Humeral condyle fractures. Humeral condyle Humeral condyle

Transcondylar fracture and epiphysiolysis of the lower epiphysis of the humerus

A transcondylar (extensor and flexion) fracture is an intra-articular fracture. It occurs when falling on an elbow bent at an acute angle. The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence (G. M. Ter-Egiazarov, 1975).

Symptoms and recognition. In area elbow joint there is swelling, and there is hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. Symptoms are uncommon, so a transcondylar fracture of the shoulder can easily be confused with a sprain ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Treatment . Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

In adults, transcondylar fractures are treated in the same way as supracondylar fractures.

Intercondylar fractures of the humerus

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example when falling on the elbow with high altitude etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be like

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of the bony protrusions is very painful. Active movements in the joint are impossible; with passive movements, strong pain, bone crunch and abnormal mobility in the anteroposterior and lateral directions. Without radiographs taken in two projections, it is impossible to have an accurate idea of the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle of 90-100°, and the forearm is fixed in an average position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped on the 18-21st day and they begin dosed movements in the elbow joint, gradually increasing in volume, using a removable splint at first. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

In children, a single-stage reduction is usually performed under anesthesia, followed by fixation with a plaster splint. The hand is suspended on a scarf. The elbow joint is immobilized at an angle of 100°. Movement in the elbow joint begins in children with displaced fractures after 10 days.

If reposition is unsuccessful, skeletal traction is indicated for the upper part of the ulnar spine with compression of the condyles for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults.

Surgical treatment. It is proven if the reduction of fragments using the described method fails or there are symptoms of a disorder of the innervation and blood circulation of the limb. The operation is performed under anesthesia. The incision is made longitudinally along

the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought above the skin (so that they can be easily removed) or left under the skin (Fig. 59). You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children – after 10 days.

In case of improperly healed fractures, severe limitation of movements, ankylosis of the elbow joint, especially in a functionally disadvantageous position, arthroplasty is performed in adults. In children, resection of the elbow joint and arthroplasty are not indicated due to possible growth arrest of the limb. Surgery should be delayed until adulthood. In elderly and senile patients with intra-articular fractures, they are limited to placing the limb in a functionally advantageous position and functional treatment.

Fracture of the lateral condyle of the humerus

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. Head radius, resting against the capitate eminence of the shoulder, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (90-180°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.

Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture great importance have radiographs taken in two projections; Without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. Cause

The point is that although the ossification nucleus of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Treatment . Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle of 90-100°.

Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

puts his hand on the inner surface of the patient’s elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded. The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he places his hands also on the anterior and posterior surfaces of the condyles of the shoulder, then on side surfaces and squeezes them. The piece gradually bends until right angle; After this, the surgeon compresses the condyles again and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is fixed in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks. In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

Surgical reduction is performed under intraosseous and local anesthesia or general anesthesia. The incision is made externally back surface humeral condyle (it must be borne in mind that the radial nerve is located more anteriorly). Remove blood clots and those embedded in the fragment bed soft fabrics.

To avoid avascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.

In most cases, the fragment is easily reduced when the elbow is extended and, if the elbow is then bent, it is held in place. The fragment can also be fixed by passing a catgut suture through soft tissue or through holes drilled with a drill or awl in the fragment and the humerus. In adults, the fragment can be fixed with a bone pin, wire, thin metal nail or screw. After this, the wound is sutured tightly and a plaster cast is applied to the shoulder and forearm, bent at the elbow joint. The forearm is given a position intermediate between pronation and supination. In adults, the plaster cast is removed after 3-4 weeks, and in children, the splint is removed after 2 weeks. Further treatment is the same as for fractures without displacement or after manual reduction.

A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, etc.) observed good results after removal of the lateral condyle for chronic fractures with limited movement. However, you should, if possible, avoid removing the lateral condyle of the shoulder, not only in fresh, but also in old cases, and strive to set the fragment. When the dislocated lateral condyle is unreduced, or after its removal, valgus elbow develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overextension, permanent trauma and even pinching. In cases where symptoms of secondary damage to the ulnar nerve appear, there may be indications for moving it from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the internal condyle of the humerus

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through

olecranon to condyle; in this case, the olecranon process is broken first, and not the internal condyle of the shoulder. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until the age of 10-12 and, therefore, has great elasticity, which resists acting force when falling on your elbow.

Symptoms and recognition. There is hemorrhage, swelling in the area of the elbow joint, pain when pressing on the internal condyle, crepitus and other usual symptoms that were mentioned when describing fractures of the external condyles, but they are determined from the inside. The forearm can be adducted at the elbow joint, which cannot be done normally and with other fractures of the humeral condyles. 42 43

Fractures of the humeral condyles occur when falling on an outstretched and abducted arm. In this case, the acting force is most often transmitted through the head of the radius, then the external condyle is damaged, in rare cases - through the olecranon process, then the internal condyle of the humerus is damaged. These fractures are intra-articular. The displacement of the condyles occurs predominantly upward and outward, although in some cases a rotational displacement is also noted and the condyle is rotated outward by the plane of the fracture.

Symptoms. With fractures without displacement, the diagnosis is difficult to make. In the area of the elbow joint there is swelling, pain corresponding to the damaged condyle, and some limitation of movements in the elbow joint due to pain. When the condyle, especially the external one, is displaced, in the first hours one can clearly see a violation of the configuration of the joint, and upon palpation a mobile displaced condyle is sometimes determined. To clarify the diagnosis, radiography in two projections is required.

For non-displaced condyle fractures, treatment is carried out by immobilizing the arm with a posterior plaster splint or circular plaster cast with the elbow bent at a right angle and the forearm placed in a mid-position between pronation and supination. A bandage or splint is applied from the heads of the metacarpal bones to the upper third of the shoulder. The fixation period is 2-3 weeks in children, 4 weeks in adults.

If the condyles are displaced, but without rotating them around their axis, it is necessary to perform a reduction, local anesthesia for adults (15-20 ml of 1% novocaine solution), and anesthesia for children. When the lateral condyle is fractured, the arm is extended at the elbow joint. The assistant fixes the hand with one hand, and with the other rests on the inner surface of the elbow joint. Traction along the axis of the forearm and adduction of the forearm along outer surface In the elbow joint, some diastasis is created, which allows the surgeon to press the displaced condyle downward and inward with the thumbs of both hands to push the fragment into place.

After this, the arm is given a flexion position to an angle of 90-100°. X-ray control is performed and, if the position of the condyle is favorable, the limb is fixed with a posterior plaster splint or circular plaster cast for a period of 2-3 weeks for children and 4 weeks for adults.

When reducing the internal condyle, the same technique is followed, but instead of adducting the forearm, abduction is performed. In cases where closed reduction was not successful, as well as in cases of condyle fractures with the fragment rotated around its axis, when closed reduction is ineffective, as well as in cases of old fractures (more than 5 days), open reduction of the condyle is indicated. The essence of the operation is to reduce and hold the condyle, which is fixed to the maternal bed with catgut or silk in children and screws, bone pins or metal knitting needles in adults (Fig. 38). Postoperative fixation with a plaster cast or posterior plaster splint for 3-4 weeks.

With all treatment methods, from the first days movements begin in the fingers, in the shoulder joint, and after immobilization stops, in the elbow joint. Massage the muscles of the shoulder and forearm. Working capacity is restored within up to 8 weeks.

Rice. 38. Fixation of the external condyle of the humerus.

Brachial bone- people put different meanings into this concept. If we consider the anatomy, the shoulder belongs to the upper part of the free upper limb, that is, hands. If we consider the anatomical nomenclature, this section starts from the shoulder joint and ends at the bend of the elbow. According to anatomy, the shoulder is the shoulder girdle. It connects the free upper part to the body. It has a special structure, thanks to which the number and range of movements of the upper limb increases.

Bone anatomy

There are two main bones of the shoulder girdle:

Spatula. As you know, this is a flat bone that has a triangular shape. It is located at the back of the body. It has three edges: lateral, medial and superior. Between them there are three angles: upper, lower and lateral. The last of them has a large thickness and a glenoid cavity necessary for the articulation of the scapula and the head of the humerus bone. Adjacent to the depression is a narrowed place - the neck of the scapula. Above the joint cavity there are tubercles - subarticular and supraarticular. The lower corner is easy to feel under the skin; it is located almost at the level of the upper edge of the rib, the eighth in a row. The upper one is located upward and inward.

The costal scapular surface faces the chest. The surface is slightly concave. With its help, the subscapular fossa is formed. The dorsal surface is convex. It has a spine that divides the dorsal scapular surface into two muscles. The spine can be easily felt under the skin. Outwardly, it transitions into the acromion, located above the shoulder joint. It is with the help of its outer extreme point that you can determine the width of the shoulders. There is also a coracoid process, which is necessary for the attachment of ligaments and muscles.

Collarbone. It is a tubular bone curved in an S-shape. It connects to the sternum at the medial end, and to the scapula at the lateral end. The collarbone is located under the skin and is easy to feel. It is attached to the chest cage with the help of ligaments and muscles. The connection to the shoulder blade is made using ligaments. Therefore, the lower surface of the clavicle has roughness - lines and tubercles.

The shoulder itself consists of one humerus bone. This is a typical tubular bone. Her body is in upper section has a round shape. The lower section has a triangular shape. At the proximal epiphysis of the bone there is the head of the humerus. Its shape is a hemisphere. She, being in this proximal section, is turned towards the scapula. The articular surface rests on it, and the anatomical neck of the humerus bone adjoins it. Outside the neck there are two tubercles that are needed for muscle attachment.

With regard to the greater tubercle of the humerus, we can say that it faces outward. The other tubercle, the small one, faces anteriorly. A crest extends from the greater tubercle of the humerus and the lesser. There is a furrow between them and the ridges. The tendon of the head of the biceps brachii muscle passes through it. There is also a surgical neck, that is, the narrowest part of the shoulder bone, which is located below the tubercles.

The humerus has a deltoid tuberosity. The deltoid muscle is attached to it. During sports training, an increase in this tuberosity and the thickness of the compact bone layer is observed. The groove of the radial nerve runs along the posterior bone surface. The condyle is formed by the distal epiphysis of the humerus.

It has the articular surface necessary to connect to the bones of the forearm. The surface of the joint on the medial side that connects to the ulna is called the trochlea of the humerus. Above it there are pits in front and behind. When flexion and extension of the forearm occur, they include the processes of the elbow bone. The lateral surface is called the head of the condyle of the humerus.

It has a spherical shape and is connected to the radius. The distal end has two epicondyles on both sides, lateral and medial. They are easy to feel under the skin. Their role is to attach ligaments and muscles.

Anatomy of the ligamentous apparatus of the shoulder

It is important to consider the anatomy of not only the bones and their location, but also the ligamentous apparatus.

Damage

The humerus is susceptible to many injuries. One of them is. They are more common in men.

The humerus can break, but in different places:

Fractures of the anatomical neck of the bone, head

They occur as a result of a fall on the elbow or due to a direct blow. If the neck is damaged, wedging of the distal part into the head is observed. The head can be deformed, crushed, and also come off, but in this case it will be turned by the cartilaginous surface towards a fragment of a distal nature.

Signs include bleeding and swelling. The person cannot make active movements and feels pain. If you perform passive rotational movements, the greater tubercle will move together with the shoulder. If the fracture is impacted, the signs are not so pronounced. The victim can make active movements. The diagnosis is confirmed using x-rays.

For impacted fractures of the neck and head, treatment is outpatient. The hand is immobilized. A person takes analgesics and sedatives internally. Physiotherapy is also prescribed. After a month, the splint is replaced with a scarf-type bandage. Working capacity is restored after two and a half months.

Surgical neck fracture

Non-displaced injuries are usually impacted or pinched. If displacement has occurred, the pearl can be adductive or abductive. Adduction fractures occur in the event of a fall with emphasis on the adducted outstretched arm. Abduction fractures occur in the same situation, only the arm is abducted.

If there is no displacement, then local pain is observed, which intensifies with axial load. The humerus may retain its function, but it will be limited. If displacement occurs, the main symptoms are severe pain, pathological mobility, disruption of the shoulder axis, shortening, and dysfunction. First aid consists of administering analgesics, immobilization and hospitalization.

The greater tuberosity suffers mainly from shoulder dislocation. It is torn off and displaced due to reflex contraction of the minor, infraspinatus and supraspinatus muscles. If an isolated fracture occurs, then, most likely, as a result of a bruise of the shoulder, displacement in this case is not observed.

Symptoms of such injuries are pain, swelling, and crepitus.

Even passive movements bring severe pain. If the injury is not combined with displacement, immobilization is performed with a Deso bandage. You can also use a scarf. The immobilization period is two or three weeks.

If the fracture is avulsion and combined with displacement, reduction and immobilization is done with a splint or plaster bandage. If there is large swelling and, shoulder traction is used for two weeks. After the patient begins to freely raise the shoulder, abduction of the arm with the splint is stopped. Rehabilitation lasts from two to four weeks.

Fracture of the diaphysis of the bone

It occurs as a result of a blow to the shoulder, as well as a fall on the elbow. Symptoms: dysfunction, shoulder deformity, shortening. Hemorrhage, pain, crepitus and pathological mobility are also observed. First aid is the administration of analgesics and immobilization with a transport splint. Fractures of the diaphysis in the lower and middle third treated with skeletal traction. Upper third injuries are treated with an abduction splint and shoulder abduction. Immobilization lasts from two to three months.

Fractures in the distal region

Extra-articular fractures can be either extension or flexion, depending on the position of the fall. Intra-articular fractures are transcondylar injuries, V- and T-shaped injuries, as well as fractures of the head of the condyle. Symptoms include pain, crepitus, abnormal mobility, and flexed forearm. First aid consists of transport immobilization with a splint; you can use a scarf. Analgesics are also administered.

Bones shoulder girdle play an important role in the implementation of movements. They need to be protected, because any damage takes a long time to heal.

The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence.

Symptoms and recognition.

There is swelling in the area of the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited.

Symptoms are uncommon, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts itself between the split condyles, moves them apart and so-called T- and Y-shaped fractures of the humeral condyles occur. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be of either flexion or extension type. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition.

When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed.

Without radiographs taken in two projections, it is impossible to have an accurate idea of the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle, and the forearm is fixed in an intermediate position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

The traction is stopped the next day and they begin measured, gradually increasing in volume movements in the elbow joint, using initially a removable splint. Treatment can be carried out; on the same day or the next, the diverged condyles of the humerus are brought together by also using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

If reposition is unsuccessful, skeletal traction on the upper part of the ulna with compression of the condyles is indicated for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.

A longitudinal incision is made in the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought out above the skin (so that they can be easily removed) or left under the skin (Fig.).

You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children after 10 days.

Rice. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and from the inside, outwards and upwards and always penetrates into the joint.

Symptoms and recognition.

A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful.

When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. The reason is that although the ossification nucleus of the external condyle is visible in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.

Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle°.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. The assistant places his hand on the inner surface of the patient's elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded.

The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The elbow is gradually bent to a right angle, after which the surgeon again compresses the condyles and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks.

In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

In order to avoid non-vascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through the olecranon process to the condyle, and the olecranon process breaks first, and not the internal condyle of the humerus. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until the age of 10-12 and, therefore, has great elasticity, which resists the force of a fall on the elbow.

Symptoms and recognition.

There is hemorrhage, swelling in the area of the elbow joint, pain when pressing on the internal condyle, crepitus and other usual symptoms that were mentioned when describing fractures of the external condyles, but they are determined with inside. The forearm can be adducted at the elbow joint, which cannot be done normally and with other fractures of the humeral condyles.

Fractures of the internal condyle in adults are treated with skeletal traction on the upper part of the olecranon process on an abduction splint for a day, and subsequently with a removable splint and movements in the elbow joint. For this purpose, you can use knitting needles with thrust pads, as well as the Volkov-Oganesyan articulated compression-distraction apparatus.

Fracture of the capitate eminence of the humerus

Damage to the capitate eminence of the humerus can be isolated or combined with a fracture of the head of the radius and other intra-articular fractures. The mechanism of isolated fracture is associated with a fall on an outstretched arm. The head of the radius, moving upward and anteriorly, injures the articular surface of the capitate eminence articulating with it. Damage to it may be limited to depression of the cartilage in a limited area of the articular surface or separation of a small cartilaginous plate or bone fragment covered with cartilage. In some cases, a significant part of the capitate eminence and the adjacent articular block are broken off. The fragment moves anteriorly and upward.

Symptoms and recognition.

In case of an isolated injury with the formation of a small osteochondral fragment and a fracture of a significant part of the capitate eminence, pain and hematoma are localized in the area of the lateral condyle. A larger fragment that has shifted anteriorly and upward can sometimes be felt in the elbow area. Movement in the elbow joint is limited and painful. For recognition, radiographs taken in anteroposterior and lateral projections are crucial. In some cases, small free fragments, often elliptical in shape, can be detected on an x-ray taken after introducing air into the elbow joint. A defect in the outer part of the capitate eminence, if the fragment is small, is sometimes not detected on an x-ray. Damage to the articular cartilage is observed more often in combination with a fracture of the radial head. This combination is found mainly during operations for fractures of the head of the radial bone. If a small plate or osteocartilaginous fragment has separated from the capitate eminence, then when flexing and rotating the forearm, a free fragment between the articular surface of the head of the radius and the capitate eminence may occur, impeding movement, in the manner of entrapment of an articular muscle. This makes it easier to recognize damage to the capitate eminence.

If the fact of a fall on an outstretched arm is established and pain is noted when flexing and rotating the forearm, and the radiograph excludes a fracture, isolated damage to the cartilage of the capitate eminence of the shoulder can be suspected.

Isolated cartilage lesions in early dates after injury, as a rule, are not recognized. Only long-term pain, blockade of the elbow joint, limitation of movements, pain during extension and rotation of the forearm that arose after a fall on an outstretched arm, and, finally, an x-ray taken some time after the injury indicate the development of osteochondritis dissecans in the area of the articular surface of the capitate eminence and suggest that vascular necrosis is a consequence of cartilage contusion.

A fracture of a significant part of the capitate eminence with anterior and upward displacement of the fragment in most cases can be reduced manually.

Rice. Fracture of the capitate eminence with displacement (a). Surgical reduction and transarticular osteosynthesis with a wire (b).

A ml of 1% novocaine solution is injected into the fracture area. The patient lies on the table, the arm is extended at the elbow joint. The assistant grabs the forearm above the hand and stretches the elbow joint. The flexion surface of the arm should be facing upward. The surgeon places the bent leg on a stool, places his knee under the patient’s elbow and presses the fragment with two thumbs downwards and backwards into its bed. Then bend the elbow to a right angle and apply a plaster cast to the shoulder and forearm in a pronated position. In some cases, the fragment is better retained when the elbow is fully extended. If the control x-ray shows good alignment of the fragments, the plaster cast is left in this position for 3-4 weeks, after which movements in the elbow joint begin. Full recovery function occurs only after 3-4 months.

The time frame for restoration of working capacity depends on the patient’s profession and on which arm is injured - the right or left. These periods range from 2-4 months. If a control radiograph shows that the fragment could not be reduced, surgical reduction is indicated rather than removal of the fragment, since in the latter case the function of the joint often suffers. In children, the fragment is fixed to the bed with catgut sutures, and in adults, with 1-2 knitting needles, which are passed transarticularly - from the extensor surface through the external condyle into the reduced fragment of the capitate eminence into the radius (Fig.). The ends of the needles remain above the surface of the skin. The needles are removed after 2-3 weeks. In case of developed osteochondritis dissecans (Konig's disease) and repeated blockades, it is indicated surgical removal separated section of cartilage.

Fracture and apophysiolysis of the internal epicondyle of the humerus

A fracture of the internal epicondyle occurs mainly with a sudden and strong abduction of the extended forearm. In this case, the internal collateral ligament is greatly strained and tears off the epicondyle, which usually moves downwards. In adolescence, with this mechanism, the epicondyle is separated along the apophyseal cartilaginous line.

This fracture is classified as periarticular. In some cases, the elbow joint bursa ruptures. Sometimes the epicondyle, torn off and connected to the internal collateral ligament, is pinched between articular surfaces olecranon and shoulder trochlea and can pull the ulnar nerve with it.

A fracture can also occur with direct severe bruise internal epicondyle, which is sometimes accompanied by damage to the ulnar nerve located in the groove behind the epicondyle. Avulsions of the internal epicondyle are also observed with dislocations of the elbow joint.

Symptoms and recognition.

In the area of the internal epicondyle, limited hematoma and swelling are visible, and pain is localized here. If the swelling is small, it is possible to palpate the movable fragment. Active and passive movements in the absence of hemorrhage in the elbow joint are possible and not very painful. When a fragment is pinched between the articular surfaces of the olecranon and the shoulder block, movements in the elbow joint are impossible and cause sharp pain. It is characteristic that against the normal forearm it is possible to abduct and give the elbow a valgus position. As soon as abduction stops, the forearm returns to its previous position. To recognize a fracture, radiographs in two projections are of great importance. The examination needs to determine whether there is damage to the ulnar nerve.

For fractures or separation of the internal epicondyle along the apophyseal line without displacement and with displacement to the level of the joint space, a plaster cast is used, which fixes the elbow joint at a right angle, and the forearm in a position intermediate between pronation and supination. The bandage is removed alternately and movements in the elbow joint are prescribed. The prognosis is good even with displacement of the internal epicondyle. Working capacity is restored after 4-6 weeks.

If the internal epicondyle is pinched in the elbow joint, urgent surgical treatment is indicated. Sometimes it is possible to remove the fragment from the joint when the shoulder is abducted without resorting to surgery. But such a reduction is not advisable, since the ulnar nerve can be injured, and this is an extremely serious complication.

The operation should be performed immediately as soon as the insertion of the internal epicondyle into the elbow joint is recognized based on clinical and radiological studies. The intervention is performed under intraosseous, local or general anesthesia. An incision is made on the inside of the elbow joint. It must be remembered that the ulnar nerve runs somewhat posteriorly. After longitudinal dissection of the deep fascia and spreading the wound with hooks, the site of the epicondyle tear is exposed and it is discovered that the epicondyle, together with the soft tissues, has penetrated into the elbow joint. By expanding the inner part of the joint space by abducting the forearm, it is easy to pull the epicondyle with the soft tissues attached to it from the joint. The internal epicondyle is sutured to the bed by passing two catgut sutures through the soft tissue. It is better to move the ulnar nerve anterior to the internal epicondyle (normally it is located in the groove behind) - this prevents subsequent trauma to the nerve in the rough posterior groove and its compression in the ossifying soft tissues. The wound is sutured tightly and a plaster cast is applied to hold the elbow at a right angle. The bandage is removed after 3 weeks and movements in the elbow joint are prescribed. Working capacity is restored after 6-7 weeks.

Rice. Infringement of the external epicondyle in the elbow joint together with the muscles attached to it before (a) and after (b) surgery.

Fracture and apophysiolysis of the lateral epicondyle of the humerus

A fracture of the external epicondyle is observed much less frequently than the internal one, occasionally in young people. Occurs when there is a sudden strong adduction of the forearm in an extended position. More often, the external tank ligament is torn off along with a small bone plate from the external epicondyle of the shoulder. Avulsions of the lateral epicondyle with varying degrees of displacement are observed, including pinching between the articular surfaces of the lateral condyle of the humerus and the head of the radius.

Symptoms and recognition.

The signs are the same as for a fracture of the internal epicondyle, but they are localized in the area of the external epicondyle. When the external epicondyle is torn off, the forearm in the elbow joint can be adducted, giving it a varus position, which immediately levels out as soon as the adduction stops. When the lateral epicondyle is displaced into the joint, a blockade is observed. Of great importance for recognition is X-ray examination, especially the radiograph in the anteroposterior projection.

For fractures of the external epicondyle without displacement or with slight displacement, a plaster cast is applied above, and in children, a splint is applied to the elbow joint bent at a right angle. Then movements in the elbow joint are prescribed. Working capacity is restored after 4-5 weeks.

The operation is performed under local anesthesia. An incision is made externally above the epicondyle area. If the epicondyle is significantly displaced, suturing the fragment to the bed is indicated. In cases of entrapment of the lateral epicondyle in the elbow joint, the fragment is removed from the joint along with the muscles attached to it and sutured to the site of the avulsion (Fig.).

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The article talks about a fracture of the shoulder in the condyle area. Methods of treatment and rehabilitation after injury are described. Transcondylar fracture of the humerus is not observed very often by traumatologists. Most injuries occur in childhood. In view of anatomical features structural injury leads to the development of complications.

Structural features

The condyles of the humerus are located in its distal section, part of the elbow joint. There are two condyles - medial and lateral. The area of bone between them is thinned, which creates the preconditions for the formation of a fracture.

Here are the attachment points for the muscles of the shoulder and forearm, blood vessels and nerves. Damage to them during a fracture leads to the development of complications. The video in this article talks about the structure of the elbow joint.

Causes and types of injury

Transcondylar fractures occur due to excessive extension or flexion of the limb. An extensor fracture of the right humerus is observed much more often than others.

The main cause of occurrence is a fall on an arm that is bent or hyperextended at the elbow. A frequently occurring fracture in children is explained by the characteristics bone tissue and its lowest strength in this area. Also, children are more active and can get injured during outdoor games.

The incidence of this fracture in childhood is so high that it is considered a fracture in a typical location. Such an injury is intra-articular, since this entire area is located in the cavity of the elbow joint.

Manifestations

What is a transcondylar fracture from a clinical point of view? Manifestations of injury are not always specific and it is necessary to distinguish it from a dislocation or severe bruise.

The deformity of the limb is not always noticeable; it is masked by pronounced swelling and a growing hematoma in the elbow area. If the fracture is flexion in nature, the limb looks longer compared to a healthy one. Conversely, if the injury occurs as a result of hyperextension of the arm, the limb is relatively shortened.

The broken section of the bone rises up and rotates due to muscle traction - this is how a displaced fracture is formed. Because of this, the position of the shoulder does not correspond to the position of the forearm. With palpation and attempts to move, there is an increase in pain in the elbow area. Pathological mobility in lateral directions is observed.

Such a fracture without displacement is quite rare. It can usually be observed in children with poorly developed arm muscles.

Fractures can be closed or open. The first option is more common.

Injury with displacement is fraught with the development of complications in the form of damage to nerves and blood vessels, as well as muscle separation.

Diagnostics

A closed injury with displacement is determined by visual inspection not always possible. Dislocation in the elbow joint is characterized by similar symptoms.

To clarify the diagnosis, X-ray examination is used. The picture is taken in two projections. The doctor evaluates the fracture line and the extent of bone damage. If necessary, a comparative photograph of a healthy elbow joint is taken.

Treatment

The victim must be taken to medical institution for diagnosis and follow-up. For transportation, it is necessary to immobilize the limb. It is carried out using ladder tires or bandage. Adequate pain relief is provided.

Basic treatment

If the fracture is incomplete and there is no displacement, it can be treated on an outpatient basis. The limb is covered with plaster for a period of 4 weeks. In the presence of displacement or complex fractures, inpatient treatment using various techniques is indicated.

Table. Treatment methods:

Important! Restoration of movements in the limb with surgical intervention occurs much faster than with conservative treatment.

Rehabilitation treatment

The injury is subject to mandatory rehabilitation. These measures are aimed at preventing complications and recovery motor function.

Rehabilitation treatment consists of:

taking medications;
physiotherapeutic procedures;
massage and therapeutic exercises;
proper nutrition.

The patient is prescribed a nutritious diet high in protein and calcium. These substances are necessary for bone tissue restoration and fracture healing.

The same goal is pursued by the prescription of medications.

They are used to make the patient feel better and prevent complications associated with damage to bones and cartilage:

Anti-inflammatory drugs. Prescribed to relieve pain and eliminate swelling. Used in the form of tablets and ointments - Ibuprofen, Ketonal.
Chondroprotectors. With intra-articular fractures, damage to cartilage is inevitable, so drugs are prescribed to restore them - Artra, Teraflex, Chondroxide. They can also be taken orally and applied to the damaged area.
Calcium preparations. This is the main element of bone tissue, so such drugs are prescribed for any fracture. The instructions provide for their oral administration - Calcium-D3-Nycomed, Kalcemin.
B vitamins. Protect nerve fibers from damage, stimulate the restoration of muscles and ligaments. Taken orally or as intramuscular injections- Kombilipen, Milgamma.

Buy medicines Available at a pharmacy, price varies depending on the manufacturer. Physiotherapeutic procedures begin on the 2-3rd day of treatment, provided normal temperature bodies.

They use techniques such as:

electrophoresis of drugs;
magnetic therapy;
paraffin applications;
diadynamic currents.

A plaster cast makes these manipulations difficult. In order not to refuse physical treatment, a small hole is cut in the plaster through which the procedures are carried out. Physiotherapy helps improve microcirculation in the damaged area, relieves pain and reduces swelling.

Massage and physiotherapy– the basis of rehabilitation treatment for fractures. These methods are aimed at restoring motor function of the limb. They also need to be started on the second or third day. At first the load is minimal.

The massage is carried out with light stroking movements, therapeutic exercises consist of passive movements of the limb. As callus forms, the volume of exercise increases.

A transcondylar fracture of the humerus heals completely in most cases. There are no motor dysfunctions. Subsequently, the development of elbow arthrosis and impaired sensitivity of the limb is possible.

Intercondylar fracture of the humerus

Symptoms and recognition. There is swelling in the area of the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. The symptoms are uncharacteristic, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches 25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.

Treatment. Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface. The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for a day. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).

In adults, transcondylar fractures are treated in the same way as supracondylar fractures.

Intercondylar fractures of the humerus

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed. Without radiographs taken in two projections, it is impossible to have an accurate idea of the nature of the fracture. It is important to diagnose damage to blood vessels and nerves in a timely manner.

Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle, and the forearm is fixed in an intermediate position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-Oganesyan articulated apparatus. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.

For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped the next day and they begin measured, gradually increasing in volume movements in the elbow joint, using initially a removable splint. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.

Fracture of the lateral condyle of the humerus

Fracture of the external condyle is not uncommon, especially common in children under 15 years of age. A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The head of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.

Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of the elbow joint. When the condyle is displaced upward, the external epicondyle stands higher than the internal one. The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; Without them it is difficult to make an accurate diagnosis. Sometimes difficulties arise when interpreting radiographs in children. Cause

Treatment. Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle°.

Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.

If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

puts his hand on the inner surface of the patient’s elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded. The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The piece is gradually bent to a right angle; After this, the surgeon compresses the condyles again and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is fixed in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks. In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it. In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.

Surgical reduction is performed under intraosseous and local anesthesia or general anesthesia. An incision is made along the outer posterior surface of the humeral condyle (it must be borne in mind that the radial nerve is located more anteriorly). Blood clots and soft tissue embedded in the fragment bed are removed.

A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, etc.) observed good results after removal of the lateral condyle for chronic fractures with limited movement. However, if possible, you should avoid removing the lateral condyle of the shoulder, not only in fresh, but also in old cases, and strive to set the fragment. When the dislocated lateral condyle is unreduced, or after its removal, valgus elbow develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overextension, permanent trauma and even pinching. In cases where symptoms of secondary damage to the ulnar nerve appear, there may be indications for moving it from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the internal condyle of the humerus

Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through

olecranon to condyle; in this case, the olecranon process is broken first, and not the internal condyle of the shoulder. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until adulthood and, therefore, has great elasticity, which resists the force of a fall on the elbow.

Transcondylar fracture of the humerus

This fracture is classified as intra-articular. The fracture plane passes over or through the epiphysis and has a transverse direction.

In cases where the fracture passes through the epiphyseal line, it takes on the character of epiphyolysis.

Causes

There are extensor transcondylar fractures, resulting from a fall on an extended arm at the elbow joint, and flexion fractures, resulting from a fall on the elbow.

Symptoms

The area of the elbow joint is increased in volume, deformed, and the contours of the joint are unevenly expanded. The forearm is bent at the elbow joint and appears shortened, the function of the elbow joint is impaired.

On palpation - pain in the upper part of the elbow joint, a positive symptom of fluctuation.

With flexion fractures, the area of the elbow joint is increased in volume, deformed due to the anterior or anterolateral part of the joint, the function is impaired, the forearm appears elongated, the contour of the olecranon process is smoothed, a positive symptom of fluctuation, Huter’s triangle and Marx’s sign are disrupted.

Passive movements in the elbow joint are sharply limited, aggravate the pain, and crepitus of the fragments is detected. Clinical picture resembles an anterior traumatic dislocation of the forearm.

Differential diagnosis

Does not present any difficulties, since children traumatic dislocations are very rare, there are no symptoms pathognomonic for dislocations - elastic mobility, and the above-mentioned reliable symptoms of a fracture come to the fore.

Urgent Care

Treatment

Conservative - closed simultaneous comparison of fragments is carried out as for fractures above the condyles of the humerus, taking into account the type of fracture (extension or bending), immobilization lasts 3-4 weeks.

With transcondylar fractures, trauma to the ulnar nerve (bruise, pinching, compression) is possible. With bruises and slight pinching of the ulnar nerve, victims complain of paresthesia in the innervation zone of the fifth and half of the fourth fingers, and when compressed, a decrease or absence of sensitivity in the innervation zone.

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Forearm injuries

Distal humerus fractures

Causes. Supracondylar (extra-articular) fractures are divided into extension ones, which occur when falling on an outstretched arm, and flexion ones, which occur when falling on a sharply bent elbow. Intra-articular fractures include transcondylar fractures, T- and V-shaped condylar fractures, and a fracture of the head of the humeral condyle (Fig. 46).

Signs: deformation of the elbow joint and the lower third of the shoulder, the forearm is bent, the anteroposterior size of the lower third of the shoulder is increased, the olecranon is displaced posteriorly and upward, and there is retraction of the skin above it. A hard protrusion (the upper end of the peripheral or lower end of the central fragment of the humerus) is palpated in front above the elbow bend. Movement in the elbow joint is painful. V.O. Marx’s symptom is positive (violation of the perpendicularity of the intersection of the shoulder axis with the line connecting the epicondyles of the shoulder - Fig. 47). In intra-articular fractures, in addition to deformation, pathological mobility and crepitus of fragments are determined. These fractures should be differentiated from forearm dislocations. Integrity control is required brachial artery and peripheral nerves! The final nature of the damage is determined by radiographs.

46. Options fractures distal metaepiphysis humerus bones.

1, 4 - lateral And medial fractures condyle ;

2 -fracture heads condyle; 3, 5-V- And T-shaped fractures ;

6, 7 - extensor And flexion supracondylar fractures; 8 -transcondylar fracture

47. Sign V.O. Marx. a-c normal ; b-pri supradisylar fracture brachial bones.

48.Reposition fragments at supracondylar fractures brachial bones. a-pri flexion fractures ; b-pri extensor fractures.

Treatment. First aid - transport immobilization of the limb with a splint or scarf, administration of analgesics. Reposition of fragments in supracondylar fractures is carried out after anesthesia by strong traction along the axis of the shoulder (for 5-6 minutes) and additional pressure on the distal fragment: for extension fractures anteriorly and inwardly, for flexion fractures - posteriorly and inwardly (the forearm should be in the position pronation). After reposition, the limb is fixed with a posterior plaster splint (from the metacarpophalangeal joints to the upper third of the shoulder), the forearm is bent to 70° (for extension fractures) or up to 110° (for flexion fractures - Fig. 48).

The hand is placed on the abductor splint. If the reposition is unsuccessful (x-ray control!), then skeletal traction is applied to the olecranon process. The period of immobilization with a plaster splint is 4-5 weeks. Rehabilitation - 4-6 weeks. Working capacity is restored after 2/2-3 months. With these fractures, there is a risk of damage to the brachial artery with subsequent disruption of muscle nutrition, which leads to the development of ischemic Volkmann contracture.

The use of external fixation devices has significantly increased the possibilities of closed reduction of fragments and rehabilitation of victims (Fig. 49). Strong fixation is ensured by external osteosynthesis (Fig. 50).

In case of an intra-articular fracture without displacement of the fragments, a plaster splint is applied to the posterior surface of the limb in a position of flexion at the elbow joint at an angle of 90-100°. The forearm is in an average physiological position. The period of immobilization is 3-4 weeks, then - functional treatment(4-6 weeks). Working capacity is restored after 2-2*/2 months.

When fragments are displaced, skeletal traction is applied to the olecranon process on an abduction splint. After eliminating the displacement along the length, the fragments are compressed and a U-shaped splint is applied along the outer and inner surfaces of the shoulder through the elbow joint, without removing traction. The latter is stopped after 4-5 weeks, immobilization - 8-10 weeks, rehabilitation - 5-7 weeks. Working capacity is restored after 21/2-3 months. The use of external fixation devices reduces the time required to restore working capacity by 1-1*/2 months (Fig. 51).

Open reduction of fragments is indicated when there is a violation of blood circulation in the limb and its innervation. To fix fragments, rods, knitting needles, screws, bolts, and external fixation devices are used. The limb is fixed with a posterior plaster splint for 4-6 weeks. Rehabilitation - 3-4 weeks. Working capacity is restored after 21/2-3 months.

49. Outer osteosynthesis at fractures condyles brachial bones.

50. Interior osteosynthesis at fractures condyles brachial bones.

51. Outer osteosynthesis intra-articular fractures brachial bones.

FRACTURES OF THE HUMERAL CONDYLE IN ADOLESCENTS observed when falling on the hand of the abducted hand. The lateral part of the condyle is most often damaged.

Signs: hemorrhages and swelling in the elbow joint; movement and palpation are painful. Huther's triangle is broken. The diagnosis is confirmed by X-ray examination.

Treatment. If there is no displacement of the fragments, the limb is immobilized with a splint for 3-4 weeks in the position of flexion of the forearm to 90°. Rehabilitation - 2-4 weeks. When the lateral fragment of the condyle is displaced, after anesthesia, traction is performed along the axis of the shoulder and the forearm is deflected inward. The traumatologist sets it by applying pressure to the fragment. When repositioning the medial fragment, the forearm is deviated outward. A control radiograph is taken in a plaster splint. If closed reduction fails, then resort to surgical treatment with fixation of fragments with a knitting needle or screw. The limb is fixed with a posterior plaster splint for 2-3 weeks, then exercise therapy. The metal retainer is removed after 5-6 weeks. Rehabilitation is accelerated with the use of external fixation devices.

FRACTURES OF THE MEDIAL EPICONYLE.

Causes: fall onto an outstretched arm with outward deviation of the forearm, dislocation of the forearm (the torn epicondyle can become pinched in the joint during reduction of the dislocation).

Signs: local swelling, pain on palpation, limited joint function, violation of the isosceles of Huter's triangle, radiography helps to clarify the diagnosis.

Treatment the same as for a condyle fracture.

FRACTURE OF THE HEAD OF THE HUMERAL CONDYLE.

Causes: falling on an outstretched arm, while the head of the radial bone moves upward and injures the condyle of the shoulder.

Signs: swelling, hematoma in the area of the external epicondyle, limitation of movements. A large fragment can be felt in the area of the ulnar fossa. Radiographs in two projections are of decisive importance in diagnosis.

Treatment. The elbow joint is hyperextended and stretched with varus adduction of the forearm. The traumatologist sets the fragment by pressing it with two thumbs downwards and backwards. The forearm is then flexed to 90° and the limb is immobilized in a posterior plaster cast for 4 to 6 weeks. Control radiography is required. Rehabilitation - 4-6 weeks. Working capacity is restored after 3-4 months.

Surgical treatment is indicated for unresolved displacement, when small fragments blocking the joint are torn off.

A large fragment is fixed with a knitting needle for 4-6 weeks. Loose small fragments are removed.

During the period of restoration of the function of the elbow joint, local thermal procedures and active massage are contraindicated (they contribute to the formation of calcifications that limit mobility). Gymnastics, mechanotherapy, sodium chloride or thiosulfate electrophoresis, and underwater massage are indicated.

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Humeral shaft fracturesForearm injuries