tubercle of the humerus:

inability to match bone fragments;
goals are not achieved from the use of immobilization;
there is more pressure on the humerus during restorative physical education;
unjustified termination of treatment.

Rehabilitation

Rehabilitation after a fracture is divided into the usual three stages. The most gentle and sparing stage is the period when, after a long wearing of the tire, it is removed. The removal of a special splint occurs only after an additional examination, which will show how correctly and well the damaged humerus has grown together, how effectively the treatment has been.

Based on the picture, the doctor will determine how much the damaged area can hurt, and prescribe an anesthetic, rehabilitating massage, restoring the therapeutic and physical education complex, wearing a special restraint bandage. An effective method of resuming the functions of the bone, joint and limb is physiotherapy. All recovery processes in the body will not be highly effective and efficient if they are not supplemented with proper and complete nutrition of the patient. During the rehabilitation period, spa treatment will benefit.

In a hospital, a rehabilitation doctor begins to conduct classes a few days after the injury according to a specially developed method that promotes the reposition of fragments in a natural way, their gradual compaction and, ultimately, the fusion and restoration of the functions of the upper limb. Continuing to treat the patient, the doctor conducts a set of passive and active exercises. During this period, passive movements are performed with the help of special mechanical simulators and devices, or are carried out by the patient with the direct participation and support of the doctor.

First stage of rehabilitation

What tasks are set for rehabilitation specialists at the 1st stage of recovery?

Complex of physiotherapy exercises:

promotes muscle relaxation, which leads to their recovery;
eliminates hematomas and subcutaneous hemorrhages;
relieves pain;
improves blood and lymph flow to the damaged area;
restores metabolism.

Exercises:

pendulum - moving forward and backward, with a relaxed injured hand;
hand movements in a circle, in one direction and the other;
flexion of the fingers;
flexion of the arm at the elbow;
raising and lowering the shoulder.

The second stage of rehabilitation

Its main purpose is:

restoration of the functioning of the injured limb;
resumption of the work of the shoulder joint;
return to the hand of the original activity.

At this stage, the exercises are performed with the help of additional sports equipment (ball, stick). The complex is performed in six sets of 10-15 times.

The third stage of rehabilitation

The purpose of this stage was the exercises:

to restore limb functions;
to increase activity and resistance to pain, endurance.

Exercises:

stops;
classes with heavy balls (3-5kg);
swimming;
volleyball basketball.

Physiotherapy activities

electrotherapy (diathermy, UHF-therapy);
paraffin applications;
balneotherapy;
treatment with ozokerite;
mud treatment;
hydrotherapy.

Massage

The main purpose of massage is:

improvement of blood and lymph flow to the damaged area;
strengthening muscle mass surrounding the damaged bone;
measures to avoid pathologies in injured tissues;
restoration of natural processes in tissues;
increased muscle tone and ability to contract.

An individual appointment and calculation of physical activity for each patient is made by the attending physician based on a visual examination of the patient and an assessment of his general condition. After a fracture, a permit for full physical activity can be obtained after 3 months.