The humeral tuberosity is a prominence on the humerus and is the site of attachment for several rotator cuff muscles. The rotator cuff is made up of four muscles that surround the head of the humerus, and the rotator cuff is involved in the movement of the arm, holding the head of the humerus in the socket (socket). Falls directly on the shoulder often result in a fracture of the greater tuberosity of the humerus. Quite often, a fracture occurs in older people due to age-related changes such as osteoporosis and osteoarthritis.
Other injuries, such as a dislocated shoulder, can also result in a fracture of the humeral tuberosity. As a rule, isolated fractures of the humeral tuberosity can occur due to anterior dislocation of the shoulder or due to impact with the acromion or the upper part of the socket. A fracture of the humeral tuberosity may be accompanied by partial damage to the rotator cuff and tear of the labrum, which can cause persistent pain in the shoulder after consolidation of the fracture. In the absence of displacement, tuberosity fractures can be successfully treated using conservative treatment methods. If there is a displacement of more than 5 mm, surgical fixation of the fragments is necessary.
Symptoms
The main symptom of a humeral tuberosity fracture is pain at the top of the shoulder. Due to the fact that fractures are often accompanied by soft tissue trauma, there may be swelling in the shoulder area. In addition, the range of motion in the shoulder is significantly reduced. A fracture of the humeral tuberosity may also be accompanied by a partial or complete tear of the rotator cuff. Damage to the cartilage ring around the shoulder may also occur. In such cases, pain and weakness will persist after consolidation of the humeral bone tissue, and symptoms of shoulder instability may appear.
Structure and functions of the clavicle
The clavicle is the only bone in the human body that connects the skeleton to the upper limb. Tubular bone mainly consists of spongy substance. It has a horizontal position and runs along the upper edge of the chest. The clavicle consists of a body and 2 ends:
- The medial (sternal) end connects to the sternum.
- Lateral (acromial) faces the collarbone.
The clavicle consists of a body and 2 ends
The medial end, like the sternum, has a convex curve forward, and its other part is curved backward. The middle part of the bone is slightly compressed from top to bottom. On its lower surface there is an opening through which blood vessels and nerves pass. On the lower surface of the medial end there is a depression to which the ligament connecting the clavicle and the cartilage of the first rib is attached. At the humeral end there is a cone-shaped tubercle and a trapezoidal line. Closer to the lateral end of the lower surface of the body of the clavicle there is a recess for the attachment of the subclavian muscle.
The front and top parts of the bone are smooth, and the lower surfaces to which the muscles and ligaments are attached have roughness in the form of tubercles and lines. On the inner surface of the thick medial end there is a large oval joint - this is the junction of the clavicle with the sternum. The lateral end is wider than the medial end, but not as thick. Above its lower surface is the acromioclavicular joint, which connects the collarbone to the bony outgrowth of the scapula (acromion).
The bony joints of the acromioclavicular joint are oblique, flat, and elliptical in shape. There is a dense fibrous membrane around it, which is strengthened by ligaments. The sternoclavicular joint is also surrounded by a wide fibrous membrane and 3 powerful ligaments. This joint is involved in movements along axes that are perpendicular to each other.
The collarbone performs a supporting function, since the scapula and arm are attached to it. In addition, the bone connects the upper limb to the skeleton, providing it with a wide range of movements. Together with the scapula and muscles, the clavicle transmits forces that affect the arms and the rest of the skeleton. In addition, the bone protects blood, lymphatic vessels, and nerves that are located between the neck and upper limb from pinching.
Diagnostics
A history of injury and examination of the shoulder may lead the doctor to suspect a fracture of the humerus. First of all, radiography is performed, which allows you to diagnose changes in bone tissue and determine the presence of a fracture. But to diagnose possible injuries to soft tissues (rotator cuff), an MRI examination is required, which will allow a more differentiated approach to treatment tactics, since damage to the rotator cuff often requires surgical treatment.
Pathology of the tendon of the long head of the biceps
Pathology of the long head of the biceps tendon often accompanies other conditions, such as: SLAP injury, impingement syndrome, ruptures of the supraspinatus and subscapularis tendons. However, even an isolated violation of the integrity of the biceps tendon can lead to dysfunction of the upper limb and requires surgical treatment.
The human biceps muscle consists of a long head, which is attached to the upper segment of the articular surface of the scapula, and a short head, which is attached to the coracoid process of the scapula. The short head bears the main load, while the long head gives the characteristic contour to the arm. When the tendon of the long head of the biceps is completely ruptured, a characteristic clinical picture occurs. The long head falls down, as a result the contour of the shoulder is deformed. This symptom is named after the famous cartoon character Popeye due to its resemblance to the hands of a sailor.
Persistent pain syndrome is supported by partial damage to the integrity of the tendon, the development of chronic tendonitis, and tendon instability in the intertubercular groove. It is difficult for the patient to perform rotational movements in the shoulder joint, push-ups and pull-ups. Pain localized in the anterior part of the joint is often accompanied by clicking sounds.
Treatment begins with conservative methods similar to SLAP injuries. To quickly relieve inflammation, a therapeutic blockade is often used. To the tendon area
An anesthetic solution with Diprospan is injected under ultrasound control. The effect is achieved quite quickly, however, in order to prevent relapse, compliance with the treatment regimen and physiotherapeutic treatment is necessary.
If conservative treatment is ineffective, the question of surgical intervention is raised. The development of technology has left no room for open surgery in this matter - all manipulations are performed under the control of an arthroscope through punctures.
The techniques used are varied and combined during the operation: debridement of the tendon (i.e., grinding of it and surrounding tissues), correction of concomitant pathology, subacromial decompression. Tenodesis of the long head of the biceps tendon is recommended for young active patients and athletes. This manipulation is performed at different levels of the intertubercular groove using arthroscopic implants. After fixation to the head of the humerus, the intra-articular part of the tendon is excised. For elderly patients, the method of choice is tenotomy - cutting off the tendon from its attachment to the scapula. This is a simpler method, but no less effective. However, in the postoperative period, Popeye's symptom may develop, about which the patient must be warned in advance.
If there is a complete rupture in a young patient, the first thing to think about is surgical treatment. The essence of the operation is to isolate the torn tendon and fix it to the anterior surface of the head of the humerus (tenodesis) in the intertubercular groove. The operation can be performed either arthroscopically or through an incision.
Treatment
In most cases, humerus fractures are treated conservatively with immobilization using splints and bandages. But it is necessary to take into account that it is necessary to maintain a small range of motion in the shoulder, since prolonged immobilization can lead to frozen shoulder syndrome. Surgical treatment methods are indicated for displacements of more than 5 mm and, in such cases, comparison of bone fragments is carried out using osteosynthesis using plates and screws. In addition, surgical treatment is necessary in the presence of rotator cuff injuries. Modern arthroscopic treatment methods make it possible to restore the integrity of the structures of the shoulder and shoulder joint quite quickly and with minimal complications.
Passive movements in the shoulder can be carried out several days after the injury, and active movements are possible only after a control x-ray. As a rule, active movements and development of the joint begin 6 weeks after the injury. Strength training should begin no earlier than 3 months after the injury. A careful rehabilitation program (physical therapy, physiotherapy) allows, in most cases, to completely restore the function of the shoulder joint in a few months.
SLAP damage
Until recently, establishing a diagnosis of SLAP injury was very difficult. With the development of MRI diagnostics and improvement of arthroscopic technologies, this pathology has become mandatory in the practice of shoulder surgery.
SLAP (superior labrum anterior posterior) is characterized by separation of the fibrous lip from the glenoid in its upper segment with anterior and posterior distribution. In this localization, the tendon of the long head of the biceps begins from the fibrous lip, which is the main vector of traction during injury.
The cause of damage is most often trauma: a fall with support on the abducted arm, a blow to the shoulder area, often found in “throwing” athletes (handball, baseball, water polo), boxers.
Conservative treatment rarely leads to full recovery, because a return to specific loads provokes a recurrence of pain and progression of the rupture.
However, in patients without heavy physical and sports activities, complex therapy provides long-term relief from pain. First of all, rest is ensured for the shoulder joint by fixing the arm on a support bandage. Anti-inflammatory non-steroidal drugs are prescribed. To reduce the inflammatory reaction and reduce pain, physiotherapeutic procedures are necessarily used, such as phonophoresis with drugs, high-intensity laser (HILT), shock wave therapy (SWT), massage, and taping. Stimulation of regeneration is achieved by taking chondroprotectors and intra-articular administration of platelet-rich plasma (PRP). After inflammation has been relieved and the resting stage has been completed, proper rehabilitation under the supervision of a physical therapist will be an important factor in restoring function.
Arthroscopic fixation of the fibrous labrum, by analogy with the usual dislocation of the shoulder, is the most rational method of treatment, because ensures precise restoration of anatomical structures. Low-traumatic surgery reduces rehabilitation time. Under camera control, anchors are installed into the glenoid cavity of the scapula and the fibrous lip is returned to its place using non-absorbable sutures.
Anatomy of the humerus
The humerus is a wide, long tubular structure. It is part of the movable upper limb, unites the ulna, radius, and hand with the human skeleton. Around the humerus there are muscles, nerve trunks, and lymphatic vessels.
Brachial bone
The shoulder structure has the following structure:
- The body of the bone (diaphysis), which is located between the epiphyses.
- Metaphysis is the section of bone that is adjacent to the epiphyseal plate.
- Epiphysis – upper proximal, lower distal end of the structure.
- Apophysis is a process of bone next to the epiphysis, to which muscle fibers are attached.
At the proximal end of the humerus is the smooth round head of the humerus, the articular cavity of the scapula, which form the shoulder joint. Next comes the anatomical neck - this is a narrow groove between the head and the body of the shoulder. Just below the neck there are 2 muscle tubercles (large and small), to which the rotator cuff muscles are attached. Under the tubercles it narrows again, forming a body. On its outer part, almost in the middle, there is a deltoid tuberosity, to which the fibers of the muscle of the same name are attached. On its posterior edge there is a groove of the radial nerve in the form of a flat, gentle groove.
The lower edge of the bone is wide, bent anteriorly, muscle fibers are attached to it, and it also participates in the structure of the elbow joint. The joint consists of the condyle of the humeral structure with the bones of the forearm. The inner edge of the condyle is the block of the humerus that connects to the ulnar structure. The head of the condyle, together with the radial structure, forms the humeroradial articulation. Above the condylar head is the radial fossa. On both sides of the trochlea are the ulnar and coronoid fossa. The humerus has lateral and medial epicondyles (rough convexities) on the outside and inside. On the surface of the medial process there is a groove with the ulnar nerve trunk.
The functions of the humerus, despite its simple structure, are important. It increases the swing when a person moves his arm. This structure helps maintain balance when the center of gravity shifts during walking. It helps determine the correct support of a person on the upper limbs in various specific body positions (for example, while climbing stairs).
Heterotopic traumatic ossification
This complication, also known as post-traumatic ossification or traumatic myositis ossificans, occurs in different areas of the skeleton. Most often, extraskeletal bone formation occurs after bruises, dislocations, fractures and fracture-dislocations of the elbow joint. This is favored by anatomical features, as well as proliferation of osteogenetic cells of the ruptured capsule, detached periosteum, perivascular tissue, damage to the brachial muscle and accumulation of blood.
Ossification is more often observed in children and young people. Appropriate treatment should limit bone formation and enhance bone resorption; otherwise, large bone masses are formed, which can significantly limit movement in the joint or even cause ankylosis. Complete rest (plaster immobilization) for at least 3-4 weeks, even if only soft tissue is damaged, is the main way to stop ossification. Repeated topical hydrocortisone may also be effective. After cessation of immobilization, active, painless and unforced movements are recommended. A contracture should never be removed by force. Massage of the elbow joint area is contraindicated. It is impossible to remove ossifications promptly in the phase of their active formation. If movements are noticeably limited, after the bone mass has matured and there are no signs of further ossification, removal of the ossification is indicated with measures taken against its recurrence (non-traumatic operation, avoidance of hematoma formation, rest, etc.).
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