Basic research. Osteosynthesis of the humerus, principle of operation Connection of bones with screws

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 extensively treated - from the top of the neck, the entire arm, from the back to the shoulder blade, from the front the entire chest to the abdomen. The assistant, with a sterile butt, lifts the treated arm vertically up by the forearm so as to lift the shoulder blade off the table. A sterile oilcloth and a double-folded sterile sheet are placed under it. The second sheet is along the torso from the armpit to the feet, the third is on top of the second, the fourth is on top and on the torso, the fifth is over the fourth with its lower end drawn from behind along the torso. The entire arm and deltoid area remain free. The sheets are fixed to the skin with clips or skin sutures.

An incision is made along the lateral groove of the shoulder, in the middle above the fracture, length 7-8 cm. The skin, subcutaneous tissue, and fascia are dissected. Between the biceps muscle and the lateral head of the quadriceps muscle, the surgeon approaches the humerus. For low diaphyseal fractures, the brachioradialis muscle is retracted outward. At this point in the lower third of the shoulder, the radial nerve passes next to the bone. It is released, taken onto a rubber holder and carefully moved to the side. When osteosynthesising low humeral fractures, isolating the radial nerve and retracting it with a holder is absolutely necessary. The ends of the fragments are not exposed from the muscles and periosteum; only their ends are exposed from the hematoma and primary callus. In this case, the central fragment is brought out 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 callus (when the operation is not performed immediately, but after 8-12 days). With comminuted fractures, the fragments do not “tear off” from the periosteum and muscles.

The rod is prepared before surgery. The required width of its upper end is determined either by an image 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 the one is selected during the operation , which fits tightly into the bone canal of the central fragment.

The rods are prepared from a wedge-shaped semi-finished workpiece, the length of the rod is selected according to the size of the healthy bone from the greater tubercle to the external condyle, and the workpiece is shortened with sandpaper from above and below so that the lower part of the rod corresponds to the width of the channel 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 off with sandpaper 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 top or base of the greater tubercle.

The sharp edges of the lower end of the rod are rolled. The lower end is bent anteriorly by the amount of physiological deviation of the lower edge of the humerus anteriorly (according to the image of the 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 gentle blows of a hammer, the rod is driven into the bone canal of the proximal fragment. The assistant uses the anterior surface of the terminal phalanges of the 2-3 fingers of the right hand to determine 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 is pushed until its lower end is level with the end of the proximal fragment (or it is possible for the end to stand out from it by 1 cm).

After this, the ends of the fragments are compared with rough movements. Based on their relief (small depressions, denticles), the surgeon eliminates rotational displacement. It is very convenient to compare fragments by inserting single-pronged hooks into the ends. If the fracture is abutment (transverse, non-comminuted), then after comparison, the assistant presses the lower fragment to the upper one and then drives the rod into the lower fragment (first he hits the upper end of the rod with a hammer, and then the rammer). A 1 cm rod with a transverse notch is left above the bone to be grasped by the instrument during removal.

If the fracture is not supported (oblique, comminuted), then the comparison and retention of the fragments is carried out by traction at the elbow, and after reposition, the oblique ends of the fragments are compressed by the Farabeuf bone holder through the muscles and periosteum (the ends of the fragments from the muscles and periosteum are not “torn 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 applied to the protruding end of the rod from the proximal fragment, and it is shortened along the transverse notch by several flexions and extensions. In this case, the surgeon or assistant fixes the rod with pliers immediately below the risks. After breaking off the rod, the sharp edges of its end are rolled with a rasp. Then the fragments are compared, and it is driven into the peripheral fragment. An end 1 cm long is left above the bone with a transverse notch for gripping with a special tool during removal.

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

Upon completion of osteosynthesis, tubular drainage is inserted into the bone through a skin puncture. The muscles and the own fascia are sewn together with catgut. If the subcutaneous fat layer is large, then a drainage made of rubber gloves is inserted through the wound. Silk sutures are placed on the skin.

An example would be clinical observation (Fig. 13.24).

When the rod is inserted antegradely into the proximal fragment, a distance from the lower end is measured on it, equal to the distance from the end of the central fragment palpated under the skin to the greater tubercle. The inner side of the lower end of the rod must be rounded so that when driving the rod from top to bottom into the central fragment, it slides with a rolled edge along the inner wall of the bone canal and does not perforate it.

The rod is punched to the mark, its distal end approaches the fracture line. A skin incision (3 cm) is made above the fracture, the fascia is dissected, and the muscles are separated with a clamp. An index finger is inserted into the wound, under whose control the fragments are repositioned; after reposition, the rod is forced into the distal fragment. This is the so-called semi-open osteosynthesis. Reposition can also be performed with an awl after spreading the muscles with hooks. This is open osteosynthesis with antegrade insertion of the rod.

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

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

shem. A pin made of titanium alloy VT-5, VT-6 of rectangular cross-section with a thickness of 4.0 mm throughout is used. The upper (wide) and lower (narrow) sections of the rod have parallel edges. The width of the lower part of the rod is selected based on a 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 curved 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 external epicondyle of the humerus 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 anterior-outer direction using a semi-open or closed technique. Additional immobilization is not used. An example of the implementation of this technique can be two clinical observations (Fig. 13.25 and 13.26).

Rice. 13.15. Modeling of a Dieterichs splint under the olecranon to prevent bedsores

Rice. 13.16. Skeletal traction for a fracture of the humerus according to the Kharkov method

A - Extra-articular fractures of the surgical neck of the humerus with displacement type A3. If closed reduction is unsuccessful, 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 a way 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 humerus with complete displacement of fragments;

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

d - after 10 weeks, fusion was confirmed;

e - design removed

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

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

Rice. 13.19. Nazaretsky apparatus for treatment with humerus traction:

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

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

b - scheme of constant traction - skeletal traction for the olecranon process of the ulna (1), traction along the length of the forearm (2) and counter-traction with a loop behind the shoulder posteriorly (3)

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

b - scheme of constant traction - skeletal traction for the olecranon process (1), additional traction for these pins posteriorly (2), counter-traction with a loop for the shoulder anteriorly (3)

Rice. 13.22. Physiological anterior curvature of the lower metaphysis and transverse sections of the humerus

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

1 - insertion of a rod aimed at the greater tubercle; 2 - insertion of the rod after matching the fragments; 3, 4 - operation completed

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

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

A - on admission;

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 an 18-year-old patient: a - during hospitalization; b - after surgery

In case of complex fractures with shoulder deformation, when there is bone fragmentation, it would be correct to use osteosynthesis of the humerus. This operation is performed when it is impossible to combine fragments of a damaged solid organ. The intervention takes place under anesthesia using screws, pins and plates connecting bone fragments.

Types of humerus injuries

Injury to the diaphysis. It is caused by mechanical injuries, impacts with the shoulder, and falling with emphasis on the arm or elbow joint.
Fracture of the neck of the humerus. With osteoporosis in older people, bones lose strength and their fragility increases, so this category of people is most susceptible to injury.

Osteosynthesis: description and features of the manipulation

Indications

Pinching and pinching of soft tissues by bone fragments.
A fracture that has not healed properly or has not healed for a long time.
A closed fracture that can become open due to pressure from the bone on the soft tissue.

Contraindications

Bone tissue becomes more fragile.

The patient's serious condition.
Open fractures with extensive damage and contamination of soft tissues.
Pathology of internal organs.
Neurological diseases that cause seizures.
Poor blood circulation in the arm.

Methodology

There are two main types of osteosynthesis: submerged and external. The internal (immersed) method uses various implants that secure bone fragments inside the body. Depending on the nature of the fracture, these may be pins, screws, plates, wires or metal rods. Connection with a pin allows you to accurately restore the chips and maintain the length of the limb. Plate osteosynthesis is used for displaced joint fractures. It stably fixes bones and minimizes damage to soft tissues. With the external method, parts of the crushed bone are connected using external fixation using the Ilizarov apparatus. The choice of shoulder osteosynthesis technique will depend on the indications for its use, the metal structures used, additional fixation and subsequent rehabilitation.

Complications

If the pain does not go away for a long time, you should consult a doctor.

Undesirable consequences of the operation occur extremely rarely. They can occur both during and after the event. All complications of the postoperative period depend on the correctly selected material, the professionalism of the doctor, and the correct choice of surgical technique. For example, retrograde osteosynthesis fixes bones and joints with nails. This method is rarely used because the nail may injure the rotator cuff tendons. Improper fixation of implants into the humerus can lead to repeated surgery. If pain occurs, you must immediately consult a doctor, otherwise unpleasant consequences will arise.

Complications may include:

infection in the wound (as a result, gangrene and sepsis);
osteomyelitis;
internal hemorrhage;
fat embolism;
anaerobic infection;
arthritis;
malfunction of the limb.

According to the results of research conducted by Doctor of Medical Sciences Litvinov I.I., internal osteosynthesis with plates reduces the risk of infectious complications and damage to the radial nerve. This method gives better results in comparison with intraosseous osteosynthesis.

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

Why is a plate needed for a humerus fracture?

For proper fusion of bone tissue, it is necessary to bring the fragments as close as possible to each other at the fracture sites. When bone fragments are displaced, doing this conservatively will be a difficult task, because the physical properties of the lever will not allow the pieces of bone to fuse together.

Titanium plate is used for:

Correct fixation of fragments relative to each other;
Removing the lever effect, when fragments can again come out of their natural position.

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

If the plate is not placed 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.

Progress of the plate installation operation

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

Main stages of the operation:

The patient lies on his back, general (less often local) anesthesia is performed;
A tourniquet is applied above the injury site;
An incision is made in the skin and muscle fascia corresponding to the size of the titanium plate;
Using medical screws through the holes in the plate, it is fixed to the bone tissue;
The soft tissues are returned to their original position, sutures are placed on the fascia and skin;
A plaster cast is applied.

The difficulty of the operation lies in the passage of the radial nerve directly next to 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:

Swelling of the hand;
Loss of muscle tone, feeling weak;
Bleeding in the area of the suture;
Temperature increase.

Implanting a 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 and antiseptics during the operation.

A long period of bone healing will be required before and after surgery. Prepare for endless examinations, including x-rays.

Here are some examples of complications:

Secondary displacement of bone fragments;
Osteomyelitis (infection in the wound);
Internal bedsores;
False union.

What to remember

A titanium plate for a humerus fracture is an expensive proposition. The price of a high-quality record can reach 110 thousand rubles. when installed over the entire length of the arm. A plate for a fracture of the humeral neck is cheaper, but the purchase is still inevitable.

Check the availability of certificates, because usually the material goes through third parties directly to the surgeon. Reason: mandatory sterility.

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

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

Conclusion

Installation of a titanium plate is an effective treatment for displaced humerus fractures. Correct installation guarantees fusion of bone fragments, normalization of motor activity of the arm 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.

I never thought I'd break anything. And even more so, I could not imagine that fractures received at home could require surgical treatment. However, there is a first time for everything.

If you found this article, you have probably also experienced a fracture or are about to undergo surgery. I found practically no useful information before the operation, although I intensively scoured the Internet. I sincerely hope that this article will help someone find answers to their questions, will calm someone down and will not be so scary.

How I broke my arm

A slippery country porch after the rain, my hands full of things - I couldn’t hold on to the railing. A split second - and I was already sitting on the steps. It hurts somewhere in the thigh area. I try to get up, but I understand that my left hand does not obey me. I hear some kind of grinding sound inside (the edges of a broken bone are rubbing against each other). There is no pain in my arm, it's because I'm in shock. Almost lost consciousness. When they lifted me up and sat me down on a chair, I noticed that I was intuitively supporting my sore arm with my healthy one. The hope of a dislocated joint quickly disappeared when I tried to move my left arm and bend it - it hung like a whip, and fragments were shaking inside, unnaturally inflating the arm from one side to the other. This sight made me feel sick, my head was spinning, and my legs were weak.

As I realized later, I fell on my hip, but during my inglorious flight my arms went to the sides, and one of them hit the railing with all its strength, which is why it broke.

An hour later I was at the emergency room in Solnechnogorsk. On a first-come, first-served basis, they took pictures and put me in a plaster cast. The pictures showed a helical fracture of the humerus in the lower third (closer to the elbow) with displacement. The local traumatologist immediately told me that surgery would be required and asked which hospital to refer me to. Thus, that same evening I was taken to the hospital at my place of residence, where at 11 pm I was hospitalized, and I fell asleep almost exhausted on the newly acquired bed 36 of the Moscow hospital.

picture immediately after the fracture (without plaster)

First hospital

I got to the hospital on Saturday night, and, of course, no one began to urgently attend to me, they just took new pictures. On Sunday they took tests and injected me with analgin a couple of times. I couldn’t understand where my doctor was, whether there would be an operation and when, how long I would be stuck in this institution where I was supposedly being treated. When they came to do an ECG, I was almost sure that this was a sure sign of preparation for the operation. But everything turned out differently: my attending physician came in the afternoon and doubted the advisability of the operation. He said that he would discuss this situation with the head of the department and get back to me. The manager came in a little later and was also full of doubts. According to him, “the bone in the cast stood up straight and will heal on its own,” so surgery is not necessary in my case. However, the doctors themselves could not make such a decision; they began to wait for the professor. The professor called a consultation and all these people came to my room. They examined me, checked whether my fingers were working and informed me that they would not operate, saying I was lucky and it should heal that way. And the next day I was discharged home. So I spent 4 days in the hospital without any treatment.

It is clear that nothing is clear

Then I was recommended to be observed at the emergency room at my place of residence. The first time I came there without photographs, only with an epicrisis. When the time came to redo the picture, 2 weeks had already passed since the fracture, and the traumatologist, seeing a fresh picture, said that I needed surgery and would do it quickly. I was at a loss: some traumatologist against the opinion of the whole council? However, the latest photo seemed scary to me too.

picture 10 days after the fracture in a cast

A couple more days passed, out of fear, I redid the picture again, but in a different projection, and what I saw there scared me wildly. Because SUCH a bone will definitely not heal.

It was clear that the bone was not standing as it was before; the fragments were moving despite the plaster splint. And I began to collect the opinions of other doctors. They all said one thing: an operation is needed, don’t delay, the longer the time passes, the harder it will be for the surgeon.

I had to take all the tests again, take an X-ray of my lungs and an ECG. At that time, I already knew that I would go to have an operation at Hospital No. 83. Through friends and acquaintances I was recommended to see Dr. Gorelov. During the consultation, he seemed reasonable and even somewhat pessimistic to me (in fact, he just honestly warned about the risks), but a qualified doctor. I couldn't find any reason not to trust him. I liked the inpatient facility in the hospital - two and single clean rooms with TV, Wi-Fi and even air conditioning. In general, I was satisfied with everything.

I was operated on on September 14, and 2 days after the operation I was discharged, making me promise to come for dressings. In general, I liked all the staff in this hospital - the doctors, my anesthesiologist and attentive nurses. I want to express my gratitude to everyone for their professionalism and help.

I.V. Gorelov is a very kind, competent, calm and patient doctor, answers all questions in detail, calms and encourages. No familiarity or attempts to tease the patient, make a bad joke, etc. Such qualities of a doctor are very important to me, because you listen to every word and, to some extent, the doctor is an authority for the patient, whom you need to completely trust and follow all instructions. And if the person himself or communication with him is unpleasant to you, then this complicates everything and there is no trace of any positive attitude.

Displaced humerus fracture and treatment options

Doctors say that breaking the humerus is not so easy - it is one of the largest and strongest human bones. Displaced fractures are extremely rarely treated conservatively. This also takes a rather long time for the bone to heal and there is a high probability that after a couple of months in plaster the bone will heal crookedly. But the most unpleasant thing is that it may not heal at all, and a false joint may form at the site of the fracture, which is very, very bad.

Surgery can be risky because the radial nerve runs along the humerus to the elbow. In simple terms, this nerve is responsible for the functioning of the hand. If it is damaged during surgery, the hand may simply “hang” for a long time. But doctors do not give guarantees, each person is individual, some may be unlucky.

The operation itself involves the installation of a titanium periosteal plate, which is secured to the bone with screws screwed into the bone. The difficulty is that the radial nerve runs straight through the bone, so in order to get to it, you need to isolate the nerve and place “shock-absorbing” muscle tissue under it (between it and the plate). This operation is not considered simple; personally, it took me about 2.5 hours to do it. What a relief it was to see that the fingers were moving, that the nerve was not damaged. After the operation, the doctor said that the muscle began to wrap around a fragment of bone, which made it impossible for it to heal. Therefore, the decision to undergo surgery was correct.

In my case (the operation was complicated by the age of the fracture), general anesthesia with a mask and tube was suggested. And fresh fractures of this type can be operated on under local anesthesia (anesthesia in the neck, which cuts off the sensitivity of the arm). Personally, I think that general anesthesia is better because you don’t see your blood and don’t hear your bones being drilled. Not every person can handle this. And I liked mask anesthesia much more than intravenous anesthesia (I had such experience) - it was easier to recover from.

Preparation for osteosynthesis with a titanium plate and the first days after it

Discuss treatment options with your surgeon. If the fracture occurred recently and the bone did not break at the joint itself, you may be offered to install a pin - a metal rod that is driven into the bone, which will fix it from the inside. Less risk to the radial nerve and small scars on the arm. Installing the plate means a big scar, preceded by a big seam (I'm already slowly thinking about a tattoo). In my case it was too late and difficult to use the pin, so we agreed on a plate.

The patient purchases this accessory himself, through a doctor, or looks for it on his own. My German plate cost 103 thousand rubles. No matter how you buy the plate, ask for receipts and documents for it. We bought from the supplier company. No one showed us the plate itself, arguing that it would be delivered directly to the doctor, and it is not recommended for mere mortals to touch this sterile device. But a bunch of certificates were handed out. Yes, the price was high, and it depends on the length of the plate. Mine covers almost the entire humerus. Someone may be luckier and find it cheaper.

Before the operation, you must undergo a standard medical examination. examination by a therapist, have a fresh fluorography on hand, as well as an ECG, blood and urine tests. With this heap of papers you come to the hospital, and the longest day of your life begins. After lunch they will no longer feed you, and in the evening they will completely cleanse your intestines and prohibit you from drinking after midnight. In the morning, on an empty stomach, you will be stripped naked, given an antibiotic injection into a vein, and taken to the operating room.

I was taken to surgery straight away with a cast on my arm. I have no idea how they filmed it - it was already under anesthesia. In the operating room, a catheter is placed in the arm and a mask is applied. I passed out after 15 seconds to the music of the band Spleen, sounding relaxed in the cold operating room.

When I woke up, I saw people in dressing gowns, they calmly talked to me, they said that I had only lost half a liter of blood, that this was not much. Then they took me to the ward. A stonehenge of ice in bags was laid out around the operated arm, taped with a bandage, and an IV was connected to the healthy arm. At this point the worst was over.

For the first 2 days, blood leaked from the stitches, so I had to put special diapers on the bed. This is absolutely normal, although it looks creepy. Also, after surgery, elevated temperature (up to 37.5 within a week) and severe swelling of the arm are normal. My hand has become 2 times larger, the sight is unsightly and scary. However, this is normal given the damage to the muscles and tissues of the arm - the blood supply needs time to recover, and this is not a couple of days.

While the stitches are bleeding, dressings are done daily, then as directed by the doctor. It is better not to disturb dry seams again. They are removed on the 12th day after surgery.

You should try to bend the operated arm (slowly develop it), massage the hand to remove swelling and wear the arm in such a position that the hand is above the elbow - this will reduce swelling. In my sleep, I put my hand on my stomach - in the morning the swelling is much less than in the evenings.

Upon discharge, I was prescribed a course of antibiotics and painkillers (if necessary).

All the bandages-scarves-splints from pharmacies seemed uncomfortable to me, they put pressure on the seams, so I wear my arm loosely, slightly bending it at the elbow. It's not difficult, don't be afraid to not support it. For the first 2 days I tied my arm with a Pavloposad scarf, but now I’m just walking (a week after the operation) without holding it in any way. I use my hand minimally - open the lid, take the mug. There is almost no strength in the arm yet, but it will return with the development and restoration of the injured muscles.

With this I want to finish the first part of my story. The next post will be devoted to the rehabilitation and development of arm muscles.

If you have questions, be sure to ask in the comments. I know from myself that in such a difficult situation you cling to every review, collect information literally bit by bit, and this ignorance is frightening and disorienting.

Health to all our readers!

Clavicle fractures are very common. In the structure of injuries to the musculoskeletal system, they occupy up to 15%, which is due to the high probability of injuries to the upper limb belt in modern life. A strong mechanical impact from the outside can not only break the bone, but also contribute to the displacement of its ends. Such an injury becomes more severe and requires slightly different approaches to treatment.

General information

Anatomically, the clavicle is a small tubular bone that connects the scapula to the sternum. It is S-shaped, which allows for proper shoulder distance and full arm function. By strengthening the girdle of the upper limb and connecting it with the axial skeleton, the clavicle creates conditions for active work and daily activities of a person. It distinguishes the following departments:

Acromial.
Sternal.
Diaphyseal.

Fractures most often occur in the latter, since it is in the diaphysis that the maximum bending is observed; it has less thickness, and therefore strength, in comparison with the articular ends of the bone. Based on the fact that the collarbone provides support for the entire arm, it has to experience significant loads. And fairly strong muscles allow you to withstand them:

Deltoid.
Trapezoidal.
Large chest.
Sternocleidomastoid.
Subclavian.

Additional stabilization is provided by the following ligaments: acromioclavicular and sternoclavicular, trapezoid and conical. But even this does not save from fractures. Moreover, reflex spasm of individual muscles contributes to the displacement of bone fragments and aggravation of the injury. And the close location of the subclavian artery, vein, nerve plexus and upper pleural cavity makes such fractures extremely dangerous.

The clavicle plays an important role in the functioning of the upper limb. And the pronounced muscular and ligamentous apparatus is designed to protect the shoulder girdle from mechanical impact.

Causes

The occurrence of a clavicle fracture is due to various reasons. The main characteristic is an indirect mechanism of injury - when a person falls on an outstretched arm or the side of the shoulder, as well as during transverse compression of the upper extremity belt (compression from rubble, road traffic accidents, at work). Less commonly, direct impact to the bone occurs during a blow to the clavicular area with a blunt object (for example, in contact sports). Other factors that may contribute to fracture include:

Age (children and elderly).
Metabolic diseases (osteoporosis).
Tumors and metastases (breast and thyroid cancer).
Infectious processes (osteomyelitis).

When a fracture occurs against the background of processes that reduce the mineral density and strength of the clavicle, it is called pathological. This requires additional examination to identify the primary source of the problem, because disorders in the body can be not only local, but also systemic.

The cause of a clavicle fracture often lies in an indirect mechanical impact on the shoulder. But there may be other factors that significantly facilitate the development of injury.

Classification

A displaced clavicle fracture can have a different nature. The classification of such injuries takes into account many aspects in the development of bone damage, which should be reflected in the diagnosis. The main types of fractures are:

Diaphyseal, sternal and acromial ends.
Oblique, transverse, helical, splintered.
Extra- or intra-articular.
Complete and incomplete.
Closed or open.
Isolated and combined (fracture-dislocations).
Uncomplicated or complicated.

Typical displacement of bone fragments is observed in fractures in the middle third of the clavicle (diaphyseal), when the central fragment deviates upward and backward, and the outermost fragment deviates outward and forward. This creates an angle that is open downward and forward. If a fracture of the outer end of the clavicle occurs, then the peripheral fragment remains associated with the acromion process or sternum, and the central one moves upward, often simulating a dislocation. However, some fractures are actually associated with dislocation of the articular surfaces due to rupture of the suspensory ligaments.

Symptoms

A clavicle fracture has a fairly characteristic clinical picture, which greatly facilitates the diagnosis. Already at the stage of a medical examination, it is possible to determine the important features of such an injury. There is no doubt about the displacement of bone fragments when the following symptoms are detected:

Visible or palpable deformity with protruding bony edges.
Pathological mobility.
Crepitation (crunching).
Smoothness of the supraclavicular fossa.
Shortening of the shoulder girdle.
Forced position of the arm: bending at the elbow, internal rotation, downward and forward deviation.
Increasing the distance from the spinous processes to the inner edge of the scapula.

These are reliable signs of a displaced fracture. Patients, of course, are concerned about pain in the shoulder girdle, the mobility of which is significantly limited (especially abduction and elevation of the arm). Swelling, hemorrhages or hematoma are noticeable at the site of injury, and if the fracture is open, then the skin is also damaged.

After a clavicle injury, a number of specific signs are observed that indicate a displaced fracture, and other symptoms that determine the overall picture of tissue damage.

Consequences

A displaced clavicle fracture can lead to various adverse consequences. Some of them are related to the very nature of the injury and are regarded as its complications, while others arise when a doctor is not consulted in a timely manner or errors are made during the treatment process. These conditions include the following:

Internal or external bleeding.
Neurological disorders in the hand (plexopathy).
Pneumothorax.
Secondary displacement.
Formation of a false joint.
Scoliotic deformity of the spine.
Infectious process in the bone (osteomyelitis).

If the fracture heals incorrectly, an external deformation of the clavicular region often results, which becomes an unpleasant cosmetic defect, especially for women. But much more important is the risk of decreased physical activity or even loss of ability to work due to incorrect comparison of bone fragments.

Additional diagnostics

Although the diagnosis of a displaced fracture is often not in doubt by the doctor, it is still necessary to confirm it with the results of an additional examination. In addition, it is important to establish the integrity of the anatomical structures lying in the subclavian space: vessels, nerves, pleura. After a clinical examination, the following diagnostic measures are prescribed:

X-ray of the shoulder girdle (in a direct projection and at an angle from bottom to top).
CT scan.
Magnetic resonance imaging.

To establish the condition of the subclavian artery, an ultrasound with Doppler sonography is performed, nerve conduction is determined using neuromyography, and pneumothorax is diagnosed based on a plain X-ray of the chest cavity.

The diagnostic program for a clavicle fracture is determined by the bone injury itself and concomitant damage to other anatomical formations.

Treatment

After receiving an injury, the patient should seek medical help as soon as possible at the nearest medical facility. The outcome of the fracture largely depends on the timeliness of treatment. To restore your previous physical activity and prevent unwanted effects, you need to trust qualified specialists.

Prehospital care

Even before going to the emergency room or hospital, you need to provide first aid to the victim. This will significantly improve his condition and protect him from some complications. First of all, the injured limb should be immobilized with a bandage, and only then, in a half-sitting position, the patient should be transported to a medical facility. An aseptic bandage is applied to the site of the open fracture. In this case, you absolutely cannot do the following:

Set bone fragments.
Pull on the upper limb.
Extend your arm.
Lean forward.

If you cannot do what is necessary on your own or with the help of others, you should immediately call an ambulance.

Conservative measures

In the hospital, after appropriate diagnostic procedures, the patient is prescribed qualified therapy. Conservative measures most often consist of simultaneous reposition of bone fragments with their further fixation in the achieved position.

Against the background of local anesthesia, the doctor's assistant stands behind the patient, holds him by the armpits with his hands, and, resting his knee on the back, spreads and raises the shoulder girdle. In this position, the surgeon performs manual reduction of the broken collarbone. And then, without weakening the traction, you need to fix the limb for successful fusion of the bone. It is better to do this using the following immobilization means:

Smirnov-Weinstein plaster cast.
Kuzminsky tire.
Chizhin frame.

Proper fixation of the shoulder girdle is difficult to achieve with Delbe rings or an 8-shaped bandage - they are used for fractures without displacement. But for elderly patients, in whom rigid immobilization can lead to limited respiratory excursions, such drugs, despite the insufficient effect, are still applicable. Fixation devices can be removed after 4–6 weeks from the moment they are applied.

Conservative treatment of fractures consists of giving the clavicle an anatomically correct shape (reposition) and further fixation.

Surgical correction

As a rule, fractures heal well even after conservative measures. But in certain conditions the need for surgical treatment is clearly justified. This applies to the following cases:

Open fractures.
Closed fracture with a perpendicular rotation of the bone fragment (risk of damage to the neurovascular bundle).
Fractures already complicated by damage to blood vessels and nerves.
Impossibility of conservative reduction.

Surgery for a displaced clavicle fracture involves fixing the fragments by osteosynthesis:

Intramedullary (with a rod or wire inserted into the bone canal).
Bony (with a plate secured with screws).
External percutaneous (with pins or external fixation device).

After eliminating the displacement of bone areas, the limb is fixed using Deso, Smirnov-Weinstein bandages or an abduction splint for a period of 4 to 5 weeks.

Clavicle surgery is not indicated for all patients with fractures, but only in certain cases.

Rehabilitation

For a displaced clavicle fracture, the recovery period lasts at least 1.5 months. The bone defect heals during immobilization, but the ability to work is fully restored later. And in older people, healing itself often occurs more slowly.

In order for the patient to quickly return to his former active life, rehabilitation after a fracture is necessary. Additional treatment is also necessary for those people who have had complications with the nerve plexus. Therefore, a rehabilitation treatment program may consist of the following:

Medicines (vitamins, vascular, neurotropic).
Physiotherapy (electro- and phonophoresis, UHF magnetic therapy).
Massage.
Physiotherapy.

These methods make it possible to improve blood flow in the affected area, normalize neurotrophic processes and restore muscle tone, which has decreased during immobilization. A properly formed rehabilitation program will allow you to avoid disturbances in motor activity and fully restore hand function.

Bone fragments are often displaced during clavicle fractures, which can create additional risks to a person's health. Therefore, you need to consult a doctor in time and start treatment. Early reduction, reliable fixation and active rehabilitation measures are the main prerequisites for complete recovery after injury.

Fracture of the surgical neck of the humerus: rehabilitation and treatment

Shoulder and wrist fractures are a very common injury that can occur in young and old people.

The anatomical structure of the humerus includes three sections:

Surgical neck and head of the humerus - they are located in the joint capsule and serve as a component for the upper part of the shoulder joint. A fracture in this area often occurs in the area of the tubercle and surgical neck of the shoulder.
The condylar zone or distal part – connects the forearm to the elbow. Fractures that occur in the lower part of the arm are called transcondylar.
The body of the humerus, which is also called the diaphysis of the shoulder. This is the longest part of the shoulder bone.

The most common is a fracture of the surgical neck of the humerus and the connecting parts of the head, namely the greater tuberosity. Damage to the head and condylar zone is classified as intra-articular injuries. Moreover, the nerves, brachial artery, and muscular system of the shoulder are often damaged along with the shoulder bone.

Symptoms of a shoulder fracture

Signs of a humeral neck fracture include:

shoulder shortening;
pain at the site of injury;
bruising, swelling in the area of injury;
deformation of the shoulder if the fracture is displaced;
limitation of motor function of the joint;
crepitus in the area of injury (during palpation you can feel the crackling of bone fragments).

In some cases, with impacted fractures, when one bone fragment is driven into another, resulting in a strong fixation, pain and other symptoms are often mild. Therefore, a person who has received such an injury may not pay attention to it for a couple of days.

Fractures of the neck of the humerus, like injuries to the wrist joint, are often closed. They are often complicated by nerve damage, which manifests itself in impaired sensitivity in the hand area and difficult movements in the fingers and hand.

Signs of a fracture of the greater tubercle include pain above the shoulder joint and a crunching sound in the area of damage upon palpation. In this case, the joint practically does not swell, and there are no visual manifestations of deformation.

There is also limited mobility, especially if the shoulder is moved to the side. Moreover, abduction is often completely absent, which indicates injury to the tendons of the periosteum muscle.

However, vessels and nerves are rarely damaged in this type of fracture. As a rule, the periosteal muscle is injured, after which a sudden disruption of the motor function of the shoulder may occur.

Manifestations of a fracture of the diaphysis of the humerus include crepitus of the fragments, severe pain and limited mobility in the area of the elbow and shoulder joint. Symptoms such as shortening of the limb, bruising, swelling and severe deformity in case of displacement also occur.

This type of injury to the shoulder joint, as well as to the wrist, is characterized by injury to the vascular and nervous system. If the nerves are affected, this affects the motor capabilities of the fingers, impaired sensitivity and is manifested by drooping of the hand.

Signs of transcondylar fractures include:

the occurrence of crunching of debris if you feel the injured hand;
pain in the forearm and elbow joint;
when displaced, deformation occurs;
swelling of the elbow joint;
limited elbow mobility.

If transcondylar fractures occur, then the brachial artery is often affected, resulting in gangrene of the arm. The main sign of arterial injury is the absence of a pulse in the forearm, where it should usually be felt.

However, fractures of the upper part of the shoulder should be distinguished from bruises, dislocations of the shoulder and injuries to the elbow and wrist joint.

Treatment

There are 3 methods of treating fractures of the shoulder and wrist joint:

conservative;
skeletal traction;
surgical

Simple fractures of the shoulder and displaced injuries to the joint are corrected using one-stage reduction, that is, reduction. Treatment is carried out by applying plaster, bandages or special fixing splints.

Treatment of injuries to the greater tubercle of the humerus is usually carried out by applying a plaster cast. As an additional therapy, an abduction splint is used to prevent the development of stiffness in the shoulder joint. In addition, the splint promotes fusion of the supraspinatus muscle, which is often damaged during the fracture of the greater tuberosity.

In case of displaced fractures, surgical treatment is used, during which the bone fragment is secured with screws or wires, which are removed after several months of therapy. In general, rehabilitation lasts from 2 to 3 months, and plaster immobilization lasts up to a maximum of 6 weeks.

In the case of a non-displaced surgical neck fracture, a plaster cast is applied to the affected area for 1 month, and then restoration is carried out, during which the arm should be developed. If the damage was displaced and it was possible to reduce it, then treatment with plaster immobilization is delayed for 6 weeks.

If the fracture of the shoulder joint, as well as the wrist joint, is incorrect, then surgical intervention is performed. Moreover, such surgical treatment involves fixation with plates.

For fractures of the greater tubercle and impacted injuries, conservative treatment is used, during which the arm is fixed on an abductor pad, if the periosteal muscle is damaged, or as a scarf. Rehabilitation lasts 4 weeks, and in this case the plaster is not adjusted.

Then physical therapy and physiotherapeutic treatment are used. The duration of such therapy is up to three months.

Fractures of the body of the humerus without displacement are treated by applying a plaster splint for 2 months. Displaced fractures are operated on, and then the arm is fixed with screws, plates or intraosseous rods.

Then a cast is applied for 1 - 1.5 months, but if the fracture is fixed well, then you can get by with a regular bandage - a scarf. After removing the plaster, recovery occurs, which lasts up to 4 months.

Rehabilitation

The most important component of treatment for a shoulder fracture is the rehabilitation process. It consists of such important components as massage, physiotherapy and physical therapy. Moreover, physiotherapeutic procedures should be carried out in courses - up to 10 procedures several weeks after the injury.

Therapeutic exercise should begin in the first days after medical treatment. So, after 3 days from the moment of injury, you should begin to make active movements, but without excessive load on the fingers of the affected hand. Also, do not forget about your healthy hand, which also needs to be exercised.

After 7 days after injury or surgery, you need to strain your shoulder muscles isometrically. Isometrically - this means that the exercise should be performed without moving the joint. But first you should train your healthy hand and only then move on to the sick one.

Such exercises should be done no more than 10 approaches per day. To begin with, 20 voltages are enough, and then their number should be gradually increased. Such rehabilitation is necessary so that the muscular system is in good shape and blood circulation in the shoulder is improved, so that the fusion of bone tissue will be rapid.

When the bandage is removed, you can begin to develop the motor function of the shoulder, elbow and wrist joints.

Intramedullary osteosynthesis

Osteosynthesis is the most common and effective method of treating bone and joint damage in modern conditions. Nowadays different types are used. Most often, such treatment is required to restore the tubular bones of the extremities. Previously, the most popular method of treating such injuries, along with casting, was the use of transosseous fixation devices. But they are bulky and inconvenient, and they often cause wound infections. Therefore, intramedullary osteosynthesis is now considered more effective to restore the integrity of tubular bones.

What is osteosynthesis

To treat bone injuries, surgery is now increasingly used rather than casting. Osteosynthesis surgery ensures more efficient and rapid bone fusion. It consists in the fact that bone fragments are combined and fixed with metal structures, pins, knitting needles or screws. Osteosynthesis, depending on the method of applying these devices, can be external or submersible.

The second method is divided into intramedullary osteosynthesis - fixation of the bone using rods inserted into the medullary canal, extramedullary, when fragments are combined using plates and screws, and transosseous - performed by special external devices of a pin design.

Characteristics of the method

The idea of intraosseous fixation of fragments was first proposed by the German scientist Kushner in the 40s of the 20th century. He was the first to perform intramedullary osteosynthesis of the femur. The rod he used was shaped like a trefoil.

But only towards the end of the century the technique of intramedullary osteosynthesis was developed and began to be widely used. Rods and other implants for locked osteosynthesis have been developed, which make it possible to firmly fix bone fragments. Depending on the purpose of use, they vary in shape, size and material. Some pins and rods allow them to be inserted into the bone without drilling out the canal, which reduces the traumatic nature of the operation. Modern rods for intramedullary osteosynthesis have a shape that follows the bends of the bone canal. They have a complex design that allows them to firmly fix the bone and prevent the fragments from moving. Rods are made from medical steel or titanium alloys.

This method is devoid of many disadvantages and complications of external structures. Now it is the most effective way to treat periarticular fractures, damage to the tubular bones of the leg, femur, shoulder, and in some cases even joints.

Indications and contraindications for use

This operation is performed for closed fractures of the femur, humerus, and tibia. These injuries may be transverse or oblique. It is possible to use such an operation if a false joint develops due to improper bone fusion. If the injury is accompanied by damage to soft tissues, it is advisable to postpone osteosynthesis, since there is a high risk of infection of the fracture site. In this case, the operation is more difficult to perform, but it will also be effective.

Intramedullary osteosynthesis is contraindicated only in complex open fractures with extensive soft tissue damage, as well as in the presence of an infectious skin disease in the place where the pin needs to be inserted. This operation is not used in elderly patients, since due to degenerative changes in bone tissue, additional introduction of metal pins can cause complications.

Some diseases can also become an obstacle to intramedullary osteosynthesis. These are arthrosis in a late stage of development, arthritis, blood diseases, purulent infections. The operation is not performed on children due to the small width of the bone canal.

Kinds

Intramedullary osteosynthesis refers to intraosseous surgery. In this case, the fragments are repositioned and fixed with a pin, rod or screws. Depending on the method of introducing these structures into the bone canal, intramedullary osteosynthesis can be closed or open.

Previously, the open method was most often used. It is characterized by exposing the damaged area of the bone. The fragments are compared manually, and then a special rod is inserted into the medullary canal to fix them. But the closed method of osteosynthesis is more effective. It only requires a small incision. Through it, a rod is inserted into the bone canal using a special guide. All this happens under the control of an X-ray machine.

The pins in the canal can be installed freely or with locking. In the latter case, they are additionally reinforced on both sides with screws. If osteosynthesis is performed without blocking, this increases the load on the bone marrow and increases the risk of complications. In addition, such fixation is not stable in case of oblique and helical fractures or under rotational loads. Therefore, it is more effective to use locking rods. Now they are produced with holes for screws. This operation not only firmly fixes even multiple fragments, but does not lead to compression of the bone marrow, which preserves its blood supply.

In addition, the operation differs in the method of inserting the rod. It can be introduced with preliminary drilling of the bone marrow canal, which leads to its injury. But recently, special thin rods are most often used, which do not require additional expansion of the channel.

There are even less common types of intramedullary osteosynthesis. Fragments can be fixed with several elastic rods. One straight and two rods curved opposite to each other are inserted into the bone. Their ends are bent. With this method, a plaster cast is not required. Another method was proposed in the 60s of the 20th century. The medullary canal is filled with pieces of wire so that it fills it tightly. It is believed that this method can provide more durable fixation of fragments.

When choosing the type of osteosynthesis, the doctor is guided by the patient’s condition, the type of fracture, its location and the severity of associated tissue damage.

Open osteosynthesis

This operation is more common because it is simpler and more reliable. But, like any other operation, it is accompanied by blood loss and disruption of the integrity of soft tissues. Therefore, complications occur more often after open intramedullary osteosynthesis. But the advantage of using this method is the possibility of using it in complex treatment together with various devices for transosseous fixation. Separately open intramedullary osteosynthesis is now used very rarely.

During the operation, the fracture area is exposed and bone fragments are compared manually without the use of devices. This is precisely the advantage of the method, especially when there are many fragments. After comparing the fragments, they are fixed with a rod. The rod can be inserted in one of three ways.

With direct insertion, it is necessary to expose another piece of bone above the fracture. In this place, a hole is punched along the medullary canal and a nail is inserted into it, using it to compare the fragments. With retrograde insertion, they begin with the central fragment, comparing it with the rest, gradually driving the nail into the medullary canal. It is possible to insert the rod along the conductor. In this case, it also starts from the central fragment.

With intramedullary osteosynthesis of the femur, the alignment of the fragments is usually so strong that the application of plaster is not required. If surgery is performed on the lower leg, forearm or humerus, it usually ends with the application of a plaster cast.

Closed osteosynthesis

This method is now considered the most effective and safe. After it is carried out, there are no traces left. Compared to other osteosynthesis operations, it has several advantages:

minor soft tissue damage;
little blood loss;
stable fixation of bones without intervention in the fracture zone;
short operation time;
rapid restoration of limb functions;
no need to cast the limb;
Possibility of use for osteoporosis.

The essence of the method of closed intramedullary osteosynthesis is that a pin is inserted into the bone through a small incision. The incision is made away from the fracture site, so complications are rare. First, using a special apparatus, the bone fragments are repositioned. The entire operation process is monitored using radiography.

Recently, this method has been improved. The fixing pins have holes on each edge. Screws are inserted into them through the bone, which lock the pin and prevent it and bone fragments from moving. This locked osteosynthesis ensures more efficient bone fusion and prevents complications. After all, the load during movement is distributed between the bone and the rod.

Fixation of the fracture site using this method is so strong that the very next day you can apply a dosed load to the injured limb. Performing special exercises stimulates the formation of callus. Consequently, the bone heals quickly and without complications.

A feature of locked intramedullary osteosynthesis is its higher efficiency compared to other treatment methods. It is indicated for complex fractures, combined injuries, and in the presence of many fragments. This operation can be used even in obese patients and patients with osteoporosis, since the pins that fix the bone are firmly attached in several places.

Complications

Negative consequences of intramedullary osteosynthesis are rare. They are mainly associated with the poor quality of the fixation rods, which can corrode or even break. In addition, the introduction of a foreign body into the bone marrow canal causes compression and disruption of blood supply. Bone marrow destruction may occur, causing a fat embolism or even shock. In addition, straight rods do not always correctly compare fragments of tubular bones, especially those that have a curved shape - tibia, femur and radius.

Recovery after surgery

The patient is allowed to move after closed intramedullary osteosynthesis within 1-2 days. Even with lower leg surgery, you can walk with crutches. In the first few days, severe pain in the injured limb is possible, which can be relieved with painkillers. The use of physiotherapeutic procedures is indicated to speed up healing. Be sure to perform special exercises, first under the guidance of a doctor, then on your own. Recovery usually takes from 3 to 6 months. The operation to remove the rod is even less traumatic than osteosynthesis itself.

The effectiveness of bone fixation depends on the type of injury and the correctness of the method chosen by the doctor. Fractures with smooth edges and a small number of fragments heal best. The effectiveness of the operation also depends on the type of rod. If it is too thick, there may be complications due to compression of the spinal cord. A very thin rod does not provide a strong hold and may even break. But now such medical errors are rare, since all stages of the operation are controlled by special equipment, which provides for all possible negative aspects.

In most cases, patient reviews of intramedullary osteosynthesis surgery are positive. After all, it allows you to quickly return to normal life after injury, rarely causes complications and is well tolerated. And the bone heals much better than with conventional treatment methods.