Traumatology and orthopedics. Cheat sheet: briefly, the most important

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Traumatology and orthopedics. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Directory / Lecture notes, cheat sheets

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Table of contents

General questions of survey methodology
Features of examination and palpation of orthopedic patients
Ausculpation, percussion and measurement of the length and circumference of the limbs
Determination of the function of the musculoskeletal system
X-ray examination and other examination methods
Hard and hardening dressings
Prosthetics and apparatus therapy
Contusion and compression of soft tissues and bones
Ligamentous, tendon and muscle injuries
Damage to blood vessels and nerves
Soft tissue wounds
The concept of traumatic dislocation of the jaw, vertebrae, collarbone
Dislocations of the shoulder, forearm, finger, hand, hip
Traumatic fractures
General principles for the treatment of bone fractures
Closed fractures of the clavicle and shoulder
Forearm fractures
Fractures of the bones of the hand
Hip fractures
Diaphyseal fractures of the femur
Injuries in the knee joint
Fractures of the shin bones
Fractures of the bones of the foot
Spinal injuries
Pelvic fractures
Breast fractures
Open injuries of the musculoskeletal system
Limb amputations
Amputation methods
Amputation pain
Traumatic shock
Qualified anti-shock measures
Prolonged Crush Syndrome (SDR)
Disaster Medical Assistance
Fibrous osteodystrophies
Common forms of fibrous osteodystrophy
Fibrous bone dysplasia
Osteochondropathy
Osteochondropathy of the apophyses of the vertebrae and articular surfaces
bone tumors
Benign bone-forming tumors
Malignant bone-forming tumors
Benign cartilaginous tumors
Malignant cartilaginous tumors
Primary reticuloendothelial tumors
scoliosis
flat foot
Osteomyelitis. Etiology and pathogenesis of hematogenous osteomyelitis
Treatment of acute hematogenous osteomyelitis
Atypical forms of hematogenous osteomyelitis
Post-traumatic osteomyelitis
Diagnosis and treatment of post-traumatic osteomyelitis
Surgical treatment of osteomyelitis
Conservative treatments for fractures
Fractures of the lower end of the radius

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.

The survey plan includes the following diagnostic studies:

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.

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.

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.

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.).

With neoplasms, it is necessary to establish the duration and nature of the course of the disease.

2. Features of examination and palpation of orthopedic patients

Examination of the patient is crucial for the diagnosis of the disease and differential diagnosis. Victims with multiple fractures usually complain about the most painful places.

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.

Distinguish limb position:

1) active - a person freely uses a limb;

2) passive - the patient cannot use the limb due to paralysis or bone fracture;

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;

b) associated with morphological changes in tissues or disorders of relationships in the articular ends;

c) pathological attitudes, which are a manifestation of compensation.

When examining the skin, a change in color, color, localization of hemorrhage, ulceration, 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.

RџSЂRё examination of the joints determine the shape and contours of the joint, 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;

2) defiguration;

3) deformations.

When examining the shoulder joint, you can notice muscle atrophy or restriction of movement of the shoulder and shoulder girdle.

Examination of the knee joint is carried out at rest and during exercise. Deformation of the joint, its contracture or instability are revealed.

Foot examination 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.

Back examination performed in diseases of the spine. The patient must be undressed and undressed. Inspection is carried out from the back, front and side.

After a preliminary determination of the place of manifestation of the disease, they begin to palpate the deformed or painful area. 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 should be separate.

To determine the pain, you can use tapping on the spine, hip joint and pressure along the axis of the limb or load in certain positions. Local pain is determined by deep palpation.

3. Ausculpation, percussion and measurement of the length and circumference of the limbs

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.

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.

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, the navel, spina ilica anterior superior, the tip of the greater trochanter, the condyles, the ankles, etc.

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. 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.

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.

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 relative length of the lower limb is determined by measuring in a straight line from the anterior superior iliac spine to the foot.

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).

2. Relative shortening (lengthening).

3. Total shortening (lengthening).

4. Projective (apparent) shortening.

5. Functional shortening.

The circumference of a segment of a limb or joint is measured with a centimeter tape at symmetrical levels of both limbs. A decrease or increase in the circumference of the joint is determined.

4. Determination of the function of the musculoskeletal system

Functionality of the musculoskeletal system are determined by:

1) range of motion in the joints;

2) compensatory capabilities of neighboring departments;

3) muscle strength.

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.

Mobility begins to be investigated from the amplitude of active movements in the joint, then it is necessary to proceed to the establishment of the boundaries of passive mobility and to establish the nature of the obstacle.

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°.

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.

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 - limitation of passive mobility in the joint.

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

Definition muscle strength carried out with a Colin dynamometer.

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

Gait changes can be very diverse, but lameness is the most common. There are the following types:

1) sparing lameness;

2) unforgiving lameness.

With sparing lameness, the patient avoids fully loading the affected leg, spares it.

Unsparing lameness, or "falling", is characteristic of shortening of the limb.

"Duck" gait - the body alternately deviates in one direction or the other.

Clubfoot. 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 leg lengthening due to deformities in the ankle or foot joints. Paralytic (paretic) gait occurs with isolated paralysis, paresis of individual muscles.

Spastic gait is observed with an increase in muscle tone in spastic paralysis. The legs of the patients are stiff, the patients move in small steps, with difficulty raising the feet.

It is most convenient to study the function of the upper limbs by offering the patient to first make a number of separate movements - abduction, adduction, flexion, extension, external and internal rotation.

5. X-ray examination and other examination methods

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 methods for examining 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.

joint puncture, subdural space, soft tissue and bone tumors, cysts are produced 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.

Spinal puncture produced 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.

6. Hard and hardening dressings

Bandage - this is a set of tools designed to protect the 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).

Firm 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. 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.

After applying the bandage, the condition of the limb is monitored for 2 days.

Types of plaster bandages.

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.

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.

Bandages target: 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.

7. Prosthetics and apparatus therapy

Prosthetics in orthopedics is divided into anatomical and medical.

Anatomical prosthetics is aimed at anatomical or functional replacement and replacement of the missing limb with a prosthesis.

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.

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

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.

Medical prosthetics 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 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.

Apparatus therapy It is used for the prevention and treatment of deformities of the musculoskeletal system after diseases or injuries (such as: poliomyelitis, spastic paralysis, spinal cord injuries after surgical interventions, etc.).

Therapeutic and training prostheses are lockless devices that create the possibility of fixing the knee joint when standing and free movement when walking, 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.

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.

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.

8. Contusion and compression of soft tissues and bones

bruised called closed damage to tissues and organs without violating the integrity of the skin, resulting from direct mechanical action. Bruises occur due to the blow of open parts of the body (more often - the limbs and head) on a solid object.

severity and character Damage caused by bruising of the skin and underlying tissues (subcutaneous tissue, blood vessels, muscles, periosteum) depends 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.

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

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 \uXNUMXb\uXNUMXbthe joints, the injured limb is given rest with the help of a pressure bandage, scarf, splint, elevated position.

With a tense subcutaneous hematoma, its puncture is performed.

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 hemarthrosis, after puncture of the joint with its subsequent immobilization for 10-14 days, physiotherapeutic procedures, physiotherapy exercises and massage are prescribed.

compression - this is damage in which the anatomical continuity of the compressed tissues is not disturbed, but due to the duration of the action of the traumatic force, dystrophic changes develop in them, leading to rapid swelling of the damaged part of the 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.

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.

9. Damage to the ligamentous apparatus, tendons and muscles

Damage to the ligaments of the joints occurs, as a rule, with sudden impulsive movements in the joint. The most common injuries are the ligaments of the ankle, interphalangeal, wrist and knee joints.

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.

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

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). In case of severe damage, a novocaine-alcohol blockade is performed, enzymes or hydrocortisone are injected, and a plaster splint is applied for 30 days. If a complete rupture of the ligaments is suspected, the limb is immobilized.

Knee ligament injury

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

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. In the hospital, after a control radiography, a knee joint puncture is performed, novocaine solution with enzymes or hydrocortisone is injected, and a circular plaster bandage is applied for 4-5 weeks.

Tendon injury is the result of a direct blow to a tense tendon or a sudden movement of a limb segment.

May be complete or partial.

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. When the tendon is damaged, the function of flexion or extension is impaired, depending on the type of tendon.

First aid: immobilization of the limb with a plaster splint (tire) in a position that ensures convergence of the ends of the tendon, the introduction 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.

Muscle injuries include ruptures, which are accompanied by damage to the fascia and the formation of a hematoma.

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.

10. Damage to blood vessels and nerves

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

With a closed injury, interstitial hemorrhage, sometimes a pulsating hematoma, and acute circulatory disorders are noted.

Damage to the vessel during injury is accompanied by external bleeding.

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.

With severe arterial bleeding, a hemostatic tourniquet is used.

The final stop of bleeding is achieved by ligation of the vessel or the imposition of a vascular suture. 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. Damage to the peripheral nerves is more often a concomitant injury with fractures of long bones or soft tissue injuries.

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

With damage to the radial nerve (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.

In case of damage to the ulnar nerve III, IV, V, the 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. If the median nerve is damaged, the ability to pronate 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.

When the sciatic nerve is damaged, the muscles of the foot and part of the lower leg are paralyzed. The flexion of the leg is broken.

When the femoral nerve is damaged, paralysis of the quadriceps femoris muscle occurs, which leads to impaired leg extension.

When the peroneal nerve is damaged, the muscles that perform dorsiflexion and abduction of the foot are paralyzed. The foot sags.

When the tibial nerve is damaged, the function of the muscles that flex the foot and fingers is disrupted. 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.

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.

11. Soft tissue injuries

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.

Chopped wounds are formed when a sharp weapon is lowered onto the skin at an angle.

Stab wounds are the result of deep penetration of a sharp, thin instrument. Possible injury to the cavities or joints.

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 as a result of the impact of a blunt instrument with a wide surface when opposed to a solid support.

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.

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 lower leg, massive detachments of muscle groups and exposure of the bone over a large extent.

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.

First aid when injured, it 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.

12. The concept of traumatic dislocation of the jaw, vertebrae, collarbone

Traumatic dislocation - this 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.

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.).

Dislocation of the lower jaw 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.

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.

Dislocations of the vertebrae are most often found in the cervical region in young people.

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.

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

After reduction of the dislocation, a long-term immobilization is performed with a thoracocranial plaster cast (semi-corset).

Dislocations of the collarbone There are 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.

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. 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.

13. Dislocations of the shoulder, forearm, finger, hand, hip

Shoulder dislocations most often caused by indirect injury (falling on the abducted arm).

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.

In most cases, it is possible to close the reduction of the dislocation under local intra-articular or general anesthesia using the method of A. A. Kudryavtsev. 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.

Dislocations of the forearm are found 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.

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.

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.

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

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 begins. Immobilization is carried out for 5 days.

Hip dislocations occur rarely 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.

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

Treatment: immediately under anesthesia, a closed reduction of hip dislocation is performed according to the Janelidze or Kocher-Kefer method.

14. Traumatic fractures

A bone fracture is a damage to the bone with a violation of its integrity, resulting from the action of an external mechanical factor.

Classification

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

1. 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.

2. 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).

3. Types of fractures:

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.

4. Along the line of bone fracture There are fractures transverse, oblique, helical, longitudinal and comminuted.

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

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.

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.

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.

15. 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 vital body systems, i.e., they can be one of the main causes of traumatic shock.

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.

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 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.

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.

16. Closed fractures of the clavicle and shoulder

The clavicle often breaks in the middle third, a typical displacement of fragments occurs. In case of clavicle fractures without displacement of fragments, an eight-shaped soft bandage is applied for 3-4 weeks. Reposition of fragments is carried out after preliminary anesthesia. Then the entire shoulder girdle, together with the distal fragment, is displaced upward and backward. Shoulder fractures are divided into fractures in the upper, middle and lower third of the humerus.

Fractures of the head and 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.

Fracture of the surgical neck of the shoulder. In this case, an impacted fracture or a fracture with displacement of fragments occurs. Fractures of the surgical neck of the shoulder with displacement of fragments are divided into abduction and adduction. 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. Shaft fractures of the shoulder occur 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. Treatment of fractures of the diaphysis of the shoulder is carried out on the outlet (abduction) splint. Fractures of the lower end of the humerus are divided into supracondylar (extraarticular) and transcondylar (intraarticular). Supracondylar (extra-articular) fractures can be extensor or flexion.

For 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. The distal fragment is displaced posteriorly and outwards, and the proximal fragment is displaced anteriorly and medially.

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. A transcondylar fracture is an intra-articular fracture. Since the fracture line passes through the zone of the epiphysis, the fracture can be called epiphysiolysis.

Intercondylar fractures, or T- and U-shaped fractures, occur when you fall on your elbow. Clinically, T- and U-shaped fractures are manifested by massive intra- and extra-articular hemorrhage. Fracture of the lateral condyle occurs when falling more often on an outstretched arm. The radius breaks off and displaces the external condyle upward.

Fracture of the internal condyle occurs when falling on the elbow. The impact force is transmitted through the olecranon to the internal condyle, breaking it off and shifting it inward and upward. A fracture of the capitate eminence of the shoulder occurs when falling on an outstretched arm. Fractures of the supracondylar eminences (internal and external) can be observed when falling onto an outstretched arm.

17. Fractures of the bones of the forearm

Fractures of the olecranon occur more often when falling on the elbow. The fracture line penetrates the joint. Clinically, the fracture is expressed by local pain, swelling and hemorrhage, restriction of movement. Radiography specifies the degree of divergence of fragments.

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.

Fracture of the coronoid process occurs with a posterior dislocation of the forearm and is accompanied by local pain.

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 occurs when falling on an outstretched hand. 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.

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

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.

Treatment consists in comparing peripheral fragments along the central axis.

Fractures without displacement of fragments, subperiosteal, with angular or rotational displacement are treated conservatively.

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

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

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°.

Fracture-dislocation Galeazzi called "reverse Monteggi" because 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.

18. Fractures of the bones of the hand

Scaphoid fracture 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.

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.

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

Often, a fracture of the navicular bone does not heal, which is the reason for surgical treatment.

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

Metacarpal fractures occur with direct and indirect trauma.

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

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.

Under local anesthesia, the fragments are repositioned: first, the extension and abduction of the first finger together with the metacarpal bone are carried out, then pressure is applied to the base of the first metacarpal bone from the radial side. The achieved reposition is fixed with a plaster cast for 4 weeks.

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°.

periarticular fractures, as well as non-repairing diaphyseal fractures are treated surgically: 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.

Fractures of fingers more often come 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.

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.

19. Hip fractures

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.

Intra-articular (medial) neck fractures the hips are subdivided 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 fractures of the femoral neck are more common in middle-aged people and occur during a fall on the abducted leg or on the trochanteric region.

With such a fracture, patients continue to walk, complaining of pain in the hip or knee joints.

The leg loses support and there are clinical signs of a fracture with a divergence of the fragments.

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 skin 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.

Adduction fractures of the femoral neck 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.

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 2-2 cm, the Roser-Nelaton line is disturbed, a positive symptom of "adhering heel" is noted, pain during axial load and palpation under the pupart ligament. Skeletal traction is removed after 3-XNUMX weeks, and the patient learns to walk on crutches.

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.

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 a large skewer.

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

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.

20. Diaphyseal fractures of the femur

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

Subtrochanteric fractures are localized in the area under the lesser trochanter and extend 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.

In supracondylar fractures, the distal fragment can shift 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.

21. 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 femoral condyles - these are isolated fractures of one condyle, more often 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.

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.

Fractures of the patella. 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 clinic is characterized by pain, restriction of movement. The leg is extended. The contours of the joint are smoothed.

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. 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 more 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. 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.

Clinical symptoms: symptom of "blockade", symptom of "ladder", atrophy of the thigh muscles and relief of the sartorius muscle, anesthesia or hyperesthesia of the skin in the area of the inner surface of the knee joint.

In cases where swelling of the joint and symptoms of meniscus injury 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.

22. Fractures of the bones of the lower leg

Diaphyseal fractures of the leg bones subdivided 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.

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.

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.

Ankle fractures account for about half of all hip 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.

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).

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

Before applying a plaster splint for 4 weeks, anesthesia is performed.

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.

23. Fractures of the bones of the foot

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

In case of fractures of the body or neck of the talus without displacement of the fragments, a plaster cast is applied to the knee joint.

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 occurs when falling from a height on the heels. These fractures are divided according to the type of fracture: transverse, longitudinal, marginal, multi-comminuted, compression.

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

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.

If the reposition fails, an open reduction is performed.

Without removing the skeletal traction, a U-shaped, then a circular plaster cast is applied for 10-1 weeks.

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

Clinically appear local moderate pain and slight swelling.

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

Metatarsal fractures most often occur with direct trauma. There is local swelling and pain. 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.

Fractures of the toes recognized without much difficulty. Local swelling and pain, pathological mobility and crepitus of fragments are noted.

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.

24. Spinal injuries

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.

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.

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.

RџSЂRё flexion fractures of the cervical vertebral bodies 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.

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. Fractures of the bodies of the thoracic and lumbar vertebrae are more often compressive and have a flexion or compression mechanism of fractures. These injuries are divided into stable and unstable, as well as uncomplicated and complicated.

Pain 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, are noted. There is tension in the back muscles. 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.

Damage to 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. 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).

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.

25. Pelvic fractures

All fractures of the pelvic bones are divided into group IV.

I group. Isolated fractures of the pelvic bones not involved in the formation of the pelvic ring.

1. Tears of the anterior superior and inferior iliac spines. Fragments move down.

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

2. Fractures of the wing and iliac crest occur.

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 pain and swelling.

4. Fracture of the sacrum below the sacroiliac joint.

Clinic: local pain and subcutaneous hematoma.

5. Fracture of the coccyx.

Clinic: local pain, aggravated by a change in position.

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 breaking its continuity.

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

This fracture is characterized by local pain that worsens when turning to the side.

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.

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

1. Fractures of the anterior section:

These types of fractures of the anterior pelvic half ring are characterized by pain in the symphysis and perineum.

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

2. Fractures of the posterior section:

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

3. Combined fractures of the anterior and posterior sections:

As a rule, with such fractures, patients develop traumatic shock, local pain on palpation.

Anti-shock measures are being taken.

IV group. Fractures of the acetabulum.

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).

26. Breast fractures

Rib fractures 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.

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.

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.

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.

With large "valves", skeletal traction is carried out for broken ribs using bullet forceps or thick nylon threads, held pericosteally. 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 occur infrequently 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.

There is swelling, local pain, limitation of function, sometimes crepitus of fragments is noted.

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.

27. 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.

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.

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.

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.

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.

The most common method is directed rational antibiotic and antimicrobial chemotherapy.

With extensive injuries, local administration of antibacterial agents in the first 6-8 hours in the wound circumference is especially indicated in the form of anti-inflammatory blockades according to Rozhkov.

3. Complete immobilization of the injured limb, primarily with a plaster cast or with the help of an extrafocal transosseous osteosynthesis apparatus.

4. Normalization of homeostasis disorders.

5. The use of drugs that normalize the immunoreactivity of the victim.

28. 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.

Absolute readings 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 readings to 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.

Amputation methods limbs 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.

29. Methods of amputation

Guillotine method - 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.

circular way involves the 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 part of the 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 amputation, in which the bone sawdust is closed with skin-fascial flaps.

The method of high fasciocutaneous amputation of the lower leg was developed to preserve the knee joint during limb amputation due to vascular diseases.

Myoplastic method 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.

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.

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.

30. 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.

Treatment 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. 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.

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.

Illusory-pain symptom complex characterized by a sensation of an amputated limb, in which burning, aching pain persists 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.

Hypnotherapy and novocaine blockade of the nodes of the boundary trunk often give a favorable result.

31. Traumatic shock

Traumatic (hypovolemic) shock - this is an acute and severe dynamic state of the body, which occurs as a result of injury and is characterized by inhibition of the vital functions of the body.

The reason traumatic shock is a decrease in the effective volume of circulating blood (BCC) (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).

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.

Torpid phase (oppression).

I degree (light). The condition of the victim is satisfactory or moderate. BP - 100/80 mm Hg. Art., pulse soft, rhythmic, 80-100, breathing speeded up to 20 breaths per minute. The face is pale, mask-like.

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.

III degree (severe). Severe condition. Arterial pressure drops to 70/50 mm Hg. Art. and lower, and sometimes not caught at all. Pulse - 140-150, threadlike. The pupils are dilated, sluggishly react to light.

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.

32. 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.

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 in 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.

2. Normalization of excitation and inhibition processes in the central nervous system. The victim must be kept calm.

3. Restoration of circulating blood volume. 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.

Albumin and plasma protein fraction effectively increase the volume of intravascular fluid, but increase fluid leakage into the interstitial lung tissue.

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 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.

The frequency, rhythm and strength of heart contractions allow you to evaluate the function of the cardiovascular system and the effectiveness of infusion therapy.

Measurement of CVP reveals hypovolemia and reflects the function of the heart, allows you to evaluate the effectiveness of infusion therapy.

33. Prolonged Crush Syndrome (SDR)

Under SDR understand the general reaction of the body that has arisen in response to pain, prolonged ischemia or degenerative changes that occur in tissues during prolonged crushing of 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.

Clinic. There are periods of SDR.

I - the 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 pain in the injured limb, swelling, purplish-bluish coloration of the skin and limitation of movement in the injured limb, 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.

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.

In parallel, the general condition worsens.

Pallor, cold sweat, rapid pulse, decreased blood pressure and diuresis appear; the amount of urine decreases sharply (up to 300 ml per day). Local changes: hemorrhages, abrasions, blisters filled with serous fluid appear on the skin in the compression zone. The pulsation of the vessels of the affected limb weakens as the edema increases.

Against the background of deepening acute renal failure, intermediate metabolic products and water are retained in the body.

Toxemia is increasing due to ischemic muscle necrosis and plasma loss, oliguria and azotemia, and a decrease in blood pressure. All this can lead to death from uremia.

Late period 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.

Complete recovery of the function of crushed muscles does not occur.

34. Medical assistance in case of disasters

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.

1. Anti-shock 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 BD in 6 hours; kontrykal, gordoks on 100000 DB 2 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 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.

35. 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 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.

X-ray examination determines the focus of enlightenment, located in the center of the bone, having a large-cellular pattern and the correct geometric shape (ovoid, fusiform, pear-shaped, etc.). The contours of the cyst are completely smooth and sharply defined.

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.

36. Common forms of fibrous 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.

In most cases, this is a benign adenoma of one of the parathyroid glands. Very rarely, diffuse hyperplasia of all bodies is determined.

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.

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).

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 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 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.

Changes in the spine lead to the development of "fish vertebrae".

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.

Deforming osteodystrophy (Paget's disease) - a disease of the skeleton of a dysplastic nature with pathological restructuring and the development of deformity.

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.

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.

Treatment is exclusively symptomatic.

37. 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 - a disease of older childhood. It begins 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.

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.

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. 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. 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.

38. 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.

Osteochondropathy of the femoral head (Legg-Calve-Perthes disease) is one of the most common osteochondropathy.

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.

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.

Osteochondropathy of the tibial tuber (Osgood-Schlatter disease). The lesion of the tibial tuberosity is usually unilateral. Spontaneous pains appear in the area of the tibial tuberosity.

Treatment It consists in limiting walking, running, physical education. Physiotherapy procedures are prescribed. Osteochondropathy of the navicular bone of the foot (Kohler-I disease) is rare and occurs after an injury. 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.

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.

Osteochondropathy of the head of the II and III metatarsal bones (Alban Koehler-II disease) is predominantly found in young women.

Pain in the foot gradually progresses, intensifying while walking. Change of shoes, moderate walking lead to clinical recovery.

Treatment it is carried out conservatively: the load on the leg is reduced, physiotherapy is carried out, it is recommended to wear arch supports that unload the forefoot.

Osteochondropathy of the semilunar bone of the wrist (Kinböck's disease).

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.

Treatment. The best results are obtained by scraping necrotic masses with a sharp spoon without removing the thickened cartilaginous part of the bone.

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.

After a fall or bruise, pain appears in the area of the affected vertebra.

Treatment. Complete unloading of the spine is required with the help of bed rest and reclination (for the entire period of vertebral regeneration).

39. Osteochondropathy of the apophyses of the vertebrae and articular surfaces

Osteochondropathy of the vertebral apophyses (juvenile kyphosis, osteochondropathic kyphosis), or Scheuermann's disease - May, 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.

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.

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.

Treatment 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.

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.

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.

Clinic 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.

In the clinical course, stage II is determined.

I stage - 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.

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".

40. Bone tumors

The bone has a multitissue structure, and tumors of various histogenesis can develop in it.

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.

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.

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 uncertain.

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.

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.

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 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.

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.

41. 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. Osteomas most often affect the bones of the skull, spongy and mixed.

Often located in long bones, mainly in the femur and humerus.

Clinical manifestations depending on localization, most often proceed painlessly.

Surgical treatment - knocking down 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.

The main localization is the diaphysis of long bones, sometimes it is also found in the pelvic bones.

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.

Common treatment method - radical surgical removal of the focus ("nest" of the tumor) as a single block with the surrounding strip of sclerotic bone tissue.

Osteoblastoclastoma (giant cell tumor) is a primary single bone tumor of a benign nature with predominant localization at the ends of the tubular bones: femur, tibia, radius, etc. The tumor affects the spongy tissue, grows slowly, reaching the border of the articular cartilage.

Clinical classification (V. Ya. Shlapobersky, 1960)

benign forms.

Group I (with a calmer course, radiographically - cellular).

Group II (with a more aggressive course, X-ray - lytic).

Group III - recurrent form.

Malignant forms:

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.

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.

In recurrent and malignant forms of the tumor, combined methods of treatment are used, combining radiation and chemotherapy with bone resection or limb amputation.

42. Malignant bone-forming tumors

Osteogenic sarcoma - 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.

Osteogenic sarcoma is a monoosseous disease, extremely aggressive, prone to early, predominantly hematogenous metastasis, most often to the lungs (60-95%), and possibly to other parts of the skeleton and lymph nodes.

Clinically, there are 2 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.

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.

Treatment complex, including radiation and chemotherapy, surgical intervention. 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.

clinical picture characterized by prolonged (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.

The method of choice for treatment paraosteal osteogenic sarcoma is considered 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.

43. 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.

clinical picture - non-specific and consists of the presence of a tumor, pain syndrome, dysfunction of the limb.

X-ray chondroblastoma is manifested by small foci of destruction 2 g per 5 cm, located eccentrically with respect to the bone. The focus is clearly delimited from healthy bone by a sclerotic strip.

RџSЂRё treatment the method of choice is segmental resection with bone grafting.

44. 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.

clinical picture 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 tissues.

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.

45. Primary tumors from reticuloendothelial tissue

Myeloma (multiple myeloma, or the disease of O. A. Rustitsky) 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 4 varieties:

1) multiple focal;

2) diffuse-porotic;

3) osteosclerotic;

4) solitary.

Multiple focal myeloma mainly affects the flat bones of the skull, pelvis, spine, sternum, and less often long bones. Multiple myeloma is more common in middle-aged men, but children and the elderly may 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 Bene-Jones protein and metastases to the spleen, liver, and lymph nodes. Cachexia, anemia, hyperproteinemia, hypercalcemia develop, ESR accelerates.

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 often observed.

Diagnostics multiple myeloma is often difficult because of 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 Bene-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.

46. 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.

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.

Clinical course depends on the type of scoliosis, the age of the child, 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.

Wrong posture at the desk is the initial provocative moment in the formation of scoliosis against the background of rickets.

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).

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.

Paralytic scoliosis can progress even after the end of skeletal growth.

Idiopathic scoliosis occurs in children and the cause is unknown.

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.

Surgical treatment is carried out with scoliosis III and IV degrees and with the failure of conservative treatment.

47. 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 according to the severity of deformation has III degree.

I degree - fatigue of the legs and pain in the calf muscles after a long walk.

II degree - pain syndrome, there are signs of deformity of the foot.

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 outwards and supinated in relation 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.

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.

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 getting 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.

Treatment foot deformities begins with the prevention of flat feet in children: dosed physical exercises, prevention of excessive overload, wearing rational shoes are recommended.

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.

48. Osteomyelitis. Etiology and pathogenesis of hematogenous osteomyelitis

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.

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 growth exfoliates with pus that has penetrated from the bone marrow space through the bone channels 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).

49. Clinical picture of hematogenous osteomyelitis

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, they increase in size, may be purple.

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).

50. 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 b-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 cephalosporins; 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 by which the intraosseous pressure is reduced.

51. Atypical forms of hematogenous osteomyelitis

Abscess Brody.

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.

Clinic diseases in the stages of an already formed abscess are 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.

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.

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.

Treatment surgical, pursuing the elimination of a focus of chronic inflammation.

52. 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.

Clinic 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 the 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.).

53. Diagnosis and treatment of post-traumatic osteomyelitis

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.

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.

54. Surgical treatment of osteomyelitis

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 extrafocal 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.

55. Conservative methods of treatment of fractures

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.

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, with compression fractures of the vertebral bodies, etc.

Skeletal traction is most often used in the treatment of bone fractures with displacement of fragments. The needle is passed through the bone at certain points, then it is fixed and stretched in a Kirschner or CITO 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.

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.

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.

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

1) open reposition of fragments without their additional fixation;

2) open reposition of fragments with fixation using various metal structures.

56. 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 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 outward, 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.

Author: Zhidkova O.I.

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