The proximal department of the shoulder bone. Fracture of the proximal department of the head of the shoulder bone: a safe and complicated outcome of treatment

Shoulder bone - this bone, which is located between the elbow and adple. Usually, the shoulder is called that part of the body, which is located between the neck and shoulder joint, but it is incorrect: the shoulder is located below.

The shoulder bone, like all tubular bones, consists of three parts: top (proximal), medium (diaphysis) and lower (distal).

The top (proximal) part of the shoulder bone has a rather complicated anatomy and together with the spatula forms a shoulder joint. In the proximal departure of the shoulder bone, hemispheric head is distinguished, due to which movements in the shoulder joint are possible. Head covered with cartilage. Below the head there is a narrowing - anatomical neck. Under the anatomical neck there are two tuberca - large and small to which muscles are attached. Small round, sirebo, and supervolor muscles are attached to the large tuberculosis (rotate the shoulder outward and hold it in the joint). The sublock muscle is attached to the small tuberculk (rotates the shoulder inside). All these muscles form the so-called rotator (rotator) shoulder cuff. There is a groove between the tubercles, in which the tendon of the long head of the leak muscle is passed. Under the tubercles there is another narrowing, which is called a surgical cervical neck. You can read more about the anatomy of the shoulder bone and shoulder joint on our website.

The bracket fracture can occur in any of its parts: proximal, medium (diaphysis) and distal. As a rule, the fracture is localized in one part, but sometimes the fracture line passes through two (for example, a fracture affects the proximal and middle part of the bone). Each of the options has its own characteristics, so we will describe them in individual articles.

When is the fracture?

Most often, the fracture of the proximal deposit of the shoulder bone occurs in the elderly, which have osteoporosis, i.e. The bone has little strength. However, young people may arise the fracture of the proximal bone.

A typical injury at which the fracture appears is a drop in hand, but the fracture may occur when directly impact over the top of the shoulder. In addition, there are also so-called tear-off fractures, and the fractures that you can read about in a separate article on our website.

Symptoms

Immediately after the fracture, the victim feels pain in the area of \u200b\u200bthe shoulder joint, movement becomes sharply painful, but more often the movement shoulder is generally impossible. Shoulder can deform.

There may be a violation of the sensitivity of the brush, forearm or shoulder. The numbness or feeling of flies, the needles can be due to damage to nerves during a fracture and as a result of edema, which, with a fracture, almost always occurs.

A few hours after the injury, swelling occurs, later, about a day, a bruise appears in the area of \u200b\u200bthe shoulder joint (it is mistakenly called hematoma, but in fact it is just a bruise - the subcutaneous fiber is soaked in blood). For several days or even weeks, this bruise can increase in size and "sliding" down, even to the brush.

First aid:

First, make sure that the victim is in full security.

If the patient can not go, call ambulance. In other cases, you can get to the doctor on our own on a taxi - which may be much faster.

Do not try to move the damaged hand. This can cause damage to blood vessels, nerves and soft tissues.

If bone fragments protrude from the wound (open fracture), do not attempt to correct them back.

With the open fracture, impose a sterile bandage (stop any car, in the first-aid kit for sterile bandages).

Do not overlap the harness! Just tightly tap the wound and give your hand a position above the level of the heart of the victim.

If you are predicted to impose a bandage, just cover the wound with sterile napkins or bandage until the ambulance brigade arrives.

If medical care is not available, and the patient must be moved, immobilize (immobilize) a damaged limb using temporary tires or jacks.

Temporary shining can be carried out by means of dugs, branches, cardboard or twisted logs. Avoid excessive squeezing hands.

Touch the hand on the tireless bandage. A creek is a segment of fabric with connected ends, dressed on the neck and supporting damaged hand.

Tightband

What are the fractures?

There are several typical options for fractures:

Given a large tubercle, a fracture of anatomical neck, a fracture of a surgical cervical neck, the separation of a small tubercle, an intra-articular fracture (splitting of the head), fracture.

Each of these typical options can be combined with another, so that a particular patient may have a combination, for example, the separation of a large tubercle and a surgery of a surgical cervion, or any other option. In addition, the fracture can be fragmented - if one fragment is pressed into another. To describe the variety of possible options for fracturing, traumatologists most often use the NEER classification, which highlights the same, two-, three- and four fragmented fractures.

As we have already mentioned, the muscles that have different focus are attached to the tubercles. In view of this, bone fragments are often shifted in the direction where they are pulled by the corresponding muscles.

Typical displacements of three-member fractures (consisting of three parts). On the left - the separation of the small tubercle and the fracture of the surgical cervix, on the right - the separation of a large tubercle with a fracture of a surgical cervix. Big tuber migrates up and back.

Displaced upwards and the stop of a big tubercle will break the lead, because at the same time it will simply guess with an acrase of the blades, limiting movement.

A fully torn big tubercle can be shifted into the suppressive space, and, in this case, subsequently it will also be impossible to remove the hand of the Welcome.

Displaced in the crude space of a large tubercle (marked with a red arrow)

In general, the options for fractures of the proximal part of the shoulder bone are very much, you can read more about them on our website.

Diagnosis

The diagnosis of the proximal bone proximal department is set according to the results of inspection and additional research methods (x-ray, computed tomography). During the inspection, the doctor will ask you about the circumstances of the injury. Try the most detailed as possible, but at the same time it is concisely talking about what happened. Do not forget to report the symptoms described above if they are (a sense of numbness, etc.).

The accurate nature of the fracture can not be installed on radiographs, since there are a lot of options for fractures, and on simple radiographs, fragments often lay on top of each other. Nevertheless, first always perform a radiograph in the front-rear projection. If the fracture is simple, this is enough, but if the fracture is complicated, it is necessary to perform either X-ray in additional projections (oblique, axial, etc.), or perform computer tomography. Radiographs in additional projections are technically complex, often require the hand to be given a special position, and this is often impossible due to severe pain. Therefore, more often surgeons prefer computed tomography.

In any case, performing computed tomography to ordinary radiographs is not always appropriate. Magnetic resonance tomography has less informativeness compared to computer tomography when diagnosing the nature of the fracture, but sometimes, if the doctor suspects damage to bundles or tendons, then this study is performed.

How to treat fractures of the proximal part of the shoulder bone?

There are two principal ways of treating fractures - conservative (without surgery) and operational. The choice of treatment method is made taking into account the nature of the fracture, the displacement of bone fragments, the lifestyle of the patient, and the concomitant diseases.

All fractures of the proximal part of the shoulder bone can be divided into two types:

Those that can be successfully treated conservatively, i.e. without surgery I.

Those that best operate.

Excessive treatment It is advisable for simple fractures without offset or with a minimal displacement of fragments (less than 1 centimeter). In addition, conservative treatment is shown in cases where, due to different reasons, the patient's hand did not function before injury (after a stroke, for example).

The hand is immobilized with the help of special longs from plaster or from modern hardened materials. There are much more comfortable modern orthoses and much more comfortable compared to conventional gypsum longs. The specific version of the suitable orthosis or the dressing is determined by the character of the fracture. The deadlines of immobilization are also determined by the nature of the fracture. Usually, with conservative treatment, there is more immobilization more than with operational.

In other cases, it is usually advisable operational treatmentwhich allows you to eliminate offset, fix fragments and earlier to start moving in the shoulder joint.

The option of fixing fragments is determined by the character of the fracture. When the large tuberca is cut, it is often fixed with wire or screw and wire.

Fixing a large tubercle with wire.

With more complex fractures, the intramedullary pins or plate fixation.

Fixation of the Philos Plate of Philos Company Synthes.

Requirements for plates for fixing fractures of the proximal part of the shoulder bone are very high. They should be made of high-quality alloys, have a large stock of mechanical strength, the screws should be blocked in the holes of the plate, and the plate itself must have additional holes for drying the rotator cuff and shoulder joint bundles. All these features determine their high cost, which in our country can easily exceed 1000 US dollars.

On the left - osteosynthesis screws, on the right - osteosynthesis of the Arthrex plate with holes for drying the tendons of the rotator (rotational) cuff

Osteosynthesis intramedullary pin is usually a less traumatic operation, but it has its own limitations. As a rule, the choice in favor of an intramedullary pin occurs with simpler fractures without tearing tubercles, or in cases where the fracture line extends to the diaphim. However, intramedullar osteosynthesis is possible with more complex fractures, but technically this operation is very complex.

In the elderly patients one of the main difficulties associated with the fractures of the proximal departure of the shoulder is osteoporosis. The bone is soft, "sugar", and the usual screws in such a bone easily dispersed and the whole design becomes unstable.

In addition, in the elderly patients, multi-skilled fractures are often not fixed at all if the ideal reposition (comparison of fragments) and fixation, due to the fact that with age, the blood supply is reduced. Therefore, if a doctor regards the blood supply to the head in an elderly patient as insufficient, it does not perform osteosynthesis, but endoprosthetics - i.e. The joint changes to a new artificial one.

Zimmer® shoulder joint endoprostheses (Anatomical SHOULDER ™, inverse and reversed)

Complications

In addition to the fact that the operation eliminates the displacement of bone fragments, it is also characteristic of the disadvantages. In particular, the main complications of surgical treatment are:

Osteolysis (resorption) head. Such a complication is due to insufficient blood supply to the head of the shoulder bone, which, being devoid of nutrition, is gradually absorbed. Usually this complication occurs when instead of the recommended primary endoprosthetics perform osteosynthesis. However, such a choice is not deprived of meaning, as osteosynthesis is an attempt to "save" the joint. In any case, the risk of osteolysis should be evaluated from each patient individually and on the basis of this assessment to plan an operation. Such a complication may occur both after the operation and after conservative treatment.

Perforation of head screws. If, during osteosynthesis, too long screws will be used, then they perforate the articular surface of the head and bubuth interfere with movements in the joint. This technical error and avoid it can only be carefully observing the rules for performing the operation. In particular, the operating must be necessarily equipped with an electron-optical converter (EEO), which allows the surgeon to perform radiographs in several projections and make sure that the correct position of the screws.

Impendzhent-syndrome. This is a collision syndrome when the mechanical obstacle prevents movements in the joint. More often, the impenthenty-syndrome of the shoulder joint is due to the collision of the displaced large tuberca or the upper edge of the incorrectly positioned plate on the acromic processed blade.

Frozen shoulder. Sometimes this complication is also called an adhesive capsule, although these concepts are not completely synonymous. Such a complication may occur both after the operation and after conservative treatment. Complication is manifested by a sharp limitation of movements.

Infectious complications - osteomyelitis. For the prevention of this complication it is necessary to comply with the requirements of aseptics, and the patient should receive antibiotics with a prophylactic goal (prescribed intravenously 30 minutes before the operation). The frequency of development of this complication is less than 1%

Rehabilitation

In the postoperative period, the hand is usually immobilized by the discharge orthosis or gypsum bandage, may be assigned painkillers, such as paracetamol or aspirin, ibuprofen.

After a normal battle of fragments, the function of the shoulder joint is gradually restored, but significant severity of the injury itself sometimes does not allow you to restore the joint function completely.

With stable fixation of the exercise to increase the volume of movements and strengthen the muscles, it can be started as soon as the pain decreases. Control examinations of the doctor and control radiographs are needed, the frequency of which determines the attending physician. During these inspections, the doctor makes recommendations on the expansion of the rehabilitation program or, on the contrary, advises to suspend the exercises.

You can see exemplary exercises for rehabilitation on our website (click the mouse to go).

What questions should be discussed with your doctor?

1. What are my individual risks of complications in surgical and conservative treatment? What method of treatment in my case will rely on the maximum success?
2. How does this injury affect the function of the hand in the subsequent?
3. Can any individual factors affect the outcome of treatment (related diseases such as diabetes mellitus, etc., bad habits)?
4. What an implant for osteosynthesis is optimal with such a fracture character?
5. How fully can I serve myself after the operation?
6. When can I return to work if my work is connected with ...?
7. When should check inspections and x-ray studies?

Fractures of the proximal deposit of the shoulder bone are 5-10% of all fractures. In the structure of postoperative complications after the treatment of fractures of the proximal head of the shoulder bone from 10% to 35%, adverse outcomes in the form of the loss of the originally achieved reposition, the routine deformation of the head with a penetration of the last screws, the outstanding or formation of a false joint, both after conservative and after operational treatment .

With the development of the operational treatment of such fractures, traumatologists meet with a large variety of shapes of the head of the shoulder bone, a variety of blood supply and innervation. In most cases, it is necessary to rely on the experience, the intuition of the doctor and the use of averaged concepts about the forms of the head of the shoulder bone, allowing only "blindly" to individualize surgical techniques and tactics of the integrated treatment of such patients. But this does not allow the individual-typological features of the structure of the proximal bone, and therefore, and to individualize the approaches to the treatment and prediction of the outcomes of the conservative and operational treatment of such patients.

It has long been known that each form of body or organ characterizes individual structural reactivity with respect to the factors of the external environment and diseases.

Work in the literature of recent years has appeared, testifying to the individual-typological variability of the shape and structure of the shoulder bone in adults of various types of physique. The types of the structure of this bone, having different features of blood supply were highlighted. The correlation relationships between the level of the diaphysaric artery entry into the shoulder bone and the type of its structure (at de colochop, mesomorphic and brahimorphic individuals) are shown and the zone of "surgical risk" is determined.

However, the markers of the individual-typological features of the shape of the proximal bone of the proximal bone should not be studied in detail, which determine or affect the individual characteristics of the course of the reparative processes (consolidation) of the bone. All this testifies to the relevance and need for research in this direction.

The purpose of this study was to conduct an exploratory analysis of the data under study (a detailed measurement of the proximal department of the brachial bone head) in 21 patient surveyed with fractures of this part of the bone. It is necessary to test the hypothesis on the presence of the relationship between the individual features of consolidation (prosperous or complicated) and the individual-typological features of the structure of the proximal shoulder bone for the development of individual approaches to the treatment of fractures and forecasting results.

The objective of the study was that, according to the results of conservative and surgical treatment of patients with a fracture of the proximal head of the shoulder bone, compare the outcomes of the fighting of such a fracture (consolidation or complication in the form of the formation of a false joint, head necrosis), due to the characteristics of the structure and shape of the proximal bone opposite to the flue of the shoulder joint on digital radiographs.

Materials and research methods

21 Male and Female Patients aged 40 to 80 years. As a basis for the choice of treatment tactics, the NEER classification is taken, according to which patients with fractures of the proximal bone, without displacement, either with a permissible displacement (an angular displacement to 45 °, a width of up to 1 cm) underwent conservative treatment.

Patients having an unacceptable displacement treated operational. Operational treatment was carried out on the third day after injury. The coiled osteosynthesis plates with the angular stability of screws were performed, intramedullar blocking osteosynthesis.

The examined patients were distributed in two groups. The first group: Patients with a fracture battle up to 3 months - 13 people. The second group: Patients who have a complication in the form of a false joint and necrosis of the head formed, - 8 people.

All patients were conducted traditional X-ray study for such fractures of the injured and additionally opposite damaged shoulder joint. The conditions for conducting were the same: in a direct projection with a turn in the test side at an angle of 30 ° on a digital X-ray machine.

All the surveyed analyzes the digital X-ray diffraction pattern of the joint opposite to the damaged, i.e., a healthy shoulder joint. According to the developed survey card, measuring the head of the proximal junction department in different directions were measured, including the angles were measured and indices were calculated, characterizing the features of the shape of the proximal head of the shoulder bone, only 87 parameters. The obtained values \u200b\u200bwere statistical processing by Mann-Whitney and Kraklala-Wallace (median and rank tests).

Research results and discussion

Comparative analysis of the features of the shape of the proximal bone department between patients with a fracture unit for up to 3 months (13 people) and patients with complication in the form of a false joint or necrosis of the head (8 people) showed the presence of reliably significant parameters separating patients with various treatment outcomes Median (Table).

This is a sign that measures the angle between an anatomical neck and a line limiting a large tubercle to a surgical neck (measured feature: Angle 47 - P< 0,009 и < 0,011; ** < 0,009). Уменьшение этого угла у лиц с неблагоприятным исходом консолидации свидетельствует об уменьшении большого бугорка и снижении уровня анатомической шейки в латеральных отделах головки. Подтверждает это и признак, измеряющий угол, образованный двумя линиями от середины хирургической шейки: первая линия проводится до точки середины латеральной части анатомической шейки, вторая линия проводится до середины самой широкой части головки (измеряемый признак: угол 56 — р < 0,0298 и * < 0,049; ** < 0,030). Последний признак также свидетельствует о том, что при не различающейся в двух сравниваемых группах ширине анатомической шейки она имеет тенденцию опускаться ниже с латеральной стороны. Это сопровождается отклонением первой линии более латерально, что увеличивает угол 56 (р < 0,0298 и * < 0,049; ** < 0,030) у пациентов с осложнениями. Об этом же косвенно свидетельствует увеличение длины латеральной части хрящевой головки (измеряемый признак 11 — р < 0,027) и расширение хрящевой части головки в ее средних отделах по отношению к анатомической шейке (индекс 17 — * < 0,019, ** < 0,044 и индекс 18 — р < 0,046) в совокупности с широтными размерами средних отделов хрящевой части головки плечевой кости (измеряемые признаки: 10 — р < 0,025 и * < 0,004; ** < 0,027; признак 11 — р < 0,027). Имеется тенденция к удлинению проксимальной головки плечевой кости (измеряемые признаки: 29 — * < 0,019; индекс 90 — * < 0,049). Кроме того, у пациентов с неблагоприятным исходом констатируется более тонкое компактное вещество в латеральных отделах головки (измеряемый признак: 86 — р < 0,0326 и ** < 0,033).

Statistical analysis also showed that there are several signs that do not have reliable differences, but approaching the value of R to reliable. For these parameters, apparently, it is also possible to talk about the presence of a tendency to the difference of the individual-typological features of the structure of the head of the shoulder bone in two compared groups. These trends are obviously more clearly shown by greater quantities of patients examined with such fractures.

Discussion and conclusions

The above pilot study showed statistically reliable differences between the two compared groups. So, in patients with disadvantaged consolidation, there is some shifting of the cartilage part of the proximal head of the shoulder bone in the lateral side and in the direction of the down and thinning of the compact substance from the lateral side, in addition, there is a tendency to elongate the cartilage and the rest of the head, especially in its lateral part.

The literature review of the typological features of the brachial bone is indicated that the differences obtained may indicate the approach to the more oval form of the proximal bone supply in patients with adverse outcome after the treatment of the fracture. Such a form of the proximal department of the head of the shoulder bone, according to O. A. Fomicheva, is more characteristic of people with a valitomorphic type of physique and the valitomorphic type of the structure of the shoulder bone. Moreover, such individuals, the diaphyseal artery is more likely of the loose type and enters the bone on the distance remote from the head, and this distance determines the "surgical risk zone" during operational interventions. It can be assumed that such a feature of the structure or the type of structure and blood supply of the shoulder bone, correlating with the type of human body, can also play some decisive role in the manifestation of individual peculiarities of the regeneration of the shoulder bone during fractures, which ultimately affects the outcome of treatment.

Thus, in the sample of patients studied and compared in exventation, the sampling of patients (with fractures in the field of the proximal bone head) there are reliable differences in median in a number of measured signs characterizing the individual-typological features of the structure of this shoulder bone. The foregoing indicates the possibility of further research in this direction, in order to search for detailed morphological markers of well-being and risk to different consolidation outcomes (favorable or complication). This, ultimately, will provide an opportunity to come close to the individual forecast of the exodus of consolidation of such fractures and, accordingly,, more customized selection of the method of treatment, which will improve the results of the treatment of fractures of the proximal shoulder bone.

In addition, exploration analysis showed the need to make some corrective and refine measurements into the working card of the patient examination for a complete study.

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A. V. Lifanov
L. T. Levchenko 1,
L. B. Reznik,doctor of Medical Sciences, Professor

GBOU VPO Omgma of the Ministry of Health of the Russian Federation, Omsk

Make up 5% of all fractures and most often found in the elderly patients. Anatomically to the fractures of the proximal department include all the fractures of the shoulder bone proximal than surgical cervix. The classification used in this text was developed by NEER. According to this classification, the proximal department of the shoulder bone is divided into four segments:
1) Big tubercle;
2) Small tubercle;
3) anatomical cervical;
4) Surgical cervical.

Classification of fractures of the proximal bone

Fractures of the proximal department of the shoulder bone Classified on the basis of anatomical and therapeutic principles.
I. Fractures:
Class A: Complete fractures with angular displacement
Class b: fractures with mixing in width
Class B: Sustal Fractures

II. Fractures anatomical cervical (epiphyse):
Class A: Fractures without displacement, including epiphyse damage

III. Fractures of large tuberca:
Class A: Fractures without displacement
Class B: Fractures with displacement

IV. Fractures of small tuberca
V. Complex fractures (three-rinofragmented)
Vi. Fractures of the articular surface

Examples of single and two-frenzy fractures described by NEER

This classification has both prognostic and therapeutic importance and depends only on the ratio of damaged bone segments and their offset.

If after injuries All fragments are not shifted in width and at an angle, the fracture is classified as one-alignment. If the fragment is displaced in width of more than 1 cm or at an angle of more than 45 ° from the rest of the intact part of the shoulder bone, the fracture is classified as two fragments. If two fragments are displaced each separately, then the fracture is classified as a tripral. And finally, if all four fragments are displaced each in their direction, the fracture will be a fourframe.

Examples of three- and four-franc fractures described by NEER

Bone fragmentcomprising two segments shifted towards the proximal department of the shoulder bone will be classified as a two-fracture fracture. It is important to remember that the displacement is determined by the discrepancy of fragments by more than 1 cm or the angular deformation of more than 45 °.

The figure in the form of diagrams is represented classification of fractures of the proximal bone of the neer. Please note that three- and fourframed fractures are often combined with dislocation. The fractures of the articular surface are not included in the NEER classification and will be considered separately at the end of this chapter.

Anatomy of the proximal department of the shoulder bone. Shown a fracture of a surgical neck

About 80% of all fractures of the proximal bone are single-adjuvant. Frames are held in place by the periosit, rotational cuff and the articular capsule. Primary stabilization and treatment of these fractures should be carried out by an emergency doctor.
Rest 20% of the fractures of the proximal department of the shoulder bone, as a rule, two-, three- or fourframed. These fractures require reposition and after it can remain unstable.

To understand the mechanism of fractures In the proximal departure of the shoulder bone and the displacement features of them, knowledge of the anatomy is necessary. Anatomy of the proximal department of the shoulder bone is presented in the figure. The articular surface, sifted with the spatula, forms a shoulder-paint joint.

Places of attaching the most important muscles to the proximal department of the shoulder bone

Articular surface ends up anatomical cervical; Consequently, fractures, localized proximal than anatomical neck, are considered as fractures of the articular surface. A surgical cervical neck is a narrowed part of the proximal deposit of the shoulder bone distally than anatomical cervix. Big tubercock and small tuberculk are called bone ledges, distal than anatomical cervical.

As depicted on figureTo the proximal department of the shoulder bone is attached, surrounding it, several muscles. The muscles of the rotational cuff include superval, shaft and small round muscles. The rotational cuff is attached to a large tubercle. With a fracture, the rotational cuffs seeks to shift the fragments in the upper direction with the front rotation. The sublock muscle is attached to a small tubercle.

With a fracture, this muscle She strives to shift fragments in the medial direction with rear rotation. The big breast muscle is fastened to the lateral lip of the interbogurgorny groove, and the deltoid muscle is attached to the jourmet of the deltoid muscle. Both of these muscles are attached distal than surgical neck and, therefore, are not part of the proximal departure of the shoulder. The big thoracic and deltoid muscles after fractures of the proximal shoulder bone, tend to put pressure on the diaphone in the direction of medial and upwards, respectively.

The course of the most important nerves and vessels considered when discussing the fractures of the proximal bone

Visor-nerve bunches of the proximal bone Depicted in the figure. It is important to note the proximity of the adjustment of the shoulder plexus, the axillary nerve and the axillary artery to the proximal department of the shoulder bone. Damage to nerves and vessels often accompany the fractures of this area.

TO farms of the proximal department of the shoulder bone Usually lead two mechanisms. The straight blow on the outer surface of the shoulder, for example, when falling, can cause a fracture. It is more commonly encountered mechanism - usually the result of falling on an elongated hand. The position of the shoulder bone diaphysis after an indirect fracture depends on the position of the limb before the fracture.

Abduction fractures, in which the fragment of the shoulder bone is assigned, occur when falling on the elongated hand. The position and type of fracture of proximal fragments depend on four factors.
1. The active force determines the severity of the fracture and to some extent its offset.
2. Rotation of the shoulder at the time of the fracture determines the type of fracture.
3. Muscle tone and equilibrium at the moment of fracture determine the degree of displacement.

4. The patient's age determines the fracture localization:
a) in children with inconspicuous epiphyseal zones of growth, no fractures are usually observed, but epiphisheolysis;
b) adolescents with precipitated epiphyse bones are very strong and therefore they often have dislocations, sometimes accompanied by fractures;
c) the elderly bones are fragile and therefore they have fractures more often.

Series radiographs When damaged, the recommended NEER, it helps a very helping the evaluation of fractures of the proximal bone. In addition, the authors recommend snapshots in the forefront of the projection with the internal rotation of the limb and in an axillary projection. These four projections make it possible to fully assess the shoulder joint and the proximal bone, including the articular surface. These pictures can be made to the patient in the position lying, standing or sitting, although the authors recommend sitting position.

With intra-articular fractures Hemartrosis is observed, while the head of the shoulder bone can shift down. X-ray this feature is referred to as a pseudovyvich, indicating the presence of an intra-articular fracture. An additional x-ray sign indicating the presence of an intra-articular fracture is the presence of a fatty liquid line.

A. Supporting and encompassing the bandage for immobilization of fractures of the proximal department of the shoulder bone.
B. Supporting and covering the bandage from commercially manufactured bandagles and elastic bandage.
V. Velpo bandage and covering the bandage used in unstable surgical cervas, provide relaxation of a big breast muscle

Treatment of fractures of the proximal bone department

Treatment of fractures of the proximal bone department Depends on the age of the patient and his lifestyle.

Fractures of shoulder bone are divided into:

• fractures of the proximal department
• fractures of diaphysis
• fractures of the distal department

Fractures of the proximal department of the shoulder bone

Fractures are a consequence of falling per hand, often arise in the elderly.

Treatment

In patients of elderly and senile age with pronounced osteoporosis in the overwhelming majority of cases, conservative treatment is shown, which consists in refusing to gypsum immobilization and the early start of active movements in the damaged joint. In patients with middle and young age, it is necessary to strive for a simultaneous closed reposition with a short-term immobilization of an orthesic bandage.

With the failure of a closed reposition in this group of patients, osteosynthesis is shown with the early early start of active movements. It is used both as cooler osteosynthesis plates with angular stability and intramedullar blocked osteosynthesis.

Shoulder Bone Fractures

Fractures of shoulder diaphysis, like all others, are divided into fractures from straight and indirect injuries. With a direct application of force, transverse, ultold and multi-skilled (including segmental) fractures arise, and with indirect - screw-like (oblique) with an additional fragment or without it. One of the typical variants of the fracture from indirect injury is closed screw-like fractures obtained during arm wrestling. In recent years, their number has increased markedly, apparently, due to the popularization of this type of martial arts.

The "gold standard" treatment of such fractures is blocked intramedullar osteosynthesis. The technique allows us through mini-access to perform a reposition and ensure stable fixation of fractures.

Fractures of the distal shoulder bone

Make up 2-3% of all fractures. Most often occurred by an antimalnery intra-articular fracture. Most of the low-energy fractures of the distal shoulder bone occur as a result of a fall on the elbow from the height of growth or in a fall in the dismissed hand. In this case, it is possible to combined damage to the proximal department of the forearm - the fracture of the elbow process, dislocate the radial bone, dislocation of the elbow bone, etc.

The cause of high-energy damage, most often, is an accident. Depending on the location of the fracture line, the fractures of the distal shoulder bone can be divided into embracing and intra-articular fractures.

The fracture of the proximal portion of the shoulder is a serious injury that, in the absence of proper treatment, leads to limiting limb. If you do not directly contact a specialist, the victim will lose the ability to work and the ability to serve yourself.

In our clinic, we use modern equipment, and high-tech treatment methods, which allows you to restore the function of the shoulder joint even after serious damage.

Fig. 1. On radiographs: a consolidated fracture of the proximal deposit of a shoulder bone with a displacement of fragments.

Mechanism of injury

The fracture is formed in the event of a fall on the brush or elbow, with a direct mechanical effect on the outer zone of the shoulder joint. Such damage is characteristic of faces of old age and can be formed with a minor fall. In young people, injury is due to an accident, falling on the limb from a height, a strong impact of shoulder about a solid surface.

Types of fractures

There are intra-articular and embracing fractures of the proximal epiphyse shoulder.

In the first case, the damaged section of the bone does not go beyond the borders of the articular capsule, which is limited to an anatomical shoulder neck. Such damage is called high-tech. They are characteristic of shocking along the outer area of \u200b\u200bthe joint.

Each-making, or subbugum fractures are located below the articular capsule. Such damage is often noted at the scene of the bone - surgical neck, or in the field of tubercles, which are the place of attachment of the tendons. Injury is found very often and especially characteristic of age patients.

Fig. 2 Schematic representation of different types of shoulder bone fractures

Subbugum fractures on the damage mechanism are divided into abduction and adduction. For each of the types of injury, a specific displacement of fragments is characteristic.

For the abduction fracture, a fall in the left limb should occur. In this situation, the central fragment deviates forward, and the peripheral - inside.

Adduction fractures occur after landing on the shove in the elbow the hand cordon. In such a situation, the peripheral fragile is shifted outside, and the central - forward and outward.

Fig. 3 Schematic representation of abduction and adduction fractures.

Shoulder fractures are with a displacement, in contact with fragments or without these changes. Damage can be supplemented with dislocation.

Clinic

When fractures without displacement, the limb configuration is not changed. The patient states the pain and restriction of the mobility of the joint. A characteristic symptom is the amplification of pain in the axial load on the hand.

Fractures with displacement are distinguished by deformation of the area of \u200b\u200bthe shoulder joint, swelling. Pain sensations are expressed, any movements in the shoulder articulation are impossible. With axial load, the pain is enhanced. At intra-articular fractures, hemarthrosis is observed. Passive shoulder discharge is impossible even after anesthesia. This is due to a violation of the joint configuration.

Diagnostics

The preliminary diagnosis can be put on complaints of the patient, the presence of a fall or a history of anamsa, inspection data. To clarify the diagnosis, identifying the nature of the fracture, the position of bone fragments is carried out x-ray. A snapshot is done in several non-standard projections. In difficult situations, computed tomography is needed.

This study allows accuracy to establish the nature of the damage in situations where the debris on the radiograph is enjoyed on each other, and the study in the necessary projection is technically impossible due to limiting limb mobility.

Treatment

Distinguish conservative and surgical treatment.

It is possible to do without surgery in the following situations:

• in the absence of displacement of fragments;
• when offset less than 10 mm;
• if the function of the limb was violated before injury.

With the conservative tactics of patient maintenance, the hand is fixed with the help of gypsum flashes or other devices that are widely used in modern traumatology. The deadlines of immobilization are determined individually taking into account the characteristics of the patient and the nature of the injury.

Rice4 a. On radiographs, the fracture of the shoulder bone, osteosynthesis pin and screws, b. Conceptual image of osteosynthesis plate and screws.

If surgical treatment is needed, osteosynthesis or endoprosthetics are performed. With osteosynthesis, metal structures are used to fix fragments: plates, screws, pins. The specialist will make an accurate reposition of fragments and reliable fixation. After treatment, the hand function is completely restored.

In the elderly patients, the head of the shoulder bone is insufficient, and the changes caused by osteoporosis do not allow to fix fragments by the osteosynthesis using multi-dashed fractures. In this case, it is advisable to endoprosthetics - replacing the damaged joint on the artificial prosthesis. The recovery period after such treatment is minimal, and the results exceed all expectations.

Fig. 5. a. On radiographs: a consolidated brachial fracture; b. Total endoprosthetics of the shoulder joint with reversible endoprosthesis.

In our clinic has accumulated enormous experience in the treatment of fractures of the proximal end of the shoulder bone. We use advanced techniques, which allows you to achieve a positive result even in difficult cases.

We will help you in a short time to restore the functions of the joint and return to the usual way of life.