One of the complications of a closed fracture is blood loss. Bleeding from a broken bone lasts up to 3-5 days. For some reason, many surgeons associate bleeding and blood loss only with damage to the main vessel and external bleeding or bleeding into the cavity.

Bleeding always occurs with a closed fracture. According to the studies of Clark (1951), V.F. Pozharissky (1972), blood loss in case of a fracture of the posterior half-ring of the pelvis can reach 2-3 l, the anterior half-ring of the pelvis - 0.8 l, the femur - 0.5-2.5 l, shins - 0.5-1.0 l. Especially dangerous is bleeding in elderly and senile patients with fractures of the ilium and sacrum, subtrochanteric and pertrochanteric fractures of the femur, high fractures of the tibia. In patients with multiple fractures, blood loss can be 2-3 liters or more.

Fat embolism is a rare but severe complication of fractures. It occurs more often in those victims who have not been diagnosed with shock and therefore have not received antishock therapy. It is believed that fat embolism develops as a result of impaired tissue circulation during shock. Pathological deposition of blood in the capillaries, acidosis as a result of hypoxia, impaired blood chemistry are links in the pathogenetic chain. In the clinic, a mixed form of embolism is more often observed - both cerebral and pulmonary.

Clinically, fat embolism is manifested by a sudden deterioration in the patient's condition ("light interval" from several hours to 2 days). The first symptom is a change in the consciousness of the victim due to increasing hypoxia of the brain up to loss of consciousness. Important signs of a fat embolism are increased respiration, cyanosis of the skin and mucous membranes (hypoxia!), an increase in body temperature to 39 ° C and above (obviously, of central origin). There are scattered symptoms of damage to the cerebral cortex, subcortical formations and the trunk: smoothness of the nasolabial fold, tongue deviation, swallowing disorder, meningeal symptoms. On radiographs of the lungs, symptoms of edema are noted - a picture of a "snow blizzard".

It is very important to differentiate a fat embolism from a growing intracranial hematoma, since in both cases there is a "light gap". With a hematoma, focal symptoms of damage to one hemisphere are more pronounced, symptoms of damage to the subcortical regions and the brain stem are less pronounced. Hematoma is also characterized by bradycardia, there is no such shortness of breath and hypoxia as with embolism. Special research methods help: a picture of a "snowstorm" on x-rays of the lungs, a shift in the midline structures of the brain on echoencephalograms with a hematoma, an increase in the pressure of the cerebrospinal fluid and blood in the cerebrospinal fluid with a hematoma. Of great importance is the study of the fundus: drops of fat can be seen in the capillaries of the fundus during embolism; varicose veins and smoothness of the contours of the optic nerve with hematoma.

Along with the general complications of closed fractures, there may be local complications. First of all, they should include an internal bedsore, which often occurs with a complete displacement of fragments of the tibia. Internal decubitus significantly complicates the use of many methods of treatment.

For closed fractures in some cases, skin necrosis develops as a result of direct trauma or pressure from bone fragments from the inside. As a result, a closed fracture can turn into an open one in a few days and is called secondary open.

The accumulation of hematoma in the subfascial space with closed bone fractures often causes the development of subfascial hypertension syndrome with circulatory disorders and innervation of the distal limbs due to compression of the neurovascular bundle.

Subfascial hypertension syndrome, compression or damage to the main vessel by a bone fragment can lead to the development of gangrene of the limb, thrombosis of venous and arterial vessels, insufficient blood supply to the limb, Volkmann contracture, and, if the nerves are damaged, to paralysis, paresis. With closed fractures, suppuration of the hematoma rarely occurs.

For open fractures

the most common complications are superficial or deep suppuration of the wound, osteomyelitis, anaerobic infection develops much less frequently.

In patients with multiple, combined injuries and open fractures, along with shock, fat embolism is possible.

For fractures, accompanied by prolonged crushing of the limb, there may be a syndrome of prolonged compression with combined damage to the main vessels - anemia.

to late complications.

fractures include malunion of fragments, delayed union, non-united fractures and false joints. Often, fractures are complicated by Zudek's syndrome. In peri- and intra-articular fractures, the most common complications are the formation of heterotopic para-articular ossifications, post-traumatic deforming arthrosis, contractures, and post-traumatic edema.

Dislocations.

Under the influence of acute or chronic infection (osteomyelitis, tuberculosis), destruction of one or both articular surfaces can occur, as a result of which the articular head is displaced relative to the articular cavity, subluxation develops, and sometimes complete dislocation. The development of a tumor in the head of the bone or in the articular cavity also disrupts the normal ratio of the articular surfaces: the enlarged head cannot fit in the articular cavity and gradually leaves it. Sprain of the ligaments of the joint during its dropsy or after an injury leads to a violation of the normal position of the articular ends of the bone, and with a slight influence of an external force, the articular surfaces can easily be displaced. Violation of the muscular apparatus of the joint (paralysis and muscle atrophy) can also contribute to the development of pathological dislocations; dislocations or subluxations can also occur due to paralysis of one muscle group while maintaining the normal strength of the antagonists.

A fracture is a violation of the integrity of bone tissue, which is often accompanied by damage to muscles, ligaments, blood vessels, nerve endings, and skin. In connection with these, there is acute pain, a change in the shape of an organ, a violation of motor activity.

Consequence

Subsequently, injuries or already in the course of treatment, complications of fractures are possible. They arise for a number of reasons, which we will discuss below. Modern medicine conventionally divides the consequences of fractures into two groups:

complications as a result of injury and violation of the integrity of the bones;
complications arising directly from the treatment of fractures.

The consequences of injury can be quite serious. After all, with a fracture, the integrity of muscle tissue can be violated, rupture of blood vessels and nerve endings can occur. Depending on the type of injury, the following are damaged:

substance of the brain (fracture of the bones of the skull);
rupture of the pleura and damage to the lung (with trauma to the chest and ribs);
damage to the genitourinary system, female reproductive organs and other consequences.

Most often, many complications arise after an injury, with improper first aid and transportation of the victim.

When, due to certain circumstances, not entirely justified treatment of a bone fracture is prescribed, or the chosen methods of therapy are violated directly by the patient, negative consequences cannot be avoided. What is going on? If the fragments were incorrectly compared, then they fuse in the wrong position, which leads to additional pain, deformation and restriction in movement (lameness, insufficient rotation, compression of internal organs, etc.) and a large callus is formed. When the bones do not grow together, a false joint is formed.

After an open fracture, with improper treatment (insufficient antiseptic, antimicrobial treatment of the wound), infection may occur, which will lead to purulent formations inside the bone. Such a complication can significantly complicate the process of recovery and even permanently harm health.

After prolonged immobilization, if the recommendations of the attending physician are not followed, the following may develop:

congestion in the lungs leading to pneumonia;
the formation of blood clots in the veins of the lower extremities;
bedsores;
muscle atrophy and joint stasis.

The following complications are also distinguished in violation of the integrity of the bones:

large blood loss;
fat embolism;
compartment syndrome.

After a fracture, bleeding can last up to five days. This phenomenon occurs when the main vessel is ruptured with an open violation of the integrity of the bone. Closed ones are also accompanied by profuse blood loss. For example, with a pelvic fracture, you can lose up to three liters of blood.

Fat embolism - occurs when traumatic shocks are incorrectly eliminated and is a rare but rather serious complication in which blood circulation in the tissues is disturbed. Allocate cerebral, pulmonary, mixed form of embolism. After fractures, it appears mixed. The victim notes a sudden deterioration in health. It appears in the form:

loss of consciousness (cerebral hypoxia);
jumps in body temperature up to 40 degrees;
frequent breathing;
cyanosis of the skin and mucous membranes;
smoothness of the nasolabial fold;
sinking of the tongue;
violation of the swallowing reflex;
the appearance of symptoms of meningitis;
there are changes in the lungs that can be seen during x-ray examinations.

With intracranial hematoma, complications of the fundus may occur. During an embolism, droplets of fat penetrate into the capillaries of the eyes, which lead to disorders.

Let us dwell in more detail on the complications that arise as a result of incorrect actions of doctors. First of all, we note that they can be systematized and classified into the following groups:

misdiagnosis and resulting complications;
violations before the start of treatment (organizational);
incorrect performance of one-time reposition of bones and their fixation;
not the right choice when installing the spokes;
complications during surgical operations;
installation of compression-distraction devices in violation of technology and rules.

With an incorrect diagnosis, and this takes place with numerous fractures, concomitant trauma, brain compression, when one diagnosis erases the symptoms of the second, fractures of the foot, spinal column, ankle, condyle of the tibia, femur are ignored. In the case of closed herbs, violations of the integrity of blood vessels (blood arteries), nerves are often ignored. These omissions lead to serious consequences.

Complications are possible when a fracture is treated by an inexperienced traumatologist, a high probability also occurs in the absence of special devices in the hospital for simultaneous reposition or skeletal traction. An insufficiently equipped medical base does not allow even an experienced doctor to take all the necessary measures to prevent all kinds of complications.

One-stage reposition should be carried out only under general anesthesia. Violation of these rules leads to injury to muscle tissue that is not completely relaxed.

Restoration of the integrity of not all fragments in the joints entails the formation of arthrosis and epiphyseolysis, especially for the child's body, whose bones continue to grow and can be deformed again.

A lot also depends on the correct and reliable fixation of the bone, as well as on the period of wearing the plaster. Poor bonding quality leads to the formation of a false joint, too tight bandage (gypsum) disrupts blood circulation and lymph flow in the tissues, which threatens with ischemic contracture and muscle weakening.

Incorrect placement of the Kirschner wire through the growth cartilage in children can lead to slow bone growth. The use of only soft tissues is fraught with the occurrence of pain. When the wire passes through the joint, it can lead to reactive synovitis and sticky arthritis. Also, serious violations are entailed by the installation of an excessive load with traction technology.

Complications are also possible during and after operations. The wrong choice of materials and devices for restoring the integrity of the bone and tissues entails a number of problems. From increasing the time for fracture healing and tissue repair to suppuration and embolic disorders, osteomyelitis.

Ischemic contracture - with untimely detection and treatment, most often leads to irreversible processes that lead to disability or even amputation of the limb. It occurs due to untimely diagnosis of arterial rupture in fractures and thrombosis resulting from impaired blood circulation and lymph flow in damaged tissues.

Prevention of complications after violation of the integrity of the bones

Prevention is of great importance for the recovery of the body after a serious injury. These methods are aimed at preventing possible complications. After a severe traumatic shock, to prevent the development of embolism, the victim is injected intravenously with a glucose solution (10-20%), and a reliable immobilization of the injured part is also carried out.

Prevention of contracture consists in the timely detection of circulatory damage and their elimination, as well as in the correct application of plaster and constant examination of the limb for tissue necrosis.

Immediately after applying the plaster, it is necessary to start doing the simplest gymnastics to prevent congestion in the tissues. In the early stages, these are just light tapping fingers on the plaster. Further introduction of morning hygienic exercises depends on the location of the injury and the degree of its complexity. In case of damage to the spine and spinal cord, gymnastics is recommended after the first improvements in the general condition. This usually happens on the fifth day.

During immobilization, the duration of gymnastic exercises does not exceed 10 minutes, you need to start from 3-5 minutes.

After removing the plaster, it is necessary for a certain time not to load the damaged areas of the skeleton (you can start walking only with the permission of the doctor). As rehabilitation measures, a whole range of methods is prescribed for the restoration of tissues and bones. Therapeutic exercise, which is developed taking into account individual indications, is the prevention of congestion and ossification of the articular bones after prolonged immobilization. It is necessary to perform the exercises for the first time under the supervision of a rehabilitation doctor, according to a strictly developed scheme.

Prevention of muscle hypotrophy and atrophy also consists in proper balanced nutrition and taking special drugs. Due to the violation of the integrity of the bones, damage also affects muscle tissue. They need additional enrichment with vitamin components and microelements. It is important at this time to include in the diet foods containing protein (an important building material) - dairy products, fish, eggs. To get the necessary vitamins in the body, you need to eat more fresh fruits and vegetables.

In case of bone fractures, for their better union and prevention of the formation of a false joint, it is necessary to ensure the consumption of a daily dose (1.5 g) of calcium. In parallel, you should drink a vitamin complex. Which one to choose, the attending doctor will tell you, based on the indications and characteristics of the body.

First aid to the wounded in the limbs includes a temporary stop of external bleeding, the application of an aseptic dressing with the help of PPI, anesthesia from a syringe tube (I 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 measures taken earlier 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 an armed conflict, first medical aid is considered as pre-evacuation preparation for aeromedical evacuation of the seriously wounded directly in the MVG

first echelon to provide early specialized surgical care. In a large-scale war, after providing first medical aid, all the wounded are evacuated to the omedb (omedo).

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

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

Among the measures for the prevention and control of traumatic shock in case of injuries of the limbs in the MPP (medr), the main ones are: intravenous injection of plasma-substituting solutions, anesthesia by performing novocaine blockades, the imposition of transport tires.

Novocaine blockades are 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 is 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.

Rules of transport immobilization.

Immobilization is carried out as soon as possible after the injury.
Before applying the splint, anesthesia is performed (introduction of analgesics, novocaine blockades).
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).
With a 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.
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.
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.
When a tourniquet is applied, the bandaging of the tire is carried out in such a way as to leave the tourniquet visible and available for additional tightening or relaxation.
In the cold season, the limbs after immobilization must be additionally insulated.

To immobilize 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 is carried out with the help of ladder, plywood tires or Dieterichs tires. In case of damage to the 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 - on the inside.

The tire, which is located on the back surface, is modeled by bending it in the area of the ankle joint at an angle of 90°, in the area of the knee joint - 160°.

The method of immobilization with a splint by M. M. Diterikhs.

The outer and inner jaws of the tire are adjusted to the length (the outer jaw should rest against the armpit, the inner jaw - against the wounded man's crotch).

The “sole” of the tire is bandaged to the foot (with shoes on or with a cotton-gauze pad on the back surface).
The 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).
A twist is being prepared, which is passed through the sole and a gap in the protrusion of the outer branch (Fig. 23.14).
Careful traction is made for the distal part of the limb, which ends with tightening the twist and fixing it.
Bone protrusions (areas of the greater trochanter, condyles of the knee joint, ankles) are additionally protected with cotton-gauze pads.
The Dieterichs bus is reinforced 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, three ladder or ladder and two plywood splints are used for immobilization, 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 is carried out by two ladder splints, 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 medical aid in the dressing room, the distal portion of the limb is also cut off, 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, the wounded with gunshot and open fractures, extensive wounds of soft tissues are given paravulnar administration of antibiotics (penicillin 1 million units). Tetanus prophylaxis is carried out for all wounded and affected - tetanus toxoid (0.5-1.0 ml) is injected subcutaneously.

Qualified surgical assistance. With a well-established aeromedical evacuation in an 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 extremities to the medical hospital (omedo Special Forces), they are given pre-evacuation preparation in the amount of first medical aid. Qualified surgical care is provided only for health reasons.

In the conditions of a 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.

Those in need of urgent surgery (continued external bleeding; wounded with tourniquets applied; 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. Injured in need of complex operations (high amputation or hip disarticulation, main vessels), are sent to the operating room.
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 soft tissue damage, including gunshot fractures of long bones and injuries of large joints; wounds,

Infected with toxic substances and radioactive substances, abundantly contaminated with 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.

Subject to further evacuation after providing the necessary medical care in the conditions of the sorting and evacuation department. According to 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.
Lightly wounded (see paragraphs 23.1.7).

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

Specialized surgical care for those wounded in limbs in an armed conflict is provided in the 1st echelon MVG, 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 performed. 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. Across

For 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 GB hospitals. 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.

Types and signs of fractures. Signs of dislocations in the joints. Rules and methods of first aid for fractures of bones and dislocations. Tire rules. Splinting and immobilization of joints in certain types of fractures and dislocations using standard and improvised means

Types and signs of fractures

1. Types of fractures. Fractures are closed, in which the integrity of the skin is not broken, there is no wound, and open, when the fracture is accompanied by injury to soft tissues.

According to the degree of damage, the fracture is complete, in which the bone is completely broken, and incomplete, when there is only a fracture of the bone or its crack. Complete fractures are divided into fractures with displacement and without displacement of bone fragments.

In the direction of the fracture line relative to the long axis of the bone, transverse (a), oblique (b) and helical (c) fractures are distinguished. If the force that caused the fracture was directed along the bone, then its fragments can be pressed into one another. Such fractures are called impacted.

In case of damage by bullets and fragments flying at high speed and having great energy, many bone fragments form at the fracture site - a comminuted fracture is obtained (e).

Fractures: a - transverse; b - oblique: c - helical; g - driven in; d - splintered

Signs of broken bones. With the most common fractures of the limb bones, severe swelling, bruising, sometimes flexion of the limb outside the joint, and its shortening appear in the area of injury. In the case of an open fracture, the ends of the bone may protrude from the wound. The injury site is sharply painful. At the same time, abnormal mobility of the limb outside the joint can be determined, which is sometimes accompanied by a crunch from friction of bone fragments. It is unacceptable to bend the limb on purpose to make sure that there is a fracture - this can lead to dangerous complications. In some cases, with bone fractures, not all of these signs are detected, but the most characteristic are sharp pain and severe difficulty in movement.

A rib fracture can be assumed when, due to a bruise or compression of the chest, the victim notes severe pain with deep breathing, as well as when feeling the site of a possible fracture. In case of damage to the pleura or lung, bleeding occurs or air enters the chest cavity. This is accompanied by respiratory and circulatory disorders.

In the case of a fracture of the spine, severe back pain, paresis and paralysis of the muscles below the fracture site appear. Involuntary excretion of urine and feces may occur due to dysfunction of the spinal cord.

With a fracture of the pelvic bones, the victim cannot stand up and raise his legs, as well as turn around. These fractures are often combined with damage to the intestines and bladder.

Fractures of bones are dangerous by damage to the blood vessels and nerves located near them, which is accompanied by bleeding, a disorder of sensitivity and movement, of the damaged area.

Severe pain and bleeding can cause the development of shock, especially if the immobilization of the fracture is not timely. Bone fragments can also damage the skin, as a result of which a closed fracture turns into an open one, which is dangerous due to microbial contamination. Movement at the fracture site can lead to serious complications, so it is necessary to immobilize the damaged area as soon as possible.

2. Signs of dislocations in the joints

A dislocation is a displacement of the articular ends of the bones. Often this is accompanied by a rupture of the joint capsule. Dislocations are often noted in the shoulder joint, in the joints of the lower jaw, fingers. With a dislocation, three main signs are observed: complete impossibility of movements in the damaged joint, severe pain; forced position of the limb, due to muscle contraction (for example, with a dislocation of the shoulder, the victim keeps his arm bent at the elbow joint and abducted to the side); change in the configuration of the joint compared to the joint on the healthy side.

Swelling due to hemorrhage is often noted in the joint area. The articular head in the usual place can not be probed, in its place the articular cavity is determined.

3. Rules and methods of first aid for bone fractures and dislocations

General rules for first aid for bone fractures.

To inspect the fracture site and apply a bandage to the wound (in case of an open fracture), clothes and shoes are not removed, but cut. First of all, the bleeding is stopped and an aseptic bandage is applied. Then the affected area is given a comfortable position and an immobilizing bandage is applied.

An anesthetic is injected under the skin or intramuscularly from a syringe tube.

For immobilization of fractures, standard splints contained in the B-2 kit or improvised means are used.

First aid for dislocations consists in fixing the limb in the position most convenient for the victims, using a splint or bandage. The doctor should correct the dislocation. A dislocation in a particular joint can be periodically repeated (habitual dislocation).

4. Rules for imposing tires. Splinting and immobilization of joints in certain types of fractures and dislocations using standard and improvised means

General rules for splinting for fractures of limb bones.
- tires must be securely fastened, well fix the fracture area;
- the splint cannot be applied directly to a bare limb, the latter must first be covered with cotton wool or some kind of cloth;
- creating immobility in the fracture zone, it is necessary to fix two joints above and below the fracture site (for example, in case of a fracture of the lower leg, the ankle and knee joints are fixed) in a position convenient for the patient and for transportation;
in case of hip fractures, all joints of the lower limb (knee, ankle, hip) should be fixed.

First aid for hip fractures. General Rules for Imposing Tires

Hip injuries are usually accompanied by significant blood loss. Even with a closed fracture of the femur, blood loss to the surrounding soft tissues is up to 1.5 liters. Significant blood loss contributes to the frequent development of shock.

The main signs of hip injuries:
- pain in the hip or joints, which sharply increases with movement;
- movement in the joints is impossible or significantly limited;
- in case of hip fractures, its shape is changed and abnormal mobility at the fracture site is determined, the hip is shortened;
- movements in the joints are impossible;
- there is no sensitivity in the peripheral parts of the leg.

The best standard splint for hip injuries is the Dieterichs splint.

Immobilization will be more reliable if, in addition to conventional fixation, the Dieterichs bus is strengthened with plaster rings in the area of the trunk, thigh and lower leg. Each ring is formed by applying 7-8 circular rounds of a plaster bandage. Only 5 rings: 2 - on the trunk, 3 - on the lower limb.

In the absence of a Dieterichs tire, immobilization is performed with ladder tires.

Immobilization with ladder tires. To perform immobilization of the entire lower limb, four ladder splints 120 cm long each are required, if the splints are not enough, it is possible to immobilize with three splints.

Tires must be carefully wrapped with a layer of gray cotton wool of the required thickness and with bandages. One tire is bent along the contour of the back surface of the thigh, lower leg and foot with the formation of a recess for the heel and lower leg muscles.

In the area intended for the popliteal region, arching is performed in such a way that the leg is slightly bent at the knee joint. The lower end is bent in the shape of the letter "L" to fix the foot in the position of flexion at the ankle joint at a right angle, while the lower end of the splint should capture the entire foot and protrude 1-2 cm beyond the fingertips.

Two other tires are tied together along the length, the lower end is L-shaped bent at a distance of 15-20 cm from the lower edge. An elongated tire is placed along the outer surface of the trunk and limb from the armpit to the foot. The lower, curved end wraps the foot over the rear tire to help prevent sagging.

The fourth splint is placed along the inner lateral surface of the thigh from the crotch to the foot. Its lower end is also bent in the shape of the letter "L" and wound behind the foot over the bent lower end of the elongated outer side tire. Tires are reinforced with gauze bandages.

Similarly, in the absence of other standard splints, as a necessary measure, the lower limb can be immobilized with plywood splints.

As soon as possible, ladder and plywood tires should be replaced with Dieterichs tires.

Errors when immobilizing the entire lower limb with stair splints:

1. Insufficient fixation of the outer elongated splint to the body, which does not allow reliable immobilization of the hip joint. In this case, immobilization will be ineffective.

2. Poor modeling of the rear ladder rail. There is no recess for the calf muscle and heel. There is no splint bend in the popliteal region, as a result of which the lower limb is immobilized fully extended at the knee joint, which in case of hip fractures can lead to compression of large vessels by bone fragments.

3. Plantar sagging of the foot as a result of insufficiently strong fixation (there is no modeling of the lower end of the side tires in the form of the letter “G”).

4. Insufficiently thick layer of cotton wool on the tire, especially in the area of \u200b\u200bbone protrusions, which can lead to the formation of bedsores.

5. Compression of the lower limb with tight bandaging.

Transport immobilization with improvised means for hip injuries: a - from narrow boards; b - with the help of skis and ski poles.

Immobilization by improvised means. It is carried out in the absence of standard tires. For immobilization, wooden slats, skis, branches and other objects of sufficient length are used to ensure immobilization in the three joints of the injured lower limb (hip, knee and ankle). The foot should be set at a right angle at the ankle joint and soft pads should be used, especially in the area of bony prominences.

In cases where there are no means for transport immobilization, the foot-to-foot fixation method should be used. The injured limb is connected in two or three places with a healthy leg, or the injured limb is placed on a healthy one and also tied in several places.

Transport immobilization in case of damage to the lower extremities using the "foot to foot" method: a - simple immobilization; b - immobilization with slight traction

Foot-to-foot immobilization of the injured limb should be replaced by standard splint immobilization at the earliest opportunity.

The evacuation of victims with hip injuries is carried out on a stretcher in the prone position. To prevent and timely detect complications of transport immobilization, it is necessary to monitor the state of blood circulation in the peripheral parts of the limb. If the limb is naked, then the color of the skin is monitored. With unremoved clothes and shoes, it is necessary to pay attention to the complaints of the victim. Numbness, coldness, tingling, increased pain, the appearance of throbbing pain, cramps in the calf muscles are signs of circulatory disorders in the limb. It is necessary to immediately relax or cut the bandage at the site of compression.

First aid for fractures of the leg. General Rules for Imposing Tires

The main signs of damage to the lower leg:
- pain at the site of injury, which increases with movement of the injured leg;
- deformity at the site of damage to the lower leg;
- movement in the ankle joint is impossible or significantly limited;
- Extensive bruising in the area of injury.

Immobilization is best achieved with a 120 cm L-curved molded rear ladder splint and two 80 cm side ladder or plywood splints. The top end of the splints should reach mid-thigh. The lower end of the side ladder rails is curved L-shaped. The leg is slightly bent at the knee joint. The foot is set in relation to the lower leg at a right angle. Tires are reinforced with gauze bandages.

Immobilization can be performed with two 120 cm long ladder splints.

Mistakes in transport immobilization of leg injuries with stair splints:

1. Insufficient modeling of the stair splint (there is no recess for the heel and calf muscle, there is no arching of the splint in the popliteal region).

2. Immobilization is performed only with the rear ladder rail without additional side rails.

3. Insufficient fixation of the foot (the lower end of the side splints is not bent in an L-shape), which leads to its plantar sagging.

4. Insufficient immobilization of the knee and ankle joints.

5. Compression of the leg with tight bandaging while strengthening the tire.

6. Fixation of the limb in a position where the tension of the skin over the bone fragments (anterior surface of the lower leg, ankle) is maintained, which leads to damage to the skin over the bone fragments or the formation of bedsores. Tension of the skin by displaced bone fragments in the upper half of the leg is eliminated by immobilization of the knee joint in the position of full extension.

Immobilization of shin injuries with three stair splints: a - preparation of stair splints; b - overlay and fixation of tires

Immobilization of leg injuries in the absence of standard splints can be performed by improvised means.

First aid for shoulder fractures. General Rules for Imposing Tires

Signs of shoulder fractures and damage to adjacent joints:
- severe pain and swelling in the area of damage;
- the pain increases sharply with movement;
- changes in the shape of the shoulder and joints;
- movements in the joints are significantly limited or impossible;
- abnormal mobility in the area of the shoulder fracture.

Immobilization with a ladder splint is the most effective and reliable method of transport immobilization for shoulder injuries.

The tire should capture the entire injured limb - from the shoulder blade of the healthy side to the hand on the injured arm, and at the same time protrude 2-3 cm beyond the fingertips. Immobilization is carried out with a ladder rail 120 cm long.

The upper limb is immobilized in the position of a small anterior and lateral abduction of the shoulder. To do this, a lump of cotton wool is placed in the axillary region on the side of the injury, the elbow joint is bent at a right angle, the forearm is positioned so that the palm of the hand is facing the stomach. A cotton wool roller is put into the brush.

Tire preparation

The length is measured from the outer edge of the scapula of the victim to the shoulder joint and the tire is bent at this distance at an obtuse angle;

Measure the distance from the upper edge of the shoulder joint to the elbow joint along the back surface of the victim's shoulder and bend the tire at this distance at a right angle;

The assisting person additionally bends the tire along the contours of the back, back of the shoulder and forearm.

The part of the tire intended for the forearm is recommended to be bent in the form of a gutter.

Having tried on a curved tire to the healthy arm of the victim, make the necessary corrections.

If the tire is not long enough and the brush hangs down, its lower end must be increased with a piece of plywood tire or a piece of thick cardboard. If the length of the tire is excessive, its lower end is folded.

Two gauze ribbons 75 cm long are tied to the upper end of the tire wrapped in gray cotton and bandages.

The tire prepared for use is applied to the injured arm, the upper and lower ends of the tire are tied with braids and the tire is strengthened by bandaging. The hand, together with the splint, is hung on a scarf or bandage.

To improve the fixation of the upper end of the tire, two additional pieces of bandage 1.5 m long should be attached to it, then bandage bands should be drawn around the shoulder joint of a healthy limb, crossed, circled around the chest and tied.

Transport immobilization of the entire upper limb with a ladder splint:

a - applying a tire to the upper limb and tying its ends;
b - strengthening the tire by bandaging; c - hanging a hand on a scarf

When immobilizing the shoulder with a ladder splint, the following errors are possible:

1. The upper end of the tire reaches only the shoulder blade of the diseased side, very soon the tire moves away from the back and rests on the neck or head. With this position of the splint, immobilization of injuries to the shoulder and shoulder joint will be insufficient.
2. The absence of ribbons on the upper end of the tire, which does not allow it to be securely fixed.
3. Bad tire modeling.
4. The immobilized limb is not suspended on a scarf or sling.

In the absence of standard splints, immobilization is carried out using a medical scarf, improvised means or soft bandages.

Immobilization with a medical scarf. Immobilization with a scarf is carried out in the position of a slight anterior abduction of the shoulder with the elbow joint bent at a right angle. The base of the scarf is circled around the body about 5 cm above the elbow and its ends are tied on the back closer to the healthy side. The top of the scarf is wound up on the shoulder girdle of the damaged side. The resulting pocket holds the elbow joint, forearm and hand.

The top of the scarf on the back is tied to the longer end of the base. The injured limb is completely covered by the scarf and fixed to the body.

Immobilization by improvised means. Several boards, a piece of thick cardboard in the form of a gutter can be placed on the inner and outer surfaces of the shoulder, which creates some immobility in the event of a fracture. Then the hand is placed on a scarf or supported by a sling.

Immobilization with a Deso bandage. In extreme cases, immobilization for fractures of the shoulder and damage to adjacent joints is carried out by bandaging the limb to the body with a Deso bandage.

Properly performed immobilization of the upper limb greatly facilitates the condition of the victim and special care during evacuation, as a rule, is not required. However, the limb should be periodically inspected so that with increasing edema in the area of damage, compression does not occur. To monitor the state of blood circulation in the peripheral parts of the limb, it is recommended to leave the end phalanges of the fingers unbandaged. If there are signs of compression, the tours of the bandage should be loosened or cut and bandaged.

Transportation is carried out in a sitting position, if the condition of the victim allows.

First aid for fractures of the forearm. General Rules for Imposing Tires

Signs of fractures of the bones of the forearm:
- pain and swelling in the area of injury;
- the pain increases significantly with movement;
- movements of the injured hand are limited or impossible;
- change in the usual shape and volume of the joints of the forearm;
- abnormal mobility in the area of injury.

Ladder splint immobilization is the most reliable and effective type of transport immobilization for forearm injuries.

The ladder splint is applied from the upper third of the shoulder to the fingertips, the lower end of the splint will stand 2-3 cm. gauze roller to hold the fingers in a half-flexed position.

A ladder splint 80 cm long, wrapped in gray cotton and bandages, is bent at a right angle at the level of the elbow joint so that the upper end of the splint is at the level of the upper third of the shoulder, the splint section for the forearm is bent in the form of a groove. Then applied to a healthy hand and correct the shortcomings of the modeling. The prepared splint is placed on the sore arm, bandaged all over and hung on a scarf.

The upper part of the splint designed for the shoulder must be long enough to securely immobilize the elbow joint. Insufficient fixation of the elbow joint makes immobilization of the forearm ineffective.

In the absence of a ladder tire, immobilization is carried out using a plywood tire, a plank, a scarf, a bunch of brushwood, a shirt hem.

Transport immobilization of the forearm:
a - a ladder tire; b - improvised means (using planks)

First aid for dislocations of limbs

The most common traumatic dislocations are caused by excessive movement in the joint. This happens, for example, with a strong blow to the joint area, a fall. As a rule, dislocations are accompanied by a rupture of the articular bag and separation of the articular articular surfaces. An attempt to compare them does not bring success and is accompanied by severe pain and springy resistance. Sometimes dislocations are complicated by fractures - fracture-dislocations. The reduction of traumatic dislocation should be as early as possible.

Help with dislocations.

Since any, even a slight movement of a limb causes unbearable pain, first of all, it is necessary to fix the limb in the position in which it ended up, providing it with peace at the stage of hospitalization. For this, transport tires, special bandages or any available means are used. To immobilize the upper limb, you can use a scarf, the narrow ends of which are tied through the neck.

In case of dislocation of the lower limb, tires or boards are placed under it and from the sides and the limb is bandaged to them.

In case of dislocation of the fingers of the hand, the entire hand is immobilized to any flat solid surface. In the area of the joints between the tire and the limb, a layer of cotton wool is laid.

In case of dislocation of the lower jaw, a sling-like bandage is brought under it (reminiscent of a bandage worn on the hand by the attendants), the ends of which are tied in a cross way at the back of the head.

After applying a splint or fixing bandage, the victim must be hospitalized to reduce the dislocation.

State budgetary educational institution of higher professional education "Voronezh State Medical Academy named after N.N. Burdenko" of the Ministry of Health of the Russian Federation

Department of General Surgery

Head of department, professor

A.A.Glukhov

"Fractures. Dislocations"

3rd year student of the Faculty of Medicine

7 groups Kulneva M.I.

Lecturer, Ph.D.:

A.P. Ostroushko

Voronezh - 2014

Classification 3-7 pp.

Clinical picture 7-8

Fundamentals of X-ray diagnostics 8-9

First aid 9-11

Basic principles of treatment (pain relief, reduction, immobilization, rehabilitation) 11-16

Complications of traumatic fractures and dislocations and their prevention:

Pain shock 16-21

Fat embolism 22-27

Acute blood loss 27-32

Development of infections 32-33

References 34

Classification

bone fracture- complete or partial violation of the integrity of the bone under a load exceeding the strength of the injured area of the skeleton. Fractures can occur both as a result of trauma and as a result of various diseases accompanied by changes in the strength characteristics of bone tissue. The severity of the condition in fractures is due to the size of the damaged bones and their number. Multiple fractures of large tubular bones lead to the development of massive blood loss and traumatic shock. Also, patients after such injuries are slowly recovering, recovery can take several months.

In modern classifications, types of fractures are distinguished depending on the following features:

Due to the occurrence

Traumatic - caused by external influences.

Pathological - arising with minimal external influence due to the destruction of the bone by some pathological process (for example, tuberculosis, tumor, or others).

According to the severity of the injury

Without displacement (for example, under the periosteum).

With displacement of fragments.

Incomplete - cracks and breaks.

The shape and direction of the fracture

Transverse - the fracture line is conditionally perpendicular to the axis of the tubular bone.

Longitudinal - the fracture line is conditionally parallel to the axis of the tubular bone.

Oblique - the fracture line runs at an acute angle to the axis of the tubular bone.

Screw-shaped - there is a rotation of bone fragments, bone fragments are "rotated" relative to their normal position.

Comminuted - there is no single fracture line, the bone at the site of damage is crushed into separate fragments.

Wedge-shaped - usually occurs with fractures of the spine, when one bone is pressed into another, forming a wedge-shaped deformity.

Impacted - bone fragments are displaced proximal along the axis of the tubular bone or are located outside the main plane of the cancellous bone.

Compression - bone fragments are small, there is no clear, single fracture line.

The integrity of the skin

Closed - not accompanied by wounds of tissues penetrating to the fracture site, and do not communicate with the external environment. Single - if one fracture of one segment of the musculoskeletal system. Multiple - if the fracture is within one segment or different segments of the musculoskeletal system.

Open - (gunshot and non-gunshot), bone fractures accompanied by soft tissue injuries and communicating with the external environment. Combined - if the fracture is combined with an injury to the internal organs, the skull. Combined - if the lesion is in one anatomical region or in different anatomical regions.

According to the location of the fracture

Within the tubular bone, there are:

metaphysis

Complications

Complicated:

traumatic shock.

damage to internal organs.

bleeding.

fat embolism.

wound infection, osteomyelitis, sepsis.

Uncomplicated.

Also, the most common types of fractures have generally accepted names - after the name of the author who first described them.

For example, a fracture of the styloid process of the radius is called a Colles fracture. Also fairly well-known types of injuries of the upper limb include a Montage fracture, which occurs when the ulnar bone is fractured in the upper third and a dislocation of the head of the radius with damage to the branch of the radial nerve, and a Goleazzi fracture, which is a fracture of the radius in the lower third with a rupture of the distal radio-ulnar joint and dislocation in this joint.

Dislocation - violation of the congruence of the articular surfaces of the bones, both with a violation of the integrity of the joint capsule, and without violation, under the influence of mechanical forces (trauma) or destructive processes in the joint (arthrosis, arthritis).

According to the degree of displacement

A dislocation can be:

complete (complete divergence of the articular ends) and

incomplete - subluxation (articular surfaces remain in partial contact). Dislocated is the distal (farthest from the body) part of the limb.

Exceptions are:

spine - the overlying vertebra is considered dislocated.

clavicle (there are dislocations of the sternal and acromial ends of the clavicle, but not dislocations).

Shoulders are divided into anterior, inferior and posterior. Depending on the displacement of the bone.

Origin

congenital

acquired dislocations

Congenital

Such damage occurs as a result of abnormal intrauterine development of the fetus - underdevelopment of the articular cavity and femoral head (dysplasia). More often, congenital dislocations of the hip joints are noted (2-5 per 1000 newborns), less often - dislocations of the patella, knee joint. In an infant, hip dislocation is manifested by asymmetry of folds along the inner surface of the thighs, limitation of leg abduction, etc.; when the child begins to walk and later - lameness and relative shortening of one lower limb, with bilateral dislocation - "duck" gait. Congenital dislocation of the patella is manifested by pain, complete immobility of the joint, its inflammation, hemarthrosis; children walk badly, often fall. Treatment of congenital dislocation of the hip (reduction, application of special splints or plaster casts) should begin as early as possible - the best results in children are 3 months, but possibly up to 2 years. With the ineffectiveness of such treatment in 2-4 years - a surgical operation. Prevention: orthopedic examination of newborns. You can’t swaddle tightly (and even more so twist), forcibly straighten the legs, prematurely put the child (before the child gets on his feet).

Acquired

They occur during trauma - traumatic or in diseases (osteomyelitis, poliomyelitis, etc.) - pathological, or spontaneous. Traumatic dislocations in most cases occur under the influence of indirect trauma, when the place of application of force is distant from the damaged joint (for example, when falling on an outstretched hand, a dislocation occurs in the shoulder joint). The cause of a traumatic dislocation may be a sudden muscle contraction that causes movement beyond the normal range of motion of the joint (eg, dislocation of the mandible due to excessive mouth opening). Dislocations from direct trauma occur much less frequently - a blow to the joint area. In children aged 1-3 years, so-called "dislocations from stretching" are observed that occur in the joints (shoulder, elbow) from a sharp jerk of the child by the hand (when he is led by the handle and he stumbled). Manifested by severe pain in the joint area, deformity, impaired or loss of movement.

With dislocations, the capsule of the joints almost always ruptures, tendons, muscles, bones, vessels and nerves can be damaged; such dislocations are called complicated. Dislocations can be closed - without damage to the skin over the joint and open, when a wound is formed that penetrates into the joint cavity. Sometimes, due to a significant stretching of the joint capsule and ligaments during dislocation, as well as without proper treatment, the dislocation occurs again even with little effort. This is the so-called habitual dislocation (most common in the shoulder joint).

Pathological dislocation often occurs in the hip and shoulder joints, usually as a result of the destruction of the articular surfaces due to the pathological process; paralytic dislocation is observed with paralysis or paresis of the muscles surrounding the joint. These dislocations occur without a noticeable application of external force, as if spontaneously, for example, while walking, turning in bed, etc.

The absence of clear signs of consolidation, the appearance of callus on the radiograph 2 months after reposition and fixation of fragments should be regarded as a slowdown in consolidation. Common causes may be age, alimentary, endocrine disorders, beriberi, concomitant diseases (diabetes, endarteritis, atherosclerosis, etc.). Local causes include insufficient fixation of fragments, poor reposition, bone defects, interposition, circulatory and innervation disorders, lymphostasis, cicatricial changes and inflammatory processes in tissues.

Medical tactics. Monitoring the stability of the fixation of fragments. Hospitalization to replace immobilization with a plaster cast for a more active method of treatment - first of all, the use of a compression device for external fixation. Correction of metabolic processes.

Recognition of the formation of a false joint is based on radiological information: sclerosis of the end plates at the ends of bone fragments, a clearly traced fracture line, excessive growth of bone tissue at the ends of the main fragments (hypervascular joints) or, on the contrary, complete lack of signs of consolidation and osteoporosis of the end sections of fragments (hypovascular joints). If double terms of the average duration of bone consolidation have passed, then the false joint is considered to be formed.

Signs: pain with axial load, with lateral and rotational loads, swelling of soft tissues. Mobility at the site of the former fracture may be subtle (tight pseudoarthrosis) or pronounced (dangling pseudoarthrosis).

In the hypervascular form, the skin in the area of neoarthrosis is thickened, hyperpigmented with a hint of hyperemia, warmer than the surrounding areas by 0.5–1.5°C. In the hypovascular form, the skin is thinned, with a bluish tinge, colder than the surrounding areas.

169. Treatment of a false joint of the tibia with the Ilizarov apparatus.

Prevention consists in the timely diagnosis of delayed consolidation, as well as in the correct choice of the method of fracture treatment and its high-quality implementation. Early inclusion in the rehabilitation process of a dosed musculoskeletal load and the use of additional means of correcting metabolic processes are important. Treatment of false joints is surgical, mainly using the methods of GA. Ilizarov (Fig. 1 6 8, 169).

CONTRACTURES AND ANKYLOSES

Each limb injury may be accompanied by the development of contracture in one or more joints, temporary or permanent, limited or severe.

Causes: intra-articular and peri-articular injuries and fractures, post-traumatic arthritis and arthrosis, prolonged immobilization (more 3 -4 months) and prolonged forced position with pain syndrome.

Lack of motor activity, congestive edema, inflammation disrupt the metabolic processes in the muscles, which leads to myodystrophy, a decrease in the contractility of muscle fibers and their replacement with connective tissue. In the first 3-4 weeks after the injury, there is an active healing of soft tissue wounds, the formation of scars, adhesions of fascio-muscular formations. If during this period there are no movements of muscles and tendons (at least passive and minimal), then scars and adhesions begin to form in the area of the sliding apparatus, which ultimately leads to the development of myofasciotenodesis. This is facilitated by elements of the periosseous wound and extensive hemorrhages. Ligaments and articular bags lose their elasticity and wrinkle. As a result of disorders of the venous and lymphatic outflow, edematous effusion and fibrin accumulate in the joints, which are the basis for the formation of intra-articular adhesions. The scars formed in their place (intermuscular, musculoskeletal, intra- and periarticular, tendon-vaginal) lead to persistent contractures. Destruction of articular cartilage due to trauma or dystrophic processes leads to the formation of strong scars and adhesions directly between the articular ends of the articulating bones. As a result, fibrous ankylosis is formed, with a very long inactivity of the joint - bone.

Signs of contracture: restriction of movements in the joint, with restriction of extension, the contracture is considered flexion, with restriction of flexion - extensor, with restriction of flexion and extension - flexion-extension. In the presence of rocking movements in the joint, they speak of joint stiffness. Complete immobility in a joint is called ankylosis.

170. Orthopedic apparatus of Vilensky - Antoshkin from Polivik with stepped hinges fixing the knee joint, having a locking device.

171. Hinged-distraction apparatus Volkov-Oganesyan on the knee joint.

172. Ilizarov apparatus for the development of the elbow (a) and knee (b) joints.

Treatment. They carry out active and passive exercise therapy, occupational therapy, massage, thermal procedures (paraffin, ozocerite), electrical muscle stimulation, phonophoresis of lidase and hydrocortisone, hydrotherapy. With myogenic contractures, exercises are shown, mainly aimed at relaxing and stretching the muscles. With desmogenic contractures, active exercises are supplemented with passive ones through mechanotherapy.

The therapeutic effect achieved by corrective exercises is fixed with fixation bandages and orthopedic means. Persistent contractures are successfully treated by redressing, external functional devices (Fig. 170-172), surgical interventions (myolysis, tenolysis, arthrolysis).

If you suspect the development of Volkmann's contracture, you should immediately remove the plaster cast, give the limb an elevated position (prevention of edema), provide local hypothermia (15 ... 20 ° C), introduce vasodilators, antispasmodics and anticoagulant drugs. Effective periarterial novocaine blockade, blockade of the cervical sympathetic node, fasciotomy.

DEFORMATIONS AND SHORTENING OF THE LIMB

Causes: delayed or inadequate treatment of fractures and dislocations in the acute period of injury, diagnostic defects, severe fractures, purulent complications.

The solution to the problem of limb length restoration and deformity correction without bone loss became possible only after the introduction of distraction methods using external bone fixation devices. GA.Ilizarov's methods make it possible to correct any deformities of the limbs and restore the length of the bones, which is especially important for the lower limbs (Fig. 173-176).

To eliminate spinal deformity, external devices with pediculocorporal fixation of the vertebrae are currently used.

174. Lengthening of the humerus according to G.A. Ilizarov.

INFECTIOUS COMPLICATIONS OF INJURIES

SMALL FORMS OF SUPPRESSION Small forms of suppuration include local foci of weakly virulent infection in the area of postoperative wounds (sources: hematoma, aseptic marginal necrosis of injured soft tissues, ligatures, foreign bodies), near-spoke wounds (permanent microtraumatization, repeated microbial invasions), injection wounds, bedsores from excessive bone pressure fragments from the inside, plaster bandages from the outside. An increase in the content of microbial bodies per 1 g of wound tissue over 10 s is a decisive factor in the development of suppuration. In most patients, these complications develop early - up to 1 month after surgery, but may occur later. Untimely and non-radical treatment of small forms of suppuration, especially hematomas, leads to the development of severe purulent processes - abscesses, phlegmon, osteomyelitis.

Signs: local intense pain in the first 2 days after surgery or injury, severe swelling, signs of general intoxication (toxic-resorptive fever with temperature rises up to 38-40°C in the evenings, tachycardia, tachypnea, chills). Complaints of headaches, insomnia, sweating, irritability, increased fatigue, painful, unpleasant sensations without a specific localization are characteristic. Severe intoxication is indicated by apathy, depression, the appearance of visual and auditory hallucinations. In the blood - persistent anemia, leukocytosis, neutrophilic shift in the blood formula to the left, lymphocytopenia, monocytosis, increased ESR. Hematomas can open spontaneously within 1 week after the onset of clinical signs, but they should be removed surgically at an earlier date. Infectious complications should be expected after prolonged operations (more than 1 1/2 hours), severe surgical blood loss (more than 0.5 l), traumatic interventions, the use of biological and synthetic materials, in the presence of concomitant diseases (diabetes, respiratory, chronic gastrointestinal intestinal diseases, stomatitis, caries, etc.).

Treatment of postoperative hematomas should be early, complex, radical. Against the background of active detoxification therapy under general anesthesia, a hematoma is widely opened (after its preliminary contrasting with methylene blue or brilliant green solutions), a thorough revision of the wound is carried out, focusing on stained tissues, non-viable tissues are removed, the wound cavity is abundantly washed with antiseptic solutions, treated with ultrasound, irradiated with a laser, vacuumed. The issues of preservation or removal of structures (rods, screws, plates, endoprostheses) are decided individually. The wound is sutured tightly after excision of the edges, leaving drains for active drainage and flow-through washing for 1-2 weeks.

In the postoperative period, active antibacterial therapy and restorative treatment are carried out. Until the wound heals, the limb is immobilized with a plaster splint.

Treatment inflammation of the near-spoke wounds is carried out according to the rules of purulent surgery. At the first signs (swelling, redness, pain, increased local temperature), the skin and subcutaneous tissue around the wire are infiltrated with novocaine with antibiotics and dissected longitudinally by at least 3 cm. The wound is treated with antiseptic solutions and packed with powdered sorbents (gelevin, coal), and in their absence - gauze swabs with hypertonic sodium chloride solution, which are changed 2 times a day. Usually within 2 days the inflammatory process stops, the wound heals by the 7-8th day. If it is not possible to eliminate the inflammation of soft tissues in 2-3 days, purulent discharges appear from the wound and a general reaction of the body develops, then the needle is removed and a wide drainage is performed through both needle holes in the skin. Assign general and local antibiotic therapy, ultraviolet radiation, laser and magnetotherapy.

LIGATURE fistulas appear after opening with scanty, but persistent serous-purulent secretions, can spontaneously close after the ligature is discharged. Being a potential cause of the development of severe purulent processes, they require early surgical intervention. X-ray contrast studies and staining of fistulous passages before surgery are mandatory.

Treatment pressure sores includes an increase in the general reactivity of the body (blood transfusion, administration of protein preparations, vitamins, anabolic steroids, immunostimulants) and stimulation of local regeneration processes by exposure to pathological and borderline tissues with proteo-ditic enzymes (chymotrypsin, terrilitin), antiseptic solutions, water-soluble ointments ( levosin, levomekol), laser irradiation, UFO. With a large area of the bedsore, free and non-free skin plasty is shown.

Prevention of purulent complications of open fractures. Primary surgical treatment of the wound should be carried out within 4-6 hours after the injury. Each hour of delay in surgery increases the likelihood of suppuration and osteomyelitis. Processing of the main bone fragments includes mechanical cleaning of their ends, removal of plugs from the bone marrow canals, consisting of bone fragments and crushed soft tissues, abundant treatment of the bone wound with antiseptic solutions using ultrasonic cavitation. Small fragments are usually removed, medium and large ones, not associated with soft tissues, are removed, cleaned, placed for several minutes in a saturated solution of antiseptics, and then in an isotonic solution of sodium chloride with antibiotics (for example, kanamycin 2 million IU per 100 ml). Fragments associated with soft tissues are treated like the main bone fragments. After reposition and fixation of the main fragments, the fragments are placed in such a way that the muscles completely isolate them from the surface tissues. For this, myoplasty can also be used. It is advisable to immediately place large free-lying fragments in intact muscle tissue (preferably in the area of the proximal main fragment), and after 2-4 weeks transport them using the apparatus according to the GA. conditions. It is a mistake to place bone fragments directly on the skeletonized areas of the main bone fragments, since the latter, being isolated from the muscles by these fragments, are sequestered. A unique opportunity to eliminate bone and bone-soft tissue defects and restore the anatomy and function of damaged limbs is provided by the methods of GA.Ilizarov. The wound should be closed with local skin, skin-subcutaneous-fascial flaps. When soft tissues are crushed, inflow-from-precise drainage of the postoperative wound is indicated for 1-2 weeks, without crushing the tissues - quite active drainage for 48 hours. Before surgery, during and after (within 2 days), it is necessary to carry out antibiotic therapy. The most effective: gentamicin, oxacillin, lincomycin, cefazolin, cefuroxime.

For open fractures

the most common complications are superficial or deep suppuration of the wound, osteomyelitis, anaerobic infection develops much less frequently.

In patients with multiple, combined injuries and open fractures, along with shock, fat embolism is possible.

For fractures, accompanied by prolonged crushing of the limb, there may be a syndrome of prolonged compression with combined damage to the main vessels - anemia.