Capitate eminence of the humerus in children. Fracture of the capitate eminence of the humerus
Anatomical features children are manifested in special factors that prevent fractures: developed covers of soft tissues, a special structure of the periosteum, the presence of elastic growth cartilage, richly supplied with blood. But skeletal damage occurs even in babies. Some injuries are more common in children. Thus, a fracture of the capitate eminence of the humerus is typical for patients aged 4–10 years.
Features of injury
Damage to the capitate eminence of the shoulder bone is always intra-articular. The fracture is more often single or in combination with other intra-articular injuries.
The occurrence of injury is associated with an indirect effect of force. Most often, an isolated fracture occurs due to support in a fall with support on the outstretched hand.
The force of impact passes through radius, as a result of which the head rests against the elevation and breaks off the fragment from the outside with an offset. Often there is a detachment of the epiphysis with a fragment of the metaphysis. Damage is sometimes limited to cartilage depression on the surface of the joint, separation of a small cartilaginous plate.
A tear or rupture of the joint capsule is accompanied by a noticeable hemorrhage. The displacement of the fragment depends on the impact force, the possible rotation of the capitate elevation by 60–180 ° around the longitudinal axis.
Rotation to a large extent depends on the traction of the extensor muscles attached to the external epicondyle.
Clinical picture
Pain, hematoma due to isolated damage to the capitate eminence, formation of an osteochondral fragment are localized in the area of the external condyle. A large fragment with an upward displacement can sometimes be determined by palpation. Movement in the elbow area becomes painful and limited.
A slight shift can be identified by the following symptoms:
- traumatic swelling on the lateral side of the joint;
- bruising (hematoma) in the affected area;
- increased pain on palpation.
Crepitus is also a clear symptom of damage, but they try to avoid manipulations to establish this sign so as not to cause suffering to patients.
A child with an intra-articular injury, as a rule, supports the diseased limb with a healthy hand. Without additional support, the injured limb hangs along the body.
A significant shift is manifested in enhanced symptoms. Added pain in the movements of the fingers.
An important role in the diagnosis of damage is assigned to radiographs in various projections. To detect small fragments in the pictures, air is injected into the elbow joint.
Sometimes the recognition of the defect is difficult if the fragment is small. Symptoms of damage are manifested in limited movements of flexion and rotation of the forearm - this occurs due to the infringement of a fragment that is between the surface of the joint and the elevation of the head of the bone. This factor contributes to the recognition of injury.
It is difficult to diagnose cartilage damage in the absence of a capitate fracture. An isolated defect in early dates not recognized.
preserved over time pain, restrictions in the movement of the forearm indicate the cause - cartilage contusion and the development of dissecting osteochondritis, which can be established on repeated x-rays.
Methods of treatment
The nature of the treatment is set depending on the complexity of the damage, the timeliness of seeking medical help.
Therapy of injuries without displacement of bone fragments
The absence of displacement of fragments due to a fracture allows immobilization on an outpatient basis for 10–14 days, taking into account the age of the child. As a rule, this is the imposition of a plaster splint in the average physiological position of the hand. After removing the fixing bandage, the stage of physiotherapy exercises with physiotherapy procedures is started until all joint functions are fully restored.
Therapy of injuries with displacement of fragments
In injuries with slight displacement or rotation of bone fragments, the surgeon can perform conservative reduction "manually". AT stationary conditions, after anesthesia in the fracture area with the introduction of novocaine solution, the doctor grabs the patient's forearm with his hands and stretches the elbow joint. The flexor surface of the patient's limb should open upward. The task of the surgeon is to insert the fragment with his fingers into his bed. For support, the patient's hand is placed on the roller. The elbow is bent until a right angle is formed and fixed with a plaster cast.
The position of the fragment is checked on the control radiograph, after which they remain immobilized for 3-4 weeks. After removing the bandage, the recovery period lasts approximately 2-4 months.
Fragment reduction is not always possible even for experienced specialists. In such cases, surgical intervention is necessary. For children, the fragment is fixed to the bed with surgical threads (catguts). Preservation, comparison of bone fragments is very important for the rehabilitation of joint functions.
Unsuccessful attempts to reduce the rotation of the fragment by more than 60°. Manipulations in such cases increase damage to the articular surfaces, ligamentous apparatus, adjacent muscles.
Risks and forecasts
Untimely access to a doctor, unqualified assistance, non-compliance with the rules during treatment can lead to complications in long term:
- outward deviation of the axis of the forearm;
- pseudoarthrosis;
- contracture elbow joint.
The consequences are eliminated much more difficult, with long-term rehabilitation, often after surgery.
It is important to admit children with a suspected fracture of the capitate of the humerus in a hospital setting, since accurate diagnosis and choice of therapy are essential for the future physical development of patients.
After completion of treatment and recovery period children with injuries of the capitate eminence of the humerus are subject to dispensary observation up to about 2 years.
Fracture of the capitate eminence of the humerus in children is intra-articular and most commonly occurs between the ages of 4 and 10 years. The fracture is usually associated with an indirect mechanism of injury, when the child falls on the outstretched hand and the main impact force is transmitted to the elbow joint along the longitudinal axis of the radius. The head of this bone rests against the capitate eminence, breaks off a 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 with a part of the metaphysis is torn off, while the fracture plane goes in an oblique direction through the distal metaepiphysis of the humerus.
Fracture of the capitate eminence of the humerus is always intra-articular and is accompanied by tearing or rupture of the joint capsule and hemorrhage into the joint. The displacement of a bone fragment depends on the force of impact and occurs, as a rule, outwards and downwards (less often upwards), and rotation of the capitate elevation from 60 to 180 ° is also often observed. In the latter case, the bone fragment faces its cartilaginous surface to the fracture plane of the humerus. Such a pronounced rotation of the bone fragment depends both on the force of impact and on the traction attached to the external epicondyle of the humerus of a large group of extensor muscles.
Clinical picture of a fracture of the capitate of the humerus
With a slight displacement of the bone fragment, traumatic swelling along the lateral side of the elbow joint area, bruising, and significant pain on palpation are determined. The injured arm hangs down along the body, and the child usually supports it with a healthy arm. In fractures with a 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. Movement in the fingers of the hand is possible, but painful.
Innervation and peripheral circulation are rarely affected, but control of the 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 that form 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 of the humerus
In case of fractures of the capitate eminence of the humerus without displacement on an outpatient basis, a plaster splint is applied 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 the termination of immobilization, physiotherapy exercises and physiotherapy procedures are started until the function of the joint is restored.
In case of fractures of the capitate eminence of the humerus (epiphysiolysis and osteoepiphyseolysis) with a slight displacement and slight rotation of the bone fragment on an outpatient basis under local anesthesia, an attempt can be made to conservative reduction. During reposition (in order to open the joint space), the elbow joint is placed in a varus position, after which reduction is performed by pressure on the bone fragment from the bottom up and from the outside inwards. In case of good adaptation, the arm is fixed with a plaster splint for a period of 14-21 days.
In the treatment of fractures of the capitate of the humerus in children, in all cases, good matching of bone fragments should be achieved; otherwise, in the long term, deviation of the axis of the forearm outward is observed due to the lag in the growth of the outer part of the condyle of the humerus, ununited 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 foregoing, if the reposition fails, and the remaining displacement threatens with permanent deformation and contracture, there is a need for surgical intervention. Open reposition is also indicated when the bone fragment is displaced and rotated by more than 60°, since an attempt to reposition 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 that form the elbow joint are excessively injured. Therefore, it is advisable to treat children with fractures of the capitate of the humerus with any displacement of bone fragments in a hospital, since it is often necessary to resort to surgical intervention to fix bone fragments. After the end of treatment, children with this pathology should be on dispensary observation within 11/2-2 years.
The shoulder is the proximal (closest to the body) segment of the upper limb. The upper border of the shoulder is a line connecting the lower edges of the pectoralis major and broad back muscles; bottom - horizontal line passing over the condyles of the shoulder. Two vertical lines drawn upward from the condyles of the shoulder conventionally divide the shoulder into anterior and posterior surfaces.
On the anterior surface of the shoulder, external and internal furrows are visible. The bone base of the shoulder is the humerus (Fig. 1). Numerous muscles are attached to it (Fig. 3).
Rice. 1. Humerus: 1 - head; 2 - anatomical neck; 3 - small tubercle; 4 - surgical neck; 5 and 6 - crest of small and large tubercle; 7 - coronal fossa; 8 and 11 - internal and external epicondyle; 9 - block; 10 - capitate elevation of the humerus; 12 - radial fossa; 13 - groove of the radial nerve; 14 - deltoid tuberosity; 15 - large tubercle; 16 - groove of the ulnar nerve; 17 - cubital fossa.
Rice. 2. Fascial sheaths of the shoulder: 1 - sheath of the beak-brachial muscle; 2-beam nerve; 3 - muscular- cutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - vagina of the triceps muscle of the shoulder; 7 - sheath of the shoulder muscle; 8 - sheath of the biceps muscle of the shoulder. Rice. 3. Places of origin and attachment of muscles on the humerus, right in front (i), behind (b) and on the side (c): 1 - supraspinatus; 2 - subscapular; 3 - wide (back); 4 - large round; 5 - beak-shoulder; 6 - shoulder; 7 - round, rotating the palm inward; 8 - radial flexor of the hand, superficial flexor of the hand, long palmar; 9 - short radial extensor of the hand; 10 - long radial extensor of the hand; 11 - shoulder-radial; 12 - deltoid; 13 - large sternum; 14 - infraspinatus; 15 - small round; 16 and 17 - the triceps muscle of the shoulder (16 - lateral, 17 - medial head); 18 - muscles that rotate the palm outward; 19 - elbow; 20 - extensor of the thumb; 21 - extensor of the fingers.
The muscles of the shoulder are divided into 2 groups: the anterior group is made up of flexors - the biceps, shoulder, coracobrachial muscles, the back group is the triceps muscle, extensor. The brachial artery, which goes under, accompanied by two veins and the median nerve, is located in the internal groove of the shoulder. The projection line of the artery on the skin of the shoulder is drawn from the most deep point to the middle of the cubital fossa. The radial nerve passes through the canal formed by the bone and the triceps muscle. The ulnar nerve goes around the medial epicondyle, located in the sulcus of the same name (Fig. 2).
Closed shoulder injuries. Fractures of the head and anatomical neck of the humerus - intra-articular. Without them, it is not always possible to distinguish from, perhaps a combination of these fractures with dislocation.
A fracture of the tubercles of the humerus is recognized only radiographically. A fracture of the diaphysis is usually diagnosed without difficulty, but is required to determine the shape of the fragments and the nature of their displacement. A supracondylar fracture of the shoulder is often complex, T-shaped or V-shaped, so that the peripheral fragment is divided in two, which can only be recognized on the picture. Possible and simultaneous dislocation of the elbow.
With a diaphyseal fracture of the shoulder, the traction of the deltoid muscle displaces the central fragment, taking it away from the body. The displacement is greater the closer to the broken bone. When the surgical neck is fractured, the peripheral fragment is often driven into the central one, which is determined on the picture and most favors the union of the fracture. With a supracondylar fracture, the triceps muscle pulls the peripheral fragment from the back and up, and the central fragment moves forward and down (to the cubital fossa), while it can compress and even injure the brachial artery.
First aid for closed fractures of the shoulder comes down to immobilizing the limb with a wire splint from the shoulder blade to the hand (the elbow is bent at a right angle) and fixing it to the body. If the diaphysis is broken and there is a sharp deformity, you should try to eliminate it by careful traction on the elbow and bent forearm. With low (supracondylar) and high fractures of the shoulder, reduction attempts are dangerous; in the first case, they threaten to damage the artery, in the second, they can disrupt the impaction, if any. After immobilization, the victim is urgently sent to a trauma facility for x-ray examination, reposition and further inpatient treatment. It is carried out, depending on the characteristics of the fracture, either in a plaster thoraco-brachial bandage, or by traction (see) on the outlet splint. With an impacted fracture of the neck, none of this is required; the hand is fixed to the body with a soft bandage, placing a roller under the arm, and after a few days, therapeutic exercises begin. Uncomplicated closed fractures of the shoulder heal in 8-12 weeks.
Shoulder diseases. From purulent processes acute hematogenous osteomyelitis is most important (see). After an injury, a muscle hernia may develop, more often a hernia of the biceps muscle (see Muscles, pathology). From malignant neoplasms meet, forcing to amputation of the shoulder.
Shoulder (brachium) - the proximal segment of the upper limb. The upper border of the shoulder is a line connecting the lower edges of the pectoralis major and broad dorsal muscles, the lower one is a line passing two transverse fingers above the condyles of the humerus.
Anatomy. The skin of the shoulder is easily mobile, it is loosely connected to the underlying tissues. On the skin of the lateral surfaces of the shoulder, internal and external grooves (sulcus bicipitalis medialis et lateralis) are visible, separating the anterior and posterior muscle groups. Own fascia of the shoulder (fascia brachii) forms a vagina for muscles and neurovascular bundles. From the fascia deep into the humerus, the medial and lateral intermuscular septa (septum intermusculare laterale et mediale) depart, forming the anterior and posterior muscle containers, or bed. In the anterior muscle bed there are two muscles - the biceps and the shoulder (m. Biceps brachii et m. brachialis), in the back - the triceps (m. triceps). In the upper third of the shoulder there is a bed for the coracobrachial and deltoid muscles (m. coracobrachialis et m. deltoideus), and in the lower third there is a bed for the shoulder muscle (m. brachialis). Under the own fascia of the shoulder, in addition to the muscles, there is also the main neurovascular bundle of the limb (Fig. 1).
Rice. 1. fascial receptacles of the shoulder (scheme according to A.V. Vishnevsky): 1 - sheath of the coracobrachialis muscle; 2 - radial nerve; 3 - musculocutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - vagina of the triceps muscle of the shoulder; 7 - sheath of the shoulder muscle; 8 - sheath of the biceps muscle of the shoulder.
Rice. 2. Right humerus in front (left) and behind (right): 1 - caput humeri; 2 - collum anatomicum; 3 - tuberculum minus; 4 - coilum chirurgicum; 5 - crista tuberculi minoris; 6 - crista tuberculi majoris; 7 - foramen nutricium; 8 - facies ant.; 9 - margo med.; 10 - fossa coronoidea; 11 - epicondylus med.; 12 - trochlea humeri; 13 - capitulum humeri; 14 - epicondylus lat.; 15 - fossa radialis; 16 - sulcus n. radialis; 17 - margo lat.; 18 - tuberositas deltoidea; 19 - tuberculum majus; 20 - sulcus n. ulnaris; 21 - fossa olecrani; 22 - facies post.
On the anterior-internal surface of the shoulder above its own fascia, two main venous superficial trunks of the limb pass - the radial and ulnar saphenous veins. Radial saphenous vein (v. cephalica) goes outward from the biceps muscle along the external groove, at the top it flows into the axillary vein. The ulnar saphenous vein (v. basilica) runs along the internal groove only in the lower half of the shoulder, - the internal cutaneous nerve of the shoulder (n. cutaneus brachii medialis) (printing table, Fig. 1-4).
The muscles of the anterior shoulder region belong to the group of flexors: the coracobrachial muscle and biceps having two heads - short and long; fibrous stretching of the biceps muscle (aponeurosis m. bicipitis brachii) is woven into the fascia of the forearm. Beneath the biceps muscle lies the brachialis muscle. All these three muscles are innervated by the musculocutaneous nerve (n. musculocutaneus). On the outer and antero-medial surfaces of the lower half of the humerus, the brachioradialis muscle begins.
Rice. 1 - 4. Vessels and nerves of the right shoulder.
Rice. 1 and 2. Superficial (Fig. 1) and deep (Fig. 2) vessels and nerves of the anterior surface of the shoulder.
Rice. 3 and 4. Superficial (Fig. 3) and deep (Fig. 4) vessels and nerves of the posterior surface of the shoulder. 1 - skin with subcutaneous fatty tissue; 2 - fascia brachii; 3-n. cutaneus brachii med.; 4-n. cutaneus antebrachii med.; 5-v. basilica; 6-v. medlana cublti; 7-n. cutaneus antebrachii lat.; 8-v. cephalica; 9 - m. pectoralis major; 10 - n. radialis; 11 - m. coracobrachialis; 12-a. et v. brachlales; 13 - n. medianus; 14 - n. musculocutaneus; 15 - n. ulnaris; 16 - aponeurosis m. bicipitis brachii; 17 - m. brachialis; 18 - m. biceps brachii; 19-a. et v. profunda brachii; 20-m. deltoldeus; 21-n. cutaneus brachii post.; 22-n. cutaneus antebrachii post.; 23-n. cutaneus brachii lat.; 24 - caput lat. m. trlcipitis brachii (cut); 25 - caput longum m. tricipitls brachii.
The main arterial trunk of the shoulder - the brachial artery (a. brachialis) - is a continuation of the axillary artery (a. axillaris) and goes along the medial side of the shoulder along the edge of the biceps muscle along the projection line from the top of the axillary fossa to the middle of the cubital fossa. The two veins accompanying it (vv. brachiales) run along the sides of the artery, anastomosing with each other (tsvetn. fig. 1). In the upper third of the shoulder outside the artery lies the median nerve (n. medianus), which crosses the artery in the middle of the shoulder and then goes with it inside. The deep artery of the shoulder (a. profunda brachii) departs from the upper part of the brachial artery. Directly from the brachial artery or from one of its muscular branches, the nutrient artery of the humerus (a. nutrica humeri) departs, which penetrates the bone through the nutrient hole.
Rice. 1. Cross cuts of the shoulder, made at different levels.
On the posterior outer surface of the shoulder in the posterior bone-fibrous bed is the triceps muscle, which extends the forearm and consists of three heads - long, medial and outer (caput longum, mediale et laterale). The triceps muscle is innervated by the radial nerve. The main artery of the posterior section is the deep artery of the shoulder, going back and down between the outer and inner heads of the triceps muscle and enveloping the humerus with the radial nerve behind. In the posterior bed are two main nerve trunks: radial (n. radialis) and ulnar (n. ulnaris). The latter is located at the top posteriorly and inside of the brachial artery and the median nerve, and only in the middle third of the shoulder enters the posterior bed. Like the median, the ulnar nerve does not give branches on the shoulder (see Brachial plexus).
Humerus (humerus, os brachii) - long tubular bone(Fig. 2). On its outer surface is the deltoid tuberosity (tuberositas deltoidea), where the deltoid muscle is attached, on the back surface is the groove of the radial nerve (sulcus nervi radialis). The upper end of the humerus is thickened. Distinguish between the head of the humerus (caput humeri) and the anatomical neck (collum anatomicum). A slight narrowing between the body and the upper end is called the surgical neck (collum chirurgicum). At the upper end of the bone there are two tubercles: a large one on the outside and a small one in front (tuberculum inajus et minus). The lower end of the humerus is flattened in the anterior-posterior direction. Outward and inward, it has protrusions that are easily palpable under the skin - epicondyles (epicondylus medialis et lateralis) - the place where most of the muscles of the forearm begin. Between the epicondyles is the articular surface. Its medial segment (trochlea humeri) has the shape of a block and articulates with the ulna; lateral - head (capitulum humeri) - spherical and serves for articulation with the beam. Above the block in front is the coronary fossa (fossa coronoidea), behind - the ulna (fossa olecrani). All these formations of the medial segment of the distal end of the bone are combined under common name"condyle of the humerus" (condylus humeri).
Dissertation abstractin medicine on the topic Treatment of fractures of the internal epicondyle and capitate eminence of the humerus in children
Ministry of Health and Medical Industry of the Russian Federation
RUSSIAN ORDER OF LABOR RED BANNER SCIENTIFIC RESEARCH INSTITUTE OF TRAUMATOLOGY AND ORTHOPEDICS named after R. R. VREDEN
As a manuscript TURKOVSKY Vladimir Borisovich UDC 616.717.4-001.5-08(04)
TREATMENT OF FRACTURES OF INTERNAL EPATSYLUM AND CAPITATE HUMERAL BONE IN CHILDREN
14.00.22 - traumatology and orthopedics
dissertations for the degree of candidate of medical sciences
St. Petersburg 1994
The work was performed at the Saratov State Medical University.
Scientific adviser - Doctor of Medical Sciences, Professor V. F. Goryainov.
Scientific consultant - Candidate of Medical Sciences, Associate Professor I. I. Ladenov.
Official opponents:
Doctor of Medical Sciences N. A. Ovsyankin,
Doctor of Medical Sciences, Professor E. V. Ulrich,
The leading institution is the St. Petersburg Military Medical Academy.
The defense of the dissertation will take place on "_"_1994.
at _hours at a meeting of the dissertation council
D. 084.20.01 at the Russian Research Institute of Traumatology and Orthopedics. R. R. Vreden (197046, St. Petersburg, Alexander Park, 5).
The dissertation can be found in the scientific library of the institute.
Scientific Secretary of the Dissertation Council
Doctor of Medical Sciences E. G. GRYAZNUKHIN
The urgency of the problem. Intra- and periarticular fractures of the distal end of the humerus in children account for 79.5-89% of all fractures of the bones forming the elbow joint (Bairov G. A., Gorely V. V., 1975; Bityugov I. A. et al., 1986; Magaramov M. A., 1990). They are diverse, differ in the complexity of diagnosis and course, as well as frequent concomitant complications (Rutsky A.V., 1975).
With generally accepted methods of treating fractures of this localization, contractures of the elbow joint are observed in the long term - in 30.2-82% of cases (Ter-Egiazarov G. M., 1971; Volynskaya L. B., Yuvonpna L. M., 1974; Znamensky A. . S., 1982); deforming arthrosis - in 23.3% (Knysh I.T., 1967; Ovsyankin N.A., 1984); non-union - in 4.5 - 81.8% (Plakseychuk Yu. A., 1972 Borisevpch K. N., 1974), osspfmkaty of paraarticular soft tissues - in 5.1% (Ovsyankin N. A., 1984; Magaramov M. A., 1990).
According to A. M. Shamsnev (1973) and G. A. Ilizarov (1985), after intra-articular fractures of the distal end of the humerus in childhood, there is a decrease in working capacity and disability in 20% of cases.
Unsatisfactory results of treatment of this contingent of victims are due to highly differentiated anatomical structure, the complexity of biomechanics (■Ritler G., Waldo H-I., 1974), the special vulnerability of the children's elbow joint in response to trauma and immobilization, the difficulty of repositioning and fixing small bone fragments (Mikhovich M.S., 1983; Vitiugov I.A. .; 1986;).
Fractures in this area require especially careful reposition of fragments, since the left deformities, unlike fractures of other bones, are not compensated with age, but tend to increase (Bairov G. A., 1962; Magerl F., 1974; Welz K. , 1984).
Violation of stability during the fixation period is the main cause of secondary displacements of bone fragments - in 8.7-64.3% of cases (Sidorenko A.S., 1965; Lukanyuk S.P., 1969; Znamensky A.S., 1970, 1984) . Therefore, most authors (Belousov V. D., Tsurkan A. M., 1974; Moroz P. F., 1976; Gassan 10. P., et al. 1977; Ter-Egiazarov G. I. et al., 1988; Emmanonilidis Th 1982) prefer surgical methods, however, the fixators used - studs, screws, AO screws, narrow plates, Kirschner wires - do not provide stable osteosynthesis (Kovalishin I.V., 1977; Kolontai Yu. 10., Sergach V. Ya 1978), and the need for additional external fixation of the limb with a plaster splint excludes the possibility of early functional therapy (Gritsun V. P., Shavarnn B. V., 1978; Sysa N. F. 1985; Mnkhovnch M. S., 1987);
The complex of optimal conditions necessary for fusion of most fractures and restoration of the function of the injured limb in the shortest possible time includes: complete comparison of fragments, their stable fixation and the possibility of early active movements in the injured joint (Volynskaya J1. B., 1975; Plaksejchuk 10. A. , 1972; Schamvecker F., Renne I., Banerle E "1975).
These requirements are met by the methods of percutaneous osteosynthesis with devices of various designs Ilizarov G. A., Averkiev V. A., Znamensky G. B. and others, but in most fractures of the elbow joint, the elimination of displacement of small-sized distal fragments with the help of compression-distraction devices, as rule is not possible. The bulkiness and inconvenience for patients of existing structures limits their use in children.
The foregoing determines the relevance of the problem of treating fractures of the internal epicondyle and capitate elevation of the humerus in children and encourages the search for more rational methods of treating these injuries.
Purpose and objectives of the study. The aim of this study was to develop a rational set of therapeutic measures for fractures of the internal epicondyle i of the capitate of the humerus in children, ensuring the achievement of the maximum number of favorable outcomes in the shortest terms of treatment of patients.
To solve this problem, the following research tasks were set:
1. To develop rational ways of repositioning and fixing fractures of the internal epicondyle and the capitate eminence of the humerus.
2. To develop a methodology for conducting early functional therapy under conditions of stable osteosynthesis.
3. Explore the possibility of application in complex therapy traveling pulsed magnetic field.
4. Determine the indications for the use of the methods proposed and tested in the clinic for the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus.
5. Conduct a comparative evaluation of the effectiveness of various methods of treating fractures of the internal epicondyle and the capitate of the humerus in children, to study their immediate, immediate and long-term results.
Scientific novelty. A complex technique has been developed for the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus, which provides optimal conditions for the course of reparative regeneration processes and shortens the rehabilitation period. The work uses new methods of treatment proposed by the author, namely: the method of transfocal compression osteosynthesis using a compression device designed by the author, the method of closed reposition of the fracture of the internal epicondyle, the method of early functional therapy under conditions of stable osteosynthesis. For the first time, the treatment complex included the method of exposure to a traveling pulsed magnetic field. Based on the applied research methods, clear indications for the use of the developed methods of treatment were determined.
The practical value of the work. On the basis of the studies carried out, indications for the use of the methods proposed and tested in the clinic for the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus were determined.
The effectiveness and expediency of using the proposed complex system for the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus has been proven.
bones in children, which contributes to an earlier and complete restoration of the lost function of the damaged joint. The total period of treatment of the patient in comparison with traditional methods of treatment was reduced by 2-3 times.
The results of the study are implemented in the clinic of surgery childhood SSMU, (Saratov) in the Saratov NIITO, traumatology and orthopedic departments of the region. " "
The proposed devices and methods for osteosynthesis of fractures of the internal epicondyle and the capitate of the humerus, as well as the developed complex method for treating these injuries, can be recommended for implementation in trauma and orthopedic departments of NIITO and hospitals.
Approbation of work. The research materials and the main provisions were discussed at scientific meetings of the Saratov Society of Traumatologists and Orthopedists (1987, 1988), scientific and practical conferences of young scientists of the Saratov NIITO (1987-1989), All-Union scientific and practical conference "Medncipe - rehabilitation for chronic diseases of children and children - disabled people "(Saratov,. 1991)..
Structure and scope of work. The dissertation is presented on 141 pages of typewritten text and consists of an introduction, literature review, 4 chapters of own research, conclusions, conclusions, a list of references, including 138 works of domestic and 34 foreign authors, illustrated with 31 figures, contains 11 tables.
MAIN PROVISIONS FOR THE DEFENSE
1. A new method of closed reposition of fractures of the internal epicondyle of the humerus allows you to completely abandon the open comparison of fragments in fresh; damage.
2. The proposed technique for osteosynthesis of fractures, the internal epicondyle, and the capitate eminence of the humerus using the developed device provides stable fixation of fracture fragments without limiting the function of the elbow joint.
3. A comprehensive system of early rehabilitation treatment of children with these injuries contributes to an earlier and complete restoration of the lost function of the injured joint, which made it possible to reduce the total treatment time by 2 times.
The basis of this work was the results of the study and treatment of 342 children with fractures of the internal epicondyle-silk and capitate eminence of the humerus, who were in the pediatric surgical clinic of Saratov medical institute from 1976 to 1991 The main age group (88.2%) consisted of children from 3 to 12 years old (Table 1).
Table 1
Age of observed patients
Fracture location Age in years Total
1-2 | 3-4 1 5-6 7-8 | 9-10 11 - 12 13-14
Fracture of the medial epicondyle ~ 1 * 5 25 59 48 28 163
Fracture of the capitate eminence 14 39 52 43 25 С - 179
Total 14 39 57 68 84 54 26 342
% 4 11,0 16,6 20 24,6 1 15,8 | 7,8 100
The terms of admission of patients to the clinic were very different (Table 2).
table 2
Terms of admission of patients to the clinic
Fracture localization Time of admission, days Total
1 2-3 | 4-7 before 21 after 21
Fracture of the medial epicondyle 74 50 | 25 7 7 103
Fracture of the capitate eminence 93 38 31 8 9 179
Total (167 88 56 15 1С 342
% 48,8 25,7 10,4 4,4 4,7 100
Only 48.8% of the total number of patients were admitted on the first day after injury. The rest were hospitalized for over late dates, which undoubtedly affected the results of treatment. The reasons for the late admission of patients to the clinic were errors in diagnosis, the occurrence of which is associated with insufficient knowledge of the anatomical and physiological characteristics of the growing organism, the radiological picture of the elbow joint in children, the predominance of symptoms of concomitant trauma (dislocation in the elbow joint), and the inadequate use of x-ray research methods.
Isolated fractures of the internal epicondyle and capitate elevation occurred in 266 patients (77.8%), 76 (22.2%) had concomitant injuries, which are presented in Table. 3.
Table 3
Concomitant injuries in patients with fractures of the medial supramental and capitate eminence of the humerus
Type of injury
Dislocation of forearm bones 3-3 9 47
Block fracture 3 - 3
Epiphyseal of the head of the radius 4 - 4
Fracture of the olecranon 2 2 4
Fractured bones of the forearm - 4 4
Damage n-radialis - 4 4
» and - ulnaris 7 - 7
» n- medialis - 3 3
Total 54 22 76
Of the 342 patients, traditional methods of treatment were used in 107 cases (31.3%), 235 children (68.7%) were treated according to our proposed method.
Patients underwent a comprehensive examination using clinical, radiological, neurological, electrophysiology and functional research methods.
The effectiveness of treatment was assessed by general clinical indicators, the main of which we considered the anatomical results and the timing of recovery of the function of the injured joint.
For an objective assessment of the effectiveness of the proposed method of treatment, the functional state of the neuromuscular apparatus in children with injuries of the elbow joint was studied. For this purpose, an electromyographic (EMG) examination of the muscles was used. upper limbs, carried out at rest, with a static load and with arbitrary muscle contractions in an isometric mode. Registration of electronic
The physical activity of the muscles was carried out using a two-channel electromyograph "Medicor" (VNR).
In the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus in children, it is necessary to ensure three main conditions: a) an accurate comparison of the fracture fragments with the restoration of the congruence of the articular surface; b) stable fixation of fragments for the entire period of fusion and c) the possibility of early functional therapy. To this end, we have developed a fundamentally new set of therapeutic measures that ensures the achievement of the maximum number of favorable outcomes in the shortest possible time of treatment. Taking into account the three main conditions of these injuries, we used transfocal compression osteosynthesis, carried out using the devices we offer. For its successful implementation, it is necessary to preliminarily perform the reposition of fragments with the achievement of complete adaptation of the fracture surfaces, since the design of the device does not provide for the possibility of correcting the position of the fragments during their fixation.
Indications for closed reposition, transfocal compression osteosynthesis were:
A. All fresh (up to 7 days from the moment of injury) fractures of the internal epicondyle, regardless of the degree of displacement.
B. Fractures of the capitate elevation without fragment displacement.
The developed method of closed reposition allowed us to completely abandon the open comparison of fragments in fresh fractures of the internal epicondyle.
The reposition was performed under general anesthesia (apiarate-mask anesthesia with halothane after preliminary premedication with 1% solution of promedol and 0.1% solution of atropine at the age dosage) with asepsis, in three stages.
Stage 1: The assistant fixes the patient's shoulder, penetrates the forearm, leads and bends at an angle of 140-160 degrees. The reconstructing surgeon, having palpated the displaced epicondyle, holds it between the index and thumb fingers of one hand, with the other hand percutaneously inserts the Kirschner wire until it stops at the epicondyle. Then, with the help of a drill1, a pin is passed through the center of the displaced epicondyle perpendicular to the plane of the fracture.
Stage 2: Using this pin as a lever, the surgeon moves the internal epicondyle to the "mother's bed", while displacing the finger of the other hand installed there, which controls the accuracy of the reposition (on reaching a smooth transition of the humeral crest to the epicondyle).
At the same time, we found that rotational displacement is eliminated by normalizing the traction of the muscles attached to the supracondyle. This is possible due to its free location on the spoke (before fixing), which acts as an axis of rotation. Necessary condition for this purpose, the repairing needle is passed through the center or upper edge of the fragment.
Stage 3: The epicondyle is fixed with the same needle, which is passed through the humerus strictly in the frontal plane from the inside out, from bottom to top at an angle of 130-145 degrees to the axis of the bone so that the needle comes out as close as possible to the opposite crest of the humerus. Objective control of the accuracy of reposition is carried out using radiography in two standard positions.
During the spinal cord and reposition, the assistant controls the movements of the fifth finger of the injured limb of the patient in order to timely prevent traumatic damage to the ulnar nerve.
In the treatment of fractures of this type, success largely depends on the accuracy of reposition, with an indispensable condition for its minimal trauma. In this regard, preference should be given to closed reduction, new way which was developed by us (rational proposal No. 1715). He allowed the majority of patients to refuse open t reposition.
In 94 patients (93.1% of the total) with fractures of the internal padcondyle, osteosynthesis was performed after closed reposition, if it was impossible, open reposition was performed, indications for which we consider:
A. Fractures of the capitate eminence with fragment displacement.
B. Chronic fractures of the internal padcondyle and capitate eminence.
In case of fractures of the capitate, we prefer open reposition, since a fracture of the capitate of the humerus with displacement of the fragment is always accompanied by ruptures of the muscular aponeurotic formations and periosteum along the outer surface of the condyle of the shoulder, which is the cause of circulatory disorders of the fragment and, in some cases, ossification of the subperiosteal hematoma . In this regard, it is necessary to perform an open reposition, which allows achieving the most accurate comparison of fragments, removing blood clots from the joint cavity, preventing periosteum displacement and restoring the integrity of the muscular aponeurotic formations.
Of the structures proposed by us for osteosynthesis of these injuries, the best results were obtained using a device containing: a spoke with a thrust pad, an anti-thrust sleeve, one end of which is beveled, and the other on the outer surface has a thread (thread pitch 0.5 mm) and a turnkey hexagonal head , a compression nut with a turnkey flat, a spherical end and a hole in the spoke. The outer diameter of the sleeve is 3 mm, the inner one exactly matches the diameter of the spoke. The length of the sleeve ranges from 20 to 50 mm and is selected individually. The weight of the device is 2-4 g, it is made of titanium, which allows using any known sterilization method (rational proposal No. 2065).
The structure is used in the following way.
Anesthetic allowance is strictly individual (general anesthesia). Depending on the indications, closed or open reposition and fixation of the fragment with a pin with a thrust platform, which is passed through the humerus strictly in the frontal plane from the side of the smaller fragment, are performed, depending on the indications, so that the pin comes out as close as possible to the crest of the humerus. In order to control the accuracy of reposition, radiography is performed in two standard positions.
The distal part of the spoke from the side of the thrust pad is bitten off with wire cutters. Next, the spoke is captured by a clamp and pulled up in the course of its introduction until the thrust pad is immersed in soft tissues all the way to the bone. After that, a compression device is put on the pin, which, due to the beveled end of the anti-thrust sleeve, easily moves up to the bone and adapts tightly with the latter, which prevents the tit from bending in the zone of its transition from the bone e
anti-slip bushing. The end of the spoke is bent over the spherical part of the compression nut. By unscrewing the nut, the necessary compression of the fragments is carried out until the tracing of the fracture line on the control radiographs stops. The apparent incomplete pressing of the thrust pad against the fragment (during fixation of the fracture of the capitate elevation) is a consequence of the discrepancy between the radiological and true size of the fragment due to incompletely ossified cartilage.
At the exit site of the compression device, a bandage moistened with an antiseptic is applied. Control over the condition of the soft tissues around the device and the toilet of the skin is performed once every 3 days. Additional compression to ensure the necessary stability of fixation is performed every 5 days by 1 mm due to the inevitable aseptic necrosis of tissues around the thrust area. The time of fixation by the device was 2-3 weeks.
The most difficult task in the treatment of fractures of the internal epicondyle and the capitate eminence of the humerus is the restoration of the function of the elbow joint, since it is necessary to provide two opposite conditions simultaneously: rest in the regeneration zone and load on the injured limb.
The complex technique developed by us for the treatment of these injuries meets these requirements. Active restorative functional therapy becomes possible due to the stable fixation of fragments by the proposed design. It includes the following main steps.
A) Physiotherapy. For the first time, we used the impact on the fracture area of a traveling pulsed magnetic field, which has the largest number of biotropic parameters. Magnetic therapy sessions were carried out with a specially designed BIMP-1 device (rational suggestion No. 1272) from the first day after the operation for 10-15 minutes with a tension of 100 oersteds. The total number of procedures is 10. Magnetic therapy sessions contributed to obtaining a good analgesic, anti-edematous and anti-inflammatory effect, accelerating the reparative regeneration of bone tissue and, consequently, earlier recovery of active movements in the injured limb.
B) Physiotherapy. The proposed method of rehabilitation treatment involves 3 stages.
Stage 1 - from 2 days after the operation - lasting 3-4 days, it solves the problems of improving local and general blood circulation, reducing tissue edema, and stimulating regenerative processes. Exercises are carried out from lightweight positions, with the support of a healthy hand.
Stage 2 - from 4-5 days after the operation until the termination of fixation. This is the period of active development of the injured joint. Tasks: increasing the range of motion in the elbow joint, maintaining mobility in other joints of the injured limb, preventing muscle atrophy. We have developed exercises for the damaged joint (along all axes and planes), everyday exercises, in relaxation, by the end of the stage with weights, using simulators.
Stage 3 - in a clinic or at home. The tasks of this stage are the elimination of residual phenomena of impaired functions. damaged organ. Proposed special exercises for the joint in all possible directions of movement.
Along with those mentioned, other traditional methods of restorative treatment were also used.
Such an integrated approach for fractures of the internal epicondyle and the capitate eminence of the humerus in children creates optimal conditions for fracture healing, complete self-care of the child from the first days after osteosynthesis, a significant reduction in treatment time and obtaining the maximum number of positive outcomes.
To assess the effectiveness of the treatment in children with fractures of the internal epicondyle and the capitate of the humerus, we conducted a comparative analysis of the recovery time of the damaged joint, long-term anatomical and functional outcomes, depending on the treatment methods used.
For this purpose, all patients were divided into three groups:
Group 1 - 107 patients who used conventional methods of treatment.
Group 2 - 182 children who used the methods we developed.
group 3 - 53 patients treated by our proposed method in combination with exposure to a traveling pulsed magnetic field.
An analysis of the observations showed that in the treatment of fractures of the internal epicondyle by conventional methods, the immobilization of the injured limb lasted an average of 3 weeks. After removal of the plaster splint, there was a sharp limitation of movements in the elbow joint. Average duration the patient's stay in the hospital was 27.4 days, the average range of motion in the joint on the day of discharge was 68.1 degrees, and complete restoration of the function of the injured joint was observed within 2 to 2.5 months only in 54.3% of patients.
The use of the proposed system for the treatment of these injuries made it possible to reduce the treatment time by more than 2 times.
The period of immobilization of the injured limb with a plaster splint for fractures of the capitate eminence of the humerus was 3-3.5 weeks. Complete recovery of the function of the elbow joint was noted after 2.5-3 months only in 67.C% of patients.
When treated according to the method developed by us, the complete restoration of joint function occurred within 1 to 1.5 months in all patients.
Thus, a comparative analysis of the dynamics of restoration of the function of the elbow joint in fractures of the internal epicondyle and capitate eminence, depending on the methods of treatment used, showed the advantages of an integrated approach to this problem (Table 4).
The best immediate results were obtained in the 3rd group of patients who received a full complex of treatment, including: transfocal compression osteosynthesis, early functional therapy and exposure to the fracture area with a traveling pulsed magnetic field.
The conducted studies showed that in all patients the EMG structure of the muscles was characterized by a decrease in the frequency of repetition of electrical potentials, a change in their polyphasicity. Dynamic observation (control after 2 weeks and a month after the operation) showed that the changes in the EMG structure of the muscles gradually returned to normal. However, in patients who underwent postoperative period exposure to a traveling pulsed magnetic field, correction of EMG parameters occurred earlier.
In chronic fractures of the internal epicondyle in 6 patients of the 1st group, an open reposition was performed with fixation of the epicondyle in 2 cases with silk sutures and in
Table 4
The average recovery time of the function of the elbow joint, depending on the generally accepted and developed methods of treatment for fresh fractures of the internal epicondyle and capitate eminence
in patients of groups 1-3
Fracture localization " Average bed-day by groups Volume of movements in the joint per day, discharges in degrees by groups Average recovery time for the function of the damaged joint, months by groups
1 | 2 | 3 | p 1 | 2 | 3 1 r 1 | 2 3
Fracture of the internal epicondyle 27.4=8.7 21.8-1.2 20.9-0.8<0,001 68,1*17,8 122,5*10,3 136*8,7 <0,05 2-2,5 1-1,5 0,75-0,85
Fracture of the capitate eminence 29.4 ± 13.4 ^2.4*1.8 20.2-2<0,001 72,8=48,7 121,9*9,1 132,5*7,3 <0,05 2,5-3 1-1,5 0,75-0,85-
4-screw. Immobilization of the injured limb with a plaster splint lasted 3-3.5 weeks. The average bed-day in this group was 32 days, the range of motion in the joint on the day of discharge was 60 degrees. Fully function of the joint was restored after 3.5 months only in one patient.
In similar 7 patients who underwent transfocal compression osteospinthesis after preliminary open reposition, the bed-day was reduced by an average of 10 days, and the total duration of treatment was halved. Complete restoration of joint function occurred in all patients within 2 months.
With chronic fractures of the capitate elevation in 4 patients of the 1st group, immobilization of the limb after performing an open reposition lasted 3-4 weeks. In the postoperative period, aseptic necrosis of the capitate elevation occurred in 2 patients. It was not possible to fully restore the function of the joint in one patient.
The use of transfocal compression osteosynthesis in 24 patients with chronic capitate fractures significantly reduced the treatment time and improved outcomes (Table 5).
Long-term results of treatment were followed up in 183 patients (77.8%). Excellent and good anatomical and functional results in fresh fractures of the internal epicondyle and capitate eminence in patients of groups 2-3 were obtained in 98.7% of cases (in group 1 of patients - 54.3%), satisfactory - 1.3% ( in group 1 - 31.2%), there were no poor outcomes (in group 1 - 14.5%).
With chronic fractures, excellent and good results were obtained in 90.7% of cases (in group 1 of patients - 20%), satisfactory - 9.3% (in group 1 - 35%). Bad results were not observed in this group of patients either (45% in group 1).
So, the clinical and radiological outcomes of treatment, as well as a comparative analysis of objective indicators of the function of the injured joint in patients, depending on the methods of treatment used, showed that transfocal compression osteosynthesis, which provides stable fixation of fragments for the entire period of fusion without limiting movements in the joint, contributes to a significant improvement outcomes of treatment and reduction of terms of rehabilitation of patients.
Table 5
The average recovery time of the function of the elbow joint, depending on the generally accepted and developed methods of treatment for chronic fractures of the internal epicondyle and the capitate eminence
in patients of groups 1-3
Fracture localization! Average bed-day by groups Volume of movements in the joint on the day of discharge in degrees by groups Average recovery time of the damaged joint function, mee. according to gr.
1 2-1-3 p 1 | 2 3 | R 1 | 2 3
Fracture of the internal epicondyle 32-4.9 22.6±1.5 22-1.1<0,001 60±12,4 120,7-14,8 123,5*11,1 <0,05 3-3,5 1 1,5-2 1 - 1,5 . 1
Fracture of the capitate eminence 33.7*15 23.5*2 20.9*1.9<0,001 65,8*18,4 117,8*12,2 119,6*11,8 <0,05 1 3-4 1,5-2 . . 1 1-1,5
In general, this made it possible to achieve favorable treatment results in 95% of patients with fresh and old fractures of the internal, epicondyle and capitate eminence.
; shoulder bone.
1. An analysis of our own experience and literature data showed that the "generally accepted methods of treating fractures of the internal epicondyle and capitate exaltation of the humerus
■1 bones in children give insufficient, good results and often do not provide a complete restoration of the function of the injured joint.
2. The technique of transfocal compression osteosynthesis for fractures of the internal epicondyle and capitate eminence of the humerus, developed and introduced into clinical practice, makes it possible to perform an accurate comparison of bone "X" fragments, ensures their stable fixation for the entire period of "" "-union,;." contributes to the primary
■ fracture healing and restoration of the lost function of the damaged joint in the shortest possible time (1-1.5 months). .
/.lesional zone "reduces the rehabilitation period for patients (up to 1: -1,; 5 mbsyatsev);: , . .
4. The use in the complex treatment of exposure to the fracture area by a running pulsed magnetic field has a good analgesic and "anti-inflammatory"
New effect, improves blood circulation and contributes to the rapid subsidence of edema, accelerates the consolidation process. Due to this, it provides the possibility of earlier and active development of the joint, with a greater range of motion, which helps to reduce the recovery time of the function of the elbow joint and the patient's stay in the hospital.
5. Analysis., clinical and radiological. outcomes showed high efficiency of the developed method of treatment
Fresh and:; old fractures of the internal epicondyle and capitate eminence of the humerus in "Children (95% of favorable results), which allows us to recommend it for widespread implementation in healthcare practice.
1. Taking into account the difficulty of diagnosing fractures of the internal epicondyle and capitate eminence, especially in children of the younger age group, radiography of symmetrical positions of a healthy limb should be performed, as well as X-ray control after elimination of dislocation in the elbow joint.
2. Indications for performing osteosynthesis using a compression device are all recent and old fractures of the internal epicondyle and capitate eminence, regardless of the child's age, the degree of displacement of the fragments and the duration of the injury.
3. The developed technique of closed reposition is indicated for fresh (up to 7 days from the moment of injury) fractures of the internal epicondyle, regardless of the degree of displacement of the fragment. Reposition is carried out by passing a pin with a thrust pad through the center of the displaced epicondyle, then, using the pin as a lever, the epicondyle is moved to the "mother's bed" and fixed with the same pin passed through the humerus.
4. In case of fractures of the capitate with displacement, an open reposition is indicated, which allows achieving precise adaptation of the fracture surfaces, restoring the congruence of the articular surface, the integrity of the muscular aponeurotic formations, and preventing detachment and displacement of the periosteum.
5. Magnetotherapy should be carried out from the first day after osteosynthesis. When using the BIMP-1 apparatus, the duration of the session is 10-15 minutes, the number of procedures is 10-15. If it is necessary to carry out magntophoresis of an antibiotic, antiseptic or analgesic, the emitter can be applied to the affected area through a layer of napkins moistened with the drug.
1. Turkovsky V. B., Antipov D. I. Experience in the use of compression osteosynthesis in the treatment of fractures of the capitate eminence and internal epicondyle in children / / Urgent surgery of children. - Saratov, 1987. S. 104.
The proximal border of the shoulder is the lower edge m. pectoralis major in front and t. latissimus dorsi in the back. The distal border is a circular line above both condyles of the humerus.
In the humerus, the proximal, distal end and diaphysis are distinguished. The proximal end has a hemispherical head. Its smooth spherical surface is turned inwards, upwards and somewhat backwards. It is limited along the periphery by a grooved narrowing of the head - the anatomical neck. Outward and anterior to the head are two tubercles: the lateral large tubercle (tuberculum majus) and the small tubercle (tuberculum minus), which is located medially and anteriorly. From top to bottom, the tubercles pass into the scallops of the same name. The tubercles and scallops are the site of muscle attachment.
Between these tubercles and scallops there is an intertubercular groove. Below the tubercles, corresponding to the zone of the epiphyseal cartilage, a conditional border is determined between the upper end and the body of the humerus. This place is somewhat narrowed and is called the "surgical neck".
On the anterolateral surface of the body of the humerus, below the crest of tuberculum majoris, is the deltoid tuberosity. At the level of this tuberosity, a groove passes in the form of a spiral from top to bottom and from the inside outward (sulcus nervi radialis) along the posterior surface of the humerus.
The body of the humerus is trihedral in the lower section; three surfaces are distinguished here: posterior, anterior medial, and anterior lateral. The last two surfaces, without sharp boundaries, merge into one another and border on the back surface with well-defined edges - outer and inner.
The distal end of the bone is flattened in the anteroposterior and expanded laterally. The outer and inner edges end in well-defined tubercles. One of them, smaller, turned laterally, is the lateral epicondyle, the other, large, is the medial epicondyle. On the posterior surface of the medial epicondyle there is a groove for the ulnar nerve.
Below the lateral epicondyle there is a capitate eminence, the smooth articular surface of which, having a spherical shape, is oriented partly down, partly forward. Above the capitate eminence is the radial fossa.
Medially from the capitate eminence is the block of the humerus (trochleae humeri), through which the humerus articulates with the ulna. There is a coronal fossa in front above the block, and a rather deep cubital fossa behind it. Both fossae correspond to processes of the same name on the ulna. The area of the bone that separates the cubital fossa from the coronoid fossa is significantly thinned and consists of almost two layers of cortical bone.
The biceps muscle of the shoulder (m. biceps brachii) is located closer to the surface than the rest, and consists of two heads: a long one, starting from the tuberculum supraglenoidal scapulae, and a short one, extending from the processus coracoideus scapulae. Distally, the muscle is attached to the tubercle of the radius. M. coracobrachialis starts from the coracoid process of the scapula, is located medially and deeper than the short head of the biceps muscle and is attached to the medial surface of the bone. M. brachialis originates on the anterior surface of the humerus, lies directly below the biceps muscle, and inserts distally on the tuberosity of the ulna.
The extensors include the triceps muscle of the shoulder (m. triceps brachii). The long head of the triceps muscle originates from the tuberculum infraglenoidale scapulae, and the radial and ulnar heads from the posterior surface of the humerus. At the bottom, the muscle is attached by a wide aponeurotic tendon to the olecranon.
Elbow muscle (m. anconeus) is located superficially. It is small and has a triangular shape. The muscle originates from the lateral epicondyle of the shoulder and the collateral ligament of the radius. Its fibers diverge, lie fan-shaped on the bag of the elbow joint, partially woven into it, and are attached to the crest of the dorsum of the ulna in its upper part. N. musculocutaneus, perforating m. coracobrachialis, passes medially between m. brachialis, etc. biceps. In the proximal part of the shoulder, it is located outward from the artery, crosses it in the middle, and passes medially to the artery in the distal part.
Blood supply is provided by a. brachialis and its branches: aa.circumflexae humeri anterior and posterior, etc. The extensors are innervated by p. radialis. It passes at the top of the shoulder behind a. axillaris, and below it enters canalis humeromuscularis along with a. and v. profunda brachii, which are located medially from the nerve.
The nerve encircles the bone in a spiral, descending in the upper part between the long and medial heads of the triceps muscle, and towards the middle of the shoulder passes under the oblique fibers of the lateral head. In the distal third of the shoulder, the nerve is located between mm. brachialis and brachioradialis.
Rice. 1. Humerus (humerus).
A-front view; B-back view.
A. 1 - large tubercle of the humerus; 2 - anatomical neck of the humerus; 3 - head of the humerus; 4 - small tubercle of the humerus; 5 - intertubercular furrow; 6 - crest of a small tubercle; 7 - crest of a large tubercle; 8 - deltoid tuberosity of the humerus; 9 - body of the humerus; 10 - anterior medial surface; 11 - medial edge of the humerus; 12 - coronal fossa; 13 - medial epicondyle; 14 - block of the humerus; 15 - head of the condyle of the humerus; 16 - lateral epicondyle; 17 - radial fossa; 18 - anterolateral surface.
B. 1 - head of the humerus; 2 - anatomical neck; 3 - large tubercle; 4 - surgical neck of the humerus; 5 - deltoid tuberosity; 6 - furrow of the radial nerve; 7 - lateral edge of the humerus; 8 - fossa of the olecranon; 9 - lateral epicondyle of the humerus; 10 - block of the humerus; 11 - groove of the ulnar nerve; 12 - medial epicondyle of the humerus; 13 - medial edge of the humerus.
