Useful information about fractures of the shoulder and forearm bones

A fracture of the humerus usually occurs when there is a sudden and strong load on one of the three bones of the shoulder. A clavicle fracture is the most common injury of this nature. There are 3 different bones in the shoulder area that can break: the collarbone, the proximal humerus, and the scapula. A fracture of the humerus usually occurs when a sudden force is applied. This happens, for example, in the event of a hard fall, an impact during sports, or an accident (for example, a car accident).

About the shoulder

Humerus, shoulder (lat. - Нumerus) - refers to the long bones. The humerus makes up the bone base of almost half of the free upper limb and is its initial section.
Like any long bone, the humerus consists of a body (diaphysis) and ends (epiphyses) - the proximal one, formed by the head of the humerus, connecting the shoulder to the scapula through the shoulder joint, and the distal one - forming the shoulder component of the elbow joint. Due to the large degree of freedom of movement of the shoulder in the shoulder joint (the ball and socket joint, the most mobile in the human body), the proximal part of the shoulder is the site of attachment of many muscles and ligaments, thanks to which an extremely complex and balanced process of movement of the shoulder is carried out in the shoulder joint, and with it and the entire free upper limb.

Moreover, during almost any movement, the head of the humerus is always strictly centered in the joint. The diaphysis of the humerus forms the lever of the shoulder and serves as the attachment point for part of the flexor and extensor muscles, providing the same movements of the shoulder in the shoulder joint, and the forearm in the elbow.

Due to the variety of functions of the shoulder and the complexity of the anatomical structure, damage to this area leads to significant dysfunction of the entire upper limb. Moreover, if we figuratively consider the free upper limb as a chain of successive links, and the shoulder is the initial link in the chain, then the higher the damage, the more significant the dysfunction of the entire chain.

The speedy restoration of the function of the upper limb plays a vital role in a person’s life: self-care, professional and creative activity, learning, tactile perception of the surrounding world.

Shoulder injuries are a fairly common pathology . There is a wide variety of injuries to both bones - bone fractures, fractures of hand bones, dislocation of the collarbone, and soft tissues (ruptures of muscles, tendons, ligaments, blood vessels and nerves), and various dislocations of the head of the humerus are also common.

Closed and open fracture of the humerus

Closed fracture

A closed fracture can occur in the upper part of the shoulder. There, the head of the bone, the lesser and greater tuberosity, the surgical and anatomical neck are susceptible to injury.

The symptoms that concern a patient who has received a closed injury to this part are the following:

Pain in the joint area.
If the injury is impacted, then the swelling is not too pronounced and grows slowly. The pain intensifies when trying to actively move the limb. Passive movements are not too limited.
If displacement is observed during a closed fracture, then deformation of the arm is more often visible, and other symptoms, including pain, appear more clearly.

If a closed fracture of the shoulder occurs in the middle section, then most often the cause is a fall or a blow to the shoulder. The injury can be splintered, oblique, transverse or helical. A fracture of this part often entails damage to the nerve bundle, namely the radial nerve. In addition, the brachial arteries and veins are affected.

The main symptoms that indicate a closed fracture of the humeral body include:

Strong pain.
Deformation, in the presence of displacement.
Decreased limb length.
Crepitation of fragments.
Swelling and hematoma, which can occupy a wide area, up to the hand.
Movements are limited mainly in the elbow and shoulder joint.
If the nerves have been damaged, there is a disturbance in finger movements and sensitivity.
The hand cannot be kept in a raised state; it hangs limply.

Open fracture

The main features of an open fracture include:

An open wound will be visible on the surface of the skin. Most often there is bone visible through it.
There is severe bleeding, which must be stopped by applying a tourniquet. Its location is the upper third of the shoulder.
The wound site is treated with any available antiseptic, after which a sterile bandage is applied.
Only after treatment and stopping the bleeding should the hand be immobilized.

Shoulder fracture

Fractures of the humerus are quite common and account for 5 to 20% of the total number of skeletal bone fractures. Fractures of the humerus, as a rule, occur in the form of isolated injuries, less often in combination with other injuries of bones and soft tissues.

Fractures of the humerus are observed under indirect impact of force - a fall on an outstretched arm, or under direct impact (impacts to the shoulder area, a fall on the shoulder brought to the body, etc.). This type of injury is quite common among men and women, among young and elderly patients.

Fractures of the humerus are characterized by great diversity.

According to location, fractures occur:
Humeral shaft fractures are fractures at the level of the body of the humerus.
The distal humerus is also intra-articular and extra-articular.
Depending on the communication of bone fragments with the external environment, open and closed fractures occur.
Complicated and uncomplicated fractures are distinguished from damage to the structures surrounding the humerus.
Depending on the presence of displacement - with or without displacement;
Based on the fracture line, simple and complex (comminuted, fragmentary, etc.) fractures are distinguished.

Treatment of a humerus fracture

Three methods are used to treat a shoulder fracture: surgical, conservative, and skeletal traction. If the fracture is not complicated by displacement or it can be corrected by performing a one-stage reduction, then applying a plaster cast or other fixing agent is sufficient.

If we consider therapy at the fracture site, we can highlight the following features:

Treatment of a large tubercle occurs by applying a plaster cast; sometimes it can be supplemented with an abduction splint. This is necessary in order to prevent the development of stiffness in the joint and ensure proper fusion of the supraspinatus muscle. If the tubercle fragment has moved out of place, it must be fixed in the correct position with knitting needles or a screw. After about 1.5 months, the structure will be removed.
If the surgical neck has been injured, but no displacement has occurred, then you can get by with a plaster cast for a month. When reduction was required, and it was successful, the cast will have to be worn for two more weeks. If it is not possible to straighten the bone fragments, then surgical intervention is necessary. Fixation inside the bone is carried out using plates. If the fracture is of the impacted type, then it is advisable to use either an abductor pillow or a special scarf. The treatment period can be extended up to 3 months.
When the fracture is localized on the body of the shoulder and displacement is observed, the most common method of treatment was skeletal traction. A person will have to spend up to a month in an immobilized position. Afterwards, plaster will be applied for the same period of time. Recently, the method of skeletal traction has faded into the background; it has been replaced by osteosynthesis, which does not confine a person to bed for such a long period of time.
Transcondylar fractures are almost always accompanied by displacement of fragments. Their comparison is carried out under anesthesia, and then it is advisable to apply a plaster cast for up to two months.

If vessels or nerves are damaged as a result of fractures, then a special operation is necessary, which involves placing sutures on them. This increases the treatment period and it is not always possible to fully restore the functionality of the limb. As for medications, it is advisable to use calcium supplements, as well as analgesics and antibiotics.

On topic: 12 folk methods for home treatment

Diagnosis of shoulder fractures

Diagnosis of humerus fractures is a clinical examination of the patient (examination, comparative assessment, measurement, palpation, etc.), X-ray examination is standard radiography, special X-ray placement if necessary.

X-ray computed tomography to verify soft tissue damage is an MRI. To make an accurate and correct diagnosis, as well as to determine further treatment tactics, it is very important that the diagnosis is carried out by a qualified specialist doctor - an orthopedic traumatologist.

Symptomatic manifestations

The most pronounced symptom indicating that the patient has such a fracture of the surgical caput humeri is severe pain. In addition to painful sensations, the limb is characterized by impaired functionality.

Immediately after the injury has been sustained, the victim begins to feel severe pain at the site of the impact. It can be eliminated with the help of specially prescribed intramuscular or intravenous medications.

It must be emphasized that only a doctor can prescribe them after a preliminary diagnosis, since it is possible to reduce pain only with the help of truly potent drugs, which in most cases turn out to be narcotics. Older patients suffer more from pain.

Development of pain syndrome

As a result of the injury, the normal functionality of the limb is lost, although sometimes patients can still bend it at the hand or elbow. It should be noted that the most comfortable position in this case is considered to be supporting the injured limb in the area of the elbow or forearm. Attempts to make more movements with the injured limb are accompanied by progression of pain, which can provoke the development of a shock reaction.

As you can see from the video in this article, the fragments can be felt, since the impact site looks like a recess when a shoulder is dislocated. Palpation in this case is distinguished by the crunch of a broken bone. A common symptomatic sign is swelling of the affected area, which can result in a hematoma of significant size.

It should be borne in mind that the injury may not be accompanied by too severe symptoms. For this reason, most victims do not even suspect the presence of such a shoulder injury and do not seek qualified help from specialists.

Unexpressed pain

In rare cases, the resulting blow can also damage nerves. The main feature of a fracture is the displacement of bone fragments.

This leads to pressure on bundles of nerves and blood vessels, which can lead to very serious complications:

swelling of the injured limb;
paralysis;
paresthesia;
tissue necrosis on the injured hand;
aneurysms.

Complications from shoulder fractures

Complications of humerus fractures : - occur quite often and in the long-term period in certain cases or with inadequate treatment are represented by non-united fractures, improperly fused fractures, as well as pseudarthrosis (false arthrosis).

At the time of injury, fractures of the humerus can be complicated by damage to the structures surrounding the humerus: damage to the neurovascular bundle, muscles and tendons manifested by bleeding, neurological disorders in the injured arm, and dysfunction of the upper limb.

Closed fracture of the surgical neck of the humerus before and after surgery. Osteosynthesis was performed with a plate.

Rehabilitation after a humerus fracture

After the bandage is removed, it is necessary to proceed to rehabilitation measures. They are an integral part of bone restoration and play no less important role than adequate therapy.

Rehabilitation necessarily includes:

Physiotherapeutic treatment - you will need to complete several courses, which consist of 10 procedures. Electrophoresis with novocaine and calcium chloride may be recommended. Ultrasound treatment has proven itself well.
A massage that, if it is impossible to visit a specialized office, can be performed independently. To speed up healing and stimulate blood circulation, you can use specialized ointments and oils.
Performing a set of special exercises.

Department of Traumatology and Orthopedics

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1A. V. SKOROGLYADOV, 1A. P. RATIEV, 1K. A. YEGHIAZARYAN, 2E. A. KURUCH, 1A. V. GRIGORIEV

1Russian National Research Medical University named after. N.I. Pirogov, Moscow

2GBUZ MO Podolsk City Clinical Hospital, Podolsk

Information about the authors:

Skoroglyadov Alexander Vasilievich – Doctor of Medical Sciences, Professor, Head of the Department of Traumatology, Orthopedics and Military Field Surgery of the Russian National Research Medical University named after N.I. Pirogov

Ratyev Andrey Petrovich – Doctor of Medical Sciences, Associate Professor of the Department of Traumatology, Orthopedics and Military Field Surgery of the Russian National Research Medical University named after N.I. Pirogov

Egiazaryan Karen Albertovich – Candidate of Medical Sciences, Associate Professor of the Department of Traumatology, Orthopedics and Military Surgery of the Russian National Research Medical University named after N.I. Pirogov

Kuruch Evgeniy Aleksandrovich – traumatologist-orthopedist of the 1st traumatology department of the Podolsk City Clinical Hospital

Grigoriev Alexey Vladimirovich – postgraduate student of the Department of Traumatology, Orthopedics and Military Surgery of the Russian National Research Medical University named after N.I. Pirogov

Fracture-dislocations of the proximal humerus are the most complex injuries and are among the most severe pathologies of this location. These injuries still remain the most important problem of modern traumatology and require careful analysis in each specific case. The article provides an analysis of foreign literature devoted to diagnosis, research methods, complications and treatment of various types of fracture-dislocations of the proximal humerus.

Key words: fracture-dislocation of the shoulder, rotator cuff, aseptic necrosis.

Introduction

The shoulder joint, due to its anatomical architecture and functional purpose, is considered one of the most complex from a biomechanical point of view [1–3] and is most often susceptible to fracture-dislocations. The large number of associated injuries is due to the complex anatomy of the shoulder joint, which is surrounded by a large number of muscles, tendons, vessels and nerves that are of fundamental importance in the functioning of the joint.

Fracture-dislocation of the shoulder is a complex injury to the joint, characterized by the associated displacement of two or more fragments of the proximal epiphysis of the shoulder relative to the joint anteriorly, posteriorly and downward. The incidence of fracture-dislocations among all injuries of the proximal shoulder ranges from 2.6 to 8% [4]. According to foreign literature, the prevalence of shoulder fracture-dislocations in Europe is 1/100,000 of the population per year [5, 6].

During a fracture-dislocation of the shoulder, soft tissue injuries and osteochondral fractures of the glenoid often occur (the most common fracture is the anteroinferior angle). Contracture of the shoulder joint in fracture-dislocations is explained by the involvement of soft tissues (tendons, capsules, ligaments) and heterotopic ossifications in patients after treatment [7, 10, 11]. You need to remember these injuries and avoid unnecessary manipulation of the joint. It is known that incorrect and rough manipulations can transform a two-part fracture dislocation into a four-part one with worsening damage to soft tissues, the rotator cuff, brachial artery or brachial plexus [6, 12]. Neer [7] classified these fractures according to the number of fragments and the direction of displacement (anterior, posterior, or inferior).

Clinical assessment

Shoulder fractures and dislocations most often occur during high-energy trauma. The same can happen during a banal domestic injury, more often in women. In most cases, this occurs while running on a hard surface and falling on the shoulder joint or on the arm extended at the elbow joint [6, 8, 12]. In rare cases, fracture-dislocation of the shoulder can occur during electrical trauma or during an epileptic seizure [6, 12]. In the emergency department, a patient with a fractured shoulder dislocation looks exhausted and supports the injured limb with his healthy arm. There is soft tissue swelling in the shoulder joint area. While trying to perform minor movements, the patient feels a sharp pain in the shoulder joint and may scream loudly. Subcutaneous hematoma is rarely seen in the acute period. It occurs in older people or in people receiving anticoagulant therapy. In young people, a subcutaneous hematoma appears 24–48 hours after the injury and is located on the arm and chest.

In the case of a two-part anterior fracture-dislocation of the shoulder, the acromial protrusion is more noticeable, at the same time, soft tissue swelling appears along the anterior surface of the shoulder girdle and the coracoid process is not palpable. The acromial protrusion is more difficult to visualize in three- and four-part anterior fracture-dislocations.

With posterior fracture-dislocations of the shoulder, the clinical picture is completely different. The coracoid process and the posterior part of the deltoid muscle are clearly visualized. The position of the upper limb is also assessed in these patients. In the case of a two-part anterior fracture-dislocation, the passive mobility of the upper limb is blocked in the position of adduction and external rotation. An attempt to rotate the upper limb medially causes severe pain. And, conversely, with a posterior fracture-dislocation, the upper limb is internally rotated and outward rotation is impossible. When the fracture involves the surgical neck, the axis of the upper limb is in a neutral position [8].

1. X-ray examination

To make a diagnosis and select treatment tactics, the primary method of examination is to perform radiographs of the shoulder joint in standard projections. If the X-ray images are insufficiently informative, computed tomography is performed, which allows one to reliably assess the fracture lines, the direction of head dislocation, damage to the anatomical structures of the shoulder joint, including the involvement of the lesser and greater tuberosities, as well as damage to the glenoid [16–18]. In patients over 40 years of age, it is advisable to perform an MRI to evaluate rotator cuff and joint capsule damage.

2. Associated damage

1. Rotator cuff injuries

The rotator cuff is often injured in a two-part fracture-dislocation with a fracture of the greater tuberosity. Robertson et al. [6] reported rotator cuff injury in 33.4% of 3633 fracture-dislocation cases. This injury may involve the interval between the supraspinatus and subscapularis muscles. Rotator cuff tears can be especially severe in three- and four-part fracture-dislocations. These lesions are usually identified and treated during osteosynthesis. However, this can be detected before surgery if an MRI is performed.

2. Neurological damage

Damage to the brachial plexus or peripheral nerves as a result of fracture dislocation or during its repair accounts for 2–30% of cases. Robertson et al. [6] reported nerve injury in 13.5% of cases after 3633 anterior fracture-dislocations (2250 men and 1383 women; mean age 47.6 years). The nature of the injury is determined by the age of the patient, the energy of the injury, the type of injury and the time between dislocation and reduction. Electromyography is the most reliable diagnostic method in identifying the severity of nerve damage. The brachial nerve is most often damaged and recovers in approximately 4–5 months, in rare cases requiring surgical treatment.

3. Vascular damage

Fracture dislocations rarely occur with damage to large vessels. In such cases, the brachial artery or vein is usually affected in older people with vascular atherosclerosis. The mortality rate during surgery for such injuries is 50%.

4. Depressed fractures and glenoid fractures

Depressed fractures of the humeral head during dislocation were first described by Hill Sachs and McLaughlin [20, 21] in the 19th century and later classified by Neer [7]. It is known that with all dislocations there is a depressed fracture of the head of the humerus and the edge of the glenoid cavity. The severity of these injuries depends on the patient's age, the energy of the injury, and the time between dislocation and repair. Impression fractures of the humeral head can be in the anterior part, near the insertion of the subscapularis tendon in the case of a posterior dislocation, or in the posterosuperior part of the head in an anterior or inferior dislocation. These injuries often go unrecognized. CT and MRI studies can identify these fractures and adjust treatment. Detailed knowledge of pathological anatomy and the time between injury and primary treatment influence the further management of the patient. For deep and extensive injuries of the humeral head, remplissage or bone fragment transplantation is indicated, especially in young people and if the bone defect is less than 45% [24]. If the defect is more than 50%, prosthetics are indicated.

3. Treatment

1. Two-part fracture-dislocations

The shape of these dislocations depends on the pathological involvement of the greater tuberosity and the surgical neck of the humerus. Two-part fracture-dislocations involving the surgical neck of the humerus are extremely rare. If the first attempt to set the head into the glenoid cavity under local anesthesia was unsuccessful, then further treatment is carried out under intravenous anesthesia. After reduction, X-ray monitoring of a fracture of the surgical neck of the humerus is necessary, since in case of its occurrence and displacement, surgical treatment is indicated. In case of two-part fracture-dislocations, there is often a fracture of the greater tuberosity [10.33%]. Bahrs et al. [25] in a study of 100 patients with a fracture of the greater tuberosity found that in 50% of cases it was associated with anterior shoulder dislocation. In these forms, an attempt to reduce the dislocation should be as atraumatic as possible and performed after a complex of examinations, including CT and radiography. After repositioning the head, the displacement of the greater tubercle spontaneously corrects. Surgical treatment is indicated for persistent displacement of more than 5 mm.

Fractures of the lesser tubercle with two-part fracture dislocations are extremely rare. Posterior shoulder dislocation is assessed by clinical presentation and CT scan. Mostly, fractures of the small tubercle occur in posterior dislocations. The treatment tactics are the same as for other two-part fracture-dislocations; they involve extension and traction of the limb along its length. If the displacement persists more than 1 cm, surgical treatment is indicated. For two-part fracture-dislocations, the deltopectoral approach is used. After selecting v. cephalica, the fascia is cut, the subacromial bursa is exposed and excised. The deltoid muscle moves laterally, and the coracobrachialis moves medially. In this way, the surgeon can evaluate the damage to the superficial part of the rotator cuff and see the possible interposition of the biceps between the fragments. If the dislocation cannot be reduced even under anesthesia, the biceps tendon is most likely caught between two main fragments. In these cases, the rotator cuff must be opened and a tenotomy performed. Thus, open reduction of the head, reposition and fixation of fragments can be performed. In the postoperative period, the upper limb is fixed with an orthosis for 4-6 weeks, only passive and active movements in the elbow and wrist joints are allowed.

2. Three-part anterior fracture-dislocations

Most often, three-part fracture-dislocations occur with anterior dislocation of the shoulder and have two fracture lines. These are a fracture of the greater tuberosity and a fracture of the surgical neck of the humerus. In such cases, the small tubercle remains attached to the head of the humerus. This is a positive sign in terms of clinical outcome, since vascularization is preserved. During the operation, it is important not to damage the circumflex artery, which supplies the head. In three-part fracture-dislocations, a fracture of the surgical neck of the humerus and the greater or lesser tuberosity usually occurs. The delto-pectoral approach is used for the operation, the biceps is used as a guide for repositioning the head. Sometimes biceps tenotomy and tenodesis, open reduction and internal fixation of fragments are performed. In more complex cases, when there is a glenoid fracture requiring osteosynthesis, the m.subscapularis is separated and a vertical capsulotomy is performed. After this, osteosynthesis of the glenoid cavity is performed with cannulated screws.

3. Three-part posterior fracture-dislocations

Three-part posterior fracture-dislocations are characterized by two fracture lines, including the surgical neck of the humerus and the lesser tubercle. A CT scan and careful preoperative planning are necessary. The decision to osteosynthesis a fracture or replace the humeral head with an endoprosthesis depends on the patient’s age, bone quality, grinding of bone fragments, and damage to soft tissues. For these operations, deltopectoral access is also used.

4. Four-part anterior and posterior fracture-dislocations

Four-part fracture dislocations are a complex joint injury, the treatment of which is still under discussion [8, 9, 11, 12, 22, 26, 27]. The stumbling block to this problem is ischemia of the head, due to impaired blood supply [28, 29], which in most cases leads to necrosis of the humeral head [6, 7, 9, 12, 15, 17, 30]. Based on these studies, shoulder arthroplasty is generally preferred in middle-aged and elderly patients, while open reduction and internal fixation may be attempted in younger patients.

conclusions

Thus, fracture-dislocations of the shoulder remain one of the most important problems in modern traumatology. Before choosing treatment tactics, a thorough examination and preoperative planning (performing functional tests, radiographs, CT, MRI), assessment of the nature of the fracture, the presence of neurocirculatory complications and taking into account the patient’s age are necessary. A positive treatment outcome directly depends on the damage to the soft tissues, the nature of the fracture, the surgical technique and the experience of the surgeon. Incorrectly chosen surgical tactics without taking into account the classification of the fracture, possible damage to the rotator cuff, periarticular vessels and nerves can lead to serious complications, such as non-union of the fracture, aseptic necrosis of the humeral head, contracture of the shoulder joint with limited limb function and loss of ability to work with possible subsequent disability of the patient.

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TREATMENT OF THE DISLOCATION-FRACTURES OF PROXIMAL HUMERUS: LITERATURE REVIEW

2E. A. KURUCH, 1A. V. GRIGORIEV, 1A. P. RATEV, 1K. A. EGIAZARYAN, 1A. V. SKOROGLYADOV

1Russian National Medical Research University named after NI Pirogov, Moscow

2 Podolsky City Clinical Hospital, Podolsk

Information about the authors:

Kuruch Evgeny Alexandrovich – doctor traumatologist-orthopedist 1st trauma department of Podolsk City Clinical Hospital 

Grigoriev Alexey Vladimirovich – of the chair of traumatology, orthopedics and military eld surgery of the Russian National Research Medical University named a er NIPirogov

Ratiev Andrey Petrovich – Doctor of Medical Sciences, associate Professor of the chair of traumatology, orthopedics and military eld surgery of the Russian National Research Medical University named a er NIPirogov

Yeghiazaryan Karen Albertovich – PhD, associate Professor of the chair of traumatology, orthopedics and military eld surgery of the Russian National Research Medical University named a er NIPirogov

Skoroglyadov Alexander Vasilyevich – Doctor of Medical Sciences, Professor, head of chair of traumatology, orthopedics and military surgery of the Russian National Research Medical University named a er NIPirogov

Dislocation-fractures of proximal humerus are the hardest injuries and appertain to the most severe pathology of this localization. ese injuries are still the major problem of modern traumatology and require careful analysis in each case. e article is considered the analysis of foreign literature dedicated to the diagnosis, research methods, complications and treatment of various types of dislocation-fracture proximal humerus.

Key words: shoulder`s dislocation-fracture, rotator cu, aseptic necrosis.