Surgical neck fracture of the humerus
The surgical neck of the humerus is located 2-3 cm below the anatomical neck and above the stop of the pectoralis major muscle, where the transition from cancellous bone to cortical bone is slightly thin and is a mechanically weak area, where fractures are more common and can occur at all ages, more often in the elderly, with more serious displacement of the surgical neck of the humerus and more local bleeding, which should be given special attention.
1.Etiology
This fracture is mostly caused by indirect violence, such as a fall with the hand or elbow on the ground, the violence is transmitted upward along the humeral stem causing fracture; direct violence on the outside of the shoulder can also cause fracture.
2. Clinical manifestations
It is similar to other shoulder fractures, but the symptoms are more serious.
1. Swelling
Because the fracture is located outside the joint, the local swelling is more obvious, especially in the involutional and comminuted type.
2. Pain
Except for the abductor type, the pain is more obvious, especially when moving, and is accompanied by ring pressure and percussion pain.
3. Restriction of movement
The latter two types are the most serious.
4.Other
Pay attention to the presence of neurovascular compression symptoms. In case of obvious misalignment, the affected limb may be shortened and angular deformed.
5.Fracture classification
(1) Crack fracture is caused by direct violence.
(2) Adductor fracture is caused by the fall of the upper extremity, and the distal segment of the fracture is abducted, while the proximal segment is correspondingly adducted, resulting in the outward angular displacement of the two fracture ends, and often the two fracture ends are inserted into each other.
(3) Inclusion fractures are caused by the inversion of the upper extremity during a fall, causing the distal segment of the fracture to adduct and the proximal segment to abduct accordingly. The two fracture ends are displaced inward at an angle, and the two fracture ends are often embedded with each other medially.
(4) Humeral surgical neck fracture combined with anterior dislocation of shoulder joint is mostly caused by the violence of upper limb abduction and external rotation, and the violence continues to act and then causes humeral surgical neck fracture.
3.Examination
X-ray examination of the shoulder can confirm the diagnosis.
4.Diagnosis
1. History of trauma
Multiple kinds of violence can cause it.
2.Clinical manifestations
It is mainly based on shoulder swelling, pain and limitation of movement.
3.Imaging examination
Conventional X-rays can show the fracture line of the surgical neck of the humerus and the angular deformity and displacement, and most of them can make a clear diagnosis; generally, MRI, CT and other examinations are not required.
5.Complications
1.Vascular injury
Proximal humerus fracture combined with vascular injury is relatively rare. The incidence of axillary artery injury is generally the highest. In elderly patients, vascular injury is more likely to occur due to vascular sclerosis and poor elasticity of the vessel wall. After arterial injury, a swollen hematoma is formed locally and pain is obvious. The limbs are pale or cyanotic, and the skin sensation is abnormal. In some cases, there is still blood supply to the extremity due to collateral circulation.
Arteriography can determine the site and nature of the vascular injury. Surgery should be performed as soon as possible to investigate, fix the fracture, and repair the damaged blood vessels, such as saphenous vein graft or artificial blood vessel graft.
2. Brachial plexus nerve injury
Brachial plexus nerve injury combined with proximal humerus fracture, the axillary nerve is the most involved, and the suprascapular nerve, musculocutaneous nerve and radial nerve injury also occur occasionally. When the axillary nerve is injured, the skin sensation of the lateral shoulder is lost, but the contraction of deltoid muscle fibers is more accurately and reliably measured. In the case of axillary nerve injury, electromyography can be used to observe the progression of nerve injury recovery. In the vast majority of cases, function can be restored within 4 months. If there is still no sign of recovery 2 to 3 months after the injury, nerve exploration can be performed early.
3.Thoracic injury
When the proximal humerus is fractured due to high energy, it is often combined with multiple injuries, and attention should be paid to exclude rib fractures, hemothorax, pneumothorax, etc.
6.Treatment
The surgical neck of the humerus is close to the glenohumeral joint, and the fracture occurs mostly in middle-aged and elderly people, so it is very easy to cause frozen shoulder as a result, so carefully understand the condition, choose the treatment method, and maintain a certain degree of shoulder joint mobility.
1.Crack fracture
Suspend the affected limb with a triangular scarf for 2 to 3 weeks, and start functional activities of the shoulder joint as soon as the pain is reduced.
2.Abductor fracture
If the fracture has insertion and the deformity angle is not too big, it is not necessary to reposition the fracture. Suspend the affected limb with a triangular towel for 2 to 3 weeks and gradually start functional activities of the shoulder joint; fractures without insertion should be repaired by manipulation and then fixed with a plaster or small splint for 3 to 4 weeks.
3.Integrated fracture
All displaced fractures should be repositioned. There are two methods of repositioning: manipulation and incision, and appropriate external or internal fixation should be given.
(1) External fixation is usually performed under anesthesia within the fracture hematoma, and then appropriate external fixation is applied according to the specific situation. The following are commonly used.
(1) External fixation with a super-shoulder splint.
②Plaster bandage fixation.
(3) Abduction brace (airplane frame) fixation. Regardless of the method of fixation, it is necessary to start functional activities early, and the fixation can be removed as appropriate in about 4-6 weeks.
(2) Indications for incisional reduction and internal fixation.
①Seriously displaced surgical neck fracture, unstable after repositioning; failure of external fixation by manipulation;
(2) Patients under 50 years of age with comminuted humeral head fracture;
③ Combined humeral tuberosity avulsion fracture with displacement and contact with the lower part of the acromion;
(④) separated epiphyseal plate fractures that cannot be repositioned (long head of the biceps muscle is embedded);
(⑤) Green branch fractures that cannot be repositioned after late treatment.
7.Prevention
This disease is caused by traumatic factors, there is no effective preventive measures, pay attention to production and life safety, avoid injury is the key.