Fractures of the shoulder condyle. Condyle of the humerus Condyle of the humerus

Percondylar fracture and epiphysis of the lower epiphysis of the humerus

Percondylar (extensor and flexion) fractures are intra-articular. It occurs when you fall on the elbow bent at an acute angle. The plane of the fracture has a transverse direction and passes directly over the epiphysis of the humerus or through it. If the fracture line passes through the epiphyseal line, it has the character of epiphyseolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, more often small. This overfilling occurs almost exclusively in childhood and adolescence (GM Ter-Egiazarov, 1975).

Symptoms and recognition... In the area of elbow joint there is swelling, 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 be easily confused with a stretching of the ligamentous apparatus. In most cases, a percondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be noted that in children, the lower epiphysis of the humerus is normally inclined somewhat (by 10-20 °) forward with respect to the longitudinal axis of the diaphysis of the shoulder. The angle of inclination forward is individual, but never reaches 25 °. To clarify the diagnosis, it is necessary to compare the lateral radiographs of the injured arm and the healthy arm. They must be made in the same and strict projections. Revealing the displacement of the lower epiphysis is of great practical importance, since fusion in the displaced position leads to a limitation of flexion, which is in direct proportion to the degree of increase in the angle of inclination of the epiphysis.

Treatment ... Reduction in children is performed under anesthesia. The surgeon puts one palm on the extensor surface of the lower shoulder, and the other applies pressure back to the lower epiphysis of the shoulder from the side of its flexion surface. In this case, the forearm should be in an extended position. After the reduction, the child's arm, extended at the elbow joint, is fixed with a plaster cast for 8-10 days. Then proceed to gradual movements in the elbow joint. Treatment can also be carried out by permanent 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 in 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 fracture of the humerus is intra-articular. T- and Y-shaped fractures are caused by direct force on the elbow, such as a fall on the elbow with great height and others. With this mechanism, the olecranon process splits the block from below and is introduced between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the diaphysis of the shoulder also inserts between the split condyles, pushes them apart and the so-called T- and Y-shaped fractures of the shoulder condyles occur. With this mechanism, sometimes there is a fragmentation of the condyles of the shoulder and often of the olecranon, or a fracture of the condyles is combined with dislocation and fracture of the forearm. These fractures can be like

flexion and extensor type. T- and Y-shaped fractures are less common in children than in adults. A fracture of both condyles of the shoulder can be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition... With a fracture of both condyles, 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 of the elbow joint in the area of the bony protrusions is very painful. Active movements in the joint are impossible, with passive movements are observed 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 fractures without displacement 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 in the middle position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using pins with thrust pads enclosed in an arc, or the Volkov-Oganesyan articulated apparatus. In children, the hand is fixed in the same position with a plaster cast and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements are prescribed in the shoulder joint and fingers. After removing the splint, the function of the elbow joint is well restored; in adults, sometimes there is a slight restriction of movement for 5-8 weeks. The ability to work of patients is restored after 4-6 weeks.

For the outcome of the treatment of T- and Y-shaped fractures of the shoulder condyles with displacement of fragments, good reduction of fragments is extremely important. In adults, it is achieved by skeletal traction behind the olecranon, which is carried out on an abduction splint or with the help of a Balkan frame when the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the separated condyles of the humerus are brought together by squeezing them between the palms and applying a U-shaped plaster splint on the outer and inner surfaces of the shoulder. Based on the X-ray, you should make sure that the fragments are in the correct position. The traction is stopped on the 18-21st day and begins to dosed, gradually increasing in the range of motion in the elbow joint, using a removable splint first. Treatment can also be carried out with the help of the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to start early movement in the elbow joint.

In children, a one-stage reduction is usually performed under anesthesia, followed by fixation with a plaster cast. The hand is suspended from a kerchief. Immobilization of the elbow joint is performed at an angle of 100 °. Movements in the elbow joint begin in children with displaced fractures after 10 days.

If reduction is not successful, skeletal traction for the upper part of the ulnar spine with compressed condyles is shown for 2-3 weeks in adults and 7-10 days in children. In some cases, if the fragments have straightened, it is possible to make closed transosseous fixation with their needles; 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 ossifying myositis and excessive calluses. Even with good standing of the fragments in cases of intra-articular fractures, there is often a restriction of movement in the elbow joint, especially in adults.

Surgical treatment. It has been proven if the reduction of fragments according to the described method fails or there are symptoms of a disorder of the innervation and circulation of the limb. The operation is performed under general anesthesia. The cut is made longitudinal 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 select it and take it on a holder from 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 condyle necrosis will occur. To connect the 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. 59). You can also use 12 thin nails or screws of the 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, carried through holes drilled or made with an awl in the bone. On the shoulder and forearm, bent at an angle of 100 °, a plaster splint is applied along the extensor surface and the hand 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 fused fractures, severe limitation of movement, 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 the possible arrest of limb growth. The operation should be postponed until adulthood. In old and senile age, intra-articular fractures are limited to the establishment of the limb in a functionally advantageous position and functional treatment.

Fracture of the outer condyle of the humerus

Fracture of the external condyle is common, especially in children under 15 years of age. The fracture occurs as a result of falling on the elbow or hand of an extended and abducted limb. Head radius, resting on the capitate eminence of the shoulder, splits off the entire external condyle, pineal gland and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The plane of the fracture has a direction from below and inwards outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, there are fractures with a slight shift of the condyle outward and upward. A more severe form is a fracture, in which the breakaway condyle is displaced outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (90-180 °) with its 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 common, followed by ulnar nerve involvement.

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

lies in the fact that although the core of the ossification of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not detected in the picture.

Treatment ... Fractures of the external 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. A percondylar multi-splintered fracture with a large displacement of fragments before and after osteosynthesis with wires.

If there is a displacement of the fragment outward with a slight rotation of the broken off 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 over the wrist joint, stretches along the length and brings the forearm. In this way, an easy varus position of the elbow is created and the space in the outer half of the elbow joint expands. The surgeon puts both thumbs on the fragment, pushes it up and inward into place. Then he puts his hands on the front and back surfaces of the shoulder condyles, then on the side surfaces and squeezes them. The chunk is gradually bent to right angle; the surgeon then compresses the condyles again and applies a plaster cast on the shoulder, forearm and hand. The elbow is fixed at an angle of 100 °, and the forearm is in a position average between pronation and supination. If the control X-ray shows that it was not possible to correct the fragment, an operative reduction is shown. If the reduction is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children - after 2 weeks. In some cases, despite the good reduction of the fragments and the timely started movements in the elbow joint, there remain varying degrees of limitation of flexion and extension in it. In order to be able to start early movements in the elbow joint, it is advisable to use closed osteosynthesis with pins with stubborn pads enclosed in an arch, or to use the Volkov-Oganesyan articulated compression-distraction apparatus.

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

In order 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, when the elbow is unbent, it can be adjusted easily and, if the elbow is then bent, it is held in place. The fragment can also be fixed by passing the catgut suture through the soft tissues or through the holes drilled with a drill or awl in the fragment and the humerus. In adults, the fragment can be fixed with a bone pin, knitting needle, thin metal nail or screw. After that, 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 midway between pronation and supination. In adults, the plaster cast is removed after 3-4 weeks, and the splint in children - 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 nice results after removal of the lateral condyle in old fractures with limited movement. You should still, if possible, avoid removing the external condyle of the shoulder, not only in fresh, but also in old cases, and strive to correct the fragment. With an unreduced dislocated external condyle, as well as after its removal, the hallux valgus develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overstretching, constant trauma and even pinching it. In cases where symptoms of a secondary lesion of the ulnar nerve appear, there may be indications for its movement from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the inner condyle of the humerus

Fractures of the inner condyle of the humerus are very rare. The mechanism of this fracture is associated with a fall and injury to the elbow. The active force \ 1 is transmitted through

olecranon to the condyle; in this case, first of all, the olecranon process breaks, and not the inner condyle of the shoulder. The fracture can also occur as a result of a blow to the inside of the elbow. In children, fracture of the internal condyle is rare because the block of the shoulder remains cartilaginous until the age of 10-12 years and, therefore, has great elasticity, which resists acting force when falling on the elbow.

Symptoms and recognition... There is hemorrhage, swelling in the elbow joint, pain when pressing on the inner condyle, crepitus, and other common symptoms that were mentioned in the description of fractures of the outer condyles, but they are determined from the inside. The forearm can be brought into the elbow joint, which cannot be done normally with other fractures of the shoulder condyles. 42 43

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

Symptoms... With fractures without displacement, the diagnosis is difficult. In the area of the elbow joint, swelling, soreness, respectively, of the damaged condyle, some restriction of movements in the elbow joint due to pain are determined. With a displacement of the condyle, especially the external one, in the first hours one can clearly see a violation of the configuration of the joint, and on palpation, a movable displaced condyle is sometimes determined. To clarify the diagnosis, radiography in two projections is required.

In case of condyle fractures without displacement, treatment is carried out by immobilizing the hand with a posterior plaster splint or a circular plaster cast with the elbow bent at a right angle and placing the forearm in the middle position between pronation and supination. A bandage or splint is applied from the heads of the metacarpals to the upper third of the shoulder. The fixation period is 2-3 weeks in children, 4 weeks in adults.

When the condyles are displaced, but without turning them around their axis, it is necessary to reposition, local anesthesia in adults (15-20 ml of 1% novocaine solution), in children - anesthesia. With a fracture of the external condyle, 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. By traction along the axis of the forearm and bringing the forearm along the outer surface of the elbow joint, some diastasis is created, which allows the surgeon to press the displaced condyle downward and inwardly on the displaced condyle into place with the thumbs of both hands.

After that, the arm is given a flexion position to an angle of 90-100 °. X-ray control is performed and, if the condyle is in a favorable position, 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 adjusting the internal condyle, the same technique is followed, but instead of bringing the forearm, abduction is performed. In cases where closed reduction was unsuccessful, as well as in fractures of the condyle with rotation of the fragment around the axis, when closed reduction is ineffective, as well as in case of stale fractures (over 5 days), open reduction of the condyle is indicated. The essence of the operation consists in the reduction and retention of 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 methods of treatment, from the first days, movements begin in the fingers of the hand, in the shoulder joint, and after the termination of immobilization, in the elbow joint. The muscles of the shoulder and forearm are massaged. Ability to work is restored in terms of 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, then 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 with the bend of the elbow. According to anatomy, the shoulder is the shoulder girdle. It connects the free upper part to the torso. He has a special structure, due to which the number and range of movements of the upper limb increases.

Bone anatomy

Two main bones of the shoulder girdle can be distinguished:

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

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

Collarbone. This is a tubular bone curved in an S-shaped way. It is connected to the sternum by the medial end, and to the scapula by the lateral end. The clavicle is located under the skin and is easy to feel. It is attached to the breast cage by ligaments and muscles. With a spatula, the connection is made using ligaments. Therefore, the lower surface of the clavicle has roughness - lines and tubercles.

The shoulder itself is made up of one humerus. This is a typical tubular bone. Her body in the upper section is rounded. The lower section has a triangular shape. On the proximal epiphysis of the bone is the head of the humerus. Its shape is hemisphere. She, being in this proximal section, is turned towards the scapula. The articular surface is supported on it, and the anatomical neck of the shoulder bone is adjacent to it. Outside the neck there are two tubercles that are needed to attach the muscles.

In relation to the large tubercle of the humerus, we can say that it faces outward. Another tubercle, small, is facing anteriorly. A crest extends from the large tubercle of the humerus and the small one. There is a furrow between them and the ridges. The tendon of the head of the shoulder muscle of the biceps type passes through it. There is also a surgical neck, that is, the most narrowed place of the shoulder bone, which is located below the tubercles.

The humerus has a deltoid tuberosity. The deltoid muscle is attached to it. In the process of sports training, there is an increase in this tuberosity and the thickness of the compact bone layer. A groove of the radial nerve runs along the posterior bony surface. With the help of the distal epiphysis of the humerus, a condyle is formed.

It has an articular surface necessary for connection with the bones of the forearm. The surface of the joint on the medial side, which connects to the ulna, is called the shoulder bone block. Above it there are pits in front and behind. In them, when flexion and extension of the forearm occurs, the processes of the elbow bone enter. The lateral surface is called the head of the condyle of the shoulder bone.

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

Shoulder ligament anatomy

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

Damage

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

The humerus bone can break, but in different places:

Fractures of the anatomical neck of the bone, head

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

Signs include hemorrhage and swelling. A person cannot make active movements, feels soreness. If you perform passive rotational movements, then the large 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 clarified using X-ray.

With impacted fractures of the neck and head, treatment is outpatient. The hand is immobilized. Inside, a person takes analgesics and sedatives. Physiotherapy is also prescribed. After a month, the splint is replaced with a kerchief-type bandage. The ability to work is restored after two and a half months.

Surgical neck fracture

Injuries without displacement are usually hammered or hammered. If displacement has occurred, the pearl can be adductive and diverting. Adduction fractures occur in the event of a fall with an emphasis on the extended outstretched arm. Abduction fractures occur in the same situation, only the arm is abducted.

If there is no displacement, then local soreness is observed, which increases with the load of the axial plan. The humerus can retain its function, but it will be limited. If there is a displacement, the main symptoms are sharp pain, pathological mobility, violation of the shoulder axis, shortening, dysfunction. First aid consists of the administration of analgesics, immobilization and hospitalization.

The large tubercle suffers mainly from shoulder dislocation. It breaks off and shifts due to reflex contraction of the small, infraspinatus and supraspinatus muscles. If an isolated fracture has occurred, then, most likely, as a result of a shoulder injury, displacement in this case is not observed.

Symptoms of such injuries are soreness, swelling, crepitus.

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

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

Fracture of the shaft 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 abnormal mobility are also observed. First aid is the administration of analgesics and immobilization with a transport bus. Fractures of the diaphysis in the lower and middle third are treated with skeletal traction. Upper third injuries are treated with an abduction splint and shoulder abduction. Immobilization lasts two to three months.

Distal fractures

Extra-articular fractures are extensor and flexion fractures, depending on the position during the fall. Intra-articular fractures are transcondylar injuries, V- and T-shaped injuries, and fractures of the condyle head. Symptoms are soreness, crepitus, abnormal mobility, and a flexed forearm. First aid consists in transport immobilization with a tire; a kerchief can be used. Analgesics are also administered.

The bones of the shoulder girdle play an important role in the implementation of movements. They need to be protected, because any damage is healed for a long time.

The plane of the fracture has a transverse direction and passes directly over the epiphysis of the humerus or through it. If the fracture line passes through the epiphyseal line, it has the character of epiphyseolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, more often small. This transfusion 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 ones are painful, extension is limited.

Symptoms are uncommon, so a transcondylar fracture of the shoulder can be easily confused with a stretching 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 noted that in children, the lower epiphysis of the humerus is normally inclined somewhat (by 10-20 °) forward with respect to the longitudinal axis of the diaphysis of the shoulder. The angle of inclination forward is individual, but never reaches 25 °. To clarify the diagnosis, it is necessary to compare the lateral radiographs of the injured arm and the healthy arm. They should be made in the same and strict projections. Revealing the displacement of the lower epiphysis is of great practical importance, since fusion in the displaced position leads to a limitation of flexion, which is in direct proportion to the degree of increase in the angle of inclination of the epiphysis.

Reduction in children is performed under anesthesia. The surgeon puts one palm on the extensor surface of the lower shoulder, and the other applies pressure back to the lower epiphysis of the shoulder from the side of its flexion surface. In this case, the forearm should be in an extended position. After the adjustment, the child's hand, unbent at the elbow joint, is fixed with a plaster cast for 8-10 days. Then proceed to gradual movements in the elbow joint. Treatment can also be carried out with permanent 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 in the elbow joint for 5-7 days (N.G. Damier, 1960).

This type of fracture of the humerus is intra-articular. T- and Y-shaped fractures occur under direct influence on the elbow of great force, 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 introduced between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the diaphysis of the shoulder also inserts between the split condyles, pushes them apart, and the so-called T- and Y-shaped fractures of the shoulder condyles occur. With this mechanism, sometimes there is a fragmentation of the condyles of the shoulder and often of the olecranon, or a fracture of the condyles is combined with dislocation and fracture of the forearm. These fractures can be of both flexion and extensor type. T- and Y-shaped fractures are less common in children than in adults. A fracture of both condyles of the shoulder can be accompanied by damage to blood vessels, nerves and skin.

Symptoms and recognition.

With a fracture of both condyles, 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 of 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 made 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 fractures without displacement 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 °, and the forearm is in the middle position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using pins with thrust pads enclosed in an arc, or the Volkov-Oganesyan articulated apparatus. In children, the hand 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 are prescribed in the shoulder joint and fingers. After removing the splint, the function of the elbow joint is well restored; in adults, sometimes there is a slight restriction of movement for 5-8 weeks. The ability to work of patients is restored after 4-6 weeks.

The traction is stopped for a day and proceeds to dosed, gradually increasing in volume of movements in the elbow joint, first using a removable splint. Treatment can be carried out with a wire, on the same day or the next, the dispersed condyles of the humerus are brought together by means of the Volkov-Oganesyan articulated compression-distraction apparatus. At the same time, it is possible to start early movement in the elbow joint.

If reduction fails, skeletal traction for 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 straightened, it is possible to make closed transosseous fixation with their needles; then the traction is removed and a plaster splint is applied.

The incision is made longitudinal 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 select it and take it on a holder from 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 condyle necrosis will occur. To connect the 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 the appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well retained with thick catgut threads passed through holes drilled or made with an awl in the bone. On the shoulder and forearm, bent at an angle of 100 °, a plaster splint is applied along the extensor surface and the hand 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. A percondylar multi-splintered fracture with a large displacement of fragments before and after osteosynthesis with wires.

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

Symptoms and recognition.

A fracture of the lateral condyle of the shoulder without displacement is difficult to recognize. There is hemorrhage and swelling in the area of the elbow joint. The outer epicondyle, when the condyle is displaced upward, is higher than the inner one. The distance between the outer epicondyle and the olecranon is greater than between it and the inner epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. sometimes it is possible to feel the displaced fragment and determine the bone crunch. Flexion and extension in the elbow joint are preserved, but the rotation of the forearm is sharply painful.

With a fracture of the external condyle with a displacement, the physiological valgus position of the elbow, especially pronounced in children and women (10-12 °), increases. The forearm is in the abduction position and can be forcibly adducted. For fracture recognition, radiographs taken in two projections are of great importance; without them, it is difficult to make an accurate diagnosis. Sometimes difficulties arise when decoding radiographs in children. The reason is that although the core of the ossification of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not detected in the picture.

Fractures of the external 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 °.

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

The surgeon puts both thumbs on the fragment, pushes it up and down into place. Then he puts his hands on the front and back surfaces of the shoulder condyles, then on the side 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 on the shoulder, forearm and hand. The elbow is fixed at an angle of 100 °, and the forearm is in a position average between pronation and supination. If the control X-ray shows that it was not possible to correct the fragment, an operative reduction is shown. If the reduction is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children - after 2 weeks.

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

In order to avoid non-vascular aseptic necrosis, it is necessary to 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.

Fractures of the inner condyle of the humerus are very rare. The mechanism of this fracture is associated with a fall and injury to the elbow. The acting force is transmitted through the olecranon to the condyle, with the olecranon first of all breaking, and not the inner condyle of the shoulder. The fracture can also occur as a result of a blow to the inside of the elbow. In children, a fracture of the internal condyle is rare because the block of the shoulder remains cartilaginous until the age of 1-12 years of age and, therefore, has great elasticity, which withstands the acting force when falling onto the elbow.

Symptoms and recognition.

There are hemorrhages, swelling in the elbow joint, pain when pressing on the inner condyle, crepitus and other common symptoms, which were mentioned when describing fractures of the outer condyles, but they are determined from inside... The forearm can be brought into the elbow joint, which cannot be done normally with other fractures of the shoulder condyles.

Fractures of the internal condyle in adults are treated with skeletal traction for the upper part of the olecranon on the abductor splint for a day, and later with a removable splint and movements in the elbow joint. For this purpose, pins with thrust pads can be used, 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 radial head and other intra-articular fractures. The mechanism of an isolated fracture is associated with a fall on an outstretched arm. The head of the radius, shifting upward and anteriorly, injures the articular surface of the capitate eminence articulating with it. Damage to it can be limited to the impression of cartilage in a limited area of the articular surface or the 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 is displaced anteriorly and upward.

Symptoms and recognition.

With an isolated injury with the formation of a small bone-cartilaginous fragment and a fracture of a significant part of the capitate eminence, pain and hematoma are localized in the area of the external condyle. A larger and displaced anteriorly and upward fragment can sometimes be felt in the elbow area. Movement in the elbow joint is limited and painful. Anteroposterior and lateral X-ray images are of decisive importance for recognition. In some cases, small free fragments, often in the form of an ellipse, can be detected on an X-ray taken after the introduction of air into the elbow joint. The defect of the outer part of the capitate eminence, if the fragment is small, is sometimes not detected on the roentgenogram. Articular cartilage damage occurs more often in combination with a fracture of the radial head. This combination is found mainly in operations for fractures of the radial head. If a small plate or a bone-cartilaginous splinter has separated from the capitate eminence, then with the flexion and rotation of the forearm, the free fragment can be impaired between the articular surface of the radial head and the capitate eminence by the type of articular muscle impingement. This makes it easier to recognize damage to the capitate eminence.

If the fact of falling on an outstretched arm is established and pain is noted during flexion and rotation of the forearm, and the radiograph excludes a fracture, an isolated damage to the cartilage of the capitate eminence of the shoulder can be suspected.

Isolated cartilage damage in early dates after injury, as a rule, are not recognized. Only long-term pain, blockade of the elbow joint, limitation of movement, pain during extension and rotation of the forearm that arose after falling on an outstretched arm, and, finally, an X-ray taken some time after the injury, indicates the development of osteochondritis in the articular region of the capitate eminence and suggest that vascular necrosis is a consequence of cartilage contusion.

Fracture of a significant part of the capitate eminence with displacement of the fragment anteriorly and upward, in most cases, can be adjusted manually.

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

In the area of the fracture injected ml of 1% solution of novocaine. The patient lies on the table, the arm is extended at the elbow joint. The assistant grabs the forearm over the hand and stretches the elbow joint. The flexion surface of the arm should be facing up. The surgeon puts the bent leg on a stool, puts the knee under the patient's elbow and presses the fragment with two thumbs downward and backward in his bed. Then the elbow is bent to a right angle and a plaster cast is applied to the shoulder and forearm in the pronation position. In some cases, the fragment is better retained with full extension of the elbow. If the control X-ray shows good standing of the fragments, the plaster cast is left in this position for 3-4 weeks, after which they begin to move in the elbow joint. Full recovery of function occurs only after 3-4 months.

The terms of restoration of working capacity depend on the profession of the patient and on which hand is injured - right or left. These terms range from 2-4 months. If the control X-ray shows that the fragment could not be set, it is shown that the fragment is reduced, rather than removing 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 pins, which are carried out transarticularly - from the side of the extensor surface through the external condyle into the repositioned fragment of the capitate eminence into the radius (Fig.). The ends of the needles remain above the skin surface. The needles are removed after 2-3 weeks. With the developed dissecting osteochondritis (Koenig's disease) and repeated blockages, the operative removal of the separated section of cartilage is indicated.

Fracture and apophysiolysis of the inner epicondyle of the humerus

Fracture of the internal epicondyle occurs mainly with sudden and violent abduction of the extended forearm. In this case, the internal lateral ligament is strongly strained and tears off the epicondyle, which is usually displaced downward. In adolescence, with this mechanism, the epicondyle is separated along the apophyseal cartilaginous line.

This fracture belongs to the periarticular. In some cases, rupture of the bag of the elbow joint occurs. Sometimes the epicondyle, torn off and associated with the internal lateral ligament, is pinched between articular surfaces olecranon and shoulder block and can pull the ulnar nerve with it.

The 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. Tears of the inner epicondyle are also observed with dislocations of the elbow joint.

Symptoms and recognition.

In the area of the internal epicondyle, a limited hematoma and swelling are visible, and pain is localized here. If the swelling is small, it is possible to probe the movable fragment. Active and passive movements in the absence of hemorrhage in the elbow joint are possible and not very painful. When the fragment is pinched between the articular surfaces of the olecranon and the block of the shoulder, movements in the elbow joint are impossible and cause severe pain. It is characteristic that against the usual forearm it is possible to deflect and give the elbow a valgus position. As soon as abduction stops, the forearm returns to its previous position. X-rays in two projections are of great importance for fracture recognition. When examining, you need to find out if there is damage to the ulnar nerve.

In case of 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 average between pronation and supination. The bandage is removed in days and movements are prescribed in the elbow joint. The prognosis is good even when the internal epicondyle is displaced. Ability to work 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 impractical, since the ulnar nerve can be injured, and this is an extremely serious complication.

The operation must be performed immediately, as soon as the introduction of the internal epicondyle into the elbow joint is recognized on the basis of clinical and X-ray studies. The intervention is performed under intraosseous, local or general anesthesia. The incision is made on the inside of the elbow joint. It must be remembered that the ulnar nerve runs somewhat behind. After a longitudinal dissection of the deep fascia and the opening of the wound with hooks, the site of separation of the epicondyle is exposed and it is found that the epicondyle, together with 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 out the epicondyle with the soft tissues attached to it from the joint. The inner epicondyle is sutured to the bed by passing two catgut sutures through the soft tissues. It is better to move the ulnar nerve anterior to the internal epicondyle (normally it is located in the back of the groove) - this prevents the subsequent trauma of 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. Ability to work 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 outer epicondyle of the humerus

Fracture of the external epicondyle is observed much less often than the internal one, rarely in young women. It occurs with a sudden strong adduction of the forearm, which is in an extended position. More often there is a separation of the external back ligament together with a small bone plate from the external epicondyle of the shoulder. There are tears of the external epicondyle with varying degrees of displacement, including infringement between the articular surfaces of the external condyle of the shoulder and the head of the radial bone.

Symptoms and recognition.

The signs are the same as in the 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 brought in, given a varus position, which is immediately leveled as soon as adduction stops. When the external epicondyle is displaced into the joint, a blockade is observed. X-ray examination is of great importance for recognition, especially radiograph in anteroposterior projection.

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

The operation is performed under local anesthesia... The incision is made from the outside over the epicondyle region. With a significant displacement of the epicondyle, suturing of the fragment to the bed is shown. In cases of infringement of the external epicondyle in the elbow joint, the fragment is removed from the joint together with the muscles attached to it and sutured to the place of separation (Fig.).

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The article describes a fracture of the shoulder in the area of the condyles. Methods of treatment and rehabilitation after trauma are described. A percondylar fracture of the humerus is not very often observed by traumatologists. Most trauma occurs during childhood. In view of anatomical features the structure of the injury leads to the development of complications.

Structural features

The condyles of the humerus are located in its distal part, being part of the ulnar articulation. There are two condyles - medial and lateral. The area of the bone between them is thinned, which creates the prerequisites for the formation of a fracture.

Here are the places of attachment of 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 describes the structure of the elbow joint.

Causes and types of injury

Percondylar fractures occur as a result of excessive extension or flexion of the limb. Extension fracture of the right humerus is observed much more often than others.

The main cause of the occurrence is a fall on a bent or overextended arm at the elbow. The frequent fracture in children is explained by the peculiarities 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 at a typical site. Such a trauma 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 perspective? The manifestations of trauma are not always specific and one has to distinguish it from dislocation or severe injury.

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

The fractured section of the bone rises and turns due to muscle traction - this is how a displaced fracture is formed. Because of this, the position of the shoulder does not match the position of the forearm. On palpation and attempts to move, there is an increase in pain in the elbow area. Abnormal lateral mobility is observed.

Such a fracture without displacement is quite rare. Usually it can be seen in children with poorly developed arm muscles.

Fractures are open and closed. The first option is more often observed.

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

Diagnostics

It is not always possible to determine a closed injury with displacement by visual examination. Dislocation in the elbow joint is characterized by similar symptoms.

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

Treatment

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

Primary treatment

If the fracture is incomplete, 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 is indicated using various techniques.

Table. Treatment methods:

Important! Restoring movements in the limb during surgery is much faster than with conservative treatment.

Rehabilitation treatment

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

Rehabilitation treatment consists of:

taking medications;
physiotherapy procedures;
massage and remedial gymnastics;
proper nutrition.

The patient is prescribed a nutritious diet with a high protein and calcium content. These substances are essential for bone repair and fracture healing.

The same goal is pursued by the prescription of drugs.

They are used to relieve the patient's well-being and prevent complications associated with damage to bones and cartilage:

Anti-inflammatory drugs. They are prescribed to relieve pain, eliminate edema. Used in the form of tablets and ointments - Ibuprofen, Ketonal.
Chondroprotectors. With intra-articular fractures, damage to the cartilage is inevitable, therefore, drugs for their restoration are prescribed - 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, therefore, such drugs are prescribed for any fracture. The instruction provides for their ingestion - Calcium-D3-Nycomed, Kalcemin.
Vitamins of group B. Protect nerve fibers from damage, stimulate the recovery of muscles and ligaments. Is taken orally or as intramuscular injection- Kombilipen, Milgamma.

Purchase medicines available at the pharmacy, the price varies depending on the manufacturer. Physiotherapy procedures begin on day 2-3 of treatment, provided normal temperature body.

They use techniques such as:

electrophoresis of drugs;
magnetotherapy;
paraffin applications;
diadynamic currents.

A plaster cast makes it difficult to carry out these manipulations. In order not to give up physiotherapy, a small hole is cut in the plaster through which the procedures are carried out. Physiotherapy improves 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 the motor function of the limb. They also need to start from the second or third day. The load is minimal at first.

Massage is carried out with light stroking movements, therapeutic gymnastics consists in passive movements of the limb. As the callus develops, the amount of exercise increases.

A percondylar fracture of the humerus in most cases heals completely. Movement disorders do not occur. In the future, it is possible to develop ulnar arthrosis and impaired sensitivity of the limb.

Intercondylar fracture of the humerus

A percondylar (extensor and flexion) fracture is intra-articular. It occurs when you fall on the elbow bent at an acute angle. The plane of the fracture has a transverse direction and passes directly over the epiphysis of the humerus or through it. If the fracture line passes through the epiphyseal line, it has the character of epiphyseolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, more often small. This overfilling occurs almost exclusively in childhood and adolescence (GM Ter-Egiazarov, 1975).

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 be easily confused with a stretching of the ligamentous apparatus. In most cases, a percondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be noted that in children, the lower epiphysis of the humerus is normally inclined somewhat (by 10-20 °) forward with respect to the longitudinal axis of the diaphysis of the shoulder. The angle of inclination forward is individual, but never reaches 25 °. To clarify the diagnosis, it is necessary to compare the lateral radiographs of the injured arm and the healthy arm. They should be made in the same and strict projections. Revealing the displacement of the lower epiphysis is of great practical importance, since fusion in the displaced position leads to a limitation of flexion, which is in direct proportion to the degree of increase in the angle of inclination of the epiphysis.

Treatment. Reduction in children is performed under anesthesia. The surgeon puts one palm on the extensor surface of the lower shoulder, and the other applies pressure back to the lower epiphysis of the shoulder from the side of its flexion surface. In this case, the forearm should be in an extended position. After the adjustment, the child's hand, unbent at the elbow joint, is fixed with a plaster cast for a day. Then proceed to gradual movements in the elbow joint. Treatment can also be carried out with permanent 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 in 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

Symptoms and recognition. With a fracture of both condyles, 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 of 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 fractures without displacement 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 °, and the forearm is in the middle position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out with the help of spokes with thrust pads, enclosed in an arc, or the Volkov-Oganesyan articulated apparatus. In children, the hand 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 are prescribed in the shoulder joint and fingers. After removing the splint, the function of the elbow joint is well restored; in adults, sometimes there is a slight restriction of movement for 5-8 weeks. The ability to work of patients is restored after 4-6 weeks.

For the outcome of the treatment of T- and Y-shaped fractures of the shoulder condyles with displacement of fragments, good reduction of fragments is extremely important. In adults, it is achieved by skeletal traction behind the olecranon, which is carried out on an abduction splint or with the help of a Balkan frame when the patient is in bed. Having eliminated the displacement of the fragments along the length, on the same day or the next, the separated condyles of the humerus are brought together by squeezing them between the palms and applying a U-shaped plaster splint on the outer and inner surfaces of the shoulder. Based on the radiograph, you should make sure that the fragments are in the correct position. The traction is stopped for a day and proceeds to dosed, gradually increasing in volume of movements in the elbow joint, first using a removable splint. Treatment can also be carried out with the help of the Volkov-Oganesyan articulated compression-distraction apparatus. At the same time, it is possible to start early movement in the elbow joint.

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 select it and take it on a holder from 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 condyle necrosis will occur. To connect the 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. 59). You can also use 12 thin nails or screws of the appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well retained with thick catgut threads passed through holes drilled or made with an awl in the bone. On the shoulder and forearm, bent at an angle of 100 °, a plaster splint is applied along the extensor surface and the hand 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.

Fracture of the outer condyle of the humerus

Fracture of the external condyle is common, especially in children under 15 years of age. The fracture occurs as a result of falling on the elbow or hand of an extended and abducted limb. The head of the radius, resting on the capitate eminence of the shoulder, splits off the entire external condyle, the pineal gland and a small piece of the adjacent part of the block. The articulating surface of the capitate eminence remains intact. The plane of the fracture has a direction from below and inwards outwards and upwards and always penetrates into the joint.

Along with fractures without displacement, there are fractures with a slight shift of the condyle outward and upward. A more severe form is a fracture in which the breakaway condyle moves outward and upward, slips out of the joint and turns in the horizontal and vertical planes (by °) 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 common, followed by ulnar nerve involvement.

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

Treatment. Fractures of the external 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 °.

Rice. 59. A percondylar multi-splintered fracture with a 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 off 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 over the wrist joint, stretches along the length and brings the forearm. In this way, an easy varus position of the elbow is created and the space in the outer half of the elbow joint expands. The surgeon puts both thumbs on the fragment, pushes it up and down into place. Then he puts his hands on the front and back surfaces of the shoulder condyles, then on the side surfaces and squeezes them. The chunk is gradually bent to a right angle; the surgeon then compresses the condyles again and applies a plaster cast on the shoulder, forearm and hand. The elbow is fixed at an angle of 100 °, and the forearm is in a position average between pronation and supination. If the control X-ray shows that it was not possible to correct the fragment, an operative reduction is shown. If the reduction is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children - after 2 weeks. In some cases, despite the good reduction of the fragments and the timely started movements in the elbow joint, there remain varying degrees of limitation of flexion and extension in it. In order to be able to start early movement in the elbow joint, it is advisable to use closed osteosynthesis with pins with stubborn pads enclosed in an arch, or to use the Volkov-Oganesyan articulated compression-distraction apparatus.

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

A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, and others) observed good results after removal of the external condyle in chronic fractures with limited movement. You should still, if possible, avoid removing the external condyle of the shoulder, not only in fresh, but also in old cases, and strive to correct the fragment. With an unreduced dislocated external condyle, as well as after its removal, the hallux valgus develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overstretching, constant trauma and even pinching it. In cases where symptoms of a secondary lesion of the ulnar nerve appear, there may be indications for its movement from the posterior groove of the epicondyle, anterior to it between the flexor muscles.

Fracture of the inner condyle of the humerus

Fractures of the inner condyle of the humerus are very rare. The mechanism of this fracture is associated with a fall and injury to the elbow. The active force \ 1 is transmitted through

olecranon to the condyle; in this case, first of all, the olecranon process breaks, and not the inner condyle of the shoulder. The fracture can also occur as a result of a blow to the inside of the elbow. In children, fractures of the internal condyle are rare because the old shoulder block remains cartilaginous and therefore has great elasticity to withstand the force of a fall on the elbow.

Percondylar fracture of the humerus

This fracture is intra-articular. The plane of the fracture passes over or through the pineal gland, 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 transcondylar extensor fractures resulting from a fall on an extended arm in the elbow joint and flexion fractures due to a fall on the elbow.

Symptoms

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

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

In flexion fractures, the area of the elbow joint is enlarged, deformed due to the anterior or anterolateral part of the joint, the function is impaired, the forearm seems elongated, the contour of the olecranon is smoothed, a positive symptom of fluctuation, the Hüther triangle and Marx's sign are disrupted.

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

Differential diagnosis

It is not difficult because children traumatic dislocations are very rare, there are no pathognomonic symptoms for dislocations - elastic mobility, and the above-mentioned reliable symptoms of a fracture come to the fore.

Urgent care

Treatment

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

With transcondylar fractures, trauma to the ulnar nerve is possible (contusion, pinching, compression). In case of bruises and minor infringements of the ulnar nerve, the victims complain of paresthesia in the innervation zone of the fifth and half of the fourth fingers, and when squeezed, they complain of a decrease or lack of sensitivity in the innervation zone.

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Forearm injuries

Distal humerus fractures

Causes. Supracondylar (extra-articular) fractures are divided into extensor, arising when falling on an outstretched arm, and flexion - when falling on an abruptly squeezed elbow. Intra-articular fractures include transcondylar fractures, T- and V-shaped fractures of the condyles, fracture of the head of the condyle of the humerus (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, there is a retraction of the skin above it. In front of the elbow, a hard protrusion is felt (the upper end of the peripheral or lower end of the central fragment of the humerus). Movement in the elbow joint is painful. VO Marx's symptom is positive (violation of the perpendicularity of the intersection of the shoulder axis with the line connecting the shoulder epicondyle - Fig. 47). With intra-articular fractures, in addition to deformity, pathological mobility and crepitus of fragments are determined. These fractures should be differentiated from dislocations of the forearm. Control over the integrity is mandatory brachial artery and peripheral nerves! The final nature of the damage is determined by radiographs.

46. Variants fractures distal metaepiphysis brachial 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; eight - transcondylar fracture.

47. Sign V.O. Marx. a-b the norm ; b-at nadysyllic fracture brachial bones.

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

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

The hand is placed on the discharge splint. If reduction has failed (X-ray control!), Then skeletal traction is applied behind the olecranon. The term of immobilization with a plaster splint is 4-5 weeks. Rehabilitation - 4-6 weeks. Ability to work 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 Volkmann's ischemic contracture.

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

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

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

Open reduction of fragments is indicated in case of impaired blood circulation in the limb and its innervation. To fix the fragments, rods, knitting needles, screws, bolts, external fixation devices are used. The limb is fixed with a posterior plaster cast for 4-6 weeks. Rehabilitation - 3-4 weeks. Ability to work is restored after 21 / 2-3 months.

49. Outer osteosynthesis at breaks condyles brachial bones.

50. Interior osteosynthesis at fractures condyles brachial bones.

51. Outer osteosynthesis intraarticular fractures brachial bones.

Fractures of the humerus condyle in adolescents observed when falling on the wrist of the abducted hand. More often the lateral part of the condyle is damaged.

Signs: hemorrhage and edema in the elbow joint, movement and palpation are painful. Violated Guuther's triangle. The diagnosis is clarified by X-ray examination.

Treatment. In the absence of displacement of 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 down by pressure on the fragment. When the medial fragment is repositioned, the forearm is deflected outward. A control X-ray is taken in a plaster splint. If the closed reduction failed, then resort to surgical treatment with fixation of fragments with a wire or screw. The limb is fixed with a posterior plaster cast for 2-3 weeks, then - exercise therapy. The metal retainer is removed after 5-6 weeks. Rehabilitation is accelerated when using external fixation devices.

FRACTURES OF THE MEDIAL SUPERIOR.

Causes: a fall on an outstretched arm with a deviation of the forearm outward, dislocation of the forearm (the torn epicondyle may be pinched in the joint during the reduction of the dislocation).

Signs: local swelling, tenderness on palpation, limitation of joint function, violation of the isosceles triangle of Hüther, radiography helps to clarify the diagnosis.

Treatment the same as for a condyle fracture.

Fracture of the head of the condyle of the humerus.

Causes: fall on an outstretched arm, while the head of the radius is displaced upward and injures the condyle of the shoulder.

Signs: swelling, hematoma in the area of the external epicondyle, limitation of movement. A large fragment can be felt in the area of the cubital fossa. In diagnosis, radiographs in two projections are of decisive importance.

Treatment. Overextension and extension of the elbow joint with varus adduction of the forearm is performed. The traumatologist sets the fragment by pressing on it with two thumbs down and back. Then the forearm is bent to 90 °, and the limb is immobilized with a posterior plaster cast for 4-6 weeks. Control radiography is required. Rehabilitation - 4-6 weeks. The ability to work is restored after 3-4 months.

Surgical treatment is indicated for unrepaired displacement, with the detachment of small fragments blocking the joint.

A large fragment is fixed with a wire for 4-6 weeks. Free small fragments are removed.

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

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Fractures of the diaphysis of the humerusForearm injuries