Главная Тезисы Лечение диафизарных переломов длинных костей MODERN APPROACHES TO OPERATIVE TREATMENT OF DISPLACED GREATER TUBEROSITY FRACTURES OF THE PROXIMAL HUMERUS

MODERN APPROACHES TO OPERATIVE TREATMENT OF DISPLACED GREATER TUBEROSITY FRACTURES OF THE PROXIMAL HUMERUS

The analysis of operative treatment of 29 patients with isolated displaced fractures of the greater tuberosity and in a combination with dislocation of the shoulder between 1999 and 2006. The indication for operative treatment was more than 5 mm displacement of the fracture the greater tuberosity.

Age of patients from 22 to 64 years. Men 19 (65,5%), women were 10 (34,5%). The right extremity was injured in 23 cases, left - in 6 cases.

In 8 patients isolated displaced fractures of the greater tuberosity, in 21 - dislocation of the shoulder with tuberosity fracture.

Splintered fractures of the greater tuberosity were in 23 patients. Among splintered fractures the 3- facets (SSP, ISP, TM) were in 8 cases, 2- facets in variants (SSP + ISP, TM) in 3 cases, (SSP, ISP + TM) in 7 cases. In 5 patients was 1 fragment of the greater tuberosity.

5 patients having a fracture that was more than 3 weeks

In 5 (17%) cases fractures associated with the rotator cuff tears. Intraarticular fractures - (26 %), extraarticular -(74%).

The clinical outcome was assessed duration of follow-up period 3, 6, 12 and 24 months after the treatment. Depending on a technique of operative treatment of patients have divided into two groups. I group was 7 patients, which have made anatomic osteosynthesis the greater tuberosity.

Patients by whom the preventive approach to the operative treatment was taken into account are related to II group, focused on the prevention of development of a subacromial impingement syndrome of the in the remote postoperative period.

3 patients was removal of fragments the greater tuberosity and refixed the rotator cuff which are related to IIA subgroup, at 9 patients anatomic reduction the greater tuberosity was combined with anterior aeromioplasty - IIB a subgroup, to 10 patients -osteosynthesis the greater tuberosity in position of bringing down - UC a subgroup (Buijanov A A., Samusenko I.V.).

In experiment on 40 samples of shoulders of cadavers are carried out morphometries researches of angular parameters of a coracoacromial arch behind the developed technique. On the basis of experimentally received data and determined role horizontal coracoacromial arch in genesis of subacromial impingement syndrome. The risk factor is the minimal corner (a) bend КАД <143,8° and a corner of an inclination acromion(b) < 15

With the purpose of definition of attributes of risk of development impingement syndrome all patients of II group behind the given technique was preoperative measurement of parameters coracoacromial arch.

Under condition of absence of parameters of risk distance of bringing down of 2 mm, at presence -4-6mm.

At an osteosynthesis fragments of the greater tuberosity used in 5 cases-sutures, in 1- sutures and the anchor screw, in 6-screws, in 3-wire, in 1-screw and a wire, T-plates - in 1 case, figurative plate as "stool" in 4 cases, the fixing with developed by us - figurative plate in 8 cases.

Immmobilization was spent with the help extremity in abduction position with used multifunctional shoulder brace (the patent of Ukraine 2005). The design of the brace creates physiological conditions of fixing of extremity in necessary position, with an opportunity of carrying out of passive - active movements in a humeral joint, active movements in elbow joint. After application of fixing regenerative treatment was appointed.

In the postoperative period the rating of function of a shoulder with Evaluation Form Nirschl-Dudff. Maximum full restoration of function of shoulder a behind calculations of the given system was spent has made 100 points.

In I to group from 90 up to 100 points 1 patient, from 80-89 points - had 4 patients, 70-79 points - 2 patients.

In II group from 90 up to 100 points -12 patients, from 80 up to 89 -1 patient had 9 patients, 70-79 points.

In I to group 1 patient had attributes impingement syndrome of the shoulder that has not allowed to reach necessary amplitude of movements during carrying out of rehabilitation and limitation movements of extremity.

Operation of extraction of a fixator was supplemented subacromial decompression acromioplasty. In 1 patient, after carried out osteosynthesis was defined the mechanical block to abduction shoulder because of the conflict of fixator with acromion, that demanded early extraction of fixator and carrying out acromioplasty

Thus, decompression of subacromial spaces as one of elements of operative intervention at fractures of the greater tuberosity promotes achievement of good functional result, of operative treatment developed by us, by the way performance osteosynthesis the greater tuberosity in position of bringing down in view of restoration injured the rotator cuff less traumatic, does not provide intervention on a coracoacromial arch and prevention of development impingement syndrome of the shoulder in the remote postoperative period.

Buijanov A.A., Samusenko I.V. 
National medical university on honour A. A. Bogomolts, Kiev, Ukraine.

 

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