Fractures of the proximal humerus account for 4-5% of all fractures and are the most common injury to the shoulder girdle. According to Nordqvist and Petersson, fractures of the proximal humerus account for about 53% of all significant injuries to the shoulder girdle.
Fractures of the greater and lesser tuberosities can occur either isolated or as part of comminuted injuries of the proximal humerus. Most authors believe that displacement of the greater tuberosity in the posterosuperior direction by 5 mm can lead to clinically significant impingement . For fractures without displacement or with minimal displacement (less than 5 mm), the main method is conservative treatment.
Clinical examination
The clinical course of fractures of the proximal humerus depends on their nature. Most of these fractures occur in older patients as a result of trauma, low-energy injury from a fall, but isolated fractures of the greater and lesser tuberosities occur in younger patients. Tuberosity fractures typically occur in men between the second and fifth decades of life and in adolescents with an open growth plate of the humerus.
The nature of the fracture is determined by the mechanism of injury. It has been determined that more than 50% of greater tuberosity fractures occur due to anterior shoulder dislocation . Eccentric loading of the tuberosities resulting from a fall on an outstretched arm is a cause of avulsion fractures and may contribute to subsequent displacement. Lesser tuberosity fractures are rare injuries occurring in young people. The arm is usually in abduction and external rotation. Severe tension in the subscapularis muscle leads to separation of the tubercle.
Another mechanism for fracture of the lesser tuberosity is posterior shoulder dislocation .
Clinical examination
Fractures of the proximal humerus often present with significant swelling. Ecchymoses spread down the arm, into the chest and into the armpit. A search for associated damage is mandatory.
According to electromyography, 67% of all patients with fractures of the proximal humerus have signs of neurological disorders. The axillary (58%) and suprascapular (48%) nerves are most often damaged.
Symptoms of an isolated fracture of the lesser tubercle: pain that occurs with passive external rotation, with internal rotation with resistance, and pain on palpation in this area. The health of the tendon-muscle complex can be assessed using pull-off and abdominal pressure tests (since the subscapularis tendon attaches to the damaged bony structure).
Visualization
Radiation diagnostics is mandatory for fractures of the proximal humerus. Primary radiography is performed according to Neer: in the anteroposterior, scapular “Y” and axillary projections. Assessing the fracture line and fragment displacement can be difficult due to the anatomy of the proximal shoulder joint.
If radiographs are ineffective, CT with three-dimensional reconstruction may be effective. For fractures of the greater tuberosity, the most accurate measurement of the amount of displacement is possible using radiographs obtained in the anteroposterior projection in the position of external rotation and with a 15° caudal tilt. Large displaced fragments of the greater tubercle are anteroposterior projection, smaller ones are axillary projection.
MRI is used to detect occult fractures of the tubercles without displacement. Zanetti noted that in patients with suspected rotator cuff injuries, the rate of occult fractures is 38%.
Classification
Neer proposed a four-part classification of fractures of the proximal humerus, which became widespread due to its simplicity.
Pros:
- A conceptual idea of the nature of the fracture, several of its types are distinguished.
Minuses:
- Poor agreement between different researchers
- Single-examiner reproducibility
Causes and types of fracture
These types of fractures often cause pronounced dysfunction of the upper limb, as well as the development of contractures in the joint.
The humerus can be compared in size with the femur and placed in second place in size in principle. At the same time, it takes part in the work of the most mobile joint - the shoulder.
Movement is provided by muscles attached to the lesser and greater tubercles.
Near the joint, almost outside the shoulder, there is a large tubercle.
If the greater tubercle is damaged, the motor functions of the limb are impaired, and it becomes impossible to turn, rotate, and extend the shoulder.
A fracture does not appear out of nowhere, so the most common cause is trauma . The most common situations in which this type of fracture occurs:
- A strong blow to the shoulder with any heavy object.
- Road accident.
- Injury resulting from sports activities.
- Emphasis on the hand at the moment of falling.
- A fall with a sharp blow to the shoulder and a hand pressed to the body.
In this case, all types of impact that lead to a fracture can be divided into two:
- direct - there is a direct blow to the shoulder, injury,
- indirect - occurs due to strong muscle traction.
In case of direct injury to the shoulder, the fractures are severe, with the presence of fragments , as well as concomitant fractures of the process of the scapula or more complex fractures of the neck of the humerus.
As a result of any of these injuries, the victim may have a dislocated shoulder with a separation, as well as an isolated fracture in the area of the greater tubercle .
In fact, several types of fracture can be identified:
- concussion, resulting from a direct blow,
- tear-off with offset,
- avulsion fracture without displacement.
A contusion fracture, in turn, can be divided into fragmented and impacted, when the tubercle seems to be partially immersed in the bone of the shoulder .
A distinction can also be made between open and closed fractures depending on whether the integrity of the skin is damaged or not.
Most often, such fractures occur in everyday life and are combined with a dislocated shoulder, which is not a professional injury.
Unfortunately, the tear-off mechanism occurs quite often when an unskilled person attempts to reduce a dislocation or reposition bone fragments .
For any manifestation of symptoms related to shoulder pain, as well as bruises and dislocations, it is necessary to contact a competent specialist as soon as possible to prevent the situation from worsening.
Symptoms of a fracture
Symptoms of a fracture of the humeral tubercle clearly indicate the type of injury:
- severe pain in the joint (occurs immediately at the time of injury and does not go away over time, becomes stronger with palpation),
- swelling in the shoulder area (occurs due to damage to surrounding tissues, a hematoma may also appear if the vessels are affected),
- deformation of the joint and forced position of the arm (turned inward and brought to the body),
- crepitus (audible crunching sound),
- restriction in movement (when trying, the pain becomes stronger, the person cannot turn the shoulder inward).
First aid
When a victim receives such an injury, first aid must be urgently provided in order to reduce pain and prevent possible displacement and movement of fragments.
First of all, it is necessary to fix the injured limb by tying the arm to the body and bending it at the elbow joint. To do this, it is possible to use a bandage, scarf, towel, or simply a torn piece of fabric.
To the place where the pain is most severe, it is necessary to apply ice or another source of cold , and also give the victim a remedy that can relieve pain.
It is necessary to take the patient to an emergency room or hospital as soon as possible to diagnose the damage and prescribe the necessary therapy.
An independent attempt to straighten the joint, as well as change the position of the arm, can lead to complications and worsening of the injury, as well as increased pain.
Immobilization for a humerus fracture
When complete immobilization of the limb is required, it is advisable to apply a thoraco-brochial bandage.
The technique for applying it is as follows:
- The victim should sit on a high stool or on a table. His limb must be flexed 80 °C for an injury to the upper part of the shoulder and 45 °C for a fracture of the lower bones.
- A layer of cotton wool should be applied to the body, which is secured with bandages.
- The joints of the hand, such as the wrist, elbow and shoulder, are also covered with cotton wool.
- Plaster splints are applied horizontally to the body, and they are attached vertically to the sides.
- One splint should be placed over the shoulder that was injured. It should be attached to the body with bandages.
- Then additional splints are applied over the body, shoulder girdle, forearm, up to the hand. All this is again fixed with bandages.
- A special spacer is inserted between the arm that will be in the cast and the body so that the limb cannot adhere to the body.
This way the limb will be immobilized and bone fusion will proceed correctly.
Diagnostics
When examining a fracture, all doctors agree that the most traditional diagnostic method is radiography . Despite all the advantages, this method may not be the most reliable, since avulsions cannot always be detected due to the overlap of shadows of the shoulder blades or collarbone.
The most optimal and most reliable study can be considered an MRI, which can detect not only damage to bone tissue, but also assess the condition of muscles, blood vessels and nerves, which are also often damaged.
Computed tomography, which scans the bone in ten projections, can also help identify all the details of the fracture.
Treatment
A fairly serious injury is a fracture of the tubercle of the humerus. Treatment is selected based on the severity of the damage, as well as symptoms.
Doctors can use either a conservative method or perform surgical intervention .
Conservative treatment
In the event that the resulting fracture turns out to be without displacement or the displacement is minimal and allows you to rotate the damaged limb so that the fragments take the correct position, then the use of a conservative method is allowed.
In this case, the limb is fixed in such a way that the elbow joint is bent at 90 degrees , the shoulder itself is slightly retracted from the body.
Therapeutic measures
In a medical facility, a patient after an injury is prescribed painkillers. After the test, a Novocaine solution is injected into the shoulder area. After a few minutes, numbness occurs and pain decreases.
Then the patient is sent to the x-ray room to establish a diagnosis. Based on the results of the examination, the treatment method is determined.
The doctor is guided by:
- Clinical picture (type, degree);
- The number of fragmentation fragments;
- The presence of displacement;
- The age of the patient;
- The presence of other pathologies;
- The level of damage to muscle tissue, tendons, capsules.
Treatment can be conservative or surgical.
Conservative therapy is prescribed for a non-displaced tubercle fracture. Progress of measures: taking analgesics, fixing the arm with a diversion bandage. Limb abduction 80 degrees, external rotation 60 degrees. Plastering is carried out circularly to the splint.
The cast is not applied to the hand and forearm. Their purpose is to practice therapeutic exercises. The limb is fixed for 30 days. If the recommendations of the traumatologist are followed, restoration of working capacity occurs in 2-3 weeks.
The operation is indicated for patients with a displaced tubercle fracture (presence of fragments, multi-fragmented wounds, disruption of capsules, rupture of ligamentous structures). For fractures with fragments, osteosynthesis is recommended. Fragment sections are secured with knitting needles, screws or plates.
When a comminuted fracture is diagnosed, the fragments are eliminated. Ligamentous and muscular joints attach to the humerus. The plate elements are removed 6 months after the operation.
Rehabilitation
Rehabilitation after a fracture of the greater tubercle of the humerus is an important stage that can give a good prognosis for a full recovery.
The following measures can be conditionally included in the rehabilitation complex:
- exercise therapy,
- physiotherapy,
- massage,
- variety of diet,
- taking vitamin complexes,
- treatment in a sanatorium,
- wearing a bandage.
Also, the entire rehabilitation period can be divided into three rehabilitation periods .
First period
At this point, it is necessary to pay attention to physical therapy exercises , which should be aimed at:
- Relaxation of the muscles of the shoulder apparatus, as well as in the area of the shoulder girdle.
- Reduction of hematomas and hemorrhages in the area of injury and the area of the humerus.
- Reducing pain.
- Improving blood circulation in the injured arm.
- Restoration of metabolism in tissues that have been damaged.
Exercises should be performed slowly, measuredly and gently. Do not overload the injured limb and the body as a whole. Be sure to perform them under the strict supervision of a specialist.
At the first stage of rehabilitation, the following exercises are performed:
- Circular movements of the limb clockwise and counterclockwise.
- Swinging your hand like a pendulum.
- Flexion and extension of the fingers of the injured hand with the thumb pressed.
- Bend the arm at the elbow.
- Move your shoulder up and down.
This period lasts about two weeks . In this case, the patient must perform each exercise 10 times daily for 7-8 approaches.
Second period
The main tasks of the second period are the initial restoration of limb mobility and the development of mobility of the joint itself .
Exercises are performed using a ball and a stick, and classes can be carried out in a special exercise therapy room.
Exercises are performed after consultation with a specialist and selection of the necessary complex for each specific case.
Third period
This stage of recovery is necessary to restore the full range of motion in the joint, as well as to increase the body's endurance .
This stage includes performing exercises such as hanging exercises, weights, exercises with dumbbells and various weights, as well as visiting the pool.
First aid for a fractured humerus
First aid for injury is as follows:
- First, you need to calm the person down and offer him a pain reliever. The following can be used as an analgesic: analgin, nimesulide, ketorol. If a person is experiencing panic, then you can give him a tincture of valerian, 20 drops will be enough, or one tablet of tazepam or triocasin. Valocordin or cordiamine can be used as a cardiovascular drug.
- Then you need to limit your hand movements as much as possible. For this purpose, immobilization is carried out. Small planks can be used as improvised means. One of them should be bandaged tightly to the shoulder, and the other to the forearm. If there are not even planks, then it is advisable to place your hand on a scarf. She throws herself over her uninjured shoulder. In this case, the arm should be bent at a right angle at the elbow. To prevent displacement, it is best to tie such a bandage as tightly as possible to the body.
- During transportation, it is advisable for the person to sit.
Complications and prevention
The most common complications are:
- Biceps injuries . Can occur at the time of injury, leading to surgery to stitch the damaged muscle.
- Non-union of tubercle fragments . Occurs when there is poor fixation of the limb and entails surgical intervention.
- Calcium deposits and ossification of muscle fibers will also require surgical removal or laser therapy at the very initial stage.
- Arthrosis. Damage to cartilage tissue may be caused, which will then be treated conservatively.
Prevention of such disorders requires initial competent treatment and contacting specialists with any questions regarding pain that raise doubts.
Completing all necessary actions prescribed by the doctor during the period of treatment and rehabilitation will help avoid complications and promote a speedy recovery.