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Traumatology and orthopedics. Lecture notes: briefly, the most important

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Table of contents

1. Methods of examination of traumatological and orthopedic patients (General questions of examination methods. Features of an objective examination)
2. Methods for the treatment of patients with injuries and diseases of the musculoskeletal system (Hard and hardening dressings. Prosthetics and apparatus therapy. Damage to the soft tissues of the organs of the musculoskeletal system. Traumatic dislocations. Traumatic fractures. Closed bone fractures. Intra-articular fractures of the bones of the forearm in the elbow joint. Diaphyseal fractures Fractures of the lower end of the radius Fractures of the bones of the hand Hip fractures Injuries in the knee joint Fractures of the leg bones Fractures of the foot bones Injuries of the spine Fractures of the pelvic bones Chest fractures Open injuries of the musculoskeletal system Limb amputations Amputation pain, extreme conditions)
3. Fibrous osteodystrophies (Localized forms of fibrous osteodystrophies. Common forms of fibrous osteodystrophies. Fibrous bone dysplasia)
4. Degenerative-dystrophic diseases of the skeleton (Osteochondropathy. Bone tumors. Primary bone tumors. Primary tumors from reticuloendothelial tissue)
5. Static deformations (Scoliosis. Flat foot)
6. Inflammatory bone diseases (Acute and chronic osteomyelitis. Hematogenous osteomyelitis. Atypical forms of hematogenous osteomyelitis. Post-traumatic osteomyelitis)

LECTURE No. 1. Methods of examination of traumatological and orthopedic patients

The basis that allows making a preliminary diagnosis and determining the directions of diagnostic search has remained and remains the classical method of examining a traumatological and orthopedic patient, without knowledge of which it is impossible to form a competent traumatologist-orthopedist.

Examination of patients with injuries and diseases of the musculoskeletal system is the most important step in the timely recognition of the disease and the correct diagnosis, which determines the choice of the optimal method of treatment and the subsequent course of the disease.

The methodology for examining traumatological and orthopedic patients is distinguished by a number of features, consisting in a strict sequence of studying the patient using not only special manual techniques and symptoms, but also the very methodology of examining the patient. The following provisions are of particular importance:

1) mandatory use of the comparative method;

2) accounting for causal relationships in the manifestations of diseases, injuries or their consequences;

3) strict anatomical conditionality of diagnostic techniques and symptoms, depending on the localization of the focus of the disease.

Stages of carrying out the main therapeutic and diagnostic measures for injuries and injuries of soft tissues:

1) determine the type of damage, make a preliminary diagnosis;

2) determine the urgency and scope of first medical and follow-up care;

3) perform urgent diagnostic studies;

4) provide medical care in the appropriate amount;

5) determine the features of transportation and transport immobilization.

When a patient enters the hospital, his general condition is first of all clarified. If the victim is in shock, anti-shock measures are taken first, then, when the patient comes out of a serious condition, they begin to question and examine.

1. General questions of survey methodology

Clinical data remain decisive in making a diagnosis and prescribing rational treatment.

The doctor should always begin the examination of the patient with a questioning (find out complaints and collect anamnestic data), then proceed to a careful examination, and then apply special research methods aimed at recognizing and evaluating clinical and other signs of injury or illness. Inspection, palpation and measurement, as well as percussion and auscultation, are methods of objective examination that have the greatest practical value and do not require the use of special instruments and are carried out in any setting.

The examination scheme includes the following diagnostic tests:

1) clarification of the patient's complaints; questioning the patient or his relatives about the mechanism of injury, the features of the disease;

2) inspection, palpation, auscultation and percussion;

3) measuring the length and circumference of the limbs;

4) determination of the amplitude of movements in the joints produced by the patient himself (active) and the doctor examining him (passive);

5) determination of muscle strength;

6) x-ray examination;

7) surgical and laboratory research methods (biopsy, puncture, diagnostic opening of the joint).

Complaints

Frequent complaints of patients with diseases and injuries of the organs of support and movement are pain (localization, intensity, nature, connection with the time of day, physical activity, position, effectiveness of drug relief, etc.), loss, weakening or dysfunction, the presence of deformation and cosmetic defect.

It should be borne in mind that often the intensity of pain does not correspond to the place of the underlying disease, but is of a reflected nature.

Anamnesis

Anamnestic data include information about age, profession, duration and development of the disease.

In case of injuries, the circumstances and time of the injury are clarified, its mechanism and the nature of the traumatic agent, the volume and content of first aid, the features of transportation and transport immobilization are established in detail. If the injury was mild or not at all, and a bone fracture occurred, one should think about a fracture against the background of a pathological process in the bone.

When examining patients with diseases of the musculoskeletal system, it is necessary to clarify a number of specific questions for this group of diseases.

With congenital deformities, a family history is specified. It is necessary to clarify the presence of such diseases in relatives, the course of pregnancy and the characteristics of childbirth in the mother, to establish the nature of the development of the deformity.

In inflammatory diseases, it is important to find out the nature of the onset of the process (acute, chronic). It is necessary to establish what the body temperature was, the nature of the temperature curve, whether there were any previous infectious diseases, ask the patient about the presence of such diseases as brucellosis, tuberculosis, venereal diseases, rheumatism, gout, etc.

With diseases of the nervous system. With deformities arising from diseases of the nervous system, it is necessary to find out from what time these changes were noticed, what preceded the development of this disease (features of the course of childbirth in the mother, infectious diseases, injuries, etc.), the nature of the previous treatment.

With neoplasms, it is necessary to establish the duration and nature of the course of the disease, previous treatment (drug, radiation, surgical), data from a previous examination.

With dystrophic processes, it is necessary to find out the good quality of their course.

2. Features of an objective examination

Inspection

Examination of the patient is crucial for the diagnosis of the disease and differential diagnosis. It must be remembered that victims with multiple fractures usually complain about the most painful places, diverting the attention of the doctor from the general examination, which often leads to the fact that other injuries are not recognized. You can not start a manual study without examining the patient. It is definitely recommended to compare the diseased limb and the healthy one.

On examination, it is necessary to determine the anomalies in the position and direction of individual parts of the body, due to changes in the soft tissues surrounding the skeleton, or in the bone tissue itself, which can lead to impaired gait and posture, to various curvatures and postures. Particular attention should be paid to the position of the limb, forced posture and features of gait.

In some diseases and injuries, the limb may be in the position of external or internal rotation, flexion or extension, abduction or adduction. Distinguish the position of the limb:

1) active - a person freely uses a limb;

2) passive - the patient cannot use the limb due to paralysis or bone fracture. For example, in a fracture of the femoral neck, the limb is in external rotation; with paralysis of the brachial plexus, the arm is brought to the body and rotated inward, and the hand and fingers retain normal mobility; with paralysis of the radial nerve, the hand and fingers are in the position of palmar flexion, active extension of the II-V fingers and abduction of the first finger are absent;

3) the forced position of the limb or the patient is observed in systemic diseases and can be of three types:

a) caused by pain - sparing installation (antalgic posture for lumbalgia);

b) associated with morphological changes in the tissues or disorders of the relationship in the articular ends, such as dislocations, ankylosis, contractures (posture of the petitioner in ankylosing spondylitis, spastic paralysis as a result of contracture and ankylosis);

c) pathological attitudes, which are a manifestation of compensation (with shortening of the limbs, pelvic tilt, scoliosis).

When examining the skin, a change in color, color, localization of hemorrhage, the presence of abrasions, ulcerations, wounds, skin tension with edema, the appearance of new folds in unusual places are determined.

When examining the limbs, an anomaly of direction (curvature) is determined, which is characterized by a violation of the normal axis of the limb due to curvature of the limb in the area of ​​​​the joints or within the segment, or due to a violation of the relationship of the articular ends (dislocations) and is most often associated with changes in the bones: the curvature may be due to rickets, degeneration or dysplasia of the bone, violation of its integrity due to trauma or neoplasm.

When examining the joints, the shape and contours of the joint are determined, the presence of excess fluid in the joint cavity (synovitis, hemarthrosis).

The shape and contours of the joints can be in the form of:

1) swelling (due to inflammatory edema of periarticular tissues and effusion into the joint cavity during an acute process);

2) defiguration (as a result of exudation and proliferation in the joint and periarticular tissues in a subacute inflammatory process);

3) deformities (violation of the correct shape of the joint that occurs in chronic degenerative disease).

When examining the shoulder joint, you can notice muscle atrophy or restriction of movement of the shoulder and shoulder girdle; when examining the elbow joint - cubitus varus and cubitus valgus, subcutaneous nodes, ulnar bursitis or restriction of movement (flexion and extension, pronation and supination), deformity of the fingers and Heberden's nodules.

Examination of the knee joint is carried out at rest and during exercise. Deformation of the joint, its contracture or instability are revealed. In this case, deformations of the genu varum (angle open inward), genu valgum (angle open outward) and hyperextension of the knee joint are possible.

Inspection of the foot is carried out at rest and under load. The height of the longitudinal arch of the foot and the degree of flat feet, foot deformities are determined: hallux valgus, hammer toe, nodulation with gout, horse (hanging) foot, varus foot or valgus foot, adducted and retracted forefoot, abnormal gait (toes apart or inward).

Examination of the back is performed for diseases of the spine. The patient must be undressed and undressed. Inspection is carried out from the back, front and side. Determine the curvature of the spine (kyphosis, scoliosis), costal hump.

Palpation

After a preliminary determination of the place of manifestation of the disease, they begin to palpate the deformed or painful area. Palpation is carried out carefully, carefully, with warm hands, so as not to cause a protective reaction to cold and rough manipulation. It should be remembered that palpation is a feeling, not pressure. When performing this diagnostic manipulation, the rule is observed - to put as little pressure on the tissues as possible, palpation is performed with both hands, and their actions must be separate, that is, if one hand makes a push, the other perceives it, as is done when determining fluctuation.

Palpation is performed with the whole hand, fingertips and the tip of the index finger. To determine the soreness, tapping along the spine, hip joint and pressure along the axis of the limb or load in certain positions can be used. Local pain is determined by deep palpation. When palpation is recommended to use a comparative assessment.

Palpation allows you to determine the following points:

1) local increase in temperature;

2) points of maximum pain;

3) the presence or absence of swelling;

4) the consistency of pathological formations;

5) normal or abnormal mobility in the joints;

6) pathological mobility throughout the tubular bone;

7) the position of the articular ends or bone fragments;

8) crepitation of bone fragments, rough crunch or clicking;

9) springy fixation in case of dislocation;

10) nodules, gouty tufus and fibrositis;

11) atrophy or muscle tension;

12) balloting and fluctuation.

Auscultation

In case of fractures of long tubular bones, bone sound conductivity is determined in comparison with the healthy side. Bone formations protruding under the skin are selected and, percussing below the fracture, sound conduction is heard with a phonendoscope above the alleged bone damage. Even a crack in the bone gives a reduction in the pitch and clarity of the sound. With a disease of the joints at the time of flexion, a wide variety of noises occur: crunching, crackling, crepitus.

Percussion

Percussion is used to determine the painful segment of the spine. The percussion hammer or the ulnar side of the fist determines general or strictly localized pain. Soreness associated with hypertonicity of the paravertebral muscles is determined by percussion of the spinous processes with the tip of the III finger, and II and IV fingers are set paravertebral. Tapping on the spinous processes causes a spasm of the paravertebral muscles, felt under the II and IV fingers.

There is a special method of percussion of the spine, which allows you to determine the increased sensitivity in the area of ​​the affected vertebra - this is a sharp lowering of the patient from socks to heels.

Measuring the length and circumference of a limb

For a more accurate recognition of an orthopedic disease or the consequences of an injury, it is necessary to have data on the length and circumference of the limb.

General rules. Measurement of the length of the limb is carried out with a symmetrical installation of the diseased and healthy limbs with a centimeter tape between symmetrical identification points (bone protrusions). Such points are the xiphoid process, navel, spina ilica anterior superior, tip of the greater trochanter, condyles, ankles, etc.

With a forced position of the limb (contractures, ankylosis, etc.), a comparative measurement is carried out by setting the healthy limb in the same position as the patient.

The preliminary stage of measurement is the study of the axis of the limb.

The axis of the upper limb is a line drawn through the center of the head of the humerus, the center of the capitate eminence of the shoulder, the head of the radius and ulna. Around this axis, the upper limb performs rotational movements.

The axis of the lower limb normally passes through the anterior superior axis of the ilium, the inner edge of the patella and the first toe in a straight line connecting these points.

Measurement of the length of the upper limb. The arms should be parallel to the body, extended at the "seams", the correct position of the shoulder girdle is determined by the same level of standing of the lower corners of the shoulder blades.

The anatomical (true) length of the shoulder is measured from the large tubercle of the humerus to the olecranon, the forearm - from the olecranon to the styloid process of the radius.

The relative length of the upper limb is measured from the acromial process of the scapula to the tip of the third finger in a straight line.

If it is necessary to measure the length of the shoulder and forearm, intermediate points are found: the tip of the olecranon or the head of the radius.

Measurement of the length of the lower limb. The patient is laid on his back, the limbs are given a symmetrical position parallel to the long axis of the body, the anterior superior iliac spines should be on the same line perpendicular to the long axis of the body.

When determining the anatomical (true) length of the femur, the distance from the top of the greater trochanter to the joint space of the knee joint is measured, while determining the length of the lower leg, from the joint space of the knee joint to the outer ankle. The sum of the measured length and lower leg data is the anatomical length of the lower limb.

The relative length of the lower limb is determined by measuring in a straight line from the anterior superior iliac spine to the foot, while the patient is given the correct position: the pelvis is located along a line perpendicular to the body axis, and the limbs are in a strictly symmetrical position.

The foot is measured both with and without load. The foot is placed on a blank sheet of paper, its contours are outlined with a pencil.

On the resulting contour, the length is measured - the distance from the fingertips to the end of the heel, the "large" width - at the level of the IV metatarsophalangeal joints, the "small" one - at the level of the posterior edge of the ankles.

There are the following types of shortening (lengthening) of the limbs.

1. Anatomical (true) shortening (lengthening): segmental measurement establishes that one of the bones is shortened (lengthened) compared to a healthy limb and is determined by the total data (thigh and lower leg separately). Anatomical shortening of the limb segment is observed in fractures of long tubular bones with displacement of fragments, with growth retardation after injury or inflammation of the epiphyseal cartilage.

2. Relative shortening (lengthening) occurs with changes in the location of the articulating segments (pelvis and thigh, thigh and lower leg), for example, with dislocations, when the articular ends are displaced relative to each other, changes in the neck-diaphyseal angle, contractures and ankylosis. In this case, it often happens that the relative length of the diseased limb is less, and the anatomical length is the same.

3. Total shortening (lengthening) - all of the listed types of length measurement must be taken into account when loading the lower limb in the vertical position of the patient. To determine the total shortening of the lower limb, special boards of a certain thickness are used, which are placed under the affected leg until the pelvis is in a horizontal position.

The height of the boards corresponds to the total shortening of the lower limb.

4. Projection (apparent) shortening is due to the vicious position of the limb due to ankylosis or contracture in the joint.

5. Functional shortening is observed with bone curvature, flexion contractures, dislocations, ankylosis in vicious positions, etc.

The circumference of a segment of a limb or joint is measured with a centimeter tape at symmetrical levels of both limbs. A decrease (for example, due to muscle atrophy) or an increase in the circumference of the joint (hemarthrosis) or limb segment (inflammation) is determined.

Thigh circumference is measured in the upper, middle and lower thirds. On the shoulder, forearm and lower leg, their most voluminous part is measured.

It is especially important to measure the circumference of the limb at the level of the joints in their pathology - an increase in the circumference of the joint indicates the presence of synovitis or hemarthrosis.

Determination of the function of the musculoskeletal system

The functionality of the musculoskeletal system is determined by:

1) range of motion in the joints;

2) compensatory capabilities of neighboring departments;

3) muscle strength.

The amplitude of mobility in the joints is determined during active and passive movements. Passive movements in the joints are more active and are indicators of the true range of motion. Restriction of mobility in the joints is caused by intra-articular or extra-articular causes.

Mobility begins to be investigated from the amplitude of active movements in the joint, then it is necessary to proceed to establish the boundaries of passive mobility and establish the nature of the obstacle that inhibits further movement in the joint. The limit of the possibility of passive movement should be considered the appearance of pain.

When measuring, the initial position should be considered the position in which the joint is established with a free vertical position of the limbs and torso.

The range of motion is measured with a goniometer. The initial position is the vertical position of the trunk and limbs, which corresponds to 180°.

Pathological mobility throughout the diaphysis. The study presents difficulties in those cases when the fracture has grown together with a fibrous scar or soft callus, allowing insignificant rocking movements. For research, it is necessary to fix the proximal part of the diaphysis so that the thumb lies on the fracture line, and with the other hand to make jerky small movements of the peripheral part.

Easy mobility is caught by a finger.

Various types of limitation of mobility in the joint can be observed.

Ankylosis (fibrous, bone) - complete immobility.

Contracture is a limitation of passive mobility in the joint, while no matter how great it is, some minimum range of motion in the joint is preserved.

Contractures are divided into:

1) by the nature of the changes underlying the process: dermatogenic, desmogenic, neurogenic, myogenic, arthrogenic, and more often combined;

2) according to the preserved mobility: flexion, extensor, adductor, abductor, mixed;

3) by severity: expressed, unexpressed, persistent, unstable.

compensatory changes. In pathological static-dynamic conditions, compensatory changes in the overlying sections are determined.

For example, with a decrease in the cervical-diaphyseal angle of the femur, a compensatory descent of the half of the pelvis from the diseased side and a compensatory scoliotic deformity of the spine occur.

The determination of muscle strength is carried out with a Colin dynamometer or, in its absence, by counteracting the active movements of the patient by the hand of the patient and always in a comparative aspect.

The score is set according to a five-point system: with normal strength - 5; when lowering - 4; with a sharp decrease - 3; in the absence of power - 2; with paralysis - 1.

Assessment of the functional ability of the musculoskeletal system is determined by observing how the patient performs a number of normal movements. Movement disorders include lameness, absence, limitation or excessive movement.

Study of gait. Changes in gait can be very diverse, but lameness is the most common. There are the following types:

1) sparing lameness - occurs as a protective reaction to pain during injuries and inflammatory processes;

2) unsparing lameness - associated with shortening of the limb and is not accompanied by pain.

With sparing lameness, the patient avoids fully loading the affected leg, spares it and, when walking, leans on it more briefly, more carefully than on a healthy leg. The torso deviates to the healthy side due to the unloading of the leg. By the "sound of walking" you can recognize sparing lameness (change in sound rhythm).

Not sparing lameness, or "falling", is characteristic of limb shortening.

A slight shortening within 1-2 cm does not cause lameness, masked by a compensatory prolapse of the pelvis. With a shortening of more than 2-3 cm, the patient, when relying on a shortened leg, transfers the weight of the body to the side of the affected leg.

"Duck" gait - the body alternately deviates in one direction or the other. Most often, this type of gait is observed with bilateral hip dislocation and other deformities leading to shortening of the pelviotrochanteric muscles.

Clubfoot. The gait with clubfoot resembles the gait of a person walking through mud: with each step, the foot rises higher than usual in order to overcome the obstacle - the other clubfoot foot.

A bouncing gait is caused by lengthening of the leg due to deformity in the ankle or foot joints (for example, with a horse-hollow foot).

Paralytic (paretic) gait occurs with isolated paralysis, paresis of individual muscles, with prolapse of more or less extensive muscle groups.

For example, when the strength of the hip abductors is weakened, Trendelenburg's symptom occurs; with paralysis of the quadriceps muscle of the thigh, the patient holds the knee with his hand, which bends at the time of the load, the hand in this case replaces the extensor of the lower leg. A "cock" gait occurs with paralysis of the peroneal muscles - with each step, the patient raises his leg higher than usual so that the front section of the drooping foot does not cling to the floor, while producing excessive flexion in the hip and knee joints.

Spastic gait is observed with an increase in muscle tone during spastic paralysis (for example, after encephalitis). The legs of the patients are stiff, the patients move with small steps, raising their feet with difficulty, dragging their feet, shuffling their soles on the floor; legs often show a tendency to cross.

It is most convenient to study the function of the upper limbs by inviting the patient to first perform a number of separate movements - abduction, adduction, flexion, extension, external and internal rotation, and then perform more complex movements, for example, put your hand behind your back (definition of complete internal rotation), comb your hair, grab the ear of the corresponding or opposite side, etc.

X-ray examination

X-ray examination, being an integral part of the general clinical examination, is of decisive importance for the recognition of injuries and diseases of the musculoskeletal system.

Several methods of X-ray examination are used: survey radiography, X-ray pneumography, tomography. Radiography is carried out in two projections (face, profile).

In some cases, for comparison, it becomes necessary to produce radiography and the healthy side.

X-ray data allow:

1) confirm the clinical diagnosis of the fracture;

2) to recognize the location of the fracture and its variety;

3) specify the number of fragments and the type of their displacement;

4) establish the presence of dislocation or subluxation;

5) monitor the process of fracture consolidation;

6) find out the nature and prevalence of the pathological process.

The standing of the fragments after the imposition of skeletal traction is controlled by radiography after 24-48 hours, and after the operation - on the operating table.

X-ray control is performed during treatment and before discharge for outpatient follow-up care.

Surgical and laboratory research methods

К surgical research methods patients with diseases of the musculoskeletal system include: biopsy, puncture, diagnostic arthrotomy.

Biopsy. To clarify the nature of tumors or chronic inflammation of the joints and other tissues, they resort to a histological examination of the material taken from the lesion by surgery.

Puncture of joints, subdural space, soft tissue and bone tumors, cysts is performed with special needles for diagnostic and therapeutic purposes. The punctate is sent for microscopic or histological examination.

The release of the joint from excess fluid brings significant relief to the patient. At the same time, after the fluid has been evacuated, if necessary, anti-inflammatory drugs are injected into the joint cavity through the same needle.

A lumbar puncture is performed in traumatic brain injury to recognize subarachnoid hemorrhage and determine hyper- or hypotension.

Diagnostic arthrotomy can be performed in difficult diagnostic and therapeutic situations.

Laboratory research methods often provide significant differential diagnostic assistance. A change in the clinical and biochemical composition of the blood after an injury or in orthopedic diseases is an indicator of the severity of their course and the choice of treatment method. Biochemical, immunological and serological reactions (C-reactive protein, anti-streptococcal antibodies, specific reactions, etc.) help confirm the clinical diagnosis.

LECTURE No. 2. Methods for the treatment of patients with injuries and diseases of the musculoskeletal system

Methods for the treatment of patients with injuries and diseases of the musculoskeletal system are divided into two main groups: conservative and operative.

Conservative methods include:

1) transport immobilization (wire splints of the Cramer type, plywood splints of the Dieterichs type for immobilization of the thigh, improvised splints and auto-immobilization);

2) soft and plaster bandages;

3) skeletal traction; skin traction;

4) cuff traction; compression-distraction method of treatment with the help of devices Ilizarov, Volkov-Oganesyan, etc.;

5) blockades;

6) prosthetics and apparatus therapy;

7) pharmacotherapy;

8) physiotherapy;

9) hyperbaric oxygenation;

10) Exercise therapy, massage, acupuncture.

Surgical treatments include:

1) open reposition of fragments;

2) open and closed extra-articular osteosynthesis;

3) operations on muscles, tendons and ligaments;

4) bone transplantation;

5) amputation of limbs;

6) reconstructive operations;

7) operations on the joints (synovectomy; arthroplasty; joint resection; endoprosthetics; arthrodesis).

1. Hard and hardening dressings

A dressing is a set of products designed to protect a wound from the harmful effects of the external environment (protective dressings); holding the dressing on the surface of the body (fixing dressings); the formation of hemostasis in the superficial veins (pressure bandages); ensuring immobilization of a body part (immobilizing, transport or therapeutic dressings); creating traction for a limb or head (stretch bandages); correction of the vicious position of the limb, head or torso (corrective bandages).

Solid, or holding, dressings are standard splints, devices and improvised fixing material designed to immobilize the diseased part of the limb. They are used for fractures of limb bones for transport or therapeutic immobilization, but can also be used for inflammatory diseases, after surgery on bones and joints.

Tire dressings, or tires, are divided into two groups: fixation (simple) and extension (devices).

Fixation splints are standard and are more often intended for transport immobilization of limbs: the Dieterikhs and Thomas-Vinogradov splint for the thigh, Cramer's wire ladder splints, mesh, plywood (luboks), etc.

Extension tires create immobility of the limb with simultaneous extension (medical metal splints, devices).

Plaster dressings belong to the group of hardening dressings and are prepared from calcium sulfate, which is rubbed into absorbent gauze bandages. Currently, ready-made bandages are used.

In the trauma department, a special room is allocated for applying and removing plaster bandages, which is equipped with special equipment and tools.

Rules for applying a plaster cast

Gypsum bandages or prepared splints are soaked in a basin of warm water.

At the end of the release of bubbles, the bandage is removed and squeezed out of the water, squeezing it from the sides.

Before applying a plaster bandage, the skin of the limb is lubricated with petroleum jelly or a cotton stocking is put on it. The applied plaster bandage is carefully modeled, then covered with a soft bandage.

To immobilize the limb in case of a fracture, a plaster cast is applied, as a rule, unlined, in other cases, cotton-gauze pads (lining bandage) are applied to the protruding parts of the limb. The plaster bandage is rolled out without tension, so as not to cause compression of the limb. For the strength of the bandage, 5-6 layers are enough. The edges of the applied and modeled gypsum bandage are cut off and covered with gypsum porridge.

After applying the bandage for 2 days, monitor the condition of the limb. If cyanosis, cold snap, edema is detected, the plaster cast is cut with plaster scissors or a special saw and the edges are moved apart.

Types of plaster casts

A circular (solid) bandage is used to immobilize the limb and trunk in case of fractures.

The splint (sleeve) is superimposed on the joint or a separate segment of the limb to give rest and immobilization. It can be removable or non-removable.

The longet-circular bandage is a longet, which is fixed with circular plaster bandages.

Longet bandage is applied to the limb and can be dorsal (back), palmar (front) and U-shaped.

Target dressings: fenestrated and bridging - for the treatment of wounds; bandages with a spacer - for reliable fixation of the limb in the abduction position.

Hinged-gypsum bandage - to develop movements in the joint.

Dressings depending on the place of application (local): collars, thoracocranial, thoracobrachial, corsets, beds, coxite and gonite plaster bandages.

Fixing plaster bandages for congenital deformities and birth injuries: semi-rigid collar - for congenital muscular torticollis; stage bandage - to correct congenital clubfoot or with congenital flat feet.

The rules for removing a plaster cast include the selection of a special tool (such as plaster scissors, saws, knives, electric saws) and the preparation of a plaster cast (wetting the cut line of the plaster bandage with a hypertonic saline solution).

2. Prosthetics and apparatus therapy

Modern prosthetics allows you to restore lost or impaired functions of the musculoskeletal organs with the help of various mechanical devices and devices.

Prosthetics in orthopedics is divided into anatomical and medical.

anatomical prosthetics is aimed at anatomical or functional replacement and replacement of a missing limb with a prosthesis for the purpose of self-service or returning the victim to work.

The process of prosthetics includes the following steps: determining the level and method of amputation, strengthening muscles and restoring movements in the joints, using training prostheses and making a permanent prosthesis.

An indispensable condition for preparing for prosthetics is strengthening the muscles and restoring movements in the joints.

The training prosthesis has articulated joints and a foot, which makes it possible to prepare for permanent prosthetics, helps to strengthen the muscles of the stump and forms a stump.

General contraindications to prosthetics include: severe and weakened condition of the patient, physical inactivity, severe cardiovascular diseases, renal edema, etc.

Local contraindications - fresh immature postoperative scar, inflammatory processes in the stump, contracture of the joints, insufficient formation of the stump.

Types of prostheses. In the manufacture of a permanent prosthesis, special requirements are imposed on the stump of the limb.

The stump should have a conical shape, be painless and mobile, and the skin scar should be soft and not soldered to the underlying tissues.

The design of a permanent prosthesis should be characterized by a certain strength, low weight and cosmetics.

For the lower limbs, the prostheses must be stable, not hindering walking and sitting, and the prostheses for the upper limbs must have a device for grasping objects.

The socket of the prosthesis for the stump can be soft or hard. Important details of the prosthesis are the hinges, which create the possibility of movement at the level of large joints and its fastening.

Prostheses are divided into cosmetic, active-cosmetic and working.

The stage of learning to use the finished prosthesis is carried out individually according to a special program for each type of prosthetics.

Internal prosthetics (endoprosthetics) is aimed at partial or complete anatomical replacement or replenishment of the elements of the musculoskeletal system.

Endoprostheses include total or semi-articular endoprostheses for the hip, knee and other joints, as well as for individual bones.

Lavsanoplasty and lavsanodesis are used in the surgical treatment of dislocations of the shoulder and clavicle, rupture of the tendon of the long head and distal tendon of the biceps brachii, Achilles tendon, annular ligament of the radius and radioulnar ligament of the distal radioulnar joint, uncomplicated fractures of the spine, transverse flatfoot.

Therapeutic prosthetics is aimed at the use of orthopedic products and devices for the purpose of preventive or therapeutic effects on the elements of the musculoskeletal system in case of orthopedic diseases and injuries.

Orthopedic products include therapeutic and training prostheses, endoprostheses, orthopedic devices, corsets, head holders, splints, splints, arch supports, orthopedic beds and other devices.

Therapeutic prosthetics should be based on the main orthopedic methods of treatment, such as:

1) creation of limb rest for the period of acute infectious or post-traumatic inflammation;

2) prevention of deformities after corrective, conservative or surgical treatment;

3) elimination of deformities with the help of manual correction and staged plaster casts, followed by the transition to orthopedic prosthetics;

4) kinesitherapy with the help of functional devices.

Apparatus therapy is used for the prevention and treatment of deformities of the musculoskeletal system after illnesses or injuries (such as poliomyelitis, spastic paralysis, spinal cord injury after surgery, etc.).

Therapeutic and training prostheses are lockless devices that create the possibility of fixing the knee joint when standing and free movement when walking, which contributes to muscle training in flaccid and spastic paralysis of the lower extremities, after damage to the spinal cord and peripheral nerves.

Unloading devices are prescribed for delayed consolidation of fractures and false joints of the thigh and lower leg, for painful arthrosis and inflammatory processes.

Corsets according to their purpose can be fixing and corrective.

Fixing corsets are used for diseases and injuries of the spine - osteochondrosis of the spine with pain syndromes, tumor and inflammatory processes in the spine.

Fixing reclining corsets are used for tuberculous spondylitis when a specific process in the spine is attenuated and there are no signs of spinal cord compression.

The reclining corset is used for spinal fractures in children and adults after 2 months of bed rest in a hospital.

Therapeutic corsets used for scoliosis should correct, unload the spine and help strengthen the muscular corset.

Immobilization of unloading and correction of the cervical spine in case of injuries and some diseases of the cervical spine (fractures and injuries, consequences of trauma, osteochondrosis, tumors, torticollis, etc.) can be achieved using a head holder made of foamed polyethylene. It is characterized by lightness and elastic elasticity (framework), moisture absorption and thermal insulation.

Splints made of gypsum or synthetic materials are made taking into account the type of injury or disease, as well as the functionally advantageous position of a particular joint in case of damage to the limbs, after surgical interventions, in inflammatory processes, arthrosis and other diseases, when the limb must be kept in a corrected position.

A derotational boot is used for immobilization of the hip joint in case of medial fractures of the femoral neck.

Corrective type arch supports for feet are used for longitudinal and transverse flat feet and deforming arthrosis of the feet joints, and heel pads for heel spurs.

In cases of a combination of flat feet with heel spurs, patients are prescribed orthopedic shoes.

For hallux valgus deformity of the big toes and hammer toes, a conservative treatment method has been developed using plastic corrector inserts that correct the deformity of the fingers or foot.

3. Damage to the soft tissues of the organs of the musculoskeletal system

Soft tissue injuries of the musculoskeletal system include bruises, compression, sprains, ruptures and wounds.

Injury

A bruise is a closed damage to tissues and organs without violating the integrity of the skin, resulting from direct mechanical action. Bruises occur due to the impact of open parts of the body (more often - the limbs and head) on a hard object.

Pathogenesis. When soft tissues are bruised, blood vessels are damaged, as a result of which hemorrhages occur in the tissues and joint cavities.

In the bruised area, intradermal, subcutaneous, subfascial hemorrhages develop, which sometimes lead to compression of blood vessels, nerves and muscles.

Subsequently, the hematoma resolves, undergoes connective tissue organization.

Soft tissue injury is accompanied by damage to nerve endings.

Violation of the blood supply and innervation of injured tissues causes local aseptic inflammation.

Clinic. The severity and nature of damage in case of bruises of the skin and underlying tissues (subcutaneous tissue, blood vessels, muscles, periosteum) depend on the acting force and the point of application. Pain, swelling, bruising occur at the site of injury, and the function of the injured limb is impaired. The bruising reaches its largest size on the 2-3rd day, then the color of the "bruise" begins to change: from blue to blue-purple, greenish and yellow.

Swelling and pain are reduced, the function of the damaged limb is restored.

In some cases, a bruise leads to the formation of a hematoma or hemarthrosis.

Extensive hematomas may be accompanied by an increase in body temperature. The absence of a peripheral pulse and impaired sensitivity in the distal limbs are signs of compression of the neurovascular bundle by a hematoma. In the post-traumatic period, hemorrhages can be complicated by purulent inflammation.

In some cases, bruises are accompanied by subcutaneous ruptures of muscles and tendons.

Diagnosis is not difficult, but more severe injuries, especially bone fractures, must always be ruled out, for which follow-up radiography is recommended.

Treatment for soft tissue injuries depends on the nature of the injury.

For mild bruises, local application of cold is prescribed for the first 2 days, then thermal procedures: warm baths (37-39 ° C). A hot bath with a water temperature above 40 ° C leads to increased swelling and increased pain.

With more severe bruises, especially in the area of ​​​​the joints, the injured limb is given rest with the help of a pressure bandage, scarf, splint, elevated position.

With a tense subcutaneous hematoma, it is punctured with a thick puncture needle in compliance with all asepsis rules.

Subungual hematoma is removed by pinpoint perforation of the nail plate with an injection needle. From the second day, UHF, Sollux, paraffin are prescribed. In case of abscess formation of a hematoma, its opening and open management with drainage are carried out.

Formed hematomas or hemarthrosis, not amenable to resorption, should be punctured, followed by the imposition of a pressure bandage.

In case of hemarthrosis, after puncture of the joint with its subsequent immobilization for 10-14 days, physiotherapeutic procedures, physiotherapy and massage are prescribed. After repeated punctures, it is recommended to inject 10-20 ml of a 1% solution of novocaine into the joint cavity or hematoma with the addition of hydrocortisone in an amount of 25 mg or the proteolytic enzyme trypsin, chemotrypsin or chemopsin - 10 mg.

compression

Compression is an injury in which the anatomical continuity of the compressed tissues is not disturbed, but due to the duration of the traumatic force, dystrophic changes develop in them, leading to rapid swelling of the damaged area of ​​\uXNUMXb\uXNUMXbthe limb, and if the damage is extensive, to intoxication of the body with decay products, the so-called traumatic toxicosis. Often, tissue necrosis is formed at the site of compression, leading to the formation of a scar and limitation of limb function.

The clinical picture with compression of a limited area is characterized, in addition to edema, pain, often punctate hemorrhages and dysfunction. Prolonged compression of the nerves and vessels with a tourniquet leads to paresis or paralysis and thrombosis of the corresponding nerves and vessels.

Treatment. Immediate release of the limb from compression, application of an elastic pressure bandage, local cold, immobilization, circular novocaine blockade above the site of compression are required. After the disappearance of acute traumatic phenomena, thermal, physiotherapeutic procedures, exercise therapy, and massage are prescribed.

Damage

Damage to the ligaments of the joints occurs, as a rule, with sudden impulsive movements in the joint, significantly exceeding the limits of normal mobility in it.

There is a partial or complete rupture of the ligament, and sometimes a complete detachment of the ligament from the zone of its attachment along with the bone fragment. The most common injuries are the ligaments of the ankle, interphalangeal, wrist and knee joints. Locally determined smoothness of the contours of the joint, limitation of function and local pain in the projection of the damaged ligaments.

The ankle joint is injured more often than others, while not "stretching" the ligaments, but damage to their fibers of varying degrees: tears, partial and complete ruptures. Ligament injury is accompanied by rupture of small vessels, which leads to varying degrees of hemorrhage into soft tissues at the site of rupture or into the joint cavity.

Clinically determined local pain at the level of the joint space, swelling, bruising, instability in the joint.

The diagnosis of ligament injury is made on the basis of the anamnesis and clinical data: the foot or lower leg turned up, a crunch was heard, or there was a sharp pain in the joint.

When making a diagnosis of ankle ligament injury, the following definitions are used:

1) slight damage to the ligaments involves tearing of single fibers, the function suffers little and the pain is negligible;

2) damage to the ligaments of moderate severity is determined by a partial rupture of the ligaments and is characterized by limited function of the ankle joint due to pain, lameness, swelling and bruising;

3) severe damage to the ligaments is observed when the ligaments of the lateral or medial group are torn and are due to loss of function due to ligament tear, severe pain, and joint deformity.

It is necessary to exclude damage to the bone by performing a control X-ray.

Treatment depends on the degree of damage to the ligaments.

In case of slight damage, it is enough to irrigate the painful area with chloroethyl and apply a gauze eight-shaped bandage to the joint.

In case of moderate damage, it is necessary to block the painful area with 10 ml of novocaine-alcohol mixture (9 ml of 1% novocaine solution and 4 ml of 96% alcohol). A pressure bandage is applied to the joint. After 5-7 days, thermal procedures and massage begin.

In case of severe damage, novocaine-alcohol blockade is performed, enzymes or hydrocortisone are injected, and a plaster splint is applied for 30 days. After removing the splint, thermal procedures, exercise therapy and massage are prescribed, and subsequently - long-term wearing of the elastic splint. In case of instability in the ankle joint, wearing orthopedic shoes (for the elderly) or surgical treatment aimed at restoring the ligaments of the joint is recommended.

If a complete rupture of the ligaments is suspected, the limb is immobilized and the victim is sent to the hospital.

Knee ligament injury

Clinic: pain, swelling, bruising, dysfunction, however, for each ligament, when it is damaged, a special clinical and diagnostic sign is characteristic.

Diagnostics of the stability of the lateral ligaments. The doctor fixes the thigh of the patient's fully extended leg with one hand, grabs the ankle joint with the other hand and abducts the lower leg inward and outward.

With a rupture of the internal lateral ligament of the knee joint, excessive external-lateral mobility of the lower leg is noted, with an incomplete rupture in acute cases - pain, most often at the attachment points.

With isolated damage to the cruciate ligaments, a "drawer" symptom is observed. It comes down to a possible passive displacement of the lower leg backwards (symptom of the "posterior drawer") with a rupture of the posterior ligament and anteriorly (symptom of the "anterior drawer") - with a rupture of the anterior ligament. The symptom is checked in a 90° flexion position. In the first case, this symptom is true, and in the second, it is false.

Patients with damage to the ligaments of the knee joint are subject to inpatient treatment. First aid in case of damage is limited to irrigation with ethyl chloride and immobilization of the joint with a transport splint.

In the hospital, after a control radiography, a knee joint is punctured under the edge of the patella raised with fluid or in the area of ​​​​the upper inversion from the inside or outside, the blood that has poured into the joint is evacuated, a solution of novocaine with enzymes or hydrocortisone is injected and a circular plaster bandage is applied for 4-5 weeks. Then physiotherapy exercises, massage, physiotherapy procedures and wearing an elastic splint are prescribed.

If, after removing the plaster cast, instability is found in the knee joint, an operation is performed aimed at restoring or plasticizing the damaged ligaments.

Damage to the tendons is the result of a direct blow to a tense tendon or a sharp movement of a limb segment.

May be complete or partial. Most often, the tendons of the extensor fingers of the hand, the quadriceps femoris and the calcaneal (Achilles) tendon are injured when injured. Sometimes there are also closed (subcutaneous) ruptures.

Clinic. Signs of damage to the tendon are its defect (retraction of tissues in the projection of the tendon), severe pain and lack of active movements in the joint. With open injuries, the localization of the wound indicates a possible violation of the integrity of the tendon.

If the tendon is damaged, the function of flexion or extension is impaired, depending on the type of tendon (fingers, hand, long head of the biceps of the shoulder, Achilles tendon, quadriceps femoris).

Emergency care for an open injury consists in stopping bleeding and applying an aseptic bandage.

First aid: immobilization of the limb with a plaster splint (tire) in a position that ensures convergence of the ends of the tendon (for example, maximum plantar flexion of the foot and flexion of the lower leg in case of injuries of the Achilles tendon), administration of analgesics and referral of the patient to the hospital.

Treatment should be aimed at restoring the integrity of the tendon, which is sutured during debridement. If the wound is crushed and contaminated, then the stitching of the tendon is transferred to the period after the wound has healed (in 1-1,5 months).

Operation technique. Primary surgical treatment of the wound is carried out and, if no more than 10 hours have passed since the moment of injury, a primary tendon suture is applied. Usually, a silk suture according to Cuneo is used with a fixation suture to the central end of the tendon according to Bennel-Doletsky. If the tendons of the flexor fingers of the hand are damaged, only the tendon of the deep flexor is sutured. The tendon of the superficial flexor is excised. Mandatory immobilization with a plaster splint for 3 weeks in a position that reduces the tension of the tendon.

К muscle damage include ruptures that are accompanied by damage to the fascia and the formation of a hematoma. The biceps brachii, gastrocnemius, and quadriceps femoris muscles are most commonly injured.

At the site of a complete rupture of the muscle, a depression forms, with a partial rupture, a deepening. Limb function is impaired.

Treatment. In the case of a fresh muscle rupture, an operation is performed - suturing the ends of the muscle with mattress sutures. In case of incomplete rupture of the muscle, the limb is immobilized with a plaster splint in the position of maximum relaxation of the damaged muscle for 2-3 weeks, then massage and exercise therapy are prescribed.

Damage to major blood vessels more often occurs with open injuries, but can also occur with severe bruises, fractures.

Symptoms. With a closed injury, interstitial hemorrhage, sometimes a pulsating hematoma, acute circulatory disorders (pallor of the skin, coldness and hypoesthesia of the limb, pain, lack of pulse) are noted.

Damage to the vessel during injury is accompanied by external bleeding. However, bleeding may soon stop due to spasm of the vessel, intima tucking inward and thrombus formation.

Emergency care, depending on the type of bleeding (venous or arterial), is aimed at performing a temporary and final stop.

Temporary ways to stop bleeding include: pressing the artery with a finger (fist), maximum flexion of the injured limb in the joint, applying a pressure bandage, tight tamponade of the wound if bleeding occurs from veins, external capillaries or small arterial vessels.

In case of severe arterial bleeding, the application of a hemostatic tourniquet (pellot), the imposition of a hemostatic clamp in the wound and the ligation of the vessel are used.

The final stop of bleeding is achieved by ligation of the vessel or the imposition of a vascular suture. As the simplest and most accessible, a manual vascular suture is most often applied, which is performed with atraumatic needles using a special suture material. The wound is not sutured. The patient is urgently sent to the vascular center, where a vascular shunt is applied to him and transport immobilization is performed. Antibiotics and anticoagulants are administered.

Peripheral nerve damage more often it is a concomitant injury with fractures of long tubular bones or with soft tissue injury.

Symptoms. Complete or partial impairment of peripheral nerves is accompanied by impaired conduction of motor, sensory and autonomic impulses.

RџSЂRё radial nerve injury (at the level of the middle third of the shoulder) movement disorders are characteristic: paralysis of the muscles that extend the hand and thumb, violation of supination, weakening of flexion in the elbow joint. There is a violation of skin sensitivity on the radial half of the back of the hand and the main phalanges of the first 2-5 fingers. Atrophy of the muscles of the interdigital space develops.

RџSЂRё ulnar nerve injury III, IV, V fingers of the hand take a "claw-like" position. The flexion of the main and nail phalanges of the IV and V fingers is disturbed.

Dilution and adduction of fingers due to paralysis of the interosseous muscles is impossible. The grasping function of the hand is impaired. Due to paralysis of the adductor muscles of the thumb, adduction is difficult.

Changed skin sensitivity in the ulnar half of the hand.

RџSЂRё median nerve injury the ability to penetrate the forearm, oppose and bend the thumb is impaired.

Atrophy of the tenor muscles sets in, as a result of which the hand takes the form of a monkey's paw. Skin sensitivity is disturbed in the zone of the first 21/2 fingers from the palmar surface and in the zone of the nail phalanges of 31/2 fingers.

RџSЂRё sciatic nerve injury the muscles of the foot and part of the lower leg are paralyzed.

The flexion of the leg is broken. Skin sensitivity changed on the outer surface of the lower leg and foot. The Achilles tendon reflex is lost.

RџSЂRё femoral nerve injury paralysis of the quadriceps femoris muscle occurs, which leads to a violation of the extension of the lower leg. Skin sensitivity was changed along the anterior surface of the thigh, inner surface of the lower leg and foot.

RџSЂRё peroneal nerve injury the muscles that perform dorsiflexion and abduction of the foot are paralyzed. The foot sags. Skin sensitivity is disturbed along the outer surface of the lower third of the lower leg and on the back of the foot.

RџSЂRё tibial nerve injury the function of the muscles that flex the foot and fingers is impaired. The muscles of the posterior group of the lower leg atrophy. The calcaneal foot is formed. The fingers are in a claw-like position.

The Achilles tendon reflex does not occur. Skin sensitivity is impaired on the plantar surface of the foot and the posterior surface of the lower leg.

Treatment. The choice of treatment method depends on the nature of the nerve damage. In case of compression, injury and partial rupture of the nerve, conservative treatment is used: rest for the first days, then massage, physiotherapy, exercise therapy, prozerin, B vitamins. Prevention of orthopedic deformities is necessary. With a complete break in the nerve resort to surgery.

The choice of treatment method depends on the degree of damage and on the time that has passed since the injury. So, with a knife wound, accompanied by the intersection of the nerve, a revision of the wound and a suture of the nerve are shown.

With contaminated and festering wounds, the nerve is not sutured, and the operation is performed after the wound has healed and the inflammatory process has been eliminated. In cases where the fracture is accompanied by a complete interruption of the nerve, metal osteosynthesis and nerve suture are indicated.

Nerve suturing technique. The ends of the damaged nerve are isolated and refreshed with a sharp blade, then they are brought together and sewn behind the perineurium with 4-6 knotty thin nylon sutures, leaving a diastasis of 1 mm between the ends. At the end of the operation, immobilization is imposed for 3 weeks.

Soft tissue wounds

Soft tissue injuries include injuries to the skin, mucous membrane, deep-lying tissues (subcutaneous tissue, muscles, etc.), as well as tendons, blood vessels and nerves. As a result of violation of the integrity of the skin, microbial contamination of the wound surface occurs, which can lead to the development of a banal or anaerobic infection.

Classification of soft tissue injuries

Cut wounds result from the direct impact of a sharp weapon on the surface of the skin. Smooth smooth edges of the wound are formed, the gaping of which is determined by the elasticity of the tissues and the direction of the incision line. At the same time, vessels, nerves, muscles and tendons can be damaged.

Chopped wounds are formed when a sharp weapon is lowered onto the skin at an angle. The edges of the wound are dispersed and serrated.

Stab wounds are the result of deep penetration of a sharp, thin instrument. Possible injury to the cavities or joints. Due to the small diameter of the wounding instrument and the small diameter of the wound channel, the edges of the wound quickly stick together.

Contusion wounds occur when some part of the body comes into contact with a hard obstacle and there is a solid support in the form of the bones of the skull or other bone.

Crushed, crushed wounds are formed due to the impact of a blunt instrument with a wide surface when opposed to a solid support. These wounds have jagged edges.

Nutrition is disrupted in the area of ​​​​the skin. When the skin gets between hard surfaces, it is severely damaged, necrosis occurs.

Bite wounds. As a result of a bite by an animal or a person, highly virulent causative agents of wound infection can enter the wound. On this basis, even small bite wounds should not be neglected.

Rats, mice, cats, dogs and foxes are carriers of a serious infectious disease - rabies. Snake bites are especially dangerous due to the possible development of paralysis (as a result of the action of a neurotoxin) and hemolytic complications.

Insect bites cause local swelling, redness, and central necrosis at the site of the bite. Sometimes there is inflammation with abscess formation.

Gunshot wounds can be penetrating or blind. Bullet wounds are more severe and more often fatal than shrapnel wounds. Mine-explosive wounds are accompanied by multiple crushed fractures, primarily of the bones of the foot and the lower third of the leg, massive detachments of muscle groups and exposure of the bone over a large area, often of a combined nature due to the general impact of a blast wave of significant intensity on the body of the victim.

The division of wounds into aseptic and bacterially contaminated is conditional, since even surgical wounds contain microorganisms in greater or lesser quantities.

Wounds can be single and multiple. Combined wounds should also be distinguished, when one injuring agent damages several organs. When damaged by chemical or radioactive agents, one should speak of a combined lesion.

In relation to the cavities, wounds are divided into penetrating and non-penetrating.

Can be with or without damage to internal organs, bones, joints, tendons, muscles, blood vessels and nerves.

Diagnostics. With soft tissue wounds are determined:

1) exact localization, shape, condition of the edges of the wound, its size (three dimensions), direction of the wound channel;

2) type and intensity of bleeding;

3) signs of wound infection;

4) the presence or absence of damage to blood vessels, nerves, tendons, muscles, bones, joints.

First aid for wounds is aimed at stopping and preventing microbial contamination and the development of infection.

For any wounds, tetanus toxoid is administered in the amount of 3000 AU according to Bezredko.

Superficial small wounds that do not penetrate into the body cavities and are not accompanied by damage to large vessels and nerves, tendons and bones are subject to outpatient treatment.

Cut and chopped wounds with smooth edges are not subject to surgical treatment.

On an outpatient basis, primary surgical treatment (PST) of superficial wounds with crushed, torn, uneven edges and heavily contaminated with earth is performed.

Regardless of the degree of contamination of the wound, adherence to the principles of asepsis during primary surgical treatment is mandatory. First, the circumference of the wound is treated. The hair is shaved around the wound, the skin is washed from dirt and blood with swabs moistened with gasoline, 0,5% ammonia solution or soapy water, followed by drying and double lubrication with iodine solution, iodonate or other antiseptic.

The operating field is isolated with sterile wipes or a towel.

On an outpatient basis, local infiltration anesthesia is used with a 0,25% or 0,5% solution of novocaine with antibiotics or conduction anesthesia (on the fingers), less often - intraosseous.

The concept of "radical primary surgical treatment" determines the observance of certain requirements:

1) wide dissection of the wound, mainly the exit opening, with economical excision of the edges of the damaged skin, turning it into a kind of gaping crater, giving access to deep lesions and providing the best conditions for biological self-purification processes;

2) decompressive fasciotomy of the main bone-fascial cases throughout the damaged segment, and, if necessary, the proximal one;

3) revision of the wound channel and all wound pockets with the removal of blood clots, foreign inclusions, small bone fragments not associated with soft tissues;

4) excision of destroyed and devoid of blood supply tissues, which are the basis for the formation and spread of foci of secondary necrosis in the circumference of the wound channel due to autocatalytic enzymatic proteolysis;

5) repeated irrigation of the wound with solutions of antiseptics with aspiration of the washing liquid;

6) preservation of all fragments associated with the periosteum and soft tissues;

7) complete drainage of the wound;

8) near-wound infiltration and parenteral administration of broad-spectrum antibiotics;

9) loose tamponade with wipes moistened with antiseptic liquids, water-soluble ointments and osmotic sorbents;

10) adequate immobilization of the damaged limb segment.

Wound closure should be carried out in such a way as to prevent the formation of residual cavities and pockets in the depth of the wound. Catgut sutures are separately applied to the muscles and thick subcutaneous adipose tissue, and the second floor of silk (nylon, lavsan) interrupted sutures is applied to the skin wound. Between the seams for 1-2 days, a graduate is usually left for wound exudate.

If there is a threat of the development of a wound infection (contaminated wounds, late or incomplete surgical treatment, the presence of non-draining wound pockets, skin maceration, bruises and hemorrhages in the surrounding tissues, etc.), then the wound is not sutured, but loosely packed with napkins moistened with an antiseptic solution.

Crushed, bruised wounds and heavily soiled, especially if tissues of doubtful viability are left, should not be sutured.

An unsutured wound heals by secondary intention, which leads to a significant lengthening of the treatment time; a wide, sometimes disfiguring and dysfunctional scar is formed.

Wound closure is performed with primary suture, primary delayed suture, early and late secondary suture. The primary suture of the wound is indicated with confidence in the usefulness of the PST performed, the absence of wound pockets and the threat of developing a wound infection.

The most common complication of the primary suture is wound suppuration. In these cases, the sutures should be urgently removed and free outflow of pus should be ensured.

In order to accelerate wound healing and improve outcomes, the use of primary delayed sutures is indicated, applied in the postoperative period before the development of granulations, if the threat of wound infection has passed.

For extensive gunshot wounds, the wound is left open for delayed or secondary suture. The immobilization of the limb has a beneficial effect.

When a person bites, the microflora of the oral cavity and teeth enters the wound, including aerobic non-hemolytic streptococci, anaerobic streptococci and staphylococci, etc. Washing and surgical treatment of the wound are indicated; if possible, provide rest to the damaged organ (the limbs are splinted). Benzylpenicillin is prescribed in high doses (2,5 million units IV every 6 hours).

When biting cats and dogs, wound infection is often caused by Pasteurella multocida and the same representatives of the microflora of the oral cavity and teeth as in human bites. Washing and surgical treatment of the wound are shown; the injured limb is splinted.

High-dose benzylpenicillin (2,5 million units IV every 6 hours) or oral amoxicillin (clavulanate) or cefuroxime is given.

The victim, after providing him with first aid, is sent to the hospital for a preventive course of treatment against rabies.

When bitten by a snake, a tourniquet is applied to the limb above the wound (for no more than 30 minutes), a bandage is applied to the wound. The victim is transported to a medical institution, where a novocaine blockade is carried out above the tourniquet and anti-gyrus serum is injected.

4. Traumatic dislocations

Dislocations can be acquired as a result of trauma or as a result of a pathological process in the joint and congenital.

Traumatic dislocation

Traumatic dislocation is a persistent displacement of the articular ends of the bones, leading to a complete or partial disruption of their normal relationship.

There are dislocations complete and incomplete; fresh (first 1-3 days), intermediate (up to 3 weeks) and old. Dislocations can be uncomplicated and complicated, as well as open, closed and habitual.

The name of the dislocation is given by the name of the bone that is located distally in the joint. An exception is the spine, in which the proximal vertebra is considered dislocated.

In terms of frequency, shoulder dislocations account for 40-58% of all traumatic dislocations and rank first among all injuries.

Depending on the direction of displacement of the dislocated segment, dislocations are distinguished as "anterior", "posterior", "back", "palmar", "central", etc.

Traumatic dislocations are accompanied by rupture of the joint capsule and damage to the tissues surrounding the joint (ligaments, blood vessels, nerves, etc.). The exception is a dislocation of the lower jaw, in which the articular capsule only stretches. As a result of the rupture of the joint capsule and blood vessels, significant bruising is formed. The blood permeates the surrounding soft tissues and pours into the joint. Due to the displacement of muscle attachment points, a violation of muscle synergy occurs.

A stable retraction of the muscles develops rapidly, which every day makes it difficult to reduce the dislocation, since it is impossible to correct the dislocation without muscle relaxation.

Sometimes a dislocation is complicated by an intra-articular fracture, then it is called a fracture-dislocation. Timely recognition of a fracture using a control x-ray of the joint in two projections helps the doctor choose the correct reduction tactics, since the reduction of a dislocation in an unrecognized fracture can lead to serious additional damage.

The clinical picture of traumatic dislocations along with general signs (such as pain, deformity, dysfunction) has significant clinical signs, which include a kind of joint deformity and a forced position of the limb.

If there is a symptom of springy fixation of the dislocated segment of the limb in an unusual position, the diagnosis is made without doubt. Decisive in the diagnosis is a mandatory X-ray examination.

The treatment of dislocations includes the following tasks: reduction of the dislocation, immobilization of the limb, restoration of the function of the affected joint.

The reduction of the dislocation is considered an emergency operation due to the fact that soon after the injury, when the pathological retraction of the muscles has not yet occurred, the reposition is possible without much difficulty. Reduction is based on a way to overcome muscle retraction, which is eliminated with the help of local or general anesthesia.

With general anesthesia during reduction, muscle relaxants are introduced to completely relax the muscles. The reduction of a dislocation without anesthesia is strictly prohibited, since a rough overcoming of muscle retraction leads to new additional damage. Reduction is carried out carefully, slowly, without gross manipulations. The dislocated end of the bone must go the same way as it went during the dislocation (only in the opposite direction), and stand in its place. Complete reduction of the dislocation leads to the restoration of the joint configuration, the disappearance of pain and muscle retraction, and the restoration of movement in the joint.

However, excessively active movements can lead to re-dislocation, since the components fixing the joint (articular capsule, ligaments and other periarticular tissues) are damaged.

After the dislocation is reduced, the limb is immobilized with a plaster splint in the middle physiological position for the period of fusion of torn tissues (from 5 to 20 days, depending on the joint).

After removing the splint, functional treatment is carried out aimed at restoring the function of the joint and limb (exercise therapy, massage, physiotherapy procedures).

Dislocation of the lower jaw

Dislocation of the lower jaw is more common in older women during yawning, vomiting, i.e., with a large opening of the mouth.

Signs: the lower jaw is displaced down and forward, speech is unclear, saliva is plentiful from the open mouth. The articular head of the lower jaw is displaced forward and is palpable under the zygomatic arch, and in its usual place in front of the auricle, depression is determined.

Dislocation reduction. The patient sits on a chair, the head is held by an assistant. The doctor, wrapping the thumbs with a bandage, introduces them into the patient's mouth. With the fingertips, it exerts pressure on the large molars, trying to move them down, with the rest of the fingers it lifts the chin up and shifts it backwards. The moment of reduction is characterized by a clicking sound.

After reduction for 1 day, a soft fixing bandage is applied to the lower jaw; for 5 days, it is recommended not to open your mouth wide, not to chew solid food.

Dislocations of the vertebrae

Dislocations of the vertebrae are most often found in the cervical region of the streets of a young age. Great mobility and weakness of the ligamentous-muscular apparatus of this section of the spine are the basis, against which excessive bending of it during a fall on the head (for example, when hitting the bottom of a reservoir) leads to rupture of the ligaments of the intervertebral joints, to displacement of the lower articular processes of the overlying vertebra forward behind superior articular processes of the underlying vertebra.

There is a flexion bilateral complete interlocking dislocation in one of the segments of the spine. There may also be unilateral dislocations.

The clinical picture is manifested by pain, head instability, spinal deformity, reflex muscle tension leading to a typical forced head position, spinal cord injury with paresis or paralysis, and sometimes difficulty in breathing, swallowing and speech. On radiographs, a picture of a dislocation of the vertebra is visible.

Treatment. Transport immobilization of the cervical spine with a soft Shants collar is required. In a hospital or trauma center, an experienced traumatologist performs a one-stage reduction of a dislocation using a special technique (according to Riche-Guter).

In most cases, reduction is possible without anesthesia or after the administration of promedol.

If you do not know the technique of reducing the dislocation in the cervical spine, traction with a Glisson loop or skeletal traction for the bones of the skull is used. Dislocations of the spine that are not amenable to closed reduction are subject to open (operative) reduction.

After reduction of the dislocation, a long-term immobilization is performed with a thoracocranial plaster cast (semi-corset) for 2-3 months; in the future - exercise therapy, massage, electrical stimulation.

Dislocations of the collarbone

Dislocations of the clavicle are of two types: acromial (more often) and sternal.

The dislocation mechanism is an indirect and direct injury (fall on the adducted shoulder, blow).

With complete dislocation of the acromial end of the clavicle, a rupture of the clavicular-acromial and clavicular-coracoid ligaments occurs.

On examination, swelling, the presence of joint deformity, limited shoulder function, local pain, and step-like deformity above the acromial process are noted.

An x-ray of both clavicles is performed in the vertical position of the patient. With complete dislocation, the acromial end of the clavicle is displaced upward.

Treatment. Under intra-articular anesthesia with a 1% solution of novocaine, pressure is applied to the dislocated end of the clavicle in a downward and anterior direction. The dislocation is reduced easily, but re-dislocation can occur just as easily. To keep the acromial end of the clavicle in the reduced position, it is fixed with a plaster or belt bandage like a harness, fixed in a tense position to the plaster corset, for 4 weeks. Then massage, exercise therapy, thermal procedures are prescribed.

With a recurrence of dislocation, surgical treatment is performed, which consists in fixing the collarbone with a metal nail or screw, or in creating torn ligaments from mylar tape.

After the operation, it is necessary to immobilize the shoulder with a Deso bandage for 3-4 weeks.

Shoulder dislocations

Shoulder dislocations are most often caused by indirect trauma (falling onto an abducted arm). Anterior shoulder dislocation occurs in 80% of cases.

Depending on the position of the dislocated head, there are anterior, posterior and inferior dislocations.

The patient complains of pain, maintains the damaged arm healthy in the position of abduction and external rotation; the head of the humerus is displaced forward.

The clinical picture of the anterior dislocation of the shoulder, which occurs more often than others, is characteristic: the shoulder is abducted and tense. When diagnosing a dislocation of the shoulder, the definition of the head in the armpit is of great importance.

Gross deformities of the joint occur due to the fact that the head of the shoulder comes out of the articular cavity, the deltoid muscle subsides, the acromial process protrudes sharply, the entire area of ​​the shoulder takes on a stepped shape.

For specification of the diagnosis the X-ray analysis is made.

Treatment. Before starting treatment, damage to the axillary nerve must be excluded.

In most cases, it is possible to close the reduction of the dislocation under local intra-articular or general anesthesia by the method of A. A. Kudryavtsev. The patient is laid on a healthy side on the floor or on a couch. A soft noose-noose is applied to the wrist joint of the injured hand, which is connected with a rope rope thrown over a hook or block driven into the ceiling.

Sipping on the rope, slowly raise and pull up the dislocated arm until the patient's chest rises 2-3 cm above the floor. The rope is fixed.

In 10-15 minutes, the dislocation is reduced on its own in 97% of cases. Immobilization of the shoulder after reduction is carried out with a Deso bandage for 2-3 weeks.

Chronic and habitual dislocations of the shoulder are subject to surgical treatment.

Dislocations of the forearm

Dislocations of the forearm occur mainly in two variants - posterior dislocation (more often) and anterior, but there may be posterolateral and isolated dislocations of the radius and ulna, which give the greatest violations of the configuration of the elbow joint. They occur when falling on an outstretched hand.

Clinic. With a posterior dislocation, the forearm is shortened and slightly bent, the elbow joint is deformed, and the olecranon protrudes posteriorly. With anterior dislocation, a shortening of the shoulder is noted, the elbow joint is rounded, in the region of the olecranon - retraction.

Significant deformity of the elbow joint is observed with dislocation of the head of the radius, which is often accompanied by a fracture of the ulna (Montaggia fracture).

Treatment of dislocation of the forearm consists in the timely and correct reduction under local or general anesthesia.

With a posterior dislocation, the assistant produces traction and flexion of the forearm, and the doctor, grabbing the shoulder with both hands and holding it with his thumbs, presses on the olecranon. After reduction of the dislocation, the forearm is fixed with a posterior plaster splint at an angle of 90° for 5-7 days, then exercise therapy is started; massage and physiotherapy procedures are not prescribed.

Dislocation of the thumb

Dislocation of the thumb is more common in men as a result of indirect trauma. The main phalanx is displaced to the dorsum of the metacarpal bone.

Clinical picture: the finger is hyperextension at the base, and its nail phalanx is bent. Spring resistance is noted.

Treatment. After control radiography and local anesthesia or under anesthesia, the finger is lubricated with cleol and covered with a gauze napkin, then it is strongly overextended at the base and displaced distally.

With sufficient traction force, a quick palmar flexion of the finger is performed and its reduction occurs. Immobilization is carried out for 5 days, then exercise therapy, massage, thermal procedures are prescribed. If reduction fails, surgery is scheduled.

Hip dislocations

Dislocations of the hip are rare and only with a large traumatic force.

Depending on the displacement of the femoral head, four types of dislocations are distinguished: posterior superior and posterior inferior, anteroposterior and anteroinferior.

More often, posterior superior dislocations occur (up to 80%).

The clinical picture of the posterior superior dislocation: the thigh is somewhat adducted and bent, the entire leg is shortened, bent and rotated inwards.

The greater trochanter is displaced upward, with the head of the femur located behind the acetabulum. The lumbar lordosis is enlarged, hyperextends at the base and shifts distally. Possible damage to the sciatic nerve.

Treatment: immediately under anesthesia, a closed reduction of the hip dislocation is performed according to the Janelidze or Kocher-Kefer method. Otherwise, ischemic necrosis of the femoral head is possible. After reduction of the dislocation, the limb is fixed in the middle physiological position on the Beler splint using skin traction for 3 weeks.

5. Traumatic fractures

A bone fracture is called damage to the bone with a violation of its integrity, resulting from the action of an external mechanical factor. Fractures are accompanied by damage to the surrounding soft tissues: edema, hemorrhage in the muscles and joints, ruptures of tendons and ligaments, bruises, wounds, or complete intersection of nerves and large vessels.

Classification

Traumatic fractures arise from flexion, shear, twisting, compression and avulsion and are classified as follows.

I. Closed and open fractures:

1) closed - a fracture without violating the integrity of the skin;

2) open - a fracture with the formation of a wound extending to bone fragments. Open fractures require emergency surgery due to the high risk of infection.

Early debridement reduces the chance of infectious complications.

When providing first aid, a sterile bandage and a splint are applied to the fracture area.

II. Intra-articular and extra-articular:

1) intra-articular;

2) extra-articular:

a) epiphyseal;

b) metaphyseal;

c) diaphyseal (in the upper, middle and lower third of the diaphysis).

III. Fracture types:

1) simple - with the formation of two bone fragments;

2) comminuted - with the formation of three or more bone fragments;

3) multiple - a fracture of one bone in two or more places.

IV. According to the fracture line of the bone, fractures are transverse, oblique, helical, longitudinal and comminuted.

V. Depending on the nature of the traumatic force and traction of the muscles, fragments can be displaced relative to each other in width, length, at an angle or along the axis, rotationally or along the periphery.

VI. Fractures in children have their own characteristics and can be:

1) subperiosteal according to the "green branch" type - bone fragments are held by a well-developed, elastic periosteum;

2) along the line of the growth zone - there is a traumatic separation of the bone in the region of the epiphysis (the so-called epiphyseolysis).

Diagnosis and clinical picture

On examination, local pain, subcutaneous hemorrhage, swelling, edema, deformity of the limb segment, and dysfunction are determined.

Palpation of the injured limb causes severe pain, pathological mobility, crepitation of fragments, impaired sound conduction, painful axial load are noted at the fracture site.

To confirm the diagnosis, radiography is performed in two projections: posterior direct and lateral. CT is used to diagnose fractures of the pelvis, spine, and complicated intra-articular fractures.

fracture healing process

In the hematoma formed in the area of ​​the fracture, a callus is formed, which can basically be either endosteal, or intermediary, or periosteal, or paraossal, and goes through several stages in its development.

At the site of the hematoma, a jelly-like callus is formed, containing the remains of blood, scraps of soft tissues and bone fragments; then a granulation callus is formed, in which cell proliferation of osteoclasts, osteoblasts occurs, cartilage cells and cartilaginous callus appear; and, finally, the primary, or osteoid callus, passing into the final callus - lamellar bone.

If the bone fragments are ideally repositioned and physiological compression is created between them, then the fracture union can proceed according to the type of primary healing, i.e., bypassing the cartilaginous stage, a bone adhesion is immediately formed. Poor comparison of fragments and the presence of mobility between them lead to the fact that the formation of callus stops at the cartilaginous stage, i.e., the fracture does not grow together.

Clinically, bone fusion is divided into four conditional stages:

1) primary "gluing" - 3-10 days;

2) soft corn - 10-15 days;

3) bone fusion of fragments - 30-90 days;

4) functional restructuring of the callus - within a year or more.

General principles for the treatment of bone fractures

Fractures of large bones, accompanied by damage to soft tissues and large blood loss, lead not only to a violation of the anatomical integrity of the bone and the function of the damaged organ, but also to a violation of the function of the vital systems of the body (central nervous system, endocrine, cardiovascular system, respiratory and metabolic organs). substances), that is, they can be one of the main causes of traumatic shock.

To save the life of the victim, it is necessary to provide him with first aid in a timely and correct manner at all stages of transportation to the hospital: this is transport immobilization, anesthesia, temporary and permanent stopping of bleeding, restoration of blood loss, resuscitation in case of shock, timeliness of surgical treatment.

With a combined injury, first of all, attention is paid to damage to the organs of the abdominal and thoracic cavities, the brain and spinal cord, and the main arteries. These injuries are more life-threatening than fractures.

To restore the integrity of a broken bone, it is necessary, according to the principle of emergency surgery, to carry out primary surgical treatment of the wound (if any), anesthetize the fracture site, apply skeletal traction, match the fragments, then apply a plaster cast or, if indicated, perform surgical osteosynthesis.

The fundamental issue for restoring the function of the affected organ or limb is the implementation of a functional method of treatment.

Anesthesia

Injuries to the musculoskeletal system are accompanied by pain and blood loss, which, if severe, leads to traumatic shock.

Therefore, the main tasks in the treatment of traumatic shock are pain relief, stopping bleeding and replenishing blood loss.

However, anesthesia is necessary not only for the prevention of traumatic shock, but also for local relaxation of the muscles that are in pathological retraction during a fracture, which makes it difficult to reposition fragments. Anesthesia of the fracture site is achieved by introducing a 1-2% solution of novocaine into the hematoma in an amount of 15-20 ml.

For painless closed reposition of fractures and dislocations in PST wounds, local anesthesia, conduction, spinal and epidural anesthesia, and in some cases intraosseous and general anesthesia are used.

Local anesthesia is carried out under the strictest asepsis.

An anesthetic is injected into the hematoma during reposition of fragments of closed fractures of the bones of the lower leg, foot, forearm, hand and shoulder, as well as fractures of the femur, pelvic bones for temporary anesthesia and reduction of pain.

A long needle in the area of ​​the fracture is first infiltrated into the skin and subcutaneous tissue, and then penetrates into the hematoma. If the needle has entered the hematoma, then during aspiration, the solution of novocaine turns red.

Enter 15-20 ml of a 1-2% solution of novocaine, then the needle is removed. For fractures in two places, 15 ml of a 1-2% solution of novocaine is injected into each area. Pain relief occurs within 10 minutes and lasts 2 hours.

Intraosseous anesthesia. Under intraosseous anesthesia, surgical interventions, reposition of fragments in fractures, reduction of dislocations and surgical treatment of open fractures of the extremities can be performed. The method cannot be used for surgical interventions in the area of ​​the upper third of the shoulder and thigh.

Intraosseous anesthesia is combined with the introduction of neuroplegic and neurolytic substances and analgesics. For anesthesia, a 0,5% solution of novocaine or trimecaine is used. The limbs for 3-4 minutes give an elevated position for the outflow of venous blood. Then a tourniquet is applied until the pulse disappears in the peripheral arteries. For the same purpose, special pneumatic harnesses are used.

With open and closed fractures, novocaine is injected into the bone point of an intact bone distal to the fracture level. With open fractures, when this is not possible, novocaine is injected into a bone point located proximal to the fracture site.

Soft tissues at the site of the proposed injection of the needle are anesthetized with 1-5 ml of a 0,25-0,5% solution of novocaine.

Soft tissues are pierced with a needle for intraosseous anesthesia, then with rotational movements with simultaneous pressure along the axis, the needle is injected into the cancellous bone to a depth of 0,5-1,5 cm (depending on the size of the bone). The first portions of the anesthetic (5-10 ml) are administered slowly, since the beginning of intraosseous administration is accompanied by pain. The amount of solution injected depends on the location of the fracture and the level of tourniquet application.

During the surgical treatment of an open fracture, antibiotics are added to the novocaine solution.

The time of anesthesia is limited by the permissible time for applying a tourniquet to the limb. In cases where it is necessary to maintain pain relief for a long period, the needle can not be removed.

When prolonging anesthesia for 5-7 minutes, the tourniquet is removed to restore blood circulation. Then it is again applied and an anesthetic is injected through the needle.

During operations on the spine, chest and proximal limbs, as well as in traumatic shock, general anesthesia is used.

The treatment of bone fractures is based on general and local factors that influence the healing process of the fracture. The younger the patient, the faster and more complete the consolidation of the fracture occurs.

Slow consolidation is observed in people suffering from metabolic disorders, with beriberi and chronic diseases, in pregnant women, etc. Fractures heal poorly with hypoproteinemia and severe anemia. In most cases, nonunion of fractures depends on local factors: the more soft tissues are damaged, the slower the fracture heals.

The type of fracture also affects the healing time of a fracture. Oblique fractures heal faster than transverse fractures. Open fractures heal more slowly.

Conservative treatment methods

Currently, conservative or surgical methods are used in the treatment of bone fractures.

Conservative treatments include:

1) closed reposition of fragments, followed by fixation with a plaster cast or splint;

2) skeletal traction followed by manual reposition of fragments;

3) reposition and fixation of fragments with the help of pins with thrust pads;

4) reposition and fixation of fragments on special devices.

Reposition of fragments should be carried out in stationary conditions or in a specially equipped trauma center.

The reposition of fragments of different localization has some peculiarities, but there is one rule for all fractures: the peripheral fragment is compared to the central one.

The achieved position of the fragments must be maintained with plaster immobilization or with the help of permanent skeletal traction.

Immobilization with a plaster bandage or splint without fragment reposition is used for closed or open bone fractures, for fractures without significant displacement of fragments, for impacted fractures.

Closed reposition of fragments with subsequent application of a plaster cast is performed for diaphyseal, periarticular and intraarticular closed and open fractures of the bones of the extremities, with displacement of fragments, for compression fractures of the vertebral bodies, as well as for some comminuted diaphyseal fractures.

Reposition is performed manually or with the help of devices.

Under anesthesia, the fragments are repositioned at the fracture site only when it is not possible to match the fragments due to severe muscle retraction.

Before reposition, 20 ml of a 1-2% solution of novocaine is injected into the hematoma.

Correctly applied plaster bandage securely fixes matched fragments.

To immobilize the fracture, it is advisable to apply a bedless plaster cast that fixes at least two adjacent joints.

After applying a plaster cast, the limb is elevated and the patient is carefully monitored. In case of pain under the cast, with numbness, coldness and cyanosis of the fingers, it is necessary to cut the bandage. Complications arising from the treatment of fractures with a plaster cast are most often associated with its incorrect application.

If a displacement of fragments is detected on the control radiograph, the plaster bandage is removed and the fragments are repositioned, followed by the application of a new plaster bandage and a control radiograph, or skeletal traction is applied.

Skeletal traction is most often used in the treatment of bone fractures with displacement of fragments. A stainless steel needle is passed through the bone at certain points using a special manual or electric drill, then it is fixed and stretched in a Kirschner or CITO bracket.

The needle is inserted under local anesthesia in the operating room with the strictest observance of asepsis rules. Then the limb is placed on the tire, and the load is suspended from the bracket.

In case of a hip fracture, the determination of the size of the load is carried out from the following calculation:

15% of the patient's weight + 1 kg for each centimeter of displacement of fragments along the length, of which 2/3 is suspended on the thigh and 1/3 - on the lower leg using skin traction.

In the ward, until the action of novocaine has ended, manual reposition of fragments is performed. With the formation of primary callus, skeletal traction is removed and a plaster cast is applied for the period necessary for complete consolidation of the fracture.

Reposition and fixation of fragments on special devices. Of all the proposed devices for repositioning and fixing fragments, the best in this respect was the apparatus of Ilizarov and Volkov-Oganesyan.

Regardless of how the reposition and fixation of fragments is carried out (with needles with thrust pads or with the help of special devices), efforts should be directed to creating favorable conditions for bone regeneration. Excessive mutual pressure of fragments should be avoided, since reporative regeneration of bone tissue does not depend on compression, but on the degree of reposition, the length of contact and stable immobility between fragments.

In cases where a double reduction is not successful, or when neither fixation nor extension methods hold the fragments in the desired position, surgery is indicated.

Operative methods of treatment

A favorable period for open reposition of fragments should be considered the first week after injury.

Extended and unreasonable use of surgical intervention for fractures worsens the final results of treatment.

Indications for surgical treatment of fractures are:

1) interposition (infringement) of soft tissues between fragments (absence of fragments crunching, retraction of soft tissues, unrepaired fragments);

2) avulsion fractures of the patella and olecranon with a divergence of fragments of more than 2 mm;

3) transverse and oblique fractures of the femur (if there are conditions and a traumatologist);

4) non-impacted fractures of the medial femoral neck;

5) helical fractures of the tibia;

6) multiple diaphyseal fractures;

7) unrepaired fractures;

8) newly displaced fractures in a plaster cast.

Contraindications for surgical treatment are:

1) poor general condition of the patient associated with injury or serious illness;

2) cardiovascular insufficiency;

3) ulcers and infected abrasions;

4) recent illnesses.

The most common methods of open connection of fragments include operations:

1) open reposition of fragments without additional fixation (rarely used);

2) open reposition of fragments with fixation using various metal structures (pins, screws, screws, nails, plates, wire, tape, plastic fixators and auto- and homotransplants, etc.).

Auxiliary restorative methods of treating fractures include exercise therapy, massage, mechanotherapy and physiotherapy.

Unloading and fixing devices, as well as prostheses, corsets, belts, splints, orthopedic shoes are used after fractures of the bones of the limbs, pelvis and spine to achieve long-term functional unloading and fixation of damaged organs in a certain position in order to correct deformities and to compensate for shortening of the limb, as well as with improperly fused or non-united fractures.

6. Closed bone fractures

Clavicle fracture

Clavicle fractures account for 5 to 15% of skeletal fractures. In men, they are observed 2 times more often than in women. A clavicle fracture occurs when a direct blow to the collarbone (direct injury) or during a fall on the elbow or shoulder (indirect injury).

The clavicle often breaks in the middle third, a typical displacement of fragments occurs. The distal fragment is displaced downward, anteriorly and medially due to the severity of the upper limb, and the proximal fragment, under the influence of the traction of the sternocleidomastoid muscle, is displaced upward and backward.

The diagnosis is made on the basis of clinical signs, expressed in pain, swelling and typical angular deformity in the clavicle. When the fragments are displaced, a drooping of the shoulder girdle and a violation of the function of the shoulder are noted, with palpation under the skin, the end of the proximal fragment is felt and pathological mobility and crepitus of the fragments are determined. Plain radiograph reveals a violation of the integrity of the clavicle.

Treatment. In case of fractures of the clavicle without displacement of fragments, an eight-shaped soft bandage is applied for 3-4 weeks.

Reposition of fragments is carried out after preliminary anesthesia of the fracture area with 20 ml of a 1% solution of novocaine. A cotton-gauze roller is placed in the armpit and the shoulder is brought to the chest to eliminate the displacement of the distal fragment along the length.

Then the entire shoulder girdle, together with the distal fragment, is displaced upwards and backwards, i.e., the displacement of the peripheral fragment downwards and anteriorly is eliminated.

Various dressings and splints have been proposed to hold the fragments in the repositioned position, but they rarely keep the fragments in the juxtaposed position.

After a Dezo bandage immobilizing the shoulder joint for 4-5 weeks, stiffness develops in it, the elimination of which requires another 3-4 weeks.

Nevertheless, traumatologists often use this bandage, strengthening it with 2-3 rounds of a plaster bandage.

In cases where it is not possible to match and hold the fragments in the repositioned position or there is compression of the neurovascular bundle, surgical treatment is indicated - intramedullary osteosynthesis with a Bogdanov metal rod, which is removed after 3-4 months.

Shoulder fractures

Shoulder fractures account for 2,2% of all bone fractures and are subdivided into fractures in the upper, middle and lower thirds of the humerus.

In turn, fractures in the upper and lower thirds are divided into intra-articular and extra-articular.

Fractures of the head of the anatomical neck of the shoulder (supra-tubercular, or intra-articular) are rare and are characterized by the occurrence of arthrogenic contracture after intra-articular hemorrhage, which is an indication for joint puncture and early physiotherapy (from 2-3 days after injury).

Intra-articular fractures with displacement of fragments require surgical treatment.

Fracture of the surgical neck of the shoulder more often occurs in older people with a fall on the arm, while there is an impacted fracture or a fracture with displacement of fragments.

With fractures of the neck of the humerus, there are often extensive bruises found on the inner surface of the shoulder, extending to the chest area. It is important to find out if the movements of the shoulder are transmitted to the head. With a non-impacted fracture, movements will not be transmitted to the head, pressure along the axis will cause severe pain. Impacted fractures are accompanied by moderate pain in the area of ​​the fracture and limited movement of the shoulder.

Treatment of an impacted fracture consists in immobilization of the shoulder joint with a plaster Longuet according to Turner for 5-7 days.

The hand is fixed on a scarf with a freely hanging elbow, and a triangular wedge-shaped pillow is placed in the armpit, which is suspended from a healthy shoulder girdle. From the 2nd day, exercise therapy is prescribed. After 4-5 weeks, the fracture grows together, movements in the shoulder joint are restored.

Fractures of the surgical neck of the shoulder subdivided into abductive and adductive.

Abduction fractures occur when falling on the abducted arm, while the fragments of the shoulder are displaced so that an angle is formed between them, open outwards.

Adduction fractures occur when falling on the adducted arm, and the angle between the fragments opens inwards.

The diagnosis is made on the basis of anamnesis, complaints of pain in the area of ​​the fracture, the presence of swelling; examination: the shoulder does not spring, as with a dislocation, but hangs freely; crepitus of fragments and pain during axial load are noted; sound conduction is impaired.

The displacement of fragments is determined by a radiograph made in two projections.

Treatment of a fracture of the surgical neck of the shoulder with displacement of fragments begins with local anesthesia and reposition of the fragments.

In case of an adduction fracture, to eliminate the displacement of fragments along the length and width, the shoulder is extended and abducted by 70°, then the shoulder is brought to the middle by 35°. The hand is placed on the abductor splint, followed by skin traction. If the fragments are displaced, skeletal traction behind the olecranon is applied.

Reposition of fragments in abduction fractures - the peripheral fragment is placed along the central one, but the hand does not fit on the tire, since when the shoulder is abducted, an even greater displacement of the fragments occurs.

It is hung on a scarf or bandage-snake with a roller in the armpit.

From the 2nd day, hand massage, exercise therapy according to Dreving-Gorinevskaya, UHF are prescribed. By the end of the month, the fracture grows together, the function of the hand and ability to work are restored.

When a fracture of the surgical neck is combined with a dislocation of the head of the shoulder, surgical treatment is indicated, however, in elderly people who have contraindications to surgery, treatment is carried out based on the formation of a false joint.

Shoulder diaphysis fractures arise from direct and indirect trauma.

In case of a fracture slightly below the surgical neck, but above the place of attachment of the pectoralis major muscle, the proximal fragment is shifted to the position of abduction by the pull of the supraspinatus muscle, the distal one - by contraction of the deltoid and pectoralis major muscles, is shifted upward, medially and rotated inward.

In case of a fracture at the border of the upper and middle thirds of the shoulder, between the attachments of the pectoralis major and deltoid muscles, the central fragment is in the position of adduction and external rotation.

In case of a fracture at the border of the middle and lower thirds, below the place of attachment of the deltoid muscle, the upper fragment is in the position of abduction and external rotation, and the lower fragment is displaced inwards and pulled up.

The diagnosis of a shoulder fracture is established on the basis of clinical findings (such as pain, deformity, swelling, abnormal mobility, crepitation of fragments, shortening of the shoulder) and x-ray examination.

With a fracture in the middle third of the humerus, the radial nerve is sometimes damaged.

Treatment of fractures of the diaphysis of the shoulder is carried out on the outlet (abduction) splint. The shoulder is abducted to a right angle (90°) and moved forward at an angle of 35°. In case of fractures without displacement of fragments, cutaneous traction is applied, with displacement - skeletal traction behind the olecranon. From the 2nd day, exercise therapy is prescribed. The traction is removed after 4-5 weeks, and the splint is removed after 6-8 weeks after the fracture.

In cases where an abduction splint cannot be applied (old age, rib fractures, pneumonia, etc.), shoulder fragments in the lower third are immobilized with a U-shaped plaster splint, and the forearm is suspended on a snake bandage. From the first days, exercise therapy is prescribed. After 4-5 weeks, the splint is removed and the hand is transferred to a scarf.

Surgical treatment is carried out with interposition of soft tissues or damage to the radial nerve. Open reposition of fragments is supplemented by intra- or extramedullary fixation using metal structures (rods, screws, bolts, plates, wire, metal tape). After the operation, a thoracobrachial plaster splint is applied and exercise therapy is performed from the 2-3rd day. Fracture union occurs after 3-6 months.

Fractures of the lower end of the humerus subdivided into supracondylar (extraarticular) and transcondylar (intraarticular).

Supracondylar (extra-articular) fractures can be extensor or flexion.

Intra-articular fractures include transcondylar, intercondylar (T- and U-shaped), fractures of the condyles (internal and external), capitate elevation, fractures of the supracondylar elevations.

Extension supracondylar fractures shoulders occur more often in children when falling on an outstretched arm, while the fracture line goes from bottom to top from front to back.

The distal fragment is displaced posteriorly and outwards, and the proximal fragment is displaced anteriorly and medially. The olecranon is displaced posteriorly, a depression is formed above it.

Such displacement of fragments can lead to compression of the neurovascular bundle with the subsequent development of Volkmann's ischemic contracture.

Signs of a developing contracture: severe pain, weakening or disappearance of the pulse on the radial artery (in the wrist), pallor of the skin of the fingers.

To confirm the diagnosis, the pressure in the fascial sheaths of the forearm is measured. If the pressure reaches 30 mm Hg. Art., shows an urgent revision of the cubital fossa and a wide fasciotomy.

If nerves and vessels are intact, closed reposition, skeletal traction with a Kirschner wire, and a plaster cast are indicated. Prevention of contracture requires early diagnosis and treatment of nerve and vascular injuries.

Flexion supracondylar fractures occur when falling on a bent elbow, while the fracture line goes from top to bottom from front to back and the distal fragment is displaced anteriorly.

Treatment of supracondylar fractures begins with local anesthesia and reposition of fragments. A posterior gypsum splint is applied along the Turner at a right angle in the elbow joint. Starting from the 2nd day, exercise therapy is prescribed.

Movements in the shoulder joint begin after 2 weeks, and in the elbow - after 3 weeks, in children - a week earlier. Massage is not prescribed, as it leads to ossification of the paraarticular tissues and contracture of the elbow joint.

From the first hours after the imposition of a plaster splint, the blood supply to the forearm and hand is monitored. With edema, cyanosis, impaired sensitivity, the plaster splint is diluted, and if the edema does not decrease, an incision is made in the skin and fascia on the forearm to prevent the formation of ischemic contracture.

In cases where the reposition of the fracture fails or the fragments are displaced in the plaster splint (X-ray control is performed immediately after the plaster splint is applied), skeletal traction is performed on the outlet splint or on the Balkan frame.

After 2 weeks, the skeletal traction is removed and a U-shaped plaster splint is applied to the shoulder or a back plaster splint to the shoulder, forearm and hand.

Surgical treatment of supracondylar fractures is performed when neither manual nor skeletal traction fails to reposition the fracture. Fragments are fixed with nails or screws.

Transcondylar fracture is an intra-articular fracture and occurs more often in childhood. Since the fracture line passes through the zone of the epiphysis, the fracture can be called epiphysiolysis.

Due to the fact that the peripheral fragment is displaced posteriorly, the clinical signs of the fracture resemble a supracondylar extensor fracture, but with a supracondylar fracture, the isosceles triangle of Gueter, formed by the protruding points of the epicondyles of the shoulder and olecranon, is disturbed. Radiography clarifies the clinical diagnosis.

The treatment is practically the same as the treatment of a supracondylar extensor fracture.

Intercondylar fractures, or T- and U-shaped fractures, occur when falling on the elbow, while the olecranon, like a wedge, is introduced between the condyles of the shoulder and displaces them to the sides.

Clinically, T- and U-shaped fractures are manifested by massive intra- and extra-articular hemorrhage, joint deformity, and severe pain. Radiography clarifies the displacement of fragments and determines the tactics of treatment.

Treatment. In the absence of fragment displacement, U-shaped and posterior plaster splints are applied, fixing the elbow joint at an angle of 90-100°, for 2-3 weeks. From the 2nd day, movements in the fingers and shoulder joint are prescribed.

When the fragments are displaced, a manual reposition of the fragments is performed or a skeletal traction for the olecranon is applied.

If skeletal traction fails, open reposition of the fragments is performed and their fixation with a coupler bolt, knitting needles or screws.

Fracture of the external condyle occurs when falling more often on an outstretched hand. The radius, with a sharp blow to the capitate, breaks off and displaces the external condyle upward. The forearm deviates outward, the Guther triangle is violated.

Mandatory x-ray of the joint in two projections.

Treatment of a fracture of the lateral condyle of the shoulder without displacement consists in the imposition of a plaster splint or split plaster cast for 3-4 weeks in adults and for 2 weeks in children. Then exercise therapy is assigned.

If the condyle is displaced, then it is repositioned under local anesthesia: the elbow joint is stretched by pulling the hand and shoulder, the forearm is displaced inwards, creating cubitus varus. The condyles of the shoulder are compressed from the sides and the forearm is bent to an angle of 100 °. If the closed reposition fails, an operation is performed - fixing the condyle in place.

Fracture of the internal condyle happens when you fall on your elbow. The impact force is transmitted through the olecranon to the internal condyle, chipping it off and shifting it inward and upward. There are cubitus varus, swelling, hemorrhage, severe pain. On the radiograph, the degree of displacement of the fragment is determined.

The treatment is carried out by skeletal traction behind the olecranon for 2 weeks, then a plaster splint is applied, and physiotherapy exercises are prescribed.

Fracture of the capitate eminence of the shoulder occurs when falling on an outstretched hand.

There is pain and swelling in the area of ​​the external condyle, restriction of movement in the elbow joint, sometimes its blockade. X-ray does not always detect a fracture, as there can only be isolated cartilage damage.

Treatment consists of surgical removal of the fragment if it is small and mostly cartilage. They try to put a large fragment of the capitate in place in a closed way, for this they stretch and hyperextension of the elbow joint. Gypsum immobilization is carried out for 3-4 weeks, then exercise therapy is prescribed.

If an attempt at a closed reposition fails, then an open reposition of the fragment is performed and its fixation with transarticular needles or catgut (in children).

Fractures over the condylar eminences (internal and external) can be observed when falling on an outstretched hand. In this case, the forearm deviates excessively into a valgus position, tearing off the internal epicondyle, or into a varus position, when the external epicondyle of the shoulder comes off and moves down. Often, when the epicondyle is torn off, the articular capsule is torn and the fragment enters the joint cavity and is infringed there.

Clinical signs are local pain, swelling, hemorrhage, mobility of the fragment and its crepitus, sometimes blockade of the joint. Radiography, produced in two projections, confirms the clinical diagnosis.

Treatment of fractures of the supracondylar eminences without significant displacement is reduced to the imposition of a plaster cast in adults and splints in children for 2-3 weeks, then proceed to dosed exercise therapy.

The operation is performed with a significant displacement of the fragment and with its intra-articular infringement.

Fixation of the epicondyle to its bed is carried out with catgut sutures or a needle percutaneously. A small fragment is removed. The terms of immobilization after any operation do not change.

Forearm fractures

Fractures of the bones of the forearm are common and account for about 25% of all fractures.

7. Intra-articular fractures of the bones of the forearm in the elbow joint

Olecranon fractures

Fractures of the olecranon occur more often when falling on the elbow.

The fracture line penetrates the joint. Due to the traction of the triceps muscle of the shoulder, the fragment is often displaced upward.

Clinically, the fracture is expressed by local pain, swelling and hemorrhage, restriction of movement. Radiography specifies the degree of divergence of fragments.

Treatment. With a divergence of fragments not exceeding 2 mm, conservative treatment is carried out. A posterior plaster splint is applied for 3 weeks. From the 2nd day, exercise therapy is prescribed. With diastasis between the fragments of more than 2 mm, an operation is performed, which consists in fixing the fragments with an elongated pin. The period of immobilization after surgery is the same as for a fracture without fragments dehiscence.

Fracture of the coronoid process

A fracture of the coronoid process occurs with a posterior dislocation of the forearm and is accompanied by local pain and swelling in the area of ​​the elbow. The fracture is identified on a lateral radiograph.

Treatment for a fracture of the coronoid process without displacement is carried out by applying a plaster cast or splint to the elbow joint at an angle of 100° for 2-3 weeks. In cases of large displacement of the process, an operation is performed - suturing the fragment to its bed with catgut sutures.

Fracture of the head and neck of the radius

A fracture of the head and neck of the radius occurs when a person falls on an outstretched hand.

clinical picture. There is local pain, swelling, hemorrhage and limitation of function. Radiography clarifies the nature of the fracture.

Treatment. Impacted fractures and fractures without displacement of fragments are treated conservatively. A plaster splint is applied with the elbow joint flexed at an angle of 90-100° for 2 weeks. Then exercise therapy is assigned.

When the fragments are displaced, a closed or open reposition is performed.

The operation ends either with the removal of the head in case of its fragmentation (in adults), or with the fixation of fragments with a needle percutaneously, transarticularly. Postoperative management is the same as for conservative treatment.

8. Diaphyseal fractures of the bones of the forearm

Diaphyseal fractures of the bones of the forearm can occur with direct trauma. Fragments are displaced along the width, along the length, at an angle and along the periphery.

Particular attention is drawn to the rotational displacement of fragments of the radius.

If both bones of the forearm are fractured in the upper third, the proximal fragment of the radius will be in the position of flexion and supination, while the distal fragment of the radius will take the pronation position.

If a fracture of the bones of the forearm occurs in the middle third, then the proximal fragment of the radius, which will have an antagonistic effect of the arch supports and the round pronator, will take a middle position. The distal fragments will shift to the position of pronation.

With a fracture in the lower third, the proximal fragment of the radius is pronated.

When both bones of the forearm are fractured at the same level, the ends of all four fragments often come close to each other.

The clinic is expressed by local pain, deformity, swelling, pathological mobility, crepitation of fragments and dysfunction of the forearm. In young children with green stick fractures and subperiosteal fractures, the clinical signs of a fracture are indistinct.

However, radiography with the capture of adjacent joints will help clarify the nature of the fracture.

Treatment consists in comparing peripheral fragments along the central axis.

Fractures without displacement of fragments, subperiosteal, with angular or rotational displacement are treated conservatively. The axis and position of the forearm are corrected and two plaster splints are applied (one on the back, the other on the palmar surface) with the capture of adjacent joints for 1,5-2 months. The elbow joint is fixed in the position of flexion at an angle of 90°, the forearm - in a position between supination and pronation, the hand - in a slight dorsal extension.

From the 2nd day, movements begin in the fingers and in the shoulder joint, UHF is prescribed.

In fractures with displacement of fragments, an attempt is made to compare the fragments in a closed way manually or on special devices.

After local anesthesia, the rotational displacement of the distal fragments is first eliminated, then, by traction of the forearm and pressure on the ends of the fragments, the displacement along the length and width is eliminated.

In a state of ongoing traction for 10-12 weeks, two plaster splints are applied to fix the elbow and wrist joints.

Longitudinal impressions are formed on the gypsum splints that have not yet hardened, thereby achieving separation of the fragments of the radius and ulna.

The control radiography is performed immediately after the imposition of a plaster splint and after the edema has subsided. Physiotherapy and exercise therapy are prescribed.

Comminuted fractures, fractures accompanied by damage to blood vessels and nerves, multiple fractures and fractures that are not amenable to closed reposition, are subject to surgical treatment.

Open reposition ends with intramedullary fixation of fragments with metal rods and external immobilization with a plaster splint for a period of 8-10 weeks.

Fracture dislocation Monteggi

Fracture dislocation of Monteggi is a fracture of the ulna at the border of the upper and middle thirds and a dislocation of the head of the radius that occurs with direct trauma.

Clinically, there is a pronounced deformity of the elbow joint and the upper third of the forearm. The forearm is shortened, movements in the elbow joint are impossible. The head of the radius is determined subcutaneously. Radiography in two projections with the capture of the elbow joint determines the fracture and dislocation.

Treatment consists in the reduction of the dislocation of the head of the radius and in the reposition of the fragments of the ulna. The forearm is supinated and is in a flexion position at an angle of 50-60°. This position is fixed with a back plaster splint or bandage for 4-6 weeks with its change for another 4-6 weeks.

Often, reluxation and secondary displacement of fragments occur under the bandage. In this case, under local anesthesia, the dislocation is repositioned and the fragments are repositioned.

The head of the radius is fixed with a needle, carried out percutaneously and transarticularly.

Irreducible and chronic fracture-dislocations are subject to surgical treatment. The ulna is fixed intramedullary with a metal rod passed retrograde through the proximal fragment, the head of the radius - transarticularly with a pin. The needle is removed after 4 weeks, the plaster cast is removed after 2 months.

Fracture dislocation of Galeazzi

Fracture dislocation of Galeazzi is called "reverse Monteggi", as it is a fracture of the radius at the border of the middle and lower thirds and a dislocation of the head of the ulna. Deformation and shortening of the forearm are noted, movements in the wrist joint are impossible. X-ray confirms the diagnosis.

Treatment is even more difficult than with Monteggi's fracture-dislocation, since it is very difficult to keep the head of the ulna in the reduced position. Reluxation is detected after removal of the plaster cast.

Therefore, when establishing a diagnosis, an operation is prescribed, the purpose of which is to firmly fix the fracture of the radius with a metal rod and the set head of the ulna with a needle percutaneously. Plaster immobilization is carried out for 8-10 weeks. Exercise therapy and physiotherapy are carried out.

9. Fractures of the lower end of the radius

Fractures of the radius in a typical location

Fractures of the radius in a typical location among the fractures of the bones of the forearm occupy the first place and account for about 70%. Occur when falling on an unbent or bent hand. The most common extension fracture, or Collis fracture, is a fracture of the distal end of the radius with displacement of the peripheral fragment to the back and outwards, i.e., to the radial side, and the central fragment deviates to the palmar-ulnar side.

When falling on a bent hand, a flexion fracture of Smith or a reverse Collis fracture occurs, while the peripheral fragment is displaced to the palmar side and is in the pronation position.

The clinic with an extension fracture is characterized by a bayonet-shaped deformity of the forearm and hand. There is local pain. Movement in the wrist joint is limited.

Sometimes a Collis fracture is accompanied by damage to the interosseous branch of the radial nerve. Turner's traumatic neuritis occurs, in which a sharp swelling of the hand and fingers develops, which leads to osteoporosis of the bones of the wrist. X-ray confirms the clinical diagnosis.

Treatment begins with anesthesia of the fracture site. If the fracture is non-displaced or impacted, a back plaster splint is applied from the elbow joint to the fingers for 2 weeks. From the 2nd day, exercise therapy and physiotherapy are prescribed.

In case of a Collis fracture with displacement of fragments, the fragments are repositioned by traction on the Sokolovsky apparatus or manually.

Manual reposition is carried out with an assistant who creates a counter traction over the shoulder. The patient sits sideways to the table, his hand lies on the table, and the brush hangs from the edge of the table. The thumb of the patient is taken with one hand, the rest - with the other. First, the forearm is stretched, then at the level of the fracture over the edge of the table, the hand is bent with great effort, rewarded and deviated to the elbow side. In this position, giving the hand a slight dorsal extension, a deep dorsal splint is applied from the metacarpophalangeal joints to the elbow joint for 3-4 weeks.

Then, a control radiography is performed, and in the case of repeated displacement of the fragments and in case of crushed fractures, a secondary reduction is performed with percutaneous fixation of the fragments with knitting needles.

The correct position of the fragments is when the radioulnar angle is +30° in the "face" position and +10° in the "profile" position.

10. Fractures of the bones of the hand

Fractures of the bones of the hand account for about a third of all bone fractures, of which phalangeal fractures account for 83%. Of the fractures of the bones of the wrist, the first place is occupied by a fracture of the navicular bone, then the lunate and trihedral.

Scaphoid fracture

A fracture of the navicular bone occurs when falling on an extended hand.

The fracture line often passes in the middle, narrowed part of the navicular bone, however, it is not always possible to detect a fracture radiologically in the first days after the injury. Only on the 10-14th day, when the ends of the fragments decalcify, a gap appears on the radiograph.

In this regard, in the recognition of a fracture of the navicular bone, as well as the separation of its tubercle, clinical signs become leading: local pain, swelling, pain during axial load, limited and painful movements in the wrist joint.

Treatment of a scaphoid fracture is a difficult task, associated with the peculiarities of blood supply, the absence of periosteum, diagnostic difficulties, and the duration of fracture union.

Usually, a dorsal plaster splint is applied from the metacarpophalangeal joints to the elbow joint in the position of dorsal extension and radial abduction with mandatory fixation of the first finger. After 2-3 months, the splint is removed and X-ray control is carried out.

In the absence of adhesion, immobilization is extended up to 6 months.

From the first day of immobilization, exercise therapy for free fingers is carried out.

Often, a fracture of the navicular bone does not heal, which is the reason for surgical treatment, which consists in compressing the fragments with a screw with mandatory bone grafting with an autograft taken from the distal part of the radius. Immobilization after surgery lasts 3-4 months.

In cases where the fracture does not heal after immobilization, and the ulnar fragment is less than one third of the bone itself, it is removed.

Metacarpal fractures

Fractures of the metacarpal bones occur with direct and indirect trauma.

Among them, in the first place in frequency is the fracture-dislocation of the metacarpal bone (Bennett's fracture).

clinical picture. The thumb is adducted, and a protrusion appears in the region of its base. With this fracture, there is local pain on palpation and axial load, pathological mobility and crepitus of fragments. Radiography clarifies the nature of the fracture.

Treatment. Under local anesthesia, fragments are repositioned: first, traction and abduction of the I finger together with the metacarpal bone are carried out, then pressure is applied to the base of the I metacarpal bone from the radial side. The achieved reposition is fixed with a plaster cast for 4 weeks. In difficult cases of reposition, skeletal traction or percutaneous fixation of fragments with a pin is performed.

In the treatment of fractures of the II-V metacarpal bones without displacement of fragments, immobilization is carried out with a palmar plaster splint from the middle third of the forearm to the tips of the corresponding fingers, the hand is given some dorsal extension up to an angle of 20-30 °, and in the metacarpophalangeal joints - palmar flexion at an angle of 10- 20°, in the interphalangeal joints - 45°. The remaining fingers remain free, without immobilization.

Periarticular fractures

Periarticular fractures, as well as non-repairing diaphyseal fractures, are treated surgically: by open reposition and percutaneous fixation of fragments with a Kirschner wire. The postoperative period of immobilization is the same as with conservative treatment. The needles are removed after 3 weeks. Physical therapy is a must.

Fractures of fingers

Finger fractures are more likely to result from direct trauma. Fragments of the phalanx are displaced at an angle open to the rear.

The clinic is characterized by deformation, shortening, local pain and swelling, pain during axial load. Radiography clarifies the fracture and displacement of fragments.

Treatment of fractures of the phalanges of the fingers needs special care, since small inaccuracies lead to a decrease in the function of the injured finger.

Under local anesthesia, precise adaptation of the fragments and fixation of the finger in a bent position at an angle of 45 ° are performed with a plaster splint or Beler's wire splint for a period of 2-3 weeks.

In cases of displacement of fragments, skeletal traction for the nail phalanx or closed or open osteosynthesis with a pin is performed.

11. Hip fractures

Diagnosis of hip injuries

In case of traumatic dislocations and fractures of the femoral neck, the position of the greater trochanter is determined in relation to the line drawn through the anterior superior spine and ischial tubercle of the pelvis (Roser-Nelaton line).

The patient is laid on a healthy side, the leg is bent at the hip joint to an angle of 135 °, a line is drawn connecting the anterior superior spine and the highest point of the ischial tuberosity. Normally, the highest point of the greater trochanter is determined in the middle of this line.

The greater trochanter is located above the line in case of traumatic dislocations, fracture of the femoral neck, below the line - in case of pubic or obturator dislocations. With a central dislocation or with an impacted fracture of the femoral neck, the greater trochanter may not change position relative to the Roser-Nelaton line, however, in these cases, the distance between the trochanter apex and the anterior superior iliac spine decreases.

Hip fractures are divided into three groups according to localization:

1) fractures of the proximal end of the femur - intra-articular and extra-articular fractures of the femoral neck;

2) diaphyseal fractures - subtrochanteric fractures, fractures in the upper, middle and lower thirds;

3) fractures of the distal end of the femur - intra-articular and extra-articular.

Fractures of the proximal end of the femur account for about half of all hip fractures.

Intra-articular (medial) fractures of the femoral neck

Intra-articular (medial) fractures of the femoral neck are divided into subcapital, transcervical and basal.

Depending on the mechanism of injury, all medial fractures of the femoral neck can be abduction (often impacted) or adduction - with a divergence of fragments and a decrease in the cervical-diaphyseal angle.

Abduction hip fractures occur more often in middle-aged people and occur during a fall on an abducted leg or on the trochanteric region. The traumatic force coincides with the direction of the femoral neck, and an impacted fracture occurs.

With such a fracture, patients continue to walk, complaining of pain in the hip or knee joints. Even radiography does not reveal a fracture. Only control radiography, performed after 10-14 days, allows you to identify the fracture line.

Quite often, by this time, the fracture is wedged, the leg loses support and clinical signs of a fracture occur with fragments dehiscence.

Treatment of an impacted fracture of the femoral neck is reduced to the prevention of wedging and divergence of fragments. The leg is placed on the Beler splint with cutaneous or skeletal traction with a load of 2-3 kg for 2-3 months, after which the patient is allowed to walk with crutches without any load on the affected leg. The load is allowed after 5-6 months. By this time, the impacted fracture should heal.

However, the occurrence of aseptic necrosis of the femoral head cannot be excluded.

Adduction fractures of the hip are more often observed in older people and occur when falling on an adducted leg.

The fracture line may be subcapital, transcervical, or at the base of the femoral neck. The distal fragment is displaced upwards, deviating the proximal fragment in the same direction, as a result of which the cervical-diaphyseal angle decreases.

Outward rotation of the thigh is clinically determined, the outer edge of the foot lies on the plane of the bed, the limb is relatively shortened by 2-3 cm, the Roser-Nelaton line is disturbed, a positive symptom of "adhering heel", pain during axial load and palpation under the pupart ligament are noted.

X-ray confirms the clinical diagnosis.

Treatment begins with intra-articular anesthesia. Superimposed skeletal traction for the tuberosity of the tibia, the patient is preparing for surgery.

Patients with severe diabetes, cardiovascular insufficiency, weakened and emaciated, in a state of senile insanity, surgery is contraindicated, and treatment is aimed at the formation of pseudarthrosis.

Skeletal traction is removed after 2-3 weeks, and the patient learns to walk on crutches. In some cases, when patients need to be turned from the first days, until the pain subsides (2-3 weeks), a disciplinary derotational plaster boot with a cotton lining is applied.

Adduction fractures of the femoral neck are treated promptly. Two types of surgical intervention have been developed: open intra-articular osteosynthesis and closed extra-articular osteosynthesis with a three-bladed nail using a guide B. A. Petrov and E. F. Yasnov. Reposition of fragments is carried out on an orthopedic table before surgery.

Walking on crutches without load on the affected leg begins after 4 weeks, with load - 5-6 months after the operation. Control radiography is performed periodically. The nail is removed 1-1,5 years after the operation.

In some elderly patients with subcapital fractures of the femoral neck, arthroplasty is performed.

In case of ununited fractures and false joints of the femoral neck and the absence of contraindications for surgery, extra-articular osteosynthesis with a three-blade nail and bone grafting with an autograft or high oblique subtrochanteric osteotomy according to Putty-McMurray, arthrodesis of the hip joint, endoprosthetics and reconstructive surgeries are used.

Extra-articular fractures of the femoral neck

Extra-articular fractures of the femoral neck, or trochanteric fractures, are fractures localized from the base of the femoral neck to the subtrochanteric line. They occur when falling on the greater trochanter, more often in elderly people due to the development of senile osteoporosis.

Clinically, such fractures are characterized by a severe general condition associated with massive damage and large blood loss.

Significant swelling and hematoma. Other symptoms of vertile fractures are similar to those of cervical fractures.

Treatment of patients begins with resuscitation (good anesthesia, blood transfusion and blood substitutes) and the imposition of skeletal traction with a load of 4-6 kg. After 5-6 weeks (and if the fragments are displaced - after 7-8 weeks), the skeletal traction is removed and the patient is prepared for walking with the help of crutches.

Exercise therapy, massage, physiotherapy are carried out. The load on the diseased limb is allowed after 3-4 months.

Other methods of treatment include osteosynthesis with metal fixators, the indication for which is a young age.

Diaphyseal fractures of the femur

Diaphyseal fractures of the femur occur as a result of direct or indirect trauma.

Subtrochanteric fractures localized in the area under the lesser trochanter and spread down the diaphysis by 5-6 cm. The central fragment is in the position of abduction, flexion and external rotation; the peripheral fragment as a result of the traction of the adductor muscles is displaced inwards and upwards.

With fractures in the middle third of the diaphysis, the displacement of fragments is the same, but the central fragment is retracted somewhat less.

Fractures in the lower third of the femur are accompanied by displacement of the peripheral fragment posteriorly and upwards. The central fragment is located in front and medially.

RџSЂRё supracondylar fractures the distal fragment can be displaced so that its wound surface is turned backwards and can damage the neurovascular bundle.

Clinically, diaphyseal fractures of the femur are characterized by a general severe condition of the patient, the supporting function of the leg is impaired, the femur is deformed. There are pathological mobility and crepitus of fragments, shortening of the limb and external rotation of the peripheral part of the limb, local pain on palpation and axial load, impaired sound conduction. On radiographs in two projections, there is a violation of the integrity of the femur.

Treatment of patients with hip fracture begins with transport immobilization and anti-shock measures. Then skeletal traction is applied for the tuberosity of the tibia or for the epicondyle of the thigh, as well as gauze-cleol traction for the lower leg.

Manual reposition of fragments is performed on the Beler splint with a suspended load (15% of the patient's weight).

In supracondylar fractures, when the peripheral fragment is displaced posteriorly, to remove it from this position, a bag of sand is placed under the distal fragment in the popliteal region, which creates an anterior bend in the fracture area. If the reposition of the fragments fails, then an operation is prescribed. Sometimes, after removal of skeletal traction, a hip plaster cast is applied for 2-3 months. X-ray control is carried out one month after reposition.

Physical therapy and massage are provided. After 2,5-3 months, the patient begins to walk with crutches.

Surgical treatment of diaphyseal femoral fractures consists in open reposition of fragments and their fixation with a metal rod. Low fractures of the diaphysis of the femur due to the difficulty of repositioning fragments are treated with an operative method.

12. Injuries in the area of ​​the knee joint

Injuries to the knee joint include:

1) intra-articular fractures of the condyles of the femur and tibia;

2) fractures of the patella;

3) sprains and ruptures of the ligamentous apparatus;

4) rupture of the meniscus, dislocation of the patella and lower leg.

Fractures of the condyles of the femur are isolated fractures of one condyle, more often the lateral, or T- and U-shaped.

Fractures of the femoral condyles

The clinic is characterized by pain and swelling of the knee joint due to intra-articular hemorrhage. The balloting of the patella is determined. When the external condyle is displaced upward, genu valgum occurs, and when the internal condyle is displaced upward, genu varum is formed. Crepitation of fragments is noted.

On radiographs, the type of fracture and displacement of fragments are determined.

Treatment depends on the degree of displacement of fragments. In case of fractures without displacement of fragments, after preliminary anesthesia and evacuation of blood from the joint, a plaster cast is applied or skeletal traction is performed for the supramallear region in a straightened position at the knee. Movements in the knee joint begin in 2-3 weeks. Traction lasts up to 6-8 weeks.

Displaced femoral condylar fractures after failed manual reduction are treated with skeletal traction or surgery. Fragments are fixed with metal screws.

Patella fractures

Patellar fractures most often occur when you fall on a bent knee. Transverse fractures predominate, but there may also be vertical or comminuted fractures with or without divergence of fragments. The divergence of fragments indicates a rupture of the lateral ligaments of the patella. Patellar fractures are intra-articular and are accompanied by hemarthrosis.

The clinic is characterized by pain, restriction of movement. The leg is extended. The contours of the joint are smoothed. X-ray confirms the diagnosis.

Treatment of patella fractures without dehiscence of fragments is reduced to the evacuation of blood from the joint and the imposition of a plaster splint in the position of slight flexion (3-5 °) for 3-4 weeks. On the 2nd day, movements begin in the free joints, and after a week the patient is allowed to walk. In cases where fragments of the patella have diverged by more than 2-3 mm, surgical treatment is performed, which consists in stitching the patella and restoring the ligamentous apparatus. With a comminuted fracture in the elderly, the patella is completely removed.

Patella fractures

Fractures of the condyles of the tibia occur when falling on straightened legs. The lateral condyle is more commonly injured.

Often there are T- and U-shaped fractures of the upper end of the tibia with displacement and without displacement of fragments.

Clinical symptoms: swelling associated with the formation of hematoma and hemarthrosis, lateral mobility of the lower leg, balloting of the patella, pain during axial loading and crepitation of fragments.

Treatment begins with anesthesia and evacuation of blood from the joint, then a plaster cast is applied in the hypercorrection position for 6-8 weeks.

Injuries to the menisci of the knee

Injuries to the menisci of the knee joint often occur in athletes with indirect injury - with a sharp flexion and extension in the knee joint or during rotation of the thigh, when the lower leg and foot are fixed.

Due to the anatomical and physiological features of the knee joint, the medial meniscus is damaged many times more often than the lateral one. There are longitudinal or transchondral median ruptures of the meniscus - like a "watering can handle", transverse anterior and posterior ruptures, as well as detachments from the articular bag. Often, a rupture of the medial meniscus is combined with a rupture of the internal lateral and anterior cruciate ligaments.

Clinical symptoms: "blockade" symptom, "ladder" symptom, atrophy of the thigh muscles and prominence of the sartorius muscle, anesthesia or skin hyperesthesia in the area of ​​the inner surface of the knee joint, increased pain under finger pressure in the meniscus during leg extension, "palm" symptom and periodic effusion in the knee joint, etc.

When menisci are torn during passive movements, Volkovich's symptom can be determined - a one-time, click-like crunch, accompanied by sharp pain and transmitted to the doctor's palm applied to the anterior surface of the joint.

The listed symptoms are not always expressed, therefore, pneumoarthrography is used to visualize the meniscus - the introduction of air into the joint cavity, followed by an X-ray examination.

In connection with the widespread introduction of arthroscopic techniques into clinical practice, pneumoarthrography is losing its significance.

Treatment. In cases where swelling of the joint and symptoms of meniscus damage are not clearly expressed, traumatic synovitis is treated.

After the blood is evacuated from the joint, 20 ml of a 2% solution of novocaine and 0,5 ml of an adrenaline solution, and sometimes 25 mg of hydrocortisone, are injected into its cavity, a back gypsum splint is applied for 1-2 weeks.

Then exercise therapy, massage, physiotherapy procedures are carried out. If the blockade of the joint is repeated, an operation is prescribed.

Reduction technique for blockade of the knee joint with a damaged meniscus. After general or local anesthesia with a bent tibia, traction, abduction and external and internal rotation of the tibia are performed - with an infringement of the medial meniscus and traction, adduction and external rotation - with an infringement of the lateral meniscus.

3-4 weeks after the reduction or after an unsuccessful reduction, the operation to remove the meniscus is performed.

13. Fractures of the bones of the lower leg

Diaphyseal fractures of the leg bones

Diaphyseal fractures of the bones of the lower leg are divided into fractures in the upper, middle and lower thirds. Fractures in the upper third often occur with direct trauma (blows), in the lower third - with indirect (flexion, torsion). Often, a fracture of the tibia in the lower third is accompanied by a fracture of the fibula in the upper third.

The clinic of fractures of the bones of the lower leg: deformity, pathological mobility, crepitus of fragments, local pain and axial load, impaired sound conduction. Radiography in two projections clarifies the diagnosis and displacement of fragments.

Treatment. 20 ml of a 2% solution of novocaine is injected into the hematoma. If the fracture is not accompanied by displacement of fragments, a plaster bandage is applied or skeletal traction is performed for the calcaneus or for the distal metaphysis in the supramalleolar region with a load of up to 6-8 kg for 3-4 weeks, followed by reposition of the displaced fragments on the Beler splint in the ward.

After the control radiography, the skeletal traction is replaced with a plaster cast. For low fractures, a plaster cast is applied to the middle of the thigh, for fractures in the upper third - to the gluteal fold.

When the fragments are not repositioned, a transverse skeletal traction is added to the skeletal traction along the axis of the damaged limb segment using pins with thrust pads.

With easily displaced fractures of the bones of the lower leg, with interposition of soft tissues or a bone fragment, with double fractures, with ununited fractures and false joints, an open (surgical) reduction of fragments is performed, followed by osteosynthesis with various metal structures.

Currently, in the treatment of fractures of long tubular bones, Ilizarov compression-distraction devices are gaining popularity. After osteosynthesis, the timing of immobilization with a plaster cast remains the same.

Ankle fractures

Ankle fractures account for about half of all tibia fractures. The mechanism of injury is often indirect - when the foot is twisted outward or inward. According to the mechanism of injury, pronation-abduction and supination-adduction fractures are distinguished.

Pronation-abduction fractures occur during pronation and abduction of the foot. The deltoid ligament is torn or the medial malleolus is torn and the foot is displaced outward. In this case, the outer ankle is broken obliquely slightly above the ankle joint, the tibiofibular joint is often torn and the foot is displaced outward (Dupuytren's fracture).

Supination-adduction fractures occur when the foot is displaced inwards. In this case, the outer ankle is first broken at the level of the joint space, and then the inner ankle is broken under the influence of the talus moving inwards (Malgenya fracture).

Ankle fractures can occur when the foot rotates excessively inward or outward. In this case, the foot is in a flexion position, a fracture of the posterior edge of the tibia may occur, and the talus will move posteriorly (Desto's posterior fracture-dislocation); when the foot is extended, the anterior edge of the tibia is broken off, and the talus is displaced anteriorly (Desto's anterior fracture-dislocation).

Clinic. There are local pain, joint deformity, swelling, subcutaneous hematoma, dysfunction. Ankle fractures are seen on radiographs.

Treatment. A fracture of one ankle without displacement of fragments is treated on an outpatient basis.

Before applying a plaster splint for 4 weeks, the fracture site is anesthetized with the introduction of a 2% solution of novocaine in an amount of 10-20 ml.

Treatment of ankle fractures with displacement of fragments is reduced to reposition of fragments under local or general anesthesia and immobilization of the limb with a plaster cast for 6 weeks - with a fracture of two ankles, 8 weeks - with a fracture of three ankles, 10 weeks - with fractures with subluxation of the foot.

After removing the plaster cast, the foot and lower leg are bandaged with an elastic bandage.

Physiotherapeutic and functional treatment is carried out. The wearing of supinators is prescribed.

Skeletal traction and surgical treatment of ankle fractures are used when manual reduction does not eliminate the displacement of fragments.

14. Fractures of the bones of the foot

Foot fractures account for about 29% of all closed fractures.

Talus fractures

Fractures of the talus are subdivided into a compression fracture of the body, a fracture of the neck, and a fracture of the posterior process of the talus with and without displacement of fragments.

A compression fracture of the talus occurs when falling from a height onto the feet, and a fracture of its neck occurs with excessive and forced dorsiflexion of the foot, and often there is a dislocation of its body posteriorly. Fracture of the posterior process of the talus occurs with a sharp plantar flexion of the foot.

Clinic. There is swelling on the back of the foot and in the region of the Achilles tendon, local pain and impaired function of the foot due to pain.

On radiographs, especially profile ones, the type of fracture and displacement of the fragment are determined.

Treatment. In case of fractures of the body or neck of the talus without displacement of fragments, a plaster cast is applied to the knee joint, after which, after 6-8 weeks, physiotherapy and exercise therapy are performed.

In case of fractures of the talus with displacement, a plaster cast is applied after the reduction of fragments for 2-4 months.

Fractures of the calcaneus

Fractures of the calcaneus occur when falling from a height onto the heels. These fractures are divided according to the type of fracture: transverse, longitudinal, marginal, multi-comminuted, compression. With transverse fractures, traumatic flat feet occur. X-ray control is mandatory.

Clinic. Swelling of the heel region, subcutaneous hemorrhage, local pain, dysfunction, flattened arch of the foot are noted.

Treatment. In case of fractures of the calcaneus without displacement of fragments or in case of marginal fractures, a plaster cast is applied to the knee joint with careful modeling of the arch of the foot, after 5-7 days the stirrup is plastered and walking is allowed. The cast is removed after 6-8 weeks.

In case of fractures of the upper part of the calcaneal tuber or transverse fractures with displacement of fragments under local anesthesia, they are repositioned. The foot is placed in an equinus position.

A plaster bandage is applied above the knee joint for 6-8 weeks. Then the plaster cast is shortened to the upper third of the lower leg and the stirrup is cast in for another 4 weeks.

After removing the plaster bandage, thermal procedures, massage, exercise therapy are carried out.

If the reposition fails, an open reduction is performed. In case of fractures of the calcaneus with flattening of the foot, skeletal traction is applied with traction in two directions along the axis of the leg and posteriorly.

Without removing the skeletal traction, a U-shaped, then a circular plaster cast is applied for 10-12 weeks. After removing the plaster cast, thermal procedures, massage, exercise therapy, walking in orthopedic shoes with an instep support are prescribed.

Fractures of the navicular, cuboid and sphenoid bones

Fractures of the scaphoid, cuboid, and cuneiform bones are rare.

Clinically appear local moderate pain and slight swelling.

Of great diagnostic importance is the reception of pressure along the length of the metatarsal bones - each toe is captured in turn between the thumb and forefinger of the researcher and pressure is applied in the proximal direction. A fracture causes severe pain. The site and type of fracture are determined on the x-ray.

Treatment is reduced to the imposition of a plaster boot with modeling of the arch of the foot for 4-6 weeks.

Plaster immobilization for 6 weeks is also carried out when the navicular tubercle is torn off, since without immobilization, severe traumatic flat feet develop. In case of a tubercle fracture with a displacement, an open reposition and its fixation to the bed with two silk ligatures are shown, followed by plaster immobilization during the same period.

Metatarsal fractures

Metatarsal fractures most often occur with direct trauma. There is local swelling and pain. On radiographs, the type of fracture and displacement of fragments are determined.

Treatment depends on the nature of the fracture. In case of fractures without displacement of fragments, a plaster cast is applied: for 4 weeks - with a fracture of one metatarsal bone, for 8 weeks - with multiple fractures. It is mandatory to wear arch supports throughout the year.

In case of fractures of the metatarsal bones with a significant displacement of the fragments, either skeletal traction or open reposition and fixation with pins are performed. A plaster bandage is applied for the same periods as for fractures without displacement.

Fractures of the toes

Fractures of the toes are recognized without much difficulty. Local swelling and pain, pathological mobility and crepitus of fragments are noted. The diagnosis is confirmed by radiography.

Treatment of finger fractures consists of circular application of an adhesive patch if the fracture is not displaced, or skeletal traction is applied for 2-3 weeks if there is a fracture with displacement of the fragments.

15. Spinal injuries

Vertebral fractures occur in both direct and indirect trauma and are common in patients with multiple injuries.

Particular attention is paid to transport immobilization: the victim is carefully placed face up on a shield or rigid stretcher, which avoids secondary damage to the spinal cord.

Diagnosis may require radiography, CT, MRI. A complete neurological examination is indicated to rule out spinal cord injury.

Spinal injuries are divided into fractures, fracture-dislocations, dislocations, subluxations, disc injuries and distortions. These types of injuries can be combined, such as fracture and dislocation, fracture and discitis. Most often, spinal injuries are not accompanied by damage to the spinal cord, but sometimes they are complicated by concussion, bruising, compression, or anatomical rupture of the spinal cord.

Fractures of the cervical vertebrae

Fractures of the cervical vertebrae occur most often with indirect trauma.

Often divers or wrestlers get an injury to the cervical spine.

There are four types of spinal injury mechanism: flexion, extensor, flexion-rotation and compression.

Clinic. There are local pain, forced position of the head (sometimes the victims hold their heads with their hands), tension of the neck muscles, limited and painful movements. With fractures accompanied by subluxation or dislocation of the vertebra, compression of the spinal cord occurs with the phenomena of tetraparesis or tetraplegia, while urination and the act of defecation are disturbed.

On radiographs - compression of the vertebral body or fracture of the arch.

Treatment of fractures and dislocation fractures without damage to the spinal cord is carried out in a hospital by traction using the Glisson loop or by the zygomatic arches with a load of 6-8 kg for a month.

With flexion fractures of the bodies of the cervical vertebrae, traction is carried out behind the head thrown back, with extensor fractures - behind the head in an inclined position. After reduction, which is controlled by a profile spondylogram, a plaster craniothoracic bandage or a plaster collar of Shants is applied for 2-3 months, with more severe injuries - for 4-6 months.

Injuries to the cervical spine, accompanied by neurological disorders that are not eliminated during skeletal traction and with simultaneous closed reduction, are subject to surgical treatment aimed at eliminating spinal cord compression. It should be noted that the closed reduction of a dislocated vertebra in the presence of a fracture of the arch (unstable injuries) is associated with a certain risk, since additional damage to the spinal cord during reduction cannot be excluded.

Decompressive laminectomy is performed after a previously applied skeletal traction either behind the zygomatic arches or behind the bones of the cranial vault.

The spinal cord is inspected. The operation should be completed with stabilization of the spine.

Using cortical bone grafts taken from the tibial crest, posterior fusion is performed.

Failure to stabilize the spine after a laminectomy usually results in a worsening of the victim's condition.

Immediately after an injury, it is difficult to determine the degree of damage to the spinal cord: whether it is a concussion, bruise or compression of the spinal cord, or its partial or complete rupture. However, neurological symptomatology in case of concussion, contusion or hematomyelia does not increase, but decreases, while with a complete rupture of the spinal cord, the neurological status remains unchanged, bedsores quickly form.

If urination is disturbed, a suprapubic fistula should be applied in a timely manner.

The intestines are emptied either with the help of enemas, or mechanically - manually.

In cases where the diagnosis of "spinal cord compression" is confirmed neurologically and radiologically, a decompressive laminectomy is performed.

Fractures of the bodies of the thoracic and lumbar vertebrae

Fractures of the bodies of the thoracic and lumbar vertebrae are more often compressional and have a flexion or compression mechanism of fractures.

These injuries are divided into stable and unstable, as well as uncomplicated and complicated.

When recognizing a spinal injury, it should be remembered that both the anterior and posterior sections of the spine can suffer in the event of an injury, which helps to choose the most rational method for treating various types of injuries.

Clinic. There are pains in the area of ​​damage, protrusion of the spinous process of the overlying vertebra and an increase in the interspinous gap, the severity of kyphosis, depending on the degree of wedge-shaped compression of the vertebra. There is tension in the back muscles.

Sometimes there are pains behind the sternum or in the abdomen, which can be so intense that they resemble a picture of an "acute abdomen".

On radiographs made in two or three projections, bone pathology of the spine is detected.

In the treatment of compression uncomplicated fractures of the bodies of the thoracic and lumbar vertebrae, the following methods are used:

1) one-stage reposition followed by immobilization with a plaster corset;

2) gradual (staged) reposition and application of a plaster corset;

3) functional method;

4) operational methods.

Simultaneous reposition of the wedge-shaped compressed vertebral body is performed under local anesthesia according to Schnek (5 ml of 1% novocaine solution is injected into the hematoma of the damaged vertebral body). The patient is placed on two tables in the position of hyperextension for 15-20 minutes. In this position, a plaster corset is applied for 2-3 months, which is replaced by a removable one for another 10-12 months.

Staged reposition is carried out gradually over 1-2 weeks by placing cotton-gauze or other dense rollers of various heights under the lower back - from 2-3 to 10 cm. Sometimes this method is combined with simultaneous traction for the armpits on an inclined plane. After 1-2 weeks, a plaster corset is applied.

functional method. In the process of traction on an inclined plane and under the influence of therapeutic exercises for 2-2,5 months, a "muscular corset" is created that holds the spine in a position of some hyperextension. After creating a good "muscle corset", the plaster corset is not applied. With significant compression of one or two or three vertebral bodies, a removable unloading corset is made, which is worn while walking during the year.

Surgical treatments for uncomplicated vertebral fractures include:

1) a complex functional method using a fixator-"screed" (for uncomplicated compression wedge-shaped fractures of the bodies of the lower thoracic and lumbar vertebrae);

2) anterior fusion (with closed uncomplicated fractures of the thoracic vertebral bodies with damage to the endplate);

3) operation of partial replacement of the vertebral body (in case of a compression comminuted fracture of the vertebral body).

Damage to intervertebral discs

Damage to the intervertebral discs occurs when lifting heavy weights, with a sharp flexion and rotational movement. IV and V lumbar discs are more often affected due to their anatomical and physiological features and degenerative processes developing in them by the age of 30-40.

Clinic. There is a sudden pain in the lower back (lumbago), forced position, irradiation of pain along the spinal roots, scoliosis.

The pain is aggravated by movement, sneezing, coughing and radiates to the buttocks (with damage to the IV lumbar root), to the area of ​​the outer surface of the thigh, lower leg, foot (V lumbar root).

It is very difficult to recognize disc damage and prolapse without control spondylography (pneumomyelography and discography).

Treatment. Conservative methods of treatment are used: bed rest, traction, analgesics, novocaine blockade of painful points or damaged intervertebral discs, thermal procedures, diadynamic currents, iontophoresis with novocaine sometimes help. Surgical methods of treatment of lumbosacral radiculitis are used in the absence of the effect of conservative methods.

16. Pelvic fractures

Pelvic fractures account for 5-6% of musculoskeletal fractures, the most common cause of which are road accidents. Pelvic fractures are severe injuries and occur when the pelvis is compressed in the sagittal or frontal direction during car accidents or when falling from a height.

More often, the thinnest bones of the pelvis are broken - the pubic and ischial.

With more significant injuries, the pubic or sacroiliac joints are torn. Severe blood loss and associated injuries, especially to the urinary tract and genitals, require emergency care.

Clinic. In fractures with a significant displacement, a change in the configuration of the pelvis is noted.

With double fractures of the pelvic ring, a typical “frog” position can be found. A widespread hemorrhage occurs at the site of the fracture. On palpation, the fracture line is determined in places where the bone can be palpated. Crepitus and pathological mobility of free fragments are revealed.

Damage to deeply located pelvic formations is determined by special techniques, such as:

1) detection of pain during transverse compression of the pelvis;

2) a symptom of eccentric compression of the pelvis (produced by grasping the iliac crests near the anterior superior spines with the hands). At the same time, the hands make an attempt to deploy the pelvis, pulling the front parts of the crests from the midline of the body;

3) vertical pressure in the direction from the ischial tuberosity to the iliac crest provides additional data on the localization of a deeply located fracture of the pelvic bones;

4) the study of the pelvic bones through the rectum is extremely valuable, especially in cases of fracture of the bottom of the acetabulum with a central dislocation of the hip and a transverse fracture of the sacrum and coccyx.

To determine the magnitude of the displacement of the wings of the pelvis (with vertically unstable fractures), the distances from the end of the xiphoid process of the sternum to the anterior superior iliac spines in front or from the spinous process of one of the vertebrae to the posterior superior spines are measured from the back.

To clarify the localization and nature of the injury in the pelvic area, radiography in standard projections and special techniques for more subtle diagnosis are used: computed tomography and magnetic resonance imaging.

Treatment depends on the nature of the fracture. For fractures without displacement, bed rest can be limited. In other cases, they resort to closed reposition of fragments with external osteosynthesis or open reposition with internal osteosynthesis.

Classification, clinic and treatment of pelvic fractures

All pelvic fractures are divided into four groups.

Group I. Isolated fractures of the bones of the pelvis, not involved in the formation of the pelvic ring.

1. Tears of the anterior superior and inferior iliac spines occur with direct impact and with a sharp contraction of m. sartorius m. tensor fascia lata. Fragments move down.

Clinic: local soreness and swelling, a symptom of "reversing".

Treatment: bed rest for 2-3 weeks.

2. Fractures of the wing and iliac crest occur when falling from a height or in car accidents.

Clinic: fractures are accompanied by pain and hematoma formation.

Treatment: cuff traction for the lower leg on the Beler splint for 4 weeks.

3. Fracture of one of the branches of the pubic and ischial bones.

Clinic: local soreness and swelling, symptom of "stuck heel".

Treatment: bed rest for 4-6 weeks.

4. Fracture of the sacrum below the sacroiliac joint.

Clinic: local pain and subcutaneous hematoma.

Treatment: bed rest up to 6 weeks.

5. Fracture of the coccyx.

Clinic: local pain, aggravated by a change in position. On radiographs - displacement of the coccyx.

Treatment: fresh fractures are repositioned under local anesthesia, chronic ones are treated with presacral novocaine-alcohol blockade or surgically.

II group. Fractures of the bones of the pelvic ring without disturbing its continuity.

1. Unilateral or bilateral fracture of the same branch of the pubic or ischium.

Clinic. This fracture is characterized by local pain, aggravated by turning to the side, a positive symptom of "stuck heel".

Treatment: bed rest in the "frog" position for 3-4 weeks.

2. Fractures of the pubic branch on one side and the ischial branch on the other. With this type of fracture, the integrity of the pelvic ring is not violated, the clinic and treatment are similar to those for the previous type of fracture.

III group. Fractures of the bones of the pelvic ring with a violation of its continuity and ruptures of the joints

1) Anterior section:

a) unilateral and bilateral fractures of both branches of the pubic bone;

b) unilateral and bilateral fractures of the pubic and ischial bones (of the "butterfly" type);

c) rupture of the symphysis.

Clinic. These types of fractures of the anterior pelvic half ring are characterized by pain in the symphysis and perineum, forced position - the position of the "frog" (Volkovich's symptom) and a positive symptom of "stuck heel". Compression of the pelvis increases pain at the fracture site.

Treatment: for fractures without displacement of fragments, the patient is placed on the shield in the "frog" position for 5-6 weeks. Exercise therapy, physiotherapy are carried out.

In case of "butterfly" fractures with displacement of fragments, the described treatment is supplemented with skeletal or adhesive traction for the legs.

Bed rest period is 8-12 weeks. When the symphysis is ruptured, treatment is carried out on a hammock for 2-3 months.

2) Back department:

a) longitudinal fracture of the ilium;

b) rupture of the sacroiliac joint.

Clinic. Such fractures are rare. There is local pain on palpation.

Treatment - in a hammock on a shield for 2-3 months.

3) Combined fractures of the anterior and posterior sections:

a) unilateral and bilateral vertical fractures (fractures of the Malgen type);

b) diagonal fracture;

c) multiple fractures.

Clinic. As a rule, with such fractures, patients develop traumatic shock, local pain on palpation, and limitation of active movements of the lower extremities. With a unilateral vertical fracture, half of the pelvis is displaced upward.

With a bilateral vertical fracture, an extensive retroperitoneal hematoma occurs and often - damage to hollow organs.

Treatment: anti-shock measures are taken, including intrapelvic blockade according to L. G. Shkolnikov and V. P. Selivanov with a 0,25% solution of novocaine in an amount of 300 ml on each side, skeletal traction for the lower limbs in the position of flexion and abduction in within 8-10 weeks. Walking is allowed after 3 months.

IV group. Acetabular fractures.

1. Detachments of the posterior edge of the acetabulum.

2. Fractures of the bottom of the acetabulum.

Clinic. With fractures of the acetabulum without displacement of fragments, active movements in the hip joints are limited due to pain.

Treatment: permanent skeletal traction for the femoral condyles on a splint with a small load (3-4 kg).

In case of fractures of the posterior edge of the acetabulum with displacement, a posterior upper dislocation of the hip occurs. Treatment: anesthesia by intra-articular injection of 20 ml of a 2% solution of novocaine, reduction in skeletal traction or during an operation aimed at open reposition and fixation of a fragment of the acetabulum.

In case of central dislocation of the femur, fragments are repositioned and the dislocation is reduced by skeletal traction by the femoral condyles and by the greater trochanter with a load of 8-10 kg for 3 months. Walking is allowed after 3,5 months on crutches.

17. Breast fractures

Rib fractures

Rib fractures are the most common closed chest injury. On impact, in addition to "direct" fractures, "indirect" damage to the ribs can occur, and when the chest is compressed, "direct" fractures. The localization of rib fractures depends on the force stresses developing in the skeleton during trauma with blunt objects.

Double fracture of the rib often occurs with a combination of direct and indirect impacts. Damage to the pleura and lung by fragments of the ribs occurs with "direct" fractures, resulting in hemothorax, pneumothorax, subcutaneous emphysema.

Clinic. There is local pain and sharp pain in the area of ​​the rib fracture. Sometimes there is crepitation of fragments. Breathing is superficial. A deep breath causes a sharp increase in pain and a reflex "break" of breathing. Ventilatory hypoxia and hypercapnia occur.

Radiography does not always confirm damage to the ribs. It is especially difficult to recognize a rib fracture at the junction with cartilage.

Therefore, the diagnosis of rib fractures is based on clinical symptomatology.

Treatment. Novocaine blockade of the fracture site of the ribs contributes to the normalization of breathing, which leads to the elimination of hypoxia and hypercapnia, is the prevention of pneumonia, especially in the elderly.

With multiple fractures of the ribs, the intercostal nerves are blocked along the paravertebral line with a novocaine-alcohol mixture.

With multiple fractures of the ribs, accompanied by damage to other organs, a vagosympathetic novocaine blockade according to A.V. Vishnevsky is recommended.

Subcutaneous emphysema, sometimes observed with fractures of the ribs, indicates damage to the pleura and lung. Small emphysema will soon resolve. By the end of the 3-4th week, the fracture of the rib grows together.

With double fractures of several ribs, folded fractures are formed, a deeper respiratory disorder is observed, due to the pathological mobility of the entire section of the chest, leading to paradoxical breathing.

During inhalation, the chest expands, the movable fragment of its wall, as it were, remains in place and sinks into the chest cavity, thereby preventing the full expansion of the lung. Exhaust air from this lung is pumped to the other lung.

During exhalation, when the chest sinks, creating increased air pressure in the lungs, the exhaled air rushes in the direction of least resistance, i.e., towards the "leaf", thereby protruding it outward and contributes to excessive expansion of the lung in the underlying area. This, in turn, leads to the pumping of exhaust air from the opposite side of the lung. Such paradoxical breathing leads to an oscillatory displacement ("balloting") of the mediastinum, heart and aorta, bending of large vessels and bronchi.

All this against the background of the pain syndrome contributes to the occurrence of anoxemia, neuroregulatory disorders of the act of respiration and circulation, the formation of pleuropulmonary shock.

The severe condition of patients is often aggravated by the formation of hemothorax and pneumothorax. Victims are disturbed by sharp pains at the fracture site, which leads to a "ragged breath". Breathing is frequent, shallow. The situation is forced.

Treatment of double rib fractures should primarily be aimed at ensuring good lung ventilation to prevent complications associated with congestion. Novocaine-alcohol conductive blockades are carried out.

To create relative rest in the fracture area, a circular adhesive bandage is applied in the lower part of the chest during the exhalation of the patient. The sticky patch can be replaced with an elastic bandage.

A good analgesic effect is achieved by prolonged epidural anesthesia for 7-10 days. A vagosympathetic blockade according to A.V. Vishnevsky is mandatory.

To restore the "skeleton" of the chest, normalize breathing and clear the airways, it is necessary to fix the rib "valve". Rib "valves", located behind, are stabilized by the weight of the patient lying on his back.

The anterior costal "valves" are fixed with a pad or sandbag.

With large "valves", skeletal traction is carried out for broken ribs using bullet forceps or thick nylon threads, held pericosteally.

In severe chest injuries, combined with craniocerebral injuries, and after laparotomy, artificial lung ventilation under high pressure for 14-60 days is widely used.

With tension pneumothorax, artificial ventilation of the lungs with oxygen inhalation is possible only after drainage of the pleural cavity, otherwise the air injected under pressure will penetrate into the pleural cavity, there will be a sharp displacement of the mediastinum and an inflection of the vessels, which will lead to sudden death of the patient.

Fractures of the sternum

Fractures of the sternum most often occur with direct trauma. The clinical picture is characterized by pain and difficulty breathing.

When the fragments are displaced, deformation is noted.

Treatment is conservative. Anesthesia is performed with a 2% solution of novocaine.

The patient lies on a roller placed under the shoulder blades. Pulling the shoulder, produce a manual reposition of the fragments.

If manual reduction fails, skeletal traction is applied with bullet forceps. It is very rare to have to resort to surgical intervention.

Fractures of the scapula

Fractures of the scapula are rare and are divided into fractures of the acromial process, coracoid process, articular cavity, anatomical and surgical necks, spine of the scapula, body of the scapula, angles of the scapula.

Clinic. There is swelling, local pain, limitation of function, sometimes crepitus of fragments is noted. The diagnosis is specified by radiographs taken in direct, oblique and lateral projections.

Treatment. The fracture site is anesthetized with 20 ml of a 2% solution of novocaine. In case of fractures of the scapula without displacement of fragments, a fixing bandage of the Dezo type with a roller in the armpit is applied for 2 weeks.

Then the hand is suspended on a scarf and physiotherapy exercises are prescribed. Ability to work is restored in 4-5 weeks.

In case of fractures of the neck of the scapula with displacement of fragments, a closed reposition of the fragments is performed and a Dezo bandage or skeletal traction behind the olecranon is applied on the outlet splint.

18. Open injuries of the musculoskeletal system

Disruption of bone continuity, accompanied by injury to the skin of the underlying tissues near the fracture, is called an open fracture.

Open fractures are divided into primary open, when skin and bone wounds occur according to a single mechanism of injury, and secondary open, when soft tissue is injured by the sharp ends of bone fragments from the inside. To determine the severity of soft tissue injury, the classification developed by A. V. Kaplan and O. N. Markova is used.

By type of wounds: stab, bruised, crushed.

By severity: I degree of severity - the size of the wound is 1-1,5 cm; II degree of severity - the size of the wound is 2-9 cm; III degree of severity - the size of the wound is 10 cm or more.

Emergency care - the imposition of an aseptic bandage, immobilization of the injured limb and urgent transportation to the hospital for inpatient treatment. After a clinical and radiological examination of the patient, a thorough primary surgical treatment of the wound is performed urgently in the operating room of the hospital. If the victim is in shock, he is first taken out of this serious condition. In the presence of bleeding from the main vessel, the operation is performed simultaneously with anti-shock measures, mainly under general anesthesia.

Prolonged intraosseous blockades interrupt the conduction of pain impulses, eliminate vasospasm and improve the nutrition of damaged bones and surrounding soft tissues, and prevent the development of wound infection.

For the prevention of infectious (purulent) complications in open (gunshot and non-gunshot) fractures of the bones of the extremities, the following is necessary.

1. High quality of primary surgical treatment of wounds using physical methods of their treatment and full drainage, and, if necessary, constant irrigation.

Primary surgical treatment of the wound depends on the nature of the damage and the timing of its implementation. The terms of early PST are limited to 6-12 hours, since it is during this period that the transformation of microbial contamination into the microflora of the wound is completed and conditions are created for the development of the infectious process.

The imposition of primary sutures on the wound with permanent active drainage should be regarded as an exception, permissible only with confidence in the usefulness of the treatment, when treating a patient in a hospital under the constant supervision of the operating surgeon.

Thus, an open fracture is translated into a closed one and treated as a closed one, using skeletal traction or a plaster cast.

2. Targeted antibiotic therapy. The main thing in the treatment of open fractures is the prevention, timely and rational treatment of infectious complications.

There is an increased risk of developing purulent complications:

1) more than 12 hours after injury;

2) with extensive contaminated wounds and open injuries;

3) with open fractures of bones and penetrating wounds of the joints;

4) with an increased risk of anaerobic infection (extensive contaminated injuries, open fractures of the limbs, concomitant damage to the main vessels, prolonged application of a tourniquet to the limb);

5) when localizing the surgical field in places of the easiest infection;

6) in elderly patients;

7) in patients treated with hormonal drugs, immunosuppressants;

8) in patients with a history of purulent infection.

The most common method is directed rational antibiotic and antimicrobial chemotherapy. The use of rapidly diffusing antibiotics: semi-synthetic penicillins, aminoglycosides, cephalosporins. High concentration in soft tissues is provided by aminoglycosides, semi-synthetic penicillins (ampicillin, carbenicillin), erythromycin, fusidine and semi-synthetic tetracyclines (metacycline, doxycycline). Lincomycin has a tropism for bone tissue.

Penicillin remains active today against many strains of Staphylococcus aureus, Streptococcus B, pneumococci.

With the infusion of an antibiotic, drugs are injected into the artery that improve microcirculation in the pathological focus (novocaine, heparin).

With the local administration of antibiotics, it is possible to obtain their high concentrations directly in the foci of contamination.

With extensive injuries, local administration of antibacterial agents is especially indicated in the first 6-8 hours in the wound circumference in the form of anti-inflammatory blockades according to Rozhkov. Infiltrate tissues during anesthesia and after suturing.

3. Complete immobilization of the injured limb, primarily with a plaster bandage or with the help of a device in non-focal transosseous osteosynthesis and the rejection of the widespread use of primary internal osteosynthesis.

4. Normalization of homeostasis disorders.

5. The use of drugs that normalize the immunoreactivity of the victim.

Passive immunization should be carried out with a pronounced clinical picture of the inflammatory (infectious) process, when it is not possible to reduce the effects of intoxication, rapid suppuration of the wound, despite massive antibacterial and infusion therapy, active surgical tactics in the treatment of the local process. After the patient's condition improves, passive immunization is reinforced by active immunization.

Expansion of indications for internal osteosynthesis, imposition of primary sutures without taking into account the degree of damage to soft tissues and localization of the wound, the absence or insufficiency of immobilization of the limb can be the starting point that will inevitably lead to infectious complications.

19. Amputations of limbs

In traumatology, the term "amputation" refers to the operation of removing a part of a limb between the joints. If the limb is cut off at the level of the joint, this is called exarticulation, or exarticulation.

The decision on the need for truncation (removal) of one or another segment of the limb is based on the threat to the life of the patient or the danger of severe health consequences.

The absolute indications are:

1) complete or almost complete detachment of limb segments as a result of trauma or injury;

2) extensive damage to the limb with crushing of bones and crushing of tissues;

3) gangrene of the limb of various etiologies;

4) progressive purulent infection in the lesion of the limb;

5) malignant tumors of bones and soft tissues when their radical excision is impossible.

Relative indications for limb amputation are determined by the nature of the pathological process:

1) trophic ulcers that are not amenable to conservative and surgical treatment;

2) chronic osteomyelitis of bones with the threat of amyloidosis of internal organs;

3) developmental anomalies and the consequences of a limb injury that are not amenable to conservative and surgical correction.

Methods of limb amputations are as follows.

1) Circular way:

a) one-stage (guillotine), when all tissues are intersected at the same level, with a life-threatening infection;

b) two-stage, when the tissues to the fascia intersect at the same level, then, after the displacement of the intersected tissues, muscles and bone are proximally intersected;

c) three-moment (cone-circular) (Pirogov's method);

2) Patchwork method - used for amputation for diseases of the limb.

In practice, early and late amputations are distinguished.

Early amputations are performed as a matter of urgency before clinical signs of infection develop in the wound. Late amputations of extremities are performed due to severe complications of the wound process that pose a threat to life, or in case of failures in the struggle to save a seriously injured limb.

Reamputation is a planned surgical intervention, which aims to complete the surgical preparation of the stump for prosthetics. Indications for this operation are vicious stumps.

A special place is occupied by amputations with elements of plastic and reconstructive surgery. Cutting off (actual amputation) of any segment of the limb can only be a stage of restorative treatment (for example, in order to lengthen another segment of the limb).

All operations on critically ill patients should be performed quickly, with careful observance of hemostasis.

Preoperative preparation begins immediately after the implementation of urgent anti-shock measures, it consists of clamping the bleeding vessels with clamps, circular blockade above the level of the tourniquet, cutting off the bridge from the soft tissues with incomplete detachments, putting ice around the limb, removing the tourniquet and additional hemostasis with clamps.

If the tourniquet was on the crushed limb for more than 1 hour, then it is preferable to do amputation without removing the tourniquet.

Immediately before the operation, the limb is thoroughly washed with soap and water, and then, including the wound surface, with a solution of one of the surfactants (diocide, chlorhexidine, degmin).

Surgical treatment of the wound in case of detachment of segments of the extremities with a small zone of tissue crushing, with an unfavorable prognosis for surgical treatment, is performed in a reduced volume and should be postponed until the time when the victim's condition improves. For prophylactic purposes, the area of ​​damage is treated with antibiotics. The wound is closed with wipes moistened with antiseptics and surfactant solutions.

All victims with detachments and crush injuries of the limbs must be administered 3000 IU of antitetanus serum according to Often and 0,5 tetanus toxoid subcutaneously. For the prevention of anaerobic infection, 30 units of antigangrenous serum administered intramuscularly are used.

Surgical treatment of the wound of the stump with a complete detachment of the limb should be performed in a reduced volume. Damaged muscles are truncated circularly within healthy tissues.

Muscles are not sutured for the purpose of their fixation to the bone or stitching under sawdust. Cutaneous nerves are not subject to mandatory truncation, since their search in the affected tissues excessively lengthens the operation and makes it life-threatening.

Amputation of a crushed limb is performed urgently in the absence of a therapeutic effect from anti-shock measures and with the exclusion of a previously unrecognized source of blood loss.

With hip and shoulder tears, a massive area of ​​crushed muscles and tissues may remain, hypoxia and necrosis of which are aggravated by a long-term tourniquet. To eliminate the focus of intoxication, it is advisable to perform an urgent patchwork-circular amputation of the stump within healthy tissues.

Exarticulation of the forearm and lower leg is a less traumatic operation than other truncations within the long segments of the limbs.

If there is a violation of the blood supply due to thrombosis or rupture of the main vessel, attempts to save the limb should be abandoned and the issue resolved in favor of amputation.

Limb amputations are performed after blood loss is replenished and blood pressure stabilizes at least 90-100 mm Hg. Art. the simplest (patchwork-circular, circular) methods and within healthy tissues. More traumatic, savings operations that require a significant investment of time should be refrained from.

Amputation of the foot and lower third of the lower leg, lower third of the forearm and hand is not urgently performed, since intoxication when they are crushed does not pose a serious danger. Truncation within the hand, foot, and lower third of the tibia can be performed after the victim is taken out of shock.

Amputation methods

The guillotine method is the simplest and fastest. Soft tissues are cut at the same level as the bone. It is indicated only in cases where there is a need for rapid truncation of the limb (for example, with the lightning-fast development of anaerobic infection).

The method has disadvantages - a high probability of developing a secondary infection, terminal osteomyelitis; the formation of a rough massive scar at the end of the stump with the involvement of nerve endings, causing severe pain in the stump, including phantom ones.

The circular method involves dissection of the skin, subcutaneous tissue and muscles in the same plane, and the bones are somewhat more proximal.

The greatest advantages are given by the three-stage cone-circular method according to Pirogov: first, the skin and subcutaneous tissue are cut with a circular incision, then all the muscles are cut along the edge of the reduced skin to the bone.

After that, the skin and muscles are retracted proximally and the muscles are re-crossed at the base of the muscle cone with a perpendicular incision.

The bone is sawn in the same plane. The resulting soft-tissue "funnel" closes the bone sawdust. Wound healing occurs with the formation of a central scar.

Indications: truncation of the limb at the level of the shoulder or hip in cases of infectious lesions of the limb, anaerobic infection and uncertainty that further development of the infection is prevented.

Patchwork method. Patchwork-circular amputation to remove the focus of intoxication during crush injuries is performed within healthy tissues and is performed 3-5 cm above the soft tissue destruction zone.

Skin-fascial flaps are cut out with a wide base.

Muscles intersect circularly. The bone is sawn along the edge of the contracted muscles.

Plastic amputation methods

Tendoplasty operations are indicated for truncation of the upper limb in the distal shoulder or forearm, for disarticulation in the elbow or wrist joint, for vascular diseases or diabetic gangrene. The tendons of the antagonist muscles are sutured together.

Fascioplasty method of amputation, in which the bone sawdust is closed with skin-fascial flaps. Crossed muscles receive inferior distal attachment.

The method of high fasciocutaneous amputation of the lower leg was developed to preserve the knee joint during limb amputation due to vascular diseases.

When suturing the wound, even minimal skin tension is excluded.

The myoplastic method of amputation has become widespread in recent years.

The main technical aspect of stump muscle plasty consists in suturing the ends of the truncated antagonist muscles over the bone sawdust to create distal muscle attachment points.

The method of amputation of the lower leg according to Godunov and Rozhkov with the movement of the plantar skin on the neurovascular bundle. Due to the significant endurance of the plantar graft, which has a good blood supply and preserved innervation, such tibial stumps are highly functional.

bone processing. The most common method of treating a bone stump is the Petit periostoplastic method. When amputating from the removed area of ​​the bone, before sawing it, a periosteal flap is formed, which closes the sawdust of the bone, and after amputation of the lower leg, both tibia bones.

The closure of the sawdust of one bone is more often used to improve the blood supply to the distal end during amputations due to vascular pathology.

Osteoplastic method - a bone graft is formed from the removed part of the bone, which is used on the periosteal pedicle to cover sawdust of one or both bones after amputation of the lower leg.

Muscle crossing. The muscles are crossed to the bone in a plane perpendicular to the long axis of the segment, taking into account their contractility from 3 to 6 cm distal to the bone filing.

After reduction, they are located at the level of the bone sawdust, are fixed by a scar to it, providing a moderately conical shape of the stump and muscle tone.

Myoplasty does not lead to an improvement in the blood supply to the distal end of the stump, since the muscle tissue soon atrophies and degenerates into scars.

Vessel processing. All vessels are tied with catgut, the main arteries - with two catgut ligatures, muscle vessels are stitched. Arterial and venous vessels are tied up separately.

Bleeding from the bone is stopped with sterile wax, tamponade, a pedunculated muscle flap, or by carefully "driving in" a wedge-shaped bone taken from the site to be removed.

nerve processing. It is used to cut the nerves with a sharp scalpel or razor blade a few centimeters above the sawdust of the bone. The nerve trunks are carefully isolated from the surrounding tissues and, after the introduction of a 0,25% or 0,5% novocaine solution under the epineurium, they are crossed.

Excessive stretching of the nerve trunk can lead to tearing of the axial cylinders and the formation of neuromas along the nerve. Shorten the main and large cutaneous nerves.

Insufficiently shortened nerve trunks can become involved in scars or be traumatized in the socket of the prosthesis, which leads to the formation of painful neuromas, causes local or phantom pain and the need for a second operation.

20. Amputation pain

Amputation pains do not occur immediately after surgery or injury, but after a certain time, sometimes they are a continuation of postoperative ones.

The most intense pain occurs after high amputations of the shoulder and hip.

Types of amputation pain:

1) typical phantom pains (illusory);

2) actually amputation pains, localized mainly at the root of the stump and accompanied by vascular and trophic disorders in the stump. They are aggravated by bright light and loud noise, by changes in barometric pressure and by the influence of mood;

3) pain in the stump, characterized by increased widespread hyperesthesia and stubborn constancy.

Pathogenetic causes of amputation pain are traumatic or infectious inflammation of the tissues around the nerve stumps, accelerated formation of a connective tissue scar, into which sympathetic fibers that accompany blood vessels are woven and infringed in the scar.

Treatment depends on the clinical form. Treatment with novocaine blockade of the neuromas of the stump and sympathetic nodes gives a long-term antalgic effect, the absence of which is an indication for surgical treatment.

Operative treatment. Reconstructive operations are carried out on the neurovascular elements of the limb stump: scars and neuromas are excised, and the stumps of nerves and blood vessels are freed from adhesions and blocked with novocaine solution.

If the reconstructive operation does not bring the expected result, resort to sympathectomy at the appropriate level: for the upper limb - the stellate node and the first two thoracic nodes, for the lower limb - the L2 node.

Reamputation of the bone stump almost always gives a persistent antalgic effect.

phantom pains. Phantom sensations or pain are observed in almost all patients after limb amputation as a vicious perception of the lost limb in their minds.

The illusory-pain symptom complex is characterized by the feeling of an amputated limb, in which burning, aching pains persist for a long time.

Often these pains take on a pulsating, shooting character or resemble the range of pain that the patient experienced at the time of the injury.

Illusory pains are most intensely expressed on the upper limb, especially in the tips of the fingers and palms, on the lower limb - in the fingers and in the entire foot. These pain sensations do not change their localization and intensity. A relapse, or exacerbation, often occurs at night or during the day under the influence of unrest or external stimuli.

Pathogenesis. There is an assumption that the phantom symptom complex is associated with numerous deep and superficial (skin) neuromas of the stump, which are constantly irritated by the scar tissue that forms at the ends of the stump.

The duration of the phantom syndrome is influenced by the mechanisms of adaptation of the sympathetic nervous system in the amputation stump of the limb.

Clinically, there is an illusory-sensory form with pronounced pain in the stump and an illusory-painful form with the absence of amputation pains.

Treatment. Hypnotherapy and novocaine blockade of the nodes of the boundary trunk often give a favorable result.

Surgical methods of treatment include surgical interventions on the peripheral somatic nerves (resection of painful nerves, neurotomy of the nerves of the stump, reamputations, intersection of the posterior roots) and on the peripheral sympathetic nervous system (peri- and para-arterial sympathectomy, ganglionectomy and ramicotomy).

21. Extreme conditions

Traumatic shock

Traumatic (hypovolemic) shock is an acute and severe dynamic state of the body that occurs as a result of trauma and is characterized by inhibition of vital body functions.

The cause of traumatic shock is a decrease in the effective volume of circulating blood (BCV) (i.e., the ratio of BCC to the capacity of the vascular bed) and a deterioration in the pumping function of the heart.

With pelvic fractures, bleeding into the retroperitoneal space is possible (blood loss averages 1500 ml). Fractures of long tubular bones are often accompanied by occult bleeding (blood loss reaches 500-1000 ml).

The mechanism of shock development. In severe mechanical trauma, a powerful flow of pain impulses from damaged organs leads to stimulation of the nervous and endocrine systems, to the release of a large amount of catecholamines and other biologically active substances into the blood, and this, in turn, leads to spasm of arterioles, shunting of blood through arteriovenous fistulas, slowing down capillary blood flow.

This increased activity requires a more intensive blood supply, which is provided by the so-called centralization of blood circulation to the exclusion of part of the blood volume from the active circulation.

In tissues in a state of hypoxia, redox processes are disturbed towards acidosis and toxic products are formed, leading to paralysis of precapillaries and disruption of hormonal tissue metabolism, changes in the rheological properties of blood and aggregation of its formed elements.

As a result of the developed aggregation of erythrocytes, a significant part of the blood does not return to the heart and the so-called decentralization of blood circulation develops. Due to acidosis and a decrease in venous return of blood to the heart, myocardial contractility and its stroke and minute volumes fall, and blood pressure progressively decreases.

Hypovolemia becomes even more pronounced, the resistance of the pulmonary vessels sharply increases, causing an additional load on the right ventricle and a decrease in cardiac output (small output syndrome), which leads to the development of a "shock lung".

From insufficient ventilation of the lungs, circulatory and tissue hypoxia intensifies, the kidneys, adrenal cortex, and liver suffer.

A vicious circle of disorders is formed, from which the body is not able to get out on its own.

Clinic. The severity of shock depends on the traumatic agent, the reactivity of the body and the area of ​​damage. There are erectile and torpid phases. The latter, depending on the severity of the course, has four degrees - mild, moderate, severe and extremely severe.

The main indicator of the depth of shock is a safe level of blood pressure - 80/50 mm Hg. Art.

Erectile phase (excitation). Blood pressure is normal or rises to 150-180 mm Hg. Art. The pulse is normal. Characterized by motor and speech excitation with preserved consciousness. Pain reaction is sharply increased. The face is pale, the look restless. The sweat is cold but not clammy. Patients loudly complain of pain.

Such excitation lasts 10-20 minutes and then passes into the phase of inhibition. The transition of the erectile phase to the torpid one takes place in a short time.

Torpid phase (oppression).

I degree (light). The condition of the victim is satisfactory or moderate. BP - 100/80 mm Hg. Art., the pulse is soft, rhythmic, 80-100, breathing is speeded up to 20 per minute. The face is pale, mask-like. There is a discrepancy between the behavior of the patient and the severity of the injury. Consciousness is preserved.

II degree (moderate). Moderate condition. Maximum blood pressure - 85-80 mm Hg. Art., minimum - 60-50 mm Hg. Art., pulse - 120-130, rhythmic, soft. Breathing is rapid, shallow.

The skin is pale and cold to the touch, clammy sweat. Pupils sluggishly react to light. Consciousness is preserved, but there is some lethargy.

III degree (severe). Severe condition. Blood pressure drops to 70/50 mm Hg. Art. and lower, and sometimes not caught at all. Pulse - 140-150, thready. The pupils are dilated, sluggishly react to light.

Sharp pallor, deep lethargy. Breathing is frequent, shallow. Hypothermia.

IV degree (extremely severe), or a terminal condition, which in its course has 3 stages.

1. Predagonal state - blood pressure is not determined. The pulse is felt only on the carotid or femoral arteries. Breathing is shallow, uneven, with pauses. Consciousness is darkened or absent altogether, the skin is pale gray, cold, covered with cold sticky sweat. The pupils are dilated, weakly or completely unresponsive to light.

2. The agonal state has the same symptoms, but is combined with more pronounced respiratory disorders of the Cheyne-Stokes type. acrocyanosis and cyanosis. Reflexes disappear.

3. Clinical death. Active functions of the central nervous system and clinical signs of life are completely absent, however, metabolic processes in the brain tissue continue for an average of 5-6 minutes.

Prevention of traumatic shock is associated with the correct organization of ambulance at the scene, during transportation and in the hospital.

The main principle of first medical aid is to perform urgent measures in the shortest possible time, an average of 20 minutes: eliminate pain and negative reflex reactions, ensure gentle immobilization and transportation. For this purpose, analgesics, neuroleptics, novocaine blockades are used.

It is necessary to identify the causes of the most dangerous functional disorders - acute respiratory and circulatory disorders - and eliminate them immediately.

In case of severe respiratory disorders, it is necessary to carry out a toilet of the oral and nasopharyngeal cavities, eliminate the retraction of the root of the tongue, insert and fix the air duct, and restore the patency of the upper respiratory tract.

With an open pneumothorax, an occlusive bandage should be applied, external bleeding should be stopped without delay by applying a tourniquet or a pressure bandage, and an aseptic bandage should be applied to the wound. Open damage must be protected from secondary contamination.

Qualified anti-shock measures

1. Elimination of the pain factor. For closed or open fractures of tubular bones of the extremities without massive crushing of soft tissues at the prehospital stage, local anesthesia and conduction anesthesia with 0,25% or 0,5% novocaine solution are sufficient, followed by immobilization of the limb.

Novocaine blockades of fractures and crushed tissues perfectly interrupt pain impulses. To do this, use a 0,25% solution of novocaine. More concentrated solutions of novocaine are used in doses - for an adult no more than 40 ml of a 2% solution.

In case of bone fractures, damage to the main vessels and large nerves, before immobilization with transport tires, intramuscular or intravenous slow injections of narcotic and non-narcotic analgesics (fentanyl, 1-2 ml of a 1-2% solution of promedol, analgin) are performed.

The side effects of narcotic analgesics can be reduced by using them at doses 2-3 times less than those indicated, but in combination with sedatives and antihistamines (5-10 mg of seduxen or relanium, 10-20 mg of diphenhydramine, 10-20 mg of suprastin, 25- 50 mg of pipolfen; the indicated doses correspond to 1-2 ml of standard ampouled solutions of each of the indicated substances), as well as sodium oxybutyrate (10 ml of a 20% solution).

2. Normalization of the processes of excitation and inhibition in the central nervous system. The victim must be kept calm. Care must be taken when transferring to a stretcher or from a stretcher to a table. The injured limb is covered with ice packs.

Antipsychotics should be used with particular caution (droperidol at an initial dose of 2,5-5 mg in combination with analgesics).

They are shown only with a sharp excitation and stable blood pressure and with undisturbed breathing.

3. Compensation of the volume of circulating blood. To increase venous return, the patient is given the Trendelenburg position (angle 20-30°).

In case of massive blood loss, in order to replenish the BCC during infusion therapy, native or dry plasma, albumin, plasma substitutes - polyglucin, reopoliglyukin, hemodez, as well as lactasol, crystalloid solutions and glucose solutions are used.

When blood pressure is below the critical level of 80/50 mm Hg. Art. it is necessary to immediately start intra-arterial blood transfusion to raise blood pressure to a safe level, and then switch to intravenous blood transfusion or blood substitutes and crystalloid solutions.

In hypovolemic shock, it is better to start infusion therapy with crystalloid solutions. They reduce blood viscosity, eliminate electrolyte imbalance. Blood substitutes are stored in the bloodstream for a long time and thus keep blood pressure from falling.

Albumin and plasma protein fraction effectively increase the volume of intravascular fluid, but increase fluid leakage into the interstitial tissue of the lungs, which can cause respiratory distress syndrome. Therefore, albumin and plasma protein fraction are commonly referred to as reserve preparations.

4. Treatment of severe acidosis. Oxygen inhalation, mechanical ventilation and infusion therapy restore physiological compensatory mechanisms and, in most cases, eliminate acidosis.

In severe metabolic acidosis (pH below 7,25), a 2% sodium bicarbonate solution is administered intravenously in an amount of about 200 ml.

Monitoring is necessary to evaluate the effectiveness and determine further treatment tactics. The main attention is paid to the restoration of organ perfusion.

Insufficient perfusion may be due to a violation of the pumping function of the heart, hypovolemia and changes in vascular resistance.

The level of consciousness reflects the severity of hypoxia, the state of circulation and the degree of injury.

Diuresis, osmolarity and composition of urine allow you to assess the water balance and kidney function, to identify damage to the urinary tract. Oliguria means insufficient compensation of the BCC. Diuresis is the best indicator of tissue perfusion. Diuresis should be maintained at 30-50 ml/h.

Diuretics are not prescribed until the BCC is fully restored.

The only indication for the appointment of diuretics is persistent oliguria against the background of an increase in CVP and normal values ​​of blood pressure and heart rate.

The frequency, rhythm and strength of heart contractions allow you to evaluate the function of the cardiovascular system and the effectiveness of infusion therapy. An ECG can detect arrhythmias and repolarization.

To normalize cardiac activity, it is enough to restore the BCC.

Measurement of CVP reveals hypovolemia and reflects the function of the heart, allows you to evaluate the effectiveness of infusion therapy.

Measurement of CVP is not mandatory, but it is indicated in patients with concomitant cardiovascular and pulmonary diseases, as well as during mechanical ventilation, massive blood transfusion and infusion therapy.

Prolonged Crush Syndrome (SDR)

Under the SDR understand the general reaction of the body that occurred in response to pain, prolonged ischemia or degenerative changes that occur in the tissues during prolonged crushing of the limbs or their segments with large weights (building debris, soil, heavy equipment).

SDR develops immediately after the release of the limb and restoration of blood flow. The more extensive and prolonged the compression, the more severe are the local and general symptoms.

Pathogenesis. The pathogenesis is based on severe microcirculation disorders, plasma loss, toxemia, and metabolic disorders.

Three factors act on the body: ischemia, venous stasis, and pain irritation due to trauma to the nerve trunks, which causes a complex set of neurohumoral and neuroendocrine disorders.

The destruction of the striated muscles contributes to the development of traumatic toxemia. It is necessary to add concomitant plasma and blood loss associated with edema and blood loss in the area of ​​crushed tissues.

Initial changes in the body are similar to severe traumatic shock, later - toxemia and acute renal failure (ARF).

Clinic. There are periods of SDR:

I - period of compression before release;

II - the period after the release of the limb from compression:

1) early - the period of acute renal failure (from 3-4th day to 8-12th day);

2) intermediate period (period of imaginary well-being);

3) late period - manifestations of local changes, lasting 1-2 months.

During the period of compression until release, the victims complain of pain in the compressed areas of the body, thirst (in 40%), shortness of breath, and a feeling of fullness in the limb. Confusion or loss of consciousness, cases of mental depression (lethargy, apathy, drowsiness) are noted.

After release from compression, there are complaints of sharp pains in the injured limb, swelling, purple-bluish coloration of the skin and limitation of movements in the injured limb, general weakness, dizziness, nausea, and vomiting. These complaints are typical for both early and intermediate periods of SDR development.

Objective signs of SDR begin to appear 4-6 hours after release from compression. During this time, the condition may be satisfactory, pulse and blood pressure - within normal limits.

The extremity is cold, pale, the pulse on the peripheral vessels is barely palpable, the fingers are cyanotic.

The early period (the first 2-3 hours) is characterized by hemodynamic disorder and local changes. The edema of the limb distal to the compression develops rapidly, reaching its maximum in 4-24 hours.

At the same time, the general condition worsens: there is a short-term excitation resembling the erectile phase of traumatic shock, but after a few hours there is a sharp lethargy, the victim is apathetic, drowsy.

Pallor, cold sweat, rapid pulse, decreased blood pressure and diuresis appear - the amount of urine decreases sharply (up to 300 ml per day). Urine becomes varnish red, then dark brown.

Local changes: hemorrhages, abrasions, blisters filled with serous fluid appear on the skin in the compression zone. Movements in the joints are limited due to pain caused by damage to the muscles and nerve trunks.

The tissues acquire a woody density due to muscle edema and a sharp tension in the fascio-muscular sheaths. Sensitivity in the area of ​​damage and in the distal extremities is reduced.

The pulsation of the vessels of the affected limb weakens as the edema increases.

The intermediate period (3-6th day), or the period of imaginary well-being, is characterized by a relative improvement in the patient's well-being.

Against the background of deepening acute renal failure, intermediate metabolic products and water are retained in the body.

Growing toxemia due to ischemic muscle necrosis and plasma loss, oliguria and azotemia, lowering blood pressure.

All this can lead to death from uremia. The edema of the extremity becomes so pronounced that the soft tissues become hard, blisters with hemorrhagic contents form on the skin.

The late period of SDR begins on the 10-14th day of illness and is characterized by the predominance of local manifestations in the compressed limb over the general ones.

The edema on the affected parts of the body decreases and foci of necrosis of the limb are revealed. There are phlegmons, ulcers, sometimes bleeding.

If compression is accompanied by bone fracture, osteomyelitis and sepsis may occur. Quite often sites of a necrosis of an extremity are sequestered and rejected.

There is a high risk of infection in wounds and sepsis. Healing occurs by granulation and extensive scarring.

Complete recovery of the function of crushed muscles does not occur.

Kidney functions are gradually restored, while polyuria is observed (up to 5 l / day), the water and electrolyte balance of the blood is normalized. Hyperproteinuria persists, the specific gravity of urine remains at the level of 1007-1001.

Disaster Medical Assistance

During the period of isolation (being in the rubble), assistance is provided in the form of self- or mutual assistance:

1) the release of the respiratory tract from dust and foreign bodies;

2) release of the squeezed parts of the body.

At the prehospital stage, medical care should be as close as possible to the lesion. Right in the rubble, even before liberation, it is possible to carry out infusion therapy, supply oxygen and alkaline solutions. In medical institutions advanced to the lesion, first medical aid is provided with elements qualified for health reasons.

1. Antishock therapy: infusions of polyglucin, rheopolyglucin, hemodez, native or dry plasma, albumin, glucose solution, physiological saline (with the volume of infusion therapy - 4-6 l / day); correction of acid-base balance (sodium bicarbonate, lactasol; anesthesia: administration of analgesics, drugs); novocaine blockade of the cross section of the damaged limb above the level of compression; administration of cardiovascular agents. Criteria for recovery from shock: stable blood pressure and pulse for 2-3 hours, hourly diuresis - 50 ml/h.

Evacuation from the lesion to specialized medical institutions should be carried out after being taken out of shock by special transport (preferably by helicopter) accompanied by a medical worker.

2. The fight against acute renal failure: pararenal novocaine blockade up to 100-120 ml of 0,25% warm solution of novocaine on each side; bladder catheterization, diuresis control; lasix in fractional doses of 200-300 mg up to 2 g / s with the restoration of diuresis.

3. Restoration of microcirculation and prevention of DIC: heparin 5000 IU every 6 hours; kontrykal, gordoks 100 IU 000 times a day.

4. Fight infection and immunosuppression:

1) the introduction of tetanus toxoid;

2) the introduction of antibiotics: aminoglycosides; cephalosporin (except ceporin).

Antibiotics can be replaced with penicillin, tetracycline or chloramphenicol; metronidazole or metrogil; thymalin, thymogen.

5. Operations for vital indications. To preserve the viability of the injured limb, local hypothermia, elastic bandaging, and immobilization are used.

Carrying out stripe skin incisions to compress the soft tissues of the limb is a big mistake that leads to the development of local infectious complications.

The most widely used is subcutaneous fasciotomy, which is advisable in the first 12 hours from the moment the victim enters the hospital.

Indications for fasciotomy:

1) pronounced progressive edema of the limb;

2) violation of tactile and pain sensitivity;

3) lack of active movements in the limb;

4) the inefficiency of the ongoing detoxification.

It consists in a longitudinal dissection of the skin and fascia on one or both sides of the damaged limb segment along its entire length.

Indications for limb amputation - irreversible ischemia according to V. A. Kornilov.

Comprehensive treatment of SDR in specialized hospitals includes extracorporeal detoxification methods: hemosorption, lymphosorption, plasmapheresis, hemofiltration, long-term arterial-venous filtration, hemodialysis.

The most pronounced effect gives a combination of 2-3 of these methods.

In the late period of SDR, treatment should be aimed at the fastest restoration of the function of the injured limb (exercise therapy, massage, physiotherapy), combating infectious complications, preventing contractures and secondary anemia.

LECTURE No. 3. Fibrous osteodystrophy

Fibrous osteodystrophies include a group of diseases grouped according to morphological changes. They are characterized by the replacement of bone tissue with fibrous connective fibrous tissue. They are based on peculiar degenerative-dystrophic and sequential regenerative processes in the bones without primary inflammatory and blastomatous changes.

The bone tissue undergoes a complete reconstruction, the normal bone at the site of the lesion is completely rebuilt. It is destroyed mainly by lacunar resorption and then recreated due to metaplastic and osteoblastic neoplasm of the bone substance.

Adipose and bone marrow tissues disappear and are replaced by fibrous fibrous connective tissue.

In addition, cysts form in the bones due to edema and liquefaction of the overgrown connective tissue, hemorrhage, giant cells develop, tumor-like growths, zones of bone substance restructuring, pathological fractures, disfigurements and deformations of bones appear.

Some fibrous osteodystrophies are characterized by frequent malignancy.

There are localized and widespread forms of fibrous osteodystrophies.

1. Localized forms of fibrous osteodystrophy

An isolated (localized) bone cyst is characterized by the formation of a single bone cyst in a long tubular bone.

It is a disease of childhood and predominantly adolescence. It occurs exclusively in the metaphyseal section of a long tubular bone, does not go beyond the epiphyseal cartilaginous line, leaving the nearby joint intact. Both (especially the proximal) metaphyses of the femur and the proximal metaphyses of the tibia and humerus are most often affected.

Clinic. The general condition of the patient does not suffer. The picture of peripheral blood and mineral metabolism do not change.

Without a visible external cause, a painless uniform thickening of the end of the bone appears in only one place in the skeleton. Possible progressive deformity of the bone. The bone is not shortened, there is no atrophy. The skin over the thickened bone is not changed.

The patient's attention is riveted to his suffering only after a pathological fracture occurs as a result of an inadequate injury and even from an awkward movement.

An x-ray examination determines the focus of enlightenment, located in the center of the bone, having a large-mesh pattern and a regular geometric shape (ovoid, fusiform, pear-shaped, etc.). The contours of the cyst are completely smooth and sharply defined.

Uniform thinning of the cortical layer of the bone is characteristic, sometimes up to 1 mm or even less, but without destruction, which confirms the expansive growth of the cyst. There is no periosteal reaction.

Operative treatment. Excochleation or resection of the affected area of ​​the bone is performed, followed by replacement of the defect with bone auto- or allografts, or a combination thereof. Extrafocal transosseous osteosynthesis is used to restore the length of the affected limb segment after resection of a cystically altered bone area.

2. Common forms of fibrous osteodystrophy

Hyperparathyroid osteodystrophy

Hyperparathyroid osteodystrophy (Recklinghausen's disease) is characterized by systemic osteoporosis and multiple bone lesions with cystic formations.

It is also called generalized cystic cystic osteodystrophy.

Generalized fibrous osteodystrophy is not a disease, but only a syndrome of a very complex disease - hyperparathyroidism, which is based on an increased functional activity of the parathyroid glands, causing a violation of phosphorus-calcium metabolism with secondary bone restructuring and increased release of calcium and phosphorus. There is always an increase in the parathyroid glands.

In most cases, this is a benign adenoma of one of the parathyroid glands. Very rarely, diffuse hyperplasia of all bodies is determined.

Pathophysiologically and biochemically, increased secretion of parathyroid hormone causes an increase in serum calcium levels and, due to a low renal threshold, a decrease in phosphorus content.

An increased amount of calcium and phosphorus is excreted from the body by the kidneys and, to a lesser extent, through the epithelium of the colon mucosa. Hypercalciuria and hyperphosphaturia are noted.

In 1/3 of cases of hyperparathyroidism, nephrolithiasis develops. Renal phenomena express the intensity of the underlying disease, and pathological bone changes - the duration of hyperparathyroidism.

The morphological basis of generalized fibrous osteodystrophy is lacunar resorption of bone tissue with the ongoing process of bone formation, which leads to general osteoporosis.

Histological changes - the transformation of the bone marrow into fibrous tissue with the destruction of bone tissue, hemorrhages, cysts, "brown tumors", etc.

Clinic. The disease develops between the ages of 30 and 40, more often in women.

In the early stage of the disease, general muscle weakness, a feeling of fatigue appear, loss of appetite, nausea, and sometimes vomiting are common. A constant symptom is thirst and associated polyuria. Sometimes the symptoms of nephrolithiasis come to the fore. Often, patients complain of abdominal pain, various dysfunctions of the large intestine (constipation, diarrhea).

Characteristic changes in the bones. Hypersensitivity or deaf pains in bones, sometimes in joints are noted. Pain is localized mainly in the diaphysis of long bones, pelvic bones, spine. Thickening and deformation of the bones appear, leading to shortening of the limb and lameness. The first manifestation of Recklinghausen's disease may be pathological fractures.

The appearance of tuberous tumors in the skull, located asymmetrically, is characteristic. Sometimes the disease begins with the epiphysis of the lower or upper jaw.

Gradually progressive deterioration of the condition, multiple pathological fractures chain the patient to bed, and he becomes disabled. Secondary anemia and malnutrition develop.

Diagnosis is based on a combination of clinical, biochemical and radiological data. During the examination, the enlarged parathyroid gland cannot be palpated. Thickening of different parts of long bones, their curvature, deformation and shortening of limb segments after pathological fractures are determined.

Repeated control weighing of patients shows a noticeable drop in weight, and this drop in weight is not reflected in the appearance of patients.

In laboratory studies, anemia is determined. The content of calcium in the blood serum is usually 2 times higher than normal, and phosphorus is lowered, the amount of alkaline phosphatase is increased, the calcium content in the daily amount of urine increases up to 300 mg (the norm is up to 200 mg).

The early stages of the disease are manifested by systemic osteoporosis. The X-ray sign is a peculiar picture of the cortical layer of the nail phalanges and a characteristic loopy lacy pattern of the spongy substance.

The affected long tubular bones are uniformly cylindrically thickened. Joints do not undergo changes. Cysts are very diverse - they can be single, multiple and randomly scattered in different parts of the skeleton.

A characteristic and important sign of Recklinghausen's disease is longitudinal stratification and then a significant thinning of the cortical layer, which is explained by the expansive growth of centrally located cysts and their pressure on the inner surface of the cortex.

The long bones of the lower extremities are gradually curved in an arcuate manner, metaphyseal varus deformity of the thigh appears, more often unilateral or asymmetric. The bone takes on the resemblance to a shepherd's crook.

Changes in the spine lead to the development of "fish vertebrae", discs are not involved in the process, and the spinal curves are significantly increased. The pelvis is deformed in the form of a card heart.

Treatment is surgical and consists in removing the parathyroid adenoma.

With the timely removal of the adenoma, the bone tissue structure is restored within a few years.

The prognosis is always unfavorable if the disease is not recognized and the patient is left without treatment. The disease progresses steadily and ends in death. Deep irreversible renal changes complicated by hypertension and uremia pose a great danger. There is no self-healing.

Deforming osteodystrophy

Deforming osteodystrophy (Paget's disease) is a disease of the skeleton of a dysplastic nature with pathological restructuring and development of deformity.

The etiology of the disease has been little studied to date. The frequency of the disease is 0,1-3%, men over the age of 40-50 are more likely to get sick.

The disease is based on a typical restructuring of bone tissue. In the affected bones, the previous and newly formed bone tissue is determined. The bone marrow is replaced by poorly differentiated connective tissue. The formation of cysts, hemorrhages and "brown tumors" is observed as a rare exception.

There are monoossal and polyossal forms. Both long bones and flat ones are affected. Most often, the tibia and femur bones change, followed by the pelvic bones, lower lumbar and sacral vertebrae. Further in the frequency of the disease is the skull, humerus, less often - the bones of the forearm. In typical cases, all of the listed bones can be involved in the process, and symmetrically.

Clinic. For many years or decades, deformation of the skeleton occurs. Patients are often worried not so much about pain in the bones of the limbs, but about the cosmetic side. Most often, the shins are deformed, and an arcuate curvature occurs in the lateral direction. With the defeat of the femur between the knees, a gap of several tens of centimeters is formed, both lower limbs take the form of the letter "O".

The curvature of the legs does not go below the ankles. The curved bone is located eccentrically in relation to the soft tissues.

The rapid growth in the volume of the bones of the skull leads to the fact that the huge brain skull hangs over the normal facial one, the head hangs down with its chin on the sternum, the patients look askance. In severe cases, due to joining kyphosis or kyphoscoliosis, deep transverse horizontal folds form on the skin of the abdomen.

The arms seem to be very long due to the shortening of the torso and lower limbs.

The whole appearance of patients with Paget's disease resembles the appearance of anthropoid monkeys.

In x-ray examination, long tubular bones are characterized by their uniform thickening around the long axis of the bone by 1,5-3 times the diameter of a normal bone and a cylindrical character along its entire circumference.

The entire diaphysis, both epiphyses, thicken, and the articular ends are the least changed.

The main pathognomonic radiological changes concern the skull: the vault and flat bones are significantly thickened (up to 1,5-2,5 cm). Their normal differentiation into external and internal compact plates between them disappears.

The outer surface becomes rough, sometimes slightly wavy.

Shadows of the arterial sulci, cranial sutures and other normal elements of the skull picture disappear. All flat bones merge into a single whole. In severe cases, the x-ray picture of the skull resembles a curly head.

Pathological fractures are observed from 6-12% to 30% of cases and are the first sign of the disease, when there are no clinical manifestations of the disease yet.

The plane of the fracture is perpendicular to the length of the bone. The surfaces of the ends of bone fragments are even, sharply defined and do not have notches, fragments are usually absent, therefore these fractures are called banana fractures. They really exactly replicate the fracture of a peeled banana. Healing of pathological fractures proceeds quite normally or in a slightly delayed time frame.

The biggest danger in Paget's disease is the threat of malignancy.

Malignancy occurs in patients older than 50 years, and most often osteogenic sarcoma occurs, then chondrosarcoma and reticulosarcoma.

Treatment is exclusively symptomatic. Iodine preparations are prescribed as resolving therapy, salicylates, vitamins, hormones (corticosteroids, androgens), calcitonin. With persistent pain syndrome, novocaine blockades are performed. With malignancy, amputation or exarticulation of the limb is indicated.

Patients with Paget's disease need constant oncological monitoring.

3. Fibrous bone dysplasia

Fibrous bone dysplasia in terms of the general picture, symptomatology, course, treatment, prognosis, morphological picture, biochemical data, and especially radiological manifestations differs significantly from all other representatives of the group of fibrous osteodystrophies, and therefore it is separated into an independent nosological unit.

Fibrous bone dysplasia is a disease of older children.

It starts imperceptibly, progresses very slowly and stops its active development after the onset of puberty. Women get sick more often.

There are monoossal and polyossal forms. In the polyostotic form, the bones of one limb (more often the lower one) are affected, less often the upper and lower limbs of one side of the body.

Clinic. At the beginning of the disease, patients do not experience pain.

In the future, the bones thicken and deform, subject to curvature. The femur, deforming, takes the form of a shepherd's crook. Often the disease is detected only after a pathological fracture.

It is very important that with bone dysplasia, urine and blood are always normal, there are no biochemical changes in the blood serum.

The level of calcium and phosphorus, in contrast to hyperparathyroidism, remains normal.

X-ray picture. Most often, fibrous dysplasia of the femur, tibia, humerus and radius is observed, a high percentage of damage also occurs in the ribs.

In long tubular bones, the focus always develops in the metaphysis and slowly moves to the middle of the diaphysis, while the epiphysis is never initially affected and even in advanced cases remains intact.

On radiographs, a limited area of ​​bone tissue enlightenment of an irregular round or oval shape of various sizes is determined.

A bone defect (or a series of defects) is located eccentrically or centrally in the cortical substance under the periosteum. There is no osteoporosis or atrophy.

Cystic enlightenments lead from the inside to a limited local swelling of the cortical layer of bones, push it apart and sharply thin.

The inner surface of the crust is rough, and the outer one is smooth.

It does not break anywhere and does not disappear completely. The periosteum is not involved in the pathological process.

Pathological fractures are often observed, which heal well, although not in such a perfect form as with an isolated bone cyst.

Some patients may experience a type of fibrous dysplasia - Albright's disease, which is characterized by a triad of symptoms expressed in endocrine disorders, skin and bone manifestations.

Precocious puberty sets in, landkart-like areas of brown skin pigmentation appear on the abdomen, back, sides, buttocks, upper thighs and perineum. Bone manifestations usually have a multi-bone unilateral character. Multiple pathological fractures are characteristic. The growth of bones in length may stop.

Malignancy of fibrous dysplasia is observed in 0,4-0,5% of patients.

Signs of malignancy are increased pain and a rapid increase in the size of the tumor, X-ray revealed an increase in lytic destruction and a breakthrough in the cortical layer of the bone.

Treatment. With limited forms of fibrous dysplasia, lesions are promptly removed. The resulting defect is replaced with a bone auto- or allograft. With malignancy, the limb is amputated.

Forecast. The disease has a very favorable course.

LECTURE No. 4. Degenerative-dystrophic diseases of the skeleton

1. Osteochondropathy

Osteochondropathy, or aseptic necrosis, is a chronic degenerative-necrotic disease, which is based on the vascular-dystrophic process of the subchondral epiphyses of some bones. The disease is more common in childhood and adolescence, has a chronic benign clinical course and a favorable outcome.

The etiology of osteochondropathy is unknown, but there is an opinion that the disease can develop as a result of trauma, infection, hereditary predisposition, impaired nervous trophism and metabolism.

Pathogenesis. Osteonecrosis develops as a result of local disruption of the vascular supply of bone tissue and bone marrow in the region of the epiphysis or apophysis.

The dystrophic-necrotic process that occurs with this disease is conditionally divided into five stages:

I stage of necrosis - the result of impaired circulation of any part of the epiphysis or apophysis;

Stage II secondary impression fracture occurs at the slightest load as a pathological fracture;

III stage of fragmentation develops against the background of resorption of individual sections of necrotic spongy bone;

IV stage of repair occurs due to the growth of connective tissue;

Stage V of consolidation occurs as a result of ossification with the formation of deformation of the epiphysis or with its complete recovery with proper treatment.

Osteochondropathy of the femoral head

Osteochondropathy of the femoral head (Legg-Calve-Perthes disease) is one of the most common osteochondropathy. Age - from 5 to 12 years, but cases of the disease up to 18-19 years are not uncommon. Boys and young men are affected 4-5 times more often than girls.

Clinic. The process is one-sided. There is no history of trauma. After walking in the hip joint, minor and unstable pains appear, which intensify in the future. Joint contracture, muscle atrophy, constant lameness and, in advanced cases, shortening of the affected limb by 1-2 cm occur.

X-ray manifestations are diagnosed only after 6 months, i.e., in the II stage of the disease, when there is a uniform darkening of the femoral head due to necrosis and an impression fracture. The head is flattened, the joint space expands.

After 1,5 years from the onset of the disease, individual fragments of the head are determined on radiographs, its even greater flattening, and only after 2-3 years does it acquire a normal bone structure and shape, if the correct treatment was carried out, or a mushroom shape.

In treatment, early unloading of the affected limb is of paramount importance to maintain the normal shape of the head with the use of orthopedic devices and crutches. In some cases, surgical interventions are used to improve blood circulation in the femoral head (tunnelization of the femoral neck, transplantation of a muscle flap into a previously prepared canal in the femoral neck).

Osteochondropathy of the tibial tuber

Osteochondropathy of the tibial tuber (Osgood-Schlatter disease). The lesion of the tibial tuberosity is usually unilateral.

Occurs and clinically manifests itself, as a rule, after an injury. Among patients very often there are strong young people who are actively involved in sports (football players, runners).

clinical picture. In the area of ​​the tuberosity of the tibia, spontaneous pains appear, which are aggravated by pressure on the tuberosity and by bending the knee joint. Swelling, slight swelling of the soft tissues are determined, with palpation - a hard bone outgrowth.

Radiologically, fragmentation or separation of the tuberosity from the bone is determined.

Treatment consists in limiting walking, running, physical education. Physiotherapeutic procedures are prescribed: warm local baths, massage, elastic bandage on the knee joint.

The disease ends in 1-1,5 years with a complete recovery, if physiotherapy and balneological procedures were carried out.

Osteochondropathy of the navicular bone of the foot

Osteochondropathy of the navicular bone of the foot (Kohler-I disease) is rare and occurs after an injury. Children 3-7 years old are ill, more often boys.

Clinical manifestations. On the back at the inner edge of the foot, for no apparent reason, swelling appears, moderate pain, sometimes forcing children to limp, walk on the outer arches of the foot.

Radiographs show fragmentation and flattening of the navicular bone in the sagittal direction in the form of a sickle or lentil.

The treatment consists in creating a long rest of the foot with the help of a plaster boot and carrying out physiotherapeutic procedures. Surgical treatment is contraindicated.

The total duration of the disease is about a year. The function of the foot is restored, and sometimes the anatomy of the navicular bone.

Osteochondropathy of the head of the II and III metatarsal bones

Osteochondropathy of the head of the II and III metatarsal bones (Alban Koehler-II disease) is predominantly found in young women. The cause is unknown, but prolonged walking in high heels is a predisposing factor.

Clinic. Pain in the foot gradually progresses, intensifying while walking. Changing shoes, moderate walking lead to clinical recovery, however, aseptic necrosis of the metatarsal head continues until the formation of deforming arthrosis.

On radiographs, a compacted head of the metatarsal bone is revealed, then its fragmentation, flattening and partial or complete resorption. The joint space is expanded, osteophytes grow in the form of deforming arthrosis.

The treatment is carried out conservatively: the load on the leg is reduced, physiotherapy is carried out, it is recommended to wear instep supports that unload the forefoot. Resection of the metatarsal head is indicated only to eliminate extensive bone growths in the head area.

Osteochondropathy of the semilunar bone of the wrist

Osteochondropathy of the semilunar bone of the wrist (Kinböck's disease). The disease occurs quite often in men aged 20-30 years after heavy physical manual labor and in athletes.

The clinic is manifested by prolonged non-disappearing pain in the area of ​​the wrist joint, a violation of its function, a sharp increase in pain when pressing on the back of the hand.

X-rays show thickening of the bone (necrosis), then spotted enlightenment, over time, the bone takes on a triangular shape.

Treatment. The best results are obtained by scraping necrotic masses with a sharp spoon without removing the thickened cartilaginous part of the bone. Of the conservative methods of treatment, long-term immobilization with a plaster cast, physiotherapy can be applied.

Osteochondropathy of the vertebral body

Osteochondropathy of the vertebral body (Calve's disease). The vertebrae of the lower thoracic and upper lumbar regions are predominantly affected, that is, the vertebrae that carry the greatest load.

Occurs more often after injury. Cause - embolic infarction a. nutricia.

Clinic. After a fall or bruise, pain appears in the area of ​​the affected vertebra, which increases during exercise and disappears at rest.

Examination of the back reveals muscle tension and protrusion of the spinous process of the affected vertebra due to wedge-shaped compression of its body.

On radiographs, there is a uniform flattening of the body, usually of one vertebra, sometimes with a small anterior wedge. Adjacent intervertebral discs are enlarged. In the words of Calve, "there is too little bone, and too much cartilage."

Treatment. Complete unloading of the spine is required with the help of bed rest and reclination (for the entire period of vertebral regeneration).

Drug therapy, vitamin therapy, irradiation with ultraviolet rays, special methods of physical therapy are used.

The prognosis of the disease is favorable. A complete restoration of the shape of the vertebra usually does not occur - the deformity in the form of a "fish vertebra" is preserved.

Osteochondropathy of the vertebral apophyses

Osteochondropathy of the vertebral apophyses (juvenile kyphosis, osteochondropathy kyphosis), or Scheuermann-Mau disease, is quite common.

Young men are more often affected. Sometimes the disease is determined only when examining conscripts. Family forms of spinal osteochondropathy are described. As a rule, the middle and lower thoracic spine are affected.

At the age of 10-12 years, additional apophyseal ossification points of the vertebral body, or "marginal bone borders", appear in the intervertebral cartilaginous discs.

This typical osteochondropathy is most likely based on multiple small necroses with subsequent recovery phenomena.

Significant deformation - osteochondropathic kyphosis - gives a poor prognosis in terms of restoring shape. Usually kyphosis remains for life.

In this case, the VIII-IX vertebrae are subjected to the greatest deformation, to a lesser extent - the VII and X vertebrae of the thoracic spine.

Clinic. The patient pays attention to fatigue in the spine, first after exercise, then after walking and sitting for a long time. Gradually, fatigue of the spine turns into pain, stoop and kyphosis appear. The disease progresses slowly over years.

Radiographically, Mau distinguishes three stages of the disease.

The initial stage of the disease is characterized by the fact that the apophyses loosen and have a variegated appearance on radiographs.

In the initial stage, the epiphyses take on a jagged appearance, and the contours of the anterior part of the vertebral body become osteoporotic.

In the destructive stage, deformation of the vertebrae occurs - the body of the affected vertebra is compressed from top to bottom and sharpens in the form of a truncated wedge from the middle of the body in the forward direction.

In the recovery stage, the structure of the vertebrae is restored and the apophyses merge with the vertebral bodies.

In severe cases, the process leads to deforming spondylosis.

Treatment is symptomatic. Patients must comply with bed rest on a hard bed with a shield in the supine position.

Gymnastics is prescribed to strengthen the muscles of the back and abdomen.

In the acute stage with severe clinical manifestations in the form of pain, they resort to the position in a plaster bed.

In mild forms of the disease, it is recommended to wear a reclining backboard to correct kyphosis.

Partial wedge-shaped osteochondropathy of articular surfaces

Cut-off osteochondrosis, or Koenig's disease, is expressed in aseptic necrosis and separation of the wedge-shaped section of the head or articular epiphysis of the medial femoral condyle. The disease is observed in children and adults.

The typical localization of the disease is the knee joint, but others (elbow, less often shoulder, hip, ankle) can also be affected.

Clinic. The detached bone-cartilaginous piece of the epiphysis falls into the joint cavity, where it moves freely, and when infringed, it blocks the joint.

There is an acute pain in the joint, which the patient gets rid of on his own, carefully bending and unbending the thigh or lower leg.

The clinic of Koenig's disease before infringement is expressed in pain in the joint while walking; on palpation of the medial condyle of the thigh, a local painful point is determined. After the blockade, an effusion appears in the joint.

There are two stages in the clinical course.

Stage I - chronic arthrosis-arthritis - lasts for 1-1,5 years. Slowly, the focus is delimited, then it is held in its place by the still intact cartilage.

Stage II - the stage of "intra-articular mice". There is an infringement of the intra-articular body, accompanied by blockade of the joint and severe pain. Cartilage slowly changes its structure and is destroyed under the influence of a small injury.

The radiological picture is very characteristic. Initially, a small oval depression in the medial condyle is determined.

After rejection of the sequester, a small and shallow defect is seen in the condyle - a "niche", and in the joint cavity - a bean-shaped sequester, called the articular mouse.

The dimensions of the niche and the intra-articular body may not correspond to each other. Articular loose body leads to chronic irritation of the joint and is the cause of secondary disfiguring phenomena.

Treatment. In stage I of the disease, the operation is technically difficult. The affected area may be hardly noticeable, the cartilage remains alive and has a normal appearance, which makes it difficult to localize and remove the focus. In stage II, the operation consists in removing the intra-articular bodies of the "articular mouse".

2. Bone tumors

Tumors of the musculoskeletal system are one of the most important and difficult in terms of diagnostics and treatment sections of clinical oncology and orthopedics. Most often, bone tumors affect children and young people.

The first place in frequency is occupied by myeloma, the second - by osteogenic sarcoma, the third - by primary chondrosarcoma, then - by other tumors of the skeleton.

Classification of bone tumors

The bone has a multitissue structure, and tumors of various histogenesis can develop in it.

In practical work, clinical classifications are important, which allow distinguishing the stages and forms of benign and malignant tumors, which helps in determining the indications for surgery and, to some extent, allows predicting the course of the disease.

The classification of bone tumors according to V. Ya. Shlapobersky distinguishes primary and secondary bone tumors, in turn, they are divided into benign and malignant.

According to morphological characteristics, primary bone tumors can be from bone tissue, cartilage tissue, reticuloendothelial tissue, connective tissue, vascular tissue, and rare bone tumors - from nervous, adipose tissue, notochord tissue, epithelial tissue, as well as odontogenic tumors.

Secondary bone tumors are divided into metastatic tumors that grow into the bone from surrounding tissues; malignant tumors developing from processes bordering on tumors (fibrous dysplasia, Paget's disease, Ollie's disease, osteochondral exostoses, etc.).

General principles of diagnosis

Additional methods are needed for diagnosis: X-ray - computed tomography, angiography, radioisotope diagnostics (scintigraphy), magnetic resonance imaging, laboratory tests, etc.

Clinic

The symptom complex of bone tumors consists of three cardinal signs:

1) pain in the affected part of the skeleton;

2) palpable tumor;

3) dysfunction of the limb.

The development of symptoms depends on the nosological form of the tumor, the nature of its growth, localization, local spread of the process. With rapidly growing sarcomas, the tumor may be detected early enough, a pathological fracture may occur.

With benign bone tumors, paraosteal sarcoma, highly differentiated chondrosarcoma, clinical signs develop slowly, sometimes over several years.

Often, patients associate the onset of the disease with trauma. If pain, swelling and dysfunction bother the patient for a long period after injury or after disappearance resume after a long "light" interval, this should alert the doctor to a possible oncological disease of the bone.

Pain is one of the main symptoms of malignant bone tumors. At the beginning of the disease, they are indefinite, gradually increase and become more and more intense, do not decrease when using immobilization and at rest.

The most intense pains are typical for Ewing's sarcoma, poorly differentiated chondrosarcoma and osteogenic sarcoma; among benign tumors, osteoid osteoma is accompanied by a pronounced pain syndrome.

With lesions of the pelvic bones and spine, often the localization of pain does not correspond to the topography of the process.

The tumor, determined by palpation, indicates a far advanced process.

The slower the tumor grows, the longer the time interval between the onset of pain and the appearance of a palpable formation.

Functional disorders are due to the anatomical location of the neoplasm. The occurrence of a tumor near large joints often leads to the development of contractures, restriction of movements due to a sharp pain syndrome leads to muscle atrophy, compression of the neurovascular bundles by tumor masses, and in case of tumors of the spine - and the spinal cord can lead to severe neurological and trophic disorders.

Primary malignant neoplasms of bones are more often localized in the area of ​​the knee joint (osteogenic sarcoma, paraosteal sarcoma), diaphyseal lesions are observed in Ewing's sarcoma, and chondrosarcoma is often localized in the pelvic bones.

Diagnostics

The X-ray method is the most important part of a comprehensive examination and includes X-ray of the bones and organs of the chest, tomography (including computed tomography), and angiography. X-ray semiotics depends on the nosological form of the tumor, growth rate, anatomical region.

Most often, foci of destruction with characteristic lysis, signs of pathological bone formation, various types of periosteal reactions are determined (for example, Codman's "visor" characteristic of osteogenic sarcoma or "bulbous" periostitis in Ewing's sarcoma).

X-ray determination of the tumor focus in the bone tissue is possible with a decrease in the calcium content by 30% or more.

morphological method. To determine the tactics of treatment, it is necessary to know the morphological form of the tumor, the stage of the disease and the prevalence of the tumor process.

Material for histological examination of the tumor can be obtained using invasive diagnostic methods - biopsy.

Closed methods include puncture biopsy to obtain material for cytological examination from hard-to-reach areas.

Open biopsy (or knife biopsy) gives the highest percentage of correct diagnoses. The negative aspects are the need to perform a surgical approach to obtain material, as well as a greater tumor trauma than with a closed biopsy.

The method of immunohistochemistry using special markers contributes to a decrease in the percentage of erroneous diagnoses.

radionuclide method. Osteotropic radionuclide preparations are used to diagnose the spread of the tumor process, to identify foci of mineral metabolism disorders in the human skeleton, which may not be detected by conventional X-ray examination.

Laboratory methods are of secondary importance. Thus, the study of proteins by serum electrophoresis and the determination of the albumin-globulin coefficient, Bence-Jones protein are reliable methods for multiple myeloma.

In osteoblastic tumors, there is a tendency to increase alkaline phosphatase, and in osteolytic tumors, a high level of calcium in the blood serum and in the urine is characteristic.

Basic principles of treatment of primary bone tumors

Surgical intervention is the main component of any complex of therapeutic measures for bone tumors. Benign bone tumors are subject only to surgical treatment.

In malignant tumors, indications and contraindications for surgery depend on the histological structure, the nature of the growth of the neoplasm, the degree of its prevalence, anatomical localization, the general condition of the patient and sensitivity to radiation and chemotherapy.

In the area of ​​resection of the pelvic bones, operations are performed from various accesses that ensure the least traumatic intervention and the achievement of good anatomical and functional results.

Tumors of the spine are aggravated by frequent neurological deficits when the dural sac is compressed by tumor tissues, and in advanced cases, by the presence of pathological fractures of the vertebral bodies.

The definitive surgical treatment for primary osteogenic sarcomas is amputation.

Surgical treatment of malignant tumors is often carried out in combination with chemotherapy and radiation therapy. In some cases, these treatments should be considered as the main ones (for example, in inoperable tumors).

The possibilities of clinical use of anticancer drugs are directly dependent on the location and stage of development of the tumor process, the histological structure of the tumor, and the characteristics of the patient's body.

When using preoperative chemotherapy, the need for radical (extensive) operations is reduced, there is a low frequency of local relapses and favorable long-term results in high-grade extremity sarcomas.

It is advisable to use it due to the high frequency of hematogenous spread of soft tissue sarcomas in the early stages of development.

Radiation therapy as an independent method of treating bone sarcomas is rarely used due to the low radiosensitivity of a number of primary bone neoplasms of the skeleton. This method is of the greatest importance as one of the components of complex therapy in combination with surgery or chemotherapy. Radiation is most effective in the treatment of Ewing's sarcoma, bone reticulosarcoma, and soft tissue sarcoma, which are characterized by high sensitivity to radiation. The use of adjuvant radiotherapy after economical surgical interventions can increase the frequency of good treatment outcomes.

Benign tumors are not subject to radiation treatment.

3. Primary bone tumors

Benign bone-forming tumors

Osteoma A benign bone tumor originating from osteoblasts. Depending on the predominance of the constituent elements, compact, spongy and mixed osteomas are distinguished. It is relatively rare (from 1,9 to 8% of cases). Osteomas most often affect the bones of the skull, spongy and mixed.

Often located in long bones, mainly in the femur and humerus. They occur with equal frequency in both sexes, aged 10 to 25 years. They grow very slowly, over several years.

Clinical manifestations depend on localization, most often this is painless.

Radiographically, tabular osteomas (on a broad base) and pedunculated osteomas are distinguished. The shape is round or oval, with even contours and clear boundaries, the structure is homogeneous, osteoporosis and destruction are absent.

Surgical treatment - knocking with a chisel from a healthy bone area. The operation is performed according to indications: the presence of pain, dysfunction, large size. There is no denigration.

Osteoid-osteoma. Most scientists attribute the disease to benign primary bone tumors, some consider it an inflammatory process. Osteoid osteoma accounts for about 10% of all benign bone tumors and occurs between the ages of 10 and 25, predominantly in men.

The main localization is the diaphysis of long bones, sometimes it is also found in the pelvic bones.

Clinic. Osteoid osteoma is characterized by severe pain in the lesion, especially at night, the pain is so intense that it sometimes deprives patients of sleep. A characteristic symptom is the subsidence of pain when taking salicylic acid.

Radiographically, in the initial phases, the tumor focus is clearly distinguished in the form of a fuzzy rounded defect, 1-2 cm in diameter ("nest" of the tumor). The bone surrounding the defect is thickened and sclerotic. At later stages, the defect is filled with newly formed bone tissue.

Histologically, the tumor is represented by osteoid and osteogenic tissue.

The generally accepted method of treatment is the radical surgical removal of the focus ("nest" of the tumor) as a single block with the surrounding strip of sclerotic bone tissue. Scraping the nest is not recommended, as it can lead to relapse. Malignancy has not been described.

Osteoblastoclastoma (giant cell tumor) is a primary single bone tumor of a benign nature with predominant localization at the ends of tubular bones: femur, tibia, radius, etc. The tumor affects the spongy tissue, grows slowly, reaching the border of the articular cartilage. It is from 12 to 25% of tumor lesions of the skeleton.

It occurs in people aged 20-40 years, but can be observed in children and the elderly. Women are affected slightly more often than men.

The morphological process consists in the destruction and replacement of the bone substance and hematopoietic elements of the bone marrow with small mononuclear (osteoblasts) and mainly giant multinuclear (osteoclasts) cells.

The tumor is a soft tissue formation penetrated by vascular plexuses, which are easily damaged and form internal hemorrhages, which gives the tumor a brown color. Hence the name "brown tumor".

Clinical classification (V. Ya. Shlapobersky, 1960)

Benign form:

1) Group I (with a calmer course, radiographically - cellular);

2) Group II (with a more aggressive course, X-ray - lytic);

3) recurrent form.

Malignant form:

1) primary malignant;

2) secondary malignant.

The clinical picture depends on the localization - it is pain in the affected limb, swelling, dysfunction. A giant cell tumor grows slowly over years and reaches a large size.

Pain usually occurs after an injury and is not intense. The skin covering the tumor is stretched, shiny, with a bluish tinge.

On palpation of the tumor, especially with effort, a small crunch can be felt, like the crunch of snow, associated with multiple tiny fractures of the thinned cortical layer of the deformed bone. Often there is a pathological fracture. Metastases are rare.

The X-ray picture is quite specific. The lesion is located asymmetrically in the epimetaphyseal zone, has a rounded shape and is clearly delimited from the unchanged bone, up to the appearance of a sclerotic rim.

The focus may have a cellular-trabecular structure or the appearance of a homogeneous bone defect. Almost always there is a "swelling" of the bone.

Treatment is carried out differentially, depending on the form of the tumor (benign, recurrent, malignant), the stage of the course and the age of the patient. To date, there is no consensus on treatment.

Excochleation of the tumor is more often used in the cellular-trabecular form, marginal and segmental bone resections - in the lytic form of osteoblastoclastoma.

In recurrent and malignant forms of the tumor, combined methods of treatment are used, combining radiation and chemotherapy with bone resection or limb amputation.

Malignant bone-forming tumors

osteosarcoma - one of the most common primary malignant bone tumors, occurs in 80% of all malignant bone tumors.

It can occur in any bone of the skeleton, most often affecting long bones, mainly the metaepiphyses of the bones that make up the knee joint (79,4%). There is a certain connection between the tumor and the areas of bone growth. Apparently, age-related acceleration of skeletal growth plays a role in the genesis of this tumor, when, under the influence of exogenous or endogenous factors, enchondral osteogenesis is disturbed, followed by blastomatous growth.

osteosarcoma - monoosseous disease, extremely aggressive, prone to early, predominantly hematogenous metastasis, most often to the lungs (60-95%), it is possible to other parts of the skeleton and lymph nodes.

Clinically, there are two types:

1) rapidly developing, with an acute onset, sharp pains and a rapidly developing lethal outcome;

2) slower developing tumors with less pronounced clinical manifestations.

In 45-50% of patients, there is an indication of trauma in the anamnesis, the period from the moment of the latter varies from several days to 1,5 years.

The main symptom is pain, at first moderate and periodic, and then more pronounced and constant. The appearance of pain is associated with the involvement of the periosteum in the process. Frequent night pains.

The second important symptom is the appearance of a palpable tumor. General symptoms develop in the later stages in the form of weight loss, poor sleep, general malaise, weakness. They are accompanied by progressive anemia, often by an increase in alkaline phosphatase.

Pathological fractures are rare and are characteristic of the osteolytic form.

Radiologically, the following varieties are distinguished:

1) osteolytic;

2) mixed;

3) osteoblastic:

a) central option;

b) peripheral option.

The most pathognomonic signs are peculiar osteophytes that occur at the border of the external defect of the compact bone layer and the extraosseous component of the tumor; they look like a characteristic visor or triangular spur (Codman's visor). Another symptom is spicules - thin needle-like calcifications located perpendicular to the long axis of the bone.

Treatment is complex, including radiation and chemotherapy, surgery. The operative benefit most often consists in amputation; recently, segmental resections are performed, followed by bone grafting or endoprosthetics. After the complex treatment, the five-year survival rate is from 35,5 to 60%.

Paraosteal osteogenic sarcoma refers to rare forms of tumors, which occurs in 2% of all malignant neoplasms of the skeleton.

It develops mainly at the age of 20-40 years. The main localization (more than 80%) is the metadiaphyseal section of the long bones that form the knee joint.

The clinical picture is characterized by a long (up to several years) development of symptoms. There are two phases: initial - benign and subsequent - malignant. The disease begins gradually with the appearance of mild aching pains, later a dense bumpy tumor appears, painless on palpation, and later (after 3-5 years) paraosteal osteogenic sarcoma acquires all the features of a malignant neoplasm: pain intensifies, the tumor grows rapidly, germinating into surrounding tissues, begins ulcerate.

In most cases, radiography reveals extraosseously located tuberous "bone masses", as the paraosteal osteogenic sarcoma grows, it can cover the entire cylinder of the bone in a muff-like fashion.

A peculiar sign is the intactness of the underlying bone layer.

The histological structure is characterized by diversity in different parts of the same tumor: there are structures characteristic of osteogenic sarcoma, chondro- and fibrosarcoma, malignant osteoblastoclastoma, osteochondral exostosis and other pathological processes.

The method of choice in the treatment of paraosteal osteogenic sarcoma is segmental resection with replacement of the defect with a metal endoprosthesis or bone grafting. In cases where this operation cannot be performed, amputation or disarticulation of the limb is indicated.

Prognosis - in general, there is a slow course of the disease, and the 5-year survival rate is up to 70%.

Benign cartilaginous tumors

Chondroma. Currently, most experts believe that chondromas should be treated with caution, keeping in mind that they can be potentially malignant tumors. Enchondromas are central chondromas, and ecchondromas are peripheral.

Chondromas are common - 10-15% of all benign bone tumors. Age can vary widely.

Chondromas are most often multiple, their favorite localization is short tubular bones (phalanges of the fingers, bones of the metacarpus and metatarsus), single forms are more common in the proximal parts of the thigh and shoulder.

With an uncomplicated course, chondromas give few clinical symptoms, which is associated with their very slow growth. The presence of pain without a pathological fracture should be alarming in terms of possible malignancy.

X-ray - enchondroma is located inside the bone and, as it grows, bursts the bone from the inside. Against a homogeneous background of enlightenment, single inclusions of foci of cartilage calcification are found. Echondroma originates from the bone and grows towards the soft tissues.

Microscopically, a chondroma consists of normal, mature cartilage.

Treatment. Currently, there is no consensus on the scope of surgical intervention in the treatment of enchondromas. Some experts believe that it is enough to scrape the latter with the replacement of the cavity with autologous bone, while others, due to the risk of malignancy, suggest performing segmental resection followed by plastic replacement of the defect.

The prognosis for a radically performed operation is favorable.

Chondroblastoma (Cadman's tumor) is a benign tumor originating from cells of the growth cartilage (chondroblasts) and characterized by a favorable outcome. Chondroblastoma is quite rare.

Favorite localization - metaepiphyseal departments of long bones.

The clinical picture is nonspecific and consists of the presence of a tumor, pain syndrome, dysfunction of the limb.

Radiographically, chondroblastoma is manifested by small foci of destruction 2 × 5 cm located eccentrically with respect to the bone. The focus is clearly delimited from healthy bone by a sclerotic strip.

In treatment, the method of choice is segmental resection with bone grafting.

Malignant cartilaginous tumors

Chondrosarcoma can develop as a primary malignant tumor and as a secondary one as a result of malignancy of a benign cartilage tumor or a dysplastic process.

Primary chondrosarcomas can occur in any bone that develops from cartilage by endochondral ossification, and are distinguished by a wide range of clinical manifestations - from a locally destructive tumor to a neoplasm with pronounced malignant potency, which depends on its morphological structure. The less pronounced anaplasia, the more favorably the disease proceeds.

The clinical picture is characterized by the same signs as in other primary malignant bone tumors (pain, swelling, dysfunction). The localization of the tumor in the bone matters. In the central form, pain first appears, the tumor as the first sign is noted mainly in the peripheral variant.

Radiologically, central highly differentiated chondrosarcomas appear as a single lesion of irregular shape, the bone is swollen and thickened, fusiformly deformed, accompanied by the formation of a cellular-trabecular structure with the presence of foci of calcification. In poorly differentiated tumors, the focus of destruction has a small-focal blurred character, the process spreads over a considerable distance along the long axis of the bone.

Treatment depends on the form of chondrosarcoma and is mainly aimed at radical surgical removal of the tumor within healthy tissue.

The prognosis for radical treatment - the percentage of 5-year survival ranges from 15 to 76,4%.

Secondary chondrosarcoma develops on the basis of previous benign cartilage tumors and chondrodysplasia. The most prone to malignancy are chondromas, osteocartilaginous exostoses, foci of dyschondroplasia (Ollier's disease) and vascular-cartilaginous dysplasia (Maffucci's disease). Cases of tumor occurrence on the background of osteomyelitis are described.

The beginning of malignancy is usually difficult to establish, it is most often manifested by a noticeable increase in pain and rapid growth.

X-ray - characterized by a rapid increase in destruction, destruction of the cortical layer, the appearance of periosteal layers.

The method of choice for treatment is a wide resection of the affected bone section.

The prognosis in the treatment of chondrosarcoma depends on the form of the tumor (primary or secondary), the degree of its morphological maturity.

4. Primary tumors from reticuloendothelial tissue

Myeloma

Myeloma (multiple myeloma, or O. A. Rustitsky's disease) is a sarcomatous tumor of the bone marrow, expressed in the intense malignant proliferation of mutated plasma cells in the bone marrow, called myeloma cells.

S. A. Reinberg divided multiple myeloma based on anatomical, clinical and radiological signs into four varieties:

1) multiple focal;

2) diffuse-porotic;

3) osteosclerotic;

4) solitary.

Multiple-focal myeloma affects mainly the flat bones of the skull, pelvis, spine, sternum, and less often - long tubular bones.

Multiple myeloma is more common in middle-aged men, but children and the elderly can suffer.

Clinic. The disease begins with pain in the bones, then there is a loss of body weight and a breakdown, often a pathological fracture occurs, which may be the only clinical sign of the disease. The malignant process progresses rapidly, complicated by kidney damage, accompanied by the release of the pathological Bens-Jones protein and metastases to the spleen, liver, and lymph nodes. Cachexia, anemia, hyperproteinemia, hypercalcemia develop, ESR accelerates.

The x-ray picture of multiple myeloma is initially characterized by diffuse osteoporosis, then multiple oval foci of osteolysis appear, primarily in flat and short bones containing red bone marrow: the sternum, ribs, vertebrae, cranial vault, pelvic and tubular bones.

The affected bone appears to be enlarged with a thinned cortical layer, without a periosteal reaction, as if perforated in many places by a punch.

Solitary myeloma (plasmocytoma) is observed mainly in flat bones. In the affected bone, a focus of decalcification is formed, slowly increasing. Sometimes the site of osteolysis can reach a large size, resemble a cystic formation without reactive periostitis.

Clinical symptomatology is not as pronounced as in multiple myeloma, but pathological fractures are common.

Diagnosis of multiple myeloma is often difficult due to the similar clinical and radiological picture with many diseases of the skeletal system.

These include: giant cell tumor, osteolytic osteosarcoma, solitary cancer metastases, Paget's and Recklinhausen's disease, etc.

Myeloma is characterized by a triad of clinical symptoms:

1) bone damage (pain, tumor formations, pathological fractures);

2) blood changes (anemia, elevated ESR);

3) kidney damage ("discharge nephrosis" with Bence-Jones protein).

To clarify the diagnosis, a bone marrow puncture is performed.

Treatment. Of all the conservative agents, radiation and chemotherapy proved to be the most effective in the treatment of multiple myeloma.

In some cases, combined treatment is used. To stabilize the blood during chemotherapy, ACTT and steroid hormones are prescribed, blood, leukocyte and platelet masses are transfused.

LECTURE No. 5. Static deformations

1. ​​Scoliosis

Scoliosis, or scoliotic disease, is a persistent lateral curvature of the spine, combined with its torsion (twisting) around the longitudinal axis. Not every lateral curvature of the spinal column should be considered scoliosis. Small lateral curvature of the spine, easily eliminated by the child himself, are functional curvatures. With true scoliosis, the curvature is always fixed due to structural disorders of the vertebrae.

As scoliosis and torsion increase, kyphoscoliosis develops. With a right-sided curvature, torsion always occurs in a clockwise direction, and with a left-sided curvature, it always occurs counterclockwise.

Scoliosis is classified (according to A. I. Kazmin) by types: upper thoracic, thoracic, thoracic, lumbar, combined. The most common type of scoliosis is thoracic.

The most pronounced torsion of the vertebrae is observed in thoracolumbar type of scoliosis, and in combined (S-shaped) scoliosis, a compensated curvature of the spine is formed.

Curvature of the spine is divided into four degrees (according to V. D. Chaklin):

at I degree, the angle of curvature is 180-175 °;

at II degree - 175-155 °;

at III degree - 155-100 °;

at IV degree - less than 100 °.

The clinical course depends on the type of scoliosis, the age of the child, and the degree of spinal deformity.

With grade I scoliosis, the lateral curvature of the spine is noted only when it is bent, the costal hump is not yet noticeable, and it is difficult to determine the torsion of the spine. Scoliotic curvature is not eliminated when lying down.

II degree - pronounced scoliotic and torsion curvature, compensatory anti-curvature of the spine, asymmetry of the shoulder girdle and the presence of a costal hump when the spine is flexed.

III degree - scoliotic curvature of the spine, skewed pelvis. The costal hump is visible in the vertical position of the patient.

The deformity of the spine and chest is fixed and cannot be corrected.

IV degree - severe fixed kyphoscoliosis, deformities of the pelvis and chest, spondyloarthrosis.

With a pronounced scoliosis, a costal hump forms on the convex side at the back, and a sinking of the chest on the concave side.

Scoliosis is divided into congenital (accessory and wedge-shaped vertebrae, etc.) and acquired - rachitic, paralytic, static and idiopathic.

Congenital scoliosis is characterized by a slight torsion and a small radius of deformation.

Acquired scoliosis is characterized by a varied clinical picture and course.

Rachitic scoliosis accounts for about 50% of all scoliosis in children aged 6 to 12 years.

Wrong posture at the desk is the initial provocative moment in the formation of scoliosis against the background of rickets.

The entire spine is affected, however, against its background, secondary fixed compensatory curvatures easily occur, especially kyphotic deformity.

Paralytic scoliosis develops in children who have had poliomyelitis, and is characterized by the totality of the lesion, the rapid development of kyphoscoliosis.

Static scoliosis develops against the background of an already existing disease of the lower limb (congenital dislocation of the hip, ankylosis, improperly healed fracture), leading to absolute or functional shortening of the limb.

There is a compensatory skew of the pelvis and persistent scoliotic curvature of the spine.

Static scoliosis can develop in schoolchildren, violinists and representatives of other professions due to the prolonged action of a monotonous posture. In the development of scoliosis in children ("school" scoliosis), rickets, muscle fatigue and asymmetric load are important.

Scoliosis is a dynamic disease. The resulting curvature of the spine progresses with the growth of the child and stops by the age of 16-18, that is, by the end of the period of skeletal growth. The criterion for the end of skeletal growth is the ossification of the growth zones of the iliac bones (Riesser's zones).

Paralytic scoliosis can progress even after the end of skeletal growth.

Idiopathic scoliosis occurs in children and the cause is unknown.

Some authors attribute it either to hormonal disorders, or to unrecognized transferred poliomyelitis, or to neurodysplastic deformities.

Diagnosis begins with a systematic preventive examination of children of school and preschool age.

Attention is drawn to the posture of children: normal - the main type; flat or plano-concave back; round back; stooped back. With a flat back, a vicious prescoliotic posture develops more often and faster.

To measure the angles of curvature of the spine, the method of V. D. Chaklin is used.

Radiography of the spine is performed in two projections: in a standing position and lying down.

The radiographs show:

1) the basal vertebra, on which the curved spine is located;

2) the culminating vertebra, which is the apex of the arch of the main or secondary curvature of the spine;

3) a beveled vertebra, which determines the place of transition of the main curvature to the countercurvature;

4) an intermediate vertebra, located between the culminating and oblique vertebrae;

5) a neutral vertebra with minimal changes in the intervertebral spaces;

6) unchanged cranial and caudal vertebrae, closing the scoliotic curvature of the spine.

Prevention. Proper nutrition and upbringing of the child are aimed at preventing rickets, poliomyelitis and other diseases leading to skeletal deformities.

In congenital scoliosis, the progression of the curvature is prevented by corrective gymnastics.

At the first signs of rachitic scoliosis, anti-rachitic treatment is prescribed, corrective plaster beds are made, trunk muscles are massaged, and the child’s posture is constantly monitored while sitting.

In children who have had poliomyelitis, prevention of orthopedic deformities of the motor apparatus is mandatory.

Children should sleep on a hard bed, regularly do general strengthening exercises, go skiing, swim in the pool.

Conservative treatment of scoliosis is used if there is no progression of scoliotic disease, and is aimed at correcting the primary curvature with the help of physiotherapy exercises, the elements of which are selected individually for each patient.

Therapeutic gymnastics is complemented by a massage of weakened muscles, corrective traction. Gypsum corrective corsets-beds are used, curvature redressing with the help of devices.

Surgical treatment is carried out for scoliosis of III and IV degrees and with the failure of conservative treatment and progression of curvature of the spine, with II degree - posterior osteoplastic fixation of the spine in the position of maximum correction according to V. D. Chaklin or A. I. Kazmin.

2. Flat foot

Flatfoot is a deformity of the foot characterized by a fixed compaction of the longitudinal arch, valgation of the posterior and abduction of its anterior sections.

Longitudinal flat feet in terms of severity of deformation has three degrees:

I degree - fatigue of the legs and pain in the calf muscles after a long walk;

II degree - pain syndrome, there are signs of foot deformity;

III degree - pronounced flat feet: deformity of the foot with the expansion of its middle part and pronation of the posterior section, while the anterior section is retracted outward and supinated relative to the posterior one.

With bilateral flat feet, the socks are turned to the sides. The gait is clumsy, running is difficult. Often, longitudinal flat feet are combined with flattening of the transverse arch of the foot, then longitudinal-transverse flat feet are formed.

There are congenital (rarely) and acquired flat feet.

Acquired flat feet are divided into static, rachitic, traumatic and paralytic. The most common is static flat feet (40-50% of the adult population).

Static flatfoot develops as a result of chronic overload of the feet, leading to a weakening of muscle strength and stretching of the ligamentous apparatus of the foot joints, resulting in a flattening of the longitudinal arch of the foot.

It often occurs in people who perform work associated with prolonged standing or lifting and carrying heavy loads.

Contributing factors are rapid growth, acceleration, obesity, pregnancy, a decrease in muscle strength due to physiological aging.

Clinic. Pain is felt after exercise in various parts of the foot, in the calf muscles, knee and hip joints, in the lower back.

Diagnostics. To determine the degree of flat feet, they resort to plantography, podometry, radiography.

Plantography is the process of obtaining a footprint. The resulting plantogram is divided by a straight line passing through the center of the heel and between the bases of the phalanges III and IV of the fingers.

With a normal foot, the shaded part in the middle section does not extend to the dissecting line.

Friedlan podometry. The height of the foot is measured (the distance from the floor to the upper surface of the navicular bone), the length of the foot (from the tip of the first finger to the back of the heel). The height of the foot is multiplied by 100 and divided by the length of the foot. It turns out the index, which is normally equal to 31-29, with flat feet - 29-27, below 25 - with significant flat feet.

X-ray of the bones of the foot is recommended to be done with a load - standing. On the profile radiograph, two lines are drawn: one from the middle part of the lower surface of the navicular bone to the fulcrum of the calcaneal tuber, the second - from the same point to the lower surface of the head of the first metatarsal bone.

Normally, an angle equal to 120 ° is obtained, the height of the arch is 39-37 mm. At degree I, this angle is 140°, the height of the arch is less than 35 mm, at the II degree - 150-155°, the height of the arch is 25 mm, at the III degree - 170°, the height of the arch is less than 25 mm.

Treatment of foot deformities begins with the prevention of flat feet in children: dosed physical exercises, prevention of excessive overload, wearing rational shoes are recommended.

At the I degree, conservative therapy is carried out - special gymnastics, warm baths, massage, arch supports, at the II degree - deformity correction and the imposition of a modeling plaster bandage for 3-4 weeks, massage, exercise therapy, wearing arch supports; at the III degree - the treatment is the same as at the II degree, and surgical treatment is indicated.

Surgical intervention is performed on soft tissues or on the osteoarticular apparatus of the foot.

With flat feet II-III degree, the deformity of the foot is eliminated by modeling correction, but soon the foot returns to its previous position, and then soft tissue surgery is performed.

A plaster bandage to the middle of the thigh is applied for 4-5 weeks. After physiotherapy exercises and massage, it is necessary to wear arch supports or orthopedic shoes.

With the bone form of static flat feet (flat-valgus foot), which is not amenable to modeling redress, a wedge-shaped resection of the foot bones is performed in the region of the apex of the arch (the base of the wedge should be turned downwards). After wedge-shaped resections of the bones of the foot, eliminating its deformation, the tendon of the long peroneal muscle is transplanted to the inner edge of the foot. If necessary, a closed Z-shaped achillotomy is added. A plaster bandage is applied for 6-8 weeks. Be sure to wear orthopedic shoes.

LECTURE No. 6. Inflammatory bone diseases

1. Acute and chronic osteomyelitis

Osteomyelitis is a purulent inflammation of the bone marrow and bone, accompanied by the involvement of the periosteum and surrounding soft tissues in this process, as well as general disorders of the patient's systems and organs. Depending on the localization of the lesion, epiphyseal, metaphyseal, diaphyseal and total osteomyelitis are distinguished.

Forms of osteomyelitis can be acute, subacute and chronic.

2. Hematogenous osteomyelitis

Hematogenous osteomyelitis accounts for up to 50% of all forms of the disease.

Etiology. Acute and chronic hematogenous osteomyelitis is caused by staphylococcus in 60-80% of patients, streptococcus - in 5-30%, pneumococcus - in 10-15%, gram-negative or mixed flora is found.

Pathogenesis. None of the existing theories of the occurrence of hematogenous osteomyelitis can fully explain its pathogenesis.

In the development of hematogenous osteomyelitis, a decrease in the reactivity of the patient's body (as a result of trauma, hypothermia, sensitization) and a violation of the blood supply to the affected bone section are important.

Pathological changes are based on destructive changes in the bone marrow.

Essentially, a purulent infection leads to resorption and melting of the bone elements.

In the initial stage, destructive changes in the bone tissue predominate. They are characterized by the formation of usuras of various sizes and shapes, defects filled with pus, pathological granulations, which over time merge into larger foci of bone destruction containing sequesters (intramedullary phase).

The transition of the acute stage of osteomyelitis to the chronic one is manifested in the violation of proliferative ossifying processes, the bone gradually thickens, the foci of destruction alternate with foci of osteosclerosis.

The formation of sequesters is the result of a violation of the blood supply to the bone, and not a consequence of the action of bacterial toxins. Depending on which part of the bone and in which layer these changes are more pronounced, sequesters of different size and structure are formed.

Sometimes a completely sequestered bone is not only viable, but over time its structure is completely restored in it, which indicates a high survival rate of bone tissue in conditions of acute inflammation of the bone marrow.

Changes in the periosteum are characterized by its thickening, proliferation of connective tissue and the formation of serous exudate.

Subsequently, the periosteum exfoliates with pus that has penetrated from the bone marrow space through the bone canals with the formation of subperiosteal abscesses (extramedullary phase). When the periosteum is ruptured, pus penetrates into the paraosseous space, which is accompanied by the development of inflammatory-necrotic changes in the soft tissues of the limb (muscle necrosis, thrombophlebitis, thromboarteritis, neuritis).

In one third of patients, the acute inflammatory process becomes subacute, and then chronic, the pathological basis of which is formed areas of bone destruction and sequestration.

Clinic. Acute hematogenous osteomyelitis most often occurs in childhood and has an acute onset.

Spontaneous pain in the limb appears, which at first has a aching character, then it quickly intensifies, becomes bursting, and at the slightest movement it increases significantly, which indicates the beginning of inflammation of the bone marrow and is a consequence of intraosseous hypertension. The pain disappears or significantly decreases with spontaneous opening of the abscess under the periosteum, and then into the soft tissues. Characterized by an increase in body temperature, deterioration of the general condition, intoxication.

Local signs of osteomyelitis. Local tenderness and swelling of the soft tissues are determined by light palpation and percussion in the area of ​​the suspected focus of inflammation.

Subsequently - a local increase in temperature, an increased pattern of superficial veins of the skin and subcutaneous tissue, flexion contracture of the joint adjacent to the affected area of ​​the skin.

Later, skin hyperemia, fluctuation appear, regional lymph nodes increase and become painful.

The "favorite" localizations are characteristic - these are bone sections that are involved in the growth of the limb in length: the distal third of the femur and the proximal third of the tibia, the fibula and ulna, and the clavicle.

Diagnostics. Laboratory studies reveal: high leukocytosis with a shift to the left with an increase in the content of neutrophils with toxic granularity, lymphopenia; acceleration of ESR; hypochromic anemia, a sharply positive reaction to C-reactive protein, dysproteinemia.

X-ray diagnostics. Early bone changes appear from the 10-14th day from the onset of the disease and are manifested by rarefaction of the bone structure, osteoporosis in the area corresponding to the inflammation zone, most often in the metaphysis.

The bone pattern becomes blurred, thinning or disappearance of bone beams occurs as a result of increased resorption. Exfoliated or linear periostitis appears relatively early. An earlier diagnosis can be made with tomograms, direct magnification radiographs, and computed tomograms.

Measurement of intraosseous pressure. In acute osteomyelitis, intraosseous pressure reaches a level of 300-400 mm of water. Art. within 5-10 minutes of measurement (in healthy people it does not exceed 50 mm of water column).

Treatment of acute hematogenous osteomyelitis. Basic principles of treatment (according to T. P. Krasnobaev):

1) direct impact on the causative agent of the disease;

2) an increase in the body's resistance to an infectious onset;

3) treatment of the local focus.

Conservative treatment. It is advisable to conduct massive antibiotic therapy from the moment of diagnosis.

Penicillin remains active today against many strains of Staphylococcus aureus, Streptococcus B, pneumococci. In severe cases, intravenous administration of 5-10 million units is justified. penicillin after 4 hours. With the resistance of the seeded strains to penicillin, ampicillin, oxacillin is prescribed, nafitillin is drugs resistant to β-lactamase. With increased sensitivity to penicillin, cephalosporins are prescribed.

When identifying gram-negative microbial strains, modern aminoglycosides are indicated. Pseudomonas is effectively affected by combinations of modern aminoglycosides with carbenicillin or ticarcillin, and Klebsiella is effectively affected by aminoglycosides and cephalosporins.

There are one-, two- and three-component treatment regimens.

Three-component treatment regimen: β-lactam drug + + aminoglycoside + antibacteroid chemotherapeutic agent (metrogil, clindamycin).

Two-component scheme: III generation cephalosporins + + aminoglycoside.

One-component scheme: IV generation cephaloeporins; carbapenems; IV generation fluoroquinolones: grepafloxacin, levafloxacin, trovafloxacin.

The course of antibiotic therapy is 1-1,5 months with a change of antibiotic after 7-10 days.

Preference is given to intravenous and intra-arterial routes of administration of antibiotics; intraosseous methods are also possible, loading of cellular elements of the patient's autologous blood.

To increase the resistance of the patient's body, staphylococcal toxoid, anti-staphylococcal hyperimmune plasma, anti-staphylococcal γ-globulin are used. Direct blood transfusion from donors who have previously been immunized with staphylococcal toxoid is effective.

In order to improve peripheral circulation and detoxification, transfusion of Hemodez, rheopolyglucin is indicated.

When signs of metabolic acidosis and hypokalemia appear, it is necessary to transfuse concentrated glucose solutions with insulin, solutions of soda and potassium, disol, stabisol, reamberin.

Conservative treatment also involves careful nursing, good nutrition, immobilization of the limb with a plaster cast and physiotherapy.

The most rational method of surgical treatment is decompressive osteoperforation, which creates decompression of the bone marrow cavity, which is under increased pressure during inflammation of the bone marrow.

The burr holes formed in the cortical layer are the valves with the help of which the intraosseous pressure decreases, which, in turn, improves blood circulation in the bone marrow cavity, and, consequently, better contact of antibiotics with microflora. Milling holes perform a drainage function, and also provide pain relief.

Treatment of chronic hematogenous osteomyelitis, see "Post-traumatic osteomyelitis".

3. Atypical forms of hematogenous osteomyelitis

Brodie's abscess

Brodie's abscess is an intraosseous abscess, most often caused by pathogenic staphylococcus aureus. The disease develops imperceptibly for the patient, without clear clinical manifestations. Sometimes it can begin acutely with a typical clinical picture of hematogenous osteomyelitis.

The clinic of the disease in the stages of an already formed abscess is poor: aching pains in the area of ​​the metaphysis of the bone, aggravated at night and after physical exertion, local soreness. There is no general reaction to an existing abscess, but it is possible with an exacerbation of the disease.

In the anamnesis, there is an increase in body temperature, as well as pain syndrome, which was mistakenly associated with some kind of injury.

X-ray diagnostics. In the spongy substance of the metaphysis of the tibia (80% of lesions), a cavity of a round or oval shape with outlined contours and perifocal osteosclerosis is determined. Periosteal changes are not observed in all patients.

During surgery, pus and a pyogenic membrane lining the inner wall of the cavity are found in the cavity. After removing the pus, scraping the cavity until the walls bleed and washing it with antiseptic solutions, muscle or bone grafting is performed, which ensures a stable recovery of patients.

Sclerosing osteomyelitis of Garre

Garre's sclerosing osteomyelitis begins subacutely, without sharp pains in the extremity, without hyperthermia. The formation of phlegmon and purulent fistulas is rare. The course of the inflammatory process is sluggish.

It is clinically characterized by pain (usually nocturnal) in the limb, dysfunction, moderate fever, increased ESR and leukocytosis.

X-ray - pronounced sclerosis of the diaphyseal part of the long tubular bone (often the tibia). Against the background of sclerosis, there are small (up to 0,5 cm in diameter) foci of rarefaction of bone tissue. The medullary cavity narrows over time and can become completely sclerotic; at the same time, the diaphysis of the bone becomes spindle-shaped thickened.

The conservative type of treatment is the main one and involves the introduction of antibiotics (preferably intraosseously or by electrophoresis), physiotherapy (UHF therapy), and radiation therapy.

Surgical treatment is complicated by the fact that it is very difficult to detect and eliminate many small osteomyelitic foci in a bone that is sharply sclerotic over a large extent, and their abandonment leads to a relapse of the disease, therefore, surgical treatment is indicated for a pronounced exacerbation of the disease with signs of abscess formation or phlegmon.

Ollie's albuminous osteomyelitis

Ollie's albuminous osteomyelitis from the very beginning proceeds without a pronounced picture of an infectious disease, with minor local changes on the limbs in the form of a slight infiltration of soft tissues and slight hyperemia of the skin.

A feature of this form is that instead of pus, a serous, protein-rich or mucin-rich liquid accumulates in the focus, with the sowing of which it is sometimes possible to sow staphylococcus or streptococcus.

Pathogenesis. Due to the low virulence of the pathogenic flora or the high level of immunoreactivity of the organism, suppuration does not occur in the primary hematogenous osteomyelitic focus.

Inflammation stops at the first stage - exudation. The sluggish course of the disease is sometimes complicated by bone destruction with the formation of sequesters or secondary infection.

Treatment is surgical, pursuing the elimination of the focus of chronic inflammation.

4. Post-traumatic osteomyelitis

In a number of purulent complications of open and gunshot fractures of the bones of the limbs, a special place is occupied by wound (post-traumatic) osteomyelitis, in most cases taking a chronic course, the treatment of which is not always effective.

Wound osteomyelitis includes:

1) post-traumatic osteomyelitis, complicating the course of open fractures;

2) gunshot - after various types of wounds;

3) postoperative - arising after surgical interventions for closed fractures, the consequences of injuries and orthopedic diseases;

4) post-radiation (radio osteomyelitis).

Post-traumatic osteomyelitis is a disease, not a local process, since it arises from general and local causes and, having already developed, causes damage to the organs and systems of the patient.

The pathoanatomical essence of the developed osteomyelitic process, regardless of whether the fracture has healed or not, is a picture of chronic suppuration, rejection of necrotic tissues, the presence of a sequestral box with sequesters, fistulous tracts, possibly secondary involvement in the purulent process of the bone marrow cavity. All tissues of the limb (affected segment) are subject to pronounced inflammatory and deep dystrophic changes.

The clinic is characterized by acute, subacute and chronic course.

The acute stage is caused not only by severe destruction in the area of ​​the fracture, but also by blood loss and a violation of the patient's body's defenses. There is a high body temperature, pronounced changes in peripheral blood (increasing anemia, leukocytosis with a shift of the leukocyte formula to the left, accelerated ESR, etc.). Reduced immunoreactivity of the patient.

Locally there are intense pains in the injured limb, especially in the area of ​​the purulent focus, an increase in edema, and abundant discharge from the wound.

X-ray examination in most cases does not provide convincing information about the involvement of bone tissue in the inflammatory process.

Local thermometry and thermography, the study of peripheral blood supply, thermal imaging, scanning can help the doctor in determining the severity and prevalence of inflammation.

Subacute and chronic course is observed more often. In the presence of fistulas and good drainage of the purulent focus, the general condition of patients suffers slightly.

When examining the affected segment of the limb, the condition of the soft tissues, the presence of fistulas and their location, the level of the existing fracture are assessed, the amplitude of movements in the joints, the presence and magnitude of shortening of the limb are determined.

With pronounced trophic changes, it is necessary to conduct a study of the state of the blood circulation of the limb (rheovasography, pulse plethysmography, angiography, etc.).

Topical diagnosis includes primarily x-ray examination of the lesion.

Tomography, X-ray with direct magnification are used, in the presence of fistulas - fistulography with separate contrasting of each fistulous passage, tomofistulography. With osteomyelitis of the pelvic bones, especially the iliac wing, osteophlebography on the operating table can be used to determine the size of the lesion.

The study of microflora and the determination of its sensitivity to antibiotics.

Antibacterial therapy should be used in strict accordance with the data of the antibiogram. In the preoperative period, it is advisable to prescribe antibacterial drugs with an exacerbation of the osteomyelitic process, with the formation of phlegmon, abscesses, purulent streaks and pronounced symptoms of intoxication.

Previously, all purulent foci should be sufficiently open and fully drained.

During the operation and in the postoperative period, intraosseous or intravenous administration is used to create the highest concentration of antibacterial drugs in the lesion, and for extensive lesions with severe suppuration, intra-arterial or intra-aortic infusion is performed.

With a sufficiently radical surgical intervention and with a generally satisfactory condition of the patient, antibiotic therapy may not be carried out, but local antibiotics are used, preferably in combination with proteolytic enzymes.

Treatment. The main task in the treatment of chronic osteomyelitis is the radical elimination of the purulent-necrotic focus.

Tactics of surgical treatment of post-traumatic osteomyelitis depends on whether there is a union of the fracture or not.

With a fused fracture, necrosequestrectomy is performed with resection of the sclerotic walls of the sequestral box. The bone cavity formed in this case is replaced by blood-supplying tissues (preferably muscle flaps on the feeding leg).

If there is a defect in the skin, free skin grafting is performed. With pronounced cicatricial changes, Italian fasciocutaneous plasty, transmyoplasty or transplantation of a complex of tissues on a vascular pedicle using microsurgical techniques are used.

In the treatment of postoperative osteomyelitis, one should not rush to remove metal structures. Their immediate removal is indicated for bone marrow phlegmon with a severe clinical course. In all other cases, good drainage is necessary, if necessary, constant irrigation of the surgical wound is carried out, a full-fledged external plaster immobilization until the fracture heals.

In the future, an operation is performed for osteomyelitis, as with a fused fracture.

Treatment of osteomyelitis, combined with ununited fractures, false joints and bone defects, using non-focal transosseous osteosynthesis, allows you to simultaneously eliminate the osteomyelitis focus, achieve union of the fracture, the false joint, eliminate the deformity of the affected limb segment and achieve its lengthening.

Treatment of patients with ununited fractures and false joints in the absence of severe suppuration, the presence of small sequesters between fragments can be carried out without intervention on the bones using the above method. Osteomyelitis of the ends of the fragments is an indication for their resection.

In the postoperative period after wound healing, transverse osteotomies of one or both fragments are performed, and after 3-5 days, restoration of the limb length begins at a rate of no more than 1 mm per day.

In the postoperative period, great importance is attached to active drainage of wounds.

Long-term irrigation with antiseptic solutions in combination with antibiotics and proteolytic enzymes with simultaneous active drainage is carried out when it is not possible to carry out sufficient radicalization during the operation and perform plastic replacement of the bone cavity.

Oxygenobarotherapy is widely used for anemia, severe symptoms of intoxication (severe limb destruction, toxic-resorptive fever, sepsis, etc.).

Chemisorption is used in patients with metabolic disorders caused by an acute infectious process or long-term chronic inflammation.

Of great importance for the success of the operation is the timely and high-quality replacement of blood loss and all homeostasis disorders caused by surgical trauma.

In order to eliminate anemia, it is most advisable to transfuse freshly stabilized blood (preferably heparinized), red blood preparations (erythrocyte mass, freshly frozen washed erythrocytes), the use of drugs that stimulate hematopoiesis (polyfer, iron preparations, etc.).

To combat intoxication, microcirculation disorders, to replenish energy costs, various blood substitutes (hemodez, gelatinol, reopoliglyukin), amino acid preparations (aminosteril, hepasteril, etc.), fat emulsions, concentrated glucose solutions (20%, 25% and 40%) with insulin, polyionic solutions. It is advisable to prescribe vitamins, especially ascorbic acid, in large doses, the use of anticoagulants (primarily heparin), antihypoxants, antihistamines, protease inhibitors.

The treatment of gunshot osteomyelitis has a number of features that are due to significant damage to soft tissues not only in the area of ​​the wound channel, but also far beyond it. This creates the prerequisites for suppuration of the wound and the development of osteomyelitis. In case of gunshot osteomyelitis, one should adhere to expectant tactics and not rush to perform radical operations until the patient's condition returns to normal.

In a severe general condition, a pronounced suppurative process with necrosis of the ends of fragments, in order to stop the infectious process and save the patient's life, it is necessary to carry out a radical operation with bone resection as soon as possible and more completely. In osteomyelitis after open and gunshot fractures with tissue destruction bordering on the viability of the limb, a possible outcome of treatment should be foreseen and, if it concerns injuries of the lower limb, the question of amputation should be raised.

Complications of hematogenous and post-traumatic osteomyelitis are local and general.

Local complications include: abscesses and phlegmons of soft tissues, purulent osteoarthritis, epiphyseolysis, thrombophlebitis, distension and destructive dislocations, spontaneous fractures, pseudoarthrosis, contractures, ankylosis, bone deformities, varicose veins, hemorrhages, soft tissue atrophy, malignant degeneration of fistulas and ulcers .

Complications of a general nature include: secondary anemia, sepsis, amyloidosis.

Author: Zhidkova O.I.

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