Osteosynthesis of the neck of the humerus with a plate. Osteosynthesis of the humerus, principle of operation. Surgical shoulder neck fracture: rehabilitation and treatment

Osteosynthesis of the humerus is indicated in cases where the connection of bone fragments is impossible without surgery. Often this phenomenon is noted when interposition of muscles between them. To fix the bone elements, structures are used, which are pins, plates and screws. Recovery after surgery is long and requires rehabilitation.

Indications for osteosynthesis of the humerus

Surgery for a fracture of the humerus is performed in difficult cases when the use of plaster casts, splints and fixing orthoses is not enough. Intra-articular violation of the integrity of the bone structure, especially the distal metaepiphysis, also requires urgent surgical intervention. Quite often, problems with rapid tissue fusion accompany a fracture of the neck of the humerus. Secondary reasons for shoulder osteosynthesis include:

  • the risk of damage to the skin by bone fragments;
  • compression of soft tissues;
  • infringement of nerve endings;
  • damage to blood vessels;
  • incorrect connection of fragments;
  • deformational changes after fusion;
  • repeated violations of the integrity of the bone;
  • the formation of false joints;
  • long-term fusion of the bone structure.

How is it done?


During the operation, the fragments are fastened with a plate on the outside of the bone.

For osteosynthesis of the humerus, the patient is placed in a horizontal position on the operating table, face up. In this case, the affected limb is placed on a separate sliding table. As a rule, retrograde osteosynthesis is performed under general or conductive anesthesia. Before the introduction, the skin of the hand, chest and scapula is treated. With the help of sterile sheets, the limb is lifted. The hand and deltoid area remain free.

The incision is made so that its middle passes over the fracture itself. With diaphyseal fractures, the brachial muscle is necessarily removed, and the nerve is retracted to the side. Access to bone fragments is carried out in two directions: posterior and anterior. After their connection, a plate is applied evenly over the elements of the bone structure. After that, it is fixed with a pin or screws. At the end of the operation, the structure is covered with muscle fibers and a nerve. Intramedullary osteosynthesis is performed more often and is used for bone fractures in several articular ends. Fragments are fixed with screws, which prevent their rotation.

After osteosynthesis of the shoulder, immobilization of the limb with reliable fixation is required.

What do they put on?

Plate osteosynthesis


The size and modification of the plate depends on the location and severity of the fracture.

The design is presented in several modifications, depending on the type of fracture and implantation into the humerus. Therefore, the plate can be either curved or straight, which fully corresponds to the anatomical structure of the bone structure. Fastening is carried out using screws or pins. Their number varies depending on the physiological characteristics of the bone. In older people, due to the porosity of the bone tissue, a more reliable attachment is established. Extra bone osteosynthesis with the help of the installation of the structure is carried out more and more often, thanks to II Litvinov, who carried out scientific work and proved the safety of the technique.

Pinning

It is carried out in mild cases when the bone fragment does not move far from the fracture site. In this case, tissue trauma is minimized, and the limb itself can be subjected to stress the next day. The pin itself is a long rod with a hook or hole at the end, which contributes to a secure fit. It is inserted into the medullary region in the hand, while bringing the bone fragments to their natural anatomical position.

Contraindications for conducting


Surgical intervention is not performed in severe stages of osteoporosis.

Severe pain with a fracture of the shoulder can be accompanied by a state of shock, in which surgery is undesirable. Also, the operation is not performed with severe bleeding. The following pathological abnormalities are contraindications to osteosynthesis:

  • fractures with extensive damage to soft tissues;
  • penetration of contamination into the wound;
  • infection;
  • patient instability;
  • complex vascular pathologies;
  • severe osteoporosis;
  • concomitant ailments of the joints in the active phase;
  • childhood;
  • violation of bone density due to age-related changes.
1

The analysis of the results of treatment of 328 patients with traumatic injuries of the humerus at different levels of the segment (proximal section - 119, middle section - 104, distal section - 105), including 79 (24%) patients with consequences of humerus injuries, who were treated at FSBI "SarNIITO" in the period from 2009 to 2013. For fastening the fragments of the humerus, extraal plates, intramedullary rods and an external fixation device were used. Based on the analysis of the results of treatment of patients, the authors recommend the optimal choice of the humerus fracture fixator, depending on the level of damage. In addition, the article provides a brief description and clinical examples of the use of original methods for treating fractures of the humerus and their consequences, developed at SarNIITO within the framework of research programs. The results of treatment were evaluated on the basis of clinical, radiation and neurophysiological data. The outcomes of the treatment of fresh fractures according to the SDI-1 system were 92 ± 2.3% of the anatomical and functional norm. Evaluation of the results of treatment according to the SOI-1 system in patients with consequences of injuries of the humerus was within the range of 68-90% of the anatomical and functional norm, which is 30% higher than the preoperative indicators.

brachial bone

osteosynthesis

false joint

1. Ankin L.N., Ankin N.L. Practical traumatology, European standards, diagnostics and treatment. M .: Medicine; 2002 .-- 480 p.

2. Barabash A.P., Kaplunov A.G., Barabash Yu.A. Norkin I.A. False joints of long bones (treatment technologies, outcomes). Saratov: Publishing house of the Saratov State Medical University; 2010 .-- 130 p.

3. Barabash A.P., Solomin L.N. "Esperanto" for carrying out transosseous elements during osteosynthesis with the Ilizarov apparatus. Novosibirsk: Science; 1997 .-- 188 p.

4. Kogan P.G., Vorontsova T.N., Shubnyak I.I., Voronkevich I.A., Lasunsky S.A. Evolution of treatment of fractures of the proximal humerus (literature review). Traumatology and Orthopedics of Russia. 2013; (3): 154-161.

5. Mironov S.P., Mattis E.R., Trotsenko V.V. Standardized Research in Traumatology and Orthopedics. M .: News; 2008 .-- 86 p.

The segment of the shoulder and its joints play a vital role in a person's life - from a cosmetic image to work. According to the literature, the incidence of injuries to the humerus is 13.5%, among other grasses of the musculoskeletal system. Shoulder diaphysis injuries are more common at the age of 20-50 years, and their proportion ranges from 50 to 72% of all humerus fractures. Injuries to the proximal and distal regions (from 5 to 15%) are more common in persons over 50 years of age. Violation of the process of consolidation of a fracture of the humerus, leading to the formation of false joints, reaches 15.7%, of which half of the cases occur in the diaphyseal part of the shoulder, and only one third (31.6%) are localized in the distal part of the shoulder. A high complication rate indicates flaws in the methodology for treating humerus fractures and their consequences. Features of the anatomical structure of the shoulder segment and its participation in the function of the joints, different levels of damage limit the versatility and dominance of one type of fastening of fragments (for example, transosseous osteosynthesis).

Purpose of the study- promotion of new technologies for the treatment of fractures of the humerus and their consequences and the differential choice of the type of osteosynthesis depending on the level of shoulder injuries.

Materials and research methods

During the period from 2009 to 2013, SARNIITO treated 328 patients with injuries of the humerus, which accounted for 5.3% of the total number of patients with fractures and consequences of long bones injury (6018 patients). 79 patients came to us with the consequences of injuries (pseudoarthrosis, defects, nonunion fractures), which constituted 24% of the total number of patients with injuries of the humerus. The distribution of fractures according to the level of damage and types of osteosynthesis is presented in Table. 1, where the levels of damage are indicated according to the "Esperanto ..." system, 1997 (Table 1).

Table 1

Distribution of fractures by levels of damage to the humerus and types of surgical interventions according to the SarNIITO archive for 2009-2013

In the treatment of fractures, closed and open methods of fastening the fragments were used. Extra-articular fractures of the proximal humerus were fixed with an extra-osseous fixator from a typical approach, mainly plates with angular stability of screws were used. When the fracture was localized in the upper and middle third of the diaphysis up to the supracondylar zone, intramedullary fixation of fragments was most often used (BIOS and the Fixion system). For the surgical treatment of low-lying fractures of the humerus (supracondylar and transcondylar), bone osteosynthesis and transosseous osteosynthesis with the use of wire rod devices according to the original SARNIITO technology (RF patents No. 2312632, 74798) were equally used.

Fastening of fragments of the humerus in slow healing fractures, pseudoarthrosis and pseudarthrosis in the form of a defect up to 5 cm, in general, did not differ from acute injuries. By mechanical action on the fragments of the humerus, the pathological process was transformed into an acute fracture, and various methods of osteogenesis stimulation were used. Techniques aimed at enhancing bone formation, had the ability to enhance vascularization due to the formation of periosteal-medullary anastomoses at the ends of the fragments and contributed to the migration of minerals to the pathological zone. Different methods of osteogenesis stimulation were used depending on the pathological manifestations formed in the area of ​​the humerus fragments. With delayed consolidation of fractures and stiff pseudoarthrosis, a longitudinal osteotomy of fragments was performed in any accessible plane with the opening of the medullary canal. To preserve the size of the fragments in their sclerosis, they resorted to artificial reconstruction of the Haversian system at the ends of the fragments, by perforating the ends of the fragments in the transverse and longitudinal directions. To ensure the migration of minerals to the pathological zone, an autograft was inserted into the metadiaphyseal part of the proximal bone. Transplantation of the contents of the medullary canal, which is a powerful stimulator of bone tissue regeneration, was ensured by the formation of longitudinal holes at the ends of the fragments and expansion in the medullary cavity of the Fixion rod (RF patents No. 2181267, 2375006, 2406462, 2438608).

Clinical and instrumental research methods (X-ray, MRI, CT, neuromyography) were used to control the healing of bone wounds in patients. Treatment outcomes were assessed using the SOI-1 system, which includes 16 parameters.

Research results and their discussion

The results of treatment of fractures of the humerus were traced in all patients for periods of up to 1 year or more. Fusion, regardless of the location of the damage and the type of fixator, was noted within 4-6 months. X-ray signs of bone wound healing were complemented by the clinical picture and restoration of full function in the joints. The absence of diastasis between the fragments and pain syndrome, sufficient muscle strength and restoration of joint function were the main criteria for fracture healing. As a rule, these patients, after 4-6 months of rehabilitation, repeatedly consulted a doctor after 1-1.5 years for the removal of the structure. Quantitative indicators of treatment outcomes according to the SOI-1 system after 1-1.5 years reached 86-98%, which indicated an almost complete recovery of the shoulder segment. In patients with concomitant injury (injury to the humerus and neuropathy of the radial nerve), hand function was restored by 3-4 months after injury.

When choosing a fixator at levels I-II, the number of fragments of the humerus formed after the fracture and the density of bone structures were taken into account. For the osteosynthesis of two fragmentary fractures against the background of age-related osteoporosis, a combined osteosynthesis was used, represented by a figuratively curved wire, which formed a support platform for interfragmental compression with a bracket with thermomechanical shape memory. For fixation of two or three fragmentary fractures of the surgical neck of the humerus against the background of satisfactory bone density, the priority was given to bone osteosynthesis with the installation of plates with angular stability of screws. When choosing a fixator for fractures of the humerus in the upper third of the diaphysis (level of damage II-III), priority was given to intramedullary constructions, however, in the presence of comminuted fractures with a transition to the shoulder neck region, extramedullary plates were used. Against the background of age-related osteoporosis and thinning of the cortical layer, when the diameter of the medullary canal reached 12 mm or more (Fig. 1, A).

Rice. 1. Radiographs of patient M., 70 years old: a) upon admission; b) closed antegrade alternate introduction of the allograft and the Fixion IL rod into the canal of the shoulder (before its expansion); c) fixation of fragments with a Fixion IL rod after its expansion and transverse blocking

To fix the fracture, an expanding intramedullary nail "Fixion" was used in combination with a bone allograft inserted into the medullary canal (Fig. 1, B and 1, C). Osteosynthesis was performed according to the technology developed in our clinic (RF patent No. 2402298, 2009).

In the treatment of transverse, oblique and comminuted diaphyseal fractures of the humerus at level III-VI, preference was given to closed reduction of fractures, under the control of an electro-optical converter; to fix the fragments, blocking intramedullary osteosynthesis was used (Fig. 2, A) and transosseous external fixation devices in the wire - rod arrangement (Fig. 2, B).

For fixation of fractures in the distal part at the level of transition of the diaphysis of the humerus to the metaphysis (level VII-VIII), transosseous osteosynthesis (39 cases) and external osteosynthesis (36 cases) were used. Comparing the results of treatment, preference was given to combined (wire-rod) transosseous osteosynthesis.

Rice. 2. X-ray of patient G., 52 years old, before and after the operation, the BIOS of the humerus was performed (A); X-ray of the humerus of patient V., 46 years old before and after surgery (B), osteosynthesis of the humerus was performed with an external fixation apparatus in the wire-rod spacer

In the period 2009-2012, 79 patients with consequences of fractures of the humerus were observed in our clinic. The majority of patients were women - 49 (62%) aged 23 to 74 years and 30 (38%) men aged 26 to 63 years. The time interval from injury to admission to our hospital varied from 3 months to 2 years. In patients with consequences of fractures of the proximal humerus (5 cases) due to the futility of reconstructive surgeries, total shoulder arthroplasty was performed.

In the surgical treatment of nonunited fractures of the middle and distal humerus (16 cases) with a prescription of 4 weeks to 3 months from the moment of injury or primary surgery, in 7 cases osteosynthesis was performed with an external fixation apparatus (EF) and in 9 cases intramedullary rods with blocking were used ... Longitudinal osteotomy of the ends of the fragments was most often used to stimulate bone formation. The results of treatment were followed in 12 patients over a period from 6 months to 2 years. Fusion of the humerus diaphysis fracture was achieved in 14 clinical observations in the period from 8 to 20 weeks. The outcomes of treatment according to the SDI - 1 system were 92 ± 2.3% of the anatomical and functional norm. In 2 patients, the fracture of the humerus did not heal; later, they underwent repeated surgical interventions.

The study of the protocols of operations of patients with pseudarthrosis of the humerus diaphysis (58 cases) showed that the tactics of surgical treatment depended on the presence and size of the defect in bone structures, as well as the length of the sclerosis zone at the ends of the fragments. An external fixation device for fixing a pseudarthrosis was used in 16 clinical cases, an intramedullary nail with blocking - in 30 cases, a nail with an intracanal blocking system "Fixion" - in 12 cases. In patients with pseudarthrosis (58 patients), fusion was achieved in 55 cases within a period from 6 months to 1 year. Evaluation of the results of treatment according to the SOI-1 system was within the range of 68-90% of the anatomical and functional norm, which is 30-40% higher than the preoperative indicators.

To illustrate the observations, we present several clinical examples.

Clinical example of surgical treatment of a long-existing pseudarthrosis of the diaphysis of the humerus in the form of a defect in the presence of severe sclerosis of the ends of fragments. Before contacting our clinic, at the place of residence, the patient underwent extraosseous osteosynthesis of a fracture of the humerus, the fracture did not heal, a pseudarthrosis was formed. X-ray of the shoulder showed complete closure of the lumen of the medullary canal, the presence of an end bone defect for 2-3 cm, sclerosis of the ends of the fragments of the humerus (Fig. 3, A).

Rice. 3. X-ray of the humerus of patient K., 52 years old, 1 year after the primary operation (A), X-ray of the humerus of patient K. 1 year after surgery (B). The patient refused to remove the rod

The patient underwent removal of the plate; economical modeling resection of the ends of the fragments to create a tight contact between the fragments; by longitudinal and transverse drilling of the ends of the fragments from the end side to a depth of 1.5-2 cm; for fixation, a “Fixion” rod with a maximum extension of up to 13.5 mm was chosen (Fig. 3, B).

After the insertion of the rod into the cavity of the humerus, its expansion was performed, as a result, the contents of the bone marrow canal was moved to the area of ​​the pseudarthrosis to stimulate the processes of bone tissue regeneration.

The generally accepted division of the shoulder segment into 3 levels (proximal, distal and diaphyseal), in our opinion, is completely insufficient. Differentiated choice of fixator requires more precise orientation of the damaged area. The "level-position" system according to "Esperanto" is time-tested, it helps doctors and clinicians to perform one or another type of fastening of fragments.

An analysis of the treatment of 328 patients with fractures and the consequences of humerus injuries in recent years has shown that the dominant trend of submerged osteosynthesis has been confirmed. For diaphyseal injuries, closed intramedullary osteosynthesis with blocking of fragments both from the outside (transversely) and from the inside (Fixion system) was used more often. Extra-bone fixation prevailed in the proximal part of the segment (74 patients), less frequently in the distal segment (36 patients), and very rarely in the middle sections. According to the algorithm adopted in the clinic for combined injuries (bone-nerve), preference was given to bone osteosynthesis (11 patients).

The experience of treating the consequences of fractures of the humerus (long-term healing fractures and pseudoarthrosis of 79 people) suggests that the usual technique of treating the ends of fragments to bleeding bone leads to shortening and does not fully guarantee bone fusion. After closed intramedullary osteosynthesis (BIOS), 7 patients were reoperated. Therefore, the stimulation of bone formation should be a prerequisite. Additional foci of bone formation with revascularization of the altered bone tissue of the ends of the fragments provide the effect of primary healing of the bone wound. Time-tested force effects (compression, distraction, torsion) on the ends of the fragments stimulate osteogenesis, and immobility provides conditions for the mineralization of the newly formed osteogenic tissue.

We propose to solve the problem of fracture treatment in conditions of age-related osteoporosis, a wide bone marrow canal of the diaphyseal part of the segment, using new surgical techniques (a combination of a rod with a graft). False joints in the form of bone defects up to 4 cm, in our opinion, do not need compensation for limb shortening (lengthening).

Damage level according to "Esperanto"

Types of osteosynthesis

Intramedullary osteosynthesis

Extra bone osteosynthesis

Transosseous osteosinesis

Combined osteosynthesis

Proximal division

Level I

Level II

Diaphyseal department

Level III - VI

Distal department

Level VII

Tier VIII

The provision of specialized medical care to patients with damage to long bones obliges the orthopedic traumatologist to adhere to the generally accepted regulations. However, this is not always possible due to various reasons, for example, insufficient equipment of medical institutions. The standards, in the form of federal clinical guidelines for the provision of orthopedic care, are not always possible to comply with due to the variety of bone injuries and their localization. But, nevertheless, we recommend fastening the fragments, based on the location of the damage (Table 2).

Bibliographic reference

Barabash Yu.A., Barabash A.P., Grazhdanov K.A. EFFICIENCY OF TYPES OF OSTEOSYNTHESIS IN HUMERAR FRACTURES AND THEIR CONSEQUENCES // International Journal of Applied and Fundamental Research. - 2014. - No. 10-2. - S. 76-80;
URL: https://applied-research.ru/ru/article/view?id=6001 (date of access: 02/01/2020). We bring to your attention the journals published by the "Academy of Natural Sciences"

Did you know that the humerus is one of the most stable parts of the skeleton? Nevertheless, there are situations associated with the displacement of bone fragments both at the head and in the area of ​​the diaphysis. There is only one solution to the problem - surgical intervention using a metal plate.

Why a plate is needed for a fractured humerus

For proper fusion of bone tissue, it is necessary to bring the fragments as close to each other as possible at the fracture sites. When bone fragments are displaced, it will be difficult to do this conservatively, because the physical properties of the lever will prevent the pieces of bone from growing together.

The titanium plate is used for:

  1. Correct fixation of the fragments relative to each other;
  2. Removal of the leverage effect when fragments can return from their natural position.

The plate is made of titanium. This material is often used in operative medicine, because causes minimal consequences for the body and is quite durable.

If you do not put the plate on time, complications may develop:

  • Damage to large arteries and nerves;
  • Development of an open fracture;
  • Non-union of bone fragments;
  • The appearance of a false joint.

Insert insertion progress


The time and complexity of the operation depends on the size of the damage site.

The main stages of the operation:

  1. The patient lies on his back, general (less often local) anesthesia is performed;
  2. A tourniquet is applied above the site of damage;
  3. An incision is made in the skin and fascia of the muscles, corresponding to the size of the titanium plate;
  4. With the help of medical screws through the holes in the plate, it is fixed to the bone tissues;
  5. Soft tissues are returned to their original position, sutures are applied to the fascia and skin;
  6. A plaster cast is applied.

The complexity of the operation lies in the passage of the radial nerve directly near the bone. In this case, a typical complication is a partial loss of motor activity of the hand.

Postoperative complications

The implantation of a titanium plate is tantamount to the appearance of a foreign body in the body. It is not surprising that complications often occur after surgery.

Among them:

  1. Swelling of the hand;
  2. Loss of muscle tone, feeling weak;
  3. Bleeding in the area of ​​the suture;
  4. Temperature increase.

The implantation of the plate requires experience, because there are more. Most often they are associated with poor-quality installation of the plate and violations of the rules of asepsis, antiseptics during the operation.

Before and after surgery, a long period of bone fusion will be required. Get ready for endless examinations, including X-rays.

Here are some examples of complications:

  1. Secondary displacement of bone fragments;
  2. Osteomyelitis (infection in the wound);
  3. Internal bedsores;
  4. False fusion.

Things to Remember

A titanium plate for a fractured humerus is expensive. The price of a high-quality disc can reach 110 thousand rubles. when installed over the entire length of the shoulder. A plate in case of a shoulder neck fracture is cheaper, but still a purchase is inevitable.

Track the availability of certificates, because usually the material comes through third hands directly to the surgeon. Reason: mandatory sterility.

Do not hesitate to see a doctor. The interval between the incident and the hospital should not exceed 1-2 days, otherwise the mechanism of incorrect bone fusion will start, or they will completely lose the ability to regenerate.

After a successful fusion, a second operation is performed to remove the plate so that it does not cause inflammatory processes and does not overgrow with surrounding tissues. Exception: elderly patients, as well as the presence of osteoporosis.

Conclusion

Insertion of a titanium plate is an effective measure in the treatment of displaced humerus fractures. Correct installation guarantees fusion of bone fragments, normalization of motor activity of the hand and elimination of post-rehabilitation defects of the limb.

You should not be afraid of the operation, because it is relatively simple to perform and leaves a minimum of cosmetic defects.

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Indications.

With closed fractures of the humerus a conservative method of treatment (plaster cast, medical splints, etc.) is successfully used, and only in some cases, for forced indications, they resort to surgery. The operation is performed when it is not possible to match the fragments with transverse, helical fractures, which is often due to the interposition of muscles between the fragments.

Damage or entrapment of the radial nerve is also an indication for nerve revision and osteosynthesis. Osteosynthesis is used in the treatment of false joints. To fix the fragments, rods, screws, plates, etc. are used.

Contraindications

Internal osteosynthesis is not indicated in patients who are in a serious condition (shock, large blood loss, etc.), in the presence of local and general inflammatory diseases, as well as in all cases where it is not possible to achieve strong fixation of fragments (multiple fractures, severe osteoporosis, etc. .).

Operational accesses.

Exposure of the diaphysis of the humerus can be performed from the antero-external, posterior, and internal approaches. With internal osteosynthesis (plates, screws, etc.), the anterior-external approach is often used.

Antero-external access.

The skin incision is performed along the sulcus bicipitalis lateralis with a continuation on the sulcus cibitalis lateralis (Fig. 35). In the distal part, the radial nerve is exposed with an incision between the brachialis and brachioradialis and, without taking the holder, it is carefully partially isolated so that the surgeon clearly knows its localization.

It is impossible to operate in the middle or lower third of the shoulder without isolating the radial nerve and not seeing it, because its intersection is possible. Through the interval between the outer head of the triceps brachii muscle and the outer edge of the biceps brachii muscle, they exit to the humerus. Fragments are exposed sparingly subperiosteally. If it is necessary to isolate the upper third of the humerus, the incision can be extended upward between the edges of the deltoid and pectoralis major muscles.

Posterior approach to the diaphysis of the humerus.

This approach is convenient for exposing the lower third of the humerus. The position of the patient is on the stomach. The incision begins at the anterior edge of the deltoid insertion site and continues distally along the midline of the posterior surface of the shoulder.

In osteosynthesis of fragments of the diaphysis of the humerus, preference should be given to stable osteosynthesis with plates, in case of helical fractures - to screws and, if they cannot be used, fixation is carried out with pins or beams.

Osteosynthesis with plates.

For osteosynthesis of shoulder fragments, a Demyanov compression plate and Kaplan-Antonov, Sivash, Tkachenko and others with removable contractors are used. Indications for their use are transverse or close to them fractures along the diaphysis of the humerus with the ineffectiveness of conservative treatment.

Methodology.

Carry out anesthesia. The position of the patient is on the back. An antero-external surgical incision is made to expose the radial nerve. Access to the fragments is carried out along their anterior or posterior surfaces, exfoliating the periosteum together with soft tissues only in the area of ​​the plate installation. The fragments are precisely matched. The plate is placed on the front surface of the shoulder so that it is evenly located on the fragments.

Compression is achieved between the fragments and the plate is finally fixed with screws. The bone and the structure are covered with muscle tissue, on which the nerve is then placed. In the postoperative period, immobilization is used with a plaster thoracobrachial bandage.

When using massive Tkachenko plates, fixed with 7 - 8 screws (Fig. 36), immobilization is carried out with an external splint and only during the first 2 weeks.

Osteosynthesis with screws.

Screw-shaped and oblique fractures are fixed, when the fracture line is 1.5-2 times greater than the diameter of the humerus. Accurate reduction and sufficient fixation are usually achieved by using two screws. In the postoperative period, for the entire period of consolidation, immobilization with a plaster thoracobrachial bandage is used.

Intramedullary osteosynthesis.

This method of immobilizing fragments of the humerus can be performed when the fracture is at least 6 cm from the articular ends.

Technical equipment: 1) rods for intraosseous fixation (Bogdanov, grooved, from the set "Osteosynthesis", etc.); 2) nozzle; 3) single-pronged hooks; 4) small chisels; 5) pliers.

Methodology.

Before the operation, select the appropriate length and thickness of the rods. The length should be such that the rod completely fills the bone marrow cavity of one and the other fragments and protrudes 1 - 1.5 cm above the bone for ease of extraction. The length of the rod, when inserted through the central fragment, should be 3-4 cm less than the length of the shoulder, and the diameter should be 6-7 mm. When the rod is inserted through a peripheral fragment, its length should be 4–6 cm shorter than the shoulder, and its diameter should be 6–1 mm. The rod thickness should be 1 mm less than the diameter of the medullary cavity.

With intramedullary insertion of the nail, it should be borne in mind that the medullary cavity of the humerus has the greatest width in the upper third, and narrows to 6 - 9 mm in the distal third. In cross-section, the medullary cavity has an oval shape. When inserting the nail through the proximal fragment, a sufficiently thick and rigid nail can be used, and through the distal one - of limited thickness and lamellar, so that it can easily bend as it is inserted.

Post insertion through the proximal fragment.

The direct method of introducing a nail is performed as follows. Fragments are exposed in the area of ​​the fracture, then the localization of the large tubercle is determined, and a skin incision is made above it and the underlying soft tissues are bluntly stratified. Slightly posterior to the sulcus bicipitalis lateralis, an awl is formed with an awl towards the medullary cavity of the humerus. A rod is driven through this hole until it emerges from the medullary cavity. The fragments are precisely matched, the rod is advanced to the full length in the medullary cavity of the peripheral fragment. It is necessary to strive not only to firmly fix the fragments, but also to get close contact between them. If the radial nerve has been exposed, then, when suturing the wound in the area of ​​the fracture, it should not be placed directly on the bone.

The retrograde method of introducing a nail is performed as follows: the fragments are exposed, a rod is inserted into the bone marrow cavity of the proximal fragment until it appears above the skin of the area of ​​the large tubercle. The skin above the protruding part of the rod is dissected and it is advanced through the proximal fragment so that its protruding part remains no more than 1 cm. The fragments are compared, and the rod is driven into the entire length of the bone marrow cavity of the peripheral fragment so that it stands 1 cm above the large tubercle. They monitor the achievement of strong osteosynthesis and close contact between the fragments.

Post insertion through the distal fragment.

The fracture site is exposed. The second incision, 5-6 cm long, is made over the ulnar fossa through the skin, subcutaneous tissue and the triceps tendon. The patient's arm is bent at the elbow joint. Departing proximal to the upper edge of the cubital fossa by 1 - 1.5 cm, a hole is drilled in the cortical layer so that it penetrates into the medullary cavity. To facilitate the introduction of the pin, a groove is knocked out of the bone with a chisel. A rod is inserted through the drilled hole to the fracture site, the fragments are compared, and the rod is advanced along the entire length of the proximal fragment. At the injection site, the rod should stand 2 cm from the bone.

It should be borne in mind that when using intraosseous osteosynthesis of the humerus with a pin, it is often not possible to achieve strong fixation of the fragments, and diastasis is often formed between them, which is explained by the peculiarities of the anatomical structure of the bone marrow cavity, therefore, in the postoperative period, immobilization with a plaster thoracobrachial bandage or a medical splint is necessary.

Osteosynthesis with beams.

Carry out anesthesia. The position of the patient is on the back. Through the antero-external operating incision, the fragments are exposed and carefully compared. A groove 0.5 - 1 cm longer than the beam is made on the outer surface of the bone. The end of the beam with the beak is inserted into the bone marrow cavity of a short fragment and then the beam is completely driven into the groove. Additional fastening of the structure is carried out with cotter pins or screws. In the postoperative period, immobilization is used with a plaster thoracobrachial bandage until the fracture consolidates.

Features of osteosynthesis in open (gunshot and non-gunshot) shoulder fractures.

The incision is often determined by the nature of the wound. The primary surgical treatment of the wound is carried out. In order to adapt the fragments, if necessary, resort to their economical resection (Fig. 37). The fixation of the fragments is carried out according to one of the above methods. After osteosynthesis, the bone must be covered with healthy muscles. The wound is well drained with thick tubes and injected with antibiotics. In the postoperative period, immobilization is shown with a plaster cast thoracobrachial bandage. With a favorable course of the wound process, delayed sutures are applied.

Osteosynthesis is often used after wound healing, when the threat of purulent complications is significantly reduced.

S.S. Tkachenko

General anesthesia or local anesthesia. Supine position. The patient's torso lies on the edge of the table, the shoulder is on a stand to the table. The surgical field is widely processed - from the top of the neck, the entire arm, from the back to the scapula, from the front, the entire chest to the abdomen. The assistant with a sterile shank raises the treated hand by the forearm vertically upwards so as to raise the scapula above the table. A sterile oilcloth and a double-folded sterile sheet are placed under it. The second sheet is along the body from the armpit to the feet, the third is on top of the second, the fourth on top and on the body, the fifth to the fourth with its lower end along the back of the body. The entire arm and deltoid area remains free. The sheets are fixed to the skin with pins or skin sutures.

An incision along the lateral groove of the shoulder, in the middle above the fracture, 7-8 cm long. The skin, subcutaneous tissue, and its own fascia are dissected. Between the biceps and the outer head of the quadriceps, the surgeon approaches the humerus. With low diaphyseal fractures, the brachioradialis muscle is retracted outward. This is where the radial nerve runs in the lower third of the shoulder next to the bone. It stands out, is taken on a rubber grip and gently pushed to the side. In osteosynthesis of low fractures of the shoulder, isolation of the radial nerve with abduction with a holder is absolutely necessary. The ends of the fragments are not exposed from the muscles and periosteum, only their ends are distinguished from the hematoma and primary callus. In this case, the central fragment is removed into the wound with a single-tooth hook, the sharp end of which is inserted into

bone canal of the fragment. The ends of the fragments are cleaned with a sharp spoon from the primary corn (when the operation is not performed immediately, but after 8-12 days). In the case of comminuted fractures, the fragments are not "torn off" from the periosteum and muscles.

The rod is prepared prior to surgery. The required width of its upper end on is determined either from a snapshot of a healthy humerus taken from 120 cm (then the width of the rod is 2 mm less than the width of the bone canal at the level of the fracture) or the surgeon prepares several rods (4-5) of different widths, and at the operation they choose one , which tightly enters the bone canal of the central fragment.

The rods are prepared from a wedge-shaped semi-finished product, the length of the rod is selected according to the size of the healthy bone from the large tubercle to the outer condyle, and the workpiece is shortened on emery from above and below so that the lower part of the rod corresponds to the width of the canal of the lower fragment (according to the image in the lateral projection of the healthy bone from 120 cm).

The excess width of the upper end of the rod is ground on emery so that this part of the rod has parallel walls and its width corresponds to the width of the bone canal at the level of the fracture.

The upper end of the rod is sharpened in the shape of a ski toe and modeled with a slight outward deviation so that when the rod is driven into the bone canal of the upper fragment, it comes out through the apex or base of the large tubercle.

The sharp edges of the lower end of the bar are rolled up. The lower end is bent anteriorly by the amount of the physiological deviation of the lower edge of the humerus anteriorly (according to a picture of a healthy bone in the lateral projection).

The surgeon inserts the upper end of the rod into the central fragment (Fig. 13.23), placing its wide plane sagittally. In this case, the end of the upper fragment is brought to the body. With light hammer blows, the rod is driven into the bone canal of the proximal fragment. The assistant with the anterior surface of the terminal phalanges of 2-3 fingers of the right hand determines the exit of the sharp end of the rod from the humerus.

A small longitudinal incision (2-3 cm) is made above it. The rod achieves until its lower end is equal to the end of the proximal fragment (or it is possible for the end to stand 1 cm out of it).

After that, the ends of the fragments are compared with non-rough movements. Focusing on their relief (shallow depressions, denticles), the surgeon eliminates rotational displacement. It is very convenient to compare the fragments by introducing single-toothed hooks into the ends. If the fracture is supporting (transverse non-splintered), then after matching, the assistant presses the lower fragment to the upper one and then drives the rod into the lower fragment (first knocks with a hammer on the upper end of the rod, and then on the rammer). Above the bone, 1 cm of the rod with a transverse notch is left for gripping it with the instrument during removal.

If the fracture is non-supporting (oblique, comminuted), then the juxtaposition and retention of the fragments is carried out by stretching by the elbow, and after reduction, the oblique ends of the fragments are compressed by the Farabef bone holder through the muscles and periosteum (the ends of the fragments from the muscles and periosteum are not "peeled off"!).

With retrograde insertion, you can take a deliberately long rod and shorten * it during surgery. To do this, after inserting the rod into the proximal fragment (the lower end is flush with the end of the fragment), the length of the canal in the distal fragment is measured with a thick blunt needle. This length is superimposed on the protruding end of the rod from the proximal fragment, and it is shortened at the transverse risk by several flexions and extensions. In this case, the surgeon or assistant fixes the rod with pliers immediately below the risks. After the rod breaks off, the sharp edges of its end are rolled up with a rasp. Then the fragments are compared, and it is driven into the peripheral fragment. A 1 cm long end with a transverse notch is left above the bone for grasping with a special tool during removal.

If there are large fragments in the fracture zone, then they are fixed with circular cerclages made of titanium wire.

Upon completion of the osteosynthesis, a tubular drainage is carried out to the bone through a puncture of the skin. Muscles, own fascia are sutured with catgut. If the subcutaneous fat layer is large, a glove rubber drainage is inserted through the wound. Silk stitches are applied to the skin.

An example would be clinical observation (Figure 13.24).

When the rod is inserted antegrade into the proximal fragment, the distance from the lower end is measured on it, equal to the distance from the end of the central fragment, palpable under the skin, to the large tubercle. The inner side of the lower end of the rod should be rounded so that when the rod is driven from top to bottom into the central fragment, it slides along the inner wall of the bone canal with its rolled edge and does not perforate it.

The rod is pierced to the mark, its distal end approaches the fracture line. A skin incision (3 cm) is made over the fracture, its own fascia is dissected, the muscles are pulled apart with a clamp. The index finger is inserted into the wound, under the control of which the fragments are repositioned, after reposition the rod is pushed into the distal fragment. This is the so-called semi-open osteosynthesis. The reduction can also be performed with an awl after the muscles have been removed with the hooks. This is an open osteosynthesis with antegrade nail insertion.

Antegrade osteosynthesis of humerus fracture taking into account the stereoscopic anatomy of the bone canal

For supporting fractures of the diaphysis of the humerus, an alternative to osteosynthesis "wedge-shaped" rod technique can be used, the essence of which is as follows:

uchem. A pin made of titanium alloy VT-5, VT-6 of rectangular cross-section with a thickness of 4.0 mm along the entire length is used. The upper (wide) and lower (narrow) portions of the bar have parallel edges. The width of the lower part of the rod is selected from the direct radiograph of the segment in accordance with the dimensions of the narrowed section of the canal. The width of the upper section of the rod is standard - 11-12 mm. The proximal end of the structure is bent outward in a plane midway between its wide and narrow edges. The length of the pin corresponds to the distance between the apex of the greater tubercle and the outer epicondyle of the shoulder minus 1.0-1.5 cm. The rod is inserted between the greater tubercle and the head of the humerus with the orientation of its wide edges in the antero-outer direction using a semi-open or closed technique. Additional immobilization is not applied. An example of the implementation of this technique can be two clinical observations (Fig. 13.25 and 13.26).

Rice. 13.15. Modeling the Dieterichs splint under the olecranon to prevent pressure ulcers

Rice. 13.16. Skeletal traction with a fracture of the humerus according to the Kharkov technique

a - Extra-articular fractures of the surgical neck of the humerus with A3 displacement. If closed reduction has not been successful, then the only treatment for this fracture is open reduction and internal fixation;

b - in the presence of a large fragment of the head, a short T-plate is used to stabilize the fracture. Care must be taken not to interfere with the movement of the biceps tendon;

c - clinical observation of a fracture of the surgical neck of the shoulder with complete displacement of fragments;

d - osteosynthesis with an angular compression plate was performed: complete restoration of function six weeks after surgery;

d - after 10 weeks adhesion was detected;

e - the structure is removed

13.18. Skeletal traction for fractures of the humerus on the CITO bus with the Nazaretsky attachment:

1 - bracket; 2 - guide tube of the thrust unit; 3 - spring of the traction unit; 4 - support sleeve; 5 - stop at the end of the tube for the spring; 6 - a hook with a screw thread; 7 - a nut that compresses the spring and thereby creates traction

Rice. 13.19. Nazareth's apparatus for the treatment of traction of the humerus:

1 - half corset; 2 - shoulder bed; 3 - forearm bed; 4 - connecting tube; 5 - rod with square thread; 6 - wing nut; 7 - thrust unit; 8 - pull rod of the shoulder and semi-corset connection; 9 - movable clutch; 10 - articulated joint; 11 - vertical rod for turning the shoulder bed anteriorly and posteriorly; 12 - collet clutch; 13 - half-corset socket; 14 - vertical rod of the thrust unit

Rice. 13.20. Supracondylar extensor fracture of the humerus: a - typical displacement of fragments;

b - scheme of constant traction - skeletal traction behind the olecranon of the ulna (1), traction along the length of the forearm (2) and backward contraction of the loop behind the shoulder (3)

Rice. 13.21. Supracondylar flexion fracture of the main bone: a - typical mixing of fragments;

b - scheme of constant traction - skeletal traction behind the olecranon (1), additional traction for this spoke posteriorly (2), counter-extension with a loop for the shoulder anteriorly (3)

Rice. 13.22. Physiological curvature anteriorly of the lower metaphysis and cross sections of the humerus

Rice. 13.23. Stages of synthesis with a directed rod for diaphyseal fracture of the shoulder:

1 - introduction of a rod directed to the large tubercle; 2 - holding the rod after matching the fragments; 3, 4 - operation completed

Rice. 13.24. Clinical observation of osteosynthesis of a fracture of the humerus with a directed titanium rod: 1 - before surgery; 2 - osteosynthesis; 3 - the rod is removed

Rice. 13.25. Clinical observation of antegrade semi-open intraosseous osteosynthesis of the left humerus in patient E., 34 years old:

a - upon enrolment;

b - after osteosynthesis (disability after surgery - 2 weeks, full restoration of function

v within 4 weeks);

c - after 6 months

Rice. 13.26. Clinical observation of closed intraosseous osteosynthesis in a 18-year-old patient: a - during hospitalization; b - after surgery

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