Shoulder

Anomalies of development. There are the following congenital malformations: lack entire limb (amelia); presence of rudiment instead of the shoulder (peromelia); embryonic development of limbs, which starts right from the body in the form of a brush (phocomelia); significant underdevelopment of all segments of the upper limb (extromelia). Unilaterally malformation P. patient adjusts to self-service and working with one hand, but needs a cosmetic prosthesis. Bilateral defect children from early years to adapt to fill feet, reaching great achievements in this way. These patients should be encouraged to actively cosmetic prosthesis.
The damage. Soft tissue injuries. Injury is often accompanied by significant subcutaneous hemorrhage; the treatment is reduced to the imposition of a pressure bandage and peace for 7 to 8 days. Breaks fascia shoulder often lead to the formation of muscle hernia (often the biceps). Damage to muscles and tendons can happen when a sudden rapid reduction or passive stretching the muscles. Especially often ruptures of the long head of the biceps P. or torn tendon her. In place of the gap is formed painful swelling, muscle function falls. At break, the muscles shown surgery - a muscle or tendon suture, and in advanced cases, muscle or fascial plastic.
From the wounds of soft tissues P. the greatest importance of firearms, especially with damage to large vessels and nerves. Treatment is carried out according to General rules (see the Wounds, wounds).
Closed fractures of the shoulder are often observed in proximal third of the humerus; the second by frequency place fractures of the distal third of the shoulder, and the third middle third. Fractures of the shoulder are often accompanied by displacement of bone fragments. Often you may experience significant secondary displacement. In all departments P. fractures can be varied both in the form of fragments, and their displacement.
Localization distinguish: fractures anatomical neck and a head of the humerus; the fractures in the field of surgical cervix (more often in the elderly), diaphyseal fractures (more often in middle age), naimisharanya fractures and fractures of the distal metaphysis, and epiphysis shoulder (mainly in children and adolescents).
In the upper part of the humerus should distinguish between intra-articular fractures of the head and anatomical cervix, fractures of the big mound, epiphyseolysis and fractures, surgical neck. The most common fractures surgical neck. On the mechanism of injury and the nature of the displacement of bone fragments, they are divided into adduction and abduction (Fig. 3). Adduction fractures are more frequent, especially in children. They arise when the fall in the back hand. Typical shift fragments at an angle, open inwards, and peripheral fragment width outwards. Abduction fracture occurs when a fall on an outstretched allocated from the body's hand. Typical displacement of fragments at an angle, open outwards, and distal fragment - turn in. The offset length at these fractures are rare.

Fig. 3. Typical fractures of the neck of the humerus: 1 - impacted; 2 - eductional; 3 - abduction.

At fracture surgery neck shoulder most unfavorable three types of movement is at an angle, open inwards (adduction fracture); at an angle, open back, and Rotatoria. The most favorable type of fracture is impacted. Treatment of this type of fractures of the neck P. requires no stretching, no long-fixing. A few days a hand hold on the bandage with cushion under his arm, then designate special therapeutic gymnastics instructor-led exercise therapy.
At the displacement of bone fragments treatment onto the bus, fixing a limb in a reserved position, by using a constant stretching (see) spin or rubber traction. Enter 1-2% solution novokaina directly in a hematoma between fragments. Efferent bus (Fig. 4) strengthen the body plaster corset. A crippled hand laid on the bus position of assignment of 90 degrees, and the front deviation 25-30 degrees; the elbow bent at a right angle. Produce a control x-ray picture. The remaining correct offset by reposition on the bus, manual, or by stretching a sticky patch. Limb is fixed to the bus soft bandages. Record set fracture can and circular coracobrachialis bandage. The fixed - 4-5 weeks, then appointed physiotherapy and functional treatment. Working capacity is usually restored within 8-9 weeks.
In the complete separation of fragments with a shift in length (the going down of bone fragments) apply skeletal traction. When nevprawima conservative fractures shown surgery - bloody mapping of fragments or osteosynthesis (see).
Diaphyseal fractures of the shoulder proximal third are over - and modeltovalidate. In the first case the proximal fragments shifted backwards and inwards, distal and forth, up and outwards. In the second proximal fragments goes upwards and outwards, peripheral - up and back (Fig. 5). Large displacement in length, as a rule, does not occur.

Fig. 4. The correct position of hands onto the bus with the imposed traction (abstraction and rotation outwards).
Figure.. 5. The displacement of bone fragments shoulder depending on the level of fracture: 1 - turn in the middle third; 2 - fracture on the border of the middle and lower thirds.

The most unfavorable for subsequent function offset at an angle, open inwards and backwards, as well as the internal rotation of the distal fragment. The first entails the restriction of the abduction of the shoulder and the marked weakening of the forces of the triceps, the second - sharp limited external rotation. With diaphyseal fractures of the humerus in the middle or distal third of may suffer the radial nerve, which leads to the impossibility extension of the hand.


Treatment of diaphyseal fractures is carried out according to the same principles as the fracture surgery of the neck. Limb is fixed onto the bus (abstraction 45-60 degrees, the adduction of the shoulder in front of the frontal plane at 30 degrees and easy external rotation P.; the elbow bend 90 degrees). After the reduction may be imposed outlet cast, but most record set fracture onto the bus extension through traction rubber, corresponding to the goods in 3-5 kg Fixing continues up to the fracture consolidation (5-6 weeks), then, if clinical-radiological monitoring will show the presence of fusion, appoint active movement in the shoulder joint. After 5-7 days, when a person raises his hand over the bus and holds it in the designated position, efferent bus removed and hand laid on a wedge-shaped pillow. Within 2 weeks apply exercises in all joints of limbs, muscle massage P. and forearm. Ability to work completely restored in 9 - 10 weeks after the fracture.
With a slight displacement convenient is the so-called hanging plaster bandage, which is applied to the upper third of the shoulder, with coverage elbow and forearm. The patient wears a hand on the scarf and the weight of the hand provides the traction of the leg. If nepravilnosti fracture (interposition of soft tissues) and in cases of compression of a radial nerve shown operation and osteosynthesis.
Over - and Razmyslov fractures are more common in children. They are flexion and extension (Fig. 6). Flexion arise when dropped on a bent elbow. In this line of fracture goes back forward and up, the fragments are shifted at an angle, open the front. Extensor fracture occurs in the fall rectified on hand, the line of the fracture is up to the front and back, fragments move at an angle, open backwards. When expressed offset peripheral fragment backwards possible compression and even rupture of the brachial artery condom Central fragment. The same can happen with a careless reposition. All these shifts are often combined with offsets distal fragment width inwards or outwards. Extensor fracture should radiographically to differentiate from the dislocation of the forearm to the back.

Fig. 6. Naimisharanya fractures of the shoulder: 1 - flexion; 2 - extention.
Fig. 7. Crushed fracture.

Treatment with careful simultaneously reposition under General anesthesia. Set broken record circular plaster cast the child within 12-14 days, the adult - 4 weeks. The best situation is when the extensor fractures should be considered bend the elbow to an acute angle, with flexion - full extension of the forearm. After reposition and fixation should carefully monitor the pulse of the radial artery, sensitivity, motion and color of the hand and fingers as possible subfascial hemorrhage, often leading to compression of the veins and nerves. When complications occur elbow immediately free from any pressure. After fixing appoint a warm bath and active exercises.
When the failed private setting, late treatment of patients (7-8-th day), fractures, complicated collateral damage nerves, applied skeletal traction, at break artery - a blood reposition.
Treatment of fractures of the condyles of the shoulder is a big challenge. At the displacement of bone fragments, you must set the last under local anesthesia or General anesthesia and record limb plaster cast. In children and adolescents bandage should remain for at least 2 weeks in adults - 3-4 weeks. Then apply the whole complex of functional therapy. Recovery in children usually occurs in 6-7 weeks in adults disabled completely restored in 9-10 months.
Fractures Razmyslov more often than fractures condyles. These fractures are mainly tear. The vast majority falls on internal nadkislot. In the absence of displacement start fixing broken. When the infringement of namesake in joint cavity needs surgery. If operations are made in the first days after the fracture, nadkislot together with the attached muscles is stitched in place. 7-10 days after injury and later have to remove nadkislot and soft tissue to fix in the margin.
Intra-articular fractures and dislocations of the shoulder - see the Shoulder joint.
Open fractures of the shoulder more often connected with his injuries, mainly fire, but sometimes soft tissue ranada inside the bone fragment. In some cases in the field of fracture can occur necrosis of the skin and then closed fracture converted to open. Surgical treatment is the primary surgical treatment of soft tissue and bone fragments according to General rules (see Fractures). Postoperative treatment onto the bus or in plaster coracobrachialis the bandage. The use of antibiotics is necessary. When complications suppuration joints must be removed to provide an outflow of pus. If you have applied osteosynthesis, pins should not be removed.
Gunshot fractures of the shoulder can be a result of the gunshot and shrapnel through and blind tangent wounds. Fractures are krupnofestonchatye, crushed (Fig. 7) and melloncollie, often complicated by damage to blood vessels and nerves, and extensive soft tissue injury, and the more bone fragments, the usually greater the damage of soft tissues. When Troubleshooting gunshot fractures always necessary to check the condition of the great vessels and nerves.
The main method of treatment of gunshot fractures P. in the rear hospitals during the great Patriotic war was deaf plaster bandage. Applied also a whole complex of measures on functional treatment to restore movement in the joints and prevent contractures. The fracture fracture of the shoulder on average came in 2-3 months. In uncomplicated cases, under condition of sufficient primary surgical treatment with the use of massive antibiotic therapy may be recommended osteosynthesis.