Fracture of the capitate eminence of the humerus. Kaplan Damage to bones and joints. A. V. Kaplan bone damage and capitate eminence of the humerus anatomy

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The anatomical features of the structure of the skeletal system of children and its physiological properties determine the occurrence of certain types of fractures that are characteristic only of this age.

It is known that young children often fall during outdoor play, but they rarely experience bone fractures.

This is explained by the child’s lower body weight and well-developed soft tissue cover, and therefore by a weakening of the impact force during a fall.

Baby bones thinner and less durable, but more elastic than adult bones. Elasticity and flexibility depend on the smaller amount of mineral salts in the child’s bones, as well as on the structure of the periosteum, which in children is thicker and richly supplied with blood. The periosteum forms a kind of sheath around the bone, which gives it greater flexibility and protects it from injury.

The preservation of bone integrity is facilitated by the presence of epiphyses at the ends of the tubular bones, connected to the metaphyses by wide elastic growth cartilage, which weakens the force of impact. These anatomical features, on the one hand, prevent the occurrence of a bone fracture, on the other hand, in addition to the usual fractures observed in adults, they cause the following skeletal injuries typical for childhood: fractures, subperiosteal fractures, epiphysiolysis, osteoepiphysiolysis and apophysiolysis.

Breaks and fractures like a green branch or a willow twig are explained by the flexibility of bones in children.

This type of fracture is observed especially often when the diaphysis of the forearm is damaged. In this case, the bone is slightly bent, on the convex side the outer layers are subject to fracture, and on the concave side they retain their normal structure.

Subperiosteal fractures are characterized by the fact that the broken bone remains covered by the periosteum, the integrity of which is preserved. These injuries occur when force is applied along the longitudinal axis of the bone. Most often, subperiosteal fractures are observed on the forearm and lower leg; In such cases, bone displacement is absent or very insignificant.

Epiphysiolysis and osteoepiphysiolysis are traumatic separation and displacement of the epiphysis from the metaphysis or with part of the metaphysis along the line of the germinal epiphyseal cartilage.

They occur only in children and adolescents until the end of the ossification process (Fig. 14.1).

Epiphysiolysis occurs more often as a result of the direct action of force on the epiphysis and, according to the mechanism of injury, is similar to dislocations in adults, which are rarely observed in children. This is explained by the anatomical features of the bones and ligamentous apparatus of the joints, and the place of attachment of the articular capsule to the articular ends of the bone is of significant importance.

Epiphyseolysis and osteoepiphysiolysis are observed where the joint capsule is attached to the epiphyseal cartilage of the bone: for example, the wrist and ankle joints, the distal epiphysis of the femur. In places where the bursa is attached to the metaphysis so that the growth cartilage is covered by it and does not serve as a place for its attachment (for example, the hip joint), epiphysiolysis does not occur. This position is confirmed by the example of the knee joint.

Here, during injury, epiphysiolysis of the femur occurs, but there is no displacement of the proximal epiphysis of the tibia along the epiphyseal cartilage.

Apophysiolysis - separation of the apophysis along the line of the growth cartilage

Apophyses, unlike epiphyses, are located outside the joints, have a rough surface and serve for attachment of muscles and ligaments. An example of this type of injury is displacement of the medial or lateral epicondyle of the humeral csti. With complete fractures of the bones of the extremities with displacement of bone fragments, the clinical manifestations are practically no different from those in adults.

At the same time, with fractures, subperiosteal fractures, epiphysiolysis and osteoepiphysiolysis without displacement, movements can be preserved to a certain extent, pathological mobility is absent, the contours of the injured limb that the child is sparing remain unchanged and only upon palpation is pain determined in a limited area corresponding to the fracture site. In such cases, only x-ray examination helps to make the correct diagnosis.

A feature of bone fractures in a child is an increase in body temperature in the first days after injury from 37 to 38°C, which is associated with absorption of the contents of the hematoma.

In children, it is difficult to diagnose subperiosteal fractures, epiphysiolysis and osteoepiphysiolysis without displacement. Difficulty in establishing a diagnosis also arises with epiphysiolysis in newborns and infants, since even radiography does not always provide clarity due to the absence of ossification nuclei in the epiphyses.

In young children, most of the epiphysis consists of cartilage and is passable for x-rays, and the ossification nucleus gives a shadow in the form of a small dot. Only when compared with a healthy limb on radiographs in two projections is it possible to establish the displacement of the ossification nucleus in relation to the diaphysis of the bone.

Similar difficulties arise during birth epiphysiolysis of the heads of the humerus and femur, the distal epiphysis of the humerus, etc. At the same time, in older children, osteoepiphysiolysis without displacement is easier to diagnose, since radiographs show a separation of the bone fragment of the metaphysis of the tubular bone.

Errors in diagnosis are more often observed with fractures in young children. Insufficient medical history, well-defined subcutaneous tissue making palpation difficult, and the absence of displacement of fragments in subperiosteal fractures make recognition difficult. Often, in the presence of a fracture, a bruise is diagnosed.

As a result of improper treatment in such cases, curvature of the limb and impairment of its function are observed. In some cases, a repeat X-ray examination performed on days 7-10 after injury helps clarify the diagnosis, which becomes possible due to the appearance of initial signs of fracture consolidation.

The leading principle is a conservative method of treatment (94%).

In most cases, a fixing bandage is applied. Immobilization is carried out with a plaster splint, usually in the average physiological position, covering 2/3 of the circumference of the limb and fixing two adjacent joints. A circular plaster cast is not used for fresh fractures in children, since there is a risk of circulatory disorders due to increasing edema with all the ensuing consequences (Volkmann’s ischemic contracture, bedsores and even necrosis of the limb).

During treatment, periodic x-ray monitoring (once a week) of the position of bone fragments is necessary, since secondary displacement of bone fragments is possible. Traction is used for fractures of the humerus, shin bones and mainly for fractures of the femur. Depending on the age, location and nature of the fracture, adhesive plaster or skeletal traction is used.

The latter is used in children over 3 years of age. Thanks to traction, displacement of the fragments is eliminated, gradual reposition is carried out and the bone fragments are held in the reduced position.

For bone fractures with displacement of fragments, one-stage closed reduction is recommended as early as possible after the injury.

In particularly difficult cases, reposition is performed under periodic X-ray control with radiation protection for the patient and medical personnel. Maximum shielding and minimal exposure allows for repositioning under visual control.

The choice of pain relief method is of no small importance.

Good anesthesia creates favorable conditions for repositioning, since the comparison of fragments should be done in a gentle way with minimal tissue trauma. These requirements are met by anesthesia, which is widely used in hospital settings.

In outpatient practice, reposition is performed under local or regional anesthesia. Anesthesia is carried out by injecting a 1% or 2% novocaine solution into the hematoma at the fracture site (at the rate of 1 ml per one year of the child’s life). When choosing a treatment method for children and establishing indications for repeated closed or open reduction, the possibility of self-correction of some types of remaining displacements during growth is taken into account.

The degree of correction of the damaged limb segment depends both on the age of the child and on the location of the fracture, the degree and type of displacement of the fragments.

At the same time, if the growth zone is damaged (during epiphysiolysis), as the child grows, a deformation may appear that was not there during the treatment period, which should always be remembered when assessing the prognosis (Fig. 14.2). Spontaneous correction of the remaining deformity occurs the better, the younger the patient is.

The leveling of displaced bone fragments in newborns is especially pronounced.

In children under 7 years of age, displacements for diaphyseal fractures are allowed in the length range from 1 to 2 cm, in width - almost across the diameter of the bone and at an angle of no more than 10°. At the same time, rotational displacements cannot be corrected during growth and should be eliminated.

In children of the older age group, more accurate adaptation of bone fragments is necessary and it is necessary to eliminate deflections and rotational displacements. In case of intra- and periarticular fractures of the bones of the extremities, accurate reduction is required with the elimination of all types of displacement, since unresolved displacement of even a small bone fragment during an intra-articular fracture can lead to blockade of the joint or cause varus or valgus deviation of the limb axis.

Surgical intervention for bone fractures in children is indicated in the following cases:

1) for intra- and periarticular fractures with displacement and rotation of the bone fragment;
2) with two or three attempts at closed reduction, if the remaining displacement is classified as unacceptable;
3) with interposition of soft tissues between fragments;
4) with open fractures with significant damage to soft tissues;
5) in case of improperly healed fractures, if the remaining displacement threatens permanent deformation, curvature or stiffness of the joint;
6) for pathological fractures.

Open reduction is performed with special care, gentle surgical access, with minimal trauma to soft tissues and bone fragments and is completed mainly by simple methods of osteosynthesis.

Complex metal structures are rarely used in pediatric traumatology. Most often, a Kirschner wire is used for osteosynthesis, which, even when carried out transepiphyseally, does not have a significant effect on bone growth in length. The Bogdanov rod, CITO, Sokolov nails can damage the epiphyseal growth cartilage and therefore are used for osteosynthesis for diaphyseal fractures of large bones.

For improperly fused and improperly fused bone fractures, false joints of post-traumatic etiology, compression-distraction devices of Ilizarov, Volkov-Oganesyan, Kalnberz, etc. are widely used.

The time frame for consolidation of fractures in healthy children is shorter than in adults. In weakened children suffering from rickets, hypovitaminosis, tuberculosis, as well as with open injuries, the periods of immobilization are extended, since the reparative processes in these cases are slowed down (Table 14.1).

With insufficient duration of fixation and early loading, secondary displacement of bone fragments and re-fracture are possible. Ununited fractures and pseudarthrosis in childhood are an exception and, with proper treatment, usually do not occur.

Delayed consolidation of the fracture area can be observed with insufficient contact between fragments, interposition of soft tissues, and with repeated fractures at the same level.

After the onset of consolidation and removal of the plaster splint, functional and physiotherapeutic treatment is indicated mainly for children with intra- and periarticular fractures, especially when movement in the elbow joint is limited. Physical therapy should be moderate, gentle and painless.

Massage near the fracture site, especially with intra- and periarticular injuries, is contraindicated, since this procedure promotes the formation of excess callus and can lead to myositis ossificans and partial ossification of the joint capsule.

Children who have suffered an injury near the epimetaphyseal zone require long-term follow-up (up to 1.5-2 years), since the injury does not exclude the possibility of damage to the growth zone, which can subsequently lead to limb deformity (post-traumatic deformity of the Madelung type, varus or valgus deviation of the limb axis, segment shortening, etc.).

Birth damage

Birth trauma includes injuries received during childbirth, as well as during the provision of manual assistance and revival of a child born in asphyxia.

More often, newborns experience fractures of the collarbone, fractures of the femur and humerus, and damage to the skull and brain. Fractures of the bones of the forearm and lower leg are extremely rare.

Clavicle fracture

In newborns, clavicle fracture occurs most often and is usually caused by pathological childbirth. Damage is possible during spontaneous childbirth in cephalic presentation, narrow pelvis, early rupture of water, etc.

The fracture is usually localized in the middle third of the diaphysis and can be complete or incomplete (subperiosteal). In the area of the fracture there is slight swelling due to edema, hematoma, displacement of fragments and pathological mobility. In case of complete fractures, the child holds the arm in a forced position and does not move it, which gives rise to an erroneous diagnosis of Erb's palsy due to damage to the brachial plexus.

The most consistent sign of a clavicle fracture in newborns is crepitus of the fragments. With subperiosteal fractures, the diagnosis is often made at the end of the 1st week of the child’s life, when a large callus appears in the clavicle area.

Fractures of the humerus and femur in children

Such fractures are a consequence of obstetric care for foot or pelvic presentation of the fetus. Typical localization is in the middle third of the diaphysis of the tubular bone; along the plane, the fracture runs in a transverse or oblique direction.

Traumatic epiphysiolysis of the proximal and distal ends of the humerus and femur are rare. This circumstance, as well as the fact that X-ray diagnostics are difficult due to the absence of ossification nuclei, often lead to untimely diagnosis of these injuries.

In diaphyseal fractures of the humerus and femur with complete displacement of bone fragments, pathological mobility at the level of the fracture, deformation, traumatic swelling and crepitus are noted. Any manipulation causes pain to the child. Fractures of the femur are characterized by a number of features: the leg is in the typical position of flexion in the knee and hip joints for a newborn and is brought to the abdomen due to physiological hypertension of the flexor muscles. Radiography clarifies the diagnosis.

There are several treatment options for newborns with diaphyseal fractures of the humerus and femur.

In case of a fracture of the humerus, the limb is immobilized for a period of 10-14 days. The arm is fixed with a plaster splint from the edge of the healthy scapula to the hand in the average physiological position or with a cardboard U-shaped splint in the position of shoulder abduction to 90°.

After immobilization, movement in the injured limb is restored in the near future without additional procedures and manipulations. For femur fractures in newborns, Schede traction is most effective. The immobilization period is the same. When monitoring the position of fragments, one should take into account the degree of permissible displacement of bone fragments (displacement in length up to 2-3 cm, in width - the full diameter of the bone, at an angle - no more than 25-30°), since self-correction and leveling will occur as they grow remaining offset; rotational displacements are not eliminated.

Traumatic epiphysiolysis in newborns has a typical picture and is more pronounced the more the fragments are displaced. Generic epiphysiolysis of the distal end of the humerus is often accompanied by paresis of the radial or median nerve.

X-ray diagnosis is practically impossible due to the lack of bone tissue in the area of the epiphyses, and only by the end of the 7-10th day on repeated X-rays can you see the callus and retrospectively decide on the nature of the former fracture.

The most typical mistake in this pathology is that a traumatic dislocation of the forearm bones is diagnosed and an attempt is made to reduce it, which, naturally, is doomed to failure. Treatment consists of one-stage closed reposition “by eye” followed by fixation in a light plaster splint in an average physiological position. At follow-up, a varus deviation of the forearm axis may be noted due to internal rotation of the humeral condyle that was not eliminated during treatment.

With epiphysiolysis of the proximal end of the femur, a differential diagnosis is made with congenital hip dislocation.

The injury is characterized by swelling, significant pain when moving, and possible bruising. Good results in the treatment of newborns with this injury are obtained by using a spacer splint. Immobilization period: 4 weeks With epiphysiolysis of the distal end of the femur in newborns, severe swelling and deformation in the knee joint are observed. During the examination, the characteristic “click” symptom is determined.

X-ray reveals a displacement of the ossification nucleus of the distal epiphysis of the femur, which facilitates diagnosis and allows the position of fragments to be monitored after reposition. The timing of clinical observation of children who have suffered a birth injury depends on the severity and location of the injury, but by the end of the first year of life it is possible, in principle, to resolve the issue of the outcome of the injury received at birth.

Clavicle fractures

Clavicle fractures are one of the most common bone injuries in childhood and account for about 15% of extremity bone fractures, second in frequency only to fractures of the forearm and humerus.

In children, a clavicle fracture is caused by indirect trauma from a fall on an outstretched arm, on the shoulder or elbow joint. Less commonly, a clavicle fracture is caused by direct trauma—a direct blow to the collarbone. More than 30% of all clavicle fractures occur between the ages of 2 and 4 years.

With incomplete clavicle fractures, deformation and displacement are minimal.

The function of the arm is preserved, only its abduction above the level of the shoulder girdle is limited. Subjective complaints of pain are minor, so such fractures are sometimes not identified and the diagnosis is made only after 7-14 days, when a callus is detected in the form of a thickening on the collarbone. For fractures with complete displacement of fragments, the diagnosis is not difficult.

Clavicle fractures heal well, and function is fully restored with any treatment method, but the anatomical result may vary. Angular curvature and excess callus under the influence of growth disappear over time almost without a trace.

In most cases, a Deso-type bandage is sufficient to fix fragments for the entire period of treatment. For fully displaced fractures in older children, stronger fixation is required with the shoulder retracted and the external clavicle fragment elevated. This is achieved using an eight-shaped fixing bandage or a Kuzminsky-Karpenko crutch-plaster cast.

Surgical treatment is used extremely rarely and is indicated only when there is a threat of perforation by a skin fragment, trauma to the neurovascular bundle and interposition of soft tissues.

Scapula fractures

Scapula fractures are very rare in children. They arise as a result of direct trauma (falling on your back, blow, car injury, etc.). The most common fracture is the neck of the scapula, then the body and acromion. Fractures of the glenoid cavity, angle of the scapula, and coracoid process are exceptions. There is almost no displacement of fragments.

A characteristic feature of scapula fractures is swelling, clearly demarcated, repeating the shape of the scapula (Comolli’s “triangular cushion” symptom).

This is caused by subfascial hemorrhage over the body of the scapula as a result of damage to the vessels supplying the scapula. Multiaxial radiography clarifies the diagnosis. Treatment consists of immobilization in a Deso-type bandage.

Rib fractures

Due to the high elasticity of the rib frame, rib fractures are not common in children. They are observed when the traumatic agent is of significant force (fall from a height, transport injury, etc.).

The diagnosis is made on the basis of clinical manifestations and X-ray data. The child accurately indicates the location of the injury. Careless movements increase the pain.

Slight cyanotic skin, shortness of breath, and shallow breathing are noted due to fear of increased pain. Compression of the chest during the examination also causes pain to the child, so you should not resort to palpation if the patient reacts negatively.

Treatment of patients with uncomplicated rib fractures consists of intercostal novocaine blockade along the paravertebral line on the affected side, anesthesia of the fracture with a 1-2% novocaine solution and injection of a 1% pantopon solution in an age-specific dosage (0.1 ml per year of the child’s life, but not more than 1 ml ).

In case of severe symptoms of pleuropulmonary shock, it is advisable to perform a vagosympathetic blockade on the affected side according to Vishnevsky. Immobilization is not required, since tight bandaging of the chest limits the excursion of the lungs, which negatively affects the recovery period (complications such as pleurisy and pneumonia are possible).

With a direct and strong impact on the chest, multiple rib fractures may occur in combination with damage to internal organs.

Significant ruptures of lung tissue and damage to blood vessels are accompanied by severe bleeding into the pleural cavity, which leads to death.

Damage to the bronchi, causing tension pneumothorax, is also dangerous. The continued flow of air into the pleural cavity collapses the lung, displaces the mediastinum, and mediastinal emphysema develops. Bulau drainage or active aspiration are advisable for minor injuries to the lungs and bronchi. In case of bronchial ruptures, increasing hemopneumothorax, or open injury, urgent surgical intervention is indicated.

Sternum fractures

Sternal fractures in children are rare. They are possible with a direct blow to the sternum area. The most common site of injury is the junction of the manubrium of the sternum with the body.

When fragments are displaced, sharp pain can cause pleuropulmonary shock. X-ray examination of the chest only in a strictly lateral projection allows us to identify the location of the fracture and the degree of displacement of the bone fragment.

Local anesthesia of the damaged area is effective, and in cases of pleuropulmonary shock - vagosympathetic blockade according to Vishnevsky. If there is a significant displacement of bone fragments, a closed reduction is performed or, according to indications, surgical intervention with fixation of the fragments with suture material.

Humerus fractures

Depending on the location, there are fractures of the humerus in the area of the proximal metaepiphysis, diaphyseal fractures and in the area of the distal metaepiphysis.

Typical types of damage to the proximal end of the humerus in children are fractures in the area of the surgical neck, osteoepiphysiolysis and epiphysiolysis, with typical displacement of the distal fragment outward with an angle open inward.

In fractures with displacement of bone fragments, the clinical picture is typical: the arm hangs along the body and the abduction of the limb is sharply limited; pain in the shoulder joint, swelling, tension in the deltoid muscle; with significant displacement (abduction fracture), a peripheral fragment is palpated in the axillary fossa. X-rays are performed in two (!) projections.

When indicated, reposition is usually performed in a hospital setting under general anesthesia and periodic monitoring of an X-ray screen. After reduction for abduction fractures, the arm is fixed in the average physiological position. In case of an adduction fracture with displacement of fragments, it is not always possible to compare bone fragments using conventional reposition, and therefore it is advisable to use the method developed by Whitman and M.V. Gromov.

During the reposition process, one of the assistants fixes the shoulder girdle, and the other carries out constant traction along the length of the limb, moving the arm upward as much as possible. At this time, the surgeon places the fragments in the correct position, pressing on their ends (be careful - the neurovascular bundle!).

The arm is fixed with a plaster splint, which goes onto the torso, in the position in which the correct position of the fragments was achieved (Fig. 14.3).

The duration of fixation in a plaster splint is 2 weeks (the time required for the formation of primary callus). On the 14-15th day, the thoracobrachial bandage is removed, the arm is transferred to the mid-physiological position and a plaster splint is again applied for 2 weeks (a total immobilization period of 28 days). Against the background of physical therapy and physiotherapy, movements in the shoulder joint are restored in the next 2-3 weeks.

In case of epiphysiolysis and osteoepiphysiolysis with significant damage to the growth zone in the long term, impaired bone growth in length can be caused. Dispensary observation is carried out for 1.5-2 years.

Humeral shaft fractures are uncommon in children.

The clinical picture is typical.

Fractures in the middle third of the humerus are dangerous due to possible damage to the radial nerve, which bends around the humerus at this level. Displacement of fragments can cause traumatic paresis or, in severe cases, disruption of the integrity of the nerve. In this regard, all manipulations for a fracture in the middle third of the diaphysis of the humerus must be performed with extreme caution.

The method of one-stage closed reduction followed by fixation in a plaster splint or the method of skeletal traction of the proximal metaphysis of the ulna is used, which gives the best result. If, during subsequent X-ray monitoring, secondary displacement of the fragments is detected, then it is eliminated by applying corrective rods. Pay attention to the correctness of the axis of the humerus, because displacement of bone fragments along the length of up to 2 cm is well compensated, while angular deformations during growth are not eliminated.

Fractures of the distal humerus are common in children.

They account for 64% of all humerus fractures.

For diagnosing injuries in the area of the distal metaepiphysis of the humerus, the most convenient is the classification proposed by G. A. Bairov in 1960 (Fig. 14.4).

Transcondylar and supracondylar fractures of the humerus are not uncommon in children.

The fracture plane in transcondylar injuries passes through the joint and is accompanied by rupture of the articular capsule and capsular-ligamentous apparatus (95% of all injuries). In supracondylar fractures, the fracture plane passes through the distal metaphysis of the humerus and does not penetrate the joint cavity (5%). The mechanism of injury is typical - a fall on an arm extended or bent at the elbow joint.

Displacement of the distal fragment of the humerus can be in three planes: anteriorly (with a flexion trans- or supracondylar fracture), posteriorly (with an extension fracture), outward - to the radial side or inward - to the ulnar side; rotation of the fragment around its axis is also noted. With significant displacement, disruption of innervation may occur as a result of injury to the ulnar, radial, transcondylar fractures of the humerus or median nerve.

It is important to promptly identify peripheral circulatory disorders. The pulse in the radial and ulnar arteries may be absent for 4 reasons: due to post-traumatic spasm of arterial vessels, compression of the arterial vessel by a bone fragment or increasing edema and hematoma, and rupture of the neurovascular bundle (the most serious complication).

For trans- and supracondylar fractures of the humerus with displacement, conservative treatment is used in the vast majority of cases.

Closed reduction is performed under general anesthesia and periodic X-ray monitoring. The introduction of novocaine into the fracture area does not provide sufficient anesthesia and muscle relaxation, which makes it difficult to manipulate the fragments and keep them in the reduced position.

After a good comparison of bone fragments, monitoring the pulse is mandatory, since compression of the brachial artery by edematous soft tissue is possible. After reposition, a deep posterior plaster splint is applied in the position of the arm in which it was possible to fix the bone fragments.

In case of significant swelling and failure of one-stage closed reduction, it is advisable to use the method of skeletal traction for the proximal metaphysis of the ulna with a load of 2 to 3 kg. If the fracture is unstable (more often observed with an oblique plane), you can use percutaneous fixation of bone fragments according to K. Papp (diafixation) or percutaneous osteosynthesis with crossed Kirschner wires according to the Judet technique.

If conservative treatment fails and there is unacceptable displacement of the fragments, open reduction may be necessary.

The operation is performed in extreme cases: with repeated unsuccessful attempts at closed reduction, with interposition of the neurovascular bundle between fragments with the threat of the formation of Volkmann's ischemic contracture, with open and improperly healing fractures.

Among the complications that are possible with this type of fracture, it should be noted myositis ossificans and ossification of the joint capsule. They are observed in children who undergo repeated closed reductions, accompanied by the destruction of granulations and primary callus. According to N.G. Damier, ossification of the joint capsule most often develops in children with a tendency to form keloid scars.

If internal rotation and inward displacement of the distal fragment of the humerus are not corrected during treatment, they lead to varus deformity of the elbow joint.

When the forearm axis deviates by 15° in girls and 20° in boys, a corrective transcondylar wedge osteotomy of the humerus is indicated.

It is performed no earlier than 1-2 years after the injury using the Bairov-Ulrich method (Fig. 14.5). Preliminary calculation of the volume of proposed bone resection is important. X-rays of two elbow joints are taken in strictly symmetrical projections.

The axis of the humerus and the axis of the forearm bones are drawn. Determine the value of the resulting angle a. The degree of physiological deviation of the forearm axis on the healthy arm is measured - angle /3, its value is added to the value of angle a and thus the angle of the proposed bone resection is determined.

The angle on the contourogram is plotted in the area of the distal metaphysis of the humerus at the level or slightly below the apex of the olecranon fossa.

The sides of the wedge should be as close to each other as possible. The stages of surgical intervention are presented in Fig. 14.6.

Fractures of the epicondyles of the humerus are typical injuries for childhood (most common in children from 8 to 14 years old).

They belong to apophyseolysis, since in most cases the fracture plane passes through the apophyseal cartilaginous zone. The most common avulsion of the medial epicondyle of the humerus occurs.

Its displacement is associated with tension on the medial collateral ligament and contraction of a large group of muscles attached to the epicondyle.

Often, separation of this epicondyle in children is combined with dislocation of the bones of the forearm in the elbow joint. When the capsular-ligamentous apparatus is ruptured, a displaced bone fragment can penetrate into the cavity of the elbow joint. In such a case, the apophysis is pinched in the humeroulnar joint; possible ulnar nerve paresis. The consequences of untimely diagnosis of a torn medial epicondyle embedded in the joint cavity can be severe: impaired articulation in the joint, stiffness, wasting of the muscles of the forearm and shoulder due to partial loss of arm function.

There are four ways to remove an osteochondral fragment from the joint cavity:
1) using a single-tooth hook (according to N. G. Damier);
2) reproducing the dislocation of the forearm bones with subsequent re-reduction (during manipulation, the fragment can be removed from the joint and reduced);
3) during surgery;
4) according to the method of V. A. Andrianov.

The method of closed extraction of the restrained medial epicondyle of the humerus from the cavity of the elbow joint according to Andrianov is as follows.

Under general anesthesia, the injured arm is held in an extended position and valgused at the elbow joint, which leads to widening of the joint space on the medial side. The hand is retracted to the radial side to stretch the forearm extensors.

With light rocking movements of the forearm and jerk-like pressure along the longitudinal axis of the limb, the medial epicondyle is pushed out of the joint, after which reposition is performed. If conservative reduction fails, open reduction with fixation of the medial epicondyle is indicated.

A fracture of the capitate eminence of the humerus (epiphysiolysis, osteoepiphysiolysis, epiphysis fracture) is an intra-articular fracture and most often occurs in children aged 4 to 10 years.

The damage is accompanied by rupture of the capsular-ligamentous apparatus, and the displacement of the bone fragment occurs outward and downward; Rotation of the capitate eminence up to 90° and even 180° is often observed. In the latter case, the bone fragment with its cartilaginous surface faces the fracture plane of the humerus. Such a significant rotation of a bone fragment depends, firstly, on the direction of the impact force and, secondly, on the traction of a large group of extensor muscles attached to the lateral epicondyle.

When treating children with a fracture of the capitate eminence of the humerus, one must strive for ideal adaptation of bone fragments.

Uncorrected displacement of the bone fragment disrupts articulation in the brachioradial joint, leading to the development of pseudarthrosis and contracture of the elbow joint.

In case of epiphysiolysis and osteoepiphysiolysis of the capitate eminence with slight displacement and rotation of the bone fragment up to 45-60°, an attempt is made at conservative reduction. During reposition (to open the joint space), the elbow joint is given a varus position, after which reduction is performed by applying pressure on the bone fragment from the bottom up and from the outside inwards.

If reposition is unsuccessful, and the remaining displacement threatens to cause permanent deformity and contracture, the need for surgical intervention arises. Open reduction is also indicated when the bone fragment is displaced and rotated by more than 60°, since an attempt at reduction in such cases is almost always unsuccessful. In addition, during unnecessary manipulations, existing damage to the capsular-ligamentous apparatus and adjacent muscles is aggravated, and the epiphysis and articular surfaces of the bones forming the elbow joint are unnecessarily injured.

Convenient surgical access to the elbow joint according to Kocher. After reposition, the bone fragments are fixed with two crossed Kirschner wires.

A good result is achieved using a compression device proposed by V. P. Kiselev and E. F. Samoilovich. Children who have suffered this injury are subject to clinical observation for 2 years, since damage to the growth zone with the formation of deformation in the later stages is possible.

Traumatology and orthopedics
Edited by corresponding member. RAMS
Yu. G. Shaposhnikova

. Fractures
condyles
brachial
bones
Transcondylar
fracture
And
epiphysiolysis
lower
pineal gland
brachial
bones
A transcondylar (extensor and flexion) fracture is an intra-articular fracture. It occurs when falling on an elbow bent at an acute angle.
The fracture plane has a transverse direction and passes directly above or through the epiphysis of the humerus. If the fracture line passes through the epiphyseal line, it is in the nature of epiphysiolysis. The lower epiphysis is displaced and rotated anteriorly along the epiphyseal line. The degree of displacement can be different, most often small. This fracture occurs almost exclusively in childhood and adolescence (G. M. Ter-Egiazarov, 1975).
Symptoms and recognition . There is swelling in the area of the elbow joint, and hemorrhage inside and around the joint. Active movements in the elbow joint are limited and painful, passive movements are painful, extension is limited. The symptoms are uncharacteristic, so a transcondylar fracture of the shoulder can easily be confused with a sprain of the ligamentous apparatus. In most cases, a transcondylar fracture is recognized only by radiographs, but even here difficulties arise when there is a slight displacement of the lower epiphysis. It should be taken into account that in children the lower epiphysis of the humerus is normally tilted slightly (10-20°) forward relative to the longitudinal axis of the humerus diaphysis. The forward tilt angle is individual, but never reaches
25°. To clarify the diagnosis, it is necessary to compare radiographs in the lateral projection of the injured arm and the healthy one. They must be made in identical and strict projections. Detection of displacement of the lower epiphysis is of great practical importance, since fusion in a displaced position leads to limited flexion, which is directly dependent on the degree of increase in the angle of inclination of the epiphysis.
Treatment. Reduction in children is performed under anesthesia. The surgeon places one palm on the extensor surface of the lower shoulder, and the other applies pressure back on the lower epiphysis of the shoulder from its flexor surface.
The forearm should be in an extended position. After reduction, the child’s arm, extended at the elbow joint, is fixed with a plaster splint for 8-
10 days. Then begin gradual movements in the elbow joint. Treatment can also be carried out with constant skeletal traction on the upper part of the ulna for 5-10 days. Then the traction is removed and a splint is applied with the forearm bent at a right angle at the elbow joint for 5-7 days (N. G. Damier, 1960).
In adults, transcondylar fractures are treated in the same way as supracondylar fractures.
Intercondylar
fractures
brachial
bones
This type of humerus fracture is intra-articular. T- and Y-shaped fractures occur under direct influence of great force on the elbow, for example, when falling on the elbow from a great height, etc. With this mechanism, the olecranon process splits the block from below and is inserted between the condyles of the shoulder. At the same time, a supracondylar flexion fracture occurs. The lower end of the humeral diaphysis also inserts between the split condyles, moves them apart and the so-called
T- and Y-shaped fractures of the humeral condyles. With this mechanism, sometimes the condyles of the shoulder and often the olecranon are crushed, or a fracture of the condyles is combined with a dislocation and fracture of the forearm. These fractures can be like

flexion and extension types. T- and Y-shaped fractures are less common in children than in adults. A fracture of both humeral condyles may be accompanied by damage to blood vessels, nerves and skin.
Symptoms and recognition. When both condyles are fractured, there is significant swelling and hemorrhage both around and inside the joint. The lower part of the shoulder is sharply increased in volume, especially in the transverse direction. Feeling the elbow joint in the area of the bony protrusions is very painful. Active movements in the joint are impossible; with passive ones, severe pain, bone crunching and abnormal mobility in the anteroposterior and lateral directions are observed. Without radiographs taken in two projections, it is impossible to have an accurate idea of the nature of the fracture.
It is important to diagnose damage to blood vessels and nerves in a timely manner.
Treatment. For non-displaced fractures in adults, a plaster cast is applied from the upper third of the shoulder to the base of the fingers. The elbow joint is fixed at an angle of 90-
100°, and the forearm is in an intermediate position between pronation and supination. A plaster cast is applied for 2-3 weeks. Treatment can be carried out using knitting needles with thrust pads enclosed in an arc, or a Volkov-articulated apparatus.
Oganesyan. In children, the arm is fixed in the same position with a plaster splint and suspended on a scarf. The splint is removed after 6-10 days. From the first days, active movements in the shoulder joint and fingers are prescribed. After removing the splint, the function of the elbow joint is well restored; in adults, there is sometimes a slight restriction of movement for 5-8 weeks. The patients' ability to work is restored after 4-6 weeks.
For the outcome of treatment of T- and Y-shaped fractures of the humeral condyles with displacement of fragments, good reposition of the fragments is extremely important. In adults, it is achieved by skeletal traction of the olecranon, which is carried out on an abduction splint or using a Balkan frame while the patient is in bed.
Having eliminated the displacement of the fragments along the length, on the same day or the next, the diverged condyles of the humerus are brought together by compressing them between the palms and applying a U-shaped plaster splint along the outer and inner surfaces of the shoulder. Based on the radiograph, you should ensure that the fragments are in the correct position. The traction is stopped on the 18-21st day and they begin dosed movements in the elbow joint, gradually increasing in volume, using a removable splint at first. Treatment can also be carried out using the Volkov-Oganesyan articulated compression-distraction apparatus. In this case, it is possible to begin movements in the elbow joint early.
In children, a single-stage reduction is usually performed under anesthesia, followed by fixation with a plaster splint. The hand is suspended on a scarf.
The elbow joint is immobilized at an angle of 100°. Movement in the elbow joint begins in children with displaced fractures after 10 days.
If reposition is unsuccessful, skeletal traction is indicated for the upper part of the ulnar spine with compression of the condyles for 2-3 weeks in adults and 7-10 days in children.
In some cases, if the fragments have been reduced, closed transosseous fixation with wires can be performed; then the traction is removed and a plaster splint is applied.
Massage, as well as violent and forced movements in the elbow joint are contraindicated, as they contribute to the formation of myositis ossificans and excess callus. Even with good alignment of the fragments, in cases of intra-articular fractures, restriction of movements in the elbow joint is often observed, especially in adults.
Surgical treatment. It is proven if the reduction of fragments using the described method fails or there are symptoms of a disorder of the innervation and blood circulation of the limb. The operation is performed under anesthesia. The incision is made longitudinally along

the middle of the extensor surface of the shoulder in the lower third. To avoid damage to the ulnar nerve, it is better to first isolate it and place it on a holder made of a thin rubber strip. The condyles should not be separated from the muscles and ligaments attached to them, otherwise their blood supply will be disrupted and necrosis of the condyle will occur. To connect fragments, it is better to use thin knitting needles with the ends brought above the skin (so that they can be easily removed) or left under the skin (Fig. 59). You can also use 12 thin nails or screws of appropriate length or bone pins. In children, in those rare cases when it is necessary to operate, the fragments are well held by thick catgut threads passed through holes drilled or made with an awl in the bone. A plaster splint is placed on the shoulder and forearm, bent at an angle of 100°, along the extensor surface and the arm is suspended on a scarf. The needles are removed after 3 weeks. Movement in the elbow joint in adults begins after 3 weeks, in children – after 10 days.
In case of improperly healed fractures, severe limitation of movements, ankylosis of the elbow joint, especially in a functionally disadvantageous position, arthroplasty is performed in adults. In children, resection of the elbow joint and arthroplasty are not indicated due to possible growth arrest of the limb. Surgery should be delayed until adulthood. In elderly and senile patients with intra-articular fractures, they are limited to placing the limb in a functionally advantageous position and functional treatment.
Fracture
outdoor
condyle
brachial
bones
Fracture of the external condyle is not uncommon, especially common in children under 15 years of age.
A fracture occurs as a result of a fall on the elbow or hand of an extended and abducted limb. The head of the radius, resting against the capitate eminence of the humerus, breaks off the entire external condyle, epiphysis and a small piece of the adjacent part of the block.
The articulating surface of the capitate eminence remains intact.
The fracture plane has a direction from below and inwards, outwards and upwards and always penetrates into the joint.
Along with fractures without displacement, fractures with a slight shift of the condyle outward and upward are observed. A more severe form is a fracture, in which the broken condyle moves outward and upward, slips out of the joint and rotates in the horizontal and vertical planes (90-180°) with the inner surface outward. Slight lateral displacement without rotation of the fragment does not prevent fusion and preservation of full function. When the fragment rotates, fibrous fusion occurs. Cubitus valgus is often observed with subsequent involvement of the ulnar nerve.
Symptoms and recognition. A nondisplaced fracture of the lateral condyle of the humerus is difficult to recognize. There is hemorrhage and swelling in the area of the elbow joint.
When the condyle is displaced upward, the external epicondyle stands higher than the internal one.
The distance between the external epicondyle and the olecranon process is greater than between it and the internal epicondyle (normally it is the same). Pressure on the lateral condyle causes pain. Sometimes it is possible to palpate the displaced fragment and determine the bone crunch. Flexion and extension of the elbow joint are preserved, but rotation of the forearm is sharply painful. When the lateral condyle is fractured with displacement, the physiological valgus position of the elbow, especially pronounced in children and women
(10-12°), increases. The forearm is in an abducted position and can be forcefully adducted. To recognize a fracture, radiographs taken in two projections are of great importance; Without them it is difficult to make an accurate diagnosis.
Sometimes difficulties arise when interpreting radiographs in children. Cause

The point is that although the ossification nucleus of the external condyle can be seen in the 2nd year of life, the fracture line goes through the cartilaginous section, which is not visible on the image.
Treatment. Fractures of the lateral condyle without displacement are treated with a plaster cast, and in children with a splint, which is applied to the shoulder, forearm and hand. The elbow joint is fixed at an angle of 90-100°.
Rice. 59. Transcondylar comminuted fracture with large displacement of fragments before and after osteosynthesis with wires.
If there is an outward displacement of the fragment with a slight rotation of the broken condyle, reduction is performed under local or general anesthesia. Assistant

puts his hand on the inner surface of the patient’s elbow, with the other hand grabs his hand above the wrist joint, stretches it along the length and brings the forearm. In this way, a slight varus position of the elbow is created and the space in the outer half of the elbow joint is expanded. The surgeon places both thumbs on the fragment and pushes it upward and inward into its place. Next, he also places his hands on the anterior and posterior surfaces of the condyles of the shoulder, then on the lateral surfaces and squeezes them. The piece is gradually bent to a right angle; After this, the surgeon compresses the condyles again and applies a plaster cast to the shoulder, forearm and hand. The elbow is fixed at an angle of 100°, and the forearm is fixed in a position intermediate between pronation and supination. If the control radiograph shows that it was not possible to reduce the fragment, surgical reduction is indicated. If the reposition is successful, the plaster cast is removed in adults after 3-4 weeks, and the plaster splint in children is removed after 2 weeks. In some cases, despite good reduction of fragments and timely movement of the elbow joint, there remains varying degrees of limitation of flexion and extension in it.
In order to be able to start movements in the elbow joint early, it is advisable to use closed osteosynthesis using knitting needles with thrust pads enclosed in an arch, or use the Volkov-Oganesyan articulated compression-distraction apparatus.
Surgical reduction is performed under intraosseous and local anesthesia or general anesthesia. An incision is made along the outer posterior surface of the humeral condyle (it must be borne in mind that the radial nerve is located more anteriorly). Blood clots and soft tissue embedded in the fragment bed are removed.
To avoid avascular aseptic necrosis, one must try not to damage or separate the fragment from the soft tissues with which it is connected, since the blood supply to the fragment is carried out through them.
In most cases, the fragment is easily reduced when the elbow is extended and, if the elbow is then bent, it is held in place. The fragment can also be fixed by passing a catgut suture through soft tissue or through holes drilled with a drill or awl in the fragment and the humerus. In adults, the fragment can be fixed with a bone pin, wire, thin metal nail or screw. After this, the wound is sutured tightly and a plaster cast is applied to the shoulder and forearm, bent at the elbow joint. The forearm is given a position intermediate between pronation and supination. In adults, the plaster cast is removed after 3-4 weeks, and in children, the splint is removed after 2 weeks. Further treatment is the same as for fractures without displacement or after manual reduction.
A number of authors (A.L. Polenov, 1927; N.V. Shvarts, 1937; N.G. Damier, 1960, etc.) observed good results after removal of the lateral condyle for chronic fractures with limited movement. However, you should, if possible, avoid removing the lateral condyle of the shoulder, not only in fresh, but also in old cases, and strive to set the fragment. When the dislocated lateral condyle is unreduced, or after its removal, valgus elbow develops. This can cause the subsequent development (sometimes many years later) of neuritis, paresis or paralysis of the ulnar nerve due to overextension, permanent trauma and even pinching. In cases where symptoms of secondary damage to the ulnar nerve appear, there may be indications for moving it from the posterior groove of the epicondyle, anterior to it between the flexor muscles.
Fracture of the _internal_condyle_of_the_humerus">Fracture
internal
condyle
brachial
bones
Fracture of the internal condyle of the humerus is very rare. The mechanism of this fracture is associated with a fall and bruising of the elbow. The acting force is transmitted through

olecranon to condyle; in this case, the olecranon process is broken first, and not the internal condyle of the shoulder. A fracture can also occur due to a blow to the inner surface of the elbow. In children, a fracture of the internal condyle rarely occurs because the shoulder block remains cartilaginous until the age of 10-12 and, therefore, has great elasticity, which resists the force of a fall on the elbow.
Symptoms and recognition. There is hemorrhage, swelling in the area of the elbow joint, pain when pressing on the internal condyle, crepitus and other usual symptoms that were mentioned when describing fractures of the external condyles, but they are determined from the inside. The forearm can be adducted at the elbow joint, which cannot be done normally and with other fractures of the humeral condyles.
Treatment. Fractures of the internal condyle in adults are treated with skeletal traction on the upper part of the olecranon process on an abductor splint for 10-12 days, and then with a removable splint and movements in the elbow joint. For this purpose, you can use knitting needles with thrust pads, as well as the Volkov-Oganesyan articulated compression-distraction apparatus.
Fracture
capitate
elevation
brachial
bones
Damage to the capitate eminence of the humerus can be isolated or combined with a fracture of the head of the radius and other intra-articular fractures. The mechanism of isolated fracture is associated with a fall on an outstretched arm.
The head of the radius, moving upward and anteriorly, injures the articular surface of the capitate eminence articulating with it. Damage to it may be limited to depression of the cartilage in a limited area of the articular surface or separation of a small cartilaginous plate or bone fragment covered by cartilage. In some cases, a significant part of the capitate eminence and the adjacent articular block are broken off. The fragment moves anteriorly and upward.
Symptoms and recognition. In case of an isolated injury with the formation of a small osteochondral fragment and a fracture of a significant part of the capitate eminence, pain and hematoma are localized in the area of the lateral condyle. A larger fragment that has shifted anteriorly and upward can sometimes be felt in the elbow area. Movement in the elbow joint is limited and painful. For recognition, radiographs taken in anteroposterior and lateral projections are crucial. In some cases, small free fragments, often elliptical in shape, can be detected on an x-ray taken after introducing air into the elbow joint. A defect in the outer part of the capitate eminence, if the fragment is small, is sometimes not detected on an x-ray. Damage to the articular cartilage is observed more often in combination with a fracture of the radial head.
This combination is found mainly during operations for fractures of the head of the radial bone. If a small plate or osteocartilaginous fragment has separated from the capitate eminence, then when flexing and rotating the forearm, a free fragment between the articular surface of the head of the radius and the capitate eminence may occur, impeding movement, in the manner of entrapment of an articular muscle. This makes it easier to recognize damage to the capitate eminence.
If the fact of a fall on an outstretched arm is established and pain is noted when flexing and rotating the forearm, and the radiograph excludes a fracture, isolated damage to the cartilage of the capitate eminence of the shoulder can be suspected.
Isolated cartilage damage in the early stages after injury, as a rule, is not recognized. Only long-term pain, blockade of the elbow joint, limitation of movements,

pain during extension and rotation of the forearm, which arose after a fall on an outstretched arm, and, finally, an x-ray taken some time after the injury indicates the development of osteochondritis dissecans in the area of the articular surface of the capitate eminence and suggests that avascular necrosis is a consequence of cartilage contusion .

Damage to the capitate eminence of the humerus can be isolated or combined with a fracture of the head of the radius and other intra-articular fractures. The mechanism of isolated fracture is associated with a fall on an outstretched arm. The head of the radius, moving upward and anteriorly, injures the articular surface of the capitate eminence articulating with it. Damage to it may be limited to depression of the cartilage in a limited area of the articular surface or separation of a small cartilaginous plate or bone fragment covered by cartilage. In some cases, a significant part of the capitate eminence and the adjacent articular block are broken off. The fragment moves anteriorly and upward.

Symptoms and recognition. In case of an isolated injury with the formation of a small osteochondral fragment and a fracture of a significant part of the capitate eminence, pain and hematoma are localized in the area of the lateral condyle. A larger fragment that has shifted anteriorly and upward can sometimes be felt in the elbow area. Movement in the elbow joint is limited and painful. For recognition, radiographs taken in anteroposterior and lateral projections are crucial. In some cases, small free fragments, often elliptical in shape, can be detected on an x-ray taken after introducing air into the elbow joint. A defect in the outer part of the capitate eminence, if the fragment is small, is sometimes not detected on an x-ray. Damage to the articular cartilage is observed more often in combination with a fracture of the radial head. This combination is found mainly during operations for fractures of the head of the radial bone. If a small plate or osteocartilaginous fragment has separated from the capitate eminence, then when flexing and rotating the forearm, a free fragment between the articular surface of the head of the radius and the capitate eminence may occur, impeding movement, in the manner of entrapment of an articular muscle. This makes it easier to recognize damage to the capitate eminence.

If the fact of a fall on an outstretched arm is established and pain is noted when flexing and rotating the forearm, and the radiograph excludes a fracture, isolated damage to the cartilage of the capitate eminence of the shoulder can be suspected.

Isolated cartilage damage in the early stages after injury, as a rule, is not recognized. Only long-term pain, blockade of the elbow joint, limitation of movements,

Treatment . Small free, easily pinched intra-articular fragments of the outer part of the capitate eminence are removed surgically on the 2-5th day after the injury.

Rice. 60. Fracture of the capitate eminence with displacement (a). Surgical reduction and transarticular osteosynthesis with a wire (b).

A fracture of a significant part of the capitate eminence with anterior and upward displacement of the fragment in most cases can be reduced manually. 15-20 ml of 1% novocaine solution is injected into the fracture area. The patient lies on the table, the arm is extended at the elbow joint. The assistant grabs the forearm above the hand and stretches the elbow joint. The flexion surface of the arm should be facing upward. The surgeon places the bent leg on a stool, places his knee under the patient’s elbow and presses the fragment with two thumbs downwards and backwards into its bed. Then bend the elbow to a right angle and apply a plaster cast to the shoulder and forearm in a pronated position. In some cases, the fragment is better retained when the elbow is fully extended. If the control x-ray shows good alignment of the fragments, the plaster cast is left in this position for 3-4 weeks, after which movements in the elbow joint begin. Full restoration of function occurs only after 3-4 months. The time frame for restoration of working capacity depends on the patient’s profession and on which arm is injured – the right or left. These periods range from 2-4 months. If a control radiograph shows that the fragment could not be reduced, surgical reduction is indicated rather than removal of the fragment, since in the latter case the function of the joint often suffers. In children, the fragment is fixed to the bed with catgut sutures, and in adults, with 1-2 knitting needles, which are passed transarticularly - from the extensor surface through the external condyle into the reduced fragment of the capitate eminence into the radius (Fig. 60). The ends of the needles remain above the surface of the skin. The needles are removed after 2-3 weeks. In case of developed osteochondritis dissecans (Konig's disease) and repeated blockades, surgical removal of the separated section of cartilage is indicated.

Fracture and apophysiolysis of the internal epicondyle of the humerus

A fracture of the internal epicondyle occurs mainly with a sudden and strong abduction of the extended forearm. In this case, the internal collateral ligament is greatly strained and tears off the epicondyle, which usually moves downwards. In adolescence, with this mechanism, the epicondyle is separated along the apophyseal cartilaginous zone. This fracture is classified as periarticular. In some cases, the elbow joint bursa ruptures. Sometimes the epicondyle, torn off and connected to the internal collateral ligament, is pinched between the articular surfaces of the olecranon process and the shoulder trochlea and can pull the ulnar nerve with it.

A fracture can also occur with direct severe contusion of the internal epicondyle, which is sometimes accompanied by damage to the ulnar nerve located in the groove behind the epicondyle. Avulsions of the internal epicondyle are also observed with dislocations of the elbow joint.

Symptoms and recognition. In the area of the internal epicondyle, limited hematoma and swelling are visible, and pain is localized here. If the swelling is small, it is possible to palpate the movable fragment. Active and passive movements in the absence of hemorrhage in the elbow joint are possible and not very painful. When a fragment is pinched between the articular surfaces of the olecranon and the shoulder block, movement in the elbow joint is impossible and causes sharp pain. It is characteristic that against the normal forearm it is possible to abduct and give the elbow a valgus position. As soon as abduction stops, the forearm returns to its previous position. To recognize a fracture, radiographs in two projections are of great importance. The examination needs to determine whether there is damage to the ulnar nerve.

Treatment . For fractures or separation of the internal epicondyle along the apophyseal line without displacement and with displacement to the level of the joint space, a plaster cast is used, which fixes the elbow joint at a right angle, and the forearm in a position intermediate between pronation and supination. The bandage is removed after 12-20 days and movements in the elbow joint are prescribed. The prognosis is good even with displacement of the internal epicondyle. Working capacity is restored after 4-6 weeks.

If the internal epicondyle is pinched in the elbow joint, urgent surgical treatment is indicated. Sometimes it is possible to remove the fragment from the joint when the shoulder is abducted without resorting to surgery. But such a reduction is not advisable, since the ulnar nerve can be injured, and this is an extremely serious complication.

Surgical treatment. The operation should be performed immediately as soon as the insertion of the internal epicondyle into the elbow joint is recognized based on clinical and radiological studies. The intervention is performed under intraosseous, local or general anesthesia. An incision is made on the inside of the elbow joint. It must be remembered that the ulnar nerve runs somewhat posteriorly. After longitudinal dissection of the deep fascia and spreading the wound with hooks, the site of the epicondyle tear is exposed and it is discovered that the epicondyle, together with the soft tissues, has penetrated into the elbow joint. By expanding the inner part of the joint space by abducting the forearm, it is easy to pull the epicondyle with the soft tissues attached to it from the joint. The internal epicondyle is sutured to the bed by passing two catgut sutures through the soft tissue. It is better to move the ulnar nerve anterior to the internal epicondyle (normally it is located in the groove behind) - this prevents subsequent trauma to the nerve in the rough posterior groove and its compression in the ossifying soft tissues. The wound is sutured tightly and a plaster cast is applied to hold the elbow at a right angle. The bandage is removed after 3 weeks and movements in the elbow joint are prescribed. Working capacity is restored after 6-7 weeks.

Rice. 61. Infringement of the external epicondyle in the elbow joint together with

muscles attached to it before (a) and after (b) surgery.

Fracture and apophysiolysis of the lateral epicondyle of the humerus

A fracture of the external epicondyle is observed much less frequently than the internal one, occasionally in boys 13-15 years old. Occurs when there is a sudden strong adduction of the forearm in an extended position. More often, the external tank ligament is torn off along with a small bone plate from the external epicondyle of the shoulder. Avulsions of the lateral epicondyle with varying degrees of displacement are observed, including pinching between the articular surfaces of the lateral condyle of the humerus and the head of the radius.

Symptoms and recognition. The signs are the same as for a fracture of the internal epicondyle, but they are localized in the area of the external epicondyle. When the external epicondyle is torn off, the forearm in the elbow joint can be adducted, giving it a varus position, which immediately levels out as soon as the adduction stops. When the lateral epicondyle is displaced into the joint, a blockade is observed. X-ray examination, especially an anteroposterior radiograph, is of great importance for recognition.

Treatment . For fractures of the external epicondyle without displacement or with slight displacement, a plaster cast is applied for 10-20 days, and in children, a splint is applied to the elbow joint bent at a right angle. Then movements in the elbow joint are prescribed. Working capacity is restored after 4-5 weeks.

Surgical treatment. The operation is performed under local anesthesia. An incision is made externally above the epicondyle area. If the epicondyle is significantly displaced, suturing the fragment to the bed is indicated. In cases of entrapment of the lateral epicondyle in the elbow joint, the fragment is removed from the joint along with the muscles attached to it and sutured to the site of the avulsion (Fig. 61).

Volkmann's ischemic contracture

Ischemic contracture develops as a result of prolonged (measured in hours) and significant (but not complete) disruption of arterial blood flow in the limb. This complication occurs after injury to the extremities and can be caused by impaired blood flow at any level of the artery. The most common forms of ischemic contracture complicate trauma to the upper limb and are predominantly found in childhood. Typically, ischemic contracture develops with supracondylar and condylar fractures of the humerus and with fractures of the bones of the forearm. In most cases, ischemic contracture is observed with tightly applied circular plaster casts, leading to disruption of the blood supply to the limb. Compression of the neurovascular bundle can occur even with a correctly applied plaster cast, but with a subsequent increase in edema. This applies to those cases when observation of patients was insufficient: the plaster cast was not cut in a timely manner and was not loosened. Volkmann's contracture can be the result of a bruise, kinking or compression of the artery by displaced fragments, the result of spasm, thrombosis, embolism, partial or complete damage to the artery, the formation of an aneurysm, etc. Primary changes occur in the muscles (primarily the deep flexor of the digitorum), sensitive and motor nerves of the forearm (median, ulnar and anterior interosseous nerves of the forearm). Insufficient blood supply to the limb with any disturbance of blood flow is enhanced by a reflex spasm of the arteries and collaterals. The developing venous and capillary stasis contributes to increased swelling, pressure and tension in the soft tissues under the deep fascia of the shoulder and forearm, which further impairs the blood supply to the muscles and nerves.

Symptoms and recognition. The most important thing is that the diagnosis of developing ischemic contracture be made within the first 1-2 hours. The main signs are pain in the flexor muscles of the forearm, despite good reduction of the fragments. Usually, if there are no complications, pain after reduction decreases or disappears completely. An important symptom is pallor or cyanosis of the fingers. Constant signs are the disappearance of the pulse in the radial artery, increasing swelling and coldness of the limb. The sensitivity and movement of the fingers are gradually impaired, they take a flexion position. Any attempt to actively or passively straighten the fingers causes excruciating pain.

Treatment . If the symptoms mentioned above are present, immediate action must be taken. A delay of 2-3 hours can lead to irreversible changes. The plaster cast must be immediately cut along its entire length and removed, despite the fact that this may involve repeated displacement of the fragments. The forearm should be extended to PO-120° and a plaster splint fixed with a simple bandage should be applied, or the arm should be suspended using cutaneous traction in the same position. A case blockade according to Vishnevsky in the upper part of the shoulder is shown. The elbow and forearm are covered with ice packs. If in the next 1-2 hours the symptoms of circulatory disorders remain persistent or increase, you should proceed with the operation without unnecessary hesitation. A delay of 3-4 hours may be an irreparable mistake and lead to irreversible impairment of limb function.

An S-shaped incision is made in the elbow bend (Fig. 62), which begins at the inner edge of the biceps muscle and continues on the forearm to the wrist joint. The fascia and fibrous bridge are dissected. The biceps muscle is retracted outward, and the brachial artery and median nerve are examined. The hematoma is removed. Sometimes this is enough to improve blood supply to the limb. If the brachial artery is severely injured and noticeably narrowed, then the narrowed part over 3-4 cm should be resected, and the proximal and distal ends of the artery should be ligated. This is usually

relieves spasm of collateral vessels. Additionally, both superficial and deep fascia are dissected on the forearm and the intermuscular septa are pulled apart. Then only the skin is sutured. After conservative treatment, as well as after surgery, if the fragments have re-displaced, reposition begins no earlier than 2-3 weeks later.

Rice. 62. Surgery for developing Volkmann's contracture.

A – skin incision; b – dissection of the fibrous bridge in the elbow bend and dissection of the fascia “a” of the forearm; c – exposure of the brachial artery and median nerve – muscle separation.

Treatment of persistent ischemic contracture should be carried out comprehensively, including medication and physiotherapeutic measures, as well as therapeutic exercises both in the preoperative and postoperative periods. Among the surgical interventions, depending on the indications, transplants of the superficial flexors according to Kausch-Epstein-Rosov to the deep flexor tendons, neurolysis, removal of the proximal row of carpal bones, arthrodesis of the wrist joint, etc. are used.

Heterotopic traumatic ossification

This complication, also known as post-traumatic ossification or traumatic myositis ossificans, occurs in different areas of the skeleton. Most often, extraskeletal bone formation occurs after bruises, dislocations, fractures and fracture-dislocations of the elbow joint. This is favored by anatomical features, as well as proliferation of osteogenetic cells of the ruptured capsule, detached periosteum, perivascular tissue, damage to the brachial muscle and accumulation of blood.

Ossification is more often observed in children and young people. Appropriate treatment should limit bone formation and enhance bone resorption; otherwise, large bone masses are formed, which can significantly limit movement in the joint or even cause ankylosis. Complete rest (plaster immobilization) for at least 3-4 weeks, even if only soft tissue is damaged, is the main way to stop ossification. Repeated topical hydrocortisone may also be effective. After cessation of immobilization, active, painless and unforced movements are recommended. A contracture should never be removed by force. Massage of the elbow joint area is contraindicated. It is impossible to remove ossifications promptly in the phase of their active formation. If movements are noticeably limited, after the bone mass has matured and there are no signs of further ossification, removal of the ossification is indicated with measures taken against its recurrence (non-traumatic operation, avoidance of hematoma formation, rest, etc.).

Fracture of the capitate eminence of the humerus in children is intra-articular and most often occurs between the ages of 4 and 10 years. The fracture is usually associated with an indirect mechanism of injury, when a child falls on the outstretched hand and the main force of the impact is transferred to the elbow joint along the longitudinal axis of the radius. The head of this bone abuts the capitate eminence, breaks off part of the distal metaepiphysis of the humerus from the outside, and the bone fragment is displaced. If the fracture plane passes through the growth zone, then we are talking about epiphysiolysis of the capitate eminence of the humerus, however, “pure” epiphysiolysis is rare, and more often the epiphysis is separated from part of the metaphysis, while the fracture plane goes in an oblique direction through the distal metaepiphysis of the humerus.

Fracture of the capitate eminence of the humerus It is always intra-articular and is accompanied by tear or rupture of the articular capsule and hemorrhage into the joint. The displacement of a bone fragment depends on the force of the impact and occurs, as a rule, outward and downward (less often upward), and rotation of the capitate eminence from 60 to 180° is often observed. In the latter case, the bone fragment faces its cartilaginous surface towards the fracture plane of the humerus. Such a pronounced rotation of the bone fragment depends both on the force of the impact and on the traction of a large group of extensor muscles attached to the lateral epicondyle of the humerus.

Clinical picture of a fracture of the capitate eminence of the humerus

With a slight displacement of the bone fragment, traumatic swelling on the lateral side of the elbow joint, bruising, and significant pain on palpation are determined. The injured arm hangs along the body, and the child usually supports it with his healthy arm. In fractures with significant displacement, all of these symptoms are more pronounced, and, in addition, there may be an increase in the outward deviation of the axis of the forearm. Movements in the fingers are possible, but painful.

Innervation and peripheral circulation are rarely affected, but control of pulse, sensitivity and motor function of the fingers is required. In fractures with displacement of bone fragments, crepitus can be determined, but this manipulation should be avoided, as it can cause suffering to the patient.

X-ray examination of the bones forming the elbow joint, performed in two projections, helps not only to clarify the degree and type of displacement of fragments, but also to resolve the issue of treatment tactics.

Treatment for a fracture of the capitate eminence of the humerus

For fractures of the capitate eminence of the humerus without displacement, a plaster splint is applied on an outpatient basis from the heads of the metacarpal bones to the upper third of the shoulder in the average physiological position for a period of 10 to 14 days (depending on age). After cessation of immobilization, physical therapy and physiotherapeutic procedures are started until joint function is restored.

For fractures of the capitate eminence of the humerus (epiphysiolysis and osteoepiphysiolysis) with slight displacement and slight rotation of the bone fragment, conservative reduction can be attempted on an outpatient basis under local anesthesia. During reposition (in order to open the joint space), the elbow joint is given a varus position, after which pressure on the bone fragment is applied from bottom to top and from the outside inwards to produce reduction. In case of good adaptation, the arm is fixed with a plaster splint for a period of 14 - 21 days.

When treating fractures of the capitate eminence of the humerus in children, good comparison of bone fragments should be achieved in all cases; otherwise, in the long term, deviation of the axis of the forearm outward is observed due to delayed growth of the outer part of the condyle of the humerus, non-united fractures (pseudoarthrosis) of the capitate eminence, contractures of the elbow joint, which require long-term rehabilitation, and in some cases, surgical intervention.

Based on the above, if reposition fails and the remaining displacement threatens permanent deformity and contracture, the need for surgical intervention arises. Open reduction is also indicated when the bone fragment is displaced and rotated by more than 60°, since an attempt at reduction in such cases is almost always unsuccessful; in addition, during unnecessary manipulations, existing damage to the ligamentous-capsular apparatus and adjacent muscles is aggravated, the epiphysis and articular surfaces of the bones forming the elbow joint are unnecessarily injured. Therefore, it is advisable to treat children with fractures of the capitate eminence of the humerus with any displacement of bone fragments in a hospital setting, since it is often necessary to resort to surgical intervention to fix bone fragments. After completion of treatment, children with this pathology should be monitored for 11/2-2 years.