Fracture at the level of the elbow joint. Fracture of the condyles of the humerus.
A fracture of the elbow joint is not a medical term; in fact, a dislocation or rupture of ligaments can occur in the joint, and the bones that form the joint are broken; in the case of the elbow joint, this is the lower end of the humerus or the upper ends of the radius and ulna.
In this article we will look at one of the most severe fractures of this anatomical region - a fracture of the lower third of the humerus, its condyles, which participate in the formation of the elbow joint.
Fractures of the lower third of the humerus involved in the formation of the elbow joint, or fractures of the condyles of the humerus, are a serious injury that requires a thoughtful surgical approach and is characterized by a difficult rehabilitation period and often unsatisfactory treatment results.
Fractures of the distal humerus are extremely severe, often extend to the articular surface, and consist of a large number of small fragments. In the vast majority of cases, they require surgical treatment, otherwise the risk of nonunion, formation of a false joint, fusion in a vicious position, post-traumatic arthrosis of the joint, and contracture of the elbow joint is extremely high.
Anatomy of the elbow joint.
Your elbow joint is made up of 3 bones: the humerus, the radius, and the ulna. The elbow joint undergoes flexion and extension due to the movement of the ulna around the humerus. Also in the elbow joint, rotation or rotation of the head of the radial bone occurs, the radial bone itself seems to intersect with the ulna, and rotation of the forearm occurs.
The elbow joint itself is formed by the lower end of the humerus and the upper ends of the ulna and radius.
The elbow joint is held in its physiological position due to the architecture of the bones that form it, the articular capsule, which envelops their articular ends like a bag, and a large number of ligaments. Fractures of the lower end of the humerus, including the articular surface, are characterized by the presence of a large number of small fragments.
Such fractures are called comminuted or multifragmentary. In most cases, these fragments are displaced relative to each other.
Causes of fracture of the lower end of the humerus.
Most often, such fractures occur as a result of three types of trauma: a fall on the elbow joint, a direct blow, such as being hit by a bumper through a door during an accident, and a fall on a straight abducted arm, in which the ulna is wedged into the lower part of the humerus.
In the case of a low-energy fracture due to an ordinary fall, suspicions of osteoporosis always arise. A decrease in bone density leads to the fact that significantly less energy is required to obtain a severe fracture, which in the absence of osteoporosis would only cause a bruise.
Symptoms of a fracture of the lower end of the humerus.
Fractures of the lower third of the shoulder are characterized by severe pain. Preventing movement in the elbow joint, swelling, bruising, pain when touched, a feeling of instability, bone crunching, or crepitus of bone fragments, and in rare cases, protrusion of bone fragments through the skin - an open fracture.
With fractures of the humeral condyles, there is a high risk of damage to blood vessels and nerves. For this reason, during a clinical examination, it is extremely important to assess the sensitivity and pulsation of the arteries at the level of the forearm and hand. If damage to blood vessels or nerves is suspected, non-invasive diagnostic methods should be used. Such as ultrasound. It is also necessary to evaluate the presence of signs of the onset and progression of compartment syndrome at the level of the forearm, and, if necessary, perform a fasciotomy.
Externally, pronounced swelling is detected at the level of the elbow joint and the lower third of the forearm; in the first day the hematoma may not be visible, but it appears and grows later, and can spread to the fingers.
Upon admission of such a patient, after applying temporary immobilization, it is necessary to send the patient for X-ray examinations. In most cases, standard radiographs may be sufficient; sometimes a CT scan is performed when the X-ray picture is not clear enough.
If a clinical examination also reveals pain at the level of the forearm, it is also necessary to take radiographs along its length to exclude fractures at this level.
The radiographs of the elbow joint shown below reveal a comminuted fracture of the condyles of the left shoulder with 4 large fragments.
First aid
First aid to a victim with a suspected transcondylar fracture is carried out according to the general algorithm:
- Immobilize the limb using available means. This is done in order to stop the displacement of fragments and facilitate future therapy in a hospital setting. To do this, you need to apply a splint from available materials and secure it with a soft cloth.
- If there is an open fracture, you should never try to set the bone yourself. It is enough to treat with antiseptics, apply a tourniquet 15-20 cm above the injury, and cover the wound with a sterile cloth to avoid infection.
- To alleviate the suffering of the victim, it is necessary to give him an anesthetic. It is better if it is an intramuscular injection, but an analgesic in tablet form is also suitable.
- The victim must be seated and his condition monitored (skin color, reaction to external stimuli and other indicators). After the initial measures have been provided, wait for the ambulance to arrive or take the patient to the doctors as soon as possible.
Important! If the fracture is closed, then it is worth applying ice to the injured area. This will help reduce increasing swelling.
Classification of humeral condyle fractures.
There are several different classifications of humeral condyle fractures. They can be divided into supracondylar fractures, distal unicondylar fractures, for which Milch proposed a separate classification system, with a fracture of the lateral condyle more often occurring.
Distal humeral condyle fractures can be subdivided depending on what fragments were formed during the fracture according to the Jupiter classification. The 5 main articular fragments include: humeral head, lateral trochlea, lateral epicondyle, posterolateral epicondyle, posterior trochlea, medial trochlea, medial epicondyle.
Classification of humeral condyle fractures AO\OTA
Includes three main types - extra-articular, partial intra-articular and intra-articular fractures and three main subgroups in each type depending on the degree of fragmentation of fragments, displacement, and the structures involved.
The Jupiter classification of humeral condyle fractures examines in more detail the various morphological types of fractures involving both columns of the distal humerus. It distinguishes the following types of fractures:
High T-shaped (above or at the level of the upper edge of the olecranon)
Low T-shaped (at the level of the fossa, above the block)
Y-shaped (2 oblique fracture lines pass through both columns and connect on the block in one line)
H – shaped (multi-fragmented, the block is a separate fragment, high risk of avascular necrosis)
Medial lambda type – fracture of the trochlea and medial column
Lateral lambda type – fracture of the trochlea and lateral column
Pathophysiology of humeral condyle fractures.
Depending on the position of the elbow joint at the time of injury, different types of fractures are possible. When an injury occurs in a position where the elbow is flexed less than 90 degrees, a fracture occurs through the lateral or medial condyle of the humerus. When receiving a direct blow from behind on an extended arm, a fracture of the olecranon process with or without a fracture of the trochlea of the humerus is possible. If you fall on an arm bent more than 90 degrees, a transcondylar fracture can occur, and often several separate fragments of the humerus block itself are formed. This type of injury may be accompanied by elbow dislocation, the "terrible triad" and "floating elbow".
The prognosis for surgical treatment is good, with most patients regaining up to 75% of range of motion and strength. With a range of motion of 30-130 degrees of flexion, 75% were satisfied with the treatment.
Surgical treatment of such fractures is considered one of the most difficult tasks in traumatology, since fractures in this area are characterized by a large number of small fragments, low bone quality, complex anatomical structure, and adequate visualization requires a traumatic approach.
Types of fractures
By location
- fractures of the upper part (head, anatomical, surgical neck and tubercles);
- fracture of the middle part;
- fracture of the lower part (side, head, epicondyles).
According to the location of the fragments
- with displacement (the fragments are not in their proper places and surgical intervention is required to return them to their normal position);
- without displacement (fracture treatment is easier).
Also in traumatology, open and closed types of fractures are distinguished, where the main criterion is the presence or absence of a wound. With closed injuries, the skin remains intact.
Treatment of humeral condyle fractures.
During your initial visit to the emergency room, your doctor will apply a cast to immobilize your elbow in a neutral position. Also, immediately after an injury, ice can be applied to reduce pain and swelling, and painkillers can be administered.
After this, the doctor will determine the indications for surgery. In the vast majority of cases, humeral condyle fractures require surgery.
Conservative treatment is possible in cases of non-displaced fractures. It also becomes the only possible option in cases of multiple severe concomitant pathologies, making surgical treatment too risky.
Conservative treatment is reduced to plaster immobilization in a neutral position; after fusion occurs, physical therapy is performed aimed at restoring the range of motion in the elbow joint.
Unfortunately, with conservative treatment of fractures of the condyles of the humerus, the formation of a false joint, joint contracture, accompanied by persistent dysfunction of the joint, is possible.
Surgical treatment of humeral condyle fractures.
If you have the necessary equipment in the operating room and adequate surgical skills, fractures of the humeral condyles in most cases require surgical treatment. The operation can be performed with the patient lying on his stomach, on his side, as well as in the supine position, with the possibility of rotating the operating table around the longitudinal axis by 20-30 degrees.
For adequate visualization, the approach with olecranon osteotomy is most often used, since it provides the best possible visualization of both the humeral condyles and the entire humeral block. With this approach, a chevron osteotomy of the olecranon is performed, which, after osteosynthesis of the humeral condyles, is fixed with knitting needles and a wire loop according to Weber.
After performing an osteotomy and careful separation of the triceps tendon, it is necessary to isolate the ulnar nerve and take it on a holder to prevent damage to it during osteosynthesis.
After mobilizing all the fragments, it becomes clear whether the bone has been crushed, and whether there is a possibility of adequate restoration of the articular surface. In the presence of a significant bone defect, bone grafting may be required; if this defect includes a large part of the humerus trochlea, primary endoprosthetics may be considered as an alternative elbow joint.
The condyles of the humerus are a triangle, the sides of which are formed by two columns and an articular surface, with an opening for the olecranon process in the center. When osteosynthesising a fracture of the humeral condyles, it is necessary to restore all 3 sides of this triangle.
First of all, the articular surface is restored. If there is no crushing of the bone or missing fragments, the trochlea and the capitate eminence can be connected with 2 compression screws. First, the fragments are temporarily fixed with Kirschner wires and bone pins, the so-called preliminary fixation.
After achieving satisfactory reduction, 1-2 compression screws are inserted through the block parallel to its long axis.
The next stage is that the already “assembled” block is fixed to the medial and lateral columns with knitting needles, and then this entire structure is fixed to the diaphysis of the humerus using plates.
In the case when you are dealing with a comminuted fracture of the humeral condyles, you want to have the strongest and most reliable implants that will ensure maximum stability of the structure even in conditions of osteoporotic, loose bone. Synthes pre-modeled anatomical plates are excellent for this purpose.
After installing the screws, the spokes are removed, since they have already fulfilled their function. The humeral condyle fracture is securely fixed with screws and two angularly stable plates.
The last stage is osteosynthesis of the osteotomized olecranon using knitting needles and a wire loop according to Weber and layer-by-layer suturing of the wound.
Such osteosynthesis is reliable enough to begin rehabilitation measures the very next day after surgery. Early mobilization of the elbow joint prevents the formation of adhesions and allows you to restore the maximum possible range of motion in the elbow joint, which is the goal of treatment.
Another clinical example of osteosynthesis of a severe fracture of the humeral condyles using Synthes angular stability plates.
Patient X, 54 years old, received an intra-articular Y-shaped fracture of the humeral condyles. The displacement of bone fragments is so significant that the diaphysis of the humerus is close to perforating the skin.
In the case of such gross displacement during the initial examination, it is advisable to anesthetize the fracture and eliminate the displacement with fixation of the limb in a posterior plaster cast. After examination and preoperative preparation, the patient was taken to the operating room. Osteosynthesis was performed using Synthes angular stability plates.
Postoperative radiographs show that the displacement of the fragments has been completely eliminated, and the normal relationships of the bones of the upper limb have been restored.
During the operation, it is necessary to evaluate the stability of the osteosynthesis to movements in the joint, since the postoperative protocol involves early loading within 1-2 days after the operation. Early movement of the joint prevents the formation of rough scars and adhesions, which could otherwise cause permanent restriction of movement in the joint.
Video assessing movements and stability after osteosynthesis surgery.
POLYTRAUMA / POLYTRAUMA
Sinitsa N.S., Kravtsov S.A., Meshcheryakov S.A.
State Autonomous Institution "Regional Clinical Center for Miners' Health", Leninsk-Kuznetsky, Russia
SEVERE CATTRAUMA IN CHILDREN. INTEGRATIVE APPROACH TO TREATMENT
In recent years, injuries have become one of the main causes of mortality in the population, while no downward trend in its frequency has been observed. Severe combined trauma ranks first among the causes of mortality [1, 2]. The share of catatrauma in the structure of all injuries is 12-20%, and in the structure of mortality from injuries it ranks second (up to 40%) after mortality from road injuries (up to 75%) [3, 4]. Every day, according to WHO, around the world, about 47 thousand children and adolescents under 20 years of age die as a result of catatrauma [3]. The term catatrauma emphasizes the mechanism of the injury. When a fall occurs, there is a sharp acceleration - deceleration of the victim's body and, depending on the height, upon contact with a hard surface, this is accompanied by a complex of, as a rule, severe combined injuries. Focusing on such a mechanism of injury allows us to immediately assume a number of typical injuries (shock, acute massive blood loss, intracranial injuries, injuries to the spine and spinal cord, injuries to the chest and abdominal organs, fractures of the pelvic bones, limbs, etc.), which dictates the need to carry out urgent, emergency treatment measures aimed at saving the patient’s life. Treatment of this group of victims is characterized by strict consistency, multi-stage and individuality. The optimal place for treatment of this category of victims is a multidisciplinary specialized hospital - a level 1 trauma center, where a multidisciplinary approach is carried out (traumatologists, resuscitators, surgeons, neurosurgeons, cardiologists, pulmonologists, endoscopists, doctors of diagnostic departments, etc.) using modern algorithms for providing specialized care. medical care. From 10 to 14 patients with severe combined injuries associated with a fall from a height are hospitalized at our center annually. Injuries to the central nervous system (craniocerebral, spinal-spinal) were recorded in 38% of cases. Among injuries to the chest organs (which, according to our observations, occur in 74%), characteristic of catatrauma is a violation of the frame of the chest - fractures of the ribs, sternum, which is accompanied by bruises, damage to lung tissue, hemopneumothorax, and possible heart contusion. In addition, this is often accompanied by aspiration syndrome, followed by the development of aspiration pneumonia. In cases of damage to the abdominal organs, damage to the liver and spleen often occurs, accompanied by acute massive blood loss. In the children we observed with ruptures of the spleen in the hilum area, due to the impossibility of ensuring effective hemostasis, splenectomy was performed. Skeletal injury was observed in 100% of cases; the greatest severity of the victims’ condition was observed in the most common type B pelvic fractures according to the AO classification, characterized by rotational instability with preservation of vertical and transverse stability. Target -
show the possibilities of an integrative approach in the diagnosis and treatment of children with severe catatrauma. The study was carried out in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association Declaration of Helsinki – Ethical Principles for Medical Resarch Involving Human Subjects, 2013) and the “Rules of Clinical Practice in the Russian Federation” (Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266) , with written consent from the patient’s parents to participate in the use of data and approved by the local ethics committee of the State Autonomous Institution of Healthcare of the Regional Clinical Center for Health and Human Welfare (protocol No. 23 of 09/04/2018).
CLINICAL CASE STUDY
Child Z. 8 years old fell from a 7th floor window. The patient was delivered by the ambulance team to the intensive care unit of our center 35 minutes after receiving the injury with a diagnosis of polytrauma. Pre-hospital stage – examination, initiation of intensive care, immobilization, transportation – 15 minutes. Scope of prehospital care: catheterization of a peripheral vein, infusion therapy - a solution of 0.9% sodium chloride 150 ml, anesthesia - morphine 1% 1 ml. Immobilization of the cervical spine with a Philadelphia orthosis, placement on a stretcher. To provide assistance to victims with polytrauma, an in-hospital multidisciplinary team led by a leading specialist of the team has been created at the State Autonomous Institution of the Regional Clinical Center for Health and Human Welfare. The role of the leading specialist of the multidisciplinary team in coordinating and determining the sequence of treatment and diagnostic measures is assigned to the responsible surgeon. The composition of the team by profile: anesthesiologist-resuscitator, pediatric surgeon, surgeon, neurosurgeon, traumatologist, if necessary, the following are involved: cardiologist, endoscopist, functional diagnostics doctor. During the initial examination in the emergency department, a full range of studies is performed to assess the severity of the condition, identify the dominant components of the injury, and determine the sequence of treatment tactics. Priority treatment measures in the intensive care unit according to the ANLS (Advanced trauma life support) protocol. Tracheal intubation, mechanical ventilation, installation of a second vascular access, catheterization of the bladder, tube into the stomach, intensive infusion and transfusion therapy. Examination in the anti-shock ward: the child is developed according to his age, has a correct physique, and has normal nutrition. The skin is pale, hands and feet are cold, dry, visible mucous membranes are pale pink, clean. In the nasal cavity and mouth there is hemorrhagic mucus. Consciousness is altered, stupor, productive contact is not available. In the frontal region, parasagitally, there was extensive bruising, abrasions of the head and face, mainly on the right. In the frontal-sagittal region on the right there is a dense and soft subgaleal hematoma. He groans in response to painful stimuli and opens his eyes. On the right are active differentiated reactions, on the left is extremely sluggish differentiation. The pupils are of medium size, S = D, the friendly photoreaction is weakened. Oculocephalic reflexes are positive. Tendon reflexes are preserved, higher on the left. The cervical and thoracic lumbar spine are not changed. The chest is of a normal configuration and evenly participates in the act of breathing. RR = 30-34 min. Air, SpO2 = 88-90%. In the lungs, breathing is harsh, moderately weakened mainly in the lower-lateral sections, isolated wheezing can be heard, more on the right. Considering the low level of consciousness and acute respiratory failure, tracheal intubation was performed and the child was placed on artificial ventilation. Heart sounds are clear and rhythmic. Blood pressure = 90/60 mm Hg, HR = 120 b/m, according to ECG (monitor) - sinus tachycardia. The abdomen is of a normal configuration, symmetrical, soft on palpation, diffusely painful. Percussion - tympanitis in the mesogastrium. Peristalsis is weakened and auscultated. The Shchetkin-Blumberg symptom is questionable. The kidneys, liver, and spleen are not palpable. A more detailed examination could not be carried out due to the low level of consciousness. Considering the mechanism of injury and the clinical picture, a closed abdominal injury cannot be excluded in the child; diagnostic laparoscopy is indicated. A urinary catheter was installed and residual urine was removed. Upon admission to the emergency department, blood and urine were taken for a general analysis, blood for acid-base balance, determination of blood type and Rh factor. Primary results: Hb = 105 g/l, er = 3.83, Ht = 30.1%, Ph = 7.133. Priority treatment measures were carried out in the intensive care unit according to the ANLS (Advanced trauma life support) protocol. Tracheal intubation, transfer to mechanical ventilation, installation of a second vascular access, catheterization of the bladder, tube into the stomach, intensive infusion-transfusion therapy was continued. Considering the child’s stable condition, instrumental diagnostics were continued. Rg-graphy of the chest: pneumothorax on the right along the costal arch with a slight shift of the mediastinum to the left. Contusion of the lung parenchyma in the lower posterior regions. CT scan of the brain: subarachnoid hemorrhage on the right in the frontal-temporo-occipital lobe. Edema in the right hemisphere with dislocation of the midline structures to the left by 3 mm. The anterior horns of the 3rd ventricle are compressed due to edema. Subgaleal hematoma in the frontal region on the right. CT scan of the chest: minimal pneumothorax on the right and local pneumothorax on the left in the area of the anterior cardiophrenic sinus. Contusion of the lungs on the right and left in the lower parts of the posterior segments, more on the left. Small bulla on the right in the lower lobe. Fracture of the 1st rib without displacement. CT scan of the cervical spine: no bone-traumatic changes were detected. Rg-graphy of the knee joints: no bone-traumatic pathology was detected. RG-graphy of the lumbar spine: no bone-traumatic pathology was detected. Rg-graphy of the pelvic bones: fracture of the floor of the acetabulum with a displacement of 5 mm into the pelvic cavity. Rg-graphy of the left elbow joint: transcondylar, flexion fracture of the humerus with displacement of fragments, fracture of the olecranon process (Fig. 1).
Figure 1. Patient Z., 8 years old. Rg-graphy of the chest, CT scan of the brain, Rg-graphy of broken bones of the extremities upon admission.
The total time of examination in the anti-shock ward and primary treatment measures was 37 minutes. The patient was transported to the operating room for emergency surgery. Under intubation anesthesia the following was performed: diagnostic laparoscopy (blood in the abdominal cavity); laparotomy (a rupture of the spleen in the hilum area was detected); splenectomy, drainage of the abdominal cavity; drainage of the pleural cavity on the right in the 2nd intercostal space along Bulau (removal of air and hemorrhagic discharge was obtained - up to 50.0 ml); closed reduction of the left humerus. The operation time was 1 hour 20 minutes, the total external blood loss was up to 200 ml. Surgical treatment of pelvic fractures was not required. After the operations, the child was transferred to the intensive care unit (ICU), where intensive therapy, clinical, biochemical and physiological monitoring continued. Diagnosis after examination and surgical treatment:
“Polytrauma. Closed craniocerebral injury. Severe brain contusion. Subarachnoid hemorrhage on the right. Subgaleal hematoma of the frontal region. Closed injury to the abdominal organs. Splenic rupture. Intra-abdominal bleeding. Condition after laparoscopy, laparotomy, splenectomy. Closed chest injury. Fracture of the 1st rib on the right without displacement. Contusion of the lower lobes of both lungs, damage to the right lung, closed pneumothorax on the right. Condition after drainage of the right pleural cavity. Multiple closed skeletal injury. Closed fracture of the pubic bone, the floor of the acetabulum on the left with displacement. Closed flexion transcondylar fracture of the left humerus with displacement of fragments. Closed fracture of the olecranon process of the left forearm. Traumatic shock of the 2nd degree.” Severity of injury on the ISS scale – 54 points (severe brain contusion – 16 points, splenic rupture – 16 points, lung contusion, closed pneumothorax – 9 points, pelvic fracture – 9 points, humerus fracture – 4 points); the injury is classified as extremely severe, the probability of death is over 30%. After surgical treatment, the child was left on prolonged artificial ventilation. Taking into account the severity of the condition in the intensive care unit, drug sedation was continued for the purpose of pain relief and synchronization with a respirator, symptomatic therapy was prescribed: cephalosporin antibiotics, correction of blood loss (packed red blood cells 5 ml/kg, FFP 10 ml/kg), infusion therapy with saline solutions, pain relief ( promedol), administration of protease inhibitors. hemastatic therapy, diagnostic and sanitation bronchoscopy, enteral nutrition through a nasogastric tube. During the period of likelihood of complications developing (3-10 days) - in our case, on the 3rd day - negative dynamics were noted in the child’s condition in the form of an increase in intoxication, the appearance of elements of maladaptation with a respirator, and an increase in respiratory failure. A control R-logical examination of the chest organs revealed collapse of the right lung, pneumothorax, which required additional drainage of the right pleural cavity (Fig. 2), active drainage during the day, followed by passive aspiration (Bulau system) to straighten the lung. The pneumothorax was not completely relieved on the first day; a parietal cavity of up to 1 cm remained in the area of the apex of the right lung. In the zone of the lower lobes on both sides and the apex on the right there is post-traumatic infiltration, more pronounced on the right - post-traumatic pneumonia. As the inflammatory process regressed, the lung expanded completely.
Figure 2. Patient Z., 8 years old. RG-graphy and CT scan of the chest on the 3rd day after admission - collapse of 2/3 of the right lung and drainage placement.
Upon admission of the child to the hospital, sinus tachycardia and a tendency to hypotension were noted. As the deficit of blood volume was eliminated, metabolic and water-electrolyte disorders were corrected, sinus tachycardia persisted, a tendency towards hypertension appeared, according to EGC - incomplete blockade of the right bundle branch; according to EchoCG, no pathological changes were detected. The appearance of these rhythm disturbances may be one of the signs of cardiac contusion. Dynamic observation (dynamic ECG and echocardiogram data - without pathology, cardiac-specific enzymes - within normal values) did not confirm this assumption. The diagnosis of cardiac contusion was removed. Due to the need to carry out prolonged artificial ventilation, therapeutic and diagnostic bronchosanitation, the child underwent a lower tracheostomy according to Bjork on the 6th day. Bronchosanitation was performed during the entire period the child was on mechanical ventilation 2-3 times a day (according to indications). After 7 days, the antibiotic was changed. The administration of anticoagulants, antisecretory and antioxidant drugs also continued. In addition, bronchodilators and mucolytics were used. Infusion therapy was carried out taking into account enteral nutrition with correction of electrolytes in the amount of the daily norm. Against the background of intensive treatment, positive dynamics were noted in the child’s condition, a decrease in the severity of the inflammatory process: normalization of temperature and leukocytosis, resolution of infiltrative changes in the right lung, regression of respiratory failure. Respiratory support was reduced as planned, with a gradual transition from controlled ventilation modes to auxiliary ones, with the patient’s gradual transition to independent breathing. The level of consciousness recovered to 14 points on the Glasgow Coma Scale. On a CT scan of the brain, the edema in the right hemosphere was relieved, the hemorrhagic focus of the contusion in the right temporal lobe was lysed. On the 13th day, the child was transferred to independent breathing through a tracheostomy tube. After an Rg-graphy of the chest organs (pneumothorax was stopped, the lungs were expanded, residual subsegmental infiltrative changes in the right lung remained), the pleural drainage was removed (Fig. 3).
Figure 3. Patient Z., 8 years old. RG-graphy of the chest and CT scan of the brain with positive dynamics on the 17th day.
On the 17th day from the moment of injury, clear consciousness was restored, spontaneous breathing became adequate, muscle tone became good, the act of swallowing was not changed - the tracheostomy tube was removed. Upon admission, the neurological status was marked by left-sided hemiparesis, which completely regressed on days 21-23. Additional examination and dynamic X-ray monitoring were carried out: ECG, EchoCG, DS of the vessels of the lower extremities (thrombosis of the sural veins in the legs of the lower extremities), DS of the vessels of the left upper limb, SCT of the brain and OGK. Throughout the entire period of treatment, the girl was observed by a pediatric surgeon, neurosurgeon and traumatologist. Additionally, she was consulted by an ophthalmologist, pediatric cardiologist and neurologist. After 26 days, the cast was removed from the left upper limb. A control radiography was performed, in which the axis of the humerus was restored, the condition of the bone fragments was satisfactory (Fig. 4).
Figure 4. Patient Z., 8 years old. RG-graphy of the left elbow joint on the 28th day after admission - consolidating fracture of the humerus, olecranon.
An important component in the treatment of patients with polytrauma is the early start of a complex of rehabilitation measures. They begin in the intensive care unit: breathing exercises, vibration massage, exercise therapy (with gradually increasing load), stage-by-stage “verticalization” of the patient, etc. After removal of the cast, exercise therapy continued in the pediatric traumatology department to restore range of motion in the left upper limb. In a state of moderate severity, on the 29th day the child was transferred for further treatment and rehabilitation to a specialized department, where he remained for another 23 days and received restorative treatment: physical therapy, exercise therapy. As a result, the range of motion in the left elbow joint was achieved: full extension, active flexion 90 degrees, passive flexion up to 75-80 degrees. By the time of discharge, the child walks with full weight-bearing on the lower extremities, the range of motion in the hip joints is full, painless, and the fractures of the pelvic bones have consolidated. The child was discharged from the institution in satisfactory condition after 52 days (Fig. 5).
Figure 5. Patient Z., 8 years old. Functional result on the 50th day, at discharge.
CONCLUSIONS:
A multidisciplinary approach to the treatment of a patient with catatrauma allows us to optimize the diagnosis of typical injuries and determine the amount of necessary treatment. Consecutive surgical interventions performed in a specialized institution on the organs of the chest, abdomen and limbs allowed us to achieve a good result.
Funding and conflict of interest information
The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.
LITERATURE / REFERENCES:
1. Agadzhanyan VV, Agalaryan AKh, Ustyantseva IM, Galyatina EA, Dovgal DA, Kravtsov SA et al. Polytrauma. Treatment of children. Novosibirsk: Nauka Publ., 2014. 244 p. Russian (Agajanyan V.V., Agalaryan A.Kh., Ustyantseva I.M., Galyatina E.A., Dovgal D.A., Kravtsov S.A. et al. Polytrauma. Treatment of children. Novosibirsk: Nauka, 2014 244 pp.) 2. Agadzhanyan VV, Kravtsov SA, Zheleznyakova IA, Kornev AN, Pachgin IV. Interpretation of criteria for polytrauma severity with international classification of diseases. Polytrauma
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2014; (1): 6-14. Russian (Agajanyan V.V., Kravtsov S.A., Zheleznyakova I.A., Kornev A.N., Pachgin I.V. Integration of criteria for the severity of polytrauma with the international classification of diseases // Polytrauma. 2014. No. 1. C 6-14) 3. Baindurashvili AG, Norkin IA, Solovyeva KS. Injury rate and orthopedic morbidity in the children of the Russian Federation. Arrangement of specialized assistance and the perspectives of improvement. Herald of Traumatology and Orthopedics named after NN Priorov
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2010; (4): 13-17. Russian (Baindurashvili A.G., Norkin I.A., Solovyova K.S. Traumatism and orthopedic morbidity in children of the Russian Federation. Organization of specialized care and prospects for its improvement // Bulletin of Traumatology and Orthopedics named after N.N. Priorov. 2010. No. 4. pp. 13-17) 4. The World Report about the Pediatric Traumatism Prophylaxis /Geneva: World Health Organization, 2008. 39 p. Russian (World report on the prevention of childhood injuries / Geneva: World Health Organization, 2008. 39 p.) 5. Sokolov VA, Byalik EI, Ivanov PA, Garaev DA. Practical administration of “DAMAGE CONTROL” conceptions in treatment of fractures of long bones of extremities in patients with polytrauma. Bulletin of Traumatology and Orthopedics by the name of NN Priorov
. 2005; (1): 3-6. Russian (Sokolov V.A., Byalik E.I., Ivanov P.A., Garayev D.A. Practical application of the DAMAGE CONTROL concepts in the treatment of fractures of long bones of the extremities in patients with polytrauma // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova, 2005, No. 1, pp. 3-6
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Possible complications of surgical treatment.
Any operation has risks. With osteosynthesis there is also a small risk of infectious complications (less than 1%).
Severe joint contracture to varying degrees is much more common. When the range of motion in the elbow joint is more than 130-60 degrees, the treatment result is considered satisfactory. An extension/flexion deficit of 10 degrees is usually not felt at all by patients in everyday life and can be regarded as an excellent functional result.
Iatrogenic damage to blood vessels and nerves occurs much less frequently during surgery. This is why it is always necessary to isolate the ulnar nerve. Since it is directly adjacent to the bone and can easily be injured when using gomen, other retractors and bone trenches.
In case of insufficient stability of the structure and excessive skeletonization of the bone, as well as in the case of concomitant vascular pathology, smoking and the presence of other risk factors, “non-union” of the fracture, lysis of the humeral trochlea, and the formation of a false joint are possible. In such severe cases, it may be necessary to undergo elbow replacement.
Diagnostics
The main diagnostic method is x-ray. It will make it possible to detect a bone fracture and its features - with or without displacement. It is also important to diagnose a rotational change in the position of the bones - rotation. X-ray examination is carried out in 2 projections. There are situations where you may need to take a picture of your healthy arm for comparison.
If necessary, a computed tomography scan can be performed; in some cases, it will give a more accurate picture of the damage. A general blood and urine test is taken to identify concomitant diseases or traumatic shock.
Rehabilitation after surgical treatment of humeral condyle fractures.
For pain relief immediately after surgery, it is advisable to perform a brachial plexus block using long-lasting anesthetics such as naropin. This allows you to completely eliminate pain for the next 10-15 hours after surgery.
In the first 2-3 days, the pain can be quite intense and require the use of narcotic and non-narcotic analgesics. For this reason, it is better to stay in the hospital for this time and be discharged after the pain has subsided. Using ice for 30 minutes every 3 hours is essential and is effective in controlling pain and swelling for weeks and even months after the injury.
Therapeutic physical training under the supervision of a specialist – a rehabilitation specialist begins the day after the operation. During the first 3 weeks, a gradual restoration of passive range of motion is carried out. From 4 weeks it is possible to engage in active movements in the elbow joint. If the course of the wound process is favorable, by the end of 6 weeks it is possible to achieve healing of the fracture and restoration of almost full amplitude.
The final fusion and remodeling of the humerus lasts 1-2 years; after complete fusion, if the metal structures cause discomfort, they can be removed. In most cases, it is sufficient to remove only the pins and wires from the olecranon, as they are located directly under the skin and can greatly irritate it.
Rehabilitation
Rehabilitation for a transcondylar fracture of the humerus with displacement in children begins even before discharge from the hospital.
All activities are focused on the prevention of post-traumatic complications and restoration of motor function:
- Taking medications. These include anti-inflammatory drugs to relieve swelling and pain, chondoprotectors, B vitamins (promote the restoration of muscle tissue and ligaments), drugs containing calcium are taken for any bone damage, since they are the main element of bone tissue.
- Physiotherapy according to indications: electrophoresis with medicine, magnetic therapy, currents and applications with paraffin. Physiotherapeutic procedures improve blood microcirculation in the damaged area, relieve pain and relieve swelling.
- Proper nutrition with a predominance of foods containing large amounts of phosphorus, calcium and protein.
- Therapeutic gymnastics should focus on the dosage of exercises. Do not warm up or forcefully move. Start the load with moderate movements, gradually increasing from the moment the callus forms.
With the right approach to treatment and rehabilitation, problems with motor function do not arise. The fracture heals without consequences.