Osteosynthesis of the humerus is performed during a fracture to heal bone fragments. The operation is not always indicated, but only if casting or traction does not produce results and the bones heal anatomically incorrectly. To prevent this from happening, auxiliary structures (plates, screws) are used to reliably fix the fragments and prevent them from diverging.

Anatomy of the humerus

The definition of the word “shoulder” in everyday terms differs from its anatomical designation. People consider the shoulder to be the place where the captain's parrot sits. But in fact, this is a section of the arm that starts from the elbow joint upward. The shoulder connects to the body through the collarbone and shoulder girdle. And thanks to the peculiarities of the joint structure, it can move freely in all directions.

The humerus is quite long, with a tubular structure. The apex ends with the articular head (epiphysis), which connects to the clavicle joint. Below there is a narrow groove - the anatomical neck, behind which, in turn, there are two tubercles: apophyses. Bone ridges are attached to them (the muscles are held on them). There is a groove between the apophyses and the ridges, and below it, at the border with the diaphysis (body) of the humerus, the surgical neck begins. This is a very fragile area that is most likely to break.

By the way! In childhood and adolescence, the upper epiphysis consists of cartilage tissue, so light stripes may be visible on x-rays. But these are not bone cracks, but anatomical features in the form of the ends of the humerus not yet fully fused.

The lower end of the humerus is widened and slightly bent forward. It ends with the epicondyles, which serve for muscle attachment. Between the epicondyles there is an articular surface that connects the shoulder to the forearm (the area from the elbow below to the hand). Here is the head of the condyle, which articulates with the radius.

Osteosynthesis for a fracture of the humerus can be carried out when certain areas of the shoulder are damaged, namely:

• proximal section (upper);
• body of the humerus (diaphysis);
• distal section (lower).

The feasibility of the operation is determined by the doctor after diagnosis, which includes an x-ray in at least 2 projections, as well as after examining the patient and consulting with him or relatives.

What is shoulder osteosynthesis?

Let's imagine that a person breaks the humerus of the upper arm. Despite the seeming improbability of this, a fracture is very, very possible. The humerus is quite thin, although some people lift quite heavy things with their hands. True, you need to “contrive” in order to break it. In everyday life, this can happen when falling from a bed on one side (especially if a person has a large body weight) or due to sudden pressure on the hand by a door.

Let's go back to the example. Let's assume that the fracture turned out to be complex, with displacement of fragments. Some of them can even damage the muscles and stick out. Those. Simply straightening them and applying plaster will not work. We need some kind of holding force that will fix the fragments in the anatomically correct position so that they can heal normally. And for this purpose, osteosynthesis is performed - fastening the fragments with a plate and other auxiliary elements.

To better understand the principle of osteosynthesis, some suggest comparing it with applying a patch to an area of ​​non-knitted clothing with several small holes, for example on a sleeve. If you simply sew them together, the item will lose its shape and the sleeve will become short. And the patch covers all the holes, maintaining comfort when wearing the item. It’s the same with osteosynthesis: the plate covers all the fragments, so they don’t move anywhere and grow together quietly.

By the way! A metal plate made of biocompatible materials not only fixes fragments of the humerus, but also holds the load. A person who has undergone shoulder osteosynthesis surgery can begin to use this arm much earlier than someone who simply has a cast applied.

Plates for shoulder osteosynthesis

It’s just called that – a plate for osteosynthesis. In fact, this is a whole structure that can have various modifications. For example, in case of a fracture of the surgical neck (this is the upper part of the humerus), a three-dimensional slightly bent plate is used, which can be conditionally divided into 2 sections.

Several pins stick out from the top: they are attached to the bones of the collarbone. There are also pins at the bottom of the plate, and they are inserted directly into the shoulder. The middle of the plate, it turns out, rests on the broken part of the shoulder.

If there is a fracture of the body of the humerus (approximately in the middle), then the plate will have an anatomical shape (i.e., almost straight). The number of pins is determined by physiological characteristics. The fact is that older people have very loose, almost porous bones, so during osteosynthesis you will have to fix the arm with a large number of fasteners.

Pins for shoulder osteosynthesis

Pinning is carried out for simple closed fractures, when the fragment departs not far from the humerus bone. The operation to insert a pin is called intramedullary (intraosseous) osteosynthesis. The morbidity of such an intervention is minimal, and it is possible and necessary to load the injured limb on the second day after pinning.

By the way! The qualitative difference between pinning and plate installation is the aesthetic component. In the first case, a small scar will remain, while osteosynthesis with a plate will require a long incision along the shoulder. Although young people disguise the remaining seam with a tattoo, for example, in the form of a longitudinal inscription.

A pin is a long rod with design features at the ends (hooks or holes) for better fixation. They are inserted directly into the medullary cavity and form the axis of the bone. At the same time, repositioning (returning to the anatomically correct position) of the fragments occurs, so they grow together without any problems.

First, a channel is drilled, the diameter of which should be exactly 1 mm narrower than the diameter of the pin. This will allow the pin to be firmly held in the bone cavity and not fall out of it. But for greater strength and fixation, osteosynthesis of the humerus is sometimes performed with specially designed locking pins.

How is osteosynthesis performed?

The operation is performed under local anesthesia only if the fracture is fresh (less than 24-36 hours) or uncomplicated. Then the patient can be given an injection in the neck so that he does not feel his arm. But he will remain conscious. Particularly sensitive patients who do not want to hear doctors talking and the sounds of drilling their own bones, as well as those who have suffered a complex fracture, are immersed in a narcotic sleep.

The position of a patient with a broken shoulder on the surgical table is determined by the doctor. This is either lying on your back or with your upper body slightly elevated. Having made an incision and gained access to the damaged bone, the trauma surgeon once again assesses the condition of the fracture and begins osteosynthesis. The entire operation takes about 2 hours.

After recovery from anesthesia, the patient remains in the hospital for a couple of days for follow-up examinations. Then he can be discharged, but he will have to travel for dressings for 8-10 days. You shouldn’t spend them at home for the first time! An unhealed wound must be treated in a sterile hospital environment!

Simultaneously with the patient’s arrival for dressings, the doctor examines him, takes a control x-ray, and invites a specialist in exercise therapy. The latter will tell you what loads can be given to the hand and what exercises must be done to develop stagnant joints.

Do structural elements need to be removed?

The plates and pins are used as support structures to fix the broken shoulder and will need to be removed once the bone has healed. The approximate time frame for removing a plate or pin is 8-10 months after osteosynthesis. It is during this time that the bones have time to grow together. If the metal structure is not removed, it can cause serious complications in the future: from simple inflammation to osteomyelitis.

Attention! Patients often delay the moment of going to the doctor for a second operation, believing that a month or two later is nothing to worry about. But if you miss the moment, the metal structure will begin to become overgrown with periosteum, and it will no longer be possible to remove it without additional injuries.

The operation to remove a plate or pin is not as scary and dangerous as many people think. The incision is usually made along the old stitches, so there is no additional disfigurement of the skin. Metal structures can be easily removed without causing harm to the patient. And the cavities left behind quickly fill up.

In general, osteosynthesis of the shoulder is considered a fairly rational operation, which allows one to avoid traction and a long stay in a supine position, and also makes it possible to quickly recover and use the broken limb. In addition, osteosynthesis with biodegradable materials has recently been developing, which gradually dissolve within the body and do not require additional intervention after a year.

One of the surgical operations is osteosynthesis of the shoulder - humerus. This is a surgical intervention during which bone fragments are connected and fixed with special devices - plates, pins.

The essence of osteosynthesis

The essence of osteosynthesis is to create the best conditions for proper healing of fractures. This type of surgery is used in cases where conservative treatment has proven ineffective. The conclusion about the need for surgery is made after using traditional methods of bone fusion.

The fragments must be correctly compared and then securely fixed using special devices to prevent the shoulder from sagging under its own weight.

The structure of the humerus

The humerus is a tubular bone located at the top of the arm. In this section the joint is rounded, triangular in shape. The head of the humerus is in the form of a hemisphere, turned towards the scapula. The articular surface is fixed on it. The neck of the humerus is adjacent to the head. The muscles are attached to two tubercles.

The diaphysis of the bone has a deltoid tuberosity. A separate muscle is attached to it. A neural groove runs behind the bone surface. The distal epiphysis forms the condyle. The articular surface connects to the forearm bones. The tubular connects to the ulna. The trochlea of ​​the bone contains small depressions in which the forearm flexes.

Possible damage

The most common injuries are dislocations, which most often occur in men. Fractures of the humerus can occur in different places. The main causes are direct blows or a fall on the elbow. Deformation of the neck and head may be observed. There are fractures:

• necks;
• bone diaphysis;
• tubercles;
• in the distal section.

Damage is eliminated with the help of special fixing devices that promote rapid fusion of fragments.

Shoulder surgery

Osteosynthesis of the shoulder joint is performed when bone fragments cannot be united due to transverse or helical fractures. This is explained by the fact that there is a certain interposition of muscles between the fragments. Exposure of the diaphysis can be carried out from the posterior, internal or external part. The latter is used for internal osteosynthesis.

To fix fragments, devices with removable contractors are used. They are used for transverse or similar fractures in the diaphysis of the shoulder. Surgery is performed when conservative treatment has failed.

Types of osteosynthesis

Osteosynthesis is divided into two main types - submersible and external. They have different patterns for matching bone fragments. With external osteosynthesis, the fracture site is not exposed. The bones are fixed with special knitting needles, using the Ilizarov technique. With immersion osteosynthesis, devices are inserted directly into the fracture. This method has three varieties:

• transosseous;
• periosteal;
• intraosseous.

The connection technique can be intramedullary, with screws, or with beams.

Scope of application

Osteosynthesis is used in the areas of:

• hip joint;
• elbow joints;
• shoulder;
• feet;
• pelvic bones;
• above and forearms;
• brushes;
• shoulder joint.

The operation involves restoring natural skeletal integrity and fixing fragments. At the same time, conditions are created for rapid rehabilitation.

Indications and prohibitions for surgery

Indications are divided into two types. Absolute fractures include fresh fractures, in which bone healing without surgery is unrealistic. Most often, injuries occur in the area of ​​the collarbone, femoral neck, elbow joint and radius. In this case, fractures are often complicated by severe displacement of fragments, rupture of ligaments and hematomas.

Relative indications include strict requirements for recovery after surgery. Urgent operations are prescribed for severe pain, improperly healed fractures, or when nerve endings are pinched.

Contraindications include a state of shock, the presence of inflammatory diseases, or in cases where strong fixation of the bones is impossible.

Instruments for osteosynthesis

At first, metal plates were used during osteosynthesis, then a three-cavity stainless steel nail was used for fixation. Gradually, special screws, elastic rods, and bone plates came into use. They are able to fix fragments even in complex displaced fractures. The devices are made of titanium.

Plates

During osteosynthesis of the shoulder joint, Demyanov, Kaplan-Antonov plates and similar plates are used. Devices are recommended for transverse and similar fractures. Used for immersion osteosynthesis of any shape. The plate is an entire structure that has many modifications.

For example, humeral neck osteosynthesis uses a three-dimensional bent design. In its upper part there are several pins that are attached to the collarbone. The lower ones are inserted directly into the shoulder. The middle of the plate directly covers the fracture itself.

If the humerus is fractured centrally, a nearly straight appliance is used. The number of pins may vary. For example, they are required more for older people, since their bones are often porous and loose.

Pins

Osteosynthesis of the humerus bone with pins is used for closed simple fractures when the fragments have moved far away. This method is called intramedullary. The operation is low-traumatic, weight bearing on the limb is possible already on the second day after surgery.

A pin is a long rod of a wound structure (there may be holes or hooks at the ends). The devices are inserted into the medullary cavity of the bone and become its axis. The difference from the plate method is that after the operation only a small and almost invisible scar remains.

Is it necessary to remove insert elements?

Pins and plates are auxiliary structures for better fastening of fragments after a fracture. Once the bones have fused, the devices must be removed. Usually after surgery this occurs in the 8-10th month.

During this period, the best fusion occurs. Leaving support structures in the shoulder can cause serious complications, ranging from minor inflammatory reactions to osteomyelitis.

The operation to remove plates or pins cannot be delayed, otherwise the devices may begin to become overgrown with tissue, and subsequently the surgical intervention will be more traumatic. To remove the devices, a small incision is made, and the structures are quickly removed. Cavities fill up very quickly.

Carrying out the operation

Surgery is performed under anesthesia. The patient lies on his back. After the anesthesia has begun to take effect, an incision is made and the radial nerve is exposed. If a plate is installed, the periosteum and soft tissue in this area are peeled off. Then the fragments are compared. The plate is placed in the front of the shoulder so that the device is evenly positioned on the bones.

When full compression is achieved between them, the clamp is secured with screws. The plate and bone on top are covered with muscles. The nerve is laid on them. Then a plaster cast is applied. If Tkachenko plates are used, they are secured with 7 or 8 screws, then plaster is applied.

Connecting bones with screws

In helical or oblique fractures, the fracture line greatly exceeds the diameter of the bone. In this case, 2 screws are used to fix the fragments. After the operation, a thoracobrachial plaster cast is applied.

Intramedullary osteosynthesis

Intramedullary osteosynthesis is performed when the fracture is 6 cm from the ends of the joints. During the operation the following are used:

• pliers;
• special nozzle;
• single-prong hooks;
• rods;
• chisels.

Before the operation, the rods are selected according to length and thickness. When the wire is inserted into the fragment, it should have a diameter 1 mm less than the diameter of the medullary cavity in the bone.

Using beams

The patient is placed on his back, anesthesia is administered to the patient. An incision is then made to expose the fragments. They are compared, and a small groove is made on the outside of the bone, 1 cm larger than the beam. Its end is inserted into the cavity of the fragment. Then the beam is carefully driven into the groove. For additional fastening, screws or cotter pins are used. Then a plaster cast is applied.

Rehabilitation period

The rehabilitation period is short. The surgery itself lasts only a couple of hours. Then the patient remains in the hospital under observation for only 2 days. At this time, surgeons perform follow-up examinations. Then the operated patient is discharged home. However, for ten days the patient must go to the clinic for daily dressing changes.

At the same time, bone fusion is monitored. For this, an x-ray is performed. During the rehabilitation period, patients are prescribed painkillers and therapeutic exercises. However, all exercises should be recommended by a doctor, since only he can establish the necessary load on the damaged area. The duration of the rehabilitation period depends on the severity and location of the fracture, the patient’s age, and his state of health.

Possible postoperative complications

Any complications after osteosynthesis are very rare. Occasionally, minor bleeding, soft tissue infection, arthritis, embolism, or osteomyelitis may occur. To prevent complications after surgery, the patient is prescribed antibiotics, painkillers and anticoagulants.

The cost of the operation depends on the clinic, the complexity of the fracture and the use of certain technology and fixators. As a result, osteosynthesis can cost from 35 to 200 thousand rubles. The operation to remove pins and plates is paid separately. Its price will be approximately 35,000 rubles. Free options are only possible under government quotas, but sometimes you have to wait a very long time for them.

Conversations with the doctor should be held both before and after surgery. Such consultations help to properly prepare for osteosynthesis, choose the right technique and decide on fixation structures. Depending on the state of health, the doctor will tell you what the level of rehabilitation should be and when you can start normal work.

Osteosynthesis is one of the modern and most optimal methods for rapid bone fusion. The operation is low-traumatic, has a quick recovery period, and has virtually no complications or side effects.

Intraosseous (intramedullary) osteosynthesis is performed using a pin that is inserted into the injured bone. This method is used to restore long tubular bones: the femur and tibia, collarbone, shoulder and forearm.

Modern pins are made from materials that are inert to bone tissue. These are special alloys that contain titanium, nickel, chromium, and cobalt. They do not affect bone tissue in any way; their microparticles are not absorbed by the body. Therefore, in many cases, it is possible not to remove the implanted pin after the fracture has completely healed.

Types of intraosseous osteosynthesis

This type of treatment for bone fractures can be performed in different ways.:

1. Open. Full access to the injured bone is provided, after which direct reduction and insertion of a pin into the medullary cavity are performed.
2. Closed. Bone repositioning is performed without direct access to the injury site, after which the pin is installed under X-ray television control. The pin is inserted through a hole in the proximal or distal fragment.
3. Half open. It is used in cases where there are fragments at the fracture site and interposition of soft tissues has occurred. A micro-incision is made just above the fracture site to perform reduction, and a pin is inserted into the bone outside this area.

The method of performing osteosynthesis surgery is selected strictly individually, depending on the nature of the injury.

Features of intraosseous osteosynthesis

There are many types of pins for intramedullary osteosynthesis. Each bone has its own pins; they can be intended for insertion over the full length of the bone, or for part of it.

Installation methods also differ. In some cases, the pin is inserted into a pre-drilled spinal canal of the bone, the diameter of which is 1 mm less than the fixing rod itself. Thus, it is firmly installed inside the bone.

In other cases, when more reliable fixation is required, the pin is secured with screws in the upper and lower parts. This type of osteosynthesis is called blocking. This eliminates the possibility of fragments moving vertically and around their axis. There are many types of locking pins that can provide complete locking of different parts, including the head of the humerus and the neck of the femur.

The main advantage of intraosseous osteosynthesis of bones is the acceleration of fusion, as well as the ability to place early loads on the limb. After just a few days, in the absence of complications, the patient is allowed to begin loading the injured segment of the limb.

If the operation is performed correctly and the recommendations are followed after osteosynthesis, no complications arise. The result is that the bone heals completely and functionality is restored.

A fracture of the humerus cannot always be cured with conservative methods. Especially if there is an unstable fracture with displacement. In such cases, the best treatment option is osteosynthesis of the humerus. There are different ways to do it. Osteosynthesis of the humerus with a plate, knitting needles, screws, pins, or external fixation devices is possible.

Advantages of the method

The osteosynthesis technique ensures correct comparison and reliable fixation of bone fragments. The possibility of functioning of the shoulder joint is ensured from the first days after surgery, the risk of complications is minimized.

How long does the procedure take?

Depending on the nature, location of the fractures and the choice of technique used for osteosynthesis of the humerus, the procedure lasts 50-90 minutes.

Preparation for the procedure

Osteosynthesis of the humerus in Moscow is performed after examining the patient, including a physical examination, laboratory and instrumental studies.

Rehabilitation period

The decision to use immobilization is made on an individual basis. From the first day after surgery, exercise therapy is prescribed with a gradual increase in the intensity of exercise.

Contraindications

Main contraindications for osteosynthesis of the humerus:

• local and general foci of infection in the body;
• severe illnesses in the stage of decompensation;
• mental disorders.

1

An analysis of the results of treatment of 328 patients with traumatic injuries of the humerus at various levels of the segment is presented (proximal - 119, middle - 104, distal - 105), including 79 (24 %) patients with consequences of injuries of the humerus who were treated at the Federal State Budgetary Institution "SarNIITO" in the period from 2009 to 2013. Bony plates, intramedullary rods, and an external fixation device were used to fasten the humerus fragments. Based on an analysis of patient treatment results, the authors recommend the optimal choice of a humerus fracture fixator depending on the level of damage. In addition, the article provides a brief description and clinical examples of the use of original methods for treating humerus fractures and their consequences, developed at SarNIITO as part of research programs. Treatment results were assessed based on clinical, radiological and neurophysiological data. The treatment outcomes for fresh fractures according to the SOI – 1 system were 92 ± 2.3 % of the anatomical and functional norm. Evaluation of treatment results using the SOI-1 system in patients with consequences of injuries of the humerus fell within the range of 68-90 % of the anatomical and functional norm, which is 30 % higher than preoperative indicators.

humerus

osteosynthesis

false joint

1. Ankin L.N., Ankin N.L. Practical traumatology, European standards, diagnosis and treatment. M.: Medicine; 2002. – 480 p.

2. Barabash A.P., Kaplunov A.G., Barabash Yu.A. Norkin I.A. False joints of long bones (treatment technologies, outcomes). Saratov: Publishing House of Saratov State Medical University; 2010. – 130 p.

3. Barabash A.P., Solomin L.N. “Esperanto” of conducting transosseous elements during osteosynthesis with the Ilizarov apparatus. Novosibirsk: Science; 1997. – 188 p.

4. Kogan P.G., Vorontsova T.N., Shubnyak I.I., Voronkevich I.A., Lasunsky S.A. Evolution of treatment of proximal humerus fractures (literature review). Traumatology and orthopedics of Russia. 2013; (3): 154–161.

5. Mironov S.P., Mattis E.R., Trotsenko V.V. Standardized studies in traumatology and orthopedics. M.: News; 2008. – 86 p.

The shoulder segment and its joints play a vital role in human life - from cosmetic appearance to work. According to the literature, the incidence of humerus injuries is 13.5% among other musculoskeletal herbs. Injuries to the humeral diaphysis are more common at the age of 20-50 years, and their proportion ranges from 50 to 72% of all humerus fractures. Damage to the proximal and distal parts (from 5 to 15%) is more common in people over 50 years of age. Violation of the process of consolidation of a humerus fracture, leading to the formation of false joints reaches 15.7%, of which half of the cases occur in the diaphyseal part of the shoulder, and only a third (31.6%) are localized in the distal part of the shoulder. A high percentage of complications indicates shortcomings in the methodology of treating humerus fractures and their consequences. Features of the anatomical structure of the shoulder segment and its participation in the function of joints, different levels of damage limit the versatility and dominance of one type of fastening of fragments (for example, transosseous osteosynthesis).

Purpose of the study- promotion of new technologies for the treatment of humerus fractures and their consequences and differential choice of the type of osteosynthesis depending on the level of shoulder damage.

Materials and research methods

During the period from 2009 to 2013, 328 patients with injuries of the humerus were treated at SARNIITO, which amounted to 5.3% of the total number of patients with fractures and consequences of injuries of long tubular bones (6018 patients). 79 patients came to us with consequences of injuries (false arthrosis, defects, non-union fractures), which amounted to 24% of the total number of patients with injuries of the humerus. The distribution of fractures by level of damage and type of osteosynthesis is presented in Table. 1, where the levels of damage are indicated according to the Esperanto... system, 1997 (Table 1).

Table 1

Distribution of fractures by level of damage to the humerus and types of surgical interventions according to the SarNIITO archive for 2009-2013

In the treatment of fractures, closed and open methods of fastening fragments were used. Extra-articular fractures of the proximal humerus were fixed with bone fixation from a typical approach, mainly plates with angular stability of screws were used. When the fracture was localized in the upper and middle third of the diaphysis up to the supracondylar zone, intramedullary fixation of fragments (BIOS and the “Fixion” system) was most often used. For the surgical treatment of low-lying fractures of the humerus (supra- and transcondylar), external osteosynthesis and transosseous osteosynthesis using wire-rod devices using the original SARNIITO technology (RF patents No. 2312632, 74798) were equally used.

The fastening of fragments of the humerus with slowly healing fractures, false joints and false joints in the form of a defect of up to 5 cm, in general, did not differ from acute injuries. By mechanical action on fragments of the humerus, the pathological process was transformed into an acute fracture and various methods were used to stimulate osteogenesis. Techniques aimed at enhancing bone formation had the ability to enhance vascularization due to the formation of periosteal-medullary anastomoses at the ends of fragments and contributed to the migration of minerals into the pathological zone. Depending on the pathological manifestations formed in the area of ​​humeral bone fragments, different methods of stimulating osteogenesis were used. In case of delayed consolidation of fractures and stiff pseudarthrosis, longitudinal osteotomy of fragments was performed in any accessible plane with opening of the medullary canal. To preserve the size of fragments during their sclerosis, they resorted to artificial reconstruction of the Haversian system at the ends of the fragments, by perforating the ends of the fragments in the transverse and longitudinal directions. To ensure the migration of minerals into the pathological zone, an autograft was introduced into the metadiaphyseal part of the proximal bone. Transplantation of the contents of the bone marrow canal, which is a powerful stimulator of bone tissue regeneration processes, was ensured by the formation of longitudinal holes at the ends of fragments and expansion of the Fixion rod in the medullary cavity (RF patents No. 2181267, 2375006, 2406462, 2438608).

To monitor the healing of bone wounds in patients, clinical and instrumental research methods (radiography, nuclear magnetic resonance imaging, CT, neuromyography) were used. Treatment outcomes were assessed using the SOI-1 system, which includes 16 parameters.

Research results and discussion

The results of treatment of humerus fractures were monitored in all patients for up to 1 year or more. Fusion, regardless of the location of the damage and the type of fixator, was observed within 4-6 months. X-ray signs of healing of the bone wound were complemented by the clinical picture and restoration of full function in the joints. The absence of diastasis between fragments and pain, sufficient muscle strength and restoration of joint function were the main criteria for fracture healing. As a rule, these patients, after 4-6 months of rehabilitation, returned to the doctor after 1-1.5 years to remove the structure. Quantitative indicators of treatment outcomes using the SOI-1 system after 1-1.5 years reached 86-98%, which indicated almost complete restoration of the shoulder segment. In patients with combined trauma (damage to the humerus and radial nerve neuropathy), hand function was restored by 3-4 months after the injury.

When choosing a fixator at levels I-II, the number of fragments of the humerus formed after the fracture and the density of bone structures were taken into account. For osteosynthesis of two fragmentary fractures against the background of age-related osteoporosis, a combined osteosynthesis was used, represented by a figuredly curved pin, which formed a support platform for interfragmentary compression with a thermomechanical shape memory staple. To fix two or three fragmentary fractures of the surgical neck of the humerus against the background of satisfactory bone density, priority was given to external osteosynthesis with the installation of plates with angular stability of screws. When choosing a fixator for fractures of the humerus in the upper third of the diaphysis (damage level II-III), priority was given to intramedullary structures, however, in the presence of comminuted fractures with transition to the area of ​​the humeral neck, bone plates were used. Against the background of age-related osteoporosis and thinning of the cortical layer, when the diameter of the bone marrow canal reached 12 mm or more (Fig. 1, A).

Rice. 1. Radiographs of patient M., 70 years old: a) upon admission; b) closed antegrade alternate introduction of the allograft shoulder and the Fixion IL rod into the canal (before its expansion); c) fixation of fragments with the Fixion IL rod after its expansion and transverse blocking

To fix the fracture, an expanding intramedullary Fixion rod was used in combination with a bone allograft inserted into the medullary canal (Fig. 1, B and 1, C). Osteosynthesis was performed using technology developed in our clinic (RF patent No. 2402298, 2009).

In the treatment of transverse, oblique and comminuted diaphyseal fractures of the humerus at levels III-VI, preference was given to closed reduction of fractures, under the control of an electron-optical converter; locking intramedullary osteosynthesis (Fig. 2, A) and transosseous external fixation devices in a wire were used to fix the fragments -rod arrangement (Fig. 2, B).

To fix fractures in the distal part at the level of the transition of the diaphysis of the humerus to the metaphysis (level VII-VIII), transosseous osteosynthesis (39 cases) and external osteosynthesis (36 cases) were used. Having compared the treatment results, we gave preference to combined (wire-rod) transosseous osteosynthesis.

Rice. 2. X-ray of patient G., 52 years old, before and after surgery, BIOS of the humerus was performed (A); X-ray of the humerus of patient V., 46 years old, before and after surgery (B), osteosynthesis of the humerus was performed using an external fixation device in a pin-rod harness

In the period 2009-2012, 79 patients with consequences of humerus fractures were observed in our clinic. The majority of patients were women - 49 (62%) aged from 23 to 74 years and 30 (38%) men aged from 26 to 63 years. The time interval from injury to admission to our hospital varied from 3 months to 2 years. In patients with consequences of fractures of the proximal humerus (5 cases), due to the futility of reconstructive operations, total shoulder arthroplasty was performed.

In the surgical treatment of ununited fractures of the middle and distal humerus (16 cases) with a duration of 4 weeks to 3 months from the moment of injury or primary surgery, in 7 cases osteosynthesis was performed with an external fixation device (AVF) and in 9 cases intramedullary rods with locking were used . To stimulate bone formation, longitudinal osteotomy of the ends of fragments was most often used. The results of treatment were monitored in 12 patients over a period of 6 months to 2 years. Union of the humeral shaft fracture was achieved in 14 clinical observations within a period of 8 to 20 weeks. Treatment outcomes according to the SOI - 1 system were 92 ± 2.3% of the anatomical and functional norm. In 2 patients, the fracture of the humerus did not heal; they subsequently underwent repeated surgical interventions.

A study of surgical protocols for patients with pseudoarthrosis of the humeral diaphysis (58 observations) showed that the tactics of surgical treatment depended on the presence and size of the defect in the bone structures, as well as the extent of the zone of sclerosis of the ends of the fragments. An external fixation device for fixation of the pseudarthrosis was used in 16 clinical cases, an intramedullary rod with locking - in 30 cases, a rod with the Fixion intracanal locking system - in 12 cases. In patients with pseudarthrosis (58 patients), fusion was achieved in 55 cases within a period of 6 months to 1 year. Assessment of treatment results according to the SOI-1 system fell within the range of 68-90% of the anatomical and functional norm, which is 30-40% higher than preoperative indicators.

To illustrate the observations, we provide several clinical examples.

A clinical example of surgical treatment of a long-existing pseudarthrosis of the diaphysis of the humerus in the form of a defect in the presence of severe sclerosis of the ends of the fragments. Before contacting our clinic, at her place of residence, the patient underwent external osteosynthesis of a fracture of the humerus, the fracture did not heal, and a false joint formed. X-ray of the shoulder showed complete closure of the lumen of the medullary canal, the presence of an end defect of bone tissue over 2-3 cm, and sclerosis of the ends of the fragments of the humerus (Fig. 3, A).

Rice. 3. X-ray of the humerus of patient K., 52 years old, 1 year after the primary operation (A), X-ray of the humerus of patient K. 1 year after surgery (B). The patient refused to remove the rod

The patient underwent plate removal; economical modeling resection of the ends of fragments to create tight contact between fragments; by longitudinal and transverse drilling of the ends of the fragments from the end side to a depth of 1.5-2 cm; For fixation, the “Fixion” rod with a maximum extension of up to 13.5 mm was chosen (Fig. 3, B).

After introducing the rod into the cavity of the humerus, it was expanded, as a result, the contents of the bone marrow canal were moved to the area of ​​the false joint to stimulate the processes of bone tissue regeneration.

The generally accepted division of the shoulder segment into 3 levels (proximal, distal and diaphyseal) is, in our opinion, completely insufficient. Differentiated choice of fixator requires more precise orientation of the damage zone. The “level-position” system according to “Esperanto” is time-tested and helps clinicians perform one or another type of fastening of fragments.

An analysis of the treatment of 328 patients with fractures and consequences of injuries of the humerus in recent years showed that the dominant trend of immersion osteosynthesis was confirmed. For diaphyseal injuries, closed intramedullary osteosynthesis with blocking of fragments both from the outside (transverse) and from the inside (Fixion system) was more often used. Bone fixation prevailed in the proximal part of the segment (74 patients), was used less frequently in the distal part (36 patients) and very rarely in the middle parts. According to the algorithm adopted in the clinic for combined injuries (bone-nerve), preference was given to external osteosynthesis (11 patients).

Experience in treating the consequences of humerus fractures (long-term healing fractures and false joints in 79 people) suggests that the usual technique of treating the ends of fragments to the bleeding bone leads to shortening and does not fully guarantee bone fusion. After closed intramedullary osteosynthesis (BIOS), 7 patients were re-operated. Therefore, stimulation of bone formation should be a prerequisite. Additional foci of bone formation with revascularization of the altered bone tissue of the ends of the fragments provide the effect of primary healing of the bone wound. Time-tested force effects (compression, distraction, torsion) on the ends of fragments stimulate osteogenesis, and immobility provides conditions for the mineralization of newly formed osteogenic tissue.

We propose to solve the problem of treating fractures in conditions of age-related osteoporosis, a wide bone marrow canal of the diaphyseal part of the segment, using new surgical techniques (combination of a rod with a graft). False joints in the form of bone defects up to 4 cm, in our opinion, do not need compensation for shortening (lengthening) of the limb.

Damage level according to Esperanto		Types of osteosynthesis
		Intramedullary osteosynthesis	Bony osteosynthesis	Transosseous osteosynesis	Combined osteosynthesis
Proximal section	Level I
	Level II
Diaphyseal section	Level III - VI
Distal section	Level VII
	Level VIII

Providing specialized medical care to patients with damage to long bones obliges the orthopedic traumatologist to adhere to generally accepted regulations. However, this is not always possible due to various reasons, for example, insufficient equipment of medical institutions. Standards, in the form of federal clinical recommendations for the provision of orthopedic care, are not always possible to comply with due to the variety of bone injuries and their location. But, nevertheless, we recommend fastening the fragments based on the location of the damage (Table 2).

Bibliographic link

Barabash Yu.A., Barabash A.P., Grazhdanov K.A. EFFECTIVENESS OF TYPES OF OSTEOSYNTHESIS FOR FRACTURES OF THE HUMERUS AND THEIR CONSEQUENCES // International Journal of Applied and Fundamental Research. – 2014. – No. 10-2. – P. 76-80;
URL: https://applied-research.ru/ru/article/view?id=6001 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"