Closed fracture of the internal epicondyle of the humerus. Fractures of the bones forming the elbow joint: features. How to develop an arm after a humerus fracture

biological activity at the ends of the fragments has completely ceased (their ends are rounded and sclerosed, the medullary canal is closed), surgical intervention is indicated. After freeing the ends of the fragments, removing the scar tissue between them, economically refreshing the edges, and opening the medullary canal, both fragments should be brought tightly together. Good fixation of fragments is achieved using compression-distraction devices. This method of immobilization is especially indicated if an outbreak of latent infection is possible. If there is no such danger, stable osteosynthesis can be carried out using a thick metal rod. Its thickness must correspond to the diameter of the medullary tube in order to create stable immobility of the fragments. Stable fixation of fragments is achieved using a Klimov, Vorontsov T-beam and a Kashtan-Antonov detorsion-compression plate. After such fixation of the fragments, autografts taken from the tibia or from the iliac wing are placed subperiosteally on the sides in the fracture area. IN last years We use bone allografts, frozen at a low temperature, or combine an autograft with an allograft. After the operation, the arm is fixed for 3-5 months in a plaster thoracobrachial cast.

Fractures of the lower end of the humerus

This group includes fractures located along the supracondylar line of the humerus, i.e., in the area of the lower triangular extension. Strictly speaking, in modern international anatomical nomenclature the term “condyles” of the humerus is not used; only the term “epicondyles” is used. However, for convenience of differentiation individual species fractures, it is more expedient to use the old, familiar terminology for now. The term “internal condyle” means inner part the distal end of the humerus together with the block (trochlea humeri) and its articular surface, and under the term “external condyle” - the outer part of the distal end of the humerus, including the capitulum humeri and its articular surface. The term “internal and external epicondyles” should be understood only as the large internal and smaller external protrusions located on the sides of the distal end of the humerus.

Fractures of the lower end of the humerus are divided into extra-articular and intra-articular. Extra-articular are supracondylar extension and flexion fractures, located slightly above or at the level of the transition of the cancellous bone of the metaphysis to the cortical bone of the diaphysis. Intra-articular include: 1) transcondylar extension and flexion fractures and epiphysiolysis of the shoulder; 2) intercondylar (T- and Y-shaped) fractures of the shoulder; 3) fractures of the external condyle; 4) fracture of the internal condyle; 5) fracture of the capitate eminence of the humerus; 6) fracture and apophysiolysis of the internal epicondyle of the humerus; 7) fracture and apophysiolysis of the lateral epicondyle of the humerus. All these fractures can be without displacement or with displacement of fragments.

Fractures at the lower end of the humerus can be extension or flexion. With many supracondylar, transcondylar and intercondylar fractures of the lower end of the humerus, in addition to the displacement of the distal fragment anteriorly or posteriorly, lateral, medial displacement and angular deviation of the distal fragment outward or inward are also often encountered. Intra-articular fractures of the lower end of the humerus are often combined with fractures of the olecranon, coronoid process, and head radius, as well as with dislocations of the forearm.

All these fractures are often accompanied by severe soft tissue damage. This is most often observed with fractures and lower epiphysis of the extensor type. Hematoma and swelling can be very large and cause disruption of the venous circulation and sometimes the arterial blood supply to the forearm. At the time of injury, the brachial artery, ulnar and median nerves can be bruised, stretched and, in very rare cases, severed. The pulse on the radial artery is sometimes weakened or completely absent. More often, "sprain and contusion of the ulnar nerve are encountered. In this regard, a study of the pulse on the radial artery, as well as motor function and sensitivity in the forearm and hand, must be undertaken before reducing the fragment or other medical procedures. The displacement of fragments in itself can cause vascular disorders and edema, so the reduction of fragments in these conditions can improve the blood supply to the limb. Good reduction and correction of angulations are important to obtain maximum restoration of function. However, rough methods of reducing fragments in general and in these fractures are especially unacceptable, because damage, bruises and compression of blood vessels and nerves, as well as thrombus formation in the fracture zone, are possible. Large swelling of the elbow, forearm and hand, absence of radial pulse, cold, cyanotic hand and pain require immediate attention, as Volkmann's contracture may develop. The ulnar nerve may become involved again many years after the injury. Sometimes, due to non-osseous fusion of fragments, after separation of the epicondyle in childhood, more often with cubitus valgus, ulnar nerve neuritis develops. All this must be kept in mind when treating patients with fractures of the lower end of the humerus.

Supracondylar fractures of the humerus

Supracondylar fractures are more common than other types of fractures of the lower end of the humerus, especially in children and adolescents. These fractures, if there are no additional cracks penetrating the elbow joint, are classified as periarticular, although with them there is often hemorrhage and reactive effusion in the elbow joint. Supracondylar fractures are divided into extension and flexion.

Extensor supracondylar fractures of the shoulder occur as a result of excessive extension of the elbow when falling onto the palm of an outstretched and abducted arm. They occur mainly in children. The fracture plane in most cases has an oblique direction, passing from below and in front, backward and upward. A small peripheral fragment, due to contraction of the triceps muscle and pronators, is pulled posteriorly, often outward (cubitus valgus). The central fragment is located anteriorly and more often medially from the peripheral one, and its lower end is often embedded in soft fabrics. An angle is formed between the fragments, open posteriorly and inwardly. Due to this displacement between the lower end of the humerus and ulna Vessels may be pinched. If the fragments are not corrected in a timely manner, ischemic contracture may develop, mainly of the finger flexors, due to degeneration and wrinkling of the forearm muscles.

Flexion supracondylar fracture of the shoulder is associated with a fall and injury back surface sharply bent elbow. Flexion fractures in children are much less common than; extensor. The plane of the fracture is the opposite of that observed with an extension fracture, and is directed from below and behind, anteriorly and upward. A small lower fragment is displaced anteriorly outward (cubitus valgus) and upward. The upper fragment is displaced posteriorly and medially from the lower one and abuts its lower ends against the triceps tendon. With such an arrangement of fragments between them

an angle is formed that is open inwardly and anteriorly. Damage to soft tissues with flexion fractures is less pronounced than with extension fractures.

Symptoms and recognition. With an extension fracture, there is usually large swelling in the area of the elbow joint. When examining the shoulder from the side, its axis below deviates posteriorly; “At the elbow, a depression is visible on the extensor surface. A protrusion is identified in the elbow bend, corresponding to the lower end of the upper fragment of the shoulder. At the site of the protrusion there is often intradermal limited hemorrhage. The lower end of the upper fragment that has shifted anteriorly can compress or damage the median nerve and artery in the elbow. During the examination, these points should be clarified. Damage to the median nerve is characterized by a sensitivity disorder on the palmar surface of the 1st, 2nd, and 3rd fingers, the inner half of the 4th finger and the corresponding part of the hand. Movement disorders are manifested by the loss of the ability to pronate the forearm, to oppose the first finger (this is expressed in the fact that the flesh of the first finger cannot touch the flesh of the fifth finger), and to bend it and the remaining fingers at the interphalangeal joints. When the median nerve is damaged, flexion of the hand is accompanied by deviation to the ulnar side. If there is compression of the artery, the pulse in the radial artery cannot be felt or is weakened.

With a flexion supracondylar fracture, there is usually a large swelling in the area of the elbow joint; at the lower end of the shoulder is marked sharp pain, sometimes a bone crunch is felt. The end of the upper fragment is palpated on the extensor surface of the shoulder. Unlike an extension fracture, there is no depression above the elbow joint. The axis of the shoulder below is deflected anteriorly. The fragments form an angle open anteriorly. When an attempt is made to displace the lower fragment, it returns posteriorly to its previous position and again deviates anteriorly.

A large hematoma in the elbow joint usually makes recognition difficult. An extension supracondylar fracture should be differentiated from a posterior dislocation of the forearm, in which the posterior angular curvature is located at the level of the elbow joint, while as with a fracture it is located slightly higher. In the area of the fracture, bone crunch and abnormal mobility in the anteroposterior and lateral directions are determined. The longitudinal axis of a supracondylar fracture is easily aligned by flexing the forearm at the elbow joint; in contrast, an attempt to align the posterior angular curvature during dislocation in this way does not achieve the goal, and is determined characteristic symptom spring resistance. Both epicondyles and the apex of the olecranon process with an epicondylar fracture are always located in the same frontal plane, and with a dislocation the olecranon process is located posterior to them. Examination for a fracture is much more painful than for a dislocation.

When the lower end of the humerus is fractured, there is often a violation of the line and triangle of Gunter and the identification sign of Marx.

Normally, when flexing the elbow joint, the apex of the olecranon and both epicondyles of the shoulder form an isosceles triangle (Panther's triangle), and the line connecting both epicondyles of the humerus (Gunther's line) is bisected by a line corresponding to the long axis of the shoulder and is perpendicular to it (sign Marx).

Radiographs in the anteroposterior and lateral projections are of great importance for recognizing a fracture. Difficulties may be encountered in interpreting elbow radiographs taken in children. It should be taken into account that by 2 years of life the ossification nucleus of the capitate eminence appears, by 10-12 years - the ossification nucleus of the olecranon process and the head of the radius, which can be mistaken for bone fragments. Equally, at this and later ages, there are zones of epiphyseal cartilage in the humerus, ulna and radius; they are sometimes mistaken for bone cracks. To recognize fractures in children, it is recommended to take radiographs of both hands.

Treatment . For supracondylar fractures without displacement of the fragments, a plaster splint is applied to the extensor surface of the shoulder, forearm and hand. The forearm is fixed in a bent position at a right angle. First, the fracture site is anesthetized by injecting 20 ml of a 1% novocaine solution. In children, after 7-10 days, and in adults, after 15-18 days, the splint is removed and non-forced movements in the elbow joint begin. Massage of the elbow joint is contraindicated. The working capacity of adults is restored through. 6-8 weeks

Displaced supracondylar fractures should be reduced as soon as possible. When healing an extensor fracture of the humeral condyles in a displaced position with an angle open posteriorly, flexion to normal in the elbow joint is limited according to the degree of angular displacement of the proximal fragment; at the same time, extension is also somewhat limited. The greater the posterior angular displacement, the more limited flexion is. In contrast, when a flexion fracture heals in a displaced position with an angle open anteriorly, extension is predominantly limited, although flexion is also somewhat difficult. In addition, valgus or varus curvature of the elbow is often observed.

And deviation of the forearm and hand to the outside and inside relative to the axis of the shoulder. Warn these functional, anatomical disorders And cosmetic defect is possible only by timely reduction and holding of the fragments in the correct position until union. The earlier the reduction is made, the easier and better it is.

For pain relief, 20 ml of a 1% novocaine solution is injected into the fracture site from the extensor surface of the shoulder. In excited patients, in children, as well as in patients with highly developed muscles, it is better to perform simultaneous reduction under anesthesia.

Simultaneous reduction of an extension supracondylar fracture with displacement of fragments is performed as follows (Fig. 56). The assistant with one hand grabs the patient's forearm in the lower part and the area of the wrist joint or takes the hand and produces a smooth and gradual, without sudden movements, stretching along the axis of the limb and at this time supinates the pronated forearm. The counter-thrust is created behind the shoulder. In this way, the axis of the limb is aligned, the displacement of fragments along the length is eliminated, and the soft tissues pinched between them are released. To realign the lower fragment, which has shifted posteriorly and outward during an extension fracture, the surgeon places one hand on the inner-anterior surface of the lower part of the upper fragment and fixes it, and the other hand on the posterior-outer surface of the lower fragment and moves it anteriorly and inward. When the lower fragment is displaced posteriorly

And Inwardly, the reduction is performed in the opposite direction. The surgeon places one hand on the outer anterior surface of the lower part of the upper fragment and fixes it, and the other hand on the posterior inner surface of the lower fragment and moves it anteriorly.

And outward. At the same time, the elbow joint is bent to an angle 60-70°. In this position, a circular circular plaster cast is applied to the shoulder and forearm. First, a cotton pad is placed in the elbow bend. The forearm is fixed in an average position between pronation and supination. After this, a control radiograph is taken immediately, until the anesthesia wears off or the patient wakes up from anesthesia. If reduction is unsuccessful, reduction should be attempted again. However, it is important to note that repeated attempts at reduction cause too much trauma to the tissue and are therefore harmful.

After application plaster cast you need to monitor and check in the first hours and days the blood supply to the limb using the pulse on the radial artery, observe the color of the skin (cyanosis, pallor), the increase in edema, impaired sensitivity (crawling, numbness), movement of the fingers, etc. At the slightest suspicion of disruption of the blood supply to the limb, the entire plaster cast should be cut and its edges pulled apart.

Rice. 56. Simultaneous reduction of a supracondylar extension fracture: lengthwise traction, pronation of the forearm, elimination of lateral displacements, flexion of the forearm.

In children, after reduction of an extensor supracondylar fracture of the shoulder, circular plaster casts should not be applied. It is enough to apply a plaster splint on the shoulder and forearm, bent at the elbow joint at angles of 70-80°. The longuet is fixed with a simple bandage and the arm is suspended on a scarf. In these cases, you also need to monitor the condition of the limb.

From the 2nd day they begin to move the fingers and shoulder joint. After 3-4 weeks in adults, and in children after 10-18 days, the plaster cast is removed and movements in the elbow joint begin; Joint functions in children are restored completely; in adults, some restrictions remain.

Massage should be avoided, as it leads to myositis ossificans, excessive callus, preventing movement in the elbow joint. You should also not make violent and forced movements, as this increases their restriction. We have been convinced of this more than once and in such cases we applied a plaster splint for 10-20 days: the phenomena of traumatic irritation subsided and after removing the splint the range of movements gradually increased. With good reposition and proper treatment in adults there is only a slight limitation of movements in the elbow

joint. In children, the prediction is better than in adults if peripheral displacement and lateral displacement are eliminated. The splint in children 3-4 years old is removed on the 7-10th day and after that the arm is suspended on a scarf. In older children, after 10-12 days, the splint remains removable for another 5-8 days; at the same time they produce movements in the elbow joint. Within 2-3 months there is some limitation of movements. In the future, as a rule, the function of the limb is restored. Surgical treatment for non-reduction of fragments in children is rarely resorted to.

Simultaneous reduction of a flexion supracondylar fracture with displacement of fragments is performed as follows (Fig. 57). After local or general anesthesia, the assistant with one hand grabs the lower part of the patient’s forearm and the area of the wrist joint or takes the hand and smoothly, without sudden movements, pulls the bent forearm along the axis, constantly straightening it until it is fully extended. At the same time, the forearm is placed in a supinated position. The counterthrust is created behind the shoulder. In this way, the axis of the limb is aligned, the displacement of fragments along the length is eliminated, and the soft tissues pinched between them are released.

To eliminate the anterior and outward displacement of the lower fragment, the assistant performs traction, the surgeon places one hand on the internal-posterior surface of the damaged shoulder at the level of the lower end of the upper fragment, and with the other hand applies pressure to the anterior-outer surface of the lower fragment in the posterior and inward direction. If the lower fragment is displaced anteriorly and inwardly, the lateral displacement is eliminated by applying pressure on the lower end of the upper fragment anteriorly and outwardly, and on the lower fragment with pressure posteriorly and inwardly. The reduced fragments are fixed with a plaster cast placed on the extensor surface of the arm extended at the elbow joint. In this case, the arm remains in a straight position, and the forearm is fixed in supination. White fragments after reduction in the position of flexion in the elbow joint at an angle of 110°-140° do not move, the arm is fixed with a splint in this position, since the function of the elbow joint is restored faster and more fully after immobilization in a bent rather than an extended position.

The longueta should cover the arm, starting from the top of the shoulder to the metacarpophalangeal joints at 2/3 of its circumference. The applied splint is bandaged with a damp gauze bandage and control radiographs are taken. To prevent swelling, the arm of the patient who remains in bed for the first 2-3 days is suspended in a vertical position, and later, when the patient begins to walk, it is given a high position on the pillow during his rest and sleep. After 18-25 days, and in children after 10-18 days, the splint is removed and movements in the elbow joint begin.

Skeletal traction for supracondylar, transcondylar and intercondylar fractures deserves attention due to its simplicity and treatment results. This method is well tolerated by patients of all ages.

Rice. 57. Simultaneous reduction of a supracondylar flexion fracture: lengthwise traction, supination of the forearm, elimination of lateral displacements, extension of the forearm.

For extension and flexion supracondylar fractures, transcondylar T- and Y-shaped fractures of both condyles with displacement, if immediate reduction is not possible or it is not possible to hold the reduced fragments with a plaster cast, we also use skeletal traction on an abduction splint. The fracture area is anesthetized and 20 ml of a 2% novocaine solution is injected. A 10 cm long needle is passed through the base of the olecranon, after anesthetizing this area with 10 ml of 0.5% novocaine solution. A special small Kaplan or other bow is put on the inserted knitting needle. A cord is tied to the bow. The hand is placed on the abductor splint, which is strengthened as described above. The cord is tied to the curved end of the tire after preliminary manual pulling by the bow or forearm (Fig. 58). Place a pad under the elbow. By applying pressure to the fracture area, the angular displacement is corrected. With an extension supracondylar fracture, the forearm is flexed to 70°, and with a flexion fracture, it is extended to 110°. To do this, in the abduction splint the part intended for the forearm is installed at the appropriate angle to the shoulder part of the splint. The forearm is given a neutral position (average between pronation and supination) for extension fractures and supination for flexion fractures. The position of the fragments should be monitored by radiographs. For intra-articular fractures, the elbow joint is given an angle of 100-110°. Skeletal traction is removed after 2-3 weeks, a U-shaped splint is applied to the shoulder and an additional splint is applied to the extensor surface of the shoulder and forearm.

Skeletal traction can also be performed using traction (load 3-4 kg). The patient lies in a bed with a Balkan frame attached; in this case, sometimes it is advisable to use additional corrective traction.

Rice. 58. Supracondylar fracture of the humerus treated with an abduction splint using a Kaplan arch. Radiographs before (a) and after (b) treatment.

From the first days, the patient must actively move his fingers and make movements in wrist joint. After 2 weeks, when the fusion of the fragments has already occurred, a plaster cast is applied to fix the arm in the described position. To do this, apply one U-shaped splint along the outer and inner surfaces of the shoulder and another splint on the extensor surface of the shoulder, elbow, ulnar surface of the forearm and dorsum of the hand. Splints for adults

reinforced with two plaster bandages. The bandage needs to be modeled well. The pin is removed and an abduction splint is applied. Strips of gauze bandage are bandaged into the plaster cast or strips of adhesive plaster are glued to it with a board and cord, which, after pulling the elbow, is tied to the upper curved end of the abduction splint. After a week, the traction is removed. Patients perform active movements in the shoulder joint 2-3 times a day. After 4 weeks, the abduction splint and plaster cast are removed, and movements in the elbow joint are prescribed.

Despite the fact that in some cases the anatomical relationships are not completely restored and, in particular, there is some posterior displacement of the distal fragment, gradually the function in the elbow joint is almost completely restored. Patients become able to work after 7-12 weeks.

Compression-distraction method. For this purpose, Ilizarov, Gudushauri, etc. apparatuses can be used. The Volkov-Oganesyan articulated apparatus has certain advantages. The wires are passed over the fracture plane, through the condyles and humerus. The device provides good fixation of fragments and the ability to produce gradual movements in the elbow joint. All devices for repositioning and immobilizing fragments can use knitting needles with thrust pads.

Surgical treatment. For supracondylar fractures, it is used only in cases where reduction by the described methods fails, which usually depends on muscle interposition. An incision is made in the area of the fracture in the longitudinal direction in the middle of the lower part of the extensor surface of the shoulder. The tendon extension of the triceps muscle and the underlying tissues are dissected and stripped longitudinally to the bone. The hematoma is removed. Usually the fragments are easily compared.

The fragments are well fixed using one or two thin pins inserted by puncturing the skin on the side of the surgical wound in an oblique direction from the lower fragment to the upper one through the fracture plane. The ends of the needles remain above the skin. The wound is sutured tightly in layers and 200,000 units of penicillin are injected into the fracture area. Then a plaster cast is applied, fixing the elbow joint at a right angle. The needles are removed after 2-3 weeks and movements in the elbow joint begin.

In some cases, fixation of fragments after surgical reduction can be accomplished with one or two wires passed intraosseously in the direction of the longitudinal axis of the humerus with the forearm bent at a right angle, through the olecranon process, the articular surface of the block into the lower and then into the upper fragment. The end of the needle remains on the surface of the skin in the area of its insertion into the olecranon process. Then a plaster splint is applied. The needle is removed after 2-3 weeks. We did not subsequently observe any dysfunction of the elbow joint in connection with a pin passed through the joint in patients. In children, in those rare cases when an operation is undertaken to fix fragments, it is enough to drill one or two holes in the upper and lower fragments and pass thick catgut threads through them; After repositioning the fragments, their ends are tied, and the wound is sutured tightly in layers. In some cases, knitting needles can be used for fixation. Then a splint is applied along the extensor surface of the shoulder and the bent at a right angle and pronated forearm.

Other types of metal retainers (plates and screws) may be used in adults. However, they are rougher and, most importantly, their removal is accompanied by additional trauma in the area of the elbow joint, which may be the cause of the development of periarticular ossification process and limitation of movements in the elbow joint that is so susceptible to this.

After the operation, a plaster cast or splint is applied for 2-3 weeks. Further treatment is carried out as described above.

biological activity at the ends of the fragments has completely ceased (their ends are rounded and sclerosed, the medullary canal is closed), surgical intervention is indicated. After freeing the ends of the fragments, removing the scar tissue between them, economically refreshing the edges, and opening the medullary canal, both fragments should be brought tightly together. Good fixation of fragments is achieved using compression-distraction devices. This method of immobilization is especially indicated if an outbreak of latent infection is possible. If there is no such danger, stable osteosynthesis can be carried out using a thick metal rod. Its thickness must correspond to the diameter of the medullary tube in order to create stable immobility of the fragments. Stable fixation of fragments is achieved using a Klimov, Vorontsov T-beam and a Kashtan-Antonov detorsion-compression plate. After such fixation of the fragments, autografts taken from the tibia or from the iliac wing are placed subperiosteally on the sides in the fracture area. In recent years, we have been using bone allografts, frozen at a low temperature, or combining an autograft with an allograft. After the operation, the arm is fixed for 3-5 months in a plaster thoracobrachial cast.

Fractures of the lower end of the humerus

This group includes fractures located along the supracondylar line of the humerus, i.e., in the area of the lower triangular extension. Strictly speaking, in modern international anatomical nomenclature the term “condyles” of the humerus is not used; only the term “epicondyles” is used. However, for the convenience of distinguishing between individual types of fractures, it is more advisable to use the old, familiar terminology for now. The term “internal condyle” means the inner part of the distal end of the humerus together with the trochlea humeri and its articular surface, and the term “external condyle” means the outer part of the distal end of the humerus, including the capitulum humeri and its articular surface. surface. The term “internal and external epicondyles” should be understood only as the large internal and smaller external protrusions located on the sides of the distal end of the humerus.

Fractures at the lower end of the humerus can be extension or flexion. With many supracondylar, transcondylar and intercondylar fractures of the lower end of the humerus, in addition to the displacement of the distal fragment anteriorly or posteriorly, lateral, medial displacement and angular deviation of the distal fragment outward or inward are also often encountered. Intra-articular fractures of the lower end of the humerus are often combined with fractures of the olecranon, coronoid process, head of the radius, as well as dislocations of the forearm.

All these fractures are often accompanied by severe soft tissue damage. This is most often observed with fractures and lower epiphysis of the extensor type. Hematoma and swelling can be very large and cause disruption of the venous circulation and sometimes the arterial blood supply to the forearm. At the time of injury, the brachial artery, ulnar and median nerves can be bruised, stretched and, in very rare cases, severed. The pulse on the radial artery is sometimes weakened or completely absent. More often, "sprain and contusion of the ulnar nerve are encountered. In this regard, a study of the pulse on the radial artery, as well as motor function and sensitivity in the forearm and hand, must be undertaken before repositioning the fragment or other medical procedures. Displacement of fragments in itself can cause vascular disorders and edema , therefore, the reduction of fragments in these conditions can improve the blood supply to the limb. Good reduction and elimination of angular curvatures are important in order to obtain maximum restoration of function. However, rough methods of reducing fragments in general and for these fractures are especially unacceptable, because damage, bruises and compression of blood vessels and nerves, as well as thrombus formation in the fracture area. Large swelling of the elbow, forearm and hand, absence of pulse in the radial artery, cold, cyanotic hand and pain require immediate attention, as Volkmann's contracture may develop. The ulnar nerve can be secondarily involved in the process many years later after injury. Sometimes, due to non-osseous fusion of fragments, after separation of the epicondyle in childhood, more often with cubitus valgus, ulnar nerve neuritis develops. All this must be kept in mind when treating patients with fractures of the lower end of the humerus.

Supracondylar fractures of the humerus

Extensor supracondylar fractures of the shoulder occur as a result of excessive extension of the elbow when falling onto the palm of an outstretched and abducted arm. They occur mainly in children. The fracture plane in most cases has an oblique direction, passing from below and in front, backward and upward. A small peripheral fragment, due to contraction of the triceps muscle and pronators, is pulled posteriorly, often outward (cubitus valgus). The central fragment is located anteriorly and often medially from the peripheral one, and its lower end is often embedded in the soft tissue. An angle is formed between the fragments, open posteriorly and inwardly. As a result of this displacement, vessels can become pinched between the lower end of the humerus and the ulna. If the fragments are not corrected in a timely manner, ischemic contracture may develop, mainly of the finger flexors, due to degeneration and wrinkling of the forearm muscles.

A flexion supracondylar fracture of the shoulder is associated with a fall and bruise on the posterior surface of a sharply bent elbow. Flexion fractures in children are much less common than; extensor. The plane of the fracture is the opposite of that observed with an extension fracture, and is directed from below and behind, anteriorly and upward. A small lower fragment is displaced anteriorly outward (cubitus valgus) and upward. The upper fragment is displaced posteriorly and medially from the lower one and abuts its lower ends against the triceps tendon. With such an arrangement of fragments between them

an angle is formed that is open inwardly and anteriorly. Damage to soft tissues with flexion fractures is less pronounced than with extension fractures.

Symptoms and recognition. With an extension fracture, there is usually large swelling in the area of the elbow joint. When examining the shoulder from the side, its axis below deviates posteriorly; “At the elbow, a depression is visible on the extensor surface. A protrusion is identified in the elbow bend, corresponding to the lower end of the upper fragment of the shoulder. At the site of the protrusion there is often intradermal limited hemorrhage. The lower end of the upper fragment that has shifted anteriorly can compress or damage the median nerve and artery in the elbow. During the examination, these points should be clarified. Damage to the median nerve is characterized by a sensitivity disorder on the palmar surface of the 1st, 2nd, and 3rd fingers, the inner half of the 4th finger and the corresponding part of the hand. Motor disorders are manifested by the loss of the ability to pronate the forearm, to oppose the first finger (this is expressed in the fact that the flesh of the first finger cannot touch the flesh of the fifth finger), and to bend it and the remaining fingers at the interphalangeal joints. When the median nerve is damaged, flexion of the hand is accompanied by deviation to the ulnar side. If there is compression of the artery, the pulse in the radial artery cannot be felt or is weakened.

With a flexion supracondylar fracture, there is usually a large swelling in the area of the elbow joint; There is a sharp pain at the lower end of the shoulder, sometimes a bone crunch is felt. The end of the upper fragment is palpated on the extensor surface of the shoulder. Unlike an extension fracture, there is no depression above the elbow joint. The axis of the shoulder below is deflected anteriorly. The fragments form an angle open anteriorly. When an attempt is made to displace the lower fragment, it returns posteriorly to its previous position and again deviates anteriorly.

A large hematoma in the elbow joint usually makes recognition difficult. An extension supracondylar fracture should be differentiated from a posterior dislocation of the forearm, in which the posterior angular curvature is located at the level of the elbow joint, while as with a fracture it is located slightly higher. In the area of the fracture, bone crunch and abnormal mobility in the anteroposterior and lateral directions are determined. The longitudinal axis of a supracondylar fracture is easily aligned by flexing the forearm at the elbow joint; in contrast, an attempt to align the posterior angular curvature during dislocation in this way does not achieve the goal, and the characteristic symptom of spring resistance is determined. Both epicondyles and the apex of the olecranon process with an epicondylar fracture are always located in the same frontal plane, and with a dislocation the olecranon process is located posterior to them. Examination for a fracture is much more painful than for a dislocation.

When the lower end of the humerus is fractured, there is often a violation of the line and triangle of Gunter and the identification sign of Marx.

And deviation of the forearm and hand to the outer and inner sides in relation to the axis of the shoulder. These functional, anatomical disorders and cosmetic defects can be prevented only by timely reduction and retention of fragments in the correct position until union. The earlier the reduction is made, the easier and better it is.

After applying a plaster cast, you need to monitor and check in the first hours and days the blood supply to the limb using the pulse on the radial artery, observe the color of the skin (cyanosis, pallor), the increase in edema, impaired sensitivity (crawling, numbness), finger movement, etc. At the slightest suspicion of a violation of the blood supply to the limb, the entire plaster cast should be cut and its edges pulled apart.

Rice. 56. Simultaneous reduction of a supracondylar extension fracture: lengthwise traction, pronation of the forearm, elimination of lateral displacements, flexion of the forearm.

Massage should be avoided, as it leads to myositis ossificans, excessive callus that interferes with movement in the elbow joint. You should also not make violent and forced movements, as this increases their restriction. We have been convinced of this more than once and in such cases we applied a plaster splint for 10-20 days: the phenomena of traumatic irritation subsided and after removing the splint the range of movements gradually increased. With good reposition and proper treatment in adults there remains only a slight limitation of movements in the elbow

Skeletal traction for supracondylar, transcondylar and intercondylar fractures deserves attention due to its simplicity and treatment results. This method is well tolerated by patients of all ages.

Rice. 57. Simultaneous reduction of a supracondylar flexion fracture: lengthwise traction, supination of the forearm, elimination of lateral displacements, extension of the forearm.

Rice. 58. Supracondylar fracture of the humerus treated with an abduction splint using a Kaplan arch. Radiographs before (a) and after (b) treatment.

From the first days, the patient must actively move his fingers and make movements in the wrist joint. After 2 weeks, when the fusion of the fragments has already occurred, a plaster cast is applied to fix the arm in the described position. To do this, apply one U-shaped splint along the outer and inner surfaces of the shoulder and another splint on the extensor surface of the shoulder, elbow, ulnar surface of the forearm and dorsum of the hand. Splints for adults

After the operation, a plaster cast or splint is applied for 2-3 weeks. Further treatment is carried out as described above.

Orthopedics

A 6-month-old child was diagnosed with left-sided congenital hip dislocation. What clinical and radiological symptoms will you identify in this child?

Your treatment tactics and prognosis.

You are examining a 1 year 3 month old child who has just started walking. “Duck” gait.

Forecast.

A 5-year-old child has been limping for the last 4 weeks and complains of pain in the right knee joint.

When examining the pathology from the outside knee joint not found. Flexion and rotation movements in the right hip joint are limited and painful. Temperature and blood tests are normal.

Your preliminary diagnosis, examination plan, treatment tactics.

A 13-year-old boy (weight 52 kg) complains of pain in the right lower limb, limps when walking.

On examination, rotational movements in the hip joint are painful; no other changes were detected.

Your preliminary diagnosis. Examination and treatment plan.

You examine the baby for 14 days and note that he holds his head in a position of tilting to the left and turning to the right. Upon palpation, a fusiform compaction is determined along the left sternocleidomastoid muscle. Lymph nodes are not enlarged. There are no signs of inflammation.

Your diagnosis and treatment tactics.

You have identified a pathological position of the feet in a 7-day-old newborn child - plantar flexion and supination.

Your diagnosis and treatment tactics. Complications with late diagnosis.

A 10-year-old boy was riding a bicycle when he fell and hit his stomach on the handlebars. Felt pain in the left hypochondrium. The child came home on his own. A few hours later, the abdominal pain intensified and began to radiate to the left shoulder girdle. There was vomiting twice. The boy was always in a forced position on his left side. Temperature - 37.6, tachycardia, A/D - 90/60 mm Hg. Stool and urination are normal.

When examined in the left hypochondrium, pain, muscle rigidity and the Shchetkin-Blumberg symptom are determined.

You are an emergency physician on duty. Your diagnosis and treatment tactics. Examination plan for hospital stage, treatment tactics.

For 3 months, an 8-year-old child has been complaining of pain in the middle third of the leg, which bothers him only in the evening and at night. At the same time, the boy is active throughout the day and does physical education at school.

Examination of the lower leg did not reveal any pathological symptoms. Blood and urine tests, blood biochemistry are normal.

In a newborn child born through caesarean section due to the transverse position of the fetus, a forced, abducted position was noted right leg. There are no active movements, passive ones are sharply painful. At the border of the upper and middle third of the thigh, angular deformation, crepitus and pathological mobility are noted.

Diagnosis, first aid, tactics of the maternity hospital doctor. Examination plan, treatment tactics and prognosis.

You are an emergency doctor. A child was hit by a car. He does not remember the circumstances of the injury. There was a brief loss of consciousness.

Upon examination, complaints of pain in the right groin area and pubis. Compression of the pelvic bones is painful. The symptom of “stuck heel” on both sides is positive. The child urinated on his own - urine without pathological impurities.

Your preliminary diagnosis. First aid at the prehospital stage. Examination plan, treatment tactics.

You are examining a 1 year 3 month old child who has just started walking. On examination, the gait is unsteady and there is lameness. There is asymmetry skin folds, shortening of the right leg. Limitation of right hip abduction.

Your preliminary diagnosis, examination and treatment plan, prognosis.

During a labor lesson, a 12-year-old boy got his hand caught in an electric saw. The 3rd, 4th and 5th fingers of the left hand were cut off. In serious condition, 2 hours after the injury, the child was taken to the clinic by an ambulance team. A tourniquet was applied before transport. Analgin and pipolfen were administered intramuscularly in an age-specific dosage.

Upon admission, the skin is pale. Pulse is weak up to 140 per minute, blood pressure is 80/40 mmHg.

The severed finger fragments were delivered in an ice pack.

Was first aid provided correctly at the prehospital stage, were anti-shock measures sufficient? Treatment tactics.

New

The child was diagnosed with fusion of 3-4 fingers from birth.

Your preliminary diagnosis, examination and treatment plan.

The child was born with an extra finger on his hand.

Your preliminary diagnosis, examination and treatment plan.

While bathing, a dense, immobile, painless formation was accidentally discovered in a child on his lower leg.

Your preliminary diagnosis, examination and treatment plan.

The child fell on his hand. Due to pain, an x-ray was taken at the trauma center.

Your preliminary diagnosis, examination and treatment plan.

Trauma - new challenges

Problem 1

Dislocation of forearm bones

IN emergency department A 14-year-old boy, accompanied by a teacher, applied. It is known that 30 minutes ago, a child in a physical education lesson, while playing volleyball, fell to the floor, leaning on his right hand. There was sharp pain and deformation in the elbow joint. Active movements in the elbow joint became impossible due to severe pain. During examination, the hand is on a bandage-scarf, the child is holding the injured limb. There is swelling in the joint area and areas of hemorrhage in the surrounding soft tissue. Movements in the fingers of the hand are preserved, capillary reaction is without significant disturbances.

Your preliminary diagnosis. Examination plan and treatment tactics.

Problem 2

Avulsion of the internal epicondyle of the humerus

A 14-year-old child complained of persistent contracture in the elbow joint after removal of the immobilizing bandage and despite ongoing exercise therapy and massage. From the anamnesis it is known that 6 weeks ago the child received an injury - a dislocation of the bones of the forearm. The dislocation was removed in the emergency room. A control radiograph was not performed. The limb was fixed in the average physiological position, in a plaster splint for 3 weeks.

Your preliminary diagnosis. Examination plan and treatment tactics.

The content of the article

Supracondylar fractures of the humerus are one of the most common types of fractures of the upper limb bones in children: they account for 15% of total number fractures of the upper limb in children under 16 years of age. Supracondylar fractures also occur in adults, but in them they are much less common.
Based on their location, supracondylar fractures of the humerus are classified as metaphyseal. The fracture plane in this type of fracture runs in a transverse or oblique direction in the interval between the line connecting the epicondyles of the humerus and the border between the lower and middle third of the humerus, i.e., the place where the diaphyseal part passes into the metaphyseal part.
Depending on the mechanism of injury, all supracondylar fractures are divided into extension and flexion. When falling on the upper limb, extended at the elbow joint, a fracture occurs with the direction of the fracture plane from anterior and inferior to posterior and superior, the distal fragment is displaced posteriorly.
When falling onto a maximally bent elbow joint, the fracture plane is directed in the front and above, and backward and downward, and the metal fragment is displaced anteriorly. Extension fractures are observed 4-5 times more often than flexion fractures.
In addition to these displacements in width, there is simultaneously displacement of the distal fragment to the lateral or medial side, displacement at an angle open anteriorly, posteriorly, laterally or medially, as well as rotational displacements.

Symptoms of a supracondylar fracture of the humerus

With a supracondylar fracture without displacement, swelling of the soft tissues, hemorrhages, and sharp limitation are observed. active movements. Passive movements are possible to a significant extent, but are painful. There is no deformation.
For supracondylar fractures with displacement, the clinical picture is different depending on whether the fracture is extensional or flexion. With an extenze fracture, the symptoms described above are accompanied by a deformity of the shoulder, which is best revealed when viewed from the side: 3-4 fingers above the olecranon there is a recess that corresponds to the site of the fracture, the entire forearm along with the olecranon is displaced posteriorly. The presence of lateral, angular or rotational displacements is determined when viewed from the front.

Diagnosis of supracondylar humerus fracture

In the diagnosis of a supracondylar fracture, palpation is of great importance.
The triangle formed by the apex of the olecranon and the epicondyles of the humerus (Hüther's triangle) remains isosceles during a supracondylar fracture. This symptom is an important diagnostic sign, as it allows one to clinically differentiate a supracondylar fracture of the humerus from a posterior dislocation of the bones of the forearm, in which Huter’s triangle loses its isosceles.
With lateral displacement of the distal fragment, the normal relationship between the axis of the shoulder and the line connecting both epicondyles of the shoulder is also disrupted: the axis of the shoulder crosses the epicondylar line away from its middle and not at a right angle, as is normal, but obliquely. The acute angle is directed in the direction where the displacement occurred.
In supracondylar fractures of the humerus with displacement, damage to peripheral nerve trunks and vessels is sometimes encountered (pinching between fragments, compression by the sharp edge of a fragment). Damage to peripheral nerve trunks is observed in 3-4% of cases of supracondylar fractures.

Treatment of supracondylar humerus fracture

Treatment of supracondylar fractures of the humerus without displacement and with displacement of fragments is in most cases conservative. For fractures without displacement or with slight displacement that do not require reduction, treatment consists of fixing the shoulder and forearm soft bandage according to Judet in a position of flexion at an acute angle in the elbow joint and supination of the forearm for 4-10 days, depending on the age of the patient, followed by therapeutic exercises and physiotherapy.
For fractures with moderate displacement of fragments, reduction is carried out as follows. After anesthesia, the patient is placed on the table, the injured arm is moved to the side table. The assistant fixes the patient's shoulder by pressing it against a semi-rigid pillow lying on the side table. At this time, another assistant, taking the victim’s hand and wrist joint and applying lengthwise traction, fully extends the forearm at the elbow joint. The surgeon, positioned on the side of the patient, first eliminates the lateral displacement with careful pressure on the fragments, then grabs the area of the metaphysis of the shoulder with both hands so that thumbs rested from behind on the distal fragment of the humerus. Under pressure from the surgeon’s fingers, the distal fragment moves not only anteriorly, but also downward and falls into place. The assistant bends the forearm to an angle of 60-70°. After this, the limb is fixed with a soft Judet bandage or a posterior plaster splint from the upper third of the shoulder to the heads of the metacarpal bones with a supinated forearm. With these types of humerus fractures, the immobilization of the limb remains somewhat longer - from 10 to 14 days.
Subsequently, movements in the elbow joint are developed in combination with physiotherapeutic procedures.
The use of a plaster cast for fractures in the elbow joint requires very careful medical supervision monitor the condition of the injured limb, especially in the first days. Edema of the limb that develops after a fracture in the presence of a tight plaster cast can cause ischemia of the forearm, degenerative changes in the muscles and, as a result of these phenomena, persistent irreversible contracture (Volkmann ischemic contracture).
In order to prevent the development of ischemic contracture, circular plaster casts should not be used for supracondylar fractures, preferring them to plaster splints.
When initial signs ischemia (pallor skin, lack of active movements in the finger joints, decreased sensitivity), it is necessary to cut the bandage (including soft bandages), which creates better conditions for blood circulation.
Reposition of displaced fragments in flexion fractures is carried out as follows. One of the assistants bends his forearm. Initially, the surgeon eliminates the lateral displacement, then the anteroposterior one. After the fragments are established, cotton pads are applied to the distal fragment along the anterior surface and to the proximal fragment along the posterior surface of the shoulder, and then the limb is fixed with a circular plaster cast in the position of extension and supination of the forearm for a period of 10-14 days in children and for 3 weeks in adults .
In case of significant displacement of fragments or a failed attempt at simultaneous reduction, treatment should be carried out using the method of constant traction. In children under 4-5 years of age, adhesive traction is used; in older children and adults, skeletal traction is used using a knitting needle or a Marx-Pavlovich elbow clamp inserted into the olecranon process. In this case, the patient lies on his back, the shoulder is set in a vertical position using traction on the olecranon process, the forearm is bent at a right angle and is held in this position by adhesive rods and a hanging loop.
The initial load on skeletal traction, depending on the age of the patient, is 2-4 kg. Increasing the load by 0.5 kg in the morning and evening for 2-3 days, bring it up to 4-6 kg. At the same time, additional loops are used to eliminate lateral and angular displacement.
12-16 days after the reduction of the fragments, the skeletal rods are replaced with adhesive rods for a period of 5-7 days, after which therapeutic exercises are performed to more fully restore the function of the damaged limb.
Surgical treatment should be used only for old or improperly healed fractures. It consists of open separation of the fragments and subsequent application of skeletal traction, as in fresh fractures, or fixation of the fragments using one of the available methods (plaster cast, Kirschner wires, etc.).
When peripheral nerves and vessels are pinched between fragments, gentle and atraumatic reduction with skeletal traction almost always results, with the exception, of course, of cases with anatomical damage, to release nerves and blood vessels, to restore their function. Therefore, in the presence of infringement of peripheral nerves and vessels, the method should always be used skeletal traction. Simultaneous reduction in these cases should be prohibited.

Fractures of the medial epicondyle of the humerus are avulsion in nature and account for 35% of all fractures of the distal part of this bone. They are a consequence of the indirect mechanism of injury and occur when falling with emphasis on the hand of an extended arm with an outward deviation of the forearm. The muscles that attach to the medial epicondyle tear it off.

In this case, a significant rupture of the elbow joint capsule occurs. The mechanism of occurrence of a fracture of the medial epicondyle corresponds to the mechanism of dislocation of the bones of the forearm. Often, when the forearm is dislocated, this epicondyle in the elbow joint is pinched. According to our statistics, 62% of dislocations of both forearm bones were accompanied by avulsion of the medial epicondyle.

The following types of fractures of the medial epicondyle of the humerus are distinguished:

fractures without displacement;

fractures with displacement along the width;

fractures with rotation;

fractures with entrapment in the elbow joint;

fractures with nerve damage;

fractures combined with forearm dislocation;

repeated breaks.

Clinical and X-ray diagnostics

There is limited tissue swelling along the anteromedial surface of the elbow joint, extensive bruising, and local pain. Upon palpation, a mobile epicondyle can be identified. This resembles the symptoms of a transcondylar fracture with displacement of the distal fragment to the lateral side. However, with the latter, the swelling spreads to the entire elbow joint, and a sharp edge of the central fragment is determined on the medial side of the elbow joint. When the medial epicondyle is torn off, extension in the elbow joint when the straightened fingers are deviated to the back side causes pain in the projection of this epicondyle, fluid is detected in the cavity of the elbow joint, and signs of nerve damage are revealed. When the bones of the forearm are dislocated, deformation of the elbow joint is observed. The nature of the deformation is determined by the type of dislocation. With repeated avulsions of the medial epicondyle, which occur with fibrous fusion of false joints, the symptoms are “blurred”, the swelling is small and limited, there is no bruising, and a soft tissue compaction associated with the humerus is palpated on the anteromedial surface of the elbow joint.

Difficulties in radiological diagnosis arise mainly in children under 6 years of age, in whom the ossification nucleus has not yet appeared, and in the absence of displacement of the epicondyle.

The combination of avulsion of the medial epicondyle and dislocation of both bones of the forearm is characteristic, therefore, when studying radiographs, it is necessary to pay attention to the area of the medial epicondyle. Sometimes it is difficult to distinguish a recurrent fracture from a primary one. Only the presence of ossifications indicates re-injury.

In children, the separation of the medial epicondyle occurs as apophysiolysis or osteoapophysiolysis. Only parts of the apophysis are torn off. Sometimes this is a cartilaginous plate that is not radiopaque. Separations of the muscular pedicle and periosteum are observed. The muscular leg is sometimes pinched in the elbow joint, dragging the ulnar nerve along with it, and signs of damage to it are determined. The latter cases are rare and difficult to recognize, but they should always be kept in mind. There are simultaneous avulsions of the lateral epicondyle of the humerus. Avulsion of the medial epicondyle is often combined with other fractures in the elbow joint.

The fragment, under the influence of muscle traction, is displaced downward and to the radial side. There are two types of entrapment of the epicondyle in the elbow joint:

when it all ends up in the joint cavity;

when only its edge is infringed.

The joint space is widened on the medial side. With a cartilaginous epicondyle, this x-ray sign becomes especially valuable. Be sure to pay attention to the degree of rotation of the fragment, the shape and size of the ossification nucleus. In children 6-7 years old, the ossification nucleus has a round shape and initially its shadow appears in the form of a point.

Treatment

If there is no displacement of the bone fragment, then treatment is limited to immobilization with a posterior plaster splint for 15-20 days. If there is a displacement of more than 5 mm, rotational displacement, or entrapment of the epicondyle, surgical treatment is indicated. When the bones of the forearm are dislocated, the dislocation is first reduced and only then the issue of surgical treatment is decided. The operation is technically simple and, if performed correctly, leads to complete recovery.

Open reduction is sought to be performed as soon as possible after injury. In the first 1-3 days, the operation is performed with minimal trauma to the soft tissues, and it is not associated with any difficulties. A skin incision is made along the anteromedial surface of the elbow joint. The soft tissues are bluntly separated and approached to the fracture site. This removes blood clots. The wound surface of the humerus is freed from the soft tissues covering it, which are retracted medially along with the ulnar nerve. The position of the epicondyle and the degree of damage to the capsule and joint are determined. If a fragment is pinched in the joint cavity, it is removed. Be sure to evacuate blood clots from the joint cavity. To compare the fragment, it must be shifted upward and somewhat posteriorly. A needle with a stop pad or an awl with a removable handle is inserted into the center of the epicondyle so that it runs perpendicular to the fracture plane. The end of the needle is brought out 0.5-1 cm above the wound surface. Using the needle, the epicondyle is pulled up. The end of the pin is then placed in the center of the facet on the humerus and, using the principle of a lever, reduction is achieved. The pin is inserted into the condyle of the humerus, pressing the epicondyle against it with a persistent platform. This technique greatly facilitates reduction, especially with stale fractures. Visually check the accuracy of the reduction. The wound is sutured tightly. X-ray control must be carried out, keeping in mind that when the epicondyle is torn off, there is a tendency to dislocate the forearm. A posterior plaster cast is applied from the base of the fingers to the upper third of the shoulder. The elbow joint is immobilized at an angle of 140°. Practice shows that from this position of the joint its function is restored faster. To avoid the formation of conflicts, the edges of the splint are folded back. IN postoperative period assign the UHF field. Immobilization is continued for at least 3 weeks. The fixation pin is removed and exercise therapy is prescribed. Movements in the elbow joint are carried out within the amplitude, not causing pain. Forced restoration of function and violent movements lead to reflex closure of the elbow joint, the formation of ossifications and, ultimately, to an extension of the time required for restoration of elbow joint function. Massaging the elbow joint and warming it up also have a negative effect.

During the first week, the first signs of movement recovery are observed. During this period, the child and his parents master the basic principles of exercise therapy quite well and, after discharge from the hospital, carry it out at home under the supervision of an exercise therapy methodologist.

Most a common complication is the formation of a false joint. With non-operative treatment, this complication is observed in 40% of cases, which is mainly associated with interposition of soft tissues. In surgical treatment, it is rare and is associated with errors in surgical technique, as well as in the treatment of old fractures.

Avulsion fractures of the lateral epicondyle of the humerus are very rare. Usually only its outer plate is torn off, to which the radial collateral ligament of the elbow joint and muscle is attached. The displacement is usually minor and can be easily corrected. The lateral epicondyle is fixed with a thin pin. The outcomes are favorable. Indications for surgical treatment occur very rarely.

Fractures of the head of the humeral condyle

Among all fractures of the bones that make up the elbow joint, fractures of the head of the humeral condyle occupy the first place in terms of the frequency of adverse outcomes. This is dysfunction of the elbow joint, delayed consolidation, formation of pseudarthrosis and other complications. These fractures account for 8.2% of all fractures in the elbow joint. They arise from an indirect mechanism of injury, when falling on an outstretched, slightly bent arm; most often occur in children aged 5-7 years.

There are several types of these fractures:

epimetaphyseal fracture of the outer part of the condyle;

osteoepiphysiolysis;

pure epiphysiolysis;

fracture of the ossification nucleus of the head of the condyle;

subchondral fractures;

fracture or epiphysiolysis in combination with dislocation in the elbow joint.

Fractures of the head of the condyle of the humerus are sometimes combined with fractures of the medial epicondyle, olecranon and neck of the radius. Fractures of the head of the condyle of the humerus in combination with dislocations in the elbow joint occur in 2% of cases. Anteromedial dislocation predominates, posteromedial dislocation is less common.

Clinical and radiological characteristics

Swelling of the lateral side of the elbow joint and sharp pain on palpation of the lateral surface of the distal part of the humerus are pronounced. Fluid and hemarthrosis are detected in the joint cavity. Sometimes the mobility of a broken bone fragment is determined. Difficulties in radiological diagnosis may arise in the absence of displacement. Typically, the broken bone fragment is displaced laterally and inferiorly, anteriorly or posteriorly, and at an angle that is open posteriorly or anteriorly. Quite often, rotation of the fragment is observed, caused by the traction of the muscles attached to it. Typically, rotation does not occur in one plane and is often quite significant. In such cases, the articular surface of the condylar head may be directed towards the wound surface of the humerus. It loses contact with the head of the radius and is in a position of subluxation or dislocation.

With osteoepiphysiolysis, the metaphyseal fragment can be of different sizes and shapes. Its characteristic crescent shape is characteristic. It occurs at the time of injury when displaced laterally and posteriorly. In this case, only a compact plate breaks off from the lateral or posterior surface of the metaphysis of the humerus. On radiographs, it is determined in the form of a sickle, which at one end approaches the lateral surface of the ossification nucleus of the head of the condyle of the humerus.

Based on the nature of the fracture plane and the degree of displacement, the depth of disruption of the blood supply to the broken fragment is determined with a sufficient degree of reliability. It suffers to the greatest extent with pure epiphysiolysis. The state of the blood supply largely determines the choice of treatment tactics.

Treatment

The treatment method is chosen based on a study of all the features of the fracture. If there is no displacement, a posterior plaster splint is applied from the base of the fingers to the top of the shoulder. If there is a slight displacement, then it is preferable to fix the fragment with knitting needles. This eliminates the possibility of delayed consolidation.

When the fragment is displaced in width, at an angle, and has slight rotation, closed reduction is used. It is carried out with very careful movements. In this case, the direction of displacement and the localization of unbroken soft tissues that connect the fragments and provide them with a certain stabilization are taken into account. When the fragment is displaced laterally and downward, the forearm is deflected medially and with finger pressure on the fragment from the outside upward and inward, it is brought closer to the humerus, introducing it between the condyle of the humerus and the head of the radius. When displaced posteriorly, they press on the fragment from behind and bend the limb at the elbow joint. Then the fragment is percutaneously fixed with knitting needles with thrust pads to the humerus. X-ray control is performed. Immobilization period is 4-5 weeks.

Fractures of the head of the condyle of the humerus in combination with dislocation in the humeroulnar joint

The study of such injuries has shown that at the time of injury, a fracture of the head of the condyle of the humerus occurs, then dislocation occurs. As a result of this, the broken fragment, through soft tissue, remains connected to part of the epicondyle of the humerus. There is a displacement in one ligament of the forearm with the head of the condyle of the humerus. This explains the possibility of bloodless reduction for such injuries. During surgical interventions It was found that children with similar fracture-dislocations had entrapment of soft tissues in the ulnohumeral joint or significant rupture of the joint capsule and other soft tissues. After eliminating the entrapment of the soft tissues in the joint cavity, free reduction of the bone fragment occurred.

Treatment Options

Based on clinical and X-ray examination patients, as well as analysis of surgical findings, a technique was developed for bloodless reduction of fractures of the head of the condyle of the humerus in combination with dislocation in the humeroulnohumeral joint. Its principle is that the fracture and dislocation are reduced at the same time. At the same time, all manipulations must be justified, targeted and as gentle as possible in order to avoid additional rupture of soft tissues. Otherwise, reduction becomes ineffective. The result of the reduction is monitored by radiography, and osteosynthesis is performed using knitting needles with thrust pads.

In children, as a rule, there are many cartilaginous elements in the elbow joint, so correct assessment of the position of the broken fragment can be difficult. The degree of rotation is especially difficult to determine. Therefore, in doubtful cases, open reduction is preferred.

The question of the timing of immobilization for all fractures of the head of the humeral condyle is of fundamental importance. Experience convinces us that reducing the time period even in the absence of displacement is unacceptable; it has shown that complications often occurred in those in whom the displacement was either absent altogether or was insignificant. Guided by this, doctors stopped immobilization in patients in this category within 2 weeks after the injury, which was the cause of bone nonunion.

The duration of immobilization depends on a number of factors and, especially, on the age of the patient, the degree of adaptation of the fragments and the disruption of the blood supply to the broken fragment. In case of epiphysiolysis, therefore, the fixation period must be longer. On average, rest of the fracture area should last at least 4-5 weeks. The data from control radiographs are of decisive importance when deciding whether to remove the plaster cast. The fear of the occurrence of post-immobilization contractures in children is not justified. With delayed consolidation, immobilization is prolonged until the fracture heals.

If there is significant rotational displacement, open reduction is used without attempting closed reduction. The operation is performed using gentle techniques. Fixation is carried out using knitting needles with thrust pads, which create a certain compression between the fragments.

Due to the peculiarities of the blood supply to the distal end of the humerus during its fractures, especially the lateral part, delayed consolidation, a false joint of the head of the condyle, and the phenomenon of avascular necrosis often occur. Ineffective and short-term immobilization contributes to these complications. Delayed consolidation and pseudarthrosis often occur with nondisplaced fractures. In such cases, doctors mistakenly shorten the time of immobilization, which is the cause of the noted complications. To treat them, closed fixation of fragments is used using a specially designed screw, which allows it to be inserted using a removable handle. If the fragment is displaced simultaneously with movements of the forearm, then the latter is installed in the position in which the head of the humeral condyle is installed in the correct position. The fragments are fixed with a knitting needle. Then a scalpel is used to make an incision up to 5 mm in the direction of the head of the humeral condyle. Using an awl through the incision, a channel is made through the head of the condyle into another fragment. A screw is passed through the channel using a removable handle. The screw creates compression between the fragments. A plaster splint is applied. Once the fracture has healed using a removable handle, the screw is removed on an outpatient basis.

Subchondral fractures of the head of the humeral condyle.

A special group of condylar head fractures are subchondral fractures. We are talking about the separation of articular cartilage with areas of bone substance. They are not that rare, but, as a rule, they are not diagnosed. They are usually classified as epiphysiolysis. Subchondral fractures are observed only in children 12-14 years old. Characteristic displacement is only anterior. They are unfamiliar to practicing doctors, since mention of them is very rare. Meanwhile, they require a special approach when diagnosing and choosing a treatment method.

Clinical and radiological signs

The clinical manifestations of subchondral fractures depend on the time elapsed since injury and the degree of displacement. In fresh cases, severe pain in the elbow joint is noted, which intensifies with movement. The contours of the joint are smoothed, local pain is detected when pressure is applied to the head of the condyle. Fluid is detected in the cavity of the elbow joint in fresh and stale cases.

Of decisive diagnostic importance is X-ray examination. The X-ray picture of the damage depends on the size of the broken articular cartilage and bone plates, as well as on the extent and displacement of it. In most cases, the fracture extends only to the head of the condyle, but it often extends to the lateral surface of the trochlear shaft. In one patient, articular cartilage was removed from the entire distal epiphysis of the humerus.

Since plates of bone substance of various sizes break off with the articular cartilage, the contours of the separated fragment are quite clearly visible on radiographs.

It should be noted that in a number of patients, the cortical plate and bone substance break off from the outer surface of the head of the condyle of the humerus. Next, the fracture plane goes inwards, separating only the articular cartilage. Therefore, on a lateral radiograph, when the fragment is displaced anteriorly, a picture of displacement of the entire epiphysis of the humerus in the form of a hemisphere is revealed.

In practice, it is advisable to distinguish 5 groups of subchondral fractures:

fractures without displacement and with slight displacement; they are visible only on a lateral radiograph; this reveals a doubling of the contour of the head of the condyle; treatment consists of immobilizing the elbow joint for 3-4 weeks;

fractures with displacement, but only at an angle open anteriorly; reposition consists of pressure on the head of the condyle from front to back and full extension at the elbow joint; in this position, a plaster splint is applied; as a rule, reposition leads to the desired result;

fractures with displacement not only at an angle, but also anteriorly in width; at the same time, the wound surfaces of the fragments are still in contact at the back; reduction is also carried out using the same techniques as for fractures of the previous group;

complete displacement of the fragment anteriorly; in this case, its wound surface is adjacent to the anterior surface of the distal part of the humerus; closed reduction fails, surgical treatment is indicated;

displacement of the fragment into the anterior inversion of the elbow joint; in such cases, movements in the elbow joint are completely restored without eliminating the displacement; with uncorrected displacements of the 3rd and 4th groups, the function of the elbow joint is sharply impaired, and, first of all, extension suffers.

For stale fractures without displacement clinical symptoms little expressed. Patients complain of moderate pain in the elbow joint, extension in it is limited. Fluid is detected in the joint cavity.

Palpation is not painful. A lateral radiograph sometimes reveals fragmentation of one of the contours of the head of the humeral condyle. Treatment begins with immobilization of the joint. Then they use exercise therapy, FTL.

Fractures of the humerus trochlea

Fractures of the humerus trochlea in children are very rare and arise from an indirect mechanism of injury, when falling on an adducted and slightly bent arm at the elbow joint. They are typical for children of the older age group. There are metaepiphyseal fractures of the medial part of the condyle of the humerus, vertical fractures of the medial edge of the block with the medial epicondyle and epiphysiolysis.

Clinical and radiological picture

A fracture of the trochlea of the humerus is characterized by swelling of the elbow joint, sometimes significant, but more localized on its medial side. With full extension of the fingers and in the wrist joint, pain also appears on the medial side of the joint.

Palpation reveals sharp pain and sometimes mobility of a bone fragment. Fluid is detected in the joint cavity, which is regarded as hemarthrosis.

Radiographs reveal a trochlear fracture of various nature. Difficulties in interpreting radiographs may arise in children in whom the block is represented by several ossification nuclei. The fragment moves inward and downward. Quite often, rotation of the fragment is observed, sometimes it can be significant, which is caused by the traction of the muscles attached to the medial epicondyle.

Treatment

Treatment of non-displaced trochlear fractures is limited to immobilization in a posterior plaster cast for 3 weeks.

Displaced fractures of the trochlea of the humerus lead to limitation of movements in the elbow joint, so they must be eliminated. When shifted along the width, accurate comparison is usually possible in a closed way by direct pressure with the fingers on the fragment. To avoid secondary displacement, osteosynthesis with wires is used. Rotation of the fragment, as a rule, cannot be eliminated closed, so open reduction is used.

Apply medial access to the fracture site. The ulnar nerve is isolated and retracted medially. Under eye control, an accurate comparison of fragments is achieved. They are fixed with knitting needles with stop pads. After layer-by-layer suturing of the wound, the arm is fixed with a posterior plaster splint for 4 weeks. The pins are removed and restoration of movements in the elbow joint begins according to the previously stated principles. Correct use of exercise therapy guarantees full recovery functions of the elbow joint.