Therapeutic physical culture in reconstructive and restorative operations after amputation of the upper limbs. Amputation and disarticulation of the phalanges of the fingers Amputation of the distal phalanx

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

It is difficult for most of us to imagine solving ordinary household tasks and professional activities without fingers. On the feet, they are needed for support and proper walking; on the hands, fine motor skills allow not only to carry out the necessary self-service skills, but also provide writing.

Unfortunately, there are situations in life when the feet and hands undergo irreversible changes, in which all organ-preserving methods of treatment cannot ensure the preservation of tissues, therefore, it becomes necessary to amputate the finger.

Amputations due to trauma and persistent unsatisfactory results are carried out only in cases where the possibilities of more gentle treatment have been exhausted or it is not feasible due to the extent of the lesion. In other words, such an operation will be performed when saving a finger is simply impossible:

• Traumatic injuries, finger avulsions, severe crushing of soft tissues;
• Severe burns and frostbite;
• Necrosis of the fingers due to vascular disorders (diabetes mellitus, primarily thrombosis and embolism of the vessels of the hands and feet);
• Acute infectious complications of injuries - sepsis, abscess, anaerobic gangrene;
• Trophic ulcers, chronic osteomyelitis of the bones of the fingers;
• malignant tumors;
• Congenital malformations of the osteoarticular apparatus of the fingers, including amputation of the toes in order to transplant them to the hand.

After the removal of the fingers and toes, the patient becomes disabled, his life changes significantly, so the question of the need for such an intervention is decided by a council of doctors. Of course, surgeons will try to the last to use all available ways to save fingers and toes.

If treatment is necessary for health reasons, then the consent of the patient is not necessary. It happens that the patient does not agree to the operation and there are no absolute indications for it, but leaving a sore finger can cause serious complications, including death, so doctors try to explain to the patient and his relatives the need to remove the fingers and get consent as soon as possible.

Before the operation, the doctor tells the patient in detail about its essence, and also chooses the most optimal option for prosthetics, if necessary, or plastic surgery, so that the cosmetic result is the most beneficial.

There are, in fact, no contraindications to amputation of a finger or toe. Of course, it will not be carried out when the patient is in an agonal state, but the transition of necrosis to the overlying parts of the limbs or a high risk of complications when only a finger is removed can become an obstacle to surgery. In such cases, amputation of the fingers is contraindicated, but a large operation is needed - at the level of large joints, etc.

Preparing for the operation

Preparation for surgery depends on the indications for its implementation and the patient's condition. In case of planned interventions, the usual list of tests and studies is required (blood, urine, fluorography, cardiogram, tests for HIV, syphilis, hepatitis, coagulogram), and to clarify the nature of the lesion and the expected level of amputation, x-rays of the hands and feet, ultrasound, determination of the sufficiency of work are performed vascular system.

If there is a need for an urgent operation, and the severity of the condition is determined by the presence of inflammation, infectious complications and necrosis, then antibacterial agents and infusion therapy will be prescribed during preparation to reduce the symptoms of intoxication.

In all cases when an operation on the hands and feet is planned, blood-thinning agents (aspirin, warfarin) are canceled, and the attending physician should be warned about taking drugs of other groups.

Anesthesia for amputation of fingers is often local, which is safer, especially in the case of a serious condition of the patient, but quite effective, because pain will not be felt.

In preparation for the amputation or disarticulation of the fingers, the patient is warned about its result, it may be necessary to consult a psychologist or psychotherapist, who can help reduce preoperative anxiety and prevent severe depression after treatment.

Amputation of fingers

The main indication for amputation of the fingers is an injury with their complete or partial separation. With detachment, the surgeon is faced with the task of closing the skin defect and preventing scar formation. In the case of severe crushing of soft tissues with their infection, there may not be opportunities to restore adequate blood flow, and then amputation is the only treatment. It is also carried out with the necrosis of soft tissues and elements of the joints of the finger.

If several fractures have occurred during the injury, the bone fragments have shifted, and the result of organ-preserving treatment is a motionless crooked finger, then surgery is also necessary. In such cases, the absence of a finger brings much less discomfort when using a brush than its presence. This reading does not apply to the thumb.

Another reason for the amputation of the fingers can be damage to the tendons and joints, in which the preservation of the finger is fraught with its complete immobility, disrupting the work of the remaining fingers and the hand as a whole.

distribution of finger and hand amputations by prevalence

The choice of amputation height depends on the level of damage. The fact is always taken into account that a fixed or deformed stump, a dense scar interferes with the work of the hand much more than the absence of the entire finger or its separate phalanx. When amputating the phalanges of long fingers, an operation that is too sparing is often performed.

When forming a stump, it is important to ensure its mobility and painlessness, the skin at the end of the stump should be mobile and not cause pain, and the stump itself should not be bulb-shaped thickened. If it is technically not possible to recreate such a stump, then the level of amputation may be higher than the edge of the damage to the finger.

During operations on the fingers, the localization of the lesion, the profession of the patient, and his age are important, therefore, there is a number of nuances that surgeons know and must take into account:

1. When amputating the thumb, they try to keep the stump as long as possible; on the ring and middle fingers, even short stumps are preserved to stabilize the entire hand during movements;
2. The inability to leave the optimal length of the stump of the finger requires its complete removal;
3. It is important to preserve the integrity of the heads of the metacarpal bones and the skin of the spaces between the fingers;
4. They try to keep the little finger and thumb as intact as possible, otherwise there may be a violation of the supporting function of the hand;
5. The need to amputate several fingers at once requires plastic surgery;
6. With severe contamination of the wound, the risk of infectious lesions and gangrene, plastic and sparing operations can be dangerous, therefore, a complete amputation is performed;
7. The profession of the patient affects the level of amputation (for mental workers and those who perform delicate work with their hands, it is important to carry out plastic surgery and preserve the length of the fingers as much as possible, for those who are engaged in physical labor, amputation to the maximum extent can be performed for speedy rehabilitation);
8. The cosmetic result is important for all patients, and in some categories of patients (women, people in public professions), it becomes crucial when planning the type of intervention.

(image: medical-enc.ru)

exarticulation- this is the removal of fragments or the entire finger at the level of the joint. For anesthesia, an anesthetic is injected into the soft tissues of the corresponding joint or into the area of ​​​​the base of the finger, then healthy fingers are bent and protected, and the operated one bends as much as possible, and a skin incision is made on the back side of the joint. When removing the nail phalanx, the incision goes 2 mm away towards the end of the finger, the middle one - 4 mm and the entire finger - 8 mm.

After dissection of the soft tissues, the ligaments of the lateral surfaces are intersected, the scalpel enters the joint, the phalanx, which is to be removed, is brought into the incision, the remaining tissues are intersected with the scalpel. The wound after amputation is covered with skin flaps cut from the palmar surface, and the sutures must be placed on the non-working side - the back.

Maximum tissue savings, the formation of a flap from the skin of the palmar surface and the location of the suture on the outer are the basic principles of all methods of amputation of the phalanges of the fingers.

In the case of injuries, both complete separation of the finger and partial separation can occur when it remains connected to the brush with a soft tissue flap. Sometimes patients bring severed fingers with them in the hope of their engraftment. In such situations, the surgeon proceeds from the characteristics of the wound, the degree of contamination and infection, and the viability of the torn fragments.

With a traumatic amputation, the suturing of a lost finger can be done, but only by a specialist who has fine techniques for connecting blood vessels and nerves. Success is more likely when restoring the integrity of a finger that has retained at least some connection with the hand, and with a complete detachment, reimplantation is performed only when there is no crushing of the tissues and proper healing is possible.

(image: medbe.ru)

Reconstructive operations on the fingers are extremely complex, require the use of microsurgical techniques and appropriate equipment, and take up to 4-6 hours in duration. The work of the surgeon is extremely painstaking and accurate, but the success is still not absolute. In some cases, skin grafting, repeated reconstructive interventions are required.

Rehabilitation after the removal of fingers or their phalanges includes not only the care of a skin wound, but also the early restoration of self-care skills with the help of hands and manipulations related to the profession. In the postoperative period, physiotherapeutic procedures and exercises are prescribed to ensure that the patient learns to use the stump or the reimplanted finger.

To facilitate the recovery process, analgesics, bed rest are indicated, the hand is predominantly in an elevated position. With severe postoperative stress or a tendency to depression, tranquilizers, sleeping pills are prescribed, it is advisable to work with a psychologist or psychotherapist.

Amputation of the toes

Unlike the fingers, which are most often subjected to traumatic injuries that lead to the surgeon's table, the need for surgery on the foot and fingers arises in a number of diseases - diabetes mellitus, endarteritis, atherosclerosis with gangrene of the distal legs.

Amputation of the toe due to diabetes performed quite often in general surgery departments. Trophic disturbance leads to severe ischemia, trophic ulcers and, ultimately, to gangrene (necrosis). It is impossible to save the finger, and surgeons decide on its amputation.

It is worth noting that it is far from always possible for diabetics to limit themselves to the removal of one finger, because nutrition is disturbed, which means that one can only hope for adequate regeneration in the scar area. In connection with significant disorders of the blood supply to soft tissues in various angiopathy, surgeons often resort to more traumatic operations - exarticulation of all fingers, removal of part of the foot, the entire foot with a portion of the lower leg, etc.

When amputating the toes, the basic principles of such interventions must be observed:

• The maximum possible preservation of the skin from the side of the sole;
• Preservation of the work of the flexors, extensors and other structures involved in multidirectional movements of the feet, in order to ensure a uniform load on the stump in the future;
• Ensuring the mobility of the articular apparatus of the feet.

With small lesions (frostbite of the distal phalanges, for example), amputation of the distal and middle phalanx is possible without a significant violation of the functionality of the foot, with the exception of the thumb, which provides a supporting function, therefore, if it is necessary to remove it, they act as economically as possible.

When amputating the second finger, at least some part of it should be left, if this is possible due to the circumstances of the injury or disease, since with a complete amputation, deformity of the thumb will subsequently occur.

Amputations on the feet are usually performed along the line of the joints (exarticulation). In other cases, it becomes necessary to cut the bone, which is fraught with osteomyelitis (inflammation). It is also important to preserve the periosteum and attach the extensor and flexor tendons to it.

In all cases of injuries, avulsions, crush injuries, frostbite of the toes and other lesions, the surgeon proceeds from the possibility of maintaining the function of support and walking to the maximum. In some cases, the doctor takes a certain risk and does not completely excise non-viable tissues, but this approach allows you to save the maximum length of the fingers and avoid resection of the heads of the metatarsal bones, without which normal walking is impossible.

Toe exarticulation technique:

1. The skin incision is started along the fold between the fingers and the metatarsus on the plantar side of the foot so that the remaining skin flap is as long as possible, the longest in the area of ​​​​the future stump of the first toe, since the largest metatarsal bone is located there;
2. After the skin incision, the fingers bend as much as possible, the surgeon opens the articular cavities, dissects the tendons, nerves and bandages the vessels of the fingers;
3. The resulting defect is closed with skin flaps, placing the seams on the back side.

If the cause of amputation of the fingers was an injury with contamination of the wound surface, a purulent process with gangrene, then the wound is not tightly sutured, leaving drains in it to prevent further purulent-inflammatory process. In other cases, a blind suture may be applied.

Healing after amputation of the toes requires the appointment of painkillers, timely treatment of sutures and change of dressings. With a purulent process, antibiotics are required, infusion therapy is carried out according to indications. The sutures are removed on the 7-10th day. With favorable healing after the primary operation, the patient may be offered reconstruction and plasty, as well as prosthetics to facilitate work, walking, resting on the foot.

Recovery from toe removal requires exercise therapy to develop the muscles and develop new skills in using the rest of the leg.

Traumatic amputation

Traumatic amputation is a partial or complete detachment of fingers or their parts during an injury. Surgical treatment for such injuries has some features:

• The operation is performed only when the patient's condition is stable (after recovery from shock, normalization of the heart and lungs);
• If it is impossible to sew back the torn part, the finger is removed completely;
• With severe contamination and the risk of infection, primary wound treatment is mandatory, when non-viable tissues are removed, the vessels are tied up, and sutures are applied later or a second amputation is performed.

If the amputated fingers are delivered with the patient, then the surgeon takes into account their shelf life and tissue viability. At a temperature of +4 degrees, fingers can be stored for up to 16 hours, if it is higher - no more than 8 hours. A storage temperature of less than 4 degrees is dangerous for tissue frostbite, and then sewing the finger into place will become impossible.

No matter how carefully the operation to amputate the fingers and toes is carried out, it is impossible to completely exclude the consequences. The most frequent of them are purulent complications in the case of traumatic amputations, the progression of the necrotic process in vascular diseases, diabetes, the formation of a dense scar, deformities and immobility of the fingers, which is especially noticeable on the hands.

For the prevention of complications, careful observance of the amputation technique and the correct choice of its level are important; in the postoperative period, recovery is mandatory with the involvement of physiotherapeutic methods and exercise therapy.

- a small operation that is performed with traumatic amputation of the finger. The purpose of the intervention is the speedy healing of the wound, ensuring the functionality of the remaining segment. The operation is performed under local or conduction anesthesia, trying to keep the maximum possible length of the stump. All non-viable tissues and bone fragments are removed, the protruding end of the bone is treated so that no sharp edges remain on it. Tendons cross. The wound is closed with a skin flap from the palmar surface of the hand or two flaps - from the palm and from the rear. Apply an aseptic bandage. When several fingers are amputated, the hand is fixed with a plaster splint.

Methodology

The wound is abundantly washed with solutions of peroxide and furacilin, small bone fragments and non-viable soft tissues are removed. The distal part of the bone emerging from the wound is treated with bone nippers so that there are no sharp spikes left. The flexor and extensor tendons are retracted and crossed transversely. A skin flap is cut along the palmar surface one and a half times longer than the anteroposterior size of the finger.

If there is not enough skin on the palmar surface of the finger, traumatologists use two flaps - from the palmar and dorsal side.

IN association with hand injuries the question often arises before the surgeon: should I amputate or should I try to save the remaining parts of the hand? Before answering the question, a number of factors must be taken into account. It is necessary to take into account which finger and how many fingers were injured at the same time, what is the level of amputation, the nature of the damage, and also take into account the age and profession of the victim.

Of all injured fingers the thumb should be kept as long as possible. It never undergoes a shortened amputation. In case of damage to the middle and ring fingers, short stumps should also be preserved, as they ensure the preservation of the transverse arch of the hand and stabilize the position index finger and little finger.

Regarding the level amputations fingers, it should be noted that the left stump can only be useful if it is of sufficient length. If it is not possible to obtain a sufficiently long stump, then it is more reasonable to carry out a complete removal of the finger, since the remaining short immovable stump only interferes with the function of more proximal segments and healthy fingers.

Finger stumps it is best to cover with a palmar skin flap. In this case, the main task is to avoid tension on the flap and prevent scarring. A stump covered with unhealthy skin is not only of no benefit, but is vicious. The line of the heads of the metacarpal bones should not be touched, as it gives strength to the position of the carpal bones. Maintaining this line is a condition for a strong grip. Its breadth and flexibility are necessary to keep it working. Therefore, resection of the metacarpal heads should be avoided.

Interdigital folds, having the ability to expand, are an essential element in the independent movement of the fingers. That is why their integrity must be preserved.

Thumb and the little finger do not have an optimal level of amputation. They should, if possible, be preserved in their entirety. The thumb is due to the opposition function, and the little finger is used as a support for the hand.

Level amputations index, middle and ring fingers is determined in terms of functional and cosmetic considerations. Which of them is decisive in this case depends on the profession of the patient.

Forefinger. In manual laborers, the base of the proximal phalanx should be retained, as it expands the supporting surface of the bone. However, if cosmetic considerations are decisive, then the finger is removed down to the base of the metacarpal bone, since as a result of such an operation, a narrow brush of the correct form is obtained, the deformation of which is barely noticeable.

Middle and ring fingers. In order to preserve the interdigital folds that hold adjacent fingers in the required position, the base of the main phalanx of both these fingers should be preserved.

With simultaneous amputations of the rest of the fingers, it is necessary to strive to preserve such a stump that is useful for movement and which is not difficult to close with a skin flap. It must not be overlooked that the main task of the surgeon is to ensure the grip of the fingers and the entire hand. If several fingers are injured, one should be more conservative and cover the defects with a skin flap taken from the lateral or dorsal surface of the fingers. In the presence of irreparably severe injuries of the fingers, the skin removed from the bone of the most severely injured finger should be considered in terms of the possibility of using it to replace skin defects in the remaining fingers or using it in the form of a pedicled flap to cover the defect of one of the neighboring fingers.

Damage at the same time several fingers significantly impairs the functionality of the hand. Multiple injuries are an indication for plastic surgery, mainly for the use of a skin flap on a leg.

By the nature of the wounds a distinction must be made between clean wounds with smooth edges and contaminated bruised wounds with crushed edges. In the presence of an incised wound, plastic surgery can be attempted, however, in the case of contaminated wounds, necrosis and infection threaten. In such cases, it seems more favorable to remove the finger, instead of risking plastic surgery, after which, due to prolonged immobilization, stiffness of neighboring fingers may also occur.

From point of view the profession of the patient is a difference between people of fine manual, physical and mental labor. The requirements of the profession in most cases coincide with the interests of the patient and the national economy.

For worker of fine manual labor the preservation of tactile sensitivity and the full length of the finger is essential. So, it should not be shortened, but vice versa - the most important fingers for work should be restored using plastic. A fine manual worker often grasps an object between the thumb and the radial edge of the index finger. For the work of a tailor, the integrity of the middle finger is very important, and for a pianist, violinist, typist, each finger is of particular importance.

Worker's brush heavy physical labor often exposed to pressure, trauma, which in fact is tolerated only by the own skin of the finger. Therefore, during amputation, the finger is shortened and the stump is covered with a palmar skin flap or a displaced finger skin flap.

In people mental labor the shortened finger does not meet the cosmetic requirements, moreover, and its function is limited (Horn). The load of the brush in such people is less. Plastic surgery, sometimes requiring quite a long time, in most cases does not interrupt the work of the patient. So, in such cases, the desire of the patient and the requirements of cosmetics are of decisive importance.

Ultimately, with one finger in the elderly patient and manual worker, the interest of the national economy requires that the victim be able to start work as soon as possible. The preferred operation is finger amputation. In mentally ill people, as well as fine manual workers, various methods of plastic surgery should be resorted to, especially on fingers I, II, III.

Operation method may vary depending on the age and sex of patients. In children, it is easy to save even a small piece of skin. Good blood supply and tissue viability very often make it possible to perform very effective operations. In addition, in the course of the growth and development of the organism for many years, such changes are also erased, which at first gave little hope for the restoration of function. In older people, prolonged plastic surgery is primarily fraught with the risk of loss of mobility of the remaining fingers.

That's why surgeons they are more willing to sacrifice damaged parts of the hand, if only to avoid prolonged immobilization. Finally, with regard to the choice of surgery depending on gender, we must not forget that aesthetic considerations, especially in women, can be decisive.

Indications for surgery change significantly depending on the ratio between the damage and the brush as a whole. For example, in the presence of an exposed tendon sheath, a skin defect can be replaced with a full-thickness skin flap, since with free transplantation, the skin fuses with the underlying tissues, which prevents the tendon from sliding.
Other diseases: Raynaud's and Dupuytren's disease, diabetes, rheumatoid arthritis, and elderly age are contraindications for plastic surgery.

Indications for surgery:
1. Cases of traumatic amputation and disarticulation- when one finger is dissected due to the injury itself - without exception, they are subject to surgical intervention. The desire of the surgeon should be directed to the prevention of scar formation (Beff). It is achieved with the primary closure of the skin wound, which must be performed under any conditions. If a finger torn off along one plane is left uncovered with skin, waiting for the formation of granulations, then after a certain period, due to retraction of the soft tissues, a bare end of the bone appears in the wound. The thin scar tissue covering the bone has no tactile sensitivity, is painful and prone to ulceration, which impairs the function of the entire hand.

2. In the presence of severe injuries of the fingers without disarticulation, there may be finger amputation. According to Ennis and Huber, finger amputation is indicated in the following cases:
a) in the presence of heavily contaminated crushed tissues, the blood supply of which is unsatisfactory, and the possibilities of restoring function are extremely minimal;
b) in the presence of multiple fractures, displacement of fragments, when as a result of restoration it is possible to obtain only a crooked fixed finger (with the exception of the thumb);
c) in the presence of tendon injury with an unfavorable prognosis; d) in case of damage to the joints, the restoration of which will inevitably be accompanied by their immobility, which disrupts the function of the remaining fingers;
e) in the presence of damage to the joints, leading to necrosis.

3. Amputation level selection. Amputation, as a rule, is performed according to the level of damage, and only if there are sufficient indications can it be performed at the level chosen by the surgeon. Long finger injuries are often treated too conservatively. Fingers, on which secondary deformations can form in the form of curvature, immobility, sensitive scars fused with surrounding tissues, or in the form of an improperly growing nail, interfere more with the work process than if they were absent.

Head - Caput

Complaints of headache, general weakness, tinnitus. The victim was hit on the head with a heavy blunt object. A few hours after the injury called SMP. She did not lose consciousness. There was no nausea or vomiting. During external examination on the parietal region, subcutaneous hematoma. Palpation of this area is painful. The contour of the vault of the skull is changed. There is a linear impression of the parietal bone. There are no cerebral or focal symptoms.

D.S. Closed skull fracture. (S02)

Fractura fornicis cranii (calvariae) clausa.

The victim was hit with a large wrench in front of the chin area. The lower jaw is deformed: the chin is displaced backwards, the mouth is half-open and fixed in this position, the bite is disturbed due to the displacement of the lower teeth backwards. Palpation of the chin area is painful. Swelling around the corners mandible. Violated act of chewing and swallowing.

D.S. Closed fracture of the mandible. (S02)

Fractura mandibulae clausa.

Man 29 years old. Complains of pain in the area of ​​the upper lip, bleeding, loss of the 2nd upper tooth on the left.
During a fight about thirty minutes ago, he was punched in the area of ​​the upper jaw. Today I drank alcohol (beer).
Objectively. The condition is satisfactory. Consciousness is clear. The skin is of normal color, the skin around the mouth is stained with blood. The upper lip is dissected on the left, there is a vertical wound with uneven edges, about 1 cm long, moderate bleeding from the wound. The second tooth on the left from above is missing, slight bleeding from the socket of the missing tooth. No other bodily injuries were found. From the mouth the smell of alcohol, speech is slurred, blurry. There is unsteadiness of gait. BP 140/90 mm Hg Heart rate 84 per minute. No anisocoria, no nystagmus.
Ds. A lacerated wound of the upper lip. Complete dislocation of the 2nd left upper tooth (22nd tooth). Signs of alcohol intoxication.(S01.5, S03.2)

Vulnus lacerocontusum labii superioris. Luxatio completa dentis secundi superioris sinistri. Signa ebrietatis.
A sterile napkin, a sling-like bandage is applied to the wound.
The patient was taken to the emergency room.

***

The victim yawned widely and could not close his mouth. Covers his mouth with his hand. The mouth is open extremely wide, the closing of the teeth is not possible. The lower jaw protrudes forward, active and passive movements not possible, spring resistance. Saliva comes out of the mouth. Speech articulation is impaired. The articular head of the lower jaw is palpable under the zygomatic arch on both sides.

D.S. Dislocation of the lower jaw. (S03)

Luxatio mandibulae.

The victim was punched in the nose. Called for help 3 hours later.

External examination reveals thickening and deformity of the nose, epistaxis. Painful palpation of the back of the nose. The mobility of bone fragments is felt.

D.S. Closed fracture of the bones of the nose without displacement. (S00.3)

Fractura ossium nasi clausa non dislocata.

7 hours ago, during a fight, the victim was punched in the front of the nose. The nose is flattened, the back of the nose is bent inward (saddle nose). Palpation of the back of the nose is painful, there is mobility of bone fragments, crepitus. There are bruises under the eyes (symptom of "glasses").

D.S. Closed fracture of the nasal bones with displacement. (S00.3)

Fractura ossium nasi clausa dislocata.

Upperlimb- Membrum superior

Brush, wrist- Manus, metacarpus

The middle-aged victim fell from a small height. Pushed forward when falling left hand. The greatest blow fell on the allotted I finger. As a result of the fall, the first finger shifted to the back and took an unnatural position, severe pain appeared at the site of injury. The main phalanx of the first finger is displaced to the rear and is located above the head of the first metacarpal bone. The finger took a characteristic bayonet-like position: the main phalanx is at a right angle to the metacarpal bone, the nail phalanx is at a right angle to the metacarpal bone, the finger is bent at the interphalangeal joint. On the palmar surface, the head of the metacarpal bone is palpated, on the back surface, the displaced base of the first finger is palpated. There are no movements in the metacarpophalangeal joint. The symptom of springy resistance is determined when trying to bend the finger.

D.S. DislocationI fingers of the left hand in the metacarpophalangeal joint. (S63)

Luxatio pollicis manus sinistrae in articulatione carpophalangea.

During the fight, the victim was twisted the fingers of his right hand. As a result, the third finger was damaged. The nail phalanx of the third finger is displaced to the rear of the hand. The interphalangeal joint is edematous, deformed, painful on palpation, active movements are impossible.

D.S. . Dislocation of the nail phalanx III fingers of the right hand. (S63)

Luxatio phalangis distalis digiti tertii manus dextrae.

A teenager's right hand got into a moving machine during agricultural work. As a result of injury, the nail phalanx of the fourth finger was crushed. The nail phalanx of the IV finger of the right hand is crushed. The skin in this area is torn. The wound is heavily contaminated with earth and technical lubricant. On palpation of the nail phalanx, crushed small bone fragments are felt under the skin. Bleeding from a lacerated wound is small.

D.S. . A lacerated wound and a small-comminuted fracture of the nail phalanx IV fingers of the right hand. (S60, S62)

Vulnus lacerocontusum et fractura comminuta phalangis distalis digiti quarti manus dextrae.

The victim worked with an electric planer and, due to careless actions, the third finger of the left hand fell under the knife. In the region of the distal interphalangeal joint of the third finger of the left hand, on the palmar surface, there is a deep incised wound with smooth edges, bleeding profusely. The nail phalanx hangs on a flap of skin on the back side. There is slight bleeding.

D.S. . Incomplete traumatic amputation of the nail phalanx III fingers of the left hand.

Amputatio traumatica incompleta phalangis proximalis digiti tertii manus sinistrae.(S68)

The victim sawed the board into bars. The left hand fell under the saw. As a result, the second finger of the left hand was amputated. The patient is pale and agitated. On examination, instead of a finger, a small stump (half of the main phalanx) remained. An amputated finger 2½ phalanx long was located here. A rubber bandage was applied to stop the bleeding. The wound was treated, closed with an aseptic bandage. The patient was referred to the Microsurgery Center for replantation.

D.S. . Traumatic amputation of 2½ phalanges II fingers of the left hand.

Amputatio traumatica duarum et dimidiae phalangium digiti secundi manus sinistrae. (S68)

A 30-year-old man, a worker at a woodworking plant. Complaints of pain in the right hand, absence of I and V fingers on the right hand. Ten minutes ago, the right hand hit a working milling machine, and two fingers were cut off by its rotating parts. Before the arrival of "03", a hemostatic tourniquet was applied by a paramedic, the bleeding was stopped. Allergological anamnesis is not burdened.

The condition is satisfactory. Consciousness is clear. The skin is of normal color and moisture. Respiration is vesicular. Respiratory rate 18 per minute. Heart rate 88 per minute, the rhythm is correct. AD 110/60 mm. On the right hand, I and V fingers were amputated at the level of the proximal phalanges. There is no bleeding from wounds.
Ds. Traumatic amputation of the I and V fingers of the right hand.

Amputatio traumatica digitorum I et V manus dextrae (S68.8).

Sol. Tramadoli 100 mg IM. Aseptic bandage.

The pain has been relieved. Delivered to the emergency room.

The victim was unloading construction material at the construction site. A heavy wooden beam broke off and hit him on the back of his right hand.

The back surface of the right hand is swollen, painful on palpation. Subcutaneous hematoma in the region of the III metacarpal bone. When loaded along the axis of the III finger, pain radiates to the area of ​​injury. Finger movements are painful and moderately limited.

D.S. Closed fracture of the III metacarpal bone of the right hand without displacement. (S62)

Fractura ossis carpi tertii manus dextrae non dislocata.

A teenager in a fight was hit with a stick on the left hand. The blow fell below the base of the first finger. After 1 hour, the victim went to the emergency room. On external examination of the left hand, the region of the first metacarpal bone was edematous. The contours of the "anatomical snuffbox" are smoothed. I finger is given and somewhat bent. There is a characteristic deformation due to the displacement of the debris. A sharp soreness is determined with a load along the axis of the first finger. Active and passive movements of the first finger are limited and painful.

D.S. Closed extra-articular fracture of the 1st metacarpal bone of the left hand with displacement. (S62)

Fractura ossis carpi primi clausa intraarticularis dislocata.

An elderly man, when falling, hit his left hand on a protruding solid object. As a result of the injury, severe pain appeared in the region of the fifth metacarpal bone.

Objectively: the dorsal surface of the left hand at the site of the bruise is edematous, there is a small subcutaneous hematoma. The movements of the fifth finger are possible, but painful. With a load along the axis of the V finger, the pain intensifies in the metacarpal bone. The angular displacement of bone fragments of the V metacarpal bone to the palmar side is determined.

D.S. Closed fracture of the V metacarpal bone of the left hand with displacement. (S62)

Fractura ossis carpi quintimanus sinistrae dislocata.

The young man pressed the third finger of his left hand in the porch of the front door. Disturbed by pain at the site of injury.

III finger is edematous, on the dorsal surface of the middle phalanx there is a subcutaneous hematoma. The finger is deformed. The victim cannot fully straighten the injured finger and clench the hand into a fist. Finger movements are limited and painful, especially extension. The load along the axis of the injured finger is painful.

D.S. Closed fracture of the middle phalanx of the third finger of the left hand without displacement. (S62)

Fractura phalangis medialis digiti tertii manus sinistrae clausa non dislocata.

The victim was doing repairs in the apartment. Punch through a concrete wall. Hammer accidentally hit on the nail phalanx of the first finger of the left hand. On external examination of the first finger, the nail phalanx is edematous, painful on palpation. Movement in the finger is limited. There is a hematoma under the nail plate. The load along the axis of the finger is painful. Capture by a finger of any subjects is impossible because of pains.

D.S. Closed fracture of the terminal phalanx and subungual hematoma of the first finger of the left hand. (S62)

Fractura phalangis distalis clausa et haematoma subunguinale digiti primi manus sinistrae.

The young man hit his hand on a wooden beam. After the injury, he was worried about pain in the II finger of the right hand.

Objectively: II finger is swollen, painful on palpation. The main phalanx is deformed. The bone fragments of the phalanx are displaced at an angle open to the dorsal surface. Finger movements are limited. The load along the axis of the finger is painful. In the region of the main phalanx on the back side, there is a subcutaneous hematoma.

D.S. Closed fracture of the main phalanx of the II finger of the right hand with displacement. (S62)

Fractura phalangis proximalis digiti secundi manus dextrae clausa dislocata.

An elderly man, standing on a chair, screwing an electric light bulb into a cartridge, fell off the chair, stretching his left arm forward. The blow fell on the palm and I finger.

An external examination of the left hand showed deformity in the area of ​​the I metacarpal-carpal joint in the form of a protrusion to the rear, slight swelling and soreness of the wrist joint, especially in the area of ​​the "anatomical snuffbox". The load along the axis of I and II fingers is painful. Movement in the wrist joint is limited and painful, especially in the dorsal-beam direction. Full compression of the hand into a fist is impossible. The gripping of objects with fingers is weak. When resting on the table with the thenar area, pain appears in the area of ​​​​the I metacarpal-carpal joint. The contours of the "anatomical snuffbox" are smoothed.

D.S. Closed fracture of the navicular bone of the left hand. (S62)

Fractura ossis navicularis manus sinistrae clausa.

The victim fell from a small height, while the arm turned out to be straightened, the hand was retracted. The maximum impact fell on the hypothenar. The palm turned sharply towards the ulna. The victim felt severe pain in the area of ​​the wrist joint.

External examination of the left hand shows local swelling and tenderness on palpation of the dorsal surface of the middle of the wrist joint. The muscle strength of the hand is reduced. Active and passive movements in the wrist joint are limited and painful. With a load along the axis of the III and IV fingers, the pain intensifies in the region of the lunate bone.

D.S. Compression fracture of the lunate bone of the left hand. (S62)

Fractura ossis lunati manus sinistrae e compressione.

Forearm - Antebrachium

An elderly plump woman slipped and fell on the icy pavement, leaning on the palm of her outstretched right hand. There were severe pains in the wrist joint.

Objectively: the right wrist joint is edematous, movements in it are very painful and limited. A “bayonet-shaped” deformity of the joint is clearly defined (the distal fragment, together with the hand, is displaced to the rear). Palpation of the dorsum of the joint is painful. Axial load causes increased pain at the site of injury.

D.S. Closed fracture of the right radius in a typical location. (S52)

Fractura ossis radii dextri clausa in loco typico.

The young man, defending himself from a blow to the head with a stick, substituted his left arm bent at the elbow joint. The blow fell on the middle third of the forearm.

On external examination of the left forearm in the middle third there is a subcutaneous hematoma, a slight deformity is determined. Palpation of the injury site is painful. With a load along the axis of the forearm, pain appears in the middle third. Movement in the forearm is limited due to pain.

D.S. Closed fracture of the left ulna in the middle third with displacement. (S52)

Fractura clausa dislocata ulnae sinistrae in tertia mediale.

The victim fell and hit his left elbow on a hard object, while the arm was bent. On external examination, the left arm is straightened, hanging down. The patient spares her, holding her with his healthy hand. The elbow joint is enlarged in volume, swelling is determined on the back surface. Palpation of the joint is painful, the pain is especially aggravated by pressure on the olecranon. A transverse fissure is palpated between the process and the ulna. The olecranon is displaced laterally. Passive movements in the elbow joint are free, but painful. Active extension is impossible, and flexion is preserved, but painful.

D.S. Displaced fracture of the left olecranon. (S52)

Fractura olecrani sinistri dislocata.

The teenager fell during the game, putting forward his right hand. The load passed along the axis of the limb, he felt severe pain in the elbow joint. Objectively: there is swelling in the cubital fossa, local pain when pressing on the coronoid process of the ulna. Maximum flexion in the elbow joint is limited and sharply painful. Pronation and supination are not disturbed.

D.S. Fracture of the coronoid process of the right ulna. (S52)

Fractura processus coronoidei ulnae dextrae.

The victim, defending himself from a blow with a stick, raised his left arm above his head, bent at the elbow joint. The blow fell on the upper third of the forearm. There was severe pain at the site of the injury. On external examination, the left forearm is bent at the elbow joint, deformed in the upper third, there is a retraction from the side of the ulna and a protrusion along the anterior surface of the forearm. The head of the radius is felt along the palmar surface of the elbow joint. Palpation of the deformed area is sharply painful. The injured forearm is somewhat shortened. Active and passive movements of the forearm are sharply limited and painful. The sensitivity of the hand and forearm is not broken.

D.S. Fracture of the upper third of the ulna with dislocation of the head of the radius of the left forearm (Montaggi fracture). (S52)

Fractura ulnae in tertia superiore cum luxatione capitis ulnae antebrachii sinistri (Fractura Monteggia).

The man was unloading lumber. Due to careless actions, a wooden beam fell off the car and hit him on the left forearm. Objectively: there is a subcutaneous hematoma at the site of the bruise (on the outer palmar surface of the lower third of the left forearm). Palpation of the injury site is painful, crepitus of bone fragments is determined. When loading along the axis of the forearm, pain appears at the site of injury. Pronation and supination are difficult, an attempt to make these movements causes a sharp pain. Flexion and extension of the forearm is almost unlimited. The distal forearm and hand are in pronation.

D.S. Fracture of the diaphysis of the radius in the lower third of the left forearm. (S52)

Fractura diaphysis ossis radii in tertia inferiore antebrachii sinistri.

The young man was kicked in the right forearm. On external examination, the lower third of the right forearm is edematous, deformed, the head of the ulna protrudes above the wrist joint. Palpation is painful in the projection of the radius, the symptom of the "key" of the dislocated head of the ulna is determined. Pronation and supination are not possible due to severe pain. Flexion and extension in the elbow joint is preserved in full. The axial load on the forearm is painful.

D.S. Fracture of the diaphysis of the radius in the lower third and dislocation of the head of the ulna of the right forearm (Goleazzi fracture). (S52, S63)

Fractura diaphysis ossis radii in tertia inferiore et luxatio capitis ulnae antebrachii dextri (fractura Galeazzi).

***

The mother was leading the child by the left hand when he slipped. She pulled the child's hand to keep him from falling. Immediately after that, there was pain in the elbow area.

Objectively: the left arm hangs along the body, slightly bent at the elbow, the hand is in the pronation position. An attempt to bend the arm at the elbow joint and supinate the hand causes the child to cry. The area of ​​the left elbow joint is not visually changed. There is pain with pressure in the projection of the head of the radius.

Ds. Subluxation of the head of the left radius. (S53.0)

Subluxatio capitis ossis radii sinistri.

The victim fell down the stairs with her left arm outstretched at the elbow. Immediately after the injury, she felt pain in the elbow joint. The outer surface of the left elbow joint is edematous, there is a small hematoma, palpation of the radial head is painful. The rotational movements of the forearm are sharply limited and painful, especially outward rotation. Flexion and extension in the elbow joint is preserved, but not in full. The load along the axis of the forearm is painful in the region of the head of the radius.

D.S. Fracture of the head and neck of the radius of the left forearm without displacement. (S52)

Fractura capitis et colli ossis radii sinistri non dislocata.

An elderly woman was descending the stairs in the entrance, stumbled, fell, putting forward her left arm extended at the elbow joint. The blow fell on the axis of the forearm. I felt a sharp pain in my forearm. The left forearm is edematous and deformed. Its palpation is painful throughout, especially at the fracture site. Pathological mobility of the bones of the forearm and crepitus are determined. The load along the axis of the forearm increases pain at the site of injury. The motor function of the forearm (pronation, supination) is severely impaired. The head of the radius does not follow the rotational movement of the forearm. Due to pain, active flexion-extensor movements in the elbow and wrist joints are limited.

D.S. Diaphyseal fracture of the radius in the middle third and ulna in the lower third of the left forearm. (S52)

Fractura ossis radii diaphysaria in tertia mediale et fractura ulnae in tertia inferiore antebrachii sinistri.

A sixth-grade high school student was riding on the stair railing. At the next attempt to move down, he fell on the left arm extended at the elbow joint, resting on the palm. At the same time, the forearm, as it were, “overbent”. As a result of this injury, there was severe pain in the elbow joint. Objectively: the left elbow joint is enlarged, deformed, the cubital fossa is smoothed. With careful palpation, the olecranon protrudes from behind. The axis of the shoulder is shifted forward. The hand is in a forced semi-extended position, the victim holds it with a healthy hand. Active movements in the left joint are impossible. When attempting passive movements, springy resistance is felt.

D.S. Posterior dislocation of the bones of the left forearm. (S53)

Luxatio ossium antebrachii sinistri posterior.

The victim fell on the tram tracks. The left hand was hit by a tram wheel. He was taken to the emergency room with a severed arm segment. On external examination, the crush zone is located in the lower third of the left forearm, directed obliquely. The crushed area occupies 10 cm. Large nerve trunks and main blood vessels of the forearm are torn. Among the crushed muscles in the wound of the stump, fragments of vessels with blood clots in the lumen were found. They are flask-like thickened, pulsating. Bleeding from the wound is insignificant. muscles and tendons are torn out and disorderly mixed. In the depths of this mass are crushed bone fragments. The stump wound is heavily soiled with earth and scraps of clothing. The torn off hand is severely destroyed and is a shapeless, bloodied musculoskeletal mass.

D.S. Traumatic amputation of the left hand. (S68)

Amputatio traumatica manus sinistrae.

The victim, when cutting sheet steel on the machine, did not have time to remove her left hand, and a heavy knife fell on her forearm. The victim was urgently taken to the trauma center along with the severed segment. Objectively: there is a transverse incision through all tissues in the middle third of the left forearm. The skin, muscles and bone of the stump have smooth edges. Thrombosed pulsating vessels are visible in the thickness of the cut among the muscles. Bleeding from the stump is small. The severed segment (the hand and a third of the forearm) bleeds slightly, has even edges of the skin, muscles and bones.

D.S. Traumatic amputation of the lower third of the left forearm and left hand. (S68)

Amputatio traumatica tertiae inferioris antebrachii sinistri et manus sinistrae.

Shoulder, clavicle, scapula- Brachium, clavicula, scapula

A middle-aged man lifted a two-pound weight and could not fix his straightened arm above his head. The hand, together with the weight, was pulled back, something crunched in the shoulder joint, severe pain appeared. The victim was forced to drop the kettlebell. After the injury, the shoulder joint took on an unusual appearance. The patient went to the emergency room. On examination the patient keeps his head bowed to the injured side. P The right arm is bent at the elbow joint, slightly retracted from the body, and the patient holds it by the forearm with a healthy hand. The shoulder joint is deformed. The roundness of the shoulder at the deltoid muscle disappeared. The clear contours of the acromion and the retraction of the soft tissues under it, in contrast to the healthy side, are determined. Under the coracoid process, a spherical protrusion is determined. Active movements in the shoulder joint are not possible. Passive movements are very painful. There is a springy resistance of the shoulder - a symptom of the "key".

D.S. Anterior dislocation of the head of the right humerus. (S43)

Luxatio humeri dextri subcoracoidea.

An elderly woman fell on her right arm, bent at the elbow. She hit her elbow on a hard object. I felt severe pain in my shoulder joint. Objectively: the victim supports her right hand, bent at the elbow and pressed to the body, with a healthy hand. The shoulder joint is enlarged. Active movements in the superior joint are impossible, passive ones are sharply painful. The axis of the shoulder is changed, it goes obliquely. The damaged area is shortened. Palpation of the upper third of the shoulder and the load along the axis of the humerus are painful at the site of injury.

D.S. Displaced fracture of the surgical neck of the right humerus. (S42)

Fractura colli chirurgici humeri dextri dislocata.

An elderly man hit the bus with his left shoulder on a metal rack. He felt severe pain at the site of injury. Objectively: the area of ​​the shoulder joint is swollen, there is local pain when pressing on the large tubercle. The shoulder is turned inward and its rotation outward is difficult. Movement in the shoulder joint is limited and painful.

D.S. Fracture of the large tubercle of the left humerus without displacement. (S42)

Fractura tuberculi majoris humeri sinistri non dislocata.

A 15-year-old teenager hit a metal crossbar with his right shoulder during a fall. The injury resulted in severe pain in the right arm. During external examination: the patient tries to press the injured arm to the body. There is swelling and deformity in the middle third of the right shoulder. On palpation, sharp local pain and crepitus of bone fragments are determined. Appeared pathological mobility at the site of injury. The motor function of the shoulder is impaired. With a load along the axis of the humerus, a sharp pain appears in the middle third of the segment. The radial nerve is not damaged, the function of the hand is preserved in full.

D.S. Displaced fracture of the right humerus in the middle third. (S42)

Fractura dislocata humeri dextri in tertia mediale.

An 18-year-old girl fell on her arm bent at the elbow and hit her elbow on the ground. I felt a sharp pain in my elbow joint. There is a subcutaneous hematoma on the posterior surface of the left shoulder in the middle third. The forearm seems to be elongated, the axis of the shoulder is deflected anteriorly. The posterior surface of the shoulder forms an arc with a convexity facing the dorsal side. Behind, above the olecranon, the end of the central fragment is palpated. There is a significant swelling of the elbow joint and a sharp pain when trying to make movements. Crepitation of bone fragments is determined by palpation. The axis of the shoulder crosses the line of the epicondyles, forming an acute and obtuse angle instead of two straight ones (Marx's symptom). The triangle formed by the apex of the olecranon and the epicondyles of the humerus (Guter's triangle) maintains isosceles. Sensitivity and motor function of the fingers are preserved in full. The pulse in the lower third of the forearm is determined.

D.S. Displaced supracondylar flexion fracture of the left humerus. (S42)

Fractura supracondylaris humeri sinistri dislocata.

A 14-year-old teenager, while playing volleyball, fell on his left hand with his elbow extended and his arm outstretched. I felt severe pain in my elbow joint. During external examination, the left elbow joint is enlarged due to edema and hemarthrosis, its contours are smoothed. The isosceles triangle of Guther is broken. Movements in the elbow joint are painful and limited, especially sharp pain appears during rotation of the shoulder. Palpation of the area of ​​the external condyle is painful, crepitus of bone fragments is determined. The axis of the shoulder intersects with the line of the condyles not at a right angle (positive Marx's sign).

D.S. Fracture of the lateral condyle of the left humerus without displacement. (S42)

Fractura condyli laterais humeri sinistri non dislocata.

A 40-year-old victim had his right hand caught in the transmission while working. Delivered to the emergency room. The right upper limb was fixed with a Cramer splint, the bandage was abundantly saturated with blood. Forearm and hand cyanotic, cold to the touch. The pulse on the radial artery is not determined. The sensitivity of the skin of the hand is sharply reduced. The general condition of the victim is severe. The skin is pale, covered with cold sweat. The patient is lethargic, with a sluggish reaction to others. BP 80/40 mm. rt. Art., pulse 120 beats. in a minute. After intensive anti-shock measures, anesthesia was given, the bandage was removed, under which a huge lacerated wound 25 by 12 cm was found, starting from the upper third of the forearm and capturing the entire front surface of the shoulder. The bottom of the wound is crushed, contaminated fragments of muscles and protruding bone fragments of the superior bone. Thrombosed ends of the crushed brachial artery were found in the depth of the wound. The victim lost about 600 ml of blood.

D.S. Traumatic shock. Open comminuted fracture of the right humerus. Extensive crushing of soft tissues. (S42, S41 - 333)

Afflictus traumaticus. Fractura humeri dextri aperta comminuta. Conquassatio textuum mollium.

***
The young man tried to lift a large load, felt a crack and severe pain in his right shoulder joint. The first two days after the injury, he did not seek medical help, and only on the third day did he go to the emergency room. Objectively: a bruise appeared on the anterior surface of the right shoulder in the upper third, the strength of the biceps muscle was reduced. The function of the elbow and shoulder joints is not impaired. When the forearm is flexed in the elbow joint, a spherical protrusion appears on the pre-outer surface of the shoulder, the size of a chicken egg. When the forearm is extended, this formation disappears. With the help of palpation, it turned out that this formation refers to the long head of the biceps muscle of the shoulder.

D.S. Avulsion of the tendon of the long head of the biceps muscle of the right shoulder. (S43)

Abruptio tendinis capitis longi musculi bicipitis humeri dextri.

A middle-aged man was carrying a load in his right hand, stumbled and fell on his right shoulder. A strong blow fell on the area of ​​the shoulder joint, which was maximally lowered at that time under the weight of the load. The man felt severe pain in the shoulder girdle. A day later, he went to the emergency room. According to a comparative examination of a healthy and damaged shoulder girdle, the right edematous, the outer (acromial) end of the clavicle protrudes in steps. There is local pain in the acromioclavicular joint. Movements in the shoulder joint, especially abduction and raising the shoulder upwards, are limited and painful. When pressing on the acromial end of the clavicle, it falls. After the cessation of pressure, it rises again - there is a springy mobility of the clavicle (symptom of the "key").

D.S. Dislocation of the acromial end of the right clavicle. (S43)

Luxatio claviculae dextrae acromialis.

During the fight, the young man's left arm was twisted back and sharply pulled down. He felt something crunch in his chest. There were severe pains. On external examination, there is swelling in the region of the left clavicular-sternal joint, the sternocleidomastoid muscle is stretched on the left. Head movements are limited and painful, especially when tilting back and turning to the healthy side. On palpation, the desolate articular cavity on the sternum and the sternal end of the clavicle protruding under the skin are determined. Raising and abducting the left shoulder is painful. When the shoulder moves, the protruding sternal end of the clavicle is easily displaced.

D.S. Dislocation of the sternal end of the left clavicle. (S43)

Luxatio claviculae sinistrae sternalis.

The teenager fell off the swing and hit the outer surface of the right shoulder joint on the ground. There were severe pains in the region of the collarbone. On external examination, there is a deformity of the right clavicle, the right shoulder girdle is shortened and lowered below the left. With a healthy hand, the patient holds the injured arm by the forearm, bent at the elbow joint, presses it to the body. The area of ​​the right clavicle is edematous. On palpation, there is a sharp pain and it is possible to determine the ends of the fragments. Movements in the right shoulder joint are painful, especially when trying to raise and withdraw the arm.

D.S. Displaced fracture of the right clavicle. (S42)

Fractura claviculae dextrae dislocata.

While unloading a truck with vegetables, an elderly man stumbled and fell on his back along with a box. He hit with his right shoulder blade on a brick lying on the ground. I felt severe pain in the area of ​​the injury. Examination of the right scapula shows swelling caused by hemorrhage, crepitus, and local tenderness on palpation. Active abduction of the right shoulder is limited due to pain, passive movements are possible to a considerable extent.

D.S. Fracture of the body of the right scapula without displacement. (S42)

Fractura corporis scapulae dextrae non dislocata.

Thorax - Thorax

A fat woman of 65 years old was washing in a bath and hit her right side on the edge of the bath. There was severe pain at the site of injury. Disturbed by severe pain in the chest on the right, which is aggravated by deep breathing, coughing, sneezing, changing position. The victim tries to sit still, leaning forward and holding the injury site with her hand, breathing shallowly, often. There is a subcutaneous hematoma in the region of the IV rib along the mid-axillary line, palpation of this place is painful, crepitus is also noted here.

D.S. Fracture 4 ribs on the right. (S22)

Fractura costae quartae dextrae.

The rigger at the construction site was pressed between the wall of the house under construction and the side of the truck that was pulling back. The mechanical force of the traumatic impact was directed from front to back and the chest caved inward. The victim felt severe pain in the chest on both sides. He was taken to the trauma department of the hospital. The patient sits on a chair, leaning forward, holding his chest on both sides with his hands, breathing quickly, shallowly. Disturbed by severe pain in the chest, especially with a deep breath, sneezing, coughing, sudden movements. Local tenderness is determined on palpation on the left in the region of the IV rib along the midaxillary line, and on the right - in the region of the V rib along the posterior axillary line. In these places, there is swelling and subcutaneous hematoma. When the chest is compressed between the palms from front to back (one palm is located on the chest, and the other on the spine), i.e. when loading along the axis, there is a sharp soreness of the chest at the site of injury (left and right).

D.S. Fracture 5 ribs on the right and 6 ribs on the left. (S22)

Fractura costae quintae dextrae et costae sextae sinistrae.

The driver of a passenger car braked sharply in front of a nearby pedestrian. As a result, he hit his chest hard on the steering wheel. The victim complains of severe pain at the site of injury, increasing with deep inspiration, coughing and palpation. The patient sits in a forced position motionless, tilting the torso forward, stooping, breathing quickly and shallowly. The sternum is painful, has a stepped deformity (the body of the sternum is displaced backwards), which is especially noticeable on palpation.

D.S. Fracture of the sternum with displacement. (S22)

Fractura sterni dislocata.

A wooden pole fell on the victim and hit him on the right half chest. Severe condition. The patient has shortness of breath, cyanosis, a feeling of fear. During auscultation on the right side of the chest, there are no respiratory sounds, percussion - tympanitis. The victim coughs and coughs up bright red frothy sputum (hemoptysis). Barrel-shaped chest, subcutaneous emphysema. Blood pressure is low, tachycardia. Edema of the extremities. Progressive respiratory failure led to the development of cardiovascular failure. X-ray revealed a fracture of the 5th right rib.

D.S. Fracture of the 5th rib on the right. Wounded right lung. Tension valvular pneumothorax. Hemothorax. subcutaneous emphysema. (S22, S29)

Fractura costae quintae dextrae. Laesio pulmonis dextri. Pneumothorax tensus valvularis. Haemothorax. Emphysema subcutaneum.

Spine - Columna vertebrarum

Complaints of pain in the cervical spine. The victim hit his head on the ground while diving in shallow water. Head in forced position. Palpation of the spinous processes of the 5th and 6th cervical vertebrae is painful. There is a deformation in the form of a noticeable protrusion of the spinous processes of these vertebrae. The patient's attempts to move his head are almost impossible, very painful and significantly limited. Sensitivity and motor function of the upper and lower extremities are preserved in full.

D.S. Uncomplicated compression fracture of the body of the 5th cervical vertebra. (S12)

Fractura corporis vertebrae cervicalis quintae incomplicata e compressione.

Complaints of burning pain in the thoracic spine. The victim was driving a car that collided with a truck. As a result of the collision, the patient is tightly pressed against the seat by the steering wheel. Removed from the car by the forces of eyewitnesses who came to the rescue. The movements in the spine are constrained. In the lower thoracic spine swelling, subcutaneous hematoma, enhanced thoracic kyphosis. The protrusion of the spinous processes of 10-11 thoracic vertebrae is noted. Palpation of the spinous processes at the level of damage is painful. The motor and sensory functions of the legs are absent. The function of the pelvic organs is impaired.

D.S. Closed compression fracture of the bodies of 10-11 thoracic vertebrae with complete rupture of the spinal cord. (S22)

Fractura clausa corporum vertebrarum thoracicarum decimae et undecimae e compressione cum ruptura medullae spinalis completa.

A 4-year-old child complains of constant pain in the area of ​​injury, poor sleep, decreased appetite. The mother was throwing the child up in her arms, and with a careless movement, the child fell off her arms and hit her back on the edge of the sofa. The mother of the child asked for help only six months later. Movements in the lumbosacral spine are limited. The child cannot stand straight for a long time, but is forced to lean on his hips with his hands. On external examination, the protrusion of the spinous vertebrae, which formed a hump, attracts attention. When tapping with fingers on the spinous processes of these vertebrae, pain is noted. Pain in the lumbar spine when pressing the palm on the head. Sensory and motor functions in both lower extremities are preserved in full.

D.S. Tuberculous spondylitis of the 3rd, 4th and 5th lumbar vertebrae. (BUT18.0)

Spondyllitis tuberculosa vertebrarum lumbalium tertiae, quartae et quintae.

An 82-year-old woman complains of pain in the thoracic spine. 10 months ago, while lifting a heavy pan below the shoulder blades, something crunched, severe pain appeared. treated with home remedies. The pains are gone. She turned to the doctor only a week after the injury, when, after hypothermia, chills appeared and back pains resumed. She was treated for osteochondrosis of the spine. The treatment did not improve: the pain persisted when walking, subsided in the supine position. After 9 months, the patient was examined, an x-ray of the spine was taken, after which she was hospitalized in an anti-tuberculosis dispensary.

On external examination of the lower thoracic spine, there is a noticeable protrusion of the spinous processes of 9-10 thoracic vertebrae. Finger tapping on the spinous processes of these vertebrae is painful. Movements in the lower thoracic spine are limited. Sensitivity and motor function of the lower extremities in full. The function of the pelvic organs is not impaired.

D.S. Tuberculous spondylitis of the 9th and 10th thoracic vertebrae. (BUT18.0)

Spondyllitis tuberculosa vertebrarum thoracicarum nonae et decimae.

Child 10 years old. About a year ago, he fell off the roof of a barn and hit his back. After some time, he became lethargic, inactive, stopped playing outdoor games. Increased fatigue. He began to walk with his hands on his hips. The posture gradually changed, a hump appeared in the upper thoracic spine. A year later, weakness appeared in the lower extremities.

On external examination of the spine in the upper thoracic region there is a curvature in the form of a hump. Tapping on the spinous processes of the 4th, 5th and 6th thoracic vertebrae is painful. The movements of the spine in the thoracic region are limited: the child turns with the whole body, instead of bending forward, he squats. The patient has motor paralysis of both lower extremities, sensory disturbances, clonus of the feet and pathological reflexes, and involuntary urination.

D.S. Tuberculous spondylitis of the 4th, 5th, 6th thoracic vertebrae with spinal disorders. (BUT18.0)

Spondyllitis tuberculosa vertebrarum thoracicarum quartae, quintae et sextae cum perturbationibus medullaribus.

A 50-year-old man, descending into the hold of a vessel along a steep staircase, stumbled, fell and hit his back on the steps. Disturbed by pain in the thoracic spine. For several months he was treated for intercostal neuralgia, diseases of the pleura and lungs. There was no improvement. The disease progressed. Six months later, he underwent an MRI at the regional hospital, and the patient was referred to a spinal center.

An external examination reveals smoothness of physiological curves, a violation of posture, a flattened back, a cautious, measured gait. The spinous processes of the 6th and 7th thoracic vertebrae protrude somewhat and are painful when tapped with fingers. Soreness in these vertebrae is also noted when pressing with the palms on the patient's shoulders (with a load along the axis of the spine). Sensitivity and motor function of the lower extremities in full. The function of the pelvic organs is not impaired.

D.S. Tuberculous spondylitis of the 6th and 7th thoracic vertebrae. (BUT18.0)

Spondyllitis tuberculosa vertebrarum thoracicarum sextae et septimae.

Complaints of pain in the coccyx, aggravated when the patient sits down and or rises from a chair. The victim hit her buttocks on the floor, sitting down past the chair. To reduce pain, sits down and rises from a chair, leaning on his hands. On external examination, there is a small hematoma in the coccyx area, palpation of this area is painful. No other visible changes were found.

D.S. Closed fracture of the coccyx. (S39)

Fractura ossis coccygis clausa.

The victim leaned sharply to the right while trying to lift a large load and at the moment of strong muscle tension felt a crunch in the lower back and severe pain. On external examination, the body is tilted to the right. Movement in the lumbar region is limited. When you try to straighten up or bend to the left, pain appears at the site of injury. The lumbar region on the right is swollen and painful on palpation. Lying on his back due to severe pain, the patient cannot raise the straightened right leg. He only bends it at the knee joint, while the foot slides along the couch and does not come off the couch (symptom of "stuck heel").

D.S. Closed fracture of the right transverse process of the 2nd lumbar vertebra. (S22)

Fractura clausa processus transversi dextri vertebrae thoracicae secundae.

The victim fell from a height of more than 3 meters on his heels, while he did not have time to bend his legs at the knee joints. As a result of the fall, the victim developed severe pain in the lumbar spine, aggravated by torso movements (anterior-posterior and lateral tilts, rotations around the axis).

During external examination, the lumbar lordosis is noticeably smoothed, the spinous process of the 1st lumbar vertebra is somewhat protruded outward, painful when tapped on it with fingers, the back muscles are tense ("muscular protection"). Movement in the lumbar spine is limited due to pain. With a load along the axis of the spine (pressing the palms on the shoulders or lightly tapping on the heels of straightened legs), the pain in the damaged vertebra increases sharply. Palpation of the spinous processes of the lumbar region at the moment when the patient lies on his back and slowly raises his straightened legs is painful (Silin's symptom). There are no neurological symptoms.

D.S. Compression fracture of the body of the 1st lumbar vertebra. (S22)

Fractura corporis vertebrae lumbalis primae e compressione.

Taz - Pelvis

The victim was crushed between railway cars. Complains of pain in the bones of the pelvis and perineum. Examination revealed swelling and bruising in the right inguinal region. Leg movements cause increased pain. The patient's legs are in a forced "frog" position. Anterior and lateral compression of the pelvis increases pain in the area of ​​injury. The pain intensifies when trying to spread the iliac bones to the sides. The patient cannot raise the straightened in knee joint leg. With difficulty bends it, dragging the heel along the bed (symptom of "stuck heel").
D.S. Fracture of the right pubic and ischial bones with discontinuity of the pelvic ring.

Fractura ossis pubis et ossis ischiadici dextri cum laesione incolumitatis cinguli pelvis.

A 28-year-old woman had a damaged pelvic ring during childbirth. The patient was transferred to the trauma department. Disturbed by pain in the frontal symphysis. The motor function of the limbs is impaired. The patient seeks to take a forced position - the legs are slightly bent at the knees and hip joints, the hips are brought together as much as possible. When you try to spread them apart, there is a sharp pain. The divergence of the pubic articulation is determined by palpation and through the vagina.

D.S. Rupture of the pubic joint.

Ruptura symphysis pubis.

An elderly man fell on his right side from a height of about 3 meters. The maximum impact fell on the greater trochanter of the right femur. Disturbed by pain in the right hip joint. The motor function of the joint is significantly limited. The leg is in a forced position - the thigh is bent and rotated inward. The load on the hip axis is painful. The large trochanter is depressed inward, tapping on it causes pain. There is a hematoma in the groin area on the right. During rectal examination on the right, respectively, the acetabulum, the femoral head, which has penetrated into the pelvic cavity, is palpated.

D.S. Fracture of the acetabulum of the right pelvic bone with a central dislocation of the hip.

Fractura acetabuli dextricum luxatione coxae centrale.

A young man was kicked in the groin during a fight. Disturbed by pain in the pubic area, aggravated by movements of the left leg. Palpation of the pubis is painful on the left. The patient cannot urinate on his own, although there is an urge. As the urinary infiltration developed, pains appeared in the lower abdomen, a burning sensation. Temperature 39 C. There were chills, tachycardia. The general condition worsened.

D.S. Fracture of the left pubic bone. Extra-abdominal rupture of the bladder.

Fractura ossis pubis sinistri. Ruptura extraperitonealis visicae urinariae.

An elderly man was taken to the clinic from the scene of an accident. Complaints of pain in the pubic region and perineum. Movement of the legs increases the pain. Palpation of the pubis is painful. From the external opening of the urethra, blood is secreted drop by drop. There is a hematoma in the perineum. The bottom of the bladder protrudes beyond the pubic symphysis. Attempting to empty the bladder results in burning pain, and this causes the patient to stop urinating.

D.S. Bilateral fracture of the pubic bones of the pelvis with a rupture of the xiphoid canal.

Fractura bilateralis ossium pubis cum ruptura urethrae.

The victim hit her right iliac bone. Pain in the region of the right iliac bone, bruising, swelling. Pressure on the wing of the ilium is sharply painful. Palpation reveals crepitus. Active flexion and abduction of the right leg exacerbates the pain. The abdominal muscles in the lower abdomen on the right are tense.

D.S. Fracture of the wing of the right iliac bone.

Fractura alae ossis ilii dextri.

Thigh Femur

The victim was in a car that ran off the road and overturned several times. Complaints of pain in the right hip joint. Can't stand on right leg. On examination, the right hip joint was deformed. The leg is slightly bent at the knee and hip joint and turned inward. Active movements in the hip joint are impossible, passive ones meet springy resistance. The right leg is noticeably shorter, the lumbar lordosis is more pronounced.

D.S. Posterior iliac dislocation of the right hip.

Luxatio coxae posterior (iliaca).

Woman 65 years old. About an hour ago, getting up from a chair, I felt a click and pain in the right hip joint, fell, could not get up. In 2011, an operation was performed to replace the hip joint on the right. Since then, the endoprosthesis component has been dislocated six times, followed by reduction in the hospital.

Objectively: The patient lies on the floor. On the skin in the projection of the right hip joint, there is a postoperative scar, pain on palpation, joint deformity, the right lower limb is straightened, the foot is rotated outwards.

D.S. . Habitual dislocation of the hip component of the endoprosthesis of the right hip joint.

Luxatio habitualis componenti iliofemoralis endoprothesis coxae dextrae.

An 80-year-old man stumbled and fell on his left side, hit the region of the greater trochanter. There were severe pains in the groin area. When examining the patient in a horizontal position, the right leg is rotated outwards. He cannot put his foot in a vertical position on his own. Trying to do this with outside help leads to severe pain in the hip joint. The symptom of "stuck heel" is positive. Tapping on the heel and on the greater trochanter is painful.

D.S. Fracture of the neck of the left femur.

Fractura colli femoris sinistri.

Man 65 years old. Does not make any complaints.

The SMP team was called to transport the patient to the CITO.

In August 2009, he fell on the street on his left side, hit his left foot on the asphalt. He felt a sharp pain in the region of the left hip joint, noted the impossibility of standing on his left leg. He was taken by the SMP team to the Department of Traumatology and Orthopedics, where he was diagnosed with a fracture of the femoral neck on the left.

The patient underwent skeletal traction for a period of 1.5 months. In connection with the delayed consolidation of the fracture in October 2009, a closed osteosynthesis operation was performed, after which the patient was discharged home two weeks later.

Contrary to the doctor's instructions, the patient began to put a load on the sore leg already one and a half to two months after the operation, and in April 2010 he went to work (associated with large physical activity). In August 2011, he began to notice discomfort and pain in the left hip joint during leg movements and load on the leg, in connection with which he turned to the Department of Traumatology and Orthopedics, where an ununited fracture of the neck of the left femur with the formation of a false joint was diagnosed. The patient was scheduled for femoral head arthroplasty, which was performed in October 2011.

Objectively. The condition is satisfactory. Consciousness is clear, position is active. Body temperature - 36.8. The skin is flesh-colored, clean, moist, the lymph nodes are not enlarged, there are no edema.

The respiratory rate is 18 per minute. Vesicular breathing over the entire surface of the chest, no wheezing. Pulse - 94 beats per minute. Heart sounds are muffled, there are no murmurs. The abdomen is oval, symmetrical, soft, painless on palpation. Shchetkin-Blumberg's symptom is negative. Normal peristaltic noises are heard. The liver is not palpable. The symptom of tapping is negative.

status localis: The skin in the area of ​​the left hip joint is hyperemic, around the greater trochanter there is an arcuate incision. The edges of the wound are edematous, hyperemic. Movements in the joint are painless, their amplitude is limited. On palpation of the wound, local pain is noted.

D.S. : Ununited fracture of the neck of the left femur with the formation of a false joint. Condition after endoprosthetics of the femoral head.

Fractura colli ossis femoris sinistri non consolidata, pseudoarthrosis. Endoprothesis capitis ossis femoris.

An eleven-year-old girl was delivered 40 minutes after a railway injury with a torn off right lower limb at the level of the hip joint, with its complete destruction and severe traumatic shock. The general condition of the patient is extremely severe. Consciousness is oppressed. The pulse on the radial artery is frequent, weak filling. BP 75/40 mm. shallow breathing, frequent. The skin is pale, covered with cold sweat. Heart sounds are muffled.

D.S. Traumatic amputation of the right lower limb at the level of the hip joint. Traumatic shock.

Amputatio traumatica coxae dextrae. Afflictus traumaticus.

A seven-year-old boy fell from a tree from a height of three meters. The main force of the blow fell on the left leg. For some time he lay under a tree, could not get up.

On examination, the left thigh is swollen, deformed, its axis is curved. Feeling the injury site is painful. Pathological mobility in the middle third of the thigh is revealed. The child cannot lift his left leg. Sensitivity and motor function of the foot are preserved in full. The pulse on the peripheral arteries is preserved.
D.S. Fracture of the left femur in the middle third.

Fractura femoris sinistri in tertia mediale.

A 44-year-old builder fell from the 3rd floor onto construction debris while working. Hurt your right leg. Delivered to the trauma department. On examination, the right femur was shortened and deformed in the middle third. Palpation of this area is painful. Pathological mobility at the site of injury is determined. The patient cannot raise the straightened leg on his own. On the anteroexternal surface of the right thigh in the middle third there are three wounds 2 by 4 centimeters.
D.S. Open transverse comminuted fracture of the middle third of the right femur.

Fractura transversocomminuta aperta femoris dextri in tertia mediale.

A 29-year-old victim was delivered to the traumatological department with a massive injury to the left thigh and crush injury of the left hand.

Objectively. The left thigh is sharply deformed, shortened by 10 cm. On the anteroexternal surface of the left thigh, there is a large, heavily contaminated wound measuring 20 by 15 cm, fragments of muscles protrude from the wound. Bone fragments of the femur are visible in the depth of the wound. The left hand is crushed, its tissues are not viable. The general condition is extremely difficult. The skin and visible mucous membranes are pale, the skin is covered with cold sweat. The victim is lethargic, adynamic. AD = 60/0 mm. rt. Art.

D.S. Open comminuted fracture of the middle third of the left femur. Crushing of the left hand. Traumatic shock.

Fractura comminuta aperta femoris sinistri in tertia mediale. Conquassatio manus sinistrae. Afflictus traumaticus.

A 38-year-old man, while working on an electric car, was crushed by an oncoming truck.

The condition is severe, excited, pulse 120 per minute, weak filling. AD = 150/110 mm. rt. Art. The skin is pale. The left thigh is deformed, shortened and twisted. On the back surface in the lower third of the left thigh there is a small wound 1 by 0.5 cm. Dark red blood flows from the wound. The thigh is significantly enlarged in volume due to edema and an extensive hematoma that has spread to the popliteal fossa. The left leg and foot are cold and pale. The pulse on the arteries of the foot is not palpable.

The radiograph revealed a comminuted fracture of the left femur in the middle third with a displacement along the length. An arteriogram shows a rupture of the femoral artery in the lower third for 8.5 cm.

D.S. Comminuted fracture of the left femur in the middle third with displacement. Rupture of the femoral artery in the middle third. Traumatic shock.

Fractura comminuta dislocata femoris sinistri in tertia mediale. Ruptura arteriae femoralis. Afflictus traumaticus.

A 37-year-old victim received extensive damage to both thighs in the lower third with crushing of soft tissues and bones on the verge of traumatic avulsion. The condition is extremely difficult. The pulse on the radial artery is not determined. BP = 40/0. The skin is pale, covered with cold sticky sweat. The patient is indifferent to others. Both lower legs are a shapeless mess of bones and muscles.

D.S. Open fracture of both thighs in the lower third with crushing of the legs. Traumatic shock.

Fractura aperta amborum femorum in tertia inferiore cum conquassatione amborum crurum.

Condition of moderate severity. On the pre-internal surface of the upper third of the right tibia there is a wound measuring 10 by 3 cm. There is a pronounced deformation and shortening of the tibia. When trying to shift the injured leg, the lower leg bends at the site of injury (abnormal mobility)

D.S. Open fracture of both bones of the right leg in the upper third. Fractura ossium cruris dextri aperta in parte tertia superiore.

The victim fell down the stairs onto her right leg straightened at the knee joint. The maximum axial load fell on the knee joint. As a result of the injury, severe pain appeared in the region of the right knee joint. There is a diffuse hematoma in the upper third of the right leg, hemarthrosis is determined. The contours of the knee joint are smoothed. The joint is enlarged and deformed. The lower leg is deflected outwards (valgus position). When feeling the joint, a sharp pain in the area of ​​​​the external condyle and balloting of the patella is determined. Active movements in the knee joint are sharply limited and painful. The patient cannot independently raise the straightened leg. There was lateral mobility of the lower leg. With a slight tapping on the heel, the pain increases sharply at the site of injury.

D.S. Fracture of the lateral condyle of the right tibia.

Fractura condyli lateralis tibiae dextrae.

When unloading concrete blocks from a car, one of the blocks fell and hit a nearby student on the leg. As a result of injury in the lower third of the leg formed a wound with intense bleeding. Prior to the arrival of the ambulance, an improvised tourniquet-twist was applied above the wound. The bleeding has stopped. During the period of transportation to the traumatology department, the tourniquet was not shifted (within 5 hours). When viewed on the anterointernal surface of the lower third of the left leg, there is a lacerated wound measuring 4 by 8 cm. Bone fragments of the tibia are visible in the depth of the wound. Below the tourniquet, the skin is pale, sensitivity is not determined. After removing the rope, a deep crushing mark remained in its place. There is no bleeding from the wound and no pulsation of the peripheral arteries. A light massage of the lower leg and foot did not change anything.

D.S. Open fracture of the left tibia in the lower third. Syndrome of prolonged compression of the left leg.

Fractura tibiae sinistrae aperta in parte tertia inferiore. Syndromum compressionis prolongatae cruris sinistri.

Anklejoint, foot- Articulatio talocruralis, pes

The woman twisted her left foot inward. As a result of this injury, there was severe pain in the ankle joint. Disturbed by pain in the outer ankle when walking. The victim cannot firmly step on the injured leg. When examining the left ankle joint, the area of ​​the outer ankle is edematous, painful on palpation. Movement in the ankle is limited and painful.
D.S. Fracture of the lateral malleolus of the left ankle joint.

Fractura malleoli lateralis articulationis talocruralis sinistrae.

A worker was hit on the outer edge of his foot by a heavy metal piece that had fallen from a workbench. On examination, there is swelling and bruising in the dorsum of the foot. Palpation of the base of the fifth metatarsal bone is sharply painful. When sipping on the V finger and with a load along the axis, the pain at the site of injury increases significantly.

D.S. Fracture of the base of the fifth metatarsal bone of the right foot.

Fractura ossis metatarsalis quinti pedis dextri.

The victim fell from a height of 2 meters. The main blow fell on the left heel. Objectively. The left heel is flattened, expanded, edematous. There was a bruise under the inner ankle. The longitudinal arch of the foot is flattened, the load on the heel is impossible. Contraction of the calf muscles causes increased pain in the heel. When viewed from the back of both feet, it is seen that on the injured side the ankles are lower, and the axis of the calcaneus is tilted inward. Active adduction and abduction, pronation and supination are absent.

D.S. Fracture of the left calcaneus.

Fractura ossis calcanei sinistri.

The basic principle of truncation of the fingers is maximum economy, cutting off only non-viable areas while preserving, if possible, the places of attachment of the tendons. In the presence of a skin defect, local tissue grafting or primary transplantation of a free skin flap or a skin flap on a leg is used.

The position of the patient on the back, the hand is taken to the side table and pronated.

Anesthesia: for amputation of the phalanges of the fingers - local anesthesia according to Lukashevich - Oberst (Fig. 161); with exarticulation of the fingers - conduction anesthesia according to Brown - Usoltseva at the level of the middle third of the intercarpal spaces or in the wrist area. According to Lukashevich - Oberst, the needle is injected into the base of the back surface of the finger and a stream of 0.5 - 1% novocaine solution is directed to the dorsal and palmar neurovascular bundles. After introducing 10-15 ml of the solution, a rubber flagellum is applied to the base of the finger.

Amputation of the distal (nail) phalanx.

The incision of the skin and subcutaneous tissue is started from the palmar side, stepping back from the cut line of the terminal phalanx by the length of its diameter. Cut out the palmar flap. On the back of the nail phalanx, the skin with subcutaneous tissue is cut along the bone at the level of the cut. Having pulled back the soft tissues, the destroyed distal part of the phalanx is sawn off with a Gigli saw, and the edges of the palmar flap and the dorsal incision are sutured with silk sutures. The hand and the operated finger are immobilized in a state of slight flexion.

Exarticulation of the distal (nail) phalanx. An incision of the skin, subcutaneous tissue, tendons and articular bag on the back side is carried out along the projection of the interphalangeal joint, which is determined along a line drawn from the middle of the lateral surface of the middle phalanx to the rear of the removed phalanx on the maximum bent finger. Scissors inserted into the joint cavity are dissected. lateral ligaments, after which the joint is fully opened. With a scalpel placed on the palmar surface of the dissected phalanx, a palmar flap is separated from it, equal in length to the diameter of the finger at the site of disarticulation. As a result of this technique, the palmar flap is full-thick at its base, and disappears towards the end, so that only the epidermis layer remains in the flap, which, when sewing up the wound, can easily be adapted to the skin of the dorsal incision (Fig. 162).

Minor bleeding is stopped by applying silk sutures to the edges of skin incisions. The hand and finger in a slightly bent position are placed on the tire.

Dissection of the middle phalanx. It differs from the previously described course of the operation in that after the removal of the phalanx in the dorsal margin and the palmar flap, the digital neurovascular bundles are found and the arteries are grasped with clamps, marking the nerves located next to the vessels.

Two dorsal and two palmar digital nerves are carefully isolated above the bone level and cut off with a safety razor blade. After that, the vessels are tied up, the wound is sutured.

Articulation of the fingers

When isolating a finger, the scar, if possible, is placed on a non-working surface: for III- IV fingers such a surface is the back, for II - radial and dorsal, for V - ulnar and dorsal, for I finger - dorsal and radial (Fig. 163).

IsolationIIAndVfingers according to Farabeu.

The incision of the skin, subcutaneous tissue starts from the rear II fingers from the level of the metacarpophalangeal joint and lead to the middle of the radial edge of the main phalanx and further along the palmar side to the ulnar edge of the metacarpophalangeal joint until the incision begins on the back. A similar incision begins on the back of the fifth finger from the level of the metacarpophalangeal joint, leads to the middle of the ulnar edge of the main phalanx, and ends on the palmar side at the radial edge of the metacarpophalangeal joint. After separating and turning away the skin-cellular flaps, the extensor tendon is dissected distally to the metacarpal head, then the metacarpophalangeal joint is opened with scissors and the lateral ligaments are cut from the side of the joint cavity. After opening the joint capsule on the palmar side, the flexor tendons are dissected somewhat distally. Focusing on the projection of the palmar and dorsal neurovascular bundles, the arteries are found and captured with hemostatic clamps; near them, they are dissected from fiber and cut off above the heads of the metacarpal bones, the digital nerves - dorsal and palmar. The flexor and extensor tendons may be sutured. The head of the metacarpal bone remains: its preservation due to the integrity of the ligaments of the inter- and metacarpal joints will provide a better restoration of the function of the hand.

The wound is sutured so that the flaps cover the head of the metacarpal bone. The shape of the soft tissue incision can be changed depending on the indications for dissection II and V fingers, the tissue defect can be closed by primary plasty.

IsolationIII - IVfingers with a slit in the shape of a racket. The incision in the form of a racket starts at the rear of the metacarpal bone, leads obliquely along the lateral side of the main phalanx to the palmar surface, then along the palmo-finger fold and along the other side of the main phalanx to a longitudinal incision on the back. Skin-subcutaneous-but-fat flaps are separated from the metacarpal bone and from the main phalanx, pulled in the proximal direction with hooks. Distal to the head of the metacarpal bone, the extensor tendon is dissected, then, pulling the finger to be dissected, the joint capsule is dissected with scissors on the dorsal, lateral and palmar surfaces. The flexor tendons and all tissues on which the finger is still held are crossed, and then it is removed. The digital vessels are seized with hemostatic clamps and, having isolated the digital nerves from the surrounding tissues, they are cut off proximal to the metacarpal head. Ligate the vessels. The flexor and extensor tendons are sutured over the metacarpal head. The wound is sutured in layers. The brush is laid in a bent position on the tire.

IsolationIfingers according to Malgen. An incision of the skin and subcutaneous tissue in the form of an ellipse from the metacarpophalangeal joint on the back of the hand is led almost to the interphalangeal fold on the palmar surface and further to the beginning of the incision on the back. Then, by pulling the removed finger and moving the edge of the dorsal incision with a hook, it is possible to open the metacarpophalangeal joint. The scalpel is brought to the palmar surface and directed at dissection of the palmar part of the articular capsule at an angle of 45° with respect to the metacarpal bone with the tip distally. This is the most important moment of the operation, which allows you to save the attachment of the muscles of the first finger to the sesamoid bones located on the anterior surface of the joint capsule. The flexor and extensor tendons of the first finger are sutured, the wound is sutured. With the removal of the first finger, the function of the hand is impaired by 50 %. In these cases, phalangization of the first metacarpal bone is used for correction.

3. Operations for femoral hernia access to hernia gate can be divided into two groups: femoral and inguinal.

Operation Bassini. Use access to the femoral canal from the side of its external opening. The skin incision is made parallel to and below the projection of the inguinal ligament. The stage of searching for a hernial sac in obese patients can present significant difficulties. It is easier to detect it if you invite the patient to strain or cough. Carefully release the hernial sac from fatty tissue and surrounding fascial membranes. The hernial sac is isolated as high as possible, opened, sutured and cut off. When isolating the hernial sac, it should be remembered that the bladder may be located on the medial side, and the femoral vein laterally. The hernial orifice is closed by suturing the inguinal and pubic (Cooper) ligaments. In total, 3-4 sutures are applied, controlling whether the femoral vein is compressed. The femoral canal is sutured with the second row of sutures between the falciform edge of the wide fascia of the thigh and the pectinate fascia.

Currently, preference is given to inguinal methods for the treatment of inguinal hernias, the main advantages of which are recognized as high ligation of the hernial sac, convenient and reliable suturing of the internal opening of the femoral canal. This approach is especially indicated for incarcerated femoral hernias, when wide access may be required for bowel resection.

Operation Ruggi-Parlavecchio. The skin incision is made parallel to and above the inguinal ligament (as in an inguinal hernia). The aponeurosis of the external oblique muscle is opened (i.e., they enter the inguinal canal). Expose the inguinal gap. Dissect the transverse fascia in the longitudinal direction. Pushing the preperitoneal tissue, the neck of the hernial sac is isolated. The hernial sac is removed from the femoral canal, opened, stitched at the neck and removed. The hernia gate is closed by suturing the internal oblique, transverse muscles, the upper edge of the transverse fascia with the pubic and inguinal ligaments. If necessary, the internal opening of the inguinal canal is sutured to a normal size, applying additional sutures to the transverse fascia. The spermatic cord (or round ligament of the uterus) is placed on the muscles. The dissected aponeurosis of the external oblique / abdominal muscles is sutured with the formation of a duplication.

4. TOPOGRAPHY OF THE PERINE,REGIOPERINEALIS

The perineum closes the exit from the pelvic cavity, being its lower wall. The crotch area has the shape of a rhombus.

The following formations are external landmarks: the lower edge of the pubic symphysis is palpated in front, the tip of the coccyx is posterior, and the ischial tubercles are palpable from the sides. The perineum is separated from the medial sections of the thigh region by a perineal-femoral fold. The lower edges of the large

gluteal muscles. Obstetric perineum - the area between the posterior commissure of the labia majora and the anus. The line connecting the ischial tubercles, both the male and female perineum is conditionally divided into two unequal triangles: the anterior one is the genitourinary region, regio urogenitalis, and the posterior one is the anal region, regio analis.

The genitourinary region (triangle) is limited in front of angulus subpubicus with lig. arcuatum pubis (in women - arcus pubis), behind - a conditional line connecting the ischial tubercles, from the sides - the lower branches of the pubic and ischial bones. In this triangle is the urogenital diaphragm of the pelvis, diaph-ragma urogenitale, through which the vagina and urethra pass in women, and the urethra in men.

The boundaries of the anal area (triangle) are in front - a conditional line connecting the ischial tubercles; behind - coccygeal bone; from the sides - sacrotuberous ligaments.

In this triangle is the pelvic diaphragm, diaphragma pelvis, through which the rectum passes.

The perineum also includes the external male and female genital organs. The skin in the perineal area is thinner, thickens in the center towards its lateral sections. In men, between the root of the scrotum and the anus is the perineal suture, raphe perinei. Around the anus there are radially located skin folds due to the fusion of the muscle fibers of the external sphincter of the anus with the skin. The skin contains a large number of sebaceous and sweat glands and is covered with hair. Subcutaneous fatty tissue and superficial fascia are more pronounced in the posterior perineum. The branches of the ilioinguinal nerve, n. ilio-inguinalis, the pudendal nerve, n. pudendus, and the perineal branch of the posterior cutaneous nerve of the thigh r are involved in the innervation of the skin of the perineum. perinealis n. cutanei femoris posterioris. The blood supply to this area is carried out by the internal pudendal artery. The outflow of blood occurs through the vein of the same name into the internal iliac vein, the outflow of lymph - into the inguinal lymph nodes.

Genitourinary triangle (Fig. 121). In the subcutaneous tissue there is a weakly expressed sheet of superficial fascia. The fascia of the genitourinary triangle is a thin loose transparent sheet that forms cases for the superficial layer of muscles located in the form of paired triangles: the bulbous-spongy muscle, m. bulbospongiosus; laterally - ischiocavernosus muscle, in. ischio-cavernosus; behind - superficial transverse muscle of the perineum, m. transversus perinei superficialis. Under the ischiocavernosus muscles, which are located along the inferomedial edges of the pubic-ischial branches of the pelvic bone, in men there are legs of the male penis, crura penis, in women - cmra clitoridis. In the center of the male urogenital triangle, under the bulbous-spongy muscle, lies the bulb of the male penis, bulbus penis. Under the base of this bulb, next to it in the thickness of the diaphragm are the bulbous urethral glands, gll. bulbourethrales (Cooperi).

Under each of m. bulbospongiosus in women is the bulb of the vestibule, bulbus ves-tibuli, which has a powerful venous plexus (corresponds to the bulb of the penis).

Muscle bundles m. bulbospongiosus in the posterior section are attached to the tendon center of the perineum, centrum tendineum perinei. Here, in this central fascial node of the perineum, the fibers m are woven, crossing. sphincter ani externus, and so on. transversus perinei superficialis. This area of ​​interweaving of muscle fibers, reinforced by tendon fibers, determines the functional interdependence of the muscles in this area and is a guideline for surgical interventions. Under the fascia of the urogenital triangle are the terminal branches of a. et v. pudendae internae and p. pudendus (a. dorsalis penis and p. dorsalis penis) (Fig. 122). Deeper than the surface layer of muscles lies the lower fascia of the urogenital diaphragm (perineal membrane), fascia diaphragmatis urogenitalis inferior (membrana perinei), then the deep transverse perineal muscle, m. transversus perinei profundus. Its muscle bundles are located transversely and cover the membranous part of the urethra in men (the urethra and vagina in women) from all sides, forming a ring - a pulp. The upper surface of the t. transversus perinei profundus is covered with the upper fascia of the urogenital diaphragm, fascia diaphragm atis urogenitalis superior, which is part of the pelvic fascia. The lower and upper fascia of the urogenital diaphragm fuse along the anterior and posterior edges of the deep transverse perineal muscle. Hence the possibility of long-term accumulation of pus in this closed space with its breakthrough into the urethra. In front of the fascia of the diaphragm form the transverse ligament of the perineum, lig. transversum perinei, which does not reach the subpubic angle. Slightly higher is lig. arcuatum pubis. In the gap between these ligaments in men passes v. dorsalis penis profunda, and in women - v. dorsalis clitoridis profunda.

Anal triangle of the perineum

IN the center of the region is the anal opening of the rectum, surrounded by semi-oval muscle bundles of the external sphincter of the anus (m. sphincter ani externus). The anterior section of this muscle is fused with the tendon center of the perineum, the posterior - with lig. anococcygeum. Lateral to the external sphincter of the anus, there is an abundant layer of fatty tissue that fills the ischiorectal fossa. This fiber is a continuation of the subcutaneous fat layer without clear boundaries between them.

ischiorectal fossa,fossaischio- rectalis. Paired, triangular-shaped spaces located on the sides of the pro-perineal part of the rectum. The boundaries of the ischiorectal fossa are from the inside t. sphincter ani externus, outside - tuber ischii, in front - t. transversus perinei superficialis, behind - the lower edge of t. gluteus maximus. The walls of the fossa are laterally - the lower 2 / s m. obturatorius internus, covered with a strong parietal fascia of the pelvis, in the splitting of which the genital neurovascular bundle (genital canal, canalis pudendalis) passes, from above and from the inside - the diaphragm of the pelvis, i.e. the lower surface of m. levator ani, covered with the lower fascia of the pelvic diaphragm, fascia diaphragmatis pelvis inferior. The muscle goes obliquely from top to bottom, outside and medially and forms an angle open downwards with the plane of the lateral wall of the fossa. Along the junction of the fascia is the tendinous arch of the fascia of the pelvis, arcus tendineus fasciae pelvis (lateral fascial node of the small pelvis). In its education take part

the fascia of the obturator internus muscle and the superior and inferior fasciae of the pelvic diaphragm. The depth of the fossa from the surface of the skin to the top of the angle in an adult is 5.0-7.5 cm. It gradually decreases anteriorly, where it is 2.5 cm. muscles, - gluteal pocket, recessus glutealis. The latter corresponds to the lower part of the deep cellular space of the gluteal region at the level of the subpiriform opening. The ischiorectal fossa may be the site of the formation of purulent accumulations (para-proctitis). Through it, in some cases, it is necessary to open the phlegmon of the subperitoneal cellular spaces of the small pelvis.

The genital neurovascular bundle emerges from the gluteal region through the small sciatic foramen and passes in the splitting of the obturator fascia (genital canal) 4-5 cm above the lower edge of the ischial tuberosity (landmark for blockade of the pudendal nerve during labor pain relief).

Under the posterior half of the sacrotuberous ligament, perforating the obturator fascia, almost in the frontal plane, the lower rectal neurovascular bundle is sent to the anus, a. et v. rectales inferiores, nn. rectales inferiores - branches of the genital neurovascular bundle. Their topography should be taken into account during operations for paraproctitis and purulent streaks from the subperitoneal floor of the pelvis. The internal pudendal artery and pudendal nerve give branches to the skin of the perineum, scrotum, penis (in women - to the labia majora, clitoris).

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