Fractures of the proximal humerus. Classification, diagnosis and treatment. Fracture of the humerus, how long does it take to heal Fractures of the diaphysis of the humerus


The humerus is the bone that is located between the elbow and the shoulder girdle. Usually the shoulder is the part of the body that is located between the neck and the shoulder joint, but this is incorrect: the shoulder is located lower.

The humerus, like all tubular bones, consists of three parts: upper (proximal), middle (diaphysis) and lower (distal).

The upper (proximal) part of the humerus has a rather complex anatomy and, together with the scapula, forms the shoulder joint. In the proximal part of the humerus, a hemispherical head is distinguished, due to which movements in the shoulder joint are possible. The head is covered with cartilage. Below the head there is a narrowing - the anatomical neck. Under the anatomical neck there are two tubercles - large and small, to which the muscles are attached. The teres minor, infraspinatus, and supraspinatus muscles are attached to the greater tubercle (they rotate the shoulder outward and hold it in the joint). The subscapularis muscle is attached to the lesser tubercle (rotates the shoulder inward). All these muscles form the so-called rotator cuff. Between the tubercles there is a groove in which the tendon of the long head of the biceps brachii passes. Under the tubercles there is another narrowing, which is called the surgical neck. You can read more about the anatomy of the humerus and shoulder joint on our website.

A fracture of the humerus can occur in any of its parts: proximal, middle (shaft) and distal. As a rule, the fracture is localized in one part, but sometimes the fracture line passes through two (for example, the fracture affects the proximal and middle parts of the bone). Each option has its own characteristics, so we will describe them in separate articles.

When does a fracture occur?

Most often, a fracture of the proximal humerus occurs in older people who have osteoporosis, i.e. the bone has little strength. However, a fracture of the proximal humerus can also occur in young people.

A typical injury that causes a fracture is a fall on the arm, but a fracture can also occur from a direct blow to the upper part of the shoulder. In addition, there are so-called avulsion fractures and fracture-dislocations, which you can read about in a separate article on our website.

Symptoms

Immediately after the fracture, the victim feels pain in the shoulder joint, movements become sharply painful, but more often, shoulder movements are completely impossible. The shoulder may become deformed.

Loss of sensation in the hand, forearm, or shoulder may occur. Numbness or a feeling of pins and needles can be caused both by damage to the nerves during a fracture, and as a result of swelling, which almost always occurs during a fracture.

A few hours after the injury, swelling occurs; later, about a day later, a bruise appears in the area of ​​the shoulder joint (it is mistakenly called a hematoma, but in fact it is just a bruise - the subcutaneous fat is saturated with blood). Over the course of several days or even weeks, this bruise may increase in size and “slide” down, even to the hand.

First aid:

First, make sure the victim is completely safe.

If the patient is unable to walk, call an ambulance. In other cases, you can get to the doctor yourself by taxi - which can be much faster.

Do not try to move your injured arm. This can cause damage to blood vessels, nerves and soft tissue.

If bone fragments protrude from the wound (open fracture), do not try to set them back.

If there is an open fracture, apply a sterile bandage (stop any car that should have sterile bandages in its first aid kit).

Do not apply a tourniquet! Simply bandage the wound tightly and place your hand above the level of the victim's heart.

If it is difficult to apply a bandage, simply cover the wound with sterile wipes or a bandage until the ambulance arrives.

If medical help is not available and the patient must be moved, immobilize (immobilize) the injured limb using temporary splints or a brace.

Temporary splinting can be done using planks, branches, cardboard or rolled up magazines. Avoid applying excessive pressure to your hand.

Suspend your arm from a scarf. A scarf is a piece of fabric with tied ends, worn around the neck and supporting the injured arm.

Headband

What types of fractures are there?

There are several typical types of fractures:

Avulsion of the greater tubercle, fracture of the anatomical neck, fracture of the surgical neck, avulsion of the lesser tubercle, intra-articular fracture (splitting of the head), fracture dislocation.

Each of these typical options can be combined with the other, so that a particular patient may have a combination of, for example, avulsion of the greater tuberosity and a fracture of the surgical neck, or any other option. In addition, the fracture can be impacted - if one fragment is pressed into another. To describe the variety of possible fracture options, traumatologists most often use the Neer classification, which distinguishes one-, two-, three- and four-fragment fractures.

As we have already mentioned, muscles that have different directions are attached to the tubercles. Because of this, bone fragments often shift in the direction where the corresponding muscles pull them.

Typical displacements of tripartite (three-part) fractures. On the left - avulsion of the lesser tubercle and a fracture of the surgical neck, on the right - avulsion of the greater tubercle with a fracture of the surgical neck. The greater tubercle migrates upward and backward.

A large tubercle displaced upward and posteriorly will interfere with abduction, since in this case it will simply collide with the acromial process of the scapula, limiting movement.

A completely severed greater tubercle may move into the subacromial space, and in this case, it will also be impossible to move the arm to the side in the future.

The greater tubercle displaced into the subacromial space (marked with a red arrow)

In general, there are a lot of options for fractures of the proximal part of the humerus; you can read more about them on our website.

Diagnosis

The diagnosis of a fracture of the proximal humerus is made based on the results of examination and additional research methods (x-ray, computed tomography). During the examination, the doctor will ask you about the circumstances of the injury. Try to be as detailed as possible, but at the same time succinctly tell about what happened. Be sure to report the symptoms described above if you have them (numbness, etc.).

The exact nature of the fracture cannot always be determined from radiographs, since there are many types of fractures, and on simple radiographs the fragments are often layered on top of each other. However, an anteroposterior radiograph is always taken first. If the fracture is simple, then this is enough, but if the fracture is complex, then it is necessary to perform either radiography in additional projections (oblique, axial, etc.) or computed tomography. Radiographs in additional projections are technically complex and often require that the hand be given a special position, and this is often impossible due to severe pain. Therefore, surgeons often prefer computed tomography.

In any case, performing a CT scan before conventional radiographs is not always advisable. Magnetic resonance imaging is less informative than computed tomography in diagnosing the nature of the fracture, but sometimes, if the doctor suspects damage to the ligaments or tendons, this study is also performed.

How to treat fractures of the proximal humerus?

There are two main ways to treat fractures - conservative (without surgery) and surgical. The choice of treatment method is made taking into account the nature of the fracture, displacement of bone fragments, the patient’s lifestyle, and concomitant diseases.

All fractures of the proximal humerus can be divided into two types:

Those that can be successfully treated conservatively, i.e. without surgery and

Those that are better to operate on.

Non-surgical treatment It is advisable for simple fractures without displacement or with minimal displacement of fragments (less than 1 centimeter). In addition, conservative treatment is indicated in cases where, for various reasons, the patient’s arm did not function before the injury (after a stroke, for example).

The hand is immobilized using special splints made of plaster or modern hardening materials. There are also modern orthoses that are much more comfortable than a conventional plaster splint. The specific type of orthosis or cast that is appropriate is determined by the nature of the fracture. The timing of immobilization is also determined by the nature of the fracture. Usually, with conservative treatment there is more long-term immobilization than with surgical treatment.

In other cases it is usually advisable surgical treatment, which allows you to eliminate displacement, fix fragments and begin movements in the shoulder joint earlier.

The type of fixation of fragments is determined by the nature of the fracture. When the greater tubercle is torn off, it is often fixed with wire or a screw and wire.

Fixation of the greater tubercle with wire.

For more complex fractures, fixation is performed with an intramedullary pin or plate.

Fixation of the fracture with the PHILOS plate from Synthes.

The requirements for plates for fixation of proximal humerus fractures are very high. They must be made of high-quality alloys, have a large margin of mechanical strength, the screws must be locked in the holes of the plate, and the plate itself must have additional holes for suturing the rotator cuff tendons and ligaments of the shoulder joint. All these features determine their high cost, which in our country can easily exceed 1000 US dollars.


On the left - osteosynthesis with screws, on the right - osteosynthesis with an Arthrex plate with holes for suturing the tendons of the rotator cuff

Osteosynthesis with an intramedullary pin is usually a less traumatic operation, but it has its limitations. As a rule, the choice in favor of an intramedullary pin occurs in simpler fractures without avulsion of the tubercles, or in cases where the fracture line extends to the diaphysis. However, intramedullary osteosynthesis is also possible for more complex fractures, but technically this operation is very difficult.

In elderly patients, one of the main difficulties associated with proximal humerus fractures is osteoporosis. The bone is soft, “sugar”, and ordinary screws in such bone easily cut through and the entire structure becomes unstable.

In addition, in elderly patients, comminuted fractures often do not heal at all, even with ideal reduction (comparison of fragments) and fixation, due to the fact that the blood supply to the head decreases with age. Therefore, if the doctor evaluates the blood supply to the head in an elderly patient as insufficient, then not osteosynthesis is performed, but endoprosthetics - i.e. the joint is replaced with a new artificial one.

Shoulder endoprostheses from Zimmer® (Anatomical Shoulder™, inverse and reverse)

Complications

In addition to the fact that the operation eliminates the displacement of bone fragments, it also has disadvantages. In particular, the main complications of surgical treatment are:

Osteolysis (resorption) of the head. This complication is caused by insufficient blood supply to the head of the humerus, which, being deprived of nutrition, gradually dissolves. Typically, this complication occurs when osteosynthesis is performed instead of the recommended primary arthroplasty. However, such a choice is not without meaning, since osteosynthesis is an attempt to “save” the joint. In any case, the risk of osteolysis must be assessed individually for each patient and surgery should be planned based on this assessment. This complication can occur both after surgery and after conservative treatment.

Head perforation with screws. If screws that are too long are used during osteosynthesis, they will perforate the articular surface of the head and interfere with movements in the joint. This is a technical error and can only be avoided by carefully following the rules for performing the operation. In particular, the operating room must be equipped with an electron-optical converter (EOC), which allows the surgeon to take radiographs in several projections and ensure the correct position of the screws.

Impingement syndrome. This is impingement syndrome, where a mechanical obstruction interferes with movement in a joint. Most often, impingement syndrome of the shoulder joint is caused by a collision of a displaced greater tubercle or the upper edge of an incorrectly positioned plate on the acromion process of the scapula.

Frozen shoulder. Sometimes this complication is also called adhesive capsulitis, although these concepts are not entirely synonymous. This complication can occur both after surgery and after conservative treatment. The complication is manifested by a sharp limitation of movements.

Infectious complications - osteomyelitis. To prevent this complication, it is necessary to comply with the requirements of asepsis, and the patient should receive antibiotics for prophylactic purposes (prescribed intravenously 30 minutes before surgery). The incidence of this complication is less than 1%

Rehabilitation

In the postoperative period, the arm is usually immobilized with an abduction orthosis or a plaster cast, and painkillers such as paracetamol or aspirin or ibuprofen may be prescribed.

After normal fusion of the fragments, the function of the shoulder joint is gradually restored, but the significant severity of the injury itself sometimes does not allow the function of the joint to be restored completely.

With stable bracing, exercises to increase range of motion and strengthen muscles can be started as soon as pain subsides. Control examinations by a doctor and control radiographs are required, the frequency of which is determined by the attending physician. During these examinations, the doctor makes recommendations on expanding the rehabilitation program or, conversely, advises stopping the exercises.

You can see sample exercises for rehabilitation on our website (click to go).

What questions should you discuss with your doctor?

  1. What are my individual risks of complications during surgical and conservative treatment? Which treatment method will allow me to count on maximum success in my case?
  2. How will this injury affect the function of the hand in the future?
  3. Can any of my individual factors affect the outcome of treatment (concomitant diseases such as diabetes, etc., bad habits)?
  4. Which implant for osteosynthesis is optimal for this type of fracture?
  5. How fully can I take care of myself after the operation?
  6. When can I return to work if my job involves...?
  7. When should follow-up examinations and x-ray examinations be carried out?

Humerus fractures are divided into:

  • proximal fractures
  • diaphysis fractures
  • distal fractures

Fractures of the proximal humerus

Fractures are caused by a fall on the arm and often occur in older people.

Treatment

In elderly and senile patients with severe osteoporosis, in the vast majority of cases, conservative treatment is indicated, which consists of abandoning plaster immobilization and early initiation of active movements in the damaged joint. In middle-aged and young patients, it is necessary to strive for one-stage closed reduction with short-term immobilization with an orthotic bandage.

If closed reduction fails in this group of patients, osteosynthesis with the earliest possible start of active movements is indicated. In this case, both external osteosynthesis with plates with angular stability and intramedullary blocked osteosynthesis are used.

Humeral shaft fractures

Fractures of the humeral diaphysis, like all others, are divided into fractures from direct and indirect trauma. With direct application of force, transverse, splintered and multi-fragmented (including segmental) fractures occur, and with indirect application, helical (oblique) fractures occur with or without an additional fragment. One of the typical types of fractures from indirect trauma are closed screw-shaped fractures received during arm wrestling. In recent years, their number has increased noticeably, apparently due to the popularization of this type of martial arts.


The “gold standard” for the treatment of such fractures is blocked intramedullary osteosynthesis. The technique makes it possible to perform reduction through mini-approaches and ensure stable fixation of fractures.


Fractures of the distal humerus

They account for 2-3% of all fractures. The most common is a transepicondylar intra-articular fracture. Most low-energy fractures of the distal humerus occur as a result of a fall onto the elbow from a standing height or a fall on an extended arm. In this case, a combined injury to the proximal forearm is possible - a fracture of the olecranon, dislocation of the radius, dislocation of the ulna, etc.

High-energy injuries are most often caused by traffic accidents. Depending on the location of the fracture line, fractures of the distal humerus are usually divided into extra-articular and intra-articular fractures.

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. 34).

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 part 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 toward 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 axillary projection is required. Vascular and neurological disorders are possible!

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 abduction position (using a roller, pillow) at 45-50°, flexion in the shoulder joint - up to 30°, in the elbow -up to 80-90°. Analgesics, sedatives are prescribed internally, and from the 3rd day - 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 joints (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, ability to work is restored after 2-2*/2 months.

Fractures of the surgical neck of the humerus.

Fractures without displacement of fragments are usually impacted or pinched. Fractures with displacement of fragments are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur during a fall with emphasis on the outstretched adducted arm: the central fragment is abducted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward, the fragments form an angle open inwardly and posteriorly. Abduction fractures occur during a fall with emphasis on the outstretched abducted arm: 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. In non-displaced fractures, local pain is detected, which intensifies with axial load 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. 35), 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. Features of reposition (Fig. 36).

For adduction fractures, the assistant lifts the patient's arm forward by 30-45° and abducts it by 90°, bends the forearm to 90°, rotates the shoulder outward by 90° and gradually smoothly applies 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 armpit area. After this, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction to 90-100°, forearm flexion to 80-90°, wrist extension to 160°. 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.

34. Fracture schememov in proximalnom department of the shoulderbone howl. 1 - anatomical necks; 2 - chreebuslide; 3 - heesurgical neck.

35. Transport immobilization for shoulder fractures. a, b - Deso bandage (1-5 moves of the bandage); in - ladder bus. 36. Reposition and retention of shoulder fragments. a, b - for abduction fractures: c - d - for adduction fractures: f - thoracobrachial bandage; and - Kaplan baking.

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, ability to work is restored after 2-4 weeks. From the first day of immobilization, patients should actively move their fingers and hand.

After turning the circular bandage into a splint (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 muscle loading). 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 full rehabilitation begins. If closed reposition of the fragments fails, then surgical treatment is indicated (Fig. 37, 38).

Fractures of the tubercles 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 shoulder contusion.

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, ability to work 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. 39).

In case of large swelling and hemarthrosis, it is advisable to use shoulder traction for 2 weeks. 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-tubercle 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 (Fig. 40).

39. Fracture of the greater tubercle of the humerus, a - slight displacement of the fragment; 6 - therapeutic immobilization. 40. Surgical treatment of a fracture of the greater tubercle of the humerus, a - large displacement of the fragment; 6 - fixation with a screw; c - fixation with wire.

Fractures of the proximal humerus account for 4-5% of all bone injuries. The age group of patients over 60 years of age is more susceptible to this type of damage. In women, fractures of the proximal humerus occur approximately 2 times more often than in men.

Mechanogenesis of damage

Fractures of the proximal humerus occur from a direct blow to the outer surface of the shoulder joint, or from a fall on the elbow or hand.
Among fractures of the proximal end of the humerus, the most common fractures are surgical neck fractures. Frequent fractures in this area are explained by the fact that the cortical layer of this area is thinner, and the surgical neck is the place where the fixed part of the shoulder (the place of attachment of muscles and ligaments) transitions into a less fixed one.
According to the line of divergence of the fragments, fractures of the surgical neck are divided into adduction (adduction) and abduction (abduction).
Abduction fractures occur during a fall with emphasis on the outstretched abducted arm: 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.
Adduction fractures occur during a fall with emphasis on the outstretched adducted arm: the central fragment is abducted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward, the fragments form an angle open inwardly and posteriorly.

Classification

There are two most common classifications of proximal humerus fractures: the AO/ASIF classification and the C.S. classification. Neer (Fig. 2.21).
Fractures, according to the universal AO/ASIF classification, can be divided into extra-articular - group A and B, and intra-articular - group C. Group A fractures are monofocal (one site of damage) fractures, group B are bifocal fractures.
Within each of these groups, fractures are divided into subgroups, according to the relative position of the fragments:
11-A extra-articular unifocal fracture.
11-A1 with damage to the greater tubercle.
11-A1.1 tuberosity fracture without displacement.
11-A1.2 fracture of the tuberosity with displacement.
11-A1.3 fracture with dislocation or subluxation of the head of the humerus.
11-A2 impacted metaphyseal.
11-A3 metaphyseal without impaction.
11-B extra-articular bifocal fracture.
11-B1 with metaphyseal impaction.
11-B2 without metaphyseal impaction.
11-B3 with shoulder dislocation.
11-C intra-articular fracture.
11-C1 with a slight offset.
11-C2 impacted with significant displacement.
11-C3 with dislocation.
Classification C.S. Neer (1970) is based on a proposal by E.A. Codman (1934) considered four fragments resulting from a fracture of the proximal humerus (the head of the humerus to the level of the anatomical neck, the greater and lesser tubercles and the diaphysis of the humerus).
Neer noted that fractures occur between one (at the border of one) or all of the four segments described below: (1) articular segment or anatomical neck, (2) greater tuberosity, (3) lesser tuberosity, (4) diaphysis or surgical neck (Fig. 2.20). In accordance with this, Neer identified two-, three- and four-part fractures and fracture dislocations.

Clinical picture

In non-displaced fractures, local pain is detected, which intensifies with axial load 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. In fractures with displaced fragments, the main symptoms are sharp pain, swelling and hemorrhage in the area of ​​the shoulder joint, 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 using x-rays. It must be remembered that a fracture of the surgical neck of the humerus can be complicated by damage to the neurovascular bundle both at the time of injury and during inept reduction.

Diagnostics

To select tactics for treating damage and prognosis for this treatment, a comprehensive assessment of the damage and a comprehensive assessment of the patient is necessary.
(see chapter “Comprehensive Damage Assessment”).

Comprehensive damage assessment includes:
- mechanism of injury (low- or high-energy injury);
- nature of the injury (exclusion of polytrauma);
- assessment of soft tissues around the fracture;
- analysis of damage to neurovascular structures;
- identification of dominant fracture (damage);
- X-ray examination of the damaged segment(s);
- determination of the fracture level;
- determination of the type of fracture
- assessment of bone tissue quality (whether there is osteoporosis);

Patient Assessment includes:
- age of the patient;
- social status;
- presence of concomitant pathology;
- previous injuries and their outcomes;
- profession before the injury and/or functional requirements for the limb;
- the patient’s consent to the operation;
- willingness to cooperate (following recommendations and following the prescribed regimen);

Damage to neurovascular structures
Fractures of the proximal humerus, especially fracture dislocations, can be complicated by injury to the axillary nerve, axillary artery, or cervicobrachial plexus, which further complicates treatment and suggests complications in long-term results. Neurovascular structures are damaged as a result of a high-energy mechanism of injury. Brachial plexus injury is a rare complication of proximal humerus fracture. Up to 50-60% of patients with traumatic injuries of the brachial plexus have concomitant damage to adjacent vessels, which must be taken into account when identifying a particular complication.
Diagnosis of axillary nerve damage:
- paralysis of the deltoid muscle - inability to move the arm;
- loss of skin and pain sensitivity in the area of ​​the outer surface of the shoulder;
Diagnosis of axillary artery damage:
- decrease in skin temperature;
- paleness of the skin;
- dense swelling of the shoulder and forearm;
- weakening of the pulse in the arteries of the forearm;
- extensive subcutaneous hematomas in the supra- and subclavian areas.
The clinical picture of brachioplexopathies depends on the location of the level of damage to the brachial plexus. Differential diagnosis should be carried out with an isolated violation of the axillary nerve. Symptoms of forearm injury include disturbances in the innervation of the forearm, impaired ulnar flexion and extension reflexes, and impaired hand function.

X-ray examination
To correctly assess the type of fracture and, therefore, to select treatment tactics in case of injury to the proximal shoulder, it is necessary to take x-rays in at least 2 projections.
When performing a direct projection, in order to correctly display the articular part of the humerus, it is necessary to rotate the patient 30° relative to the cassette and 60° to the line of the x-ray beam (Fig. 2.22).
To image the proximal humerus in the anterior-external projection, it is necessary to rotate the patient at an angle of 60° to the cassette and direct the x-ray beam along the spine of the scapula (Fig. 2.23). The planes of these projections are mutually perpendicular.
In some cases, when diagnosing injuries to the glenoid cavity of the scapula or to diagnose a fracture of the lesser tubercle of the humerus, an axial projection is required. To do this, you need to place the patient on the table, abduct the shoulder and place the cassette over the shoulder joint, the beam passes through the armpit (Fig. 2.24). Retraction in this case may be painful for the patient, but the patient usually allows this procedure to be performed.
Note: It should be noted that the so-called posterior dislocation of the humeral head is very often combined with an impression fracture of the posterior edge of the glenoid cavity of the scapula and, in this case, the axial projection will be the most informative.
In addition to X-ray examination, CT examination is used to diagnose injuries of the proximal shoulder. This study allows us to determine depressed (crushing) fractures of the cartilage of the humerus or avulsion fractures of the edge of the glenoid cavity of the scapula. CT examination clarifies the picture of the tuberosity fracture. To clarify the diagnosis of damage to the soft tissue structures of the proximal shoulder - rotator cuff damage, damage to the capsule of the shoulder joint, Bankart injury*, Hill-Sachs injury*, SLAP injury*, an MRI study is used.
- Bankart injury refers to the separation of the capsule and labrum from the glenoid cavity of the shoulder.
- Hill-Sachs injury - bone damage to the posterolateral part of the humeral head upon impact with the edge of the glenoid cavity after dislocation.
- Damage to the SLAP (Superior Labrium Anterior-Posterior lesion) - the site of damage to the glenoid cavity of the shoulder. Refers to the avulsion of the insertion of the long head of the biceps, which is attached to the upper part of the labrum and, when avulsed, pulls it with it, while tearing it anteriorly and posteriorly from the insertion.
It must be taken into account that CT examination is a standard examination in foreign clinics when diagnosing intra-articular fractures.

Treatment

Most proximal humerus fractures can and should be treated conservatively. This is due, first of all, to the age group of these fractures and the characteristics of the blood supply to the head of the humerus. An important stage in the conservative treatment of fractures of the proximal humerus is the patient’s post-traumatic rehabilitation and physical exercises that develop the shoulder joint.
Note: It must be remembered that detection of a rotator cuff injury on an MRI examination is an indication for surgical treatment of the injury.
Using the classification according to Neer, there are:
- Fractures without displacement. Regardless of the number of fragments and the fracture line, it is advisable to treat such fractures conservatively, performing weekly X-ray examination to monitor the position of fragments.
- Two-part fractures: treatment tactics depend on the components of the fracture:

Avulsion fractures of the tubercle are treated conservatively if the fragment is displaced< 5 мм для молодых пациентов и < 1 см - для пациентов старше 60 лет. При смещении бугорка на расстояние, превышающее вышеуказанный промежуток, рекомендовано оперативное лечение, заключающееся в фиксации фрагмента винтом из короткого разреза (рис. 2.30) или использование серкляжной проволоки в качестве стягивающей петли (рис. 2.31). В зависимости от оснащения, опыта хирурга и типа перелома возможно использование закрытых техник репозиции и фиксации;
- a fracture at the level of the anatomical neck causes loss of blood supply to the articular fragment and can lead to avascular necrosis of the head. Conservative treatment of such a fracture consists of displacement reduction and application of a functional bandage or Deso bandage. It is possible to fix such a fracture with an angularly stable plate. In the presence of an image intensifier, it is preferable to use a minimally invasive technique of osteosynthesis with a plate from a lateral approach;
- fractures at the level of the surgical neck can be treated conservatively - with a functional bandage or Deso bandage with successful closed stable reduction of the fracture. Reduction in this case should be performed under intravenous or conduction anesthesia. In the presence of an image intensifier, the stability of the fracture is checked as follows: the doctor makes passive movements of the injured limb in the shoulder joint within 30° of abduction, flexion and extension. A fracture is considered stable if these movements do not cause loss of reduction.

Indications for surgical treatment of two-part fractures of the proximal humerus are:
- unsatisfactory reduction or instability after reduction of the fracture;
- damage to neurovascular structures;
- open fracture;
- polytrauma;
- bifocal damage;
- floating shoulder.
Three-part fractures. The best treatment for these fractures is open reduction and fixation with immersion hardware. In a three-part fracture, one of the tubercles remains with the articular fragment of the fracture, providing blood supply to the head.
Four-part fractures. The most complex fractures. Due to the loss of blood supply to the humeral head, the risk of avascular necrosis of the head increases. There is no consensus on the treatment of these fractures. In countries with a developed medical insurance system, this fracture is accepted as a direct indication for endoprosthetics, but this option can always be used as a backup. An important parameter is the size of the fragments. Large fragments, as a rule, are easier to reposition and fixate than small ones. For treatment, the method of open reposition and fixation with a submersible metal fixator (usually a plate) can be used. The choice of treatment tactics towards conservative or surgical treatment is based on a number of factors: the nature of the fracture, the condition of the bone tissue, the general somatic condition of the patient, and the patient’s expectation of further function after a joint injury.

AO/ASIF Recommendations
Indications for conservative treatment of injuries to the proximal humerus are fractures of group A1.1, as well as groups A1.2 and A1.3 (after successful reduction of the dislocation), if the displacement of the tubercles is less than
5 mm - for young patients and< 10 мм - для пациентов старше 60 лет. Для переломов группы А2, А3, В и С показаниями для консервативного лечения являются:
- displacement of the tubercles< 5 мм,
- displacement of the diaphysis in relation to the head< 1 см (или наличие контакта между отломками > 50%),
- angular displacement of the head< 40°,
- as well as any of the contraindications to surgical treatment.
When treating group A fractures, it must be remembered that tension in the rotator cuff can cause displacement of the tubercle (Fig. 2.25), which, in turn, can cause impingement syndrome and impaired abduction and rotation of the shoulder. This is especially important when treating young patients and athletes.
Conservative treatment of proximal humerus fractures includes treatment with a Deso bandage and treatment with a functional bandage.
Note: The use of conservative methods of treating patients presupposes good contact between the doctor and the patient: the necessary level of control of the fracture and the consistency of the fixing element, as well as the patient’s compliance with the recommendations of the attending physician.

Immobilization with Deso bandage
Advantage of treatment: reduced risk of postoperative complications.
Disadvantages: possibility of non-union or delayed healing of the fracture.
Prolonged immobilization of the shoulder and elbow joints can lead to stiffness.
The use of the Deso bandage in the treatment of group A fractures is recommended for no more than 4-5 weeks. From the 4th week, the Deso bandage can be replaced with a scarf-type bandage and development in the shoulder joint can begin with a gradual increase in the range of motion according to an individual program. After this, it is recommended to undergo a rehabilitation course or actively develop the shoulder and elbow joint according to the recommendations of the attending physician.

Functional bandage(Fig. 2.26)
The method is based on repositioning the fracture under the limb's own weight. For reposition and further healing of the fracture, the integrity of the soft tissues of the joint is of great importance. The patient is recommended to have early mobilization of the shoulder joint (pendulum-like movements in the sling, starting with
3-4 weeks).
Note: This method of treatment requires the patient to consciously follow the recommendations of the attending physician. Its use is not recommended if the patient has mental disorders or neglects the doctor’s recommendations.
The advantage of this method is its low trauma and the possibility of early mobilization in adjacent joints.
Flaws:
- pain when wearing a bandage in the first 2 weeks after injury;
- higher risk of secondary displacement compared to the Deso bandage;
- the need for constant close monitoring of the patient.
The recommended period of wearing the bandage is 4-6 weeks.

Surgical treatment of proximal humerus fractures
The choice of surgical treatment technique, as well as the type of implant, depend on the condition of the bone, the skills and equipment of the surgeon, as well as the type of fracture itself.
Patient position on the operating table. A semi-sitting position of the patient with a torso tilt of 30° to the horizontal plane is recommended - the so-called. “beach chair” with support for a broken limb (Fig. 2.27).

Methods of surgical treatment of fractures of the proximal humerus
There are closed and open methods of surgical treatment of these injuries. The choice of one or another method of surgical treatment is based on the following factors:
- type of damage,
- availability of equipment and tools,
- experience in carrying out similar operations.

Closed method using immersion clamps(required to have an image intensifier)
Provides for closed reduction and placement of a fixator without exposing the fracture zone, which can only be possible with an image intensifier.
Advantages:
- stable fixation with the possibility of early function;
- low invasiveness of the intervention (preserving the intactness of the fracture zone).
Flaws:
- difficulty in anatomical reduction of fragments.
Closed reduction technique
Reposition of the fracture is carried out using traction and abduction of the limb. It is possible to use 2 Kirschner wires inserted into the head of the humerus percutaneously as control joysticks (Fig. 2.28). Reposition control is carried out using an image intensifier.
After achieving satisfactory alignment of the fracture fragments, the head is fixed to the diaphysis with a Kirschner wire to prevent loss of reposition during fixation with a metal structure.

Percutaneous fracture fixation with Kirschner wires indicated in cases of two-part fractures, satisfactory alignment of fracture fragments and good bone quality, more often in young patients. The main contraindication to this fixation method is osteoporosis. Since the fracture zone is not visualized, intraoperative control of reposition using an image intensifier is a prerequisite.
Kirschner wires should remain under the skin. It is not advisable to leave the needles above the skin.
A variant of the method is to use a special device for fixing the spokes - Resch block (Fig. 2.29). Using a Resh block reduces the risk of spoke migration. Due to the lack of equipment in operating rooms, the Resch block is rarely used in routine practice.

Advantages:
- low invasiveness of the method.
Flaws:
- migration of the spokes without the use of special devices for their fixation;
- possible loss of primary reposition due to inaccuracy in determining the porosity of the head;
- it is necessary to remove all implants 6-8 weeks after the fracture.
When using this method of fixation, one should be wary of perforation of the head of the humerus by the wires and damage to the glenoid cavity of the scapula and intra-articular components.

Percutaneous fracture fixation with a cannulated screw It is advisable for two-fragment fractures, when one of the two fragments is represented by the tubercle of the humerus. In cases of three-part fractures, the closed method of reduction and fixation of fracture fragments with a screw is unacceptable.
Advantages:
- low invasiveness of the method.
Flaws:
- risk of fragment splitting.
Note: When using a closed technique of reduction and fixation of the tubercle with a cannulated screw, it is not possible to assess the condition of the rotator cuff.

Intramedullary blocked osteosynthesis
Indications:
- satisfactory standing of the fracture fragments after closed reduction;
- subcapital fracture zone;
- double fracture - subcapital in the proximal area and fracture of the diaphysis of the humerus;
- pathological fracture;
Contraindications:
- unsatisfactory position of fragments after closed reduction.
Advantages of the method:
- reliable fixation (functional stability) of the fracture;
- maintaining the integrity of the fracture zone.
Flaws:
- impingement syndrome is often observed.

Surgical approach for insertion of an intramedullary nail
A linear skin incision (about 2 cm long) from the anterior outer edge of the acromion in the direction of the fibers of the deltoid muscle. The fibers of M.deltoideus are delaminated. An incision is made in the tendon of M. supraspinatus. The tendon fibers are sutured with a tendon suture. Access was made to the area of ​​the cartilage of the head medial to the greater tubercle, through which the rod is inserted.
Note: Remember that using an antegrade approach for nail insertion damages M. supraspinatus, which is involved in the formation of the rotator cuff. It is mandatory to stitch it together after inserting the rod.

Open methods of treating proximal humerus fractures involve open reduction of the fracture and fixation with a metal fixator with access to the fracture site through the tissue.
Indications:
- impossibility of closed reduction;
- damage to the neurovascular bundle.
Contraindications:
- high anesthetic risk.
Advantages:
- anatomical reposition;
- early function;
- the ability to visually assess rotator cuff damage.
Flaws:
- risk of surgical complications;
- possibility of impingement syndrome;
- devascularization of the bone can lead to nonunion, partial or total avascular necrosis of the humeral head.
Note: During open surgical treatment of fracture-dislocations of the humeral head (especially old ones), there is a danger of damage to the axillary artery.
When treating elderly patients, it is recommended to use locking plates (LCP) because... With age, the ability of the spongy tissue inside the humeral head to hold screws is lost, and the humeral head takes on the appearance of a so-called “eggshell.” Secondary displacement of fracture fragments is possible when using a non-locking plate.

Surgical approaches for open reduction and plate fixation:
- Anterior deltoid-pectoral approach.
- Lateral transdeltoid access (minimally invasive).
- Rear access.

Anterior deltoid-pectoral approach is classic for surgical interventions in the area of ​​the proximal humerus. The anatomy of the incision, if necessary, allows for expanded access downwards. Several modifications of this access are also known. They are used due to the need to install a plate on the lateral surface of the humerus.

Lateral transdeltoid approach can be performed in the case of an isolated fracture of the tubercles using the “tightening loop” technique, as well as using a minimally invasive plate installation technique. The main inconvenience and danger of this approach is that below it is limited by the presence of N.axillaris and its branches innervating the deltoid muscle. To perform this access, it is necessary to draw a line from the apex of the acromion process of the scapula along the lateral surface of the shoulder by 6 cm. Along this line, a skin incision can be made and the deltoid muscle can be separated. To limit access downwards, it is recommended to suture the deltoid muscle at the end of the incision. The advantage of this approach is that it allows the fracture fragments to be reduced along the lateral surface of the humerus and a fixator to be installed. It is most advisable to use this approach for two-part fractures.
The posterior approach is rarely used, but is recommended in cases of correction of the posterior sections of the shoulder joint: with Hill-Sachs damage, damage to the neck and posterior edge of the glenoid cavity of the scapula, removal of loose bodies in the posterior section of the joint, drainage of the joint (allows drainage of the joint in position of the patient on his back). When performing access, one should be careful of damage to A. et N. suprascapularis, A. circumflexa humeri posterior, N. axillaris.

The “tightening loop” technique (Fig. 2.31) is used in the case of a two-part fracture, when one of the fragments is represented by the tubercle of the humerus. When comparing the techniques for fixing the tubercle with a screw and cerclage wire, it should be noted that the latter is used in cases where the fragment is small and there is a risk of splitting it with a screw.
Indications:
- isolated avulsion of the tubercle.
Contraindications:
- pronounced local osteoporosis.
Advantages:
- the ability to perform the operation from a minimally invasive approach.
Flaws:
- with a traumatic technique for passing the wire under the muscle mass, damage to the rotator cuff and/or the development of a subacromial conflict is possible.

Fixation of the fracture with a plate(Fig. 2.32).
Given the “characteristic age” of proximal humerus fractures and the concomitant decline in bone quality, the use of angular stability plates is recommended for older patients.
When planning an operation, it is necessary to carefully analyze the type of fracture and the displacement of the fragments, because this will affect the reduction technique and access to the fracture site. It is possible to use the anterior deltoid-pectoral or lateral transdeltoid approach.
Features of plate fixation of proximal humerus fractures are:
- location of the plate on the lateral surface of the humerus;
- it is advisable to use 3.5-4 mm screws. Larger screw diameters are not recommended.
Indications:
- pronounced local osteoporosis;
- impossibility of closed reposition or instability after reposition;
- comminuted nature of the fracture.
Contraindications:
General contraindications to open reduction/fixation.
Advantages:
- angular stability;
- possibility of use in osteoporotic bones;
- reduced risk of secondary loss of reposition;
- early functional rehabilitation;
- modern implants allow additional fixation of fragments with thread or wire through a plate.
Flaws:
- high cost of the implant;
- the risk of developing avascular necrosis of the head of the humerus due to insertion of screws into it;
- risk of development impingement syndrome if the plate installation technique is violated.

When planning surgical intervention, it is necessary to remember that the most successful type of osteosynthesis is that which can provide early functional activity of the shoulder and elbow joints.

Removal of implants
For many patients, implant removal is the final stage of treatment. However, it is necessary to inform the patient about the risks (anesthesiological, operating), cost and possible consequences of surgery to remove the implant.

Planned removal of the implant is recommended no earlier than 1-2 years after surgery.
- Planned removal of the implant is recommended for young patients involved in highly active sports or professional athletes. This is due to two reasons: firstly, with the need to perform high-amplitude power movements in the shoulder joint, which can lead to migration, fracture of the implant, or compression of soft tissue by the implant during movement. The second reason is that when energy from a fall/direct impact is transferred through the implant-fixed area, a point of stress concentration occurs on the implant itself or on the bone, which can lead to implant failure or re-fracture.
- In the case of elderly patients, implants, as a rule, are not removed due to the high anesthetic risk, prevention of postoperative complications associated with re-operation.
- For the proximal upper limb, indications for planned removal of a submersible implant may include:
- implant migration;
- allergic reactions (mainly for steel implants);
- irritation of soft tissues;
- pain when moving the joint (must be differentiated from other causes).
- When planning an operation, it is necessary to take a radiograph in 2 projections and evaluate:
- formation of callus along the entire diameter of the fracture;
- type, condition, quantity and position of the implant(s);
- After removal of the implant, it is necessary to explain to the patient the postoperative orthopedic regimen. In particular, after removal of large implants, the patient is recommended to limit active sports and heavy physical activity for 2-4 months.

Note: If Kirschner wires are used to fix a fracture, the wires are removed 6-8 weeks after fixation.

Fractures of the proximal humerus account for 5-10% of all fractures. In the structure of postoperative complications after treatment of fractures of the proximal head of the humerus, from 10% to 35% are unfavorable outcomes in the form of loss of the initially achieved reduction, varus deformation of the head with penetration of the latter by screws, nonunion or formation of a pseudarthrosis, both after conservative and after surgical treatment .

With the development in recent years of surgical treatment of such fractures, traumatologists are faced with a wide variety of shapes of the head of the humerus, a variety of blood supply and innervation. In most cases, one has to rely on the experience, intuition of the doctor and the use of average concepts about the shape of the head of the humerus, which only allows one to “blindly” individualize the surgical technique and tactics of complex treatment of such patients. But this does not allow us to identify individual typological features of the structure of the proximal humerus, and, consequently, to individualize approaches to treatment and predicting the outcomes of conservative and surgical treatment of such patients.

It has long been known that each shape of the body or organ characterizes individual structural reactivity in relation to environmental factors and diseases.

In the literature of recent years, works have appeared indicating individual typological variability in the shape and structure of the humerus in adults of various body types. The types of structure of this bone, which have different features of blood supply, have been identified. The correlation relationship between the level of entry of the diaphyseal artery into the humerus and the type of its structure (in dolichomorphic, mesomorphic and brachymorphic individuals) is shown and the “surgical risk” zone is determined.

However, markers of individual typological characteristics of the shape of the head of the proximal humerus, which determine or influence the individual characteristics of the course of reparative processes (consolidation) of the bone, have not yet been studied in detail. All this indicates the relevance and necessity of conducting research in this direction.

The purpose of this study was to conduct an exploratory analysis of the study data (detailed measurement of the proximal humeral head) in 21 patients with fractures of this part of the bone. It is necessary to test the hypothesis about the relationship between the individual characteristics of consolidation outcomes (favorable or complicated) and the individual typological characteristics of the structure of the proximal humerus in order to develop individual approaches to the treatment of fractures and predicting results.

The objective of the study was to compare, based on the results of conservative and surgical treatment of patients with a fracture of the proximal head of the humerus, the outcomes of healing of such a fracture (consolidation or complication in the form of the formation of a false joint, necrosis of the head), in connection with the peculiarities of the structure and shape of the proximal humerus opposite the shoulder fracture on digital radiographs.

Materials and research methods

21 male and female patients aged from 40 to 80 years. The basis for choosing treatment tactics was the Neer classification, according to which patients with fractures of the proximal humerus without displacement or with acceptable displacement (angular displacement up to 45°, width displacement up to 1 cm) underwent conservative treatment.

Patients with unacceptable displacement were treated promptly. Surgical treatment was carried out on the third day after injury. External osteosynthesis with plates with angular stability of screws and intramedullary blocking osteosynthesis were performed.

The examined patients were divided into two groups. Group 1: patients with fracture healing within 3 months—13 people. The second group: patients with complications in the form of a formed pseudarthrosis and necrosis of the head - 8 people.

All patients underwent an X-ray examination of the injured shoulder joint, which is traditional for such fractures, and additionally the shoulder joint opposite to the injured one. The conditions were the same: in a direct projection with a turn to the side under study at an angle of 30° on a digital X-ray machine.

In all subjects, a digital radiograph of the joint opposite to the damaged one, i.e., the healthy shoulder joint, was analyzed. According to the developed examination map, measurements of the head of the proximal humerus were taken in different directions, including angles were measured and indices were calculated that characterize the shape features of the proximal head of the humerus, a total of 87 parameters. The obtained values ​​were subjected to statistical processing by the Mann-Whitney and Kruskal-Wallace methods (median and rank tests).

Research results and discussion

A comparative analysis of the features of the shape of the proximal humerus between patients with fracture healing within up to 3 months (13 people) and patients with complications in the form of a formed pseudarthrosis or necrosis of the head (8 people) showed the presence of significantly significant parameters separating patients with different treatment outcomes by median (table).

This is a sign that measures the angle between the anatomical neck and the line delimiting the greater tuberosity to the surgical neck (measured feature: angle 47 - p< 0,009 и < 0,011; ** < 0,009). Уменьшение этого угла у лиц с неблагоприятным исходом консолидации свидетельствует об уменьшении большого бугорка и снижении уровня анатомической шейки в латеральных отделах головки. Подтверждает это и признак, измеряющий угол, образованный двумя линиями от середины хирургической шейки: первая линия проводится до точки середины латеральной части анатомической шейки, вторая линия проводится до середины самой широкой части головки (измеряемый признак: угол 56 — р < 0,0298 и * < 0,049; ** < 0,030). Последний признак также свидетельствует о том, что при не различающейся в двух сравниваемых группах ширине анатомической шейки она имеет тенденцию опускаться ниже с латеральной стороны. Это сопровождается отклонением первой линии более латерально, что увеличивает угол 56 (р < 0,0298 и * < 0,049; ** < 0,030) у пациентов с осложнениями. Об этом же косвенно свидетельствует увеличение длины латеральной части хрящевой головки (измеряемый признак 11 — р < 0,027) и расширение хрящевой части головки в ее средних отделах по отношению к анатомической шейке (индекс 17 — * < 0,019, ** < 0,044 и индекс 18 — р < 0,046) в совокупности с широтными размерами средних отделов хрящевой части головки плечевой кости (измеряемые признаки: 10 — р < 0,025 и * < 0,004; ** < 0,027; признак 11 — р < 0,027). Имеется тенденция к удлинению проксимальной головки плечевой кости (измеряемые признаки: 29 — * < 0,019; индекс 90 — * < 0,049). Кроме того, у пациентов с неблагоприятным исходом констатируется более тонкое компактное вещество в латеральных отделах головки (измеряемый признак: 86 — р < 0,0326 и ** < 0,033).

Statistical analysis also showed that there are several characteristics that do not have significant differences, but are approaching significant differences in p value. For these parameters, apparently, we can also talk about the presence of a tendency towards differences in the individual typological features of the structure of the head of the humerus in the two compared groups. These trends will obviously be more clearly evident with a larger number of patients examined with such fractures.

Discussion and conclusions

The above pilot study showed statistically significant differences between the two comparison groups. Thus, in patients with unfavorable consolidation outcomes, there is some displacement of the cartilaginous part of the proximal head of the humerus to the lateral side and downward and thinning of the compact substance of the head on the lateral side, in addition, there is a tendency to lengthen the cartilaginous and the rest of the head, especially in its lateral part.

A review of the literature on the typological features of the structure of the humerus indicates that the differences obtained may indicate an approach to a more oval shape of the proximal humerus in patients with an unfavorable outcome after fracture treatment. This form of the proximal part of the head of the humerus, according to O. A. Fomicheva, is more typical for people with a dolichomorphic body type and a dolichomorphic type of structure of the humerus. Moreover, in such individuals, the diaphyseal artery is more often of the scattered type and enters the bone at a distance further from the head, and this distance determines the “surgical risk zone” during surgical interventions. It can be assumed that such a structural feature or the type of structure and blood supply of the humerus, which correlates with a person’s body type, may also play some determining role in the manifestation of individual characteristics of the regeneration of the humerus during fractures, which ultimately affects the outcome of treatment.

Thus, in the sample of patients studied and compared in terms of fusion outcomes (with fractures in the area of ​​the proximal head of the humerus), there are significant differences in the median of a number of measured signs characterizing the individual typological features of the structure of this part of the humerus. The above indicates the possibility of further research in this direction, with the aim of searching for detailed morphological markers of well-being and risk for different consolidation outcomes (favorable or complication). This will ultimately make it possible to approach an individual prognosis of the outcomes of consolidation of such fractures and, accordingly, a more individualized choice of treatment method, which will improve the results of treatment of fractures of the proximal humerus.

In addition, the exploratory analysis showed the need to introduce some corrective and clarifying measurements into the patient’s examination worksheet in order to conduct a complete study.

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A. V. Lifanov
L. T. Levchenko 1,
L. B. Reznik,Doctor of Medical Sciences, Professor

State Budgetary Educational Institution of Higher Professional Education Omsk State Medical University of the Ministry of Health of the Russian Federation, Omsk

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