In what kind of injuries is there a shortening of the damaged limb. Injuries. A set of exercises for recovery after injuries of the lower and upper extremities

Bruises and hematomas of soft tissues without violating the integrity of the skin occur upon impact, fall. With a bruise, the subcutaneous fat, muscles, and blood vessels are partially destroyed. The main symptoms of a bruise are: pain in the bruised area, hemorrhage. In the presence of a hematoma, fluctuation is determined (subcutaneous fluctuation of the blood poured into the soft tissues).

First aid: rest, cold for 2-3 days per limb; tight bandaging in the area of injury. From the 4th day, thermal procedures are prescribed: a heating pad, warming compresses, physiotherapy. At suppuration of a hematoma opening of an abscess is shown.

Closed muscle injuries can occur at different levels: at the level of the muscle belly, at the point of transition of the muscle into the tendon, at the place of its attachment to the bone. The most common injuries are to the biceps brachii and gastrocnemius muscles. Injuries result from a direct blow.

Signs of soft tissue damage, bruises and bruises:

pain syndrome;
hematoma;
retraction at the site of muscle rupture;
function may be preserved if there is no complete rupture of the muscle.

First aid: incomplete muscle ruptures are treated conservatively: immobilization, cold, and after 3-5 days thermal procedures are prescribed. With a complete rupture of the muscle, surgical treatment is indicated - stitching the muscle.

Tendon injuries

Complete and partial subcutaneous ruptures and tendon ruptures often occur as a result of a sharp muscle contraction when lifting weights in athletes.

When the tendons are damaged, there is a sharp pain at the time of muscle contraction. Patients note a "crunch" in the limb, muscle strength is weakened. With active contraction of the muscle, its contour is deformed.

Joint damage

A bruise is accompanied by pain in the joint area, hemorrhage. Simple bruises are treated with a pressure bandage, cold, thermal procedures.

Ligament sprains. The ligaments that strengthen the joint are strongly stretched during sudden excessive movements. If the tension of the ligament exceeds the limit of physiological elasticity, then a rupture may occur.

Signs of a sprain are as follows:

acute local pain;
swelling in the joint area;
hemorrhage;
the function is not broken.

A plaster splint is used for 8-12 days, thermal procedures, physiotherapy.

Damage to the meniscus of the knee joint. It is more common in older males. The medial meniscus is damaged more often than the lateral one.

Signs of damage to the meniscus of the knee joint are as follows:

joint pain;
hemorrhage in the joint;
the contours of the joint are smoothed;
on palpation, pain along the joint space;
increased pain when walking down stairs (symptom of "stairs").

Limb bone injury

Damage to the bones of the extremities is a violation of the integrity of the bone under the influence of a single-stage action of a traumatic force.

Classification of bone injuries.

I. By origin and development reasons:

congenital bone injuries - appear during fetal development due to an inferior process of osteogenesis of the fetal skeleton;
acquired - at birth or in the process of life.

II. For reasons of occurrence:

traumatic - deep mechanical impact due to bone flexion, rotation, compression;
pathological lesions (osteomyelitis, tumors, metabolic disorders, syringomyelia).

III. According to the condition of the integumentary tissues at the fracture site :

closed damage;
open (damage to the skin by sharp bone fragments).

A closed fracture can turn into an open fracture during transport if the limb is not splinted or is done carelessly.

Also, bone injuries are classified according to localization in case of damage to tubular bones, according to the direction of the fracture line, according to the shape and type of fracture.

Symptoms of damage to the bones of the limbs.

Pain in the injured limb occurs during a fracture due to injury to the nerve trunks by bone fragments, compression by a hematoma, and tissue edema. The deformation is due to the displacement of fragments, edema.

Violation of function and support ability accompanies all fractures. With fractures of long tubular bones with displacement, the victim cannot move due to pain.

Pathological mobility accompanied by bone crunch (crepitus), which appears when the bone fragments are displaced.

limb shortening due to displacement of bone fragments due to muscle contraction. The limb is compared in length with the healthy side.

With open fractures, there is damage to the skin through which bone fragments protrude, blood flows out. There is tissue swelling.

First aid for fractures should be aimed at resting the limb, relieving pain, preventing shock, and preventing displacement of bone fragments.

With open fractures, a temporary stop of bleeding is necessary. At the site of injury, assistance begins with the release of the body of the victim, if possible, painkillers should be administered. With an open fracture, it is necessary to temporarily stop bleeding: a pressure bandage, a tourniquet, a hemostatic clamp.

Immobilization is the deprivation of the joints of the limbs of the ability to move, as a result of which the immobility of the broken limb is achieved. It is used to ensure rest and prevent displacement of fragments, to reduce pain. At the scene, immobilization is carried out with improvised means: plywood, cardboard, boards, skis. The injured upper limb is fixed to the body, the leg to the healthy leg. Transport immobilization should provide maximum rest, immobility of the injured limb during transportation. For closed fractures, splints are placed over shoes and clothing. With open fractures, the reduction of fragments is unacceptable; the wound is closed with a sterile dressing. At least two joints are fixed, and in case of damage to the hip and shoulder - three joints. Cotton wool, a towel, grass are placed under a hard tire to prevent compression of blood vessels and nerves.

In case of damage to the lower extremities, a standard Diterichs wooden splint is used. It consists of two sliding bars of different lengths, a wooden footrest for stretching and a twist stick.

For hip fractures, three ladder splints can be used: two are tied together so that they fix the leg from the armpit to the outer edge of the moan, and the third from the gluteal crease to the fingertips.

In case of damage to the collarbone or scapula - a scarf, Dezo bandages, Delbe rings.

In case of fractures of the humerus in the upper third, a cotton-gauze roller is placed in the armpit and the arm is bandaged to the chest. The forearm is hung on a scarf. Ladder splint is used for fractures of the diaphysis of the shoulder. It fixes three joints (shoulder joint, elbow and wrist joints).

In case of fractures of the forearm, the elbow and wrist joints should be fixed. The elbow joint should be bent at a right angle.

For damage in the area of the wrist joint and fracture of the phalanges of the fingers, ladder tires, plywood tires are used.

Therapeutic immobilization is reduced to the imposition of plaster bandages.

Fractures of the clavicle most often occur at the border of its outer and middle thirds. Usually, the peripheral fragment is displaced downward and forward, and the central fragment is displaced upward and backward.

In connection with the anatomical features and position, the shoulder joint is more likely than other joints to undergo various injuries: bruises, ligament injuries, tendon ruptures, dislocations, fractures.

Shoulder bruises

clinical picture. The victim complains of severe pain in the shoulder joint. Movement is possible, but limited due to pain. With a significant injury, hemorrhage and swelling are noted, sometimes reaching large sizes. The hematoma gradually descends, spreading to the elbow joint and below. With hemorrhage in the joint cavity, its tension is noted during palpation, swaying. On x-ray, the joint space is enlarged. A bruise must be differentiated from damage to the ligamentous apparatus, dislocation and fracture of the neck of the humerus.
Treatment. With mild degrees of bruising, special treatment is usually not required. In the presence of pain, a Dezo bandage should be applied for 2-3 days.
With hemarthrosis, a joint is punctured with blood evacuation and the introduction of 20 mm 1% novocaine solution into its cavity. From the 2-3rd day, UHF therapy and exercise therapy are prescribed. With severe bruises, the ability to work is restored after 2-3 weeks.

Ligament injuries

Shoulder ligament injuries are caused by a fall on an outstretched and abducted arm. Damage can be complicated by tendon rupture, tear or rupture of the articular bag.
Clinical picture characterized by acute pain in the joint during movement, local pain is felt, there is swelling of the tissues and often bruising. There are no changes on the radiograph.
Treatment. In mild cases of ligament damage (tears), several times after 1-2 days, 20 ml of a 1% solution of novocaine is injected into the periarticular tissues and immobilized with a Deso bandage for 5 days. From the 5th day, rehabilitation treatment is carried out. In severe cases (ruptures), immobilization is carried out on the outlet splint for 7-8 days. From the 14th day, the vitreous body, aloe are introduced, and a course of pyrogenal therapy is carried out.

tendon ruptures

clinical picture. Rupture of the tendons in the area of the shoulder joint can occur with a direct injury and a strong sudden contraction of the muscles (flexion at the elbow joint, lifting the weight up with a jerk). This type of injury is observed in people in middle and especially in old age, when degenerative changes occur in tissues. The tendon of the biceps brachii and the supraspinatus tendon most often rupture. At the moment of rupture of the tendon of the biceps muscle of the shoulder, patients experience severe pain. On examination, there is swelling of the tissues, bruising. After the edema decreases, it turns out that when the forearm is flexed, the biceps muscle contracts only in the lower section, there is a retraction in the upper part of the muscle. Treatment in this case is only surgical.
When the tendon of the supraspinatus muscle is ruptured, severe pain occurs, radiating to the middle of the shoulder, abduction of the limb is sharply limited. Patients experience pain for a long time, the function of the limb is impaired. When feeling the shoulder, the greatest pain is determined in the region of the large tubercle of the humerus.
Conservative treatment possible only with incomplete rupture. When assisting the victim, the place of greatest pain is anesthetized with 20 ml of 1% novocaine solution and the arm is immobilized on the outlet splint for 4 weeks, then restorative physiotherapy is carried out.
In cases of complete rupture of the tendon, an operation is indicated, which can be performed under conduction anesthesia or anesthesia. The position of the patient - on the back with a pad under the operated shoulder joint. The incision has an arcuate shape and starts from the outer end of the spine of the scapula, reaches the acromioclavicular joint and descends along the abdomen of the deltoid muscle for 5 cm. They bluntly penetrate between its fibers (the axillary nerve passes below).
The acromioclavicular joint is opened with a scalpel and the acromion is excised with a chisel. The part of the deltoid muscle released by the osteoplastic method is retracted outwards, downwards and anteriorly, and then the capsule of the shoulder joint with the supraspinatus tendon located above it becomes accessible and visible. Set the break point.
With transverse ruptures of the supraspinatus muscle, a transverse channel in the humerus is hollowed out with a chisel, towards the anatomical neck. In the distal edge of the canal, 5-6 holes with a diameter of 0.3 cm are drilled, connecting the canal wall with the outer surface of the humerus. After that, the released end of the supraspinatus muscle is fixed to the refreshed channel. This is done with silk threads or with a tape from the wide fascia of the thigh. First, the fascia or thread is passed through one end of the muscle, a knot is tied, passed through one of the holes in the bone, then the muscle is again captured through the adjacent hole, and so on until the end.
A longitudinal tear usually occurs along the * front edge of the muscle, where it borders the subscapularis muscle along the coraco-capsular ligament. With large ruptures of the supraspinatus muscle, the subscapularis muscle is completely released, which, pulling the head down and forward, can cause subluxation of the head, therefore, longitudinal muscle ruptures are sutured during surgical intervention from the same access as the transverse ones. After restoration of the muscle, the acromion fragment is sutured with several sutures to the place where it was taken from. The wound is sutured in layers, and the arm is immobilized for 4 weeks with a plaster thoracobracheal bandage or a CITO splint in the arm abduction position at 90°. After removing the plaster bandage, physiotherapy is carried out.
The technique for repairing biceps tears depends on the location of the injury. The tendon of the long head is most often damaged. Detachment can be intra-articular, extra-articular low and above the articular fossa.
The incision starts from the border between the outer and middle thirds of the clavicle and goes down the deltoid-pectoral groove to a distance of about 8 cm. the arm is rotated inside - a torn tendon protrudes into the operating field. With an extra-articular rupture, the proximal end is not retracted, while the distal one quickly goes below the rupture site. If both ends of the tendon can be brought together, then they are sutured; if this is not possible, the defect should be performed with a tendon (from the long palmar muscle) or fascial (from the muscle of the wide fascia of the thigh) transplant.
The tendon graft is sutured according to Bennel, and the fascial tape is sutured with separate sutures, first to the distal end of the tendon, and then to the proximal one (the muscle should be moderately taut). In the absence of tendon wire, the seam can be made with thin but strong silk. If there is retraction of the proximal end of the tendon, then it is necessary to cut the cover over the head of the humerus. When the proximal end of the tendon is avulsed, it is best to sutured it to the tendon of the short head of the biceps muscle or implant it in the coracoid process or in the humerus just below the capsule.
The wound is sutured in layers and a plaster bandage of the Velpo type is applied with flexion at the elbow joint at an angle of 70°. Immobilization is carried out for 3-4 weeks, followed by physiotherapy. Within 8 weeks after the operation, active movements in the elbow joint without weights should be carried out.

Shoulder dislocations are common and account for 50-60% of all dislocations. Shoulder dislocation usually occurs when you fall on an outstretched and abducted arm. Depending on the direction of the acting force, the head of the shoulder is displaced, which determines the type of dislocation.
There are anterior, inferior and posterior dislocations of the shoulder (Fig. 1). Anterior dislocations can be subcoracoid, subclavian, and knutrikorakoid. This is due to the fact that the articular bag in the anteroinferior section is easily torn. Subcoracoid dislocations account for about 75% of all shoulder dislocations.
Lower dislocations are much less common, when the head of the shoulder is displaced into the armpit. They make up about 23%.
Dislocation of the shoulder is always accompanied by a rupture of the articular bag and ligaments, in some cases there is a detachment of the large and small tubercle of the humerus, a rupture of the tendon of the long head of the biceps muscle, and sometimes the neurovascular bundle is injured. As a result of a rupture of the axillary nerve, paresis or paralysis of the deltoid muscle occurs.
clinical picture. When the shoulder is dislocated, patients complain of severe pain in the shoulder joint. There is a forced retracted position of the shoulder (the patient supports it with a healthy hand). With an axillary dislocation, the shoulder of the diseased arm seems to be lengthened, and with a subcoracoid, it is shortened. The area of the shoulder joint on the diseased side is thickened compared to the healthy side, the acromial process stands out sharply. Palpation is determined by an empty articular cavity. The head of the shoulder with an anterior dislocation can be felt under the coracoid process, with a lower dislocation - in the armpit. Active movements are impossible, passive ones are sharply painful and limited. An attempt to raise the patient's arm or take it away causes spring resistance characteristic of dislocation in the joint. Offset head

Rice. 1. Shoulder dislocations:
a - anterior subcork; b - intracoracoid; c - lower pre-articular; g - lower axillary; d - rear

can compress blood vessels and nerve trunks, as a result, severe pain, cramps in the muscles of the limb, paresis or paralysis of the nerve, there is a feeling of numbness, cyanosis or pallor of the skin of the fingers, the pulse on the radial artery is weakened or completely absent. Of the nerve trunks, the axillary nerve is most often damaged, which leads to a violation of the sensitivity of the skin over the deltoid muscle, paresis and paralysis of this muscle.
Dislocation of the humerus may be accompanied by a fracture of the edge of the articular surface of the scapula, coracoid process, separation of the large or small tubercle of the humerus, fracture of the entire head and neck of the shoulder.
When a dislocation of the shoulder is combined with a fracture of the surgical neck with displacement of fragments, the shoulder is shortened and not retracted, there is no spring resistance characteristic of dislocation. It is very important to timely diagnose a dislocation of the shoulder with a simultaneous impacted fracture of the neck, since the further tactics of the doctor depend on this.
Examination of the patient ends with an X-ray examination, which clarifies the nature of the dislocation.
Treatment. Diagnosed dislocation of the shoulder requires urgent reduction, which is performed under local anesthesia or anesthesia. Before anesthesia, 1 ml of a 1% solution of morphine is injected (for adults), and then 20 ml of a 2% solution of novocaine (or 30-40 ml of a 1% solution) is injected into the cavity of the shoulder joint.
Anterior and posterior dislocations of the shoulder should be reduced according to Kocher (this method is contraindicated in old age due to bone porosity and in case of a fracture of the shoulder neck, as it can cause a fracture or splitting of the fracture).
Lower and posterior dislocations and a combination of dislocation with a fracture of the surgical neck should be reduced according to Dzhanelidze and Mot.
Kocher method. The reduction technique involves four successive stages (Fig. 2).

Rice. 2. Reduction of shoulder dislocation according to Kocher: a, b, c, d - stages 1-4

First stage. The assistant fixes the patient's shoulder girdle with both hands placed on the shoulder girdle. The surgeon with one hand grabs the patient's shoulder over the elbow, with the other - the forearm over the wrist joint. The patient's arm is bent at the elbow joint at a right angle. Pulling the shoulder down with force and slowly overcoming the springy resistance of the muscles, they press the patient's elbow to his torso. This achieves an outward rotation of the head of the shoulder.
Second phase. The patient's shoulder pressed against the body with the help of the forearm used as a lever is slowly turned outwards until the palmar surface of the forearm coincides with the frontal plane of the body. As a result of this technique, the head of the shoulder becomes against the articular surface of the scapula. Sometimes during this stage, the dislocation is reduced.
Third stage. Without weakening the traction, the patient's elbow pressed against the body is slowly advanced to the midline and upwards (the elbow is in front of the chest). With this movement, the head of the shoulder usually becomes against the place of rupture of the articular bag.
Fourth stage. The patient's forearm is placed on the chest in such a way that the hand of the affected limb touches the healthy shoulder girdle. In this case, the dislocation is usually reduced, as indicated by a characteristic clicking sound. If the reduction did not occur, then all steps should be repeated again. After reduction of the dislocation, it is necessary to make a control radiograph by applying a plaster bandage of the Deso type. Immobilization should be carried out for 2 weeks. After removing the plaster bandage, a hand massage and a course of exercise therapy are performed.
Janelidze method. After anesthesia, the patient lies on his side with a dislocated limb hanging down, resting his shoulder blade on the edge of the table. The assistant supports the patient's head. In this position, the patient should remain for 15-20 minutes. Under the weight of the injured limb, the muscles of the shoulder girdle gradually relax. The surgeon stands in front of the patient and bends his dangling arm at the elbow joint at a right angle, as a result of which tense muscles relax. The doctor puts one of his hands on the palmar surface of the patient's forearm at the elbow bend, and with the other hand covers the patient's forearm at the wrist joint. On the patient's hand fixed in this position, the doctor with one hand presses down on the forearm at the elbow bend; at the same time, with the other hand, covering the patient’s forearm at the hand, the doctor performs rotational movements outward and then inward in the shoulder joint. In this case, the dislocation is reduced (Fig. 3).
When repositioning according to Yu. Yu. Dzhanelidze, you can modify the technique: do not wait 10-20 minutes, but immediately, when anesthesia occurs, apply pressure in the area of \u200b\u200bthe elbow bend with the knee, transferring the weight of your body, while the free hand is located in the armpit. The dislocation can be reduced quickly and atraumatically.
Mota method. The patient is placed on his back. One assistant takes both ends of the sheet, which is brought under the back from the side of the dislocated arm, encircles the chest and is brought out towards the healthy shoulder joint; the second assistant grabs the shoulder above the elbow joint with one hand, and the forearm above the wrist joint with the other, bends the patient's arm at the elbow joint to a right angle, rotates it slightly outward, abducts and raises it to a right angle. After that, both assistants produce smooth traction in different directions, and the surgeon presses with his palm on the palpable head of the shoulder in the armpit. Usually, at the moment of repositioning the head into the articular cavity, a characteristic clicking sound is heard (Fig. 4).
Cooper's (Hippocrates) method. The patient lies on his back. The surgeon sits down and produces a strong longitudinal extension of the

Rice. 3. Reduction of shoulder dislocation according to Dzhanelidze

Rice. 4. Reduction of the dislocation of the humerus according to Mot

Rice. 5. Reduction of the dislocation of the humerus according to Hippocrates

twisted hand, which he grabs with both of his hands above the wrist joint, and at the same time with the heel of his foot puts pressure on the head, which has shifted into the armpit. In this case, the head of the humerus is reduced into the articular cavity (Fig. 5).

Dislocations of the forearm

Forearm dislocations are second only to shoulder dislocations and are more common in younger people. They may be complete or incomplete. With incomplete dislocations, partial contact of the articular surfaces of the bones is preserved, with complete dislocations, it is not preserved. Dislocations of both bones of the forearm posteriorly (posterior dislocation) are more common than dislocations of both bones anteriorly (anterior dislocation). Often there are dislocations of the forearm outward, inwards, diverging dislocation, as well as dislocation of one radius anteriorly, backwards, outwards. Extremely rare dislocation of one ulna posteriorly.
Dislocations of the forearm occur under the influence of direct and indirect trauma. Posterior dislocation occurs when a fall occurs on the palmar surface of the arm with full extension of it at the elbow joint (indirect injury) and when a force is applied to the lower part of the shoulder in the position of flexion at the elbow joint at an angle of 90 ° (direct injury). This dislocation is accompanied by a rupture of the anterior part of the articular capsule, often with a detachment of the tendon of the shoulder muscle from its place of attachment, and a fracture of the coronoid process.
With dislocation of the forearm inside and out, severe damage to the soft tissues, bag and ligamentous apparatus occurs.
clinical picture. With dislocations of the forearm, patients complain of pain in the elbow joint and are forced to support the forearm with a healthy hand. The area of the elbow joint is deformed, swelling of the tissues and hemorrhage in them are visible, there is an indefinite sharp pain. With a posterior dislocation, the shoulder seems elongated, and the forearm is shortened (as with a divergent dislocation), with an anterior dislocation, the opposite is true - the forearm seems elongated, and the shoulder is shortened.
With posterior dislocation, the axis of the forearm (as with dislocation of the forearm inwards) is displaced inward or outward (as with dislocation of the forearm outward), the forearm is in a forced position of incomplete extension at an angle of 120-140 ° and is somewhat pronated, as in case of dislocation of the head of the radius backwards; with an anterior dislocation, this angle is open posteriorly. The olecranon protrudes sharply posteriorly immediately below the arcuate depression, the head of the radius protrudes posteriorly and externally, and the lower (distal) end of the shoulder protrudes anteriorly and more medially to the elbow bend. Gunther's triangle is broken due to the location of the olecranon above the condyles of the shoulder, as in a divergent dislocation of the bones of the forearm. Normally, Gunther's triangle is isosceles: it is formed by two condyles and the olecranon.
With an anterior dislocation, the olecranon is not palpable, and with a lateral dislocation, it is displaced inwards or outwards.
With posterior and anterior dislocations of the forearm, a symptom of springy resistance is determined, as a result of which active and passive movements are impossible. With other types of dislocations, movement is limited.
With divergent and lateral dislocations of the bones of the forearm, the elbow joint is expanded in the transverse direction. With a dislocation of the forearm, the external condyle is well felt inside, with a dislocation outwards, the internal one.
Dislocations of the forearm are often accompanied by a fracture of the articular ends of the lateral condyle and radius in the upper third.
X-ray examination specifies the type of dislocation or confirms the fracture.
Conservative treatment. It is possible to correct the dislocation on the first day after the injury, but in the following days it is extremely difficult to do this due to significant tissue edema. Manipulation is carried out under local anesthesia. To do this, a 1% solution of novocaine in the amount of 30 cm3 is injected into the cavity of the elbow joint. General anesthesia should be used for heavily muscled patients and children.
Reduction of the anterior dislocation of the forearm and one radius anteriorly according to the Cooper method. The patient lies on his back with his arm abducted to the level of the shoulder girdle. The surgeon stands near the table from the side of the dislocation and puts his leg on a stool (in case of dislocation of the right forearm - right, in case of dislocation of the left forearm - left), grabs the patient's shoulder in the middle third with one hand, and with the other - the forearm above the wrist joint and, at the same time, resting his knee into the elbow bend of the patient, stretches the forearm and flexes the elbow (Fig. 6, a).
Reduction of the posterior dislocation of the forearm. The position of the patient is the same as for the Cooper reduction. The surgeon stands behind the patient's abducted arm and with both hands covers the shoulder above the elbow joint so that the thumb of one hand rests on the displaced olecranon, and the thumb of the other hand rests on the head of the radius. The assistant covers the forearm in the lower third with one hand, and the brush with the other. Then they simultaneously stretch the patient's arm, bending it at the elbow joint, while the surgeon tries to move the olecranon and head of the radius anteriorly with his thumbs, thus eliminating the dislocation (Fig. 6.6).
Reduction of dislocation of both bones outwards and inwards. To reduce the dislocation of the forearm outwards, the assistant holds the patient's shoulder, the surgeon with one hand stretches the forearm, and with the other hand first presses the upper part of the forearm downwards, outwards and backwards, and then supinates the forearm and pushes its upper part around the external condyle of the shoulder. Following this, the forearm is bent at the elbow joint to an angle of 80°, without squeezing the edematous soft tissues.
When reducing the dislocation of the forearm inwards, one assistant holds the patient's shoulder by the armpit, the surgeon at this time produces traction for the forearm with one hand, and with the other hand exerts pressure on the upper part of the forearm outward. A click is heard when repositioning. Then the forearm is bent at the elbow joint and fixed with a plaster bandage-longuet for 5-10 days (as in the case of anterior and posterior dislocations).
Reduction of divergent dislocations of the bones of the forearm. The doctor's assistant holds the patient's shoulder by the armpit, and the surgeon performs traction for the forearm with one hand. With anteroposterior dislocation (the ulna is behind, and the radius is anterior to the condyles of the pleura that have penetrated between them)

Rice. 6. Reduction of dislocation of the forearm:
a - front according to the Cooper method; b - rear

ca) first set the ulna (as in the case of a posterior dislocation of the forearm; thumb pressure is applied only to the olecranon). After reduction of the dislocation of the ulna, the dislocation of the head of the radius is reduced. To do this, stretch the forearm of the arm straightened at the elbow joint, penetrate the forearm and bring the arm to the chest. Then, exerting pressure on the head of the radius outward, bend the arm at the elbow joint and supinate the forearm.
In the second option (both bones are located on the sides of the condyles of the shoulder embedded between them), reduction is carried out in the same way as three dislocations of the forearm inwards or outwards.
Reduction of irreducible and chronic dislocations of the shoulder and forearm. The cause of irreducible and chronic dislocations of the shoulder and forearm can be the interposition of soft tissues between the head of the humerus and the glenoid cavity of the scapula (in case of dislocation of the humerus and bones of the forearm), the interposition of tendons in case of dislocation of the forearm, as well as untimely diagnosis of dislocation. One of the reasons for unsuccessful attempts to reduce a shoulder dislocation is usually the overhang of a part of the articular bag that has come off the neck of the shoulder along with the articular cavity.
With an irreducible dislocation of the shoulder, the operation described below is performed under anesthesia. To do this, the tissues that go along the anterior edge of the deltoid muscle are cut. After the allocation of this part of the articular bag, the dislocation is easily reduced; the articular bag with intraosseous sutures is sutured to the upper part of the anatomical neck of the shoulder in a taut state. This is done with any part of the articular bag that is in interposition; if the tendon of the long head of the biceps muscle prevented the reduction, then it is isolated and placed in its place. With dislocations complicated by fractures, osteosynthesis is performed. The operation ends with the imposition of a thoracobrachial plaster cast in the position of arm abduction at an angle of 30-40°.
With chronic dislocations of the shoulder, reduction is performed under anesthesia. In the case of a slight re-dislocation, it is necessary to “fix the head of the shoulder with two crossed needles, passed from above through the acromial process of the scapula and the outer part of the head of the shoulder.
In case of failed reduction, surgical treatment is indicated, as with an irreducible dislocation of the shoulder. With irreducible dislocations of the forearm, surgery should be performed as soon as possible. In cases of chronic dislocation in adults, surgical intervention, unfortunately, gives poor results: already 2-4 weeks after the injury, dense scar tissue and ossificates form, filling the bone pits. In children with chronic dislocations, only surgical treatment is indicated. In the elderly, if there is no pain and no significant functional impairment, if closed reduction is not possible, surgery may not be appropriate. For people engaged in manual labor, when a lot of arm strength is needed, arthrodesis or arthroplasty is advisable.
Open reduction of dislocation of the forearm. The incision is started 6-7 cm above the olecranon, descends to it, then turns outward, to the lateral condyle, again turns down the forearm and continues for about 5 cm. The skin incision is slightly arched. Dissect the tissues and expose the tendon part of the triceps muscle of the shoulder. To avoid postoperative contracture, a high triangular flap is isolated from the aponeurosis with its base facing the olecranon. Through a longitudinal incision, they penetrate through the muscle fibers to the bone throughout the entire length of the skin incision, after which the fibers are cut across on both sides of the process and the articular ends are isolated, having previously highlighted the ulnar nerve in its groove. First, the radius is reduced, and then the ulna, the movements are checked, the arm is bent at an angle of 90 ° in the elbow joint and the tissues are sutured in layers (by lengthening the tendon of the triceps muscle of the shoulder). The arm is immobilized with a split plaster bandage for 8-10 days. Then the patients are engaged in therapeutic exercises and undergo a course of physiotherapy; immobilization is carried out with a splint up to 2-3 months after the operation.

Surgical treatment of habitual shoulder dislocations

Khitrov and Krasnov's method. General anesthesia should be used. The patient lies on his back. The incision starts from the border between the outer and middle third clavicle and continues along the groove between the deltoid and pectoralis major muscles to the most distal part of the deltoid muscle. The tissues are dissected, V. cephalica is retracted inwards and bluntly penetrated between the muscles to the joint capsule and the tendon of the long head of the biceps muscle. Then this tendon is isolated. According to the Khitrov method (Fig. 7, a), the shoulder is turned outward, and this tendon 1 is fixed in the bone groove 2 of the humerus with immersing silk sutures directly under the place of attachment of the lower edge of the capsule and the edge of the subclavian muscle. According to Krasnov's method, tendon 1 is placed under the cleft of the greater tubercle 2 (Fig. 7b).
Friedland method. Operational access is the same as during the Khitrov operation. The shoulder is rotated outward and under the surgical neck, as much as possible from its inner side, a through hole is made with a drill with a diameter of 4 mm. A pre-prepared autotape 25 cm long and 2-3 cm wide from the wide fascia of the thigh is passed through this 1 canal in the neck of the humerus and, pulling up the ends, sutured: one end to the acromion 3, and the other to the coracoid process 4. Then the outer and inner edges the tapes are sutured to the underlying parts of the joint capsule (Fig. 7c). This operation creates two additional ligaments: acromial and coracohumeral. The exit from the operation is normal.

Rice. 7. Methods surgical treatment habitual dislocation of the shoulder:
a, b - Khitrov and Krasnov's method; c - Friedland method; d - Weinstein method

Weinstein method. The tissue cut is the same. In a blunt way, they penetrate between both muscles, then expose the coracoid process with the short head of the biceps, coracobrachial and pectoralis minor muscles attached to it. Below them is the subscapularis muscle. The coracoid process, together with the first two muscles attached to it, is cut off and pulled downward, and then the anterior surface of the subscapularis muscle is well exposed. The subscapularis muscle 2 together with the capsule is dissected in the ladder in the horizontal direction. Then the canal of the long head of the biceps muscle is opened and, having selected its tendon 1, it is transferred under the place of dissection of the subscapularis muscle. The tendons of the long head of the biceps muscle are fixed in the fold of the capsule with several silk sutures, and the muscle is sutured with elongation above the fold of the capsule (Fig. 7d). After surgery for dislocation, a posterior plaster splint is applied in the position of adduction of the arm and flexion in the elbow joint at an angle of 90°. In addition, the splint is strengthened with a plaster bandage of the Deso type. Immobilization is carried out for 5 weeks. This is followed by a recovery period with physiotherapy and exercise therapy.

Collarbone and shoulder blade injuries

Dislocations of the acromial and thoracic ends of the clavicle occur most often as a result of the direct action of injury when falling against the shoulder joint or against the elbow. The dislocation is accompanied by a rupture of the ligamentous apparatus of the acromioclavicular joint and the coracoclavicular ligament.
With a dislocation of the sternal end of the clavicle, the sternoclavicular and costoclavicular ligaments are torn, in some cases the intraarticular disc is torn off from its bed or is infringed between the articular surfaces.
clinical picture. In case of dislocation of the acromial or thoracic end of the clavicle, the victim, due to pain in the area of the joints, where there is deformation, swelling of the tissues, sometimes bruising, tries to keep his hand in the adduction position. The acromial and thoracic end of the clavicle protruding under the skin is determined by palpation. When pressing on the protruding end, the dislocation is reduced, when the pressure stops, it reappears. In this case, one speaks of a symptom with a key. With retrosternal dislocation of the thoracic end of the clavicle, tissue sinks. When causing this symptom, there may be crepitus. In such cases, there is a fracture-dislocation in the joint. The range of motion in the shoulder joint is limited. X-ray examination should be performed with weighting
hands in a vertical position (for the acromioclavicular joint).
Treatment. With incomplete and complete rupture of the clavicular-acromial joint, it is possible to achieve its restoration in a conservative way.
Upon admission of such patients, the joint is anesthetized with a 1% novocaine solution in an amount of 5 cm3.

Rice. 8. Methods of conservative and surgical treatment of dislocation of the acromial end of the clavicle

at an angle of 20 °, a screw cap of A. N. Shimbaretsky is strengthened above the acromial end of the clavicle, and by twisting it, the subluxation of the clavicle is eliminated (determined by a control x-ray).
To restore the function of the peripheral joints of the hand, physiotherapy exercises are prescribed, which they begin to practice from the 2nd day, and for the shoulder joint - after 4 weeks.
Patients who were engaged in heavy physical labor before the injury can return to their previous work after 3 months.
In case of rupture of the sternoclavicular joint, after local anesthesia, the clavicle is reduced, spreading the shoulder joints back and fixing them with an eight-shaped bandage for 3-4 weeks (the gap must be controlled by an x-ray). Unfortunately, this method gives repeated dislocation and subluxation. In this case, you have to resort to surgical intervention.

Surgical treatment of ruptures of the acromioclavicular and sternoclavicular joint

Bonding of the acromioclavicular joint with knitting needles in a closed way performed under local anesthesia. The patient lies on his back with a roller under the shoulder girdle and shoulder joints. The doctor's assistant eliminates the dislocation of the acromial end of the clavicle with the fingers of one hand and holds it, and with the other hand fixes the olecranon. The surgeon through the acromion and the acromial end of the clavicle with an electric drill draws two needles from the outside inwards. With the correct introduction, the symptom with the key disappears, and on the radiograph, the ratios of these articular ends become normal (Fig. 9). This operation should be done in the first 2-3 days after the injury.
Reconstruction of the clavicular-acromial joint according to Bennel performed under general anesthesia. The patient lies on his back half-side. An epaulette incision 12 cm long opens access to the acromioclavicular joint, the articular ends and the acromion are isolated. An electric drill drills one hole in the acromial process and two in the clavicle (1 cm from the edge of the articular surface). Through these holes, a thick silk thread rubbed with paraffin is passed, which passes from top to bottom through the hole in the acromial process and from bottom to top through the external hole in the clavicle, and then with a Deschamps needle this thread is passed from the inside outward under the coracoid process. The end of the thread, brought out from under the coracoid* process, is passed from bottom to top through the second hole in the clavicle. Both free ends of the thread are pulled and tied with a surgical knot (the symptom disappears with the key) (Fig. 10). The wound is sutured in layers. Immobilization of the arm is carried out with a thoracobrachial plaster bandage for 4 weeks (a roller is inserted into the armpit, the arm is bent at the elbow joint and somewhat pulled back). After this period, the plaster is removed, the immobilization of the hand continues on a scarf, the patient is engaged in exercise therapy.

Rice. 9. Pinning the acromioclavicular joint

Rice. 10. Restoration of the acromioclavicular joint according to Bennel

The patient lies on his back with a cushion under the upper thoracic spine so that the shoulder joints are turned back. Anesthesia is local. A horizontal tissue incision of 4-5 cm opens access to the sternoclavicular joint, releases the articular ends, eliminates the dislocation and fixes them. The fastening can be done with two knitting needles, inserted in an oblique direction from above, behind and outside, obliquely down, inside and forward (Fig. 11, a), or use a narrow strip from the wide fascia of the thigh and silk thread for this purpose. The suture material is passed through the holes in the articular ends and tied with the correct ratio of the articular surfaces. When using the first option, two holes are drilled in each articular end, stepping back 2 cm from the edge (Fig. 11.6), in the second option, two holes are also drilled, which must pass through the entire thickness of the clavicle and sternum from front to back (Fig. 11, c). Further management of the patient is the same as after the restoration of the acromioclavicular joint.

Rice. 11. Restoration of the sternoclavicular joint:
a - silk twist; 6 - with silk thread and a strip from the wide fascia of the thigh;
in - two knitting needles

Clavicle fractures

Clavicle fractures are quite frequent view injury. They occur when falling on the lateral surface of the shoulder or under the influence of a direct blow, as a result of which the clavicle breaks in the middle third or at the border of the outer and middle thirds. These fractures can sometimes be accompanied by damage to the neurovascular bundle of the pleura. In acute bone fragments, the skin is damaged.
clinical picture. The victim is taken to a medical institution with the immobilization of the hand with rings or an eight-shaped bandage. When removing the immobilization, the victim's hand is brought forward, and he supports it by the forearm with a healthy hand. There is swelling of the tissues, sometimes bruising, the shoulder girdle is shortened, sharp pain and crepitus of fragments are determined. Finishing the examination, it is necessary to check the pulsation on the radial artery and the sensitivity in the hand. X-ray image clarifies the nature of the fracture.
Treatment. In case of fractures of the clavicle without displacement of fragments or with a slight displacement, with severe pain, anesthesia should be performed with 10 cm3 of 1% or 2% novocaine solution, and then an eight-shaped or plaster bandage of the Dezo type should be applied, leaving the entire medial and middle third of the clavicle free (the plaster bandage must be have a plaster cast through a healthy shoulder girdle).
In case of fractures with displacement of fragments, after anesthesia, the fragments are repositioned and immobilized on the Kuzminsky splint (Fig. 12) or an eight-shaped bandage, supplemented with a Dezo-type plaster bandage with a plaster cast through a healthy shoulder girdle. You can also use the Kuznetsov triangle or the Kramer tire, which is brought into the armpit, lifting the sore shoulder girdle, and fixing the plaster

Rice. 12. Bus Kuzminsky for the treatment of fractures of the clavicle

bandages to the chest and a healthy shoulder girdle; this bandage must be supplemented with an eight-shaped bandage. With a successful reposition, immobilization is continued for 5-6 weeks, and then, taking into account the x-ray data, the patient is engaged in exercise therapy, the hand during the recovery period can be immobilized with a scarf.
If there is an interposition of soft tissues or a bone fragment, and it is not possible to compare the fragments, surgical treatment is indicated.
Upon admission of a patient with an open fracture and damage to the vascular bundle in emergency cases, surgery is indicated immediately.
Osteosynthesis of the clavicle. The patient lies on his back with a cushion under the shoulder blades. The operation is performed under general or local anesthesia. The fracture site is exposed with a longitudinal incision up to 6 cm long, fragments are isolated, and then fastened with metal clamps. For transverse fractures, it is better to use a pin, for comminuted ones, a wire or a plate. The pin is inserted into the reamed hole in the cortical layer of the medial fragment, and then it is advanced to the fracture site. The fragments are repositioned, and the pin is advanced 4 cm into the peripheral fragment, the central end of the pin is bitten if it protrudes from the bone by more than 1 cm and lifts the skin. When osteosynthesis with wire, it is advisable to make twist and intraosseous wire sutures. The operation ends with layer-by-layer suturing of the wound and the application of a plaster bandage of the Dezo type.

Fractures of the scapula

Fractures of the scapula occur with a direct blow or a fall on the elbow with the shoulder abducted. Depending on the anatomical location, there are longitudinal and transverse fractures of the body of the scapula, fractures of the anatomical and surgical necks, fractures of the articular cavity, fractures of the spine of the scapula, fractures of the upper and lower angles of the scapula, and fractures of the acromial and coracoid processes.
Fractures of the neck of the scapula are sometimes accompanied by damage to the axillary nerve, and, therefore, paresis of the deltoid muscle.
clinical picture. For fractures of the scapula, the patient's arm is adducted. Fractures of the neck of the scapula with displacement of fragments are accompanied by deformity of the shoulder joint due to the protrusion of the shoulder process and displacement of the shoulder joint anteriorly or, more rarely, backwards. There is pain in the neck of the scapula and crepitus of fragments in this area, active movements in the shoulder joint are impossible due to pain. For fractures of the body of the scapula, the symptoms of any fracture are characteristic. A significant array of muscles makes it difficult to examine.
With fractures of the articular cavity, there is a picture of hemarthrosis, active movements in the shoulder joint are sharply limited, passive ones are possible, but not in full, the load along the axis is painful.
A fracture of the acromial process of the scapula is characterized by signs of any fracture and can sometimes be combined with a rupture of the acromioclavicular joint.
With a fracture of the coracoid process, there is a sharp decrease in the strength of the biceps of the shoulder.
Treatment. Upon admission, the patient is given local anesthesia. In case of fractures of the articular cavity without displacement of fragments, but with displacement of the neck of the scapula, it is necessary to apply skeletal traction in the position of abduction behind the olecranon for 4 weeks. After 2 weeks, the patient should do exercise therapy for the shoulder joint. After removing the traction, a massage course is carried out.
In case of fractures of the acromial process with displacement of fragments, immobilization should be carried out for 4 weeks on the abduction splint CITO with fixation 10° back from the frontal plane, and in case of fractures of the coracoid process, with fixation forward by 80° and flexion in the elbow joint at an angle of 90°. In other cases, immobilization is carried out with a bandage of the Deso type.

Humerus fractures occur at the proximal (upper) end (up to and including the surgical neck), the diaphysis, and the distal (lower) end (from the supracondylar region and below).
In the region of the proximal end, there may be fractures of the head, anatomical neck, supratubercular, subtubercular, transtubercular and fractures of the surgical neck of the shoulder - impacted (Fig. 13, a), adductive (Fig. 13, b), abductive (Fig. 13, c ).

Rice. 13. Fractures of the surgical neck of the shoulder:
a - driven in; b - adduction; c - abduction

Shaft fractures of the shoulder are divided into oblique, transverse, helical and comminuted.
In the region of the distal end of the humerus, two groups of fractures are distinguished: extra-articular and intra-articular. In turn, extra-articular fractures are divided into supracondylar extensor and flexion (Fig. 14.7), and intra-articular - into transcondylar extensor, flexion, epiphysiolysis; intercondylar (T- and U-shaped) shoulders; external condyle; internal condyle; capitate elevation; fracture of the apophyseolysis of the internal epicondyle of the shoulder; fracture and apophysiolysis of the external epicondyle of the shoulder (Fig. 14).
Fractures of the proximal end of the humerus occur mainly in the elderly when falling on the elbow and when hitting the anterior surface of the shoulder joint. In this case, fragments can be displaced at an angle in width and length or wedged into each other.
Diaphyseal fractures often occur from a direct blow to the middle third of the shoulder or from flexion and rotation of the forearm.
Fractures of the lower end of the humerus occur when falling on a straight or bent arm at the elbow joint.

Rice. 14. Humerus fractures:
1 - supracondylar; 2 - transcondylar; 3,4 - external and internal epicondyles; 5, 6 - condyles; 7 - L-shaped; 6 - L-shaped; 9 - fracture of the capitate

clinical picture. In case of fractures of the proximal (upper) end of the humerus with displacement of fragments, the arm is in a forced position of adduction (with an adduction fracture of the surgical neck) or some abduction (with an abduction fracture of the surgical neck), there is swelling, hemorrhage, and severe pain. Palpation with abduction fractures determines the retraction of tissues between fragments, with adduction fractures, it is sometimes possible to feel the anteroexternal protrusion in the fracture zone, and with a detachment of a large tubercle, a movable bone fragment. Active movements are absent, passive ones are possible (with subtubercular fractures, bone mobility in an atypical place and fragment crepitus are determined). The load along the axis and rotational movements are painful, there is a functional shortening of the shoulder due to anatomical and projection shortening.
In fractures of the proximal end of the humerus without displacement of fragments, the clinical picture is less pronounced, as in impacted fractures of the surgical neck of the shoulder.
The clinical picture of diaphyseal fractures of the humerus coincides with the clinical picture of long tubular bones. Fractures of the diaphysis of the humerus in the middle and lower sections are often accompanied by damage to the radial nerve. During the examination, we see the drooping of the hand, there is no active extension of the hand and main phalanges, decreased sensitivity on the radial side of the hand and the extensor surface of the forearm. This is associated with infringement, compression, bruising, and less often with a rupture of the radial nerve.
In case of fractures of the distal (lower) end of the humerus, the elbow joint is deformed, hemorrhage occurs, movements in the elbow joint are disturbed, the axis of the limb is displaced, there is crepitus of fragments, and sometimes the function of the median nerve suffers.
With extensor supracondylar fractures, the axis deviates posteriorly, the end of the central fragment is palpated in the elbow bend, the peripheral one is deviated posteriorly, and tissue retraction is observed at the back.
With flexion supracondylar fractures, the clinical picture is the opposite of extensor fractures. When combined with damage to the median nerve, there is a sensitivity disorder on the palmar surface of I, II, III and the inner surface of the IV fingers and the corresponding part of the hand, the pronation of the forearm and opposition thumb, the victim cannot bend the thumb and other fingers in the interphalangeal joints, and the flexion of the hand is accompanied by its deviation to the ulnar side.
Transcondylar fractures of the shoulder can also be extensor and flexion, the plane of the fracture passes over or through the epiphysis of the humerus. This type of fracture is typical mainly for childhood and adolescence. The clinical picture of these fractures is uncharacteristic and is recognized only by radiographs (it must be compared with a radiograph of a healthy hand).
Intercondylar fractures are accompanied by a sharp increase in the lower third of the shoulder in the transverse direction, active movements are disturbed, while passive ones are very painful, Gunther's triangle changes (formed by the olecranon and two epicondyles), remains isosceles, but with a wide base.
In case of fractures of the external and internal condyles and epicondyles of the humerus, with the displacement of the fragments, the axis of the limb changes (the axis becomes valgus or varus, respectively), Gunther's triangle is violated. The rest of the clinical picture is similar to any intra-articular fracture.
Fractures of the capitate eminence lead to the formation of a hematoma in the region of the external condyle, pain is also felt here. Movement in the elbow joint is limited and painful, sometimes large fragments can be palpated.
These types of fractures, of course, are specified by X-ray examination.
Conservative treatment. Treatment of fractures of the upper end of the humerus. In case of supratuberculous impacted fractures without displacement or with a slight displacement of fragments, upon admission of the patient, anesthesia is performed with a 2% solution of novocaine (20 cm3). A posterior plaster splint is applied to the arm - from the opposite scapula to the metacarpophalangeal joints with a roller in the armpit, in the position of bringing the arm and bending at the elbow joint at an angle of 90 °. After 8 days, the splint is removed and the immobilization of the hand is continued with a scarf for another 3 weeks. At this time, the patient is engaged in exercise therapy (for the joint joint).
For fractures with crushing of the head and without displacement of fragments, the arm should be immobilized in the position of abduction at an angle of 30° using a posterior plaster splint and a triangular pad in the axilla for 14 days. Then comes the recovery period.
In case of fractures with displacement of fragments, skeletal traction behind the olecranon should be applied on the abduction splint CITO with abduction at an angle of 30° and an attempt should be made to reposition the fragments. After 3 weeks, immobilization is carried out with a scarf and a course of rehabilitation treatment is carried out.
With pain and a sharp limitation of movements in the shoulder joint, arthrodesis of the shoulder joint is indicated in a functionally advantageous position.
Subtuberculous fractures may be accompanied by impacted fragments without displacement and with displacement at an angle. In the latter case, if there are no contraindications from the general condition of the patient, it is necessary to correct the axis of the humerus, which is important for the subsequent function of the shoulder joint.
In case of impacted fractures without displacement of fragments or with their slight displacement, a posterior plaster splint should be applied in the adducted position of the arm and immobilized for 14 days, and then the patient should engage in exercise therapy and fix the arm with a scarf.
In case of abduction and adduction fractures of the surgical neck of the humerus, immediately upon admission of the patient, reposition of fragments should be performed, and in cases where it does not lead to the desired result, skeletal traction should be applied. If it is impossible to apply skeletal traction (old age of the patient, chronic cardiopulmonary insufficiency), it is advisable to carry out treatment according to E. F. Drewing. In case of failure of conservative treatment, the question of surgical treatment is raised.
Reposition for adduction fractures is performed as follows: the patient lies on his back, the assistant brings the sheet into the armpit and brings its ends to the area of the shoulder girdle of the healthy arm (one from the back, the other from the chest). The surgeon grabs the patient’s hand in the area of the elbow bend with one hand, and with the other hand in the area of the wrist joint with the elbow joint bent. the position is fixed with a thoracobrachial plaster cast.
With abduction fractures, the position of the patient is the same as with adduction. The assistant takes the same position, and the surgeon takes the patient's hand by the forearm in the area of the elbow bend with one hand and, developing traction, brings the hand to the anterior wall of the chest and rotates the shoulder somewhat outward. With the fingers of the other hand, simultaneously with this movement, it exerts pressure on the outer surface of the head of the shoulder in the inward direction, and on the upper end of the distal part of the humerus region - outward. In this position, a thoracobrachial plaster cast is applied and a control x-ray is taken.
With successful reposition of abduction and adduction fractures of the surgical neck of the humerus, immobilization is carried out for 5 weeks, followed by a recovery period.
If attempts at reposition were unsuccessful, then skeletal traction behind the olecranon on the CITO splint should be applied with the shoulder position as in reposition. On the 2nd day it is necessary to make a control x-ray. When comparing fragments, traction is continued up to 4-5 weeks, and then transferred to a thoracobrachial plaster cast for another 3 weeks. This is followed by a recovery period (exercise therapy, hand massage, electrical stimulation, paraffin applications). With unsuccessful skeletal traction, surgical treatment is indicated.
In those patients for whom reposition and skeletal traction are contraindicated in general condition, one should resort to treatment using the method of E. F. Drewing. It consists in the fact that the patient's hand is suspended on a scarf-snake so that the elbow is bent at an angle of 60-70° and the arm is retracted at an angle of 15-35° due to a cotton-gauze roller or a soft triangular-shaped pillow brought into the axillary hollow. During the period of pain, anesthesia is performed. Under the influence of the gravity of the arm, the muscles of the limb gradually relax and the angular displacement of the humerus is leveled. From the 2nd day the patient is engaged physical therapy for the hand and wrist joint, and from the 4th-5th - for the shoulder joint. By about the 8th week, the patient can put his hand behind his head, raise and retract it.
In case of fractures of the large and small tubercles without displacement of the fragment, after anesthesia, a plaster bandage of the Dezo type should be applied for 3 weeks, and then restorative treatment should be carried out. If there is displacement, then the arm must be given a 90° abduction, as a result of which the fragment will fall into place. After this period, rehabilitation treatment is carried out.
Treatment of fractures of the diaphysis of the humerus. In case of fractures of the diaphysis of the humerus without displacement of the fragments or with a slight displacement after local anesthesia, it is necessary to apply a thoracobrachial plaster cast in the position of arm abduction at an angle of 30° and opposition at an angle of 20°. After 6 weeks, a control x-ray is taken, and if there is consolidation, then immobilization is stopped and restorative physiotherapy is carried out.
Upon admission of the victim to the hospital with transverse or oblique fractures of the humerus with displacement of fragments, it is urgent to reposition the fragments under local anesthesia of the fracture with 30 cm3 of 1% or 2% novocaine solution. If attempts at reposition are unsuccessful, skeletal traction is indicated.
Skeletal traction is used for oblique, helical fractures of the diaphysis of the humerus. It is carried out on the outlet bus CITO. The angle of abduction depends on the level of the fracture. In case of fractures in the upper third of the humerus, it will be the largest - up to an angle of 90 °, since the upper fragment is in a position of significant abduction, turned outward around its longitudinal axis and displaced anteriorly in the frontal plane, and the central end of the lower fracture is displaced inward and anteriorly, pulled up up and rotated inward; with fractures at the border of the upper and middle thirds of the humerus, the angle of abduction is the smallest, since the central fragment is in the position of adduction, turned outward around its longitudinal axis and displaced inward and forward, and the central end of the lower fragment is abducted, pulled up and turned inward.
In case of fractures of the humerus in the middle third, the angle of abduction on the splint should be equal to 45°, since the upper fragment is in the position of moderate abduction, displaced outward, forward and rotated around its longitudinal axis. The lower fragment is always pulled up, displaced inward and anteriorly, and also turned inward.
On the 2nd day, a control X-ray should be taken; with a successful reposition, skeletal traction is continued for up to 6 weeks, and then transferred to immobilization with a thoraco-brachial plaster cast. If, due to tissue interposition, fragments cannot be compared, then such fractures should be operated on.
Treatment of fractures of the lower end of the humerus. In case of fractures of the lower end of the humerus without displacement of fragments or with a slight displacement of them, immediately upon admission of the patient, local anesthesia should be performed and a posterior plaster splint should be applied from the opposite scapula to the metacarpophalangeal joints, with the arm bent at the elbow joint at an angle of 90 °, and immobilization should be carried out 4-b weeks Fractures with displacement of fragments are subject to reposition. The peripheral (distal) fragment should always be brought under the central one. In supracondylar and transcondylar extensor fractures, traction along the length of the humerus is performed to eliminate the displacement of fragments. The arm is bent at the elbow joint to the angle at which the posterior angular displacement has occurred. During reposition, the resulting varus or valgus curvature of the elbow is also eliminated.
In case of flexion supracondylar and transcondylar fractures, the displacement of fragments is eliminated by traction along the axis and the forearm is extended at the elbow joint to an angle of 100°, since the angle between the fragments is open anteriorly. The forearm is placed in supination position. It should be remembered that lateral displacements must be eliminated immediately after the axial thrust, and then one or another angle should be given to the elbow joint.
T- and U-shaped fractures with displacement of fragments cause a violation of the congruence of the articular surfaces of the humerus and therefore the ability of the victim to work depends on successful reposition. In case of intercondylar fractures, it is necessary to apply skeletal traction behind the olecranon and first achieve elimination of the displacement of fragments along the length and then along the width (mandatory in the first two days after the injury). The divergence of fragments in width is eliminated by compressing the condyles between the palms. After 3-4 weeks, skeletal traction is removed and dosed movements in the elbow joint begin to be carried out. During this period, the hand is immobilized with a removable plaster splint.
If this technique is unsuccessful (if the fragments do not come together), it is necessary to apply compression osteosynthesis according to Chanli, F. S. Yusupov: under local anesthesia, two counter-wires with counter-supports are inserted through both fragments of the humerus and, shifting them with spoke tensioners on a bracket or a special arc relative to each other , bring together the dispersed fragments (Fig. 15, a). At the same time, two wires can be used to fix fragments according to Greifensteiner after their longitudinal and transverse displacement has been eliminated (Fig. 15, b). If these methods are unsuccessful, then it is necessary to resort to surgical treatment.
In case of fractures of the external and internal condyles of the humerus with displacement of fragments, reposition is also performed under local or general anesthesia.
Repositioning is done as follows. In case of a fracture of the external condyle, the assistant grabs the patient's hand by the wrist joint with one hand and produces longitudinal traction, and with the other hand moderately presses on the inner surface of the elbow joint. This creates a varus position of the elbow. The surgeon, with his thumbs, tries to move the fragment upward and inwards, and then with his palms puts pressure on the region of the condyles of the humerus in the mutual anteroposterior and internally external directions. Gradually, the patient's arm is bent at the elbow joint to an angle of 100°, and the forearm is placed in the mid-physiological position. Then a deep plaster splint is applied and a control radiograph is taken.

Rice. 15. Transfocal compression osteosynthesis of the shaft of the humerus:
a - using two spokes with persistent cannulas (platforms) according to Chanli, F. S. Yusupov; b - transosseous osteosynthesis of a fracture using two wires and a Kirschner arc according to Greifensteiner

In case of a fracture of the internal condyle, the technique for reducing the fragment is the same as for the external one, except that the arm in the elbow joint must be given a valgus position during reposition, and not a varus one.
After 3-4 weeks, and in children after 2 weeks, the splint is removed and dosed movements in the elbow joint, forearm massage, electrophoresis of the elbow joint region with novocaine are started.
The failure of these treatments is an indication for surgery.
A broken and displaced capitate elevation in some cases can be repositioned as follows. The patient's arm should be extended at the elbow joint and turned with the front surface up. Then the assistant stretches the limb, and the surgeon tries to press the fragment downward and backward with his thumbs. After completing the reposition, the arm is bent at the elbow joint at an angle of 90°, a posterior plaster splint is applied, and a control X-ray examination is performed. The plaster bandage is removed after 3-4 weeks. The patient produces dosed movements in the elbow joint.
Fractures of the epicondyles of the humerus are periarticular fractures and are sometimes accompanied by a rupture of the bag of the elbow joint with infringement of the fragment between the articular surfaces of the olecranon and the block of the shoulder. Displaced fractures are subject to reposition. With a moderate displacement, the fragment can be returned to its place by bending the arm at the elbow joint to an angle of 80 °, shifting it to its anatomical place; the forearm should be in the middle physiological position. If this cannot be done, then surgery must be applied. With successful reposition, a posterior plaster splint is applied for 3-4 weeks, and after this period, rehabilitation treatment is carried out.

Surgical treatment of fractures of the humerus

Arthrodesis of the shoulder joint. The most acceptable way to immobilize the shoulder joint should be considered intra-articular arthrodesis. It allows you to completely fuse the articular surfaces in a functionally advantageous position of the upper limb. The operation is performed under general anesthesia. The patient lies on his back, the arm is abducted at an angle of 45 °. A skin incision is made starting from the end of the spine of the scapula, going over the shoulder joint and descending along the deltoid-thoracic groove to the middle of the deltoid muscle, dissect the subcutaneous fat, fascia, and then separate the deltoid muscle in its middle third with a chisel and cut the acromion with a chisel. Then the acromion with the muscles attached to it is taken down and the capsule is exposed. It is dissected in a T-shape to the cartilaginous edge, then the head of the humerus is dislocated, the cartilage is removed from the articular surfaces with a chisel and cutters. The head of the humerus is set, the density of contact of the fitted surfaces is checked, the arm is retracted to an angle of 70°, opposed anteriorly by an angle of 30°, and rotated inwards by an angle of 15°. In this position, a screw or three-bladed nail is passed through the head of the humerus and fixed to the shoulder blade. The acromion is repositioned and fixed with a screw to the head of the humerus. The wound is sutured in layers and a thoracobrachial plaster cast is applied in this installation position. After 3 months, a control x-ray is taken. Gypsum immobilization is stopped only in the presence of radiological evidence of complete consolidation.
Osteosynthesis of a fracture of the surgical neck of the humerus. The operation is performed under anesthesia. The patient lies on his back. Access to the upper third of the humerus is an anterolateral incision, which starts from the anterior part of the acromioclavicular joint, runs along the anterior edge of the clavicle to the border between its outer and middle thirds, and then goes down the anterior edge of the deltoid muscle to the border between the middle and lower thirds. . The skin-subcutaneous-fat flap is separated and turned outwards. Determine the deltoid-thoracic groove and bluntly penetrate into it. The encountered tendon of the long head of the biceps is ecartiated, and if it interferes, then it is cut between two ligatures. Now the fibers of the deltoid muscle are cut in the transverse direction at a distance of 1 cm from their beginning on the bones, and the muscle is retracted outwards. The area of the coracoid process and the anterior surface of the articular capsule, covered by the subscapularis, become accessible, which is dissected and the capsule of the shoulder joint is exposed under it (if necessary, it is opened with an arcuate incision parallel to the anterior edge of the articular cavity). Such a tissue incision makes it possible to operate on the head, neck and upper third of the humerus.
In fractures of the surgical neck of the shoulder, depending on the type of fracture, there is a characteristic displacement of fragments. The fracture site is isolated, the ends of the fragments are repositioned and fastened with a metal rod or A. V. Kaplan's plate. During osteosynthesis with a metal pin, the latter is inserted retrogradely through a large tubercle, and then advanced into the diaphysis. During osteosynthesis with A.V. Kaplan’s plate, the sharp ends are first driven into the head of the humerus from the side of the large tubercle (in this case, the plate is adjacent to the surface of the humerus), and then compression is performed with a removable compression device and the plate is fixed with screws (Fig. 16).
Osteosynthesis of the humerus with a fracture in the middle third. The operation is performed under general anesthesia, the patient lies on his back with his arm abducted. Surgical intervention is carried out through anterior external access. The skin incision can be large or medium in size, depending on the type of fracture and the method of fixing the fragments. It starts from the lower third of the deltoid muscle and passes first along
-its inner edge, and then - along the outer edge of the biceps muscle of the shoulder to the elbow joint. After the skin incision, the fascia of the shoulder is dissected, preserving the superficial brachial vein. In the upper section of the wound, they penetrate to the bone, pushing the deltoid muscle outward, and the biceps inward.

Rice. 16. Osteosynthesis of a fracture of the surgical neck of the humerus with a Kaplan plate

In the middle section of the wound, along the outer edge of the biceps muscle, they penetrate to the bone and reach the belly of the brachialis muscle. The shoulder muscle is cut longitudinally to the bone and both edges of the wound are subperiosteally bred to the sides. In this area, the radial nerve is located in the outer soft tissues.
The lower part of the incision is a dangerous area, since here the radial nerve goes around the humerus and comes forward. They penetrate to the humerus after dissecting the fibers of the brachial muscle until it intertwines with the beginning of the brachioradialis muscle (then the radial nerve will remain outside in the fibers of the brachioradialis muscle). Fragments are isolated, soft tissues are taken out of interposition and osteosynthesis is performed with Kaplan and Antonov's paw plate. Check the stability of osteosynthesis. In case of fractures of the humerus at the border of the lower third with the middle third, osteosynthesis should be carried out with a plate or screws. The operation ends with the application of a lightweight thoracobrachial plaster cast.
Osteosynthesis of T- and U-shaped fractures of the humerus. The fragments are penetrated through a skin median posterior incision, slightly convex towards the radius. The subcutaneous tissue, the brachial fascia are dissected, and a triangular flap with a base at the olecranon is cut out from the tendon of the triceps muscle. This flap is retracted downward, the muscle fibers are dissected longitudinally, and transversely at the lower end. The area of the metaphysis and both condyles of the humerus is exposed with a raspator and the elbow joint is opened. It should be remembered that the internal condyle borders on the ulnar nerve. Fragments are isolated, clots, small fragments are removed, repositioned (under the control of the congruence of the articular surfaces) and fastened with a Y-shaped plate. The joint capsule is sutured with catgut, the dissected tendon of the triceps muscle of the shoulder is restored, and layered sutures are applied. The operation ends with the imposition of a thoracobrachial plaster cast in the position of abduction of the arm and flexion in the elbow joint at an angle of 90°. After 3 weeks, the plaster cast is removed, and the patient can engage in dosed physiotherapy exercises.
Osteosynthesis of fractures of the external and internal condyles of the humerus. Operative access is respectively external and internal skin incisions 7-8 cm long above the epicondyles of the humerus. In case of a fracture of the internal condyle during the operation, the ulnar nerve is isolated and isolated in the groove, retracting it posteriorly. The condyles of the humerus are found (a bone fragment of the external condyle of the humerus is usually located in the joint cavity and is always connected to the lateral radial ligament), set in its anatomical place and fixed with a screw or two needles inserted at an angle to each other (after that, an x-ray is necessarily taken snapshot). The wound is tightly sutured in layers and a posterior plaster splint is applied from the opposite scapula to the metacarpophalangeal joints (the angle of flexion of the elbow joint is 90°). After 4-5 weeks, the splint is removed and treated with a patient with exercise therapy.

Fractures of the bones of the forearm

Fractures of the bones of the forearm are divided into three groups.
I. Fractures of the distal end of the radius without displacement and with displacement of fragments:
1) fractures of the lower metaepiphysis of the radius with and without avulsion of the styloid process (Colles and Smith fracture);
2) epiphyseolysis with and without avulsion of the styloid process.
I. Diaphyseal fractures of both bones of the forearm:
1) fractures of the diaphysis of both bones of the forearm;
2) Montage fracture;
3) Galeazzi fracture.
III. Intra-articular fractures of the proximal end of the bones of the forearm with and without displacement of fragments:
1) fractures of the coronoid process of the ulna;
2) fractures of the olecranon;
3) fractures of the head and neck of the radius.
Fractures of the distal end of the radius or fractures of the radius in a typical location (Colles fracture) occur in most cases under the influence of indirect trauma - a fall on the palm of an outstretched arm (an extension fracture or epiphyseolysis occurs) or on the back surface of the hand (a flexion fracture or epiphyseolysis occurs - a fracture Smith). These fractures occur mainly in the elderly, since in older people there is a thinning of the cortical layer of the bone.
Diaphyseal fractures are more likely to occur under the influence of direct trauma and less often indirect. Upon impact, push, compression, transverse fractures of both bones of the forearm occur at the same level, when falling on the hand, at different levels (the ulna in the lower third, and the radius in the middle), or a fracture of the diaphysis of the ulna and dislocation of the head of the radius (fracture) occurs. Montage) (Fig. 17), or a fracture of the shaft of the radius and dislocation of the head of the ulna (fracture of Galeazzi).
Fractures of the coronoid process and the head of the radius can occur when the forearm is dislocated, falling on an outstretched arm. The coronoid process also breaks with a sharp contraction of the shoulder muscle. The olecranon is damaged only when falling on it.

Rice. 17. Montage fracture

Fractures of the distal ends of the bones of the forearm

clinical picture. Fractures of the bones of the forearm without displacement of the fragment cause a slight visible swelling of the tissues and their pain; load along the axis of the limb causes pain, as does movement in the wrist joint.
Fractures of the distal ends of the bones of the forearm must be differentiated from injuries in the wrist joint.
In case of fractures of the bones of the forearm with displacement of fragments, there is a deformation of it directly above the wrist joint. With an extensor type of fracture, the protrusion of the distal fragment is determined directly above the wrist joint on the back surface of the forearm; with a flexion fracture, the same deformation is observed from the side of the palmar (anterior) surface of the forearm. In this area, a sharp pain is determined, sometimes crepitus of fragments, active movements are sharply limited, passive ones are possible, but painful, there is an anatomical shortening of the forearm, the load along the axis is sharply painful.
The radiograph specifies the type of fracture and the nature of the displacement of fragments. The fracture causes a flattening of the radioulnar angle (normally it is 15-30°) (Fig. 18) and a violation of the angle of inclination of the articular area of the radius.
Treatment fractures without displacement of fragments begins with the imposition of a deep dorsal and narrow palmar splint from the upper third of the forearm to the metacarpophalangeal joints in the average physiological position of the hand and forearm (the hand is set in the position of dorsiflexion at an angle of 16-18 ° and the middle position of the forearm between supination and pronation ). Immobilization of the hand should be carried out for 4-5 weeks.
For fractures of the bones of the forearm with displacement of fragments, local anesthesia is performed with 20 cm3 of 1% or 2% solution

Rice. 18. Scheme of the ratio of the distal ends of the radius and ulna:
a - radioulnar angle; b - the angle of inclination of the site of the radius in the palmar side

novocaine (the needle is injected from the back of the forearm), and then manual reposition or hardware reduction is performed (Sokolovsky, Ivanov devices) (Fig. 19, 20).
The technique of manual reposition consists in the fact that the patient is seated on a chair or laid on his back, the arm is bent at the elbow joint at an angle of 90 ° and fixed in this position with a strap for the elbow bend in the position of arm abduction on a table substituted to the side.
I, II, III, IV fingers are smeared with cleol and a bandage is applied separately on fingers I and II-IV. Moisten two splints, bandage them to the forearm and hand, and immediately pull the fingers in the longitudinal direction. Then, without weakening the traction, the hands are given palmar flexion (with an extensor fracture) to an angle of 60° and the hand is brought out to an angle of 20°, and in case of a flexion fracture, the hand is dorsiflexed to an angle of 45-60° and then the hand is brought out to an angle of 16° dorsal flexion at the wrist joint. The plaster cast is given the opportunity to harden (during this period, traction is continued with correction of the hand), traction is stopped and sent for a control x-ray.
The technique of reposition on Ivanov's and Sokolovsky's tensile apparatus (see Fig. 19, 20) consists in the fact that its clamps are used to counterextension, and then the pressure of the hand on the moistened plaster cast from the back or palmar side (depending on the type of displacement of the fragments) gives the desired angle of palmar or dorsiflexion at the wrist joint (as in manual reduction). The quality of the reposition can be controlled by an image intensifier tube (EOP) or by a control x-ray

Rice. 19. Reposition of the bones of the forearm on the Sokolovsky apparatus

Rice. 20. Reposition of the bones of the forearm on the Ivanov apparatus

directly on the device. It should be noted that epiphysiolysis sometimes requires a fairly significant angle of dorsal or palmar flexion of the hand in order to achieve good matching of fragments.
Restoration of the radioulnar angle on the control X-ray images indicates the correct alignment of the fragments. Immobilization after reposition in adults should be carried out for 3-4 weeks, in children - 2 weeks.
Surgical treatment of these fractures is resorted to only with unsuccessful conservative treatment, which is very rare.

Diaphyseal fractures of the bones of the forearm

clinical picture. With diaphyseal fractures with displacement of fragments, the function of the forearm is impaired, there is a significant deformation of it, an angle is formed between the fragments, open posteriorly. In the area of the fracture, all signs of any diaphyseal fracture with displacement of fragments are determined.
Montage type fractures (fracture of the diaphysis of the ulna with dislocation of the head of the radius). Deformation, sharp pain, crepitus of fragments and tissue edema are determined. In the area of the head of the radius there is swelling of the tissues, a sharp pain in the dislocated (anteriorly or outwards) head. There is a functional shortening of the forearm due to the anatomical shortening of the ulna and the relative shortening of the radius. With dislocation of the head of the radius anteriorly, active flexion is possible up to an angle of 100-110 °, passive meets resistance beyond the indicated angles with active flexion. This dislocation can sometimes be accompanied by damage to the radial nerve.
Fractures of the Galeazzi type. There are clinical signs of a fracture of the diaphysis of the radius. A dislocated head of the ulna is palpated in the region of the dorsal or palmar side of the wrist joint. Adduction of the hand is impossible, active movements are limited in the wrist joint. There is a functional shortening of the forearm due to the anatomical shortening of the radius and the relative shortening of the ulna.
Conservative treatment fractures of Montage and Galeazzi lies in the fact that after local anesthesia, manual reposition is performed, and if unsuccessful, hardware. The forearm is given a certain position, depending on the level of fracture of the bones of the forearm.
Fractures in the upper third. The forearm is given a position of full supination, since the radius is broken above the attachment of the pronator teres and therefore the proximal fragment is supinated and pulled anteriorly by the biceps brachii.
Fractures in the middle third. The forearm is placed in a middle position between supination and pronation, since the pronator round sets the proximal fragment of the radius in this position, and the biceps muscle pulls it anteriorly.
Fractures of the bones of the forearm in the lower third. The forearm is given a pronation position, since the pronator round pronates the proximal fragment of the radius.
Immobilization for diaphyseal fractures should be carried out from the middle third of the shoulder to the metacarpophalangeal joints with flexion at the elbow joint at an angle of 90 °.
With oblique fractures of the bones of the forearm and interposition of tissues, reposition is usually unsuccessful, and then the question of surgical intervention has to be decided.

Treatment of Monteggia fractures

With a flexion fracture of the Montage type (fragments of the ulna form an angle open anteriorly, the head of the radius is dislocated backward or outward) and with an extensor fracture (fragments of the ulna form an angle open posteriorly, the head of the radius can be dislocated anteriorly as well) reposition the fragments and set dislocation follows the apparatus of Sokolovsky or Ivanov or on the Kaplan table. At first, it is advisable to try to apply manual reposition. The surgeon with one hand creates traction for the patient's hand (the arm is bent at the elbow joint at an angle of 90 °), and with the fingers of the other hand presses on the head of the radius from the back, outer or front side (depending on the type of dislocation). The forearm is maximally supinated and the arm is bent at the elbow joint (with anterior dislocation - at an angle of 60 °, with posterior and external - at an angle of 160 °). If the head of the radius is not held in place, it should be transarticularly fixed with a pin inserted through the lateral condyle of the humerus at the above-mentioned flexion angles in the elbow joint. After 2 weeks, the pin is removed, and after 4 weeks, the plaster cast is changed, bringing the forearm to the position of flexion at the elbow joint at an angle of 90°. After another 2-3 weeks, the plaster cast (in the presence of radiographic signs of consolidation) is completely removed and begin to work with the patient exercise therapy.
With this type of fracture, radial nerve paresis sometimes occurs, so the dislocation of the radial head should be corrected as soon as possible. Unsuccessful conservative treatment is an indication for surgery.

Intra-articular fractures of the proximal end of the bones of the forearm

clinical picture. The most striking clinical picture occurs with a fracture of the olecranon, when a bruise, moderate swelling of the tissues are determined in the area of injury, the arm is in a forced position of incomplete extension in the elbow joint, palpation is determined by a sharp pain and retraction of tissues between the dispersed fragments.
With a fracture of the head of the radius, in addition to the usual symptoms of an intra-articular fracture, supination and pronation of the forearm will be sharply limited and painful, flexion and extension are less limited, adduction of the forearm causes pain in the area of injury.
In case of a fracture of the coronoid process, the victim tries to keep his arm in flexion at the elbow joint, there is a slight swelling of the anterior parts of the elbow joint, where indefinite pain is determined. Pain occurs with active flexion and especially with extension in the elbow joint. Sometimes the clinical picture is even more blurred.
X-rays specify the type of fracture.
Conservative treatment. In case of fractures of the olecranon without displacement of fragments, a plaster splint should be applied in the position of flexion at the elbow joint at an angle of 90° and immobilization should be carried out for 3 weeks. If there is a divergence of fragments up to 0.5 cm, then the arm after local anesthesia is fully extended in the elbow joint, a posterior plaster splint is applied and x-ray control is performed. If such a reposition fails, an operation is indicated.
Immobilization of the arm with a plaster splint for fractures of the head of the radius and the coronoid process without displacement of the fragments must be carried out for 2-3 weeks in the position of flexion at the elbow joint at an angle of 90° and the position of extreme supination. After removing the plaster splint, the patient should be engaged in dosed physiotherapy exercises, full burdening of the arm is possible only 7-8 weeks after the fracture.
With a significant displacement of the coronoid process, with comminuted and marginal fractures head of the radius shows early surgical intervention, which consists in fixing the coronoid process to the site of its separation and resection of the head of the radius.

Surgical treatment of fractures of the bones of the forearm

Osteosynthesis of the ulna. Operative access to the fracture site is a tissue incision along the posterior surface of the ulna area, overlapping the fracture level. The fragments are isolated, a metal rod is inserted retrogradely into the proximal fragment, repositioned, and the rod is advanced into the distal fragment. If the end of the rod protrudes from the olecranon, then it should be shortened to 0.4 cm. The wound is sutured in layers, a split plaster * bandage is applied from the middle third of the shoulder to the metacarpophalangeal joints, bending the arm at the elbow joint at an angle of 90 °.
Osteosynthesis of the radius. An operative approach to a fracture in the upper and middle thirds of the radius is a skin incision starting from the ulnar fold and descending along the anterior edge of the brachioradialis muscle to the border between the middle and distal thirds of the forearm. Dissect the fascia and penetrate inside between the brachioradialis muscle and the radial flexor of the forearm. Here you need to be careful, since the radial artery passes between the aforementioned muscles, and under the brachioradialis muscle there is a superficial branch of the radial nerve, which is retracted outward with a dilator, and the radial flexor of the forearm is inward. Then the tissues are dissected between the supinator, which has an oblique direction in the upper half of the surgical wound, and the round pronator. Subperiosteally open access to the radius.
In case of fractures of the radius in the upper third, osteosynthesis is best done with a metal pin, and at the border of the upper and lower thirds - with a metal plate. A metal pin should be inserted through the entry hole in the cortical layer of the distal fragment, and then, after the reposition of the fragments, it should be advanced into the bone marrow canal of the central fragment. In osteosynthesis with a plate, the latter must be placed on the outside of the radius (the plate should be no more than 5 cm long and no less than four screws).
In case of a fracture of the radius in the lower third, the operative approach is a skin incision starting from the styloid process of the radius and continuing upward by 6-8 cm along the outer-posterior part of the radius. The subcutaneous fat, fascia of the forearm are dissected, and then the tendon of the long common extensor of the thumb is isolated and retracted outward, and the tendon of the short and long radial extensor of the hand, together with the long extensor of the thumb, is retracted inwards. Then they manipulate on the radius itself. Osteosynthesis of the radius in the lower third is more reliable to carry out with a metal plate. The wound is sutured, a plaster bandage is applied.
Radial head resection, osteosynthesis, reduction of dislocation. An operative approach to this area is a skin incision starting 2.5 cm above the epicondyle and going down over the area of the head of the radius and descending 5 cm below the level of the elbow joint. The fascia is dissected and penetrated between the brachioradialis muscle and the two radial extensors of the hand, which are located lateral to the common extensor of the fingers, which is retracted medially. In the depth of the operational field there is an arch support. The deep branch of the radial nerve is located much more lateral and runs along the edge of the short radial extensor of the hand. The joint capsule is opened directly above the edge of the supinator, thus opening access to the head of the radius. With comminuted and marginal fractures, its resection is indicated. All loose bone fragments are removed. The periosteum is separated with a raspator from top to bottom to the level of resection, it is cut with a Gigli saw (you can use a chisel) necessarily above the attachment of the biceps brachii on the tuberosity of the radius. Then the remnants of the circular ligament of the former head of the radius are excised, leaving no particles, since osteophytes can subsequently form from them. If only the head of the radius is fractured, resection should be performed above the circular ligament of the radius.
If the reposition allows you to completely restore the anatomical shape of the head, then its osteosynthesis is performed.
With a Montage fracture, a dislocation of the head of the radius and a fracture of the diaphysis of the ulna occur, so it is necessary to perform osteosynthesis and reduce the dislocation of the head of the radius.
Dislocation of the head of the radius usually occurs anteriorly and medially, therefore, in order to eliminate the traction of the biceps muscle, the forearm is bent at the elbow joint, rotated to the supination position and, by applying direct pressure on the head, it is repositioned. Now they find the ends of the torn circular ligament and sew it with catgut. If this fails, then a ligament is formed from a strip of the broad fascia of the thigh (the dimensions of the strip are 1X12 cm). To fix the newly formed ligament on the bone, an additional incision (5 cm long) exposes the upper posterior surface of the ulna and, at a distance of 2.5 cm below the head of the radius, a transverse channel is pierced through which the posterior end of the tape is passed, and then both ends are pulled together and sutured near the neck radius bone. The wound is sutured in layers and a plaster cut bandage is applied from the upper third of the shoulder to the metacarpophalangeal joints in the position of flexion at the elbow joint at an angle of 90° and the middle position between supination and pronation. After 3 weeks, the plaster immobilization is removed, and the patient begins dosed physical therapy exercises.
Osteosynthesis of the olecranon. Operative access to the olecranon is a skin incision up to 8 cm long, starting 2 cm above the apex of the olecranon and going down the crest of the ulna. The aponeurosis of the triceps muscle of the shoulder is dissected and the site of the fracture is isolated. Remove blood clots, check the quality of reposition. An electric drill is used to make a transverse canal in the distal fragment 1–1.3 cm below the fracture site, and one end of the wire is inserted into it, and the other is led past the top of the olecranon, piercing the tendon part of the triceps muscle of the shoulder. The split-off olecranon is brought down with a single-toothed hook and the ends of the wire are twisted. After checking the quality of osteosynthesis, the wound is sutured in layers and a cut plaster bandage is applied from the opposite scapula to the metacarpophalangeal joints in the position of flexion in the elbow joint at an angle of 90°. After 4-5 weeks, plaster immobilization is stopped, and the patient begins dosed movements in the elbow joint. In the intervals between exercise therapy sessions, immobilization is carried out on a scarf. Osteosynthesis is also possible with the help of a hook or screw (Fig. 21). The operation is usually performed under local anesthesia, supplemented by conduction anesthesia. After dissection of the tissues with a single-toothed hook, the displaced olecranon is repositioned, and a Beck's wire is inserted from the side of its apex so that the tip of the wire goes through the cortical layer of the distal fragment by 2-3 mm. Then the pin is bent on the distal fragment, deposited with a nozzle in the region of the olecranon apex and wrapped around the screw inserted into the distal fragment, stepping back 1.5 cm from the fracture line. The screw is screwed all the way into the ulna, the osteosynthesis is tested for strength. The plaster bandage is not applied, it is prescribed from the second day
exercise therapy.

Rice. 21. Osteosynthesis of the olecranon with a hook

Hand and finger injuries

Injuries to the hand and fingers occur as a result of direct (impact, pressure) and indirect (pulling the fingers between the rotating parts of the machine, excessive flexion or extension in the joints, when falling at emphasis on the hand) injuries. All open injuries require urgent surgical intervention, and closed ones can be initially treated conservatively.
The following types of injuries of the hand and fingers are distinguished: 1) dislocation, fracture of the lunate bone; 2) dislocation, fracture of the navicular bone; 3) dislocations and fractures of other bones of the wrist;
4) dislocation of the hand; 5) dislocation of the metacarpal bones and fingers; 6) fractures of the metacarpal bones and phalanges of the fingers with and without damage to the tendons.

Dislocations and fractures of the bones of the wrist

clinical picture. With dislocations of the lunate and scaphoid bones, diffuse swelling is visible in the area of the wrist joint. A dislocation of the lunate causes flexion of the fingers as the bone itself shifts to the palmar side and presses on the tendons and sometimes on the median nerve. With a dislocation of the navicular bone, the hand deviates to the side, and the thumb is in the abduction position. Palpation of the lunate bone is determined from the palmar side above its location, and the scaphoid is almost in the area of the "anatomical snuffbox". Other bones of the wrist joint are determined above their usual location. Dislocation of the lunate and navicular bones causes a sharp limitation of motion in the wrist joint, which is uncharacteristic of dislocation of other bones. With fractures of the bones of the wrist, movements of the hand are possible, but painful, especially extension.
To clarify the diagnosis, x-rays are taken. In addition to the usual x-rays(frontal and lateral projections sometimes make it possible to reveal a fracture of the bones of the wrist), a three-quarter view is necessary, which allows better identification of the profile of the navicular bone. A direct x-ray should be taken with slight dorsiflexion of the hand. If there are clinical signs of a fracture, and radiological signs are absent, then again after 2-3 weeks a control x-ray should be taken, and the hand should be immobilized with a plaster cast. During this period (bone fusion), due to decalcification, a gap will appear in the area of the crack, which will be quite clearly visible on the x-ray.
A characteristic feature of fractures is a positive axial load: in fractures of the lunate, capitate and hamate bones, pain occurs with a push along the axis of the III-IV fingers, with fractures of the scaphoid, large and small trapezoid bones - with a push along the axis of the I-II fingers. Dislocation of the lunate and scaphoid bones causes a sharp limitation of motion in the wrist joint, which is uncharacteristic of dislocation of the bones.
Conservative treatment of dislocations of the wrist bones. They need to be urgently reduced under local or general anesthesia. The upper limb of the patient is fixed on the Sokolovsky or Ivanov apparatus, sufficient stretching of the wrist joints is developed, and then the surgeon presses the dislocated bone with his thumbs in the direction of its anatomical location (the pressure on the bone should be unfolding).
The hand is bent at the wrist joint at an angle of 140-150° and a dorsal plaster splint is applied. The correctness of the reduction is checked by a control x-ray. The failure of conservative reduction is an indication for emergency surgical intervention.
Surgical treatment of dislocations of the bones of the wrist can be performed under intraosseous anesthesia (tourniquet on the shoulder) or general anesthesia. Operative access is a dorsal skin incision above the anatomical location of the bone. The dorsal ligament of the wrist is dissected, the tendons are moved apart, the capsule of the corresponding joint is opened, the return stroke is released for the bone, the wrist joints are stretched, and the dislocated bone is set in its place. (A dislocated bone can also be reduced through a palmar incision of the tissues.) The operation ends with layer-by-layer suturing of the tissues and the application of a plaster splint.
When the bones are dislocated to the palmar side of the hand, palmar flexion is given, and when the bones are dislocated to the back, the back is flexed at an angle of 140-150 °. After 2 weeks, the hand is removed from this position until it is fully extended in the wrist joint; again, longitudinal immobilization is performed for 2 weeks. The patient is engaged in exercise therapy. After removing the plaster splint, physiotherapy is carried out.
Conservative treatment of wrist fractures. In case of a fracture of the navicular bone in the region of the tubercle, fusion occurs at the usual time, as in the case of detachment of the dorsal process of the lunate bone, therefore, with such fractures, immobilization should be carried out only for 3-6 weeks in a circular unlined plaster bandage. In case of fractures of the body of these bones, the fusion is slow, since the intraosseous vessels are damaged and blood circulation is completely disturbed in the only possible way. The term of immobilization reaches 4-6 months, and sometimes more. In the absence of fusion, Beck's operation or bone grafting is indicated.
In case of fractures of other bones of the wrist without displacement of fragments, consolidation occurs in the usual time (4-6 weeks). To do this, it is necessary to apply a well-modeled plaster cast without bedding. After the expiration of the immobilization period, restorative treatment is carried out.

Dislocations and fractures of the metacarpal bones and phalanges of the fingers

Dislocation of the hand very rare; occurs as a result of indirect and direct injuries. Dislocation usually occurs to the rear and less often - to the palmar side, outward and inward.
The clinical picture and treatment are similar to a fracture of both bones of the forearm in a typical location.
The only feature of the treatment is the fixation of the hand with a plaster bandage after reduction of the palmar dislocation in the position of dorsal flexion, and after reduction of the dorsal dislocation - in the position of palmar flexion at an angle of 140°. In this position, the hand is immobilized for 2 weeks and another 2 weeks - in a neutral position.
Dislocation of the I finger occurs more often to the rear, less often forward and outward. On examination, there is a forced position of the first finger, the finger is shortened, the head of the first metacarpal bone is palpated from the back, from the palmar side or from the outside, depending on the dislocation, movements in the first metacarpophalangeal joint are impossible, a symptom of spring resistance is noted. X-ray examination gives an accurate idea of the nature of the dislocation.
The dislocation should be reduced under local anesthesia. The finger is lubricated with cleol, a napkin is applied, and then a longitudinal traction is developed for the finger. With successful reduction, the symptom of springy mobility disappears, active and passive movements become possible. A palmar plaster splint is applied from the middle third of the forearm to the I interphalangeal joint, bending the dislocated finger in the metacarpophalangeal joint. After 3 weeks, the plaster bandage is removed and rehabilitation treatment is carried out.
Dislocation of the middle and nail phalanges under the influence of trauma, it can occur anteriorly, posteriorly, outwards and inwards, which determines the corresponding clinical picture. With anterior palmar dislocation, which is quite rare, the finger is in the extension position, with posterior dorsal dislocation - in the flexion position, with external and internal dislocations of the phalanges - respectively, in the position of abduction and adduction. The joint area is deformed, sharply painful, the symptom of spring resistance is positive, there are no active movements of the phalanges. When the tendon is torn off, the finger is sharply bent towards the intact tendon. X-ray confirms the diagnosis.
The dislocation of the phalanges should be reduced under local anesthesia. With a dorsal dislocation, overextension and traction are performed, with a palmar dislocation, flexion and traction, and with lateral dislocation, traction. The restored ratio of the articular surfaces is fixed with a plaster splint for 3 weeks.
With a detachment of the attachment of the tendons, surgical intervention is indicated.

Fractures of the metacarpal bones and phalanges of the fingers with and without damage to the tendons

Fractures of the metacarpal bones and phalanges of the fingers occur both when hitting the back of the hand (direct injury) and from excessive axial load (indirect injury).
Depending on the location, they are divided into fractures of the distal end of the phalanges and metacarpal bones; fractures of the diaphysis of the phalanges and metacarpal bones; fractures of the proximal end of the phalanges and metacarpal bones.
These fractures may be open or closed, with or without tendon injury.
clinical picture. Fractures of the distal and proximal ends of the phalanges and metacarpal bones are intra-articular fractures (with the exception of the nail phalanges), so the clinical picture will correspond to this pathology. With concomitant damage to the tendons, extension and flexion of the phalanges are completely absent (if the tendon of the deep flexor is damaged, there is no flexion of only the nail phalanges, if the tendons of the deep and superficial flexors are damaged, flexion of all phalanges is absent). Great difficulties for diagnosis are the detachment of small periarticular fragments and a fracture without displacement of the fragments, since the clinical picture resembles a sprain.
In a separate group, a fracture of the base of the first metacarpal bone (Bennett's fracture) should be distinguished: the first finger is in the adduction position, there is swelling of the I metacarpophalangeal joint, and the bone protrusion is palpated here. Crepitation of fragments is determined; axial loading and finger traction are painful. Radiographs with a Bennett fracture state a fracture of only the ulnar edge of the base of the first metacarpal bone. The finger, together with a peripheral fragment of the metacarpal bone, is dislocated in the metacarpal-carpal joint in the dorsal-radial side.
When the distal ends of the nail phalanges are fractured, the nail is quite often broken, and the nail bed has a bruised wound, the bottom of which is the fracture site. With a closed injury, the nail is cyanotic, sharply painful with pressure in the transverse and longitudinal directions.
Fractures of the diaphysis of the phalanges of the fingers and metacarpal bones are not difficult to diagnose, since the clinical picture is similar to any diaphyseal fracture.
With open fractures, there is a wound over the area of the fracture. At the site of injury with open fractures, an aseptic bandage should be applied and a transport splint (special or from improvised materials) should be bandaged. If the injury was accompanied by scalping of the skin or amputation of the fingers, then these autotissues must be delivered to a medical institution, where they are used for plastic surgery.
Conservative treatment. Fractures of metacarpal bones without displacement of fragments. A palmar splint should be applied in the position of dorsiflexion of the hand at an angle of 160° and flexion of the fingers at an angle of 45°. The plaster bandage captures the hand and forearm up to its upper third. The immobilization period is 3 weeks.>
Fractures of the phalanges of the fingers. The plaster splint should reach the border between the middle and lower thirds of the forearm.
Fractures of the metacarpal bones and phalanges of the fingers with displacement of fragments require especially careful reposition, since their fusion in the displacement position causes a sharp restriction of movement in the joints.
Transverse fractures of the diaphysis of the metacarpal bones. It is possible to reposition fragments by manual reposition: first,
anesthesia of the fracture site 4 cm3 with 1-2% solution of novocaine, then the surgeon develops longitudinal traction for the finger with one hand, and with the fingers of the other combines the fragments, restoring the axis of the bone, applies a palmar plaster bandage-longuet, bending the patient's fingers in the metacarpophalangeal joint at an angle of 10 -20°, in the first and second interphalangeal joints - at an angle of 45°.
Bennett fracture. They develop traction for the first finger, maximally retract it together with the first metacarpal bone, without weakening the traction, and press on the base of the first metacarpal bone from the radial side. This position is fixed with one plaster palm splint from the first interphalangeal joint to the middle third of the forearm (Fig. 22). Produce a control x-ray.

Rice. 22. Plaster cast for Bennett's fracture

With unstable fractures, reposition of fragments is achieved by skeletal traction, and with irreducible fractures, surgical treatment is indicated.
Fracture of the neck of the metacarpal. The repositioning technique consists in developing longitudinal traction, and then bending the finger at a right angle in the metacarpophalangeal joint with simultaneous pressure from the palmar side to the back on the metacarpal head. With this fracture, the head of the metacarpal bone almost always rotates to the palmar side, forming an angle between the fragments, open to the palmar side (apex on the back of the hand). The fingers in the interphalangeal joints are bent at an angle of 45 °. This position is fixed with a palmar plaster splint. To prevent re-displacement, the achieved position (after the control x-ray) should be fixed with a pin inserted through the head and diaphysis of the metacarpal bone in a closed way (the pin is inserted on the side of the extensor tendon). At a distance of 1 cm from the surface of the skin, the needle is bitten. After 3 weeks, it is removed, and the patient begins to produce dosed movements in the joints of the hand.
If treatment with these methods is unsuccessful, skeletal traction for the nail phalanx should be resorted to. To do this, it is necessary to apply a palmar plaster splint from the metacarpophalangeal joints to the border between the lower and middle thirds of the forearm in the position of the back flexion of the hand at an angle of 120 °, then fix it with a plaster bandage, starting from the middle third of the hand and above, and insert a pin under local anesthesia into the nail phalanx laterally. After that, cast the Böhler splint to the plaster cast by bending its long metal bar so that the fingers are bent at an angle of 45 ° in the metacarpophalangeal joint and in the interphalangeal joints. The doctor performs traction with his hands, possible reposition, and then regulates the skeletal traction with the necessary correction. In the first three days, the question of the effectiveness of skeletal traction is decided on the basis of control x-rays. If conservative treatment fails, surgery is indicated.
Fractures of the phalanges of the fingers without displacement of fragments. A plaster cast is applied for 2 weeks in the physiological position of the hand and fingers. Fractures with displacement of fragments are subject to reposition. With a transverse fracture, fragments can be compared by manual reposition. Oblique and comminuted fractures should be treated immediately with skeletal traction. The failure of conservative treatment is an indication for surgery.
Surgical treatment of hand injuries. Osteosynthesis of Bennett's fracture. Operative access is a dorsal incision 5-6 cm long, starting from the middle of the 1st metacarpal bone to the hand and turning to the palmar crease by 2 cm. it is attached with two crossed knitting needles). The stability of osteosynthesis is checked, and then the wound is sutured in layers and a plaster cast is applied. After 4-5 weeks, immobilization is stopped, after a control x-ray, restorative physiotherapy is started.
Osteosynthesis of a fracture of the metacarpal bones and phalanges of the fingers. The operative approach is a dorsal skin incision 5-6 cm long above the fracture site. Fragments are isolated on the side of the tendon, in case of transverse fractures, a thin pin or Kirschner wire is retrogradely inserted into the distal fragment until it protrudes from the fragment at the fracture site by 2-3 mm (the peripheral end of the fixator usually comes out of the metacarpal head or the distal end of the phalanx). Then reposition is performed and a metal fixator is driven into the proximal fragment for the entire length of the diaphysis of this bone. A retainer up to 5 mm is left above the skin. Oblique fractures should be secured with two cerclage wire sutures. The wound is sutured in layers and a plaster cast is applied for 3 weeks, after which the fixative is removed, and the issue of further immobilization is decided depending on the X-ray data.
Tendon stitching. Restoration of the integrity of the subcutaneous rupture of the extensor tendon when it is separated from the place of attachment to the nail phalanx. Treatment must begin as early as possible. It lies in the fact that the torn end of the extensor tendon of the nail phalanx is brought closer to the place of separation, giving the nail phalanx a position of hyperextension. and the middle phalanx, the position of moderate flexion (angle 60°). In this position, a well-modeled plaster splint is applied from the fingertip to the middle third of the forearm (the plaster splint should cover the finger on 3/4 of its surface) (Fig. 23). After 6 weeks, this immobilization is stopped and usually the tendon engraftment to the nail phalanx is noted.

Rice. 23. The position of the phalanges of the finger:
a - with a rupture of the extensor tendon; b - plaster cast for rupture of the extensor tendon; in - the position of the finger for the introduction of the spokes; d - transarticular fixation of the finger with a pin in this injury

You can also apply transarticular fixation of the finger in this position by passing a thin needle through the nail, middle and main phalanges of the finger. The ends of the needles are bitten so that they are under the skin. After 6 weeks, the needle is bitten on the palmar surface and its ends are removed. Beginning rehabilitation treatment.
In chronic cases, the use of a removable wire blocking suture according to Bennel is indicated.
An operative access to the place of detachment from the nail phalanx is a Z-shaped skin incision. Through this incision, the severed tendon and its bed on the nail phalanx are released from scar tissue, a channel is drilled in the nail phalanx to the bed of the fragment, a thin wire is passed through the fragment, and another wire is passed under its wire loop. Then, with a needle, both ends of the wire are passed through the bone canal in the nail phalanx and removed above the skin of the fingertip. The wire is stretched (a fragment with a tendon fits snugly against the bed - the place of separation) and its ends are tied over the installed button. The ends of the other wire are brought into the hole in the tissues on the skin. The wound is sutured in layers, a plaster palm splint is applied in the above position. After 4-5 weeks, immobilization is stopped, the wire is removed from the tendon by the wire holder (cutting the wire directly under the button) and rehabilitation treatment is started.
Restoration of the integrity of the damaged flexor tendons of the fingers. The tendon is most commonly injured in direct trauma, and the wound is usually located over the intersection of it. The edges of this wound are excised (intraosseous, intravenous conduction anesthesia is used) and Z-shaped expand up and down only in the area of the fingers and forearm. If the central end of the tendon cannot be isolated through this incision, then an additional incision is made along the middle palmar fold, respectively, the projection of the damaged tendon, and the selected tendon is pulled to the rupture site with a conductor and taken on a holder.
The most promising for restoring the function of the fingers of the hand is suturing the tendon end-to-end according to Bennel (as in the restoration of the extensor tendon), with the only difference being that here the wire is passed only in the tendon, making one cross, at its proximal end; during surgery on the palm or in the proximal parts of the fingers, both needles are passed through the skin, while working on the distal parts - through the tip of the finger (Fig. 24).

Rice. 24. Tendon suturing with Bennel wire:
a - a wire is inserted into the ends of the tendon and two buttons are fixed on it; b, c - the ends of the tendons are sutured

Immobilization is carried out with a plaster splint for 3 weeks. Then comes the recovery period.

Limb injury is quite common, because the increase in injuries in recent years is 4.7%. Injuries of the musculoskeletal system take the second place in the structure of mortality of the population, among them injuries of the limbs are in the first place. If you know the signs of injuries, you can quickly navigate the situation and competently provide first aid. A person's life often depends on it.

Causes and types of limb injuries

Limbs are injured due to many reasons:

falls,
fight,
sports,
car accidents.

There are the following types of limb injuries:

closed soft tissue injuries (bruises, sprains, tears);
bone damage (dislocations and fractures).

Signs of limb injury

Limb injuries usually have characteristic symptoms that depend on both the type of injury and the mechanism of injury.

bruises not accompanied by visible tissue damage. They can be caused by a blow with a blunt object to a limb or the last one to an object. A bruise is accompanied by pain in the limb, swelling of soft tissues, hemorrhage. When a joint is injured, blood flows out of the joint cavity, it deforms, and the range of motion is limited.

With sudden movements of the limb, the ligaments are stretched - their partial rupture while maintaining the anatomical integrity. Sprain of the ankle joint occurs when the foot fails to turn outward: there is a violation of its function, pain, swelling and hematoma.

Gap- this is a closed tissue damage, in which the integrity of their structure is violated. There are ruptures of tendons, ligaments, muscles. Tendon rupture occurs with a sharp contraction of the muscles of the limb. At the time of injury, severe pain occurs, muscle function is impaired, a slight hematoma and a visible gap between the ends of the torn tendon may form.

At the moment of hyperextension of the joint, sometimes there is a rupture of its ligaments. When the ligaments of the ankle joint are torn, there is a sharp pain and hemorrhage around it, hemarthrosis, dysfunction. When the intra-articular ligaments of the hip and knee joints are torn, a crunch and clatter is heard in the joint during its flexion. Due to a strong contraction of the muscle, a rupture of the fascia can occur: a defect is formed at the site of injury, through which the muscle protrudes during contraction. Rupture of a muscle occurs due to its stretching, tension or contraction. The victim complains of severe pain, with muscle contraction, the defect in the place of its rupture increases.

Dislocation- this is a steady displacement of the articular ends of the bones. The function of the injured limb is impaired. The most common dislocations of the shoulder, forearm, hip.

fracture is called an injury, as a result of which the integrity of the bone is violated.
Fractures of the extremities are closed (without skin damage) and open (with damage to it). They can be both without offset and with offset; displacement of fragments occurs along the length, width or in several planes. The main signs of fractures of the extremities: pain at the site of injury, pathological mobility of fragments and crepitus (a characteristic crunch is heard when pressing on the fragments). At the site of injury, hemorrhage occurs, and deformity of the limb is often noted. An open fracture may bleed. With a closed fracture of the hip, hidden blood loss is 2 liters, of the shoulder - 1.3 liters, so in these cases signs of blood loss may appear.

Emergency care for limb injuries

The main first aid measures for limb injuries are anesthesia, immobilization, and, if necessary, stopping bleeding.

To anesthetize the injury site with a bruised limb, a bag with snow, ice, cold water is applied topically. If there is chloroethyl in the medicine cabinet, it is advisable to use it for local anesthesia. In case of stretching, cold is applied locally. When the ligaments are ruptured, transport immobilization is performed with a bandage bandage, anesthesia with chlorethyl. In the event of a rupture of the fascia or muscle, a pressure bandage should be applied to the injury site.

In case of dislocation, cold or chloroethyl should be applied topically. The upper limb should be immobilized with a bandage or scarf, the lower one can be immobilized by bandaging the injured leg to a healthy one or fixing it to improvised means (for example, to a board). In modern first-aid kits there should be standard scarf bandages. It is categorically impossible to try to return the limb to its normal position or straighten it yourself; the victim must be taken to the emergency room.

When a limb is fractured, the fracture site is anesthetized with chloroethyl or cold is applied topically. In case of a fracture of the shoulder and hip, 3 joints are immobilized, and in case of a fracture of the lower leg and forearm, the two closest to the fracture site. For transport immobilization, you can also use standard tires or improvised means: boards, sticks, skis. It is advisable to use vacuum tires. In case of an open fracture, the edges of the wound must be treated with a 5% alcohol solution of iodine, covered with a sterile napkin and bandaged.
To fix fragments, the arm can be bandaged to the chest, and the lower limbs to each other. Of the medications for injuries, analgin, ibuprofen, diclofenac are used for pain relief. For the prevention of pain shock in case of a fracture of a limb, it is necessary to cover the victim, give hot sweet tea to drink. With signs of blood loss, it is necessary to lower the head lower and raise intact limbs up.

Knowing the signs of various injuries to the limbs, mastering first aid techniques, you can competently provide emergency care at the scene of the incident before the arrival of the ambulance team, prevent serious complications and save a person’s life. Remember: victims with limb injuries definitely need to consult a traumatologist to provide qualified medical care and choose further treatment.

Combat injuries of limbs during the Great Patriotic War 1941-1945. and in modern local wars they make up 60-70% in the structure of combat surgical trauma. The incidence of injuries to the lower extremities is almost twice as high as the frequency of injuries to the upper extremities. In terms of localization among all segments of the limbs, injuries of the femur and lower leg predominate.

The high frequency of recovery of combat capability and return to duty of this category of the wounded is the reason for great attention to it as a reserve for replenishing the personnel of the Armed Forces.

23.1. SOFT TISSUE DAMAGE,

BONE FRACTURES AND INJURIES

LARGE JOINTS OF THE LIMB

He was the first to develop a detailed system for the treatment of limb injuries Hippocrates. In the treatment of fractures, he used limb traction and simultaneous reduction of bone fragments using various devices. However, gunshot fractures up to the Crimean War of 1853-1856. were considered an indication for primary limb amputation due to inevitable septic complications (J.J. Larrey). After analyzing the lethality among the wounded during amputation of the hip (95%) and shoulder (50%), N.I. Pirogov came to the conclusion that "early amputation belongs to the most deadly operations" and introduced the "saving" treatment of gunshot fractures in the war, proposing to use a plaster cast for this (1854).

The founder of domestic military traumatology is G. I. T urn e r(1858-1941) - founder of the country's first department of traumatology and orthopedics at the Military Medical Academy (1900). A significant contribution to the development of methods for the treatment of combat injuries of limbs in different years was made by R. R. Vreden, I. L. Krupko, S. S. Tkachenko, V.S. Grandfather ushkin, V.M. Shapovalov, V.K. Nikolenko.

In both world wars, a plaster cast and skeletal traction remained the main method of treating fractures, although already in the 19th century. began to develop methods of osteosynthesis. During the local wars of the second half of the twentieth century. in the treatment of gunshot fractures of long bones, external fixation devices were used for the first time: during the Afghan war, compression-distraction devices by G.A. Ilizarov, during the hostilities in the North Caucasus - rod devices of the KST-1 set ( E.K. Gumanenko).

23.1.1. Terminology and classification of limb injuries

stand out firearms and non-firearms limb injuries.

Gunshot injuries (Table 23.1) are subdivided into bullet wounds, shrapnel wounds, MVR and explosive injuries. By the nature of the wound channel - into blind, through and tangent. In addition, injuries are divided according to the location of the damage and the type of damaged tissue.

MVR - the result of exposure to the body of an explosive munition in the affected area by an explosive shock wave, accompanied by explosive destruction of tissues or separation of limb segments.

explosive injuries called open or closed injuries resulting from the propelling action of explosive ammunition and the impact on the human body of surrounding objects in an open area or in a confined space.

Non-firearms (mechanical) injury arise during road accidents, falls from a height, collisions with military equipment and are fundamentally divided into open and closed. According to the localization of damage, the type of damaged tissue and the consequences, they are classified in the same way as gunshot injuries.

To life-threatening consequences limb injuries include bleeding and acute ischemia (in case of damage to the main vessels).

Among all injuries of the extremities stand out isolated, multiple and combined.

isolated are called such injuries in which there is one damage. It should be noted that soft tissues, bone, large vessels, and nerves can be simultaneously involved in one morphological substrate. And, if simultaneous soft tissue injury

Table 23.1. Classification of combat injuries of the limbs

and bones in one place are unanimously considered one injury and, therefore, an isolated injury, then simultaneous damage in one place of soft tissues, bone and a large vessel or nerve trunk by a number of specialists (mainly angiosurgeons, less often neurosurgeons and traumatologists) is also considered one injury, but combined (first) or multiple (third) trauma. This approach is narrow-profile, is not consistent with the generally accepted (in our country and in the world) views on the classification of injuries in this section, and it is justified by the need for the participation of several specialists in the treatment of such injuries. From the point of view of military field surgery, simultaneous damage in one place of soft tissues, bones, large vessels or nerve trunk is one damage and, therefore, an isolated injury.

This is based on a single mechanism for the occurrence of damage to these formations, the same methods of providing assistance and treatment, and, finally, on a single outcome of treatment.

Multiple called limb injuries in which there are several injuries within the same anatomical region (according to the terminology generally accepted in injury surgery, two upper and two lower limbs make up one of the seven regions, designated as "limbs")

Combined called injuries in which there are several injuries (one or more RS in relation to gunshot wounds) located in different anatomical regions of the body. In case of combined injuries, the damaged areas are listed in the diagnosis according to the “top-down” principle.

Diagnosis examples.

1. Severe concomitant explosive trauma to the head, abdomen, limbs.

Open penetrating traumatic brain injury. Brain contusion of moderate severity. Subarachnoid hemorrhage. Open fracture of the base of the skull. Left-sided otoliquorrhea.

Closed abdominal trauma with damage to the spleen. Continued intra-abdominal bleeding.

Closed multiple injury of the extremities. Closed fracture of the right femur in the middle third. Closed multi-comminuted fracture of the bones of the right leg in the upper third with damage to the main arteries of the leg and the peroneal nerve. Uncompensated ischemia of the right leg and foot.

Acute massive blood loss. Traumatic shock III degree.

2. Shrapnel blind wound of the soft tissues of the upper third of the left thigh

3. Bullet through wound of the left leg with a fracture of both bones in the middle third and extensive damage to the soft tissues.

4. Bullet wound through the right shoulder with a fracture of the humerus in the middle third, damage to the brachial artery and radial nerve. Compensated ischemia of the right upper limb. Traumatic shock I degree.

5. Explosive wound. Detachment of the left tibia in the middle third with extensive destruction of soft tissues up to the lower third of the thigh. Acute massive blood loss. Traumatic shock II degree.

6. Shrapnel blind penetrating wound of the right knee joint with minor bone damage. Hemarthrosis of the knee joint.

7. Closed comminuted fracture of both bones of the left leg in the upper third with displacement of fragments. Peroneal nerve injury.

A unified interpretation of the basic concepts and terms in military field surgery, knowledge of the classifications of combat injuries are very important for formulating the diagnosis of BT.

In turn, the correct diagnosis allows you to make the most rational decision in the medical sorting of the wounded, i.e. determine the place of assistance, priority and volume. In accordance with the diagnosis, the most rational list of measures of one or another type of medical care is selected, the order, method and timing of evacuation are determined, and at the final stage of treatment, rational tactics of treatment and rehabilitation are determined.

23.1.2. Diagnostics and treatment of gunshot wounds of extremities

Soft tissue wounds. More than half (62%) of gunshot wounds of the extremities are soft tissue wounds, which are characterized by varying degrees of damage to the skin, muscles, fascia and tendons. For the most part, they do not pose an immediate threat to life and, with proper treatment, have a favorable prognosis in terms of restoring combat capability. MVR can cause extensive soft tissue damage, with skin detachment, crushing and tissue defects, which are moderate to severe injuries and usually require long-term treatment. Treatment gunshot wounds of soft tissues consists in the primary surgical treatment of wounds (according to indications) or the toilet of wounds.

A significant part of the wounded in this group are lightly wounded(See Ch. 23 Sec. 23.1.7).

Gunshot wounds of extremities with bone fractures. Gunshot wounds with fractures of the bones of the extremities occur in more than a third of cases of gunshot wounds of the extremities (38% in the total structure of injuries of the extremities).

Gunshot fractures are divided into 2 groups.

1. Incomplete (perforated, edge).

2. full, which, in turn, are further divided into 2 subgroups: - simple (transverse, oblique); - splintered (large or small splintered, crushed)

Rice. 23.1. X-ray of a large-ringed gunshot fracture of the right humerus

With comminuted fractures, the most typical of gunshot wounds, primary defects may be observed. bone tissue. Areas of bone marrow damage in the form of continuous hemorrhagic infiltration, confluent and punctate hemorrhages, and individual fatty necrosis, depending on the type and rate of MS, can spread over a considerable distance on both sides of the focus of direct damage. The complex course of the wound channel in gunshot fractures, additional damage caused by free bone fragments as secondary MS, create favorable conditions for the development of wound infection.

In diagnostics gunshot fractures should be guided by the presence of a wound and typical

There are some clinical signs of a fracture (deformity, increase in volume, shortening of the limb, pathological mobility, bone crepitus, pain during axial load), sometimes bone fragments are visible in the wound (Fig. 23.2 color illustration). X-ray examination allows you to get an accurate idea of the type of fracture, the nature of the displacement of fragments.

Treatment gunshot wounds of extremities with bone fractures consists in the primary surgical treatment of wounds (according to indications) and therapeutic immobilization. These two components of treatment are closely interrelated, and the method of their implementation is determined by the medical and tactical situation.

The standard "classic" PST of a musculoskeletal wound includes wide dissection and excision of damaged tissues with removal of all free-lying (not associated with soft tissues) bone fragments. The wound is left gaping to ensure good drainage

detachable. This technique of PST of gunshot fractures developed during the years of the world wars with late evacuation of the wounded and a high risk of anaerobic infection, taking into account the possibilities of the methods of therapeutic immobilization used then - skeletal traction and a plaster cast. The functional results of such treatment were often unsatisfactory. Delayed consolidation and non-union of fractures, significant shortening of the limb, joint stiffness, osteomyelitis occurred in many wounded. The frequency of primary limb amputations was also high, especially in case of gunshot fractures (up to 40-50% during the Great Patriotic War).

With a significant change in the conditions for providing assistance to the wounded during the war in Afghanistan 1979-1989. (antibiotic prophylaxis, early aeromedical evacuation to the MVG, if necessary - the possibility of observing the wounded until the outcome is determined) a number of traumatologists put forward the concept of "savings" PHO gunshot fractures (V.S. Dedushkin, A.A. Artemyev). The main provisions of this concept, aimed at improving the functional results of fracture treatment, focused only on specialized assistance and come down to the following.

1. PHO is not indicated for gunshot fractures without significant displacement of fragments, with pinpoint (up to 1 cm) inlet and outlet openings of the wound channel, without bleeding and intense hematomas. An alternative to it is rigid immobilization of the fracture with the Ilizarov apparatus with adequate drainage and anti-inflammatory blockades in the postoperative period.

2. In the course of PST, in case of gunshot fractures, the bone tissue is preserved to the maximum, only small, free-lying bone fragments are removed.

3. With the "saving" surgical treatment of comminuted fractures with extensive damage to soft tissues, stable transosseous extrafocal osteosynthesis according to Ilizarov is carried out as its final stage. The operation is performed by a trained traumatologist using special devices for fracture reposition (field orthopedic table or repositioning attachments).

4. An obligatory element of surgical treatment is fasciotomy. A local effect on the wound area is carried out (paravulnar and intraosseous novocaine blockades with antibiotics, long-term intra-arterial infusions, etc.).

5. The wound after PST is either sutured with a primary suture with the establishment of tidal drainage, or is open using water-soluble ointments and closed with a primary delayed suture.

Even from a brief description of the methodology of "savings" PHO, significant requirements for the conditions for its implementation are obvious, which are possible only when organizing the provision of early SHP.

Thus, in local wars, the indications for PST for gunshot fractures of long tubular bones at the stage of CCP should be maximally reduced . PST of gunshot wounds of extremities with bone fractures at this stage of evacuation should be carried out only in the following cases:

Continued external bleeding from damaged great vessels;

Uncompensated limb ischemia due to damage to the main arteries;

Extensive contamination of the wound;

Delayed evacuation more than 12 hours.

In addition, with the development of anaerobic infection, VMO is performed.

The rest of the wounded should be limited to thorough wound dressing, passive drainage through the wound channel, large-volume anti-inflammatory blockade and, if necessary, transport immobilization using service splints.

If it is necessary to perform surgical treatment for gunshot bone fractures at the stage of CCP, the surgical technique should be savings and the treated wound is left open. At the end of the intervention, it is imperative to carry out medical and transport immobilization.

Medical transport immobilization fractures of long bones is called temporary immobilization of bone fragments in the fixation mode (i.e., without careful reposition) with rod devices for external fixation or pin devices of a simplified design. The main purpose of medical and transport immobilization for gunshot fractures in military field surgery is reliable and durable immobilization of bone fragments of the injured limb to ensure safe transportation of the wounded to the next stage of evacuation, prevent the development of traumatic shock, prevent wound infection and create favorable conditions for wound healing. The second indication for

therapeutic and transport immobilization are severe combined injuries and injuries, when temporary and non-traumatic immobilization of fractures makes it possible to make the wounded mobile, prevents the development of life-threatening consequences and complications of injuries (respiratory distress syndrome, fat embolism, congestive pneumonia, etc.).

The most convenient for therapeutic and transport immobilization are rod devices of extrafocal osteosynthesis. Unlike wire systems, they are easier to use, do not require additional devices for application, and the duration of osteosynthesis does not exceed 15-20 minutes. Their weak side is the insufficient rigidity of fixation, which requires additional immobilization with a load on the limb and does not allow them to be used as the final treatment option.

At present, the military medical service of the Armed Forces of the Russian Federation has accepted for supply, starting from the stage of providing qualified medical care, a set of universal rod devices and surgical devices - set for the treatment of combined injuries KST-1. The advantages of using rod devices KST-1 in military field conditions are obvious - they allow medical and transport immobilization of any fractures of long tubular bones (Fig. 23.3a, b, c color illustration).

Method of application of rod devices KST-1 . Osteosynthesis is carried out without the use of special devices on a conventional operating table or resuscitation bed. The supporting structure of the device is pre-assembled, taking into account the anatomical features of the fixed segment, the nature of soft tissue damage, and the type of fracture. Threaded rods are inserted. Before the introduction of the rod with a scalpel, the skin is punctured and a channel is formed with the help of a trocar until it stops in the bone. On limb segments with a large array of soft tissues, the direction of the canal is determined by introducing long injection needles all the way into the bone. The trocar stylet is removed, and both cortical bone layers are drilled with a 3.8 mm drill. It is screwed through the tube of the trocar cortical threaded rod until its free end extends beyond the second cortical layer by 3-5 mm. With the introduction rods with cancellous cutting in the metaepiphyses of long bones or the pelvic bone, an awl with a diameter of 3-3.5 mm can be used to form bone channels.

In this case, the through passage of the rod is not required. The rods are connected to the pre-assembled supporting structure of the apparatus. All connecting elements must be relaxed to ensure maximum mobility of the apparatus nodes. Simultaneous manual traction along the axis of the limb is performed, the task of accurate reposition is not set at this stage of treatment. The rods are rigidly fixed in the apparatus by tightening all the nuts.

Available some features of the introduction of rods KST-1 depending on the location of the fracture: Brachial bone. 2 rods are inserted into each of the fragments (Fig. 23.4b; 23.4a, color illustration).

The location of the extreme spongy rods: in the central fragment, the rod is inserted into the head of the humerus from the outer surface along the axis of the anatomical neck, in the peripheral fragment - into the epicondyles from the outer surface perpendicular to the bone. Cortical rods are inserted into the diaphysis no closer than 5 cm from the fracture site.

Femur. The most durable fixation of femoral fractures is achieved with the introduction of three rods into each of the fragments. However, for the purposes of therapeutic-transport immobilization, the introduction of two rods into each fragment is quite sufficient (Fig. 23.5b; 23.5a color illustration).

The location of the extreme spongy rods: in the central fragment, the rod is inserted from under the greater trochanter from the outer surface of the thigh from the bottom up

Rice. 23.4. Osteosynthesis using the KST-1 apparatus: b - X-ray of a fracture of the humerus fixed with the KST-1 apparatus

the axis of the femoral neck, in the peripheral fragment - into the condyles, from the outer surface, perpendicular to the bone. Cortical rods are inserted into the diaphysis from the anteroexternal surface no closer than 5 cm from the fracture site.

In case of fractures of the femoral neck, trans- and subtrochanteric fractures, osteosynthesis is carried out by applying a frame structure to the pelvis of the rod apparatus with a long bearing bar attached to it, on which the attachment points of 2-3 rods inserted into the femur below the fracture site are located (Fig. 23.6b; 23.6a color illustration).

Lower leg bones . With osteosynthesis tibia the device is located on the anterior or anterointernal surface (Fig. 23.7b; 23.7a color illustration).

Two rods are screwed into the proximal and distal fragments from the anterior-inner side, from front to back. For more rigidity

Rice. 23.5. Osteosynthesis using the KST-1 apparatus: b - radiograph of a femoral fracture fixed with the KST-1 apparatus

Rice. 23.6. Osteosynthesis using the KST-1 device: b - X-ray of osteosynthesis of a fracture of the proximal femur

fixation due to the crossing of the rods, one rod can be inserted into the proximal metaepiphysis from the anterolateral side and connected to the apparatus using a 100 mm rod.

For therapeutic and transport immobilization, it is possible to use Ilizarov apparatus in a simplified layout(Fig. 23.8 color illustration). In this case, a base of two rings connected by telescopic rods is superimposed, an approximate

reposition. Fixation is carried out by means of two pairs of mutually intersecting pins passed through the metaepiphyses of the bones. However, when using such a simplified layout and the Ilizarov apparatus, mobility in the fracture zone can be maintained due to the springy action of the spokes. Attempts to increase the rigidity of fixation lead to the complication of the apparatus, lengthening the operation time and are impossible without the use of special repositioning and suspension devices.

Thus, the apparatus of choice for medical transport immobilization at the stages of medical evacuation is the rod apparatus of the KST-1 set.

Among the methods therapeutic immobilization with bone fractures, they differ: skeletal traction, plaster casts, extrafocal osteosynthesis and submersible osteosynthesis (on-bone, intra-osseous).

Skeletal traction currently cannot be considered as a definitive method

Rice. 23.7. Osteosynthesis using the KST-1 apparatus: b - X-ray of a tibial fracture fixed with the KST-1 apparatus

treatment for gunshot fractures and should only be used during preoperative preparation.

Gypsum bandage retains its value as a method of treatment of incomplete, simple complete fractures without displacement of bone fragments, while a prerequisite is the limited nature of soft tissue damage.

Extrafocal transosseous osteosynthesis devices G.A. Ilizarov or wire-rod compression-distraction apparatus is currently the main method of treatment of gunshot fractures of long tubular bones of the extremities, especially with extensive damage to soft tissues. It is not advisable to use rod devices as the final method of treatment due to the insufficient rigidity of fixation and the impossibility of carrying out a staged correction of the position of the fragments.

All types internal osteosynthesis with gunshot fractures are contraindicated due to the threat of AI development and can only be used in individual wounded after uncomplicated healing of the wound and against the background of a satisfactory general condition. Internal osteosynthesis is carried out not earlier than 10 days after the final healing of the wound under the guise of rational antibiotic prophylaxis.

Given the large number of methods for treating fractures of long bones (each method has its own advantages and disadvantages) and the desire to improve treatment outcomes, more and more supporters have recently been gaining tactics of programmed multi-stage surgical treatment fractures of the bones of the limbs (see paragraphs 23.1.5).

Gunshot wounds of extremities with damage to large joints. Gunshot wounds of extremities with damage to large joints (shoulder, elbow, hip, knee) can be penetrating and non-penetrating into the joint cavity.

Diagnostics A penetrating injury is not difficult if there is a large wound in the joint area with the outflow of synovial fluid from it and the detection of the articular ends of the bone in the wound. In other cases, one should take into account such clinical signs of joint damage as smoothness of its contours and an increase in volume, pain on palpation and movements, fluctuation in hemarthrosis, deformation in severe bone injuries and dislocations. The decisive role in the diagnosis of joint injuries often belongs to x-ray examination.

According to the degree of damage to soft tissues and bones, gunshot wounds of the extremities with damage to large joints are divided into 3 groups, which determines the method of surgical treatment.

1. Point wounds of soft tissues without bone damage that do not require surgical treatment (these wounded are only punctured the joint and immobilized with plaster splints).

2. Soft tissue wounds with minor bone damage requiring surgical treatment (arthrotomy, surgical debridement, if possible, tidal drainage of the joint cavity and immobilization with plaster splints or external fixation devices).

3. Extensive soft tissue defects with significant bone damage (arthrotomy and resection of the joint, immobilization with external fixation devices).

Gunshot wounds of the extremities with damage to the hand. Hand injuries represent a special group due to their multiplicity (reaching 15-20% among combat injuries of the limbs), the complexity of the anatomical structure and the functional significance of the hand as an organ.

Gunshot wounds of the hand, by classification E.V. Usoltseva, are divided into 3 groups:

1. Limited - with damage to part of the fingers, or the tena-ra or hypothenar area.

2. Extensive - capturing the whole department (fingers, metacarpus, wrist) or part of two departments of the hand while maintaining only the simplest types of capture.

3. Brush destruction - accompanied by damage to two or more departments, in which it loses its significance as an organ.

PXO of gunshot wounds of the hand is performed only at the stage of providing specialized surgical care and comes down to stopping bleeding, cutting off only clearly necrotic tissues, mandatory decompression of the hand by cutting the carpal ligament, infiltration of the wound circumference with an antibiotic solution. Thanks to a good blood supply to the hand, even significantly damaged tissue survives. The operation should begin and end with abundant washing of the wound with antiseptics, which allows you to remove foreign bodies, tissue scraps, blood clots. The wound is drained with rubber graduates and plastic tubes. For

to prevent a wound infection, a bandage with sorbents or an antiseptic solution is applied. The optimal method of immobilization is the apparatus of G.A. Ilizarov (Fig. 23.9 color illustration). The resulting areas of necrosis are excised during repeated surgical treatment with elements of reconstructive surgery of the hand.

Gunshot wounds of the extremities with damage to the foot. According to the severity of damage are distinguished limited , extensive wounds and destruction feet is similar to the classification of wounds of the hand. The most severe foot avulsion injuries occur when exposed to anti-personnel mines.

In the primary surgical treatment of foot wounds, it is very important to thoroughly mechanically clean the tissues with washing with antiseptics, complete decompression of the foot tissues with the obligatory dissection of its fascia and tendon stretching in the lower third of the lower leg. The primary suture of foot wounds is strictly prohibited. The best functional results in the treatment of severe shrapnel and mine-explosive wounds of the foot are achieved when the surgical treatment is completed by applying the Ilizarov apparatus. Taking into account the importance of the anatomical formations of the foot for maintaining the support function, it is advisable to use a two-stage surgical treatment of wounds (as with injuries of the hand).

Since the foot has a poor blood supply, unlike the hand, the following are important in treatment: rigid immobilization of the foot with an external fixation device and regional (intraosseous, intra-arterial) infusions of drugs that improve blood circulation, antibiotics, enzyme inhibitors, glucocorticoid hormones.

23.1.3. Diagnosis and treatment of non-gunshot limb injuries

Non-gunshot injuries (wounds and closed injuries) of the extremities in war do not differ significantly from peacetime injuries. These include soft tissue injuries, bone fractures, and damage to large joints.

Soft tissue injuries divided into limited and extensive (with an area of more than 200 cm 2), the treatment of which consists in suturing or (with lacerated, bruised, crushed wounds) primary surgical treatment of wounds.

Treatment is a major challenge traumatic skin detachment encountered when hit by wheeled vehicles.

In most cases, traumatic skin detachment is not difficult to diagnose, but it is important to correctly assess the viability of detached skin flaps. It is determined by the layered depth and area of the detached flap. This can most accurately be done by making a small incision of the detached flap 4-5 cm long along its lower edge along the projection line and revision of the detachment cavity with a finger. If a the detached tissue area is skin or skin with crushed subcutaneous fat, it must be cut off strictly along the perimeter, regardless of the area of detachment, since the blood supply in it is either absent or impaired due to crushing or a large area of detachment of the subcutaneous fat. After that, a painstaking and lengthy operation, especially with extensive detachments, begins. - free skin autoplasty according to V.K. Krasovitov . It distinguishes two stages, which in peacetime are usually performed simultaneously by two surgical teams, since when the skin of the lower limb is detached from the foot to the groin, the duration of the operation in specialized centers is 4-6 hours.

1st stage - preparation of the recipient bed, those. careful PST of the wound formed after cutting off the flap.

2nd stage - preparation of a "donor" skin flap. The peculiarity of skin autoplasty according to V.K. Krasovitov is that a full-thickness skin flap is used, which does not split, but is only thoroughly cleaned of subcutaneous fat on an adhesive dermatome. After that, the resulting rectangular skin flaps (corresponding to the area of the dermatome) are perforated manually with a scalpel in a checkerboard pattern or using a perforator, placed on the recipient bed and sutured around the perimeter with absorbable suture material. At the final stage, the joints are fixed with an external fixation device so that the entire limb is in a suspended state with the possibility of treating the wound with an open method (Fig. 23.10 color illustration).

Diagnostic and tactical problems arise when detachment of a full-thickness skin-subcutaneous-fascial flap, which looks quite viable, bleeds in places and is a great temptation for surgeons in terms of simplifying the operation to simply suturing the flap to the underlying tissues and draining the detachment cavity. However, this path is possible only with limited tissue detachment - up to 200 cm 2 . With extensive detachment, blood circulation

the exfoliated tissue flap turns out to be insolvent, ischemia of the covering tissues occurs, then their necrosis; but the insidiousness of pathology lies in the fact that these processes spread from the depth to the surface and therefore are poorly manifested. At the same time, endogenous intoxication with dead tissue products progresses - endotoxicosis develops, on the 3rd day - acute renal failure, and on the 4th-5th day - death.

So there is only one therapeutic tactic in the diagnosis of extensive detachment of the skin-subcutaneous-fascial flap - cutting off the flap, PST of the wound with primary free skin autoplasty according to V.K. Krasovitov.

Non-gunshot fractures of the bones of the extremities can be open and closed .

There are many classifications open fractures, however, the classification proposed by R. Gustilo (1984) is currently the most common.

Classification of open fractures:

1. I type- a clean wound less than 1 cm long.

2. II type- wound from 1 to 5 cm, but without significant damage to the soft tissues.

3. III type- wound more than 5 cm with extensive soft tissue damage:

BUT- bone fragments at the fracture site are covered with periosteum and soft tissues;

AT- bone fragments are exposed due to extensive destruction of soft tissues;

With- the fracture is accompanied by a violation of blood circulation, requiring revascularization of the limb.

In addition, type III fractures include open polyfocal segmental fractures, destruction of limb segments, gunshot fractures, fractures with damage to the main vessels, and fractures in victims who are treated within more than 8 hours from the moment of injury.

In case of open isolated fractures of type I-II, after performing PST (if necessary), it is possible to suture the wound and perform primary internal osteosynthesis, and for diaphyseal fractures, osteosynthesis with a blocked nail is the method of choice.

In type III fractures, the question of the method of closing the wound after PST (primary suture, primary suture with tidal drainage, primary delayed suture) is decided taking into account the adequacy

the treatment performed, the possibility of closing the wound with local tissues, the experience and preferences of the operating surgeon. However, PST must necessarily be completed with osteosynthesis of the fracture with an external fixation device. At the same time, in the conditions of staged treatment, as well as in case of polytrauma, preference is given to simple and quick osteosynthesis with the CST apparatus.

At closed fractures bones of the extremities, due to the preservation of the integrity of the integumentary tissues and the low risk of AI, it is possible to use in the treatment of all types of modern osteosynthesis and conservative methods of treatment.

Gypsum bandage is the most appropriate method of immobilization of bone fragments in closed bone fractures of any localization without displacement of fragments, in metaepiphyseal fractures amenable to one-stage closed reposition and held in a plaster cast, as well as in the presence of contraindications to surgical treatment of fractures.

Skeletal traction It is used more often as a temporary method of treatment, however, it can be definitive if there are contraindications to surgical methods. In these cases, traction is carried out until a fibrous callus is formed, with further replacement with plaster immobilization.

Internal osteosynthesis continues to develop at a rapid pace. Almost any closed fracture can be fixed with submersible structures. Minimally invasive methods of osteosynthesis are being actively developed, when surgery is performed without exposing the fracture zone, under the control of an electron-optical transducer (osteosynthesis with blocked rods (Fig. 23.11), plates with angular stability of screws, cannulated screws).

However, in field conditions, the implementation of high-tech methods of internal osteosynthesis is possible only in the second and third echelons of the stage of providing specialized medical care.

Indications for extrafocal osteosynthesis with the use of various types of external devices for closed fractures have recently been reduced due to the large arsenal of means of internal osteosynthesis, which give significantly better functional results of treatment. However, there are conditions when the use of internal osteosynthesis is impossible due to the general serious condition of the wounded in severe trauma or due to developed systemic

Rice. 23.11. Radiographs of modern methods of internal osteosynthesis of fractures

complications. Then the least invasive osteosynthesis of fractures with external fixation devices is performed as an element multi-stage surgical tactics (clause 23.1.5)

Non-gunshot injuries of large joints divided into closed and open (penetrating, non-penetrating). According to the type of soft tissue damage, bruises and damage to the internal structures of the joints (with hemarthrosis, without hemarthrosis) are distinguished.

According to the nature of damage to the articular surface, similarly to a gunshot injury, there are three groups of open injuries of the joints: without damage to the articular surfaces(only joint puncture is performed for hemarthrosis), limited damage(arthrotomy is performed, surgical treatment of the wound of the joint) and extensive damage(resection of the articular surfaces is performed). The operation on the joint ends with the imposition of a compression-distraction apparatus.

23.1.4. Amputation of limbs in combat trauma

Limb amputations are carried out according to primary and secondary indications. Primary indications to amputation are detachment (incomplete detachment) or destruction of the limb with wounds and injuries, charring with burns. Secondary readings to amputation occur with the development of severe complications: necrosis of the limb (gangrene) as a result of damage to the main arteries, prolonged compression, purulent-necrotic or anaerobic infection; deep burns or frostbite.

In case of gunshot wounds and open injuries, accompanied by detachment or destruction of the limb with continued bleeding from the stump, despite the tourniquet, amputation is a component of anti-shock care and is performed urgently in parallel with intensive care activities.

In MVR with limb avulsion, surgical tactics have significant differences. . Since the avulsion of the limb during MVR is accompanied by twisting and thrombosis of the great vessels, burns and coagulation of the tissues of the stump, bleeding is usually reliably stopped with a tourniquet. In addition, MVR in most cases have a combined character, and the cause of the severity of the condition of the wounded is not only the separation (destruction) of the limb, but also distant intracavitary injuries with ongoing bleeding, bruises of the heart, lungs, and brain. Therefore, amputation of the damaged segment

limbs during MVR is carried out in the second place (according to urgent indications ) and only after stabilization of vital functions and emergency operations on other areas of the body.

Technical and limb amputation for primary indications can be made either within intact tissues by the standard methods described in the manuals for operative surgery, or "by the type of PHO" .

The indications for amputation "by the type of PHO" are.

1. Saving the life of the wounded in an extremely serious unstable condition - with continued bleeding from the stump (during separation) or from the destroyed limb, despite the applied tourniquet. Amputation is performed in an atypical way, as quickly and atraumatically as possible, cutting off only necrotic tissues in order to stop bleeding from the stump and remove the tourniquet.

2. Attempt to save a large joint limbs with high detachments of the lower leg or forearm, or an attempt to maintain the longest possible stump with high detachments of the thigh or shoulder (to provide more functionally beneficial limb prosthetics). Amputation "by the type of PXO" in these wounded is performed atypically (often even without cutting out skin flaps) and as distally as possible. The intervention technique consists in excision of areas of primary necrosis on the stump, ligation of the main vessels, processing of the nerve trunks and filing the bone at the chosen level of limb preservation. It should be noted that, as a rule, it is impossible to perform amputation “according to the PXO type” with MVR due to the extensiveness and greater extent of damage to the tissues of the stump.

In the case of an amputation operation “by the type of PXO”, in the future, for the formation of a stump, as a rule, reconstructive reamputation of the limb is necessary.

Regardless of the amputation technique for combat trauma, it is mandatory fasciotomy with decompression of all limb stump cases. The stump wound is not sutured(bandages with sorbents, water-soluble ointments are used). Immobilization of the stump is carried out by a U-shaped ladder splint with immobilization of the proximal joint. Optimal is immobilization using two rings of the Ilizarov apparatus with the closure of the adjacent joint. With a favorable course, the stump is closed with a delayed primary suture.

Amputations of limbs performed according to secondary indications,

have their own characteristics. They can be carried out against the background of a serious condition of the wounded, due to intoxication. In these cases, amputations are performed by guillotine(to reduce the duration of the operation) within healthy tissues, with the opening of streaks, fasciotomy in all fascial cases. Mandatory conditions for successful treatment are adequate drainage of a wide-open wound of the stump, good immobilization, local and general use of antibiotics.

23.1.5. Tactics of programmed multi-stage surgical treatment (“orthopaedic damage control”) for severe wounds and injuries with fractures of the long bones of the extremities

The tactics of treating fractures of long tubular bones in severe concomitant wounds and injuries is still the subject of controversy. If, in isolated fractures, the use of expectant tactics with subsequent osteosynthesis in a delayed order is justified by the best final results of treatment, then in combined injuries and injuries, unfixed fractures of long bones are sources of excessive afferent impulses, foci of endotoxicosis and lead to immobilization of the wounded in the supine position. The risk of such terrible complications of a traumatic disease as fat embolism syndrome, thromboembolism of various localization, hypostatic pneumonia, respiratory distress syndrome increases, which significantly increases mortality. In addition, early fixation of gunshot fractures reduces the risk of developing AI.

Domestic and foreign authors in recent years are unanimous in their opinion that the best way to prevent complications in severe injuries is early fixation of fractures of long tubular bones. At the same time, although surgical stabilization of fractures eliminates foci of endotoxemia, eliminates excessive afferent impulses, ensures the mobility of the wounded, prevents the development of AI, but, on the other hand, prolonged and traumatic fixation of fractures of long bones can worsen the already decompensated condition of the wounded.

Thus, the timing of surgical fixation of fractures of long bones in severe injuries should be determined by two provisions.

1. The sooner the better.

2. As soon as the general condition of the casualty permits. All of the above dictates the need to create a system for the treatment of fractures of long bones in severe wounds and traumas, based on the idea of the earliest possible minimally invasive osteosynthesis. This system was named tactics of programmed multi-stage surgical treatment, which has been widely used in the clinic of military field surgery since 1992. In foreign sources, this tactic is called orthopedic damage control. Its essence is to divide the treatment of fractures into three stages.

On the I stage, during the first 12 hours from the moment of injury, after performing all urgent surgical interventions, relative stabilization of the condition (the severity of the condition on the scale of the IPH-SP - no more than 30 points, SBP - at least 90 mm Hg), is minimally traumatic extrafocal osteosynthesis fractures using the KST-1 apparatus or the module of the Ilizarov apparatus. Osteosynthesis is performed with indicative reduction fragments along the axis of the limb, i.e. the task of accurate reposition of fractures at this stage of treatment is not set. When using the Ilizarov apparatus, fixation is carried out with needles inserted only in the outer rings of the apparatus, which can significantly reduce the duration and trauma of the surgical intervention.

On the II stage a complex of intensive care measures aimed at stabilization the condition of the wounded and their preparation for subsequent surgical intervention. After the condition of the wounded person has stabilized, when the severity index on the WHC-SS scale decreases to 45 points or less, the wounded person is ready for next step treatment.

On the Stage III (after 8-10 days) remounting or dismantling of devices, precise reposition of fractures and their final fixation by various methods is performed.

23.1.6. Assistance to the wounded in the limbs during the stages of medical evacuation

First aid wounded in the extremity includes a temporary stop of external bleeding, the application of an aseptic dressing with the help of PPI, anesthesia from a syringe tube (1 ml of a 2% solution of promedol), transport immobilization with improvised means and the use of an antibiotic tablet (doxycycline).

First aid is carried out by a paramedic, who controls the correctness of the previously carried out activities and eliminates the noted shortcomings. In a state of shock, jet intravenous injection of plasma substitutes is being established for the wounded, cardiac and vascular analeptics are administered.

First aid. in armed conflict first medical aid is considered as pre-evacuation preparation for aeromedical evacuation of the seriously wounded directly to the 1st echelon MVG to provide early specialized surgical care. In a large scale war after providing first aid, all the wounded are evacuated to the omedb (omedo).

Among the wounded in the limbs, the following sorting groups stand out.

1. In need of urgent first aid measures. This group includes the wounded with bleeding, severe shock, with tourniquets, with detachment or destruction of a limb - they are sent to the dressing room in the first place.

2. Those in need of first aid measures in the dressing room- in order. These include the wounded with fractures of long bones without shock, with extensive damage to soft tissues.

3. Subject to further evacuation after the provision of medical care at the sorting yard. This group includes all other wounded in limbs without lightly wounded. According to indications, bandages soaked with blood are bandaged, analgesics, antibiotics, tetanus toxoid are administered, transport immobilization is carried out or improved.

4. lightly wounded(see paragraphs 23.1.7).

Among the measures to prevent and combat traumatic shock with injuries of the limbs in the MPP (medr), the main ones are: jet intravenous administration of plasma-substituting solutions, pain relief by performing novocaine blockades, the imposition of transport tires.

Novocaine blockades carried out in the dressing room. For gunshot wounds and open bone fractures, the method of choice is conduction and sheath blockades, carried out within healthy tissues proximal to the injury site. With closed fractures of the bones of the extremities, the most rational way of anesthesia is the introduction of novocaine into the hematoma (for the technique of performing blockades, see Chapter 6).

Improvised means of transport immobilization, if they are ineffective, are replaced with standard ones (set B-2), especially in case of hip fractures, injuries of the hip and knee joints.

Transport immobilization carried out according to the following indications: bone fractures; damage to the joints, main vessels and nerves; extensive damage to soft tissues; SDS; extensive burns and frostbite.

Transport immobilization rules.

1. Immobilization is carried out as soon as possible after the injury.

2. Before splinting, anesthesia is performed (administration of analgesics, novocaine blockades).

3. At least two adjacent joints adjacent to the damaged segment of the limb are immobilized (three joints are immobilized in case of hip and shoulder fractures).

4. In case of gross deformation of the limb as a result of bone fractures - to prevent compression of the main vessels and nerves - the limb is given the correct position.

5. Fixation of the injured limb is carried out in the middle physiological position (at which the balance of the flexor and extensor muscles is achieved). This ensures minimal mobility of bone fragments, and the immobilized limb segments are in a comfortable position for the wounded.

6. It is obligatory to protect bone protrusions from injury with a splint: splints must be superimposed on uniforms and shoes. Additionally, cotton-gauze pads are used.

7. When a tourniquet is applied, the bandaging of the tire is carried out in such a way as to leave the tourniquet visible and accessible for additional tightening or relaxation.

8. In the cold season, the limbs after immobilization must be additionally insulated.

For immobilization of the upper limb ladder and plywood tires, scarves are used. In case of damage to the shoulder joint, humerus and elbow joint, a ladder splint is used, which is applied from the fingertips to the opposite shoulder joint. The injured upper limb is brought to the body, in the armpit - a cotton-gauze roller, the elbow joint is bent at an angle of 90?, the forearm is in the middle position

between supination and pronation, the hand is in the position of dorsal flexion, which is achieved with the help of a cotton-gauze roller inserted into the wounded man's hand. The ends of the ladder bus are tied together, and the upper limb is additionally fixed with a scarf (Fig. 23.12).

The injured forearm and wrist joint are immobilized with a ladder splint from the fingertips to the upper third of the shoulder. If the hand is damaged, a plywood splint is used up to the elbow joint. In these cases, the upper limb is hung on a bandage or belt.

Transport immobilization of the lower limb carried out with the help of ladder, plywood tires or Dieterichs tires. In case of damage hip joint, femur and knee joint, a Dieterichs tire is used (Fig. 23.13) or 4 ladder tires: one along the back surface from the fingers to the middle of the back, the other along the front surface from the ankle

joint to the navel, one more along the outer surface and the last - along

internal.

The tire, which is located on the rear surface, is modeled

by bending it in the ankle joint at an angle of 90?, in

area of the knee joint - 160?.

The technique of immobilization with a splint M.M. Diterichs.

1. Adjustment is made along the length of the outer and inner branches of the splint (the outer branch should rest against the axillary fossa, the inner one - against the crotch of the wounded).

Rice. 23.12. Transport immobilization in case of fracture of the shoulder with a ladder splint

Rice. 23.13. Imposition of the Dieterichs bus (explanations in the text)

2. The “sole” of the tire is bandaged to the foot (with shoes on or with a cotton-gauze pad on the back surface).

3. Branches of the tire are passed through the metal brackets of the sole and applied to the limb. This position is fixed with wide fabric braids attached to the branches (one of the ribbons is necessarily held around the shoulder girdle on the opposite side of the wounded torso).

4. A twist is being prepared, which is passed through the sole and a slot in the protrusion of the outer jaw (Fig. 23.14).

5. Careful traction is made for the distal part of the limb, which ends with tightening the twist and fixing it.

6. Bone protrusions (areas of the greater trochanter, condyles of the knee joint, ankles) are additionally protected with cotton-gauze pads.

7. The Dieterikhs bus is strengthened with two ladder tires: along the back surface (with modeling in the knee joint area) and around the pelvis at the level of the hip joints, and then bandaged to the limb.

In case of damage to the lower leg and ankle joint for immobilization, three ladder or ladder and two plywood splints are used, located from the fingertips to the upper third of the thigh along the back

Rice. 23.14. The method of traction when applying the Dieterichs bus

Rice. 23.15. Transport immobilization of the lower limb with ladder splints in case of fracture of the leg bones

surfaces (stair rail), outer and inner surfaces (plywood tires) of the lower limb (Fig. 23.15).

Immobilization of the injured foot carried out by two ladder tires, one of which is located on the back surface from the fingers to the knee joint, the second - on the outer and inner surfaces after the U-shaped bend.

When providing first aid in the dressing room, cutting off the distal portion of the limb, hanging on a small skin or musculoskeletal flap and completely lost its viability . This operation is performed in order to reduce trauma to the limb during further evacuation. A prerequisite is good anesthesia: intramuscular injection of promedol, conduction novocaine blockade and local infiltration anesthesia of the transected flap.

To prevent AI for the wounded with gunshot and open fractures, extensive soft tissue wounds, paravulnar administration of antibiotics (penicillin 1 million units). All the wounded and affected are given tetanus prophylaxis - injected subcutaneously tetanus toxoid (0.5-1.0 ml).

Qualified surgical assistance.With a well-established aeromedical evacuation in armed conflict it is advisable to deliver all the wounded in the limb directly to the stage of providing SHP,

bypassing omedb (omedo). In such conditions, the stage of providing qualified medical care is used for its intended purpose only in case of violation of evacuation by air. When delivering the wounded in the limbs to the omedb (omedo SpN), they are pre-evacuation preparation in the scope of first medical aid.

In conditions large-scale war Qualified surgical care is provided in volumes - from urgent to complete.

When sorting the wounded in the limb, the following groups are distinguished.

1. Needing emergency surgery(continued external bleeding; wounded with applied tourniquets; detachments and destruction of limbs with bleeding despite the applied tourniquet. They are sent to the dressing room for the seriously wounded in the first place. The wounded who need complex operations (high amputation or disarticulation of the thigh, damage to the main vessels), are sent to the operating room.

2. Subject to surgical treatment for urgent indications(wounded with uncompensated ischemia due to damage to blood vessels; anaerobic infection; ischemic necrosis of the extremities; wounds of the extremities with significant damage to soft tissues, including gunshot fractures of long bones and injuries of large joints; wounds contaminated with poisonous substances and RV, heavily contaminated earth; severe concomitant combat injury with multiple fractures of long bones). These wounded are sent to the dressing room for the seriously wounded on a first-come, first-served basis. The wounded with an anaerobic infection are immediately sent to the "anaerobic" tent.

3. Subject to further evacuation after providing the necessary medical care in the conditions of the sorting and evacuation department. According to the indications, they are re-introduced penicillin, in case of pain - promedol, dressings soaked with blood are bandaged, and transport immobilization improves. Dieterikhs tires are reinforced with plaster rings. Then the wounded are sent to the evacuation tents.

4. lightly wounded(see paragraphs 23.1.7).

In the case of gunshot fractures of long bones performed in the dressing room of the PHO (in the presence of urgent or urgent indications for intervention), the operation is completed with medical and transport immobilization using KST-1 devices.

wounded in the limb in armed conflict turns out to be in the MVG of the 1st echelon, where (during the initial delivery of the wounded) medical sorting into the above groups is carried out, urgent and urgent, and then delayed operations are carried out. However, these operations are carried out by specialists in an exhaustive manner, and in the treatment of the wounded, new effective technologies are used (external osteosynthesis of fractures, reconstruction of blood vessels, etc.), which significantly improves the outcome of injuries. After 2-3 days, the wounded are evacuated for aftercare to medical institutions of the 2nd-3rd echelons.

In a large scale war specialized surgical care for the wounded in the limb is provided in several hospitals of the GB. The wounded with fractures of long bones and injuries of large joints are treated in the VPTRG; with detachments, destructions or after amputations of limbs, with severe injuries of the hand and foot, with extensive injuries of soft tissues - in the VPHG; lightly wounded - in VPGLR.

Aftercare of the wounded in the limbs with bone fractures, given the long periods of immobilization and the need for repeated interventions, is carried out in the TGZ.

23.1.7. Lightly wounded and their treatment at the stages of medical evacuation

lightly wounded constitute a special category of wounded military personnel, distinguished on the basis of the possibility of a quick cure and the ability to return to duty.

The importance of the lightly wounded in replenishing manpower during combat operations is paramount. As you know, during the Great Patriotic War, daily a division of fired soldiers was returning, mostly from among the lightly wounded.

Definition of the concept of "lightly wounded". These include the injured:

retained the ability to move independently and self-service;

who do not have penetrating wounds of the cavities (skull, chest, abdomen, eyeball and large joints), fractures of long bones, damage to the main vessels and nerve trunks, extensive soft tissue damage, superficial burns of more than 10% of the body surface, penetrating radiation damage of more than 1 .5 Gy; treatment can be completed within 2 months; upon completion of treatment will be fit for military service. In the structure of combat surgical trauma, the lightly wounded make up 60-70%. Among them, localization is dominated by damage to the limbs (80%), soft tissue injuries of the head account for up to 10%, other injuries - 10%.

With the introduction into the practice of military field surgery of methods for an objective assessment of the severity of injuries (Humanenko E.K. et al., 1997), it became possible to differentiate the structure of the lightly wounded. Determined that the category of lightly wounded includes not only the wounded with minor injuries (0.05-0.4 points on the VPKh-P scale), but also the wounded with moderate injuries (0.5-0.9 points on the VPKh-P scale). Thus, “lightly wounded” is not a nosological, but a medical-tactical concept, orienting military doctors to provide full-fledged, comprehensive medical care to a special group of the wounded, the essence of which is that they are able to move independently, serve themselves and are promising for a quick return to duty. For everything else, it's a very heterogeneous group both in terms of localization and severity of injuries, and, as a result, in need for various types medical care. For some “lightly wounded” (with minor injuries), the efforts of military level medicine are enough, for others (with moderate injuries), specialized hospitals with the most modern equipment and highly qualified doctors are needed.

Organization of assistance to the lightly wounded at the stages of medical evacuation in a large-scale war provides for the earliest possible release of the flow of lightly wounded; the desire to provide early specialized surgical care to the lightly injured, which ensures the best functional results of treatment; medical and social rehabilitation from the first days of treatment.

First aid and first aid lightly wounded is according to the usual principles. The use of a syringe tube with promedol from AI for minor injuries is impractical, because due to the general effect of a narcotic analgesic, a lightly wounded person will have to be evacuated on a stretcher.

First aid. At the sorting post MPP (omedr) stands out group of "walking" wounded assisted in the third turn. While waiting for medical assistance, the lightly wounded, so that they do not interfere with the work of the staff, should be placed separately from the stretchers, provided with hot tea and sandwiches. Among these wounded are the following: groups: those who need only outpatient treatment, who, with the necessary recommendations, return to the unit under the supervision of the battalion paramedic; with superficial skin abrasions, soft tissue bruises with limited subcutaneous hematomas; they can be detained in the MPP (medr) for treatment for a period no more than 5 days; the rest of the lightly wounded - medical assistance is provided to them in a sorting tent. The introduction of non-narcotic analgesics, antibiotics, tetanus toxoid, the application and correction of dressings, transport immobilization with standard equipment is carried out. If possible, the evacuation of these wounded is carried out directly to the VPGLR using general-purpose transport, in a sitting position, without accompanying them. . In omedb (omedo) lightly wounded are allocated in a separate stream , for which special functional units are being deployed - sorting, dressing and evacuation for the lightly wounded.

At the JV, a medical instructor singles out a group of "walking" wounded, which is immediately sent to the sorting tent for the lightly wounded. During the medical sorting, the following groups of the wounded are distinguished:

"walking" wounded who are not classified as lightly wounded (with fractures of the bones of the forearm, with signs of damage to the main vessels or nerves, penetrating wounds, etc.); they are sent to functional units for the seriously wounded; lightly wounded, in need of qualified surgical care (stopping external bleeding, removal of superficially located foreign bodies of the eye, reduction of dislocations, etc.); after providing medical assistance in the dressing room for the lightly wounded, they are sent to the evacuation room for the lightly wounded;

Lightly wounded with terms of treatment up to 10 days , which remain in the recovery team omedb (omedo) with subsequent return to the unit; This group includes the wounded who have superficial shrapnel wounds and other minor wounds that are not subject to surgical treatment; bruises of soft tissues without pronounced subcutaneous hematomas; damage to the ligamentous apparatus that does not prevent active movements; superficial burns of the trunk and limbs (up to 5% of the body area) and frostbite of the 1st degree of functionally inactive areas; slight damage to the organ of vision (superficial non-penetrating wounds of the eyes). lightly wounded with a treatment period of more than 10 days - after providing first aid in a sorting tent, they are sent to the evacuation room, then to the VPGLR. Triage of the lightly wounded carried out on an outpatient basis. To the doctor sitting at the table, the orderlies take turns bringing the wounded. The doctor dictates the diagnosis to the registrar, the nurse injects an antibiotic, tetanus toxoid, bandages the bandages that have gone astray.

The treatment of the lightly wounded in the team of convalescent omedb (omedo) is carried out at the hospital department with accommodation in the barracks. It is planned to provide a full range of qualified surgical care, medical and professional rehabilitation of the lightly wounded. To this end, treatment is combined with combat and physical training, occupational therapy (as freelance orderlies).

Specialized surgical care turns out to be in the VPGLR, which are intended for the treatment of the lightly wounded and lightly ill until their full recovery, rehabilitation and return to duty.

The system of treating the lightly wounded in local wars and armed conflicts differs significantly from traditional approaches based on the experience of large-scale wars.

The possibilities of the stages of providing qualified surgical care for the treatment of lightly wounded are very limited, primarily for tactical reasons. Medical units designed to assist large flows of the wounded cannot be overloaded with the wounded who have retained the ability to self-service. This requires the distraction of medical staff from providing assistance to the wounded who need it for health reasons. Therefore, the optimal amount of medical care for the lightly wounded delivered to the omedb (omedo Special Forces) will be Events

first aid. Detaining the lightly wounded in the military level in the conditions of local wars and armed conflicts is inappropriate.

The flow of lightly wounded is formed in the MVG of the 1st echelon , where special storage departments with their own medical staff are deployed for applicants. The purpose of these, in fact, sorting and evacuation departments, firstly, is to maximize the unloading of hospital personnel to assist the flow of the seriously wounded, and secondly, to prevent the approach to the lightly wounded "according to the residual principle" with the provision of medical care to them last. In these departments receive SHP lightly wounded with minor wounds, whose share can be up to 40-50% of the total incoming flow of the wounded. The treatment time for the wounded with light wounds (mainly soft tissue injuries) takes up to 20 days, so the problem is the periodically occurring overload of the 1st echelon MVG with lightly wounded, as a result of which further evacuation of those lightly wounded who are able to quickly return to duty is inevitable. A possible way out would be the creation of rehabilitation centers for the lightly wounded and lightly ill, the need for which became apparent during counter-terrorist operations in the North Caucasus. Those convalescent servicemen who initially did not belong to the category of lightly wounded, but the terms of their treatment and rehabilitation do not exceed 20-30 days, can also be transferred to these centers.

In the MVG of the 1st echelon (in the process of medical triage according to the scale for assessing the severity of an injury of the VPKh-P), lightly wounded with moderate injuries(with limited wounds of the hand, foot, bone fractures, non-penetrating eye wounds, etc. - up to 20% of the total number of wounded), requiring highly specialized SHP measures. These lightly wounded are evacuated without delay to 2nd echelon hospitals with a special organizational and staffing structure (VPGLR) deployed on the territory of a warring military district. The terms of treatment of this group of lightly wounded, as a rule, do not exceed 40-60 days.

23.2. DAMAGE TO THE MAIN VESSELS OF THE LIMB

The frequency of wounds of blood vessels in the Great Patriotic War 1941-1945. did not exceed 1% in the overall structure of injuries. In modern local wars and armed conflicts, combat injuries of the main blood vessels occur in 6-9% of the wounded. The proportion of damage to the vessels of the extremities in the overall structure of vascular injury is 90%.

Due to the late evacuation of the wounded and the high incidence of wound infection in the world wars, damaged arteries were ligated in most cases with a limb amputation rate of 49.6% ( B.V. Petrovsky, M. Debecchi). In the conditions of local wars, favorable conditions are formed for the restoration of blood vessels, which made it possible to reduce the level of postoperative amputations to 13.5% during the Vietnam War (N. Rich), 18.4% in Afghanistan and 15.7% in the North Caucasus ( THEM. Samokhvalov).

23.2.1. Classification, clinic and diagnosis of damage to blood vessels

Differ firearms (bullet, shrapnel and MVR) and non-gunshot injuries of blood vessels (non-gunshot wounds and closed injuries). With gunshot wounds of blood vessels in half of the cases, simultaneous damage to the arteries and veins occurs.

Depending on the the nature of damage to the vascular wall the destruction of a section (defect) of the vessel, a complete and incomplete break, a lateral wound (of one wall or through to half the circumference of the vessel), contusion and compression are distinguished (Fig. 23.16).

Vessel contusion occurs with an indirect mechanism of damage (closed trauma, lateral impact of the RS) and manifests itself in the form of traumatic spasm and subadventitial rupture. Compression of the vessel, as a rule, is caused by bone fragments or intense interstitial hematoma. All forms of injury and compression of the vessel, in turn, can lead to complete or incomplete thrombosis of its lumen.

Injuries to blood vessels are accompanied by a number of general and local disorders of body functions.

General violations conditioned acute blood loss, the signs of which are weakness, dry mouth, dizziness, pallor, weak and frequent pulse, decreased blood pressure. Bleeding at the time of examination of the wounded by a doctor, as a rule, has already been stopped in one way or another or has stopped on its own. The severity of blood loss is determined by the intensity of bleeding, as well as the nature of the injury. Blood loss is less significant with complete interruptions of the arteries (the ends of the vessel contract, causing a spontaneous stop of bleeding), with narrow holes in the wound channels in the surrounding tissues (the outflowing blood compresses the vessel due to the formation of a tense hematoma).

to local symptoms. vascular injuries include: localization of the wound channel in the projection of the main vessel; the presence of a tense sub-fascial hematoma in the circumference of the wound; hematoma pulsation and listening to pathological noises over it during auscultation;

Rice. 23.16. Types of damage to the vascular wall: 1 - destruction of the site (defect) of the vessel; 2 - complete break; 3 - incomplete break; 4 - lateral wound (one wall); 5 - lateral through wound; 6 - bruise (subadventional razrav); 7 - bruise (separation of the intimal area); 8 - compression; 9 - traumatic spasm

Signs of acute ischemia (pallor and coldness of the skin of the distal parts of the injured limb, weakening or absence of peripheral pulsation, impaired sensitivity and mobility of the limb).

Taken together, the listed general and local signs are found in 85% of the wounded with vascular injury, while the diagnosis of vascular injury does not cause difficulties. At the same time, in the remaining 15% of the wounded, vascular damage can be easily seen due to the absence of external bleeding (in the case of a closed vascular injury) and signs of acute ischemia (with good collateral blood flow), in the presence of severe concomitant injuries, etc.

The diagnosis of vascular injury can be clarified using ultrasound dopplerography and radiopaque angiography. In unclear cases, surgical revision of the area of the alleged vessel injury.

If a “fresh” injury to the great vessels remains undiagnosed, long-term consequences of vascular injury as pulsating hematoma, around which a capsule gradually forms, with the transformation of a hematoma into traumatic (false) aneurysm. With close contact between the injury site, the artery and vein are formed traumatic arterio-venous fistulas.

Primary traumatic violation of the main blood flow, ligation or unsuccessful restoration of the vessel may be complicated by the development ischemic necrosis limbs or are accompanied by the formation chronic arterial or venous insufficiency.

23.2.2. Principles of treatment of vascular injuries of the extremities

When assisting the wounded with vascular injuries, the following main tasks are consistently solved:

Saving the life of the wounded in case of bleeding and blood loss;

Preservation of the viability of the limb;

Treatment of complications and consequences of vascular injuries. Timely and correctly performed temporary stop of bleeding, together with the rapid replenishment of blood loss, is the basis for saving the life of the wounded with vascular injury. Directions for the provision of medical care and treatment of the wounded with acute blood loss are discussed in Ch. 7.

The possibility of saving a limb in case of vascular damage is determined by the depth of arterial ischemia. Classification of acute ischemia, prognosis and therapeutic tactics in case of injury to the arteries of the extremities according to V.A. Kornilov are given in table. 23.2.

The presence of sufficient collateral blood flow in the limb with a damaged main artery is manifested preservation of active movements, tactile and pain sensitivity(compensated ischemia ). With compensated ischemia, there is no threat of ischemic necrosis. If the operation is completed by ligation of the damaged artery, chronic ischemia may develop, which can be eliminated by reconstructive surgery in the long term.

In a situation where the level of preserved collateral blood flow is not enough to ensure the vital activity of tissues, a picture develops already 30-40 minutes after the injury. uncompensated ischemia (loss of active movements, tactile and pain sensitivity). If the blood flow through the main artery is not restored, then after 6-8 hours ischemic contracture of the striated muscles of the limb will inevitably develop ( irreversible ischemia ). Attempt to save the limb by repairing the artery

Table 23.2. Classification of limb ischemia in arterial injury, prediction of its outcomes and treatment tactics

Degree of ischemia	Main clinical signs	Forecast	Treatment
Compensated (due to collates)	Active movements, tactile and pain sensitivity are preserved	No threat of gangrene	There are no indications for urgent restoration of the artery; vessel ligation is safe
Uncompensated	Loss of active movements, tactile and pain sensitivity	The limb dies within the next 6-8 hours	Urgent artery repair indicated
irreversible	Passive movements are impossible - acute ischemic contracture of the limb	Impossible to save a limb	Amputation shown; restoration of the artery can lead to the death of the wounded from intoxication

with irreversible ischemia, it leads to deadly endotoxicosis due to the leaching of potassium ions, myoglobin, polypeptides, aggressive free radicals, etc. from long-term ischemic muscles ( ischemia-reperfusion phenomenon).

Most often, irreversible ischemia due to "anatomical insufficiency" of existing collaterals develops with injuries to the popliteal artery (up to 80%), the common iliac artery (50%), the femoral artery in the lower third (30%), and the subclavian artery in the initial section (25%). Wounds of other arteries proceed more favorably, although their damage with extensive destruction of soft tissues, accompanied by a violation of collateral blood flow, can also lead to limb gangrene.

Operations for vascular injuries it is advisable to carry out under general anesthesia. Given the possibility of intraoperative bleeding, it is necessary to have a stock of preserved blood prepared for transfusion. Angiotraumatological operations are performed in three stages. First, the zone of vascular damage is identified and the temporary hemostasis atraumatic clamps. Then, taking into account the nature of damage to the vascular wall, the degree of arterial ischemia and other factors, final hemostasis by repair or ligation of the vessel (or temporary intravascular prosthesis). The final stage of the operation is PHO ran(if there are relevant indications).

Reconstructive interventions on damaged vessels are not feasible in all medical institutions, which is explained by their complexity and the lack of surgeons trained in angio-rheumatology. In addition, special instruments and atraumatic suture material are required for vascular operations.

Technical repair of damaged main artery is carried out by applying a lateral or circular suture, performing autovenous plasty, in rare cases, by sewing in an autovenous patch. Side seam it is advisable to apply with transverse wounds that make up no more than half the circumference of the vessel, and with longitudinal wounds no more than 1-1.5 cm long. In other cases, the artery, even with incomplete damage, it is advisable to cross and restore circular seam. In the presence of a vasoconstrictor (ASC-8), a mechanical circular suture can be used.

It is possible to impose a circular vascular suture with defects in the artery wall no more than 2-3 cm long, while it is necessary to additionally mobilize the vessel, bend the limb in the joint. In the case of more extensive defects, autovenous plasty arteries using a segment of the great saphenous vein of an intact lower limb (in this case, the peripheral end of the vein is sutured to the central end of the artery so that the venous valves do not interfere with the blood flow).

According to modern concepts, it is advisable to restore all damaged main arteries. Artery ligation as a method of finally stopping bleeding, it is allowed to be performed only on the wounded with compensated ischemia and in cases where there are no surgeons who know the technique of vascular suture or a complex medical and tactical situation.

In the wounded with uncompensated ischemia limbs, in case of impossibility of the final restoration of the vessel, it is necessary to temporary intravascular grafting of arteries as a method of their two-stage recovery . With compensated ischemia temporary vessel replacement contraindicated due to the threat of worsening blood circulation in case of thrombosis of the prosthesis.

For temporary prosthetics standard vascular prostheses are used (made of foamed polytetrafluoroethylene manufactured by Ecoflon, RF) or improvised (polyvinyl chloride from blood transfusion systems) tubes that are inserted into the lumen of the damaged artery and thus temporarily restores blood flow in the ischemic limb (Fig. 23.17).

Rice. 23.17. The technique of temporary prosthetics of the damaged artery

The use of temporary prosthetics of the arteries involves the urgent evacuation of the wounded to a specialized medical institution or a call to the wounded specialist-angiosurgeon for the final restoration of the vessel.

Indication for mandatory restoration damaged main veins(imposition of a lateral or circular suture) are signs of venous hypertension, which is more common with injuries of large veins of the lower extremities - iliac, femoral.

During operations against the background of threatening ischemia and in a number of other cases of injuries of blood vessels, wide subcutaneous incision all fascial sheaths of the ischemic limb segment using long scissors (prophylactic fasciotomy). Skin incisions are sutured with rare skin sutures to eliminate the gate of infection. Prophylactic fasciotomy when restoring the arteries of the limbs, it is performed according to the following indications: uncompensated ischemia of the limb; prolonged (1.5-2 hours) stay on the limb of a hemostatic tourniquet; concomitant injury of the main vein; extensive soft tissue damage and significant limb edema; the serious condition of the wounded with a previous long period of arterial hypotension. The most commonly used fasciotomy of the lower leg due to the structural features of the bone-fascial cases.

Evacuation of the wounded after vascular surgery possible 6-12 hours after the intervention, subject to stabilization of the general condition and replenishment of blood loss. From the 3rd to the 10th day, evacuation by land transport is dangerous due to the possibility of developing secondary bleeding. Before evacuation, all the wounded, regardless of the nature of the intervention on the vessels of the limbs, are transport immobilized and provisional tourniquets are applied (the presence of an accompanying person is mandatory).

23.2.3. Assistance during the stages of medical evacuation

First aid. Temporary stop of external bleeding begins with finger pressing of the bleeding vessel in the wound or throughout in typical places (Fig. 23.18, 23.19). Then applied to the bleeding wound pressure bandage. At the same time, PPI cotton-gauze pads are applied to a bleeding wound in a folded state in the form of a pelote. Over the wound is tightly bandaged, crossing the bandage (Fig. 23.20).

Rice. 23.18. Typical pressing points of the main arteries: 1 - superficial temporal artery; 2 - facial artery; 3 - common carotid artery; 4 - subclavian artery; 5 - axillary artery; 6 - brachial artery; 7 - ulnar artery; 8 - radial artery; 9 - common femoral artery; 10 - superficial femoral artery; 11 - posterior tibial artery; 12 - dorsal artery of the foot

Rice. 23.19. Technique of digital pressure of the artery

Rice. 23.20. Pressure bandage technique

If bleeding continues, apply tourniquet(an impromptu tourniquet-twist or a service rubber band tourniquet).

Rules for applying a hemostatic tourniquet:

A tourniquet is applied above the wound and as close to it as possible to limit the area of bleeding of the limb;

A tourniquet is applied to clothing or a soft lining to prevent skin damage;

Stopping the bleeding is achieved by the first round of the tourniquet, the subsequent ones only ensure the maintenance of the achieved level of arterial compression (Fig. 23.21 a);

Rice. 23.21. Temporary control of external bleeding with a rubber band (explanations in the text)

Compression of the limb with a tourniquet should not be excessive, otherwise additional tissue damage is possible,

The tourniquet must be fixed on the limb by using the latches on it or a chain with a hook, or tied into two knots (Fig. 23.21 b);

When the wound is located in the upper third of the limb, the tourniquet is applied to the root of the limb in the form of a “figure eight” with an additional pad and fixing the ends around the body (Fig. 23.22);

After applying the tourniquet, it is mandatory to use anesthesia (1 ml of a 2% solution of promedol from a syringe tube), transport immobilization;

The tourniquet should be clearly visible from the side, it should not be covered with a bandage or immobilizing splint (it is recommended to write on the face of the wounded " HARNESS!»);

It is necessary to indicate the time of applying the tourniquet in the accompanying documents: the period of safe stay of the tourniquet on the limb is 2 hours (in winter, due to additional vasospasm - 1.5 hours);

The wounded with a tourniquet must be evacuated as a matter of urgency (preferably by air transport).

Rice. 23.22. Scheme of the technique of applying a tourniquet to the root of the limb

First aid consists in replacing tissue-traumatic hemostatic tourniquets from improvised means with standard ones. A tourniquet applied too high is shifted closer to the wound. Blood-soaked bandages are additionally bandaged. With signs of massive blood loss, a jet intravenous injection of crystalloid solutions (0.9% sodium chloride - 400 ml, 5% glucose solution, etc.) begins without fail, which continues during further evacuation.

First aid. Selective sorting highlights the wounded with continued bleeding from wounds; with bandages soaked in blood, and with tourniquets applied. They are sent to the dressing room primarily to stop bleeding, control the tourniquet, and continue intravenous infusion of plasma-substituting solutions (with signs of acute blood loss).

In the conditions of the dressing, the following methods are used to temporarily stop external bleeding:

clamping on a bleeding vessel visible in the wound, followed by ligation or stitching; if the flashing of the vessel is difficult, then the clamp is not removed, the jaws of the clamp are firmly tied with a bandage and fixed to the body. The use of this method is realistic for superficial wounds, for injuries of the head and distal extremities. In no case should you try to stop the bleeding blindly in the depth of the wound; applying a pressure bandage from folded napkins 1-2 dressing bags; if the pressure bandage gets wet, another one with an additional pad should be applied over it; tight tamponade of the wound, which is made with gauze swabs, starting from the depth of the wound (from the place of bleeding from the vessel) to the edges; the edges of the wound are pulled together over the tampon with interrupted sutures (Fig. 23.23); in the presence of local hemostatic agents (Gemacept sponge, etc.), they should be injected into the wound along with tampons; tourniquet, which is performed only if it is impossible to stop bleeding in other ways; above the level of the applied tourniquet, local anesthesia is performed (conduction or case anesthesia); the limb is immobilized with standard splints. In the wounded with previously applied tourniquets in the dressing room, the validity and correctness of their use (control of the tourniquet) is controlled. The purpose of harness control is to provide temporary

stop bleeding in less traumatic ways. As you know, half of the tourniquets are applied not according to indications, and in 25% of the remaining cases - the tourniquets are applied with gross errors.

In the wounded with signs of irreversible limb ischemia, tourniquet removal is strictly contraindicated!

Harness control is carried out in the following sequence: after anesthesia, the bandage is removed from the wound, the assistant presses the artery above the tourniquet, then the tourniquet relaxes. In the absence of external bleeding and signs of damage to the main vessels, the tourniquet is removed. In doubtful cases, even if bleeding does not resume after removing the tourniquet, a pressure bandage is applied to the wound, and the tourniquet is left loose on the limb ( provisional tourniquet). When bleeding resumes, you should try to stop it without a tourniquet (ligation of the vessel, pressure bandage, tight tamponade of the wound). If this fails, then the tourniquet is applied again.

Rice. 23.23. The method of tight tamponade of the wound in case of damage to the artery

Before re-tightening the tourniquet, which has already been lying on the limb for a long time, it should be tightened for 10-15 minutes recirculate blood to limbs along collateral vessels with a clamped damaged artery. After this manipulation, the terms for the relatively safe presence of the tourniquet on the limb are extended by 1-1.5 hours (the time of the tourniquet control is noted in the primary medical card).

Re-application of a tourniquet on a limb when providing first aid is a responsible decision, since under conditions of staged treatment, a delay in the evacuation of such a wounded person will inevitably lead to severe disability.

All wounded with temporarily stopped bleeding are subject to evacuation in the first place in the prone position. The wounded with provisional tourniquets are evacuated with escorts.

If it is possible to evacuate by air the wounded with damage to the main vessels, it is advisable to send them directly to the VG, where specialized angiotraumatological care is provided (bypassing the stage of providing qualified medical care).

Qualified medical care. in armed conflict with an established aeromedical evacuation of the wounded from medical companies directly to the MVG of the 1st echelon, when delivering the wounded with damage to blood vessels to the medical hospital (omedo Special Forces) - they pre-evacuation preparation in the scope of first medical aid. Qualified surgical care is provided only for health reasons.

In a large-scale war or in violation of the evacuation of the wounded, in omedb (omedo) during selective sorting, the following groups of the wounded with damage to the vessels of the extremities are distinguished: with unstopped bleeding;

With superimposed tourniquets (with preserved limb viability).

1. Wounded with uncontrolled bleeding and with applied tourniquets are sent first to the dressing room for the seriously wounded (or operating room) and are operated on according to urgent indications. If these wounded have acute massive blood loss, intensive care is carried out during preparation for surgery and in parallel with surgical intervention.

2. Wounded with reliably stopped bleeding (pressure bandage, tight tamponade of the wound) with uncompensated limb ischemia and

wounded with necrotic limbs due to prolonged compression by the tourniquet, they are sent to the operating room (or dressing room) in the second place for operations according to urgent indications.

3. The wounded with compensated ischemia without a history of bleeding, with pulsating hematomas without the threat of bleeding, with ischemic necrosis of the limb that occurred without the application of a tourniquet, advisable after assistance in the sorting and evacuation department evacuate for surgical treatment at the stage of specialized assistance (mandatory with an accompanying tourniquet and provisionally applied tourniquet).

When performing a surgical intervention in a wounded man with damage to the main vessel, the final stop of bleeding is shown with the restoration of the patency of the main vessel side or circular seam(Fig. 23.24).

A contraindication for reconstructive operations is irreversible ischemia (limb amputation is performed). If it is impossible to finally restore the damaged main artery in the wounded with uncompensated ischemia, temporary prosthetics vessel. In the wounded with compensated ischemia, it is possible to perform artery ligation.

In case of significant technical difficulties in stopping profuse bleeding from deep-lying large vessels, a temporary stop of bleeding is acceptable to save the life of the wounded. tight tamponade of the wound. This method of stopping bleeding is dangerous by creating the preconditions for the development of anaerobic infections.

When using temporary arterial prosthesis or tight tamponade of the wound - the wounded after removal from shock, it is necessary urgently evacuate by air transport with an escort to a specialized hospital.

The rest of the wounded with vascular injuries are evacuated after stabilization.

wounded with broken blood vessels in armed conflict turns out to be in the MVG of the 1st echelon, where (during the initial delivery of the wounded) medical sorting into the above groups is carried out, urgent and urgent, and then delayed operations are carried out. However, these operations are performed by specialists in an exhaustive manner and with the use of new effective technologies(serial

Rice. 23.24. Circular suture of a blood vessel according to Carrel: a - the imposition of three sutures-holders; b - twisting seam between stretched holders

angiographic diagnostics, complex vascular reconstructions, endovasal interventions, etc.), which significantly improves the outcomes of injuries. After 2-3 days, the wounded are evacuated for aftercare to medical institutions of the 2nd-3rd echelons.

In a large scale war specialized surgical care for the wounded with damage to blood vessels is provided in general surgical and trauma (with simultaneous fractures of long bones) hospitals, which are reinforced by an angio-surgical group.

To perform operations for traumatic aneurysms, arterio-venous fistulas, as well as to restore bandaged, thrombosed and hemodynamically significant stenotic vessels with the development of chronic arterial and venous insufficiency, the wounded may early dates are evacuated to specialized vascular departments of the TGZ.

23.3. PERIPHERAL NERVE INJURIES

The overall incidence of peripheral nerve damage ranges from 1.5 to 10% among all wounded with combat surgical trauma. Nerve injuries do not lead to life-threatening consequences, but significantly affect the functional outcomes of injuries. According to modern concepts, optimal results in the treatment of peripheral nerve injuries are achieved when they are restored within the first three weeks after injury by a neurosurgeon using an operating microscope and microsurgical instruments under conditions of complete subsidence of inflammation in the wound ( K.A. Grigorovich).

23.3.1. Terminology and classification of peripheral nerve injuries

Differ firearms(bullet, shrapnel wounds, MVR) and non-gunshot injuries(non-gunshot wounds and blunt trauma) of peripheral nerves.

With gunshot and non-gunshot wounds, there may be complete anatomical rupture of the nerve trunk, partial anatomical rupture of the nerve trunk, intratruncal nerve injury. With a complete anatomical break, the continuity of all fibers of the nerve trunk is disrupted. May break if interrupted

a different number of nerve bundles - from a few to the majority. With intra-stem injuries, the epineurium may not be damaged or damaged slightly, but at the same time, conduction along the nerve bundles is disturbed to one degree or another (such injuries are formed due to a side impact during gunshot wounds).

Closed nerve injuries are classified into concussions, bruises, compression, partial and complete interruption of the nerve. They are observed in fractures of bones, bruises and dislocations of the limbs.

Depending on the nature of the nerve damage, a complete or partial break in the conduction of the nerve trunk occurs, accompanied by corresponding movement disorders, disorders of sensitivity and autonomic functions in certain anatomical areas.

23.3.2. Clinic, diagnosis and principles of surgical treatment of peripheral nerve injuries

Violations of motor functions consist in flaccid paralysis of the corresponding muscles. Sensitivity disorders are expressed in the appearance of zones with a complete or partial loss of sensitivity, but along with this, nerve irritation phenomena are possible - hyperesthesia, paresthesia. Autonomic disorders are trophic and vasomotor disorders. Sometimes, when the nerves are damaged, causalgia occurs, which is characterized by excruciating, burning pains in the limbs and a number of trophic disorders on the part of the skin and its appendages - hair, nails.

Diagnostics nerve damage is based on the definition of clinical symptoms and the use of electrodiagnostics.

Shoulder plexus. If the entire brachial plexus is damaged, flaccid atrophic paralysis of the upper limb, anesthesia and areflexia of the limb develop.

Damage to the upper primary bundle(C V -C VI cervical roots) is accompanied by impaired conduction of the musculocutaneous, axillary and partially radial nerves (Erb-Duchenne palsy). In this case, paralysis occurs in the proximal parts of the upper limb with the impossibility of actively lifting the shoulder and bending in the elbow joint, impaired sensitivity along the outer surface of the shoulder and forearm.

Damage to the lower primary bundle(C VII -T hI roots) is accompanied by impaired conduction of the ulnar, internal skin

nerves of the shoulder and forearm and partially the median nerve (Dejerine-Klumpke palsy). This paralysis is characterized by symptoms in the distal limbs with impaired movements in the hand and muscles of the forearm, a disorder of sensitivity on the forearm, hand and fingers.

Radial nerve. It is often damaged when the humerus is fractured in the middle third or when the tourniquet is incorrectly applied. As a result of nerve damage, there is a loss of functions of the muscles - the extensor of the forearm. At the same time, the hand passively hangs down (“hanging” hand), active extension of the hand and the main phalanges of the fingers, as well as supination of the hand are impossible. Impossible extension (abduction) of the thumb(Fig. 23.25, 1). There is a violation of sensitivity on the rear of the forearm, the radial half of the rear of the hand and in the area of the first interdigital space. Sensitivity may not be completely disturbed due to the “overlapping” of the zone of innervation of the radial nerve by neighboring nerves.

median nerve. Nerve damage at the level of the shoulder and upper third of the forearm is characterized by loss of function of the muscles of the flexor surface of the forearm and thumb. In this case, the flexion of the hand is disturbed, pronation is difficult. Impossible opposition and flexion of the thumb(Fig. 23.25, 2). When you try to clench your hand into a fist, the index and middle fingers remain unbent. In the same fingers, sensitivity disorders are noted. Trophic disturbances are observed,

Rice. 23.25. Diagnosis of nerve damage in the upper limb:

1 - damage to the radial nerve;

2 - damage to the median nerve;

3 - damage to the ulnar nerve

especially in the region of the terminal phalanx of the II finger, where trophic ulcers can form. The muscles in the thenar area atrophy, the first finger is in the same plane with the rest, and the hand takes on the appearance of a “monkey paw”.

Ulnar nerve. Damage to the nerve at all levels leads to paralysis of the small muscles of the hand. High nerve damage at the level of the shoulder and upper third of the forearm is accompanied by a dysfunction of the ulnar flexor of the hand and part of the deep flexor of the IV and V fingers. The hand takes the form of a “claw-like” (the main phalanges of the fingers, especially IV and V, are unbent, and the terminal and middle ones are half-bent). Breeding and adduction of fingers are broken. Adduction (flexion) of the thumb is impossible(Fig. 23.25, 3). Sensitivity disorders are most pronounced along the ulnar edge of the hand and in the area of the little finger.

Femoral nerve. If the nerve below the inguinal ligament is damaged, extension of the lower leg is impossible, the knee reflex is lost, and atrophy of the quadriceps femoris muscle is noticeable. Sensitivity disturbances are determined along the anterior-inner surface of the lower leg.

If the nerve is damaged above the inguinal ligament, sensitivity disorders on the anterior surface of the thigh join. With the highest injuries, the impossibility of flexing the hip (bringing it to the stomach) and lifting the body in a supine position is noted.

Sciatic nerve. With high damage to the nerve above the gluteal fold, the function of the muscles on the thigh is disrupted - the impossibility of flexing the lower leg, and the functions of the tibial and peroneal nerve also fall out. At lower nerve damage, the clinical picture is due to symptoms of injury only to the greater and peroneal nerves.

Tibial nerve. If the nerve is damaged at the level of the thigh and upper third of the leg, paralysis of the muscles of the back of the leg and small muscles of the foot occurs, which is manifested by the impossibility of plantar flexion of the foot and fingers. Achilles reflex is lost. The wounded cannot lean on the toe of the foot. A violation of sensitivity is determined along the back surface of the lower leg, on the sole and plantar surfaces of the fingers, on the back of their terminal phalanges. There may be pain in the foot and fingers. The foot is in an extension position: a protruding heel, a deep arch and a "clawed" position of the fingers.

Peroneal nerve. If the nerve is damaged, it is impossible to extend (dorsal flexion) of the foot and fingers, as well as turn the foot outward. Sensory disorders occur on the outer surface of the lower leg and the dorsum of the foot. The foot hangs down ("hanging" foot), slightly turned inside, the fingers are slightly bent. The wounded cannot walk on his heels. The gait becomes “cock-like”: the wounded man raises his leg high and first steps with his toe, then with the outer edge of the foot, and finally with the sole.

The main method of reconstructive surgery for damaged peripheral nerves is an epineural suture - accurate comparison and fixation in contact of the transverse sections of the central and peripheral ends of the nerve (Fig. 23.26).

Rice. 23.26. Epineural nerve suture

The best results are obtained when using perineural suture of the nerve superimposed on separate fascicular groups nerve trunk using an operating microscope, microsurgical instruments and atraumatic suture material.

Reconstructive surgery on the nerves should be performed only if there is no inflammatory changes in the wound.

Varies primary seam nerve superimposed during PST, and delayed seam applied at a later (up to 3 weeks) time. It is necessary to strive to restore the nerves precisely in these terms, before the development of atrophy of the effector apparatus of the innervated segment of the limb.

23.3.3. Assistance during the stages of medical evacuation

First aid and first aid consist in applying an aseptic bandage to the wound with the help of PPI, anesthesia from a syringe tube, transport immobilization, warming the limb in the winter season.

First aid the wounded with signs of damage to the peripheral nerves are in the sorting tent in the order of priority: bandaging of the bandages that have gone astray, transport immobilization with standard equipment, administration of antibiotics and tetanus toxoid are performed.

Qualified medical care limited to first aid measures (if they have not been performed), with the exception of situations where surgical treatment of wounds is indicated.

Since up to 50% of injuries of the nerve trunks are combined with fractures of long bones, and 30% - with damage to the main vessels, the wounded may need to perform PST for the dominant injury. It is not necessary to specifically search for a damaged nerve trunk, but if a nerve injury is found during the operation, then epi-neural suture may be applied. During the operation, one should strive not to cause additional damage to the nerve trunk.

In case of isolated nerve injuries, the wounded after rendering assistance in the sorting and evacuation department are subject to evacuation to the stage of specialized surgical care.

Specialized medical care wounded with damage to peripheral nerves in armed conflict turns out to be in the MVG of the 1st echelon, where (during the initial delivery of the wounded) specialists perform operations using new effective technologies (electrodiagnostics, complex reconstruction of nerves using microsurgical techniques, etc.), which significantly improves the outcome of injuries. After 2-3 days, the wounded are evacuated for aftercare to medical institutions of the 2nd-3rd echelons.

In a large scale war specialized surgical care for the wounded with damage to peripheral nerves is provided by neurosurgeons of specialized military field hospitals - VPNhG or VPTrG . Reconstructive nerve surgeries are performed either during repeated debridement or electively after the wounds have completely healed. At discrepancy

ends of the nerve up to 5 cm superimposed epineural or perineural suture, with a larger diastasis - performed autoplasty(inserted from the superficial cutaneous nerve of the leg). The wounded after the restoration of nerves need a long medical rehabilitation.

Test questions:

1. What is the difference between immobilization in case of fractures of the bones of the extremities in the provision of first aid and first medical aid?

2. What is the advantage of a pressure bandage and tight tamponade of a wound in stopping bleeding over a tourniquet?

3. Describe the traditional and "saving" methods of performing PST of gunshot bone fractures.

4. List the indications for medical transport immobilization.

5. Can submersible (on-osseous and intraosseous) osteosynthesis be used in the treatment of gunshot bone fractures? Justify your answer.

6. In case of injury of what peripheral nerve is it impossible to oppose the thumb to other fingers of the hand?

7. What are the indications for amputation of the limbs "by the type of PHO"?

8. At what degree of acute limb ischemia is tourniquet control prohibited?

9. Can a wounded person with a penetrating wound of the shoulder joint be classified as a lightly wounded person? Justify your answer.

little finger off? 11. Is the tourniquet checked in case of limb avulsions?

The girdle of the upper limbs of a person consists of two pairs of clavicles and shoulder blades, forming the shoulder girdle, and a free upper limb, consisting of the bones of the shoulder, forearm and bones of the hand (wrist, metacarpus and phalanges of the fingers).

Let's look at the most common injuries of the upper limbs, and draw up an algorithm for providing emergency care to the victim.

Usually occurs when falling from a height onto an outstretched arm or as a result of a strong blow to this area.

The result is:

Acute sharp pain, which decreases at rest, but intensifies when trying to move a limb;
Characteristic posture: a person presses a damaged limb bent at the elbow joint to the body;
Sometimes parts of the collarbone can protrude under the skin in the form of a so-called "tent";
Edema, swelling, limitation of movement of the limb, especially when raising the arm up;

Sometimes, upon examination, a person may complain of dizziness, sticky sweat, darkening in the eyes. The skin around the injury acquires a purple-bluish hue. This indicates subcutaneous bleeding or damage to a large vessel as a result of a fracture, which is a complication and requires immediate action. Also, as a result of injury, nearby nerve endings can be damaged. In this case, the person loses sensitivity at the site of the fracture, up to complete paralysis.

First aid for a fracture of the clavicle:

To seat the victim, calm down, take a tablet of analgin, ibuprofen, nise.
Call an ambulance;
If possible, immobilize the limb: roll a small roller out of the existing clothes and put it in the armpit on the side of the affected limb. Next, put the arm bent at the elbow on the scarf so that the forearm and hand are completely placed on it. Fasten the edges of the scarf around the neck;
You can apply any cold compress to the injured limb, but not more than 15 minutes.
If there is a wound at the fracture site (open fracture), then treat the edges of the wound with any skin antiseptic and apply a sterile napkin;

The bones of the forearm include the ulna and radius. How to determine where each of them is? Everything is very simple. On the side of the 1st finger is the radius, and on the side of the little finger - the ulna. The ulna is also part of the bones of the elbow joint, along with the humerus. The radius is more massive. It is part of the bones of the wrist.

The most common are fractures of the radius, especially around the wrist. Often there are combined fractures of both bones, which, of course, represent the greatest danger in terms of the development of further complications. Fractures can also be open (with damage to the skin), and closed. There may also be a fracture of one bone and a dislocation of another.

One of the main causes of such injuries is a fall on an outstretched hand or a blow to a hard object.

Main symptoms:

Sharp pain after injury;
Restriction of movement in the limb or vice versa its pathological mobility;
Edema, hematoma, bleeding from the wound (with an open fracture);
In severe fractures, the joint can be “turned inside out”, movements are impossible (Malgenya fracture). In this case, nerve endings can be damaged, as the olecranon is damaged. The pain is unbearable, pain shock may occur.

First aid:

Calm the victim, seat or lay in a comfortable position, take an anesthetic.
Call an ambulance.
If the wound is open and the bleeding is not massive, then apply a sterile or clean napkin to the treated wound. If the bleeding is heavy enough, then it is necessary to apply a pressure bandage. In no case is it allowed to move or touch the protruding fragments on your own, they must also be covered with a clean napkin.
It is necessary to fix the damaged joint. To do this: position the sore arm parallel to the ground, apply a splint from improvised materials (sticks, a piece of hard cardboard, a small board) so that the shoulder joint and hand are simultaneously captured. We impose a splint on the outer surface of the forearm. If the patient cannot position the arm in this position, then the arm is fixed in the most comfortable position.
If there is no material at hand for splinting, then you can wrap the injured arm to the body, also placing it parallel to the ground, or, if it is more convenient for the patient, place the arm along the body. At the same time, we also fix the elbow joint, forearm and hand.

Elbow dislocation

This injury is very common in children aged 2 to 4 years. At this age, the ligamentous apparatus is still very weak and any awkward movement can lead to dislocation. This is especially common when the baby is pulled by one hand or led by both hands at the same time. Trauma tends to recur.

Also, dislocation of the elbow joint is quite common in sports, especially in weightlifting, as a result of habitual subluxation or sprain.

The main symptoms of a dislocated elbow are:

Intolerable pain in the elbow;
The joint is deformed, swollen, any movement causes pain;
In the elbow area, tingling, burning, or numbness of the limb, up to paresis, may be noted;
Growing general symptoms (headache, nausea, dizziness) associated with the possible development of pain shock;
The skin around the elbow, as well as in the area of the forearm and hand, is pale, cold to the touch.

First aid:

Never try to straighten the joint yourself! The danger of such an injury is that it can damage an artery or nearby nerves, which can lead to grave consequences and even disability.

We hang the damaged joint on a bandage - a scarf;
We give the victim any pain medication (nise, ibuprofen, ketorol, nimesid);
We provide maximum rest for both the injured limb and the victim.
You can apply a cold compress or ice pack to the affected area, but not more than 5-10 minutes. If necessary, the procedure can be repeated after 15-20 minutes.
We call an ambulance team for further diagnosis and treatment in a hospital.

The most popular injury, especially in the autumn-winter period, when, when falling on a limb, a person automatically leans on the hand. Often, such injuries accompany athletes, especially when doing weightlifting, where objects can fall on the hand, as well as when doing winter sports (skiing, skating, hockey) with a high degree of injury in a fall or collision.

Often, such an injury can be obtained while participating in a street fight, as well as during boxing and kickboxing.

Most often, the phalanges of the fingers suffer, they occupy 2/3 of the total number of hand injuries. The remainder includes fractures of the bones of the wrist and metacarpus.

Main symptoms:

Inability to clench the injured limb into a fist;
When patting with the back of the hand on the fingertips of the affected hand, a person feels severe pain radiating to the forearm;
If a fracture occurs in the area of the phalanx of the fingers, then there is a deformation of the joint, severe pain, swelling, restriction of movement in this area;

First aid for fractures of the hand:

Since extensive edema occurs as a result of any fracture, it is necessary to remove all jewelry (bracelets, rings) from the injured limb as soon as possible in order to prevent further compression and necrosis of the damaged area;
An ice pack wrapped in a piece of cloth or a towel should be applied to the fracture site for 10-15 minutes.
If the pain is unbearable, then any pain medication should be taken.
The injured limb is suspended on a scarf and in this position the patient is taken to the nearest emergency room.
If the fracture occurred in the area of the phalanx of the fingers, then the damaged finger can be bandaged to a healthy one.