Where is the humerus? Anatomy: Humerus

The special anatomy of the shoulder joint ensures high mobility of the arm in all planes, including 360-degree circular movements. But the price for this was the vulnerability and instability of the joint. Knowledge of the anatomy and structural features will help to understand the cause of diseases that affect the shoulder joint.

But before proceeding to a detailed review of all the elements that make up the formation, two concepts should be differentiated: shoulder and shoulder joint which many people confuse.

The shoulder is the upper part of the arm from the armpit to the elbow, and the shoulder joint is the structure that connects the arm to the torso.

Structural features

If we consider it as a complex conglomerate, the shoulder joint is formed by bones, cartilage, joint capsule, bursae, muscles and ligaments. In its structure, it is a simple, complex spherical joint consisting of 2 bones. The components that form it have different structure and functions, but are in strict interaction designed to protect the joint from injury and ensure its mobility.

Shoulder joint components:

• spatula
• brachial bone
• labrum
• joint capsule
• synovial bags
• muscles, including the rotator cuff
• ligaments

The shoulder joint is formed by the scapula and humerus, enclosed in a joint capsule.

The rounded head of the humerus is in contact with the fairly flat articular bed of the scapula. In this case, the scapula remains practically motionless and the movement of the hand occurs due to the displacement of the head relative to the articular bed. Moreover, the diameter of the head is 3 times larger than the diameter of the bed.

This discrepancy between shape and size provides a wide range of movements, and the stability of the articulation is achieved through the muscular corset and ligamentous apparatus. The strength of the articulation is also given by the articular lip located in the scapular cavity - cartilage, the curved edges of which extend beyond the bed and cover the head of the humerus, and the elastic rotator cuff surrounding it.

Ligamentous apparatus

The shoulder joint is surrounded by a dense joint capsule (capsule). The fibrous membrane of the capsule has varying thicknesses and is attached to the scapula and humerus, forming a spacious sac. It is loosely stretched, which allows you to move and rotate your hand freely.

The inside of the bag is lined with a synovial membrane, the secretion of which is synovial fluid that nourishes articular cartilage and ensuring the absence of friction when they slide. On the outside, the joint capsule is strengthened by ligaments and muscles.

The ligamentous apparatus performs a fixing function, preventing displacement of the head of the humerus. Ligaments are formed by strong, poorly tensile tissues and are attached to bones. Poor elasticity causes damage and rupture. Another factor in the development of pathologies is an insufficient level of blood supply, which is the cause of the development of degenerative processes of the ligamentous apparatus.

Shoulder joint ligaments:

1. coracobrachial
2. upper
3. average
4. lower

Human anatomy is a complex, interconnected and fully thought-out mechanism. Since the shoulder joint is surrounded by a complex ligamentous apparatus, for the sliding of the latter, mucous synovial bursae (bursae) are provided in the surrounding tissues, communicating with the joint cavity. They contain synovial fluid, ensure smooth operation of the joint and protect the capsule from stretching. Their number, shape and size are individual for each person.

Muscular frame

The muscles of the shoulder joint are represented by both large structures and small ones, due to which the rotator cuff is formed. Together they form a strong and elastic frame around the joint.

Muscles surrounding the shoulder joint:

• Deltoid. It is located on top and outside the joint, and is attached to three bones: the humerus, scapula and clavicle. Although the muscle is not directly connected to the joint capsule, it reliably protects its structures on 3 sides.
• Biceps (biceps). It is attached to the scapula and humerus and covers the joint from the front.
• Triceps (triceps) and coracoid. Protects the joint from the inside.

The rotator cuff allows a wide range of motion and stabilizes the head of the humerus by holding it in the socket.

It is formed by 4 muscles:

1. subscapularis
2. infraspinatus
3. supraspinatus
4. small round

The rotator cuff is located between the head of the humerus and the acromin, the process of the scapula. If the space between them narrows due to various reasons, the cuff is pinched, leading to a collision of the head and acromion, and is accompanied by severe pain.

Doctors called this condition “impingement syndrome.” With impingement syndrome, injury to the rotator cuff occurs, leading to its damage and rupture.

Blood supply

The blood supply to the structure is carried out using an extensive network of arteries, through which nutrients and oxygen enter the joint tissues. Veins are responsible for removing waste products. In addition to the main blood flow, there are two auxiliary vascular circles: the scapular and the acromial deltoid. Risk of rupture of those passing near the joint large arteries significantly increases the risk of injury.

Elements of blood supply

• suprascapular
• front
• back
• thoracoacromial
• subscapularis

• humeral
• axillary

innervation

Any damage or pathological processes in the human body are accompanied by pain. Pain can signal the presence of problems or perform security functions.

In the case of joints, soreness forcibly “deactivates” the diseased joint, preventing its mobility to allow injured or inflamed structures to recover.

Shoulder nerves:

• axillary
• suprascapular
• chest
• ray
• subscapular
• axle

Development

When a child is born, the shoulder joint is not fully formed, its bones are separated. After the birth of a child, the formation and development of shoulder structures continues, which takes about three years. During the first year of life, the cartilaginous plate grows, the articular cavity is formed, the capsule contracts and thickens, and the ligaments surrounding it strengthen and grow. As a result, the joint is strengthened and fixed, reducing the risk of injury.

Over the next two years, the articulation segments increase in size and take on their final shape. The humerus is the least susceptible to metamorphosis, since even before birth the head has a rounded shape and is almost completely formed.

Shoulder instability

The bones of the shoulder joint form a movable joint, the stability of which is provided by muscles and ligaments.

This structure allows for a large range of movements, but at the same time makes the joint prone to dislocations, sprains and ligament tears.

Also, people often encounter a diagnosis such as instability of the articulation, which is made when, when moving the arm, the head of the humerus extends beyond the articular bed. In these cases, we are not talking about an injury, the consequence of which is a dislocation, but about the functional inability of the head to remain in the desired position.

There are several types of dislocations depending on the displacement of the head:

1. front
2. rear
3. lower

The structure of the human shoulder joint is such that it is covered from behind by the scapula, and from the side and above by the deltoid muscle. The frontal and internal parts remain insufficiently protected, which causes the predominance of anterior dislocation.

Functions of the shoulder joint

High mobility of the joint allows for all movements available in 3 planes. Human hands can reach any point of the body, carry heavy loads and perform delicate work that requires high precision.

Movement options:

• lead
• cast
• rotation
• circular
• bending
• extension

It is possible to perform all of the listed movements in full only with the simultaneous and coordinated work of all elements of the shoulder girdle, especially the collarbone and acromioclavicular joint. With the participation of one shoulder joint, the arms can only be raised to shoulder level.

Knowledge of the anatomy, structural features and functioning of the shoulder joint will help to understand the mechanism of injury, inflammatory processes and degenerative pathologies. The health of all joints in the human body directly depends on lifestyle.

Excess weight and lack of physical activity harm them and are risk factors for the development of degenerative processes. A careful and attentive attitude towards your body will allow all its constituent elements to work for a long time and flawlessly.

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There are fractures of the head, anatomical neck (intra-articular); transtubercular fractures and surgical neck fractures (extra-articular); avulsions of the greater tubercle of the humerus (Fig. 1). The main types of fractures are given in the AO/ASIF UKP.

Rice. 1. Fractures in the proximal part of the humerus: 1 - fractures of the anatomical neck; 2 — transtubercular fractures; 3 — surgical neck fractures

Fractures of the head and anatomical neck of the humerus

Causes: a fall on the elbow or a direct blow to outer surface shoulder joint. When the anatomical neck is fractured, the distal fragment of the humerus usually becomes wedged into the head.

Sometimes the humeral head becomes crushed and deformed. The head can be torn off, with its cartilaginous surface turning towards the distal fragment.

Signs. The shoulder joint is increased in volume due to swelling and hemorrhage. Active movements in the joint are limited or impossible due to pain. Palpation of the shoulder joint area and tapping the elbow are painful. During passive rotation movements, the greater tuberosity moves with the shoulder. With concomitant dislocation of the head, the latter cannot be felt in its place. Clinical signs less pronounced with an impacted fracture: active movements are possible; with passive movements, the head follows the diaphysis. The diagnosis is confirmed by x-ray; an axial projection is required. Mandatory monitoring of vascular and neurological disorders is necessary.

Treatment. Victims with impacted fractures of the head and anatomical neck of the humerus are treated on an outpatient basis. 20-30 ml of a 1% solution of novocaine is injected into the joint cavity, the arm is immobilized with a plaster splint according to G.I. Turner in the position of abduction (using a roller, pillow) by 45-50°, flexion in the shoulder joint up to 30°, in the elbow - up to 80-90°. Analgesics, sedatives are prescribed, from the 3rd day they begin magnetic therapy, UHF on the shoulder area, from the 7-10th day - active movements in the wrist and elbow and passive movements in the shoulder joint (removable splint!), electrophoresis of novocaine, calcium chloride , UV irradiation, ultrasound, massage.

After 4 weeks the plaster splint is replaced with a scarf bandage, and rehabilitation treatment is intensified. Rehabilitation - up to 5 weeks.

Working capacity is restored after 2-2 1/2 months.

Indications for surgery: impossibility of reduction in unstable fractures with significant displacement of fragments, interposition of soft tissues and fragments between articular surfaces (type A3 and more severe).

Fractures of the surgical neck of the humerus

Causes. Fractures without displacement of fragments are usually impacted or pinched. Fractures with displacement of fragments, depending on their position, are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur when falling with emphasis on the outstretched adducted arm. In this case, the proximal fragment is retracted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward. Abduction fractures occur when falling with emphasis on the outstretched abducted arm. In these cases, the central fragment is adducted and rotated medially, and the peripheral fragment is internally and anteriorly displaced forward and upward. An angle is formed between the fragments, open outward and posteriorly.

Signs. With impacted fractures and non-displaced fractures, local pain is determined, which increases with load along the axis of the limb and rotation of the shoulder; the function of the shoulder joint is possible, but limited. During passive abduction and rotation of the shoulder, the head follows the diaphysis. The x-ray determines the angular displacement of the fragments. For fractures with displacement of fragments, the main signs are sharp pain, dysfunction of the shoulder joint, pathological mobility at the level of the fracture, shortening and disruption of the axis of the shoulder. The nature of the fracture and the degree of displacement of the fragments are clarified radiographically.

Treatment. First aid includes the administration of analgesics (Promedol), immobilization with a transport splint or Deso bandage (Fig. 2), hospitalization in a trauma hospital, where a full examination is carried out, anesthesia of the fracture site, reposition and immobilization of the limb with a splint (for impacted fractures) or a thoracobrachial bandage with mandatory radiographic control after the plaster has dried and after 7-10 days.

Rice. 2. Transport immobilization for fractures of the humerus: a, b - Deso bandage (1-5 - bandage stroke); in — ladder tire

Features of reposition(Fig. 3): for adduction fractures, the assistant lifts the patient’s arm forward by 30-45° and abducts it by 90°, bends it elbow joint up to 90°, rotates the shoulder outward by 90° and gradually smoothly produces traction along the axis of the shoulder. The traumatologist controls the reposition and performs corrective manipulations in the area of ​​the fracture. The traction along the axis of the shoulder should be strong; sometimes for this, an assistant applies counter support with the foot in the area of ​​the armpit. After this, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction to 90-100°, flexion at the elbow joint to 80-90°, extension at the wrist joint to 160°.

Rice. 3. Reposition and retention of fragments of the humerus: a, b - with abduction fractures; c-e - for adduction fractures; e - thoracobrachial bandage; g - treatment according to Kaplan

For abduction fractures, the traumatologist corrects the angular displacement with his hands, then reposition and immobilization are carried out in the same way as for adduction fractures.

The duration of immobilization is from 6 to 8 weeks; from the 5th week, the shoulder joint is released from fixation, leaving the arm on the abduction splint.

Rehabilitation time is 3-4 weeks.

Working capacity is restored after 2-2 1/2 months.

From the first day of immobilization, patients should actively move their fingers and hand. After turning the circular bandage into a sponge bandage (after 4 weeks), passive movements in the elbow joint are allowed (with the help of a healthy arm), and after another week - active ones. At the same time, massage and mechanotherapy are prescribed (for dosed load on the muscles). Patients practice exercise therapy daily under the guidance of a methodologist and independently every 2-3 hours for 20-30 minutes.

After the patient can repeatedly raise his arm above the splint by 30-45° and hold the limb in this position for 20-30 seconds, the abduction splint is removed and full rehabilitation begins. If closed reduction of fragments fails, then it is indicated surgical treatment(Fig. 4).

Rice. 4. Osteosynthesis for a fracture of the surgical neck of the humerus, bone (a) and Ilizarov apparatus (b)

After open reduction, the fragments are fixed with lag screws with a T-shaped plate. If the bone is osteoporotic, then knitting needles and a tightening wire suture are used. Four-part fractures of the head and neck of the humerus (type C2) are an indication for endoprosthetics.

Fractures of the tuberosities of the humerus

Causes. A fracture of the greater tuberosity often occurs with a dislocated shoulder. Its separation with displacement occurs as a result of a reflex contraction of the supraspinatus, infraspinatus and teres minor muscles. An isolated nondisplaced fracture of the greater tuberosity is primarily associated with a direct blow to the shoulder.

Signs. Limited swelling, tenderness and crepitus on palpation. Active abduction and external rotation of the shoulder are impossible, passive movements are sharply painful. The diagnosis is confirmed by x-ray.

Treatment. For fractures of the greater tubercle without displacement after blockade with novocaine, the arm is placed on an abductor pillow and immobilized with a Deso bandage or scarf for 3-4 weeks.

Rehabilitation - 2-3 weeks.

Working capacity is restored after 5-6 weeks.

In case of avulsion fractures with displacement, after anesthesia, reposition is carried out by abduction and external rotation of the shoulder, then the limb is immobilized on an abduction splint or with a plaster cast (Fig. 5).

Rice. 5. Fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - therapeutic immobilization

For large edema and hemarthrosis, it is advisable to continue for 2 weeks. use shoulder traction. Abduction of the arm on the splint is stopped as soon as the patient can freely lift and rotate the shoulder.

Rehabilitation - 2-4 weeks.

Working capacity is restored after 2-2 1/2 months.

Indications for surgery. Intra-articular supra-tubercular fractures with significant displacement of fragments, failed reduction in a fracture of the surgical neck of the humerus, entrapment of the greater tubercle in the joint cavity. Osteosynthesis is performed with a screw or a tightening wire loop (Fig. 6).

Rice. 6.Surgery fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - fixation with a screw; c - fixation with wire

Complications are the same as with shoulder dislocations.

Traumatology and orthopedics. N. V. Kornilov

ENCYCLOPEDIA OF MEDICINE /SECTION^

ANATOMICAL ATLAS

The structure of the humerus

Brachial bone- a typical long tubular bone, forms the proximal (upper) part of the arm. It has a long body and two ends, one of which articulates with the scapula at the shoulder joint, the other with the ulna and radius bones at the elbow joint.

The apex of the humerus—its proximal end—has a large, smooth, hemispherical articular surface that articulates with the glenoid cavity of the scapula to form the shoulder joint. The head is separated from the rest by a narrow interception - an anatomical neck, below which there are two bony protrusions - the greater and lesser tubercles. These tubercles serve as sites of muscle attachment and are separated by the intertubercular groove.

BODY OF HUMERUS

_(DIAPHYSUS)_

There is a slight narrowing at the top of the body of the humerus - the surgical neck is a common site for fractures. The relatively smooth surface of the diaphysis has two distinctive features. Approximately in the middle of the length of the body of the humerus, closer to its upper epiphysis on the lateral (side) surface, there is a deltoid tuberosity, to which the deltoid muscle is attached. Below the tuberosity, a spiral groove runs along the posterior surface of the humerus radial nerve. In the deepening of this groove pass the radial nerve and deep arteries of the shoulder.

The lateral edges of the diaphysis in its lower part pass into protruding medial (internal) and lateral epicondyles. The articular surface is formed by two anatomical formations: the trochlea of ​​the humerus, which articulates with the ulna, and the head of the condyle of the humerus, which articulates with the radius.

Humerus, posterior view

humerus

Articulates with the glenoid cavity of the scapula at the shoulder joint.

Anatomical -

It is a remnant of the growth plate where bone growth occurs in length during childhood.

Body of humerus

The diaphysis makes up the bulk of the length of the bone.

Radial nerve groove

It runs obliquely along the posterior surface of the middle part of the body of the humerus.

Humerus block

Medial epicondyle -

More prominent bony projection than the lateral epicondyle.

Greater tuberosity

Place of muscle attachment.

Humerus, front view

Lesser tubercle

Place of muscle attachment.

Surgical neck

Narrow interception, frequent site of fractures.

Deltoid tuberosity

Insertion site of the deltoid muscle.

Head -

humeral condyle

It has a spherical shape, articulates with the head of the radius.

Lateral epicondyle

External bony prominence.

Anatomical neck

Intertubercular groove

It contains the tendon of the biceps brachii muscle.

At these points the bone can be easily felt under the skin.

Humerus fractures

Most fractures of the upper humerus occur at the level of the surgical neck as a result of a fall on an outstretched arm. Fractures of the body of the humerus are dangerous due to possible injury to the radial nerve, which lies in the groove of the same name on the posterior surface of the bone. Damage to it can cause paralysis of the muscles of the back of the forearm, which is manifested by drooping of the hand. H This x-ray shows a fracture of the upper body of the humerus. This injury usually occurs when falling on an outstretched arm.

In children, fractures of the humerus are often localized in the supracondylar region (in the lower part of the body of the humerus above the elbow joint). Typically, the mechanism of such an injury is a fall on the arm, slightly bent at the elbow. This can damage nearby arteries and nerves.

Sometimes, with complex fractures of the humerus, there is a need to stabilize it with a metal pin, which holds the bone fragments in the correct position.

Medial epicondyle

A bony prominence that can be felt on the inside of the elbow.

Humerus block

Articulates with the ulna.

The long tubular bone, divided into a diaphysis, proximal and distal epiphyses, fossa, tubercle and surgical neck, is the humerus. A fracture in this area is a common occurrence in surgical practice, occurring in both young and elderly people. Shoulder injuries occur due to impacts and falls and are one of the most common household injuries.

What is the humerus

1. Fractures of the upper sections. They can form due to damage to the head, separation of the small or large tubercle, or fracture of the necks. Falling on an abducted arm, elbow or shoulder are the main causes of injury. Patients complain of pain, swelling, and pain when trying to perform active movements. Passive actions are not very limited. A displaced fracture is accompanied by severe pain, deformation occurs in the joint area, and the limb becomes shorter. Crunching of bones and swelling accompany the damage.
2. Fracture of the middle part of the shoulder. Occurs when you fall on your arm or get hit on the shoulder. There are comminuted, oblique, transverse, and helical fractures. Accompanied by damage to the radial nerve, arteries, and veins. The victim experiences swelling, pain, deformation, crepitus, and pathological bone mobility. The patient cannot straighten his fingers and wrist. To make a diagnosis, an x-ray is taken, based on the results of which treatment is prescribed.
3. Fracture in the lower sections. There are extra-articular and intra-articular fractures. Extra-articular injuries include supracondylar injuries, and intra-articular injuries include injuries to the trochlea, capitate eminence of the humerus, and intercondylar fractures. Supracondylar injuries of the shoulder can be flexion or extension. The shoulder swells greatly and there is severe pain. With flexion fractures, the forearm lengthens, and with extension fractures, it shortens. Injuries to the condyles are accompanied by accumulation of blood in the elbow, while transcondylar injuries are accompanied by pain, swelling, and limitation of movements in the joints.

Treatment

Simple fractures are fixed with a plaster splint for about a month. Immobilization should ensure complete immobility of the arm. If the fragments are displaced, surgery or repositioning is performed under anesthesia. Fractures are fixed with knitting needles, screws, a Turner bandage, and adhesive plaster or skeletal traction is used. For rehabilitation, physical therapy, mechanotherapy, and physiotherapeutic procedures are carried out.

Splint for humerus fracture

To fix the damage, use a Kramer splint, which is applied across the back from the healthy shoulder. For a fracture of the elbow joint, a wire splint is used; for damage to the wrist joint, a long plywood splint is used. Fixation is made on the forearm. In some cases, a ball of cotton wool should be placed in the patient's palm. If the forearm is fractured, 2 splints are applied, after first fixing the arm in the palm-up position. The bent limb is suspended on a scarf.

Photo of the humerus

Video

Humerus, humerus, is a long lever of movement and develops like a typical long tubular bone. According to this function and development, it consists of a diaphysis, metaphyses, epiphyses and apophyses. The upper end is equipped with a spherical articular head, caput humeri (proximal epiphysis), which articulates with the glenoid cavity of the scapula. The head is separated from the rest of the bone by a narrow groove called the anatomical neck, collum anatomicum. Immediately behind the anatomical neck there are two muscular tubercles (apophyses), of which the larger one, tuberculum majus, lies laterally, and the other, smaller one, tuberculum minus, slightly anterior to it. From the tubercles downwards there are bone ridges (for muscle attachment): from the large tubercle - crista tuberculi majoris, and from the small tubercle - crista tuberculi minoris. Between both tubercles and ridges there is a groove, sulcus intertuberculdris, in which the tendon of the long head of the biceps muscle is located. The part of the humerus lying immediately below both tubercles at the border with the diaphysis is called the surgical neck - collum chirurgicum (the place of the most common fractures of the shoulder).

Body of humerus in its upper part it has a cylindrical outline, while at the bottom it is clearly triangular. Almost in the middle of the body of the bone, on its lateral surface there is a tuberosity to which the deltoid muscle, tuberositas deltoidea, is attached. Behind it, along the posterior surface of the body of the bone, from the medial side to the lateral side, a flat groove of the radial nerve, sulcus nervi radidlis, seu sulcus spiralis, runs in the form of a gentle spiral.

The widened and slightly bent anteriorly lower end of the humerus, condylus humeri, ends on the sides with rough protrusions - the medial and lateral supramidal fissures and, epicondylus medialis et lateralis, lying on the continuation of the medial and lateral edges of the bone and serving for the attachment of muscles and ligaments (apophyses). The medial epicondyle is more pronounced than the lateral one, and on its posterior side it has a groove for the ulnar nerve, sulcus n. ulnaris. An articular surface is placed between the epicondyles for articulation with the bones of the forearm (disgal epiphysis). It is divided into two parts: medially lies the so-called block, trochlea, which looks like a transversely located roller with a notch in the middle; it serves for articulation with the ulna and is covered by its notch, incisura trochlearis; above the block, both in front and behind, is located along the fossa: in front is the coronoid fossa, fossa coronoidea, behind is the fossa of the olecranon, fossa olecrani. These pits are so deep that the bony partition separating them is often thinned to the point of being translucent, and sometimes even perforated. Lateral to the block is the articular surface in the form of a segment of a ball, the head of the condyle of the humerus, capitulum humeri, which serves for articulation with the radius. Anteriorly above the capitulum there is a small radial fossa, fossa radialis.

Ossification. At birth, the proximal epiphysis of the humerus still consists of cartilage tissue, therefore, on an x-ray of the shoulder joint of a newborn, the head of the humerus is almost not visible. Subsequently, three points appear sequentially:

1. in the medial part of the head of the humerus (0-1 year) (this bone core can also be present in a newborn);
2. in the greater tubercle and lateral part of the head (2-3 years);
3. in tuberculum minus (3-4 years).

These nuclei merge into a single head of the humerus (caput humeri) at the age of 4-6 years, and synostosis of the entire proximal epiphysis with the diaphysis occurs only at the 20-23rd year of life. Therefore, on radiographs of the shoulder joint belonging to children and young people, according to the indicated ages, clearings are noted at the site of the cartilage separating the parts of the proximal end of the humerus that have not yet fused from each other. These lucencies, which represent normal signs of age-related changes, should not be confused with cracks or fractures of the humerus.

Which doctors to contact for examination of the humerus:

Traumatologist

What diseases are associated with the humerus:

What tests and diagnostics need to be performed for the humerus:

X-ray of the humerus

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Other anatomical terms starting with the letter "P":

Esophagus

Chin

Spine

Navel (navel)

Penis

Prostate

Crotch

Liver

Parathyroid glands

Pancreas

Bud

Medulla

Pleura

Peripheral nerves

Membranous labyrinth

Subglottic cavity

Oral cavity

Rectum

Plasma

Vertebrae

Lumbar vertebrae

Shoulder joint

Groin area

Shoulder

Forearm

Finger

Peripheral nervous system

parasympathetic nervous system

Sweat gland

Sex glands

Prostate

Placenta

Epididymis and periovarian

Paraganglia

Right ventricle

conduction system of the heart

Atrioventricular node

Pericardium

Brachiocephalic trunk

Subclavian artery

Axillary artery

Brachial artery

Popliteal artery

Anterior tibial artery

Brachiocephalic veins

Anterior jugular vein

Subclavian vein

Vertebral venous plexuses

Right lymphatic duct

Isthmus of the rhombencephalon

forebrain

The proximal border of the shoulder is the lower edge of m. pectoralis major in front and latissimus dorsi in back. The distal border is a circular line above both condyles of the humerus.

The humerus is divided into a proximal, distal end and diaphysis. The proximal end has a hemispherical head. Its smooth spherical surface faces inward, upward and somewhat backward. It is limited along the periphery by a grooved narrowing of the head - the anatomical neck. Outward and anterior to the head there are two tubercles: the lateral greater tubercle (tuberculum majus) and the lesser tubercle (tuberculum minus), which is located more medially and anteriorly. Below, the tubercles turn into scallops of the same name. The tubercles and scallops are the site of muscle attachment.

Between these tubercles and ridges there is an intertubercular groove. Below the tubercles, corresponding to the zone of the epiphyseal cartilage, a conditional boundary 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 anterior outer surface of the body of the humerus, below the crest of the tuberculum majoris, there is a deltoid tuberosity. At the level of this tuberosity, a groove runs along the posterior surface of the humerus in the form of a spiral from top to bottom and from inside to outside (sulcus nervi radialis).

The body of the humerus is triangular in the lower part; here three surfaces are distinguished: posterior, anterior medial and anterior lateral. The last two surfaces pass into one another without sharp boundaries and border the rear surface with well-defined edges - outer and inner.

The distal end of the bone is flattened anteroposteriorly and expanded laterally. The outer and inner edges end in well-defined tubercles. One of them, the smaller one, facing laterally, is the lateral epicondyle, the other, the larger one, 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 downward, partly forward. Above the capitate eminence is the radial fossa.

Medial to the capitate eminence is the block of the humerus (trochleae humeri), through which the humerus articulates with the ulna. In front above the trochlea there is a coronoid fossa, and behind there is a rather deep ulnar fossa. Both fossae correspond to the processes of the same name of the ulna. The area of ​​bone separating the ulnar fossa from the coronoid fossa is significantly thinned and consists of almost two layers of cortical bone.

The biceps brachii muscle (m. biceps brachii) is located closer to the surface than the others and consists of two heads: a long one, starting from the tuberculum supraglenoidale scapulae, and a short one, extending from the processus coracoideus scapulae. Distally the muscle attaches to the tubercle radius. M. coracobrachialis originates from the coracoid process of the scapula, is located medial 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 immediately beneath the biceps muscle, and inserts distally on the tuberosity of the ulna.

The extensors include the triceps brachii muscle (m. triceps brachii). The long head of the triceps muscle starts from the tuberculum infraglenoidae scapulae, and the radial and ulnar heads start from the posterior surface of the humerus. Below, the muscle is attached by the wide aponeurotic tendon to the olecranon process.

The elbow muscle (m. anconeus) is located superficially. It is small and triangular in shape. The muscle originates from the lateral epicondyle of the humerus and the collateral ligament of the radius. Its fibers diverge, lie fan-shaped on the bursa of the elbow joint, partially woven into it, and are attached to the crest of the dorsal surface 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 outside the artery, in the middle it crosses it, and in the distal part it passes medial to the artery.

Blood supply is provided by a. brachialis and its branches: aa.circumflexae humeri anterior and posterior, etc. The extensors are innervated by the p. radialis. It passes at the top of the shoulder behind a. axillaris, and below is included in canalis humeromuscularis along with a. and v. profunda brachii, which are located medially from the nerve.

The nerve encircles the bone in a spiral manner, descending in the upper part between the long and medial heads of the triceps muscle, and towards the middle of the shoulder it 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-rear view.

A. 1 - greater tubercle of the humerus; 2 - anatomical neck of the humerus; 3 - head of the humerus; 4 - lesser tubercle of the humerus; 5 - intertubercular groove; 6 - crest of the lesser tubercle; 7 - crest of the greater tubercle; 8 - deltoid tuberosity of the humerus; 9 - body of the humerus; 10 - anteromedial surface; 11 - medial edge of the humerus; 12 - coronoid 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 - greater tubercle; 4 - surgical neck of the humerus; 5 - deltoid tuberosity; 6 - groove of the radial nerve; 7 - lateral edge of the humerus; 8 - fossa of the olecranon process; 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.

Skeletal bones are unique formations that arose during the process of evolution. Each bone has a unique structure, best suited for performing work, which is associated not only with supporting the body and moving it in space, but also with protecting organs. The main and largest component of the arm is the humerus, which is surrounded by muscles, nerves and choroid plexuses. There are also joints in which this bone takes part - the humerus and the elbow, with the help of which many functions are performed.

Proximal end

The part that is located near the shoulder joint is called the proximal end. Here is the nerve plexus of the shoulder, the anatomy of which consists of three bundles that can be damaged by injury. The head of the humerus is involved in the formation of the joint; it has a structure that is different from other areas, which allows you to perform the range of arm movements that is familiar to every person.

The head of the bone is smooth and covered with cartilage, which is required for the joint, but it is larger in volume than the surface with which it comes into contact, as a result of which shoulder dislocations occur. Below is the anatomical neck, it is a groove, and the human joint capsule is attached to it.

Below the anatomical neck, the structure suggests the presence of two tubercles - large and small; many muscles are attached to them in humans; there is also a nerve plexus nearby. The rotator cuff of the shoulder, which is responsible for rotation and function, is attached to these formations. The anatomy of these formations is such that it is in this place that fractures appear during a fall, and not only the rotator cuff suffers, but also other muscles, as important anatomical formations of this part of the limb.

A ridge extends down from each of the tubercles, which bears the same name. Together with the tubercles, the ridges form another formation - the intertubercular groove. In this place lies the tendon of the long head of the biceps muscle, which is also involved in the movement of the shoulder joint and its normal function. The rotator cuff is also located in this place, the tendons of which can be damaged if injured.

If you look below, there is a formation that is no different from the body of the bone, but is important in the practical work of a doctor. The anatomy of this section of the shoulder is designed in such a way that a surgical neck is located under the head. This place received its name as the weakest place in humans, which is most often subject to injury. Especially in the elderly, the bone breaks in this area, sometimes with muscle damage from fragments. In a child, this place corresponds to the growth zone of the arm and its bone component.

Body of bone

The main part of the bone is, of course, the body, which performs significant functions; it accounts for the bulk of the mass, like a lever. It is hidden in the thickness of the muscles and has a circular cross-section in the upper section, and a triangular cross-section in the lower section. The triangular shape of the bone is given by ridges, among which there are anterior, external and internal. There are also three surfaces: one back, and also outer and inner. There are nutrient openings in the body area; small arteries of the arm pass through them, delivering blood inside the bone.

In this part of the arm there is one formation located in this place - the groove of the radial nerve. It runs in a spiral, surrounded by muscles, here the radial nerve passes almost close to the bone, which can also be damaged by injury. Then below it goes into the thickness of the muscles, and if the condyle of the bone is fractured, the ulnar nerve, located on the inside, can be damaged. On the inner surface there is another formation no less important for the human hand; it is called the deltoid tuberosity and serves to fix the tendon of the muscle of the same name. Next to it there is also a vascular and nerve plexus.

Distal end

The part near the elbow is called the distal end and has its own structure. The anatomy of this area is such that, in addition to the attachment of muscles, this component of the arm is involved in the formation of the joint. There is also a plexus of blood vessels and nerves that can be damaged by injury or fracture.

The lowest part, which participates in the formation of the joint, is called the condyle of the humerus. Its anatomy is complex, on the inside it is formed by the shoulder block, the ulna bone articulates with it using a joint, and on the outside the head, which forms the articular surface with the radius. But this is not the whole structure of this part of the arm; in addition to the thickness of the soft tissues, the coronoid fossa is located on the front surface, the function of which is that the coronoid process of the ulna bone enters it during flexion. Nearby is a less pronounced radial fossa, its functions are similar, only it is intended for the radius.

On the back of the arm in this section there are also muscles and the choroid plexus. The structure of this section of the shoulder is represented by the olecranon fossa; it enters it during extension of the joint.

In the upper part of the condyle there are epicondyles, muscles are attached to them, as well as the joint capsule. The external and internal epicondyle are distinguished; muscle tendons are fixed to them, the functions of which are to move the forearm and shoulder. Ridges rise upward from each epicondyle; this is the attachment point for the muscles of the shoulder and forearm.

Due to greater muscle attachment, the development of the internal epicondyle occurs more strongly. On its posterior surface is the ulnar nerve plexus and there is a groove for this nerve.

This formation has a protrusion to which the muscles are fixed (flexor carpi radialis); it is called the supracondylar process. The condyles, as the site of attachment of tendons, can be felt under the skin, as well as the groove of the ulnar nerve. These projections can be landmarks that can be used to guess where the choroid or nerve plexus is located.

The structure of any part of the humerus is as simple as it is unique; like a cuff, it is surrounded by muscles, blood vessels and nerves. This powerful lever helps a person perform many functions without which it is difficult to imagine everyday life.

- this is a violation of the integrity of the humerus in its upper part, just below the shoulder joint. More often occurs in women of elderly and senile age, the cause is a fall on a hand laid back or pressed to the body. It is manifested by pain, swelling and limitation of movement in the shoulder joint. Sometimes bone crunch is determined. To clarify the diagnosis, an X-ray examination is performed. Treatment is usually conservative: anesthesia, reduction and immobilization. If it is impossible to match the fragments, the operation is performed.

ICD-10

S42.2 Fracture of the upper end of the humerus

General information

Fracture of the neck of the shoulder - damage to the upper end of the humerus. It is more often detected in older women, which is due not only to osteoporosis, but also to a characteristic restructuring of the metaphysis of the humerus: a decrease in the number of bone beams, an increase in the size of the medullary cavities, and thinning of the outer wall of the bone in the area of ​​​​the transition of the metaphysis to the diaphysis. A fracture usually occurs as a result of indirect trauma. It may be impacted, accompanied or not accompanied by displacement of fragments.

In most cases, a fracture of the neck of the shoulder is a closed isolated injury; open injuries in this area are almost never found. With high-energy impacts, combinations with fractures of other bones of the limbs, pelvic fracture, spinal fracture, head injury, rib fractures, blunt abdominal trauma, rupture Bladder, kidney damage, etc. Treatment of fractures of the neck of the shoulder is carried out by orthopedic traumatologists.

Causes

According to the observations of specialists in the field of traumatology and orthopedics, usually the cause of a fracture of the neck of the shoulder is an indirect injury (falling on the elbow, shoulder or hand), in which there is a flexion of the bone in combination with pressure on it along the axis. The effect of applied forces depends on the position of the hand at the time of injury. If the limb is in a neutral position, the fracture line is usually transverse. The peripheral fragment is introduced into the head, an impacted fracture is formed. In this case, the longitudinal axis may be preserved, but the formation of a more or less pronounced angle, open posteriorly, is more often observed.

If the shoulder is in the adduction position at the time of injury, the central fragment “goes” into the abduction position and turns outward. In this case, the peripheral fragment turns inward, shifts anteriorly and outwards. An adduction fracture occurs, in which the angle between the fragments is open posteriorly and medially. If the inner edge of the distal fragment is embedded in the head, an impacted adduction fracture of the surgical neck of the shoulder is formed. If the introduction does not occur (it is quite rare), damage is formed with a complete displacement and separation of the fragments.

When the shoulder is abducted at the time of injury, the central fragment “leaves” into the adduction position and turns inwards. In this case, the peripheral fragment is pulled forward and upward, turns inward and moves anteriorly. The fragments form an angle open posteriorly and outwards. This injury is called an abduction fracture. As in the previous case, with abduction injuries, a part of the peripheral fragment usually penetrates into the head of the shoulder; complete separation and displacement of the fragments is rarely detected. The most common fractures are abduction.

Pathoanatomy

The humerus is a long tubular bone consisting of a diaphysis (middle), two epiphyses (upper and lower) and transitional zones between the diaphysis and epiphyses (metaphyses). The upper end of the bone is represented by a spherical articular head, immediately below which is a natural narrowing - the anatomical neck of the shoulder. Fractures in this area are very rare. Just below the anatomical neck are two tubercles (places of attachment of muscle tendons) - large and small.

Below the tubercles and above the place of attachment of the pectoralis major muscle, there is a conditional border between the upper end and the diaphysis of the bone. This border is called the surgical neck of the shoulder, it is in this area that fractures most often occur. The articular capsule of the shoulder joint is attached just above the tubercles, so transtubercular fractures, as well as fractures of the actual surgical neck of the shoulder, are classified as extra-articular injuries. The division of these injuries is very conditional, taking into account the general symptoms and principles of treatment, most clinicians combine them into a general group of fractures of the surgical neck of the shoulder.

Such fractures usually heal well, the formation of false joints is extremely rare. However, in the presence of a sufficiently pronounced displacement and the absence of reposition in the long-term period, a significant limitation of movements is possible, due to both the consolidation of fragments in the wrong position and the proximity of the ligaments and the articular bag, which are easily involved in the adhesive process. The most unfavorable from the point of view of the subsequent limitation of function is an unrepaired adduction fracture, after which a pronounced restriction of abduction may occur.

Fracture symptoms

Patients with impacted fractures of the neck of the shoulder complain of moderate pain in the joint area, aggravated by movement. The joint is edematous, hemorrhages are often found. Active movements are possible, but limited due to pain. Palpation of the head of the shoulder is painful. With fractures with displacement, the symptoms are more pronounced: the rounded shape of the joint is disturbed, some protrusion of the acromial process and retraction in the head region are noticeable.

A change in the axis of the shoulder is noted: it runs obliquely, while the central end of the axis is directed forward and inward. The elbow is displaced backward and away from the body, however, there is no fixation of the elbow joint (as in case of dislocation), the symptom of spring resistance is not detected. The shortening of the diseased shoulder by 1-2 cm is determined. Active movements are impossible, passive ones are sharply limited due to pain and are sometimes accompanied by a bone crunch. During rotational movements, the head does not move with the humerus.

On palpation of the surgical neck, there is a sharp local pain. In thin patients with poorly developed muscles in the armpit, it is possible to palpate the end of the distal bone fragment. In some cases, a displaced fragment can compress the neurovascular bundle, which is manifested by cyanosis due to impaired venous outflow, swelling of the limb and a feeling of crawling.

Diagnostics

To clarify the diagnosis, an x-ray of the shoulder joint is prescribed in two projections: direct and "epaulet" (axial). An "epaulette" shot is performed by moving the shoulder away from the body at an angle of 30-40 degrees. Greater abduction is categorically not recommended, as it can aggravate the displacement of fragments. In doubtful cases, CT of the shoulder joint is used. If compression of the neurovascular bundle is suspected, patients are referred for a consultation with neurologists or neurosurgeons and vascular surgeons.

Treatment of a fracture of the neck of the shoulder

Elderly patients with impacted fractures do not require reposition in most cases. The area of ​​damage is anesthetized with novocaine and a fixing bandage is applied for a period of 6 weeks. If a moderately displaced impacted fracture has been diagnosed in a young or middle-aged person, reduction is indicated. For patients of all ages, reposition is performed for comminuted and non-impacted fractures. Then the limb is immobilized, painkillers and UHF are prescribed. Therapeutic exercises begin from the second day, light movements (slight adduction, abduction and swaying) in the shoulder joint - from the fifth day. Subsequently, the range of motion is gradually increased.

As a means for immobilizing a fracture, depending on the nature of the damage and the age of the patient, a conventional scarf bandage (in senile patients) or a snake scarf, on which a bent arm is hung, can be used. If necessary, the scarf is supplemented with a roller in the armpit. In some cases, with impacted adduction fractures with angular displacement and easily displaced non-impacted fractures with complete divergence of fragments, skeletal traction is performed on the abduction or abduction splint.

Surgical treatment is indicated for significant angular displacement, complete separation of the fragments and the impossibility of matching the fragments by closed reposition. The operation is carried out in a traumatology department under general anesthesia. As a rule, an antero-medial incision is used. To hold fragments in adults, osteosynthesis with a plate is performed; in children, fixation with knitting needles is possible. The wound is sutured in layers and drained.

IN postoperative period immobilization is carried out using a curved Kremer splint or bandage with a pad in the armpit. Painkillers and antibiotics are prescribed. From the third day, exercise therapy begins with movements in the fingers, elbow and wrist joint. The sutures are removed on the 10th day, movements in the shoulder joint begin on the 20th day after the operation. The results of surgery are usually good.

Very rarely, with crushing of the upper parts of the humerus and aseptic necrosis of the head, arthroplasty of the shoulder joint is indicated. Depending on the age and physical condition of the patient, it is possible to use unipolar endoprostheses (replacement of only the head of the humerus) or total endoprosthesis (replacement of both the head and glenoid cavity of the scapula). If there are contraindications to endoprosthetics, arthrodesis is performed.

According to statistics, 7% of fractures occur in the humerus. Such damage occurs mainly due to falls and impacts. Fractures of the humerus are possible in different parts of it, which is accompanied by different symptoms and sometimes requires separate approaches to treatment.

Anatomical structure

The humerus is divided into three parts: the body or diaphysis is the middle part, and the ends are called epiphyses. Depending on the location of the damage, they speak of fractures of the upper, middle or lower part of the shoulder. The upper section is also called proximal, and the lower is called distal. The diaphysis is divided into thirds: upper, middle and lower.

In turn, the epiphyses have complex structure, since they are the ones that enter the joints and hold the muscles. At the top of the humerus there is a semicircular head and an anatomical neck - the area immediately below the head. They and the articular surface of the scapula enter the shoulder joint. Under the anatomical neck there are two tubercles, which serve as attachment points for muscles. They are called the greater and lesser tubercle. The bone tapers even further, forming the so-called surgical neck of the shoulder. The lower part of the humerus is represented by two articular surfaces at once: the head of the condyle, which has a rounded shape, articulates with the radius of the forearm, and the block of the humerus leads to the ulna.

Main types of fractures

Fractures are classified according to several parameters. On the one hand, fractures of the humerus are grouped by location, i.e., by department. So, a fracture is distinguished:

- in the proximal (upper) section;

- diaphysis (middle section);

- in the distal (lower) section.

In turn, these classes are further divided into varieties. In addition, a fracture may occur in several places at once within one department or in neighboring ones.

On the other hand, injuries can be divided into fractures with and without displacement, as well as comminuted (comminuted) fractures. There are also open injuries (with damage to soft tissues and skin) and closed ones. At the same time, the latter predominate in everyday life.

Specification of the type of fracture by department

A proximal fracture can be classified as intra-articular or extra-articular. With intra-articular (supratubercular) the head itself or the anatomical neck of the bone may be damaged. Extra-articular is divided into a fracture of the tubercle of the humerus and a fracture of the underlying surgical neck.

When the diaphysis is damaged, several subtypes are also distinguished: fracture of the upper, middle or lower third. The nature of the bone fracture is also important: oblique, transverse, helical, comminuted.

The distal portion may also be affected in various ways. It is possible to distinguish a supracondylar extra-articular fracture, as well as fractures of the condyles and block, which are intra-articular. A deeper classification distinguishes flexion and extensor supracondylar, as well as transcondylar, intercondylar U- or T-shaped and isolated fracture of the condyles.

Prevalence

In everyday life, due to falls and blows, the surgical neck of the upper part, the middle third of the diaphysis, or the epicondyles of the lower part of the humerus mainly suffer. Closed fractures predominate, but very often they can be displaced. It should also be noted that several types of fractures can be combined simultaneously (usually within one department).

Fractures of the humeral head, anatomical and surgical neck most often occur in older people. The lower section often suffers in children after an unsuccessful fall: intercondylar and transcondylar fractures are not uncommon in them. The body of the bone (diaphysis) is susceptible to fractures quite often. They occur when struck on the shoulder, as well as when falling on the elbow or straightened arm.

Proximal fractures

Intra-articular fractures include a fracture of the head of the humerus and the anatomical neck located immediately behind it. In the first case, there may be comminuted fracture or additional dislocation may be observed. In the second case, an impacted fracture may occur, when a fragment of the anatomical neck is embedded in the head and can even destroy it. With direct trauma without avulsion, the fragment can also be crushed, but without significant displacement.

Also, injuries to the proximal part include fractures of the greater tubercle of the humerus and the lesser: transtubercular and avulsions of the tubercles. They can occur not only when falling on the shoulder, but also when the muscles contract too strongly. A fracture of the tubercle of the humerus can be accompanied by fragmentation without significant displacement of the fragment or by its movement under the acromedial process or down and outward. This injury can occur from direct trauma or dislocation of the shoulder.

The most common fracture is the surgical neck of the humerus. The cause most often is a fall. If the arm was abducted or adducted at the time of the injury, an abduction or adduction fracture of the bone is noted; if the limb is in the middle position, an impacted fracture may result when the distal fragment is embedded in the overlying section.

A fracture can occur in several places at the same time. The bone is then divided into two to four fragments. For example, a fracture of the anatomical neck may be accompanied by a separation of one or both tubercles, a fracture of the surgical neck may be accompanied by a fracture of the head, etc.

Symptoms of a fracture in the upper part of the shoulder

An intra-articular fracture is accompanied by swelling of the area or even hemorrhage into the joint. Visually, the shoulder increases in volume. Pressing on the head is painful. A fracture of the neck of the humerus gives pain during circular movements and palpation. With an impacted fracture of the surgical neck, movement in the shoulder joint may not be impaired. If there is a displacement, the axis of the limb may change. There may be hemorrhage, swelling, or simply swelling in the joint area. When a characteristic bony protrusion appears on the anterior outer surface of the shoulder, we can speak of an adduction fracture, and if a retraction appears there, then this indicates an abduction fracture.

Also, a surgical fracture of the humerus can cause abnormal mobility. Fractures with large displacement or comminution can block active movements, and even minor axial loads and passive movements cause sharp pain. The most dangerous option is in which a fracture of the neck of the humerus occurs with additional damage, pinching, and compression of the neurovascular bundle. Compression of this bundle causes swelling, decreased sensitivity, venous congestion and even paralysis and paresis of the arm.

A fracture of the greater tubercle of the humerus gives pain in the shoulder, especially when turning the arm inward. Movements in the shoulder joint are impaired and become painful.

Symptoms of a diaphysis fracture

Fractures of the humerus in the diaphysis area are quite common. There is swelling, pain and uncharacteristic mobility at the site of injury. The fragments can move in different directions. Hand movements are impaired. Hemorrhages are possible. Severely displaced fractures are visible even to the naked eye by the deformation of the shoulder. If the radial nerve is damaged, it is impossible to straighten the hand and fingers. However, to study the nature of the damage, an x-ray is needed.

Distal fractures and their symptoms

Distal fractures are divided into extra-articular (supracondylar extension or flexion) and intra-articular (condylar, transcondylar, fractures of the capitate eminence or trochlea of ​​the humerus). Disturbances in this department lead to deformation of the elbow joint itself. There is also pain and swelling, and movement becomes limited and painful.

Supracondylar flexion injuries occur after a fall on a bent arm, leading to edema, swelling over the site of injury, pain and a noticeable lengthening of the forearm to the naked eye. Extensor pain occurs when the arm is hyperextended during a fall; they visually shorten the forearm and are also accompanied by pain and swelling. Such fractures can also be combined with simultaneous dislocation in the joint.

Fractures of the external condyle most often accompany a fall on an outstretched arm or direct injuries, while the internal one breaks when falling on the elbow. There is swelling in the elbow area, pain, and sometimes bruising or bleeding into the joint itself. Movement in the elbow joint is limited, especially with hemorrhage.

A fracture of the capitate eminence can occur when falling on a straight arm. Movement in the joint is also limited and pain occurs. Typically, this is a closed fracture of the humerus.

First aid and diagnostics

If a fracture is suspected, the limb must be properly fixed to prevent the situation from worsening. You can also use analgesics for pain relief. After this, the victim should be taken to the hospital as soon as possible for accurate diagnosis and professional assistance.

A fracture can be diagnosed based on the above symptoms, but definitive results can only be obtained after radiography. Usually pictures are taken in different projections to clarify the full picture. Fractures of the humerus are sometimes not clearly expressed; they are then difficult to distinguish from dislocations, sprains and bruises, which require different treatment.

Treatment of minor fractures

A non-displaced humerus fracture requires immobilization of the limb with a cast or abduction splint. Complications here are extremely rare. If a slight displacement is observed, then reposition is performed followed by immobilization. In some cases, it is enough to install a removable splint, in others, complete fixation is required.

Minor fractures of the proximal part make it possible to perform UHF and magnetic therapy within three days, and after 7-10 days to begin developing the elbow and wrist joints, conduct electrophoresis, ultraviolet radiation, massage and ultrasound. After 3-4 weeks, the plaster cast, splint or special fixatives are replaced with a bandage, continuing exercise therapy and procedures.

Restoring displaced fragments without surgery

More serious injuries, such as a surgical neck fracture or a displaced humerus fracture, require reduction, a cast, and regular x-ray monitoring in a hospital setting. The cast can be applied for 6-8 weeks. In this case, it is necessary to move the hand and fingers from the next day, after 4 weeks you can perform passive movements of the shoulder joint, helping with a healthy hand, then move on to active movements. Further rehabilitation includes exercise therapy, massage and mechanotherapy.

The need for surgical interventions

In some cases, reposition is not possible due to severe fragmentation or simply does not give the desired results. If such a fracture of the humerus is present, treatment is required with surgery to achieve alignment of the fragments. Strong displacements, fragmentation or fragmentation, instability of the fracture site may require not only reduction, but also osteosynthesis - fixing the fragments with knitting needles, screws, plates. For example, a fracture of the neck of the humerus with complete separation of fragments requires fixation with a Kaplan-Antonov plate, pins, a Vorontsov or Klimov beam, a pin or rod, which avoids the appearance of angular displacement during fusion. The fragments are held until fusion with screws or an Ilizarov apparatus. Skeletal and adhesive traction is additionally used for crushed fractures of the lower section, after which a splint is applied and therapeutic exercises are performed.

Non-displaced epicondylar fractures require a plaster cast for 3 weeks. Displacement may require surgical intervention. Condylar (intercondylar and transcondylar) fractures are often accompanied by displacement of fragments and are operated on. In this case, the reposition is performed open to make sure that the correct position of the articular surfaces is restored and osteosynthesis is performed. Next, restorative treatment is used in a complex.

Treatment of complicated fractures

A displaced fracture of the humerus, accompanied by damage to the radial nerve, requires comparison of bone fragments and conservative treatment of the nerve itself. The fracture is immobilized and supplemented with drug therapy so that the nerve can regenerate itself. Later, exercise therapy and physiotherapy are added. But if the functionality of the nerve is not restored after several months, then surgery is performed.

In the most difficult cases, when the bones are too fragmented, the fragments can be removed, after which prosthetics are required. An endoprosthesis is used in the shoulder joint instead of the head. If there is excessive damage to the tubercle, the muscles can be sutured directly to the humerus.

Treatment of any fracture requires compliance with all recommendations of specialists, as well as a serious approach to rehabilitation. Immobilization and complete rest of the damaged surface are replaced over time by certain loads. Courses of physiotherapy, physical therapy, massage and similar procedures can be prescribed repeatedly with some breaks until complete recovery. It is also important to conscientiously follow all instructions for rehabilitation at home and protect yourself from re-injury.

Fracture of the shoulder and humerus and its treatment

Good day to all. Today we have another article on the topic of injuries and fractures. Today we will look at all types of fractures of the shoulder and humerus, and also talk about rehabilitation procedures for such injuries.

Humerus fracture

The humerus is a long bone of the upper limb, which is anatomically divided into a body (diaphysis) and two ends (epiphyses). About 7% of all fractures in traumatology are fractures of the humerus and main reason are impacts and falls. All of these injuries are types of arm fracture.

A shoulder fracture is accompanied by deformation of the shoulder, abnormal mobility in one area or another, pain and severe swelling.

When providing first aid, correct fixation of the hand is necessary, the use of analgesics is indicated, and timely hospitalization of the victim is necessary.

Anatomical features of the humerus

At the top, the humerus forms a semicircular head, which, together with the articular surface of the scapula, forms the shoulder joint. The area located just below the head is called the anatomical neck of the humerus. Just below the anatomical neck are the lesser and greater tubercles, to which the muscles are attached. The slight narrowing of the bone inferior to the tuberosities is called the surgical neck of the shoulder.

The lower part of the humerus contains two articular surfaces: the rounded head of the condyle, which articulates with the radius, and the trochlea of ​​the humerus, which faces the ulna.

What are the types of fractures of the shoulder and humerus?

Depending on the damage to one or another part of the humerus, the following types of fractures are distinguished:

• A fracture in the proximal part, which, in turn, is divided into intra-articular (fracture of the head and anatomical neck of the shoulder joint) and extra-articular (fracture of the tubercle of the humerus and fracture of the surgical neck).

• Fracture of the diaphysis of the shoulder (fracture of the upper, middle or lower third is distinguished).
• Distal fracture.

There are supracondylar and condylar fractures (transcondylar, T- and U-shaped intercondylar and isolated condylar fractures)

In most cases, there is a fracture of the upper end of the shoulder in the area of ​​the surgical neck, as well as a fracture in the middle third of the shoulder and at the location of the epicondyles in the lower third. As a result of domestic trauma, a closed fracture of the humerus most often occurs, which is not accompanied by damage to the skin. Such fractures are the easiest to treat and often do not cause complications.

Proximal humerus fracture

Intra-articular fracture (fracture of the head of the humerus or anatomical neck of the shoulder) occurs mainly in older people. A fracture of the anatomical neck is characterized by penetration of the fragment into the head with the formation of a so-called impacted fracture. In case of a strong blow, the head between the articular surface of the scapula and the distal fragment may be destroyed.

Symptoms of a proximal humerus fracture:

• An increase in the volume of the shoulder due to swelling and hemorrhage into the joint cavity (hemarthrosis).
• Comminuted head fractures and neck fractures with significant displacement of fragments are characterized by a complete absence of active movements. With passive movements and axial load, sharp pain occurs. Pressure on the head is accompanied by severe pain.

Taking into account the mechanism of injury, the following are distinguished:

• Fracture due to direct trauma.

Accompanied by fragmentation of the fragment without significant displacement.

• Avulsion fracture.

It is accompanied by the separation of a small fragment of the greater tubercle, which, under the action of muscles, is displaced either outward and downward, or under the acromedial process. Typically, a greater tuberosity fracture occurs when the shoulder is dislocated.

Surgical humeral neck fracture

With an indirect mechanism of injury, a fracture of the surgical neck of the humerus usually occurs. If at the time of the fall the arm is abducted, an abduction fracture of the shoulder occurs; if the arm is adducted, an adduction fracture of the humerus occurs. When the arm is in the middle position, a fracture more often occurs with the insertion of a distal fragment into the proximal one (impacted fracture of the surgical neck).

The following symptoms are typical for a surgical neck fracture:

• Pain when feeling the fracture site, as well as when moving in a circular motion.
• During movements, a joint displacement of the greater tubercle and the head occurs (typical of an impacted fracture).
• A displaced fracture of the humerus is accompanied by a change in the axis of the limb, swelling and hemorrhage in the joint area. In this case, active movements are impossible, and passive movements are accompanied by severe pain.
• Pathological mobility and crepitation of bone fragments may occur.
• Adduction fractures are characterized by the appearance of a bony protrusion on the anterior outer surface of the shoulder, while abduction fractures are characterized by retraction.
• Shoulder shortening.

A fracture of the humeral neck can be complicated by injury to the neurovascular bundle at the time of trauma or due to improper reposition.

Features of an open fracture of the shoulder

An open fracture of the humerus is accompanied by a wound on the surface of the shoulder and bleeding, to stop which it is necessary to apply a tourniquet in the upper third of the shoulder. Afterwards, a sterile bandage is applied and the arm is immobilized with a splint in the middle position.

Features of diagnosis and treatment

To diagnose a fracture, radiography of the joint in different projections is used.

Treatment of a humerus fracture is carried out by reduction and plaster immobilization. A removable splint is used, which allows the administration of magnetic therapy and UHF from the 3rd day. After a week or 10 days, active movements in the wrist and elbow joints, passive movements in the shoulder joint are indicated, electrophoresis with novocaine, calcium chloride, ultrasound, ultraviolet radiation, and massage are prescribed. After 4 weeks, the plaster is replaced with a scarf and rehabilitation treatment continues.

Treatment of a surgical neck fracture is usually inpatient, using reduction and x-ray control after the cast has dried, which is repeated after a week or 10 days. Gypsum is applied for up to 8 weeks, from the 5th week - a diverting splint. Active movements of the fingers and hand are shown from the 1st day; after a month it is possible to include passive movements in the shoulder joint using a healthy arm, and then active movements in the shoulder joint.

If necessary, resort to a combined treatment method using skeletal traction for the elbow fragment and a circular plaster cast on the forearm.

Rehabilitation after a fracture of the humerus includes massage, exercise therapy and mechanotherapy.

Restoration of work capacity for a non-displaced fracture occurs after approximately 2 months, and for a displaced fracture – after 2.5 months.

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Types of humerus fractures and principles of treatment

The humerus is quite long, and a fracture can occur in any part of it:

• anatomical neck of the shoulder (intra-articular fracture);
• surgical neck of the shoulder (extra-articular fracture);
• humeral diaphysis (main part of the bone);
• distal section (closer to the elbow).

Fractures of the surgical neck of the humerus are especially dangerous, as they can lead to damage to the neurovascular bundle, which means hemorrhage and possible paresis in the future.

Treatment of a humerus fracture is usually conservative (reposition of the fragments, casting and observation), but in some cases it may be necessary surgical intervention. The start of treatment usually coincides with the rehabilitation period.

The main goal of rehabilitation is to restore full range of motion. The set of exercises is adjusted by the attending physician and physical therapy doctor individually for each patient. Exercise therapy promotes muscle relaxation, correct alignment of bone fragments, reduces pain, and activates the processes of regeneration and adaptation.

Immobilization stage (first 3 weeks after fracture)

The entire complex should be performed 6-8 times a day for 30 minutes (6-10 repetitions for each exercise). Starting position – standing with a forward bend.

• Breathing exercises.
• The hand must be in a bandage at all times (except for activities).
• Active movements (rotation, flexion/extension, pronation/supination) in the elbow, wrist joints, and hands stimulate blood circulation in the arm, reducing swelling and reducing the risk of blood clots.
• Rotate your arms clockwise and counterclockwise.
• Pendulum-like movements of the hands. This exercise is great for relieving pain at any time. It is enough to remove the sore arm from the bandage and, in a standing position, bending forward, make several pendulum-like swings with the relaxed limb.
• Abduction and adduction of the arm or just the elbow to the body.
• Clap in front of the chest and then behind the back.
• Crossing your arms in front of your chest.
• Torso twists with hands clasped in front of the chest.

Physiotherapy treatments include cryotherapy to reduce pain syndrome, reducing swelling and inflammation.

The patient receives a list of exercises upon discharge home. It is necessary to continue practicing, otherwise it will be impossible to restore the mobility of your hand.

Functional stage (3-6 weeks)

During this period, the fracture is already considered healed, which is confirmed by x-rays. The goal of rehabilitation at this stage is to restore the previous range of passive and active movements. The set of exercises expands, the starting position remains the same. The patient should strive for gradual extension and perform exercises while standing without bending forward. Exercise frequency - 4-6 times a day up to 6-10 repetitions.

• Raise a straight arm in front of you.
• Active use of block exercise machines: raising and lowering the sore limb, raising the arms to the sides.
• Wave your arms forward, backward, to the sides. Starting position - standing with a slight inclination forward.
• The abduction of the hands behind the back with the reduction of the shoulder blades. Starting position - arms in front of the chest are bent at the elbows.
• water procedures. While visiting the pool, you should perform exercises that imitate breaststroke and freestyle swimming, crossing your arms in front of your chest, and various movements of your limbs. Staying in water puts additional stress on the muscles, which improves blood circulation in them and increases the effectiveness of training.

Physiotherapy includes magnet, massage, balneotherapy. Courses of 10-12 procedures.

Training phase (7-8 weeks)

It is believed that by this time the patient had almost completely restored the functionality of the injured arm and shoulder. Exercises are performed to strengthen muscles and fully restore range of motion. Training should take place 3-4 times a day for 10-12 repetitions.

• Raise a straight arm in front of you. Starting position: standing straight.
• Exercises for abduction, adduction, pronation, supination, arm rotation. Hanging on a bar or wall bars, hand rests and push-ups, manipulations with medicine balls and dumbbells weighing no more than 5 kg. It is necessary to continue physical therapy to strengthen the deltoid muscle and rotator cuff, which are the muscular framework for the shoulder joint. It should be borne in mind that exercises that require a large load should not be prescribed to elderly patients.
• Stretching exercises. “Walking” with your fingers up and to the sides along the wall, placing a towel or gymnastic stick behind your back. The listed manipulations make it possible to achieve complete restoration of mobility in all directions.
• Swimming pool – swimming in a comfortable style.

Physiotherapy still includes magnet, massage, balneotherapy.

With a rationally selected rehabilitation scheme, the patient’s full recovery occurs within 2-3 months. Only after this it is necessary to perform exercises designed to develop physical strength, stretching, and endurance. Need to accept vitamin complexes and special supplements, and also ensure that there is enough calcium in food (dairy products).

Video “Rehabilitation after a humerus fracture”

Fractures of the humerus in the proximal part

There are fractures of the head, anatomical neck (intra-articular); transtubercular fractures and surgical neck fractures (extra-articular); avulsions of the greater tubercle of the humerus (Fig. 1). The main types of fractures are given in the AO/ASIF UKP.

Rice. 1. Fractures in the proximal part of the humerus: 1 - fractures of the anatomical neck; 2 - transtubercular fractures; 3 - surgical neck fractures

Fractures of the head and anatomical neck of the humerus

Causes: a fall on the elbow or a direct blow to the outer surface of the shoulder joint. When the anatomical neck is fractured, the distal fragment of the humerus usually becomes wedged into the head.

Sometimes the humeral head becomes crushed and deformed. The head can be torn off, with its cartilaginous surface turning towards the distal fragment.

Signs. The shoulder joint is increased in volume due to swelling and hemorrhage. Active movements in the joint are limited or impossible due to pain. Palpation of the shoulder joint area and tapping the elbow are painful. During passive rotation movements, the greater tuberosity moves with the shoulder. With concomitant dislocation of the head, the latter cannot be felt in its place. Clinical signs are less pronounced with an impacted fracture: active movements are possible; with passive movements, the head follows the diaphysis. The diagnosis is confirmed by x-ray; an axial projection is required. Mandatory monitoring of vascular and neurological disorders is necessary.

Treatment. Victims with impacted fractures of the head and anatomical neck of the humerus are treated on an outpatient basis. 20-30 ml of a 1% solution of novocaine is injected into the joint cavity, the arm is immobilized with a plaster splint according to G.I. Turner in the position of abduction (using a roller, pillow) by 45-50°, flexion in the shoulder joint up to 30°, in the elbow - up to 80-90°. Analgesics, sedatives are prescribed, from the 3rd day they begin magnetic therapy, UHF on the shoulder area, from the 7-10th day - active movements in the wrist and elbow and passive movements in the shoulder joint (removable splint!), electrophoresis of novocaine, calcium chloride , UV irradiation, ultrasound, massage.

After 4 weeks the plaster splint is replaced with a scarf bandage, and rehabilitation treatment is intensified. Rehabilitation - up to 5 weeks.

Working capacity is restored after 2-21/2 months.

Indications for surgery: impossibility of reduction in unstable fractures with significant displacement of fragments, interposition of soft tissues and fragments between articular surfaces (type A3 and more severe).

Fractures of the surgical neck of the humerus

Causes. Fractures without displacement of fragments are usually impacted or pinched. Fractures with displacement of fragments, depending on their position, are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur when falling with emphasis on the outstretched adducted arm. In this case, the proximal fragment is retracted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward. Abduction fractures occur when falling with emphasis on the outstretched abducted arm. In these cases, the central fragment is adducted and rotated inward, and the peripheral fragment is inward and anteriorly displaced forward and upward. An angle is formed between the fragments, open outward and posteriorly.

Signs. With impacted fractures and non-displaced fractures, local pain is determined, which increases with load along the axis of the limb and rotation of the shoulder; the function of the shoulder joint is possible, but limited. During passive abduction and rotation of the shoulder, the head follows the diaphysis. The x-ray determines the angular displacement of the fragments. In fractures with displaced fragments, the main symptoms are severe pain, dysfunction of the shoulder joint, pathological mobility at the level of the fracture, shortening and disruption of the axis of the shoulder. The nature of the fracture and the degree of displacement of the fragments are clarified radiographically.

Treatment. First aid includes the administration of analgesics (Promedol), immobilization with a transport splint or Deso bandage (Fig. 2), hospitalization in a trauma hospital, where a full examination is carried out, anesthesia of the fracture site, reposition and immobilization of the limb with a splint (for impacted fractures) or a thoracobrachial bandage with mandatory radiographic control after the plaster has dried and after 7-10 days.

Rice. 2. Transport immobilization for fractures of the humerus: a, b - Deso bandage (1-5 - bandage stroke); c - ladder bus

Features of reposition (Fig. 3): for adduction fractures, the assistant lifts the patient’s arm forward by 30-45° and abducts it by 90°, bends the elbow joint to 90°, rotates the shoulder outward by 90° and gradually smoothly extends it along the axis of the shoulder. The traumatologist controls the reposition and performs corrective manipulations in the area of ​​the fracture. The traction along the axis of the shoulder should be strong; sometimes for this, an assistant applies counter support with the foot in the area of ​​the armpit. After this, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction to 90-100°, flexion at the elbow joint to 80-90°, extension at the wrist joint to 160°.

Rice. 3. Reposition and retention of fragments of the humerus: a, b - with abduction fractures; c-d - for adduction fractures; e - thoracobrachial bandage; g - treatment according to Kaplan

For abduction fractures, the traumatologist corrects the angular displacement with his hands, then reposition and immobilization are carried out in the same way as for adduction fractures.

The duration of immobilization is from 6 to 8 weeks; from the 5th week, the shoulder joint is released from fixation, leaving the arm on the abduction splint.

Rehabilitation time is 3-4 weeks.

From the first day of immobilization, patients should actively move their fingers and hand. After turning the circular bandage into a sponge bandage (after 4 weeks), passive movements in the elbow joint are allowed (with the help of a healthy arm), and after another week - active ones. At the same time, massage and mechanotherapy are prescribed (for dosed load on the muscles). Patients practice exercise therapy daily under the guidance of a methodologist and independently every 2-3 hours for 20-30 minutes.

After the patient is able to repeatedly raise his arm above the splint by 30-45° and hold the limb in this position for 20-30 seconds, the abduction splint is removed and rehabilitation begins in full. If closed reposition of the fragments fails, then surgical treatment is indicated (Fig. 4).

Rice. 4. Osteosynthesis for a fracture of the surgical neck of the humerus, bone (a) and Ilizarov apparatus (b)

After open reduction, the fragments are fixed with lag screws with a T-shaped plate. If the bone is osteoporotic, then knitting needles and a tightening wire suture are used. Four-part fractures of the head and neck of the humerus (type C2) are an indication for endoprosthetics.

Fractures of the tuberosities of the humerus

Causes. A fracture of the greater tuberosity often occurs with a dislocated shoulder. Its separation with displacement occurs as a result of a reflex contraction of the supraspinatus, infraspinatus and teres minor muscles. An isolated nondisplaced fracture of the greater tuberosity is primarily associated with a direct blow to the shoulder.

Signs. Limited swelling, tenderness and crepitus on palpation. Active abduction and external rotation of the shoulder are impossible, passive movements are sharply painful. The diagnosis is confirmed by x-ray.

Treatment. For fractures of the greater tubercle without displacement after blockade with novocaine, the arm is placed on an abductor pillow and immobilized with a Deso bandage or scarf for 3-4 weeks.

Rehabilitation - 2-3 weeks.

Working capacity is restored after 5-6 weeks.

In case of avulsion fractures with displacement, after anesthesia, reposition is carried out by abduction and external rotation of the shoulder, then the limb is immobilized on an abduction splint or with a plaster cast (Fig. 5).

Rice. 5. Fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - therapeutic immobilization

For large edema and hemarthrosis, it is advisable to continue for 2 weeks. use shoulder traction. Abduction of the arm on the splint is stopped as soon as the patient can freely lift and rotate the shoulder.

Rehabilitation - 2-4 weeks.

Working capacity is restored after 2-21/2 months.

Indications for surgery. Intra-articular supra-tubercular fractures with significant displacement of fragments, failed reduction in a fracture of the surgical neck of the humerus, entrapment of the greater tubercle in the joint cavity. Osteosynthesis is performed with a screw or a tightening wire loop (Fig. 6).

Rice. 6. Surgical treatment of a fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - fixation with a screw; c - fixation with wire

Complications are the same as with shoulder dislocations.

Traumatology and orthopedics. N. V. Kornilov