The concept of injury to the musculoskeletal system. Damage to the musculoskeletal system
THERAPEUTIC PHYSICAL EDUCATION IN TRAUMATOLOGY, SURGERY AND ORTHOPEDICS
Part three
Chapter 9
Exercise therapy for injuries to the musculoskeletal system (MOD)
Traumais the sudden impact on the human body of environmental factors (mechanical, physical, chemical, etc.), leading to a violation of the anatomical integrity of tissues and functional disorders in them.
There are the following types of injuries: industrial, household, street, transport, sports and military.
There are different types of injuries spicy, arising after a strong simultaneous impact, and chronic– arising after repeated exposure to a damaging factor of low force on a certain part of the body. Injuries may be accompanied by damage to the skin or mucous membranes - this is open injuries(wounds, fractures); can be without damage to the integument - this is closed injuries(bruises, sprains, ruptures, dislocations, bone fractures).
The most common injuries to the musculoskeletal system are caused by mechanical forces: bone fractures, sprains and muscle tears, or sprains, dislocations.
With minor exposure to a damaging factor, local symptoms of injury predominate: redness, swelling, pain, dysfunction. With extensive damage, along with local symptoms, disturbances occur in the central nervous, cardiovascular and respiratory systems, gastrointestinal tract, excretory organs and endocrine glands.
The set of general and local pathological changes in the body when the organs of support and movement are damaged is called; traumatic illness.
A traumatic illness can begin with the development of traumatic shock, collapse or fainting.
Fainting (syncope). Sudden loss of consciousness caused by insufficient blood circulation to the brain. When fainting, dizziness, nausea, ringing in the ears, cold extremities, sharp pallor of the skin, decreased blood pressure.
Collapse. A form of acute vascular insufficiency. It is characterized by a weakening of cardiac activity as a result of a decrease in vascular tone or circulating blood mass, which leads to a decrease in venous blood flow to the heart, a decrease in blood pressure and brain hypoxia. Symptoms of collapse: general weakness, dizziness, cold sweat; consciousness is preserved or clouded.
Traumatic shock. A severe pathological process that occurs in the body as a response to severe injury. It manifests itself as an increasing depression of vital functions - due to disruption of nervous and hormonal regulation, activity of the cardiovascular, respiratory, excretory and other systems of the body. There are two phases in the development of shock: erectile and torpid.
The erectile phase (excitement phase) is characterized by psychomotor agitation, anxiety, talkativeness, and an increase in heart rate and blood pressure.
After 5-10 minutes, the state of excitement gives way to depression - the torpid phase of shock develops. In this phase, there is a suppression of the activity of all body systems, increased oxygen starvation, which ultimately can lead to the death of the victim. The development of traumatic shock depends on the extent, nature of the injuries and their location.
Most often, shock develops with injuries to the pelvic bones and lower extremities, which is associated with damage to large nerve trunks, blood vessels and muscles. Timely and competently provided pre-medical and medical assistance may prevent the development or deepening of shock.
After the patient is removed from the state of shock and treatment begins, a traumatic disease develops, which has its own specifics and symptoms.
Long-term bed rest and immobilization of the injured body segment, usually used for injuries of the musculoskeletal system, improve the patient's condition and reduce the intensity of pain. However, long-term preservation of a forced position (lying on the back), associated with traction, a plaster cast, etc., leads to the fact that a large number of unusual impulses enter the central nervous system, which cause increased irritability of patients and sleep disturbances. Reduced motor activity (hypokinesia) during bed rest has a negative impact on the functional state of various body systems of victims.
In a forced position, the excursion of the chest decreases in patients; congestion develops in the lungs, which can lead to the development of pneumonia.
Hypokinesia also causes changes in activity of cardio-vascular system. There are stagnation phenomena in big circle blood circulation, which can lead to the formation of blood clots, and subsequently to thromboembolism.
Gastrointestinal dysfunction is associated with decreased intestinal motility; constipation and flatulence are observed. At the same time, the evacuation of processed food slows down, and decay products are absorbed into the blood, which causes intoxication of the body.
All these negative phenomena manifest themselves to a greater extent if anesthesia was used during the surgical treatment method.
Long-term immobilization of the damaged segment of the musculoskeletal system causes a number of specific local changes. Develops in immobilized muscles atrophy, which manifests itself in a decrease in size, strength and endurance.
Long-term absence or insufficient axial load in injuries of the lower extremities contributes to the development osteoporosis– decreased bone density as a result of a decrease in the amount of bone substance or loss of calcium. Further; this can lead to bone deformation and pathological fractures.
With prolonged immobility, pronounced degenerative-dystrophic changes also occur in the tissues of the joint and in the formations surrounding it, which is accompanied by a limitation of mobility in the joints - the formation contractures Depending on the participation of a particular tissue in the formation of contractures, they are distinguished dermatogenic(skin, formed due to tightening of the skin), desmogenic(wrinkling of aponeuroses), tendogenic(tendon shortening) and myogenic(shortening muscle scars) contractures. As a result of damage to the joint, there may be ankylosis– complete lack of mobility in the joint caused by bone fusion.
Fracturesis a violation of the anatomical integrity of the bone caused by mechanical stress and accompanied by damage to surrounding tissues and dysfunction of a body segment.
Fractures resulting from pathological process in the bones (tumors, osteomyelitis, tuberculosis), called pathological.
Distinguish open fractures accompanied by damage to the skin, and closed, when the integrity of the goats is preserved.
Fractures may be extra-articular And intra-articular.
Depending on the location, fractures of tubular bones are divided into diaphyseal, metaphyseal And epiphyseal.
In relation to the axis of the bone, they are distinguished transverse, oblique, longitudinal, helical, impacted fractures.
If the bone is damaged with the formation of fragments, then splintered fractures.
When a large number of small bone fragments form, fractures are called fragmented.
Under the influence of external force and subsequent muscle traction, most fractures are accompanied by displacement of fragments: in width, length, at an angle, along the periphery, around the axis (rotational).
With insignificant force of the traumatic agent, fragments can be held by the periosteum and not move - this subperiosteal fractures.
In bones with a spongy structure (spine, calcaneus, epiphyses of long tubular bones), during injury, the mutual penetration of broken trabeculae occurs - a compression fracture
The diagnosis of a fracture is made on the basis of relative (pain, swelling, deformation, dysfunction) and absolute (pathological mobility, crepitus) signs. A conclusion about the presence and nature of a fracture is obtained on the basis of an x-ray.
Treatment of fractures involves restoring the anatomical integrity of the broken bone and the function of the damaged segment. The solution to these problems is achieved through: early and accurate comparison of fragments; strong fixation of reduced fragments - until they heal completely; creating a good blood supply in the fracture area; timely functional treatment of the victim.
To treat diseases and injuries of the musculoskeletal system, two main methods are used: conservative and surgical. Despite the development of surgical treatment methods in traumatology, the conservative method has been the main one until recently.
IN conservative method There are two main stages of treatment: fixation and traction. By means fixation There may be plaster casts and corsets, splints, various devices, etc.
A correctly applied plaster cast holds the associated bone fragments well and provides immobilization of the injured limb. To achieve immobility and rest of the injured limb, a plaster cast fixes 2-3 nearby joints. The variety of plaster casts (Fig. 6) is divided into plaster casts and circular casts.
Basic principles skeletal traction are relaxation of the muscles of the injured limb and a gradual increase in load in order to eliminate the displacement of bone fragments and their immobilization (immobilization). Skeletal traction is used in the treatment of displaced fractures, oblique, helical and comminuted fractures of long tubular bones, some fractures of the pelvis, upper cervical vertebrae, bones in the ankle joint and calcaneus. Currently, the most common traction is using a Kirschner wire, stretched in a special bracket (Fig. 7). The needle is passed through different segments of the limb, depending on the indications. A load is attached to the bracket using a cord, the size of which is calculated using a certain method. After removing the skeletal traction, after 20-50 days (depending on the patient’s age, location and nature of the damage), a plaster cast is applied.
At surgical treatment fractures applied osteosynthesis– surgical connection of bone fragments in various ways. To fix bone fragments, rods (Fig. 8), plates, screws, bolts, wire sutures, as well as various compression devices (Ilizarov apparatus, etc.) are used (Fig. 9).
The advantage of the surgical treatment method is that after fixing the fragments, it is possible to make movements in all joints of the damaged segment of the body, which cannot be done with a plaster cast, which usually covers 2-3 nearby joints.
Bruises.
Damage to tissues and organs without compromising the integrity of the skin is called bruises. Depending on the force of the impact, bruises are classified as light, medium and severe. With mild bruises, small hemorrhages occur with the formation of bruises. With moderate ones, there are more significant hemorrhages with the formation of a bruise. Severe bruises can result in life-threatening internal bleeding.
In case of a bruise, not only superficial tissues can be damaged, but also internal organs - liver, kidneys, etc. A concussion is especially dangerous. Even a short-term loss of consciousness during a fall or vomiting after it requires immediate medical attention. Walking is contraindicated for such a patient; it is better to take him to the emergency room on a stretcher.
First aid measures for bruises are aimed primarily at reducing pain and internal bleeding. Cold is used for this purpose. It is not recommended to apply a bottle of cold water or ice directly to the body: it must be wrapped in cloth.
Sprain.
In case of injuries, violent or awkward movements, when the displacement of the bones in the joint is greater than the permissible value or does not correspond to the usual direction, damage and sprain of the ligaments occurs. Swelling soon develops around the damaged joint and severe pain occurs. Often, sprains are accompanied by damage to blood vessels and hemorrhages.
If a ligament is sprained, the injured joint must be cooled. To do this, you can use a rubber heating pad or a plastic bag with a small amount of cold water or snow, and if this is not possible, just a wet cloth. After 15 - 20 minutes, the joint should be tightly bandaged, and the victim should be taken to a medical facility.
Dislocations of joints.
With significant sudden movements in the joints, the matter is not limited to spraining the ligaments. In these cases, displacement of the ends of the bones forming the joint is possible - dislocation: the head of one bone may partially or completely come out of the articular cavity of the other. As a result, the contact of the articular surfaces is disrupted. The slightest movement causes acute pain in the damaged joint. First aid should consist of applying cold, ensuring complete rest of the injured limb and immediately transporting the victim to a medical facility.
Bone fractures.
A complete or partial disruption of the integrity of a bone is called a fracture. If the skin and muscles are not damaged, fractures are classified as closed, and if violated - to open. It can be quite difficult to distinguish a fracture from a bruise. Signs indicating the presence of a fracture are the following: acute pain when trying to change the position of the damaged part of the body, the appearance of mobility in places where it should not be.
For open fractures, you must first stop the bleeding and treat the wound and apply a bandage. You should not try to force the bones into their natural position, as broken ends of the bones can damage soft tissue, rupture a blood vessel, or damage a nerve. The affected part of the body must be immobilized, that is, it must be fixed.
If an arm or leg is injured, a splint is placed on it. To do this, use either special medical splints or improvised means - planks, cardboard. The splint must cover at least two adjacent joints. The splint is applied from the side of uninjured tissue areas. There should be soft fabric - cotton wool or clothing - under the splint. You cannot put a splint on a naked body. The splint is not bandaged very tightly: it should not put pressure on the damaged surface.
If the bones of the shoulder, forearm and hand are fractured, it is advisable to bend the arm at the elbow and, in addition to the splint, secure the arm with a scarf. You can tie the ends of the scarf around your neck and put your hand with a splint in it. If you don’t have a scarf, you can pin the half of the jacket on the side of the affected hand to the lapel of the jacket and put your hand in the resulting fold
If the femur or leg bones are fractured, a splint is applied along the outstretched leg. As a last resort, you can bandage the sore leg to the healthy one.
If the bones of the chest (ribs, sternum) are fractured, a splint cannot be applied. The victim is asked to hold his breath during the exhalation phase and apply a tight bandage. After this, he is allowed to breathe, but shallowly, and is taken to the emergency room.
For spinal injuries, the victim is placed face down on a flat floor. It is impossible to seat, let alone transport or carry the victim in a sitting position.
For skull injuries, the victim is placed on his back. The head is fixed with a roller made of clothing or a blanket. The cushion is placed in the shape of a horseshoe to keep the head motionless. The victim's face should be turned to the side in case of vomiting. You can't put your head on the pillow.
QUESTIONS
Damage to the musculoskeletal system
| Type of damage | Characteristic signs | First aid |
| Sprain | Sharp pain in the joint when moving, its swelling; when ruptured - bruising | Pressure bandage, cold |
| Dislocation | Severe pain, joint immobility, change in joint shape | Provide rest to the joint, apply a splint, cold; painkiller |
| Fractures | ||
| Sharp pain, extensive bruising, swelling, inability to move, or abnormal movement or bone deformity | Immobilize - apply a splint; painkillers |
| Sharp pain, damage to the skin, possibly bone fragments visible from the wound. Do not set bone fragments! | If there is bleeding, apply a tourniquet; sterile gauze bandage ( remember the rules of asepsis and antiseptics); tire; painkillers |
Severe sharp pain in the left shin area, swelling. Abnormal leg mobility. In this case, there is swelling and pain in the ankle joint.
Determine the diagnosis. Help; determine transportation.
№2 Aching pain in the knee joint (right leg). Swelling and pain when moving gradually develop. In addition, the victim complains of pain in the shoulder (right) after a fall, but although moving the arm is painful, there are no other external signs. Determine the diagnosis. Help. Determine the method of transportation.
After a sharp jump and falling on his side, the victim feels severe pain in his right thigh and it is impossible to move his leg. The left joint (ankle) was very swollen and turned blue. Assume the type and extent of damage. Provide assistance; method of transportation.
№4 The victim fell on his outstretched arm. The right elbow joint is swollen and feels severe pain. There is also swelling on the index finger of the right hand. Help. Suggest a method of transportation.
The victim complains of pain in the forearm. Bone fragments sticking out of the wound. The patient periodically loses consciousness.
Determine the type of damage.
Help.
Suggest a method of transportation. **The correctness of the task is assessed by a medical professional, “bandage specialists from other teams.”
Additional questions for consolidation:
1. Why are fractures less dangerous in youth than in old age? (In youth, there is still a lot of cartilaginous tissue in the skeleton, and organic substances in the bones, so bone tissue is quickly restored).
2. Why does swelling appear when a ligament is sprained or torn? (Articular fluid leaks out, hemorrhage occurs - inflammatory effect).
3.What is “habitual dislocation”? Who does it happen to? (For athletes. There is a very large load on the joints, so the ligaments lengthen and the bones come out of the joints).
1. During a multi-day hiking trip in the taiga, a tourist twisted his foot. The ankle joint quickly swells and acute pain makes it impossible to step on the affected leg. Indicate first aid measures. How to help the victim in the following days?
(To the injured tourist from acute pain the cold will help. To do this, you can place your foot in a forest stream or apply a plastic bag with cold water. It is necessary to apply a tight bandage to the ankle joint and ensure rest. It is advisable not to walk. This is most likely a sprain.)
2. After falling off a bicycle, the boy began to complain of pain in the shoulder joint. The patient can lift left hand, but pain, redness and swelling indicate injury. What would you diagnose?
(If the joint has retained its mobility, in case of a dislocation it is impossible to raise the arm, as in the case of a fracture, most likely the victim has a sprain or bruise of the joint, ruptures of the joint capsule and ligaments are possible).
3. A group of tourists, having walked a long distance, find a place to rest on the wooded bank of the river. Heavy backpacks have been dropped. The youngest, the most impatient, taking off their clothes as they go, run to the river. One jumps headfirst into clean, clear water with a running start. But for some reason he stayed under water for a long time? And then a strangely limp, seemingly lifeless body emerges. Comrades rush to the rescue and pull the diver ashore. What happened?
(Apparently, the young man dived and hit his head either on the bottom of the reservoir, or on some object that was under water. Probably, a fracture and dislocation of the cervical vertebra occurred. This is a very serious injury. In 70% of cases, such injuries are fatal. If If the victim is saved, he often remains disabled. The diver must be picked up under the arms, turned towards him, placed on his hip, and his head must be supported under water. On the shore, he must be placed on his back on a hard, flat surface. it must be immobilized. Call an ambulance. Before diving, find out the depth of the reservoir, examine its bottom. Remember, your life and safety depend on your caution).
Testing.
In what sequence should pre-medical care be provided for a dislocated joint?
A. Take the victim to a doctor.
B. Immobilize the limb.
B. Apply cold to the damaged area.
D. Bandage the damaged joint tightly.
What should you do when helping a person with a fractured ulna?
A. Apply a splint.
B. Send the victim to a doctor.
B. Cover the limb with soft material.
D. Bandage the splint to the limb.
4. Testing the mastery of skills in providing first aid for skeletal injuries. (Group work on completing task assignments followed by defending answers.)
· A person has a fractured ribs of the chest. Describe your actions and justify them.
· A person has an open fracture of the lower leg. Describe your actions and justify them.
· A person has a fracture of the humerus. Describe your actions and justify them.
(Demonstrate techniques for providing assistance on human models. The school doctor participates in checking the performance of the work.)
Related information.
Municipal Educational Institution
Secondary school No. 11 named after P. M. Kamozin
Examination essay on life safety
"Injuries to the musculoskeletal system. First aid for these injuries"
Bryansk 2009
Introduction
Sprains and ligament tears
Bone fractures
Traumatic brain injury
Literature
Introduction
Soft tissue injuries are extremely common and account for 50–70% of all injuries. According to the mechanism and the resulting functional and anatomical disorders, closed and open injuries are distinguished. The first includes bruises, sprains and ruptures, the second - fractures.
Depending on the predominant damage to a particular tissue, damage to the skin, muscles, tendons, ligaments, periosteum, and cartilage is distinguished.
Many nosological forms of soft tissue damage fall under the competence of a polyclinic or family doctor.
Types of musculoskeletal injuries:
Sprains and tears
Fractures
Bruises
Bruises – mechanical damage soft tissues without visible violation of the integrity of the skin. They occur when struck with a blunt object or when dropped from a small height onto a flat surface. With bruises, as a rule, there are no serious anatomical damage tissues or organs. Bruises can be part of wounds; such wounds are called bruised. Bruises are also observed with closed bone fractures resulting from a direct blow (for example, so-called bumper fractures).
Bruises are the most common type of injury, which can occur either independently or accompany other more severe injuries (dislocations, fractures, internal organs). Most often we encounter bruises of the skin and subcutaneous tissue, however, bruises of internal organs (bruise of the brain, heart, lungs) are also possible.
For bruises, changes in the vessels are most characteristic - the permeability of their walls is impaired, which is accompanied by swelling and often hemorrhage into the surrounding soft tissue or in the joint cavity. Multiple bruises are often accompanied by a pronounced general reaction with an increase in body temperature and intoxication. Thus, with small impacts in the area of the thigh, buttocks, and back, which are rich in soft tissue, limited bruises occur, often without external manifestations or clinical symptoms. With bruises of the joints, damage to the vessels of the capsule is possible, which is accompanied by hemorrhage into the joint cavity. Hemorrhage into soft tissues leads to their saturation with blood. In the case of an oblique blow, detachment of the skin and subcutaneous tissue is possible with the formation of hematomas.
In areas where large blood vessels pass (femoral, brachial arteries), bruises or tears in the walls of the vessels sometimes occur, followed by thrombosis. As a result, soft tissue necrosis is possible.
With bruises in the area where the peripheral nerves (most often the ulnar, radial and fibular) are located close to the bone, symptoms of loss of their function appear. Usually, sensory and motor disturbances quickly pass, but sometimes with intra-trunk hemorrhages or compression by a hematoma they persist long time.
The most common clinical signs of soft tissue bruises of the extremities or trunk are pain at the site of application of force and traumatic swelling. After some time (the period depends on the depth of the hemorrhage), a bruise appears on the skin. It is impossible to accurately judge the strength and nature of the blow by its size. With deep bruises or with increased fragility of blood vessels (with hypovitaminosis C, in elderly people), extensive bruises occur, descending downwards in relation to the site of injury under the influence of gravity. The color of the bruise is an important criterion for determining the age of the bruise.
With bruises of the abdomen and lumbar region, ruptures of the liver, spleen, and kidneys are possible.
With a significantly strong blow to the chest, damage to soft tissues and lungs is possible. The clinical sign of lung contusions is pain when breathing. Decreased breathing in the area of the bruise is characteristic.
Often with closed chest injuries, heart contusions occur (for example, when a driver hits his chest with steering wheel cars). Victims complain of pain in the heart area, and collapse often occurs. To clarify the diagnosis, electrocardiographic and echocardiographic studies are performed.
Treatment of bruises
Treatment of soft tissue bruises during the first 24 hours consists of local application of cold for the purpose of hemostasis, reducing pain and swelling. For this purpose, you can apply an ice pack, a heating pad with cold water, etc. to the damaged area. A pressure bandage is applied to the area of the bruised limbs. Extensive bruises of the extremities must be differentiated from fractures and dislocations. In these cases, a transport splint is applied and the victim is taken to the surgical department. From 2-3 days, to speed up the resorption of hemorrhage, a warm compress, a warm heating pad, warm baths, and UHF therapy are prescribed. Somewhat later, massage and therapeutic exercises are used, especially for bruises of large joints or the periarticular area. In cases of subcutaneous hematoma formation due to hemarthrosis, puncture and removal of blood is indicated.
If a bruise of the abdomen, chest or heart is suspected, emergency hospitalization in the surgical department is indicated.
Dislocations
Dislocation is a persistent mutual displacement of the articular ends of articulating bones beyond the limits of their physiological mobility, accompanied by dysfunction of the joint. With complete dislocation, the articular surfaces of the displaced bones completely lose contact with each other. In case of incomplete dislocation (subluxation), they partially touch.
Dislocations are distinguished between congenital and acquired. In turn, acquired ones are divided into traumatic, pathological and habitual.
Congenital dislocations are usually caused by a violation of intrauterine development. The most common are congenital hip dislocations.
Traumatic dislocations are the most common type and account for 2-4% of all skeletal injuries, 80-90% of all other dislocations. They occur in all age groups, but predominantly in men aged 20-50 years, who account for 60-75% of injuries.
Habitual dislocations are most often observed in the shoulder joint. Such dislocations occur repeatedly, sometimes as a result of insignificant physical effort or during any specific movement in the joint.
Pathological dislocations occur with lesions of the joints, accompanied by destruction of the articular ends of the bones, for example with tuberculosis, osteomyelitis, as well as with some organic diseases of the nervous system, occurring with the development of flaccid paralysis.
The cause of dislocations is most often injuries of an indirect mechanism - violent movements that exceed the functionality of the joints. In this case, as a rule, the joint capsule and partially the ligamentous apparatus are torn, and the surrounding soft tissues are injured. Sometimes all the coverings of the joint are destroyed, including the skin - in such cases they speak of an open dislocation. In addition, dislocations can be complicated by fractures (fracture dislocation).
Based on the time elapsed since the articulation was disrupted, dislocations are divided into fresh, stale and old. Dislocations are considered fresh when no more than 3 days have passed since the injury, stale - from 3 days to 3 weeks, old - 3 weeks or more.
Types of dislocations:
Dislocation of the vertebrae
Clavicle dislocation
Shoulder dislocation
Forearm dislocation
Dislocation of the wrist bones
Metacarpal dislocation
Dislocation of fingers
Dislocation of the pelvic bones
Hip dislocation
Dislocation of the lower leg
Patella dislocation
Dislocation of the foot bones
Treatment of dislocations
First medical aid for a traumatic dislocation consists of administering painkillers and ensuring complete rest of the injured limb using a transport splint or fixing bandage.
Depending on the location and degree of mutual displacement of the articular ends of the bones, as well as on the means available to the doctor, local, conduction or general anesthesia is performed. For dislocations of the shoulder, forearm, phalanges of the fingers and toes, ankle joint, collarbone, patella, good pain relief and sufficient muscle relaxation are achieved by intra-articular injection of a 1 or 2% solution
novocaine Hip dislocations, as well as recent dislocations of other locations, can be reduced only under anesthesia. Old and irreducible dislocations are reduced surgically. The duration of immobilization after a traumatic dislocation of the shoulder is 3-4 weeks, the forearm is up to 2 weeks, the hip is up to 4 weeks, the collarbone is 4-6 weeks.
A patient with a habitual dislocation is immediately referred to a doctor. In such cases, surgical intervention is performed in the hospital aimed at strengthening the ligamentous apparatus of the joint.
Treatment of pathological dislocation is carried out in a specialized hospital. It is aimed primarily at the underlying disease and the possible restoration of the function of the affected joint.
Sprains and ligament tears
Damage to tissue with partial rupture while maintaining anatomical continuity is called stretching. Joint sprains are more common. The mechanism of injury is caused by tissue stretching by two forces acting in opposite directions when the body, organ or area is fixed. Usually when falling, lifting heavy objects, running, etc.
A muscle or tendon rupture is a fairly rare injury. It requires excessive effort to occur. The rupture most often occurs in the muscles that experience the heaviest stress - the biceps of the arm or the triceps of the calf. A tendon rupture (a muscle ruptures extremely rarely) is manifested by the formation in the area of the shoulder or lower leg of a relief that is uncharacteristic for these parts of the body - hunching of the muscles. This is accompanied by severe pain and immobility of the limb.
If the acting force exceeds the resistance of the tissues, then ligaments, fascia, muscles, tendons, nerves, etc. rupture.
Sprains are the most common musculoskeletal injury encountered in everyday life. It manifests itself as pain in the joint area. The pain usually does not go away for a long time, although there are no external manifestations of the injury.
A sprain does not require special treatment; you usually need to create rest conditions for the injured joint. A faster restoration of joint function is facilitated by the use of certain medicines.
Clinically, ligament rupture is characterized by the appearance of severe pain, impaired movement, hemorrhage into the soft tissues, and sometimes into the joint cavity (hemarthrosis), its edema, and swelling. For example, filling with blood knee joint raises the patella above the articular surfaces of the bones. When you release pressure on the knee pads, you can feel it hit the bone and then rise again (symptom of patella balloting). The main concern in these cases is to ensure rest and apply a pressure bandage to fix the joint. After resorption of the hemorrhage, from the end of 2 weeks after the injury, they proceed to careful active movements, physical therapy, and physiotherapeutic procedures. With extensive hemorrhages into the joint, scars and cords form on the synovial membrane, which sometimes lead to a significant limitation of joint mobility.
The fascia covering the muscle is rarely torn. This usually occurs from a direct blow to them. The result of damage is a slit-like defect in the fascia, which, when the muscle contracts, leads to its protrusion (muscle hernia). The treatment for these ruptures is surgery.
Complete or incomplete muscle ruptures are rare and usually occur with strong and rapid contraction, when lifting heavy weights or when falling.
Pathologically altered muscles are more likely to rupture. When a muscle is completely ruptured, its contracted ends diverge. Main symptoms: pain, hemorrhage and transverse muscle defect upon palpation. Rest, immobilization of the limb, cold on the area of injury, and subsequently physiotherapeutic procedures and physical therapy - treatment of incomplete muscle ruptures. Complete ruptures are treated promptly.
Falling, lifting heavy objects, etc. can lead to rupture of the tendon or to its separation from its attachment with a piece of bone.
Treatment of ligament tears and sprains
Treatment of both complete and partial ligament injuries is aimed at restoring their integrity and mechanical strength.
Treatment of ruptures is only surgical - suturing the torn tendon.
In some cases, a tight bandage of the joint is necessary to immobilize it.
The basis of treatment is early pain relief and anti-inflammatory therapy of soft tissues. For this purpose, methods of hirudotherapy, reflexology, and apitherapy are used.
Treatment with leeches perfectly relieves swelling and eliminates inflammation.
A special therapeutic massage restores mobility to damaged muscles.
In some cases, physical therapy and dry heat are necessary.
And in the treatment of severe sprains of the spine, kinesiotherapy aimed at stretching it is indispensable.
Bone fractures
A fracture is a violation of the anatomical integrity of a bone due to trauma. Most often, fractures occur after road traffic accidents. There are transverse, longitudinal, oblique, helical, T-shaped, Y-shaped, stellate and perforated fractures. The fracture can also be complete or incomplete, open or closed. In case of an incomplete fracture - part of the diameter of the bones, a crack. With a complete fracture - complete crumbling of the bones. With fractures, displacement of bone fragments in the victim’s body is observed. The general condition of victims with most fractures is satisfactory or moderate, less often severe. However, with multiple fractures, especially in the presence of open or combined injuries, as a rule, a severe or extremely severe condition, and sometimes traumatic shock, quickly develops.
Signs of fractures:
Sharp pain to the point of shock (increased with the slightest movement and load on the limb)
Changing the position and shape of a limb
Impaired limb function, i.e. inability to use a limb
Swelling, bruising, hematomas, shortening of the limb
With an open fracture, the following is observed:
Bleeding, pain, open wound
Protrusion of bone fragments
First aid for fractures:
Create immobility in the fracture area
Fast and prompt delivery of the victim to the nearest medical institutions
Immobilization - creating immobility of bones in the area of the fracture, which reduces pain and prevents shock, applying a splint - Dietrich or Kramar.
Healing of fractures
The nature of restoration of skin integrity depends on a number of general and local factors. The general ones include the age of the patient, his physical and neuropsychic state, constitution, function of the endocrine system, metabolism, nutritional status, etc. In children, fusion occurs much faster than in adults. Delayed fracture healing is observed in cases of hypovitaminosis, diabetes mellitus, radiation sickness, etc. The duration of fusion is influenced by local factors such as localization, degree of displacement and mobility of fragments.
Types of fractures:
Fractures of the ribs of the sternum and the girdle of the upper limb:
Rib fractures
Sternum fractures
Clavicle fractures
Scapula fractures
Fractures of the bones of the upper limb:
Shoulder fractures
Forearm fractures
Fractures of the bones of the hand
Fractures of lower limb bones
Hip fractures
Fractures of the bones forming the knee joint
Tibia fractures
Ankle fractures
Foot fractures
Traumatic brain injury
Vertebral body fractures
Damage to vertebral ligaments
Damage to intervertebral discs
Complicated spinal fractures
Vertebral body fractures
Injuries to the pelvis and pelvic organs
Fractured ribs
Rib fractures occur with severe direct impact in the chest, falling from a height. Fractures of one or more ribs may occur.
Signs of a rib fracture:
Sharp pain in the area of the fracture, which intensifies with breathing
Respiratory failure
Internal bleeding
Pulmonary punctures
First aid :
Immobilization of the victim's body
Apply a circular bandage to the chest
Give painkiller
Transport the victim to a hospital facility
In case of a severe fracture, transport the victim on a stretcher in a half-lying, half-sitting position.
Clavicle fracture
A clavicle fracture is often observed when the victim falls on a straight, outstretched arm. A fracture of the collarbone leads to complete immobilization of the victim's arm.
Signs of a fracture:
Severe pain in the shoulder area
Immobility of a limb
Soft tissue swelling
First aid:
Immobilization in the area of the fracture - fix the victim’s arm using a bandage
Give the victim painkillers
Immediate transportation of the victim to a hospital facility
Spinal fractures
Spinal fractures are observed when falling from a height, falling over heavy objects, with a direct strong blow to the back, or in car accidents.
Spinal injuries are classified as severe and account for 0.2 to 6% of all musculoskeletal injuries. Destruction of some part of the spine can occur due to a direct or indirect mechanism of violence. In the first case, it is a blow inflicted on the spine by a hard object or a similar injury when the victim falls. The only difference is that in the first option the wounding projectile moves, and the spine remains motionless, while in the second option everything happens the other way around.
Signs:
Severe sharp pain in the back, the slightest movement leads to sharp pain
Sensory impairment
Paralysis of the limbs (lack of sensation in the limbs)
It is forbidden to sit down or lift the victim, or give him any position!
First aid:
Create silence
Place the victim on a hard surface
Call an ambulance and quickly transport the victim to the nearest hospital facility
Pelvic fracture
When a fracture occurs, damage to internal organs and the victim's state of shock are observed. The causes of the fracture are a fall from a height, compression, or a direct blow.
Signs:
Severe sharp pain in the pelvic area when moving
If the pelvis is damaged, the patient is in a frog-shaped position
First aid:
Place the patient in the same position in which they were found
Place a tight roller 25-30 cm high under your knees
Undertake an anti-shock venture
Transport the victim to a hospital facility
Traumatic brain injury
Traumatic brain injury is damage to the skull and brain as a result of mechanical impact.
When the brain is damaged, problems occur cerebral circulation, liquor circulation, etc. Brain edema develops, which, together with other reactions, causes an increase in intracranial pressure. There are closed and open craniocerebral injuries. Closed injuries include those in which the integrity of the scalp is not damaged or there are wounds to the soft tissues of the head. With open injuries, there are fractures of the bones of the calvarium with injury to adjacent tissues or a fracture of the base of the skull, accompanied by bleeding or liquorrhea (from the nose or ear).
The following clinical forms of traumatic brain injury are distinguished: concussion; mild, moderate, severe brain contusion; brain compression.
Brain concussion observed in 60-70% of cases of traumatic brain injury. The main clinical sign is loss of consciousness, lasting from a few seconds to several minutes. Nausea and vomiting are often observed. After regaining consciousness, there are usually complaints of headache, dizziness, general weakness, tinnitus, flushing, sweating, sleep disturbances. Amnesia is often observed - the patient does not remember the circumstances of the injury, nor the short period of events after it.
Brain contusion– a more severe form of brain damage, differing from a concussion by the presence of areas of damage to the brain substance. A mild brain injury is characterized by loss of consciousness for a period of several minutes to 1 hour. A moderate cerebral contusion is accompanied by loss of consciousness for a period of several tens of minutes to 4-6 hours. Amnesia is pronounced, and mental disorders are sometimes observed. A severe brain injury is characterized by loss of consciousness for a period of several hours to several weeks. There are threatening disturbances in vital functions with a disorder in the frequency and rhythm of breathing, a sharp increase or decrease in blood pressure, and fever.
Among the causes of cerebral compression come first intracranial hematomas(epidural, subdural, intracerebral), then depressed fractures of the skull bones, etc. It is characterized by the following symptoms: increased headache, repeated vomiting, psychomotor agitation, unilateral dilation of the pupil, increased blood pressure, limited upward gaze, etc.
Traumatic brain injury is one of the most common injuries and accounts for 50-60% of their total number, and if we consider that the mortality rate for severe injuries of the skull and brain reaches 70-80%, it becomes clear that all doctors are required to know this nosological form , including non-surgical specialists.
First aid:
Create peace, reassure the victim
Give a stationary position
Apply a cold compress
Transport the victim to a hospital facility
Literature
Great Soviet Encyclopedia 1975
Housekeeping tips. Murmansk book publishing house 1973
B.V. Petrovsky. Brief medical encyclopedia in three volumes. Publishing house " Soviet encyclopedia" 1989, 1990
G. Z. Minedzhyan collection "Medicine and Health". Publishing house "Technoecos" 1991
Journal "Faculty of Health" for 1990 Issue No. 5
Monthly "Your Health" for 1989 Issue No. 2
Great Soviet Encyclopedia 1975
Housekeeping tips. Murmansk book publishing house 1973
B.V. Petrovsky. Brief medical encyclopedia in three volumes. Publishing house "Soviet Encyclopedia" 1989,1990.
Causes of the disease
Injuries to the musculoskeletal system are one of the most common injuries in industrial and transport accidents, as well as in areas of natural disasters. According to WHO statistics, severe mechanical injuries among the causes of mortality are second only to tumors and cardiovascular diseases, especially in people under 45 years of age.
Mechanisms of occurrence and development of the disease (pathogenesis)
Physiological regeneration is the restructuring of bone tissue during which partial or complete resorption of bone structures and the creation of new ones occurs.
Reparative (restorative) regeneration is observed in case of bone fractures. Restoration of the integrity of damaged bone occurs through the proliferation of cells of the cambial layer of the periosteum (periosteum), endosteum, poorly differentiated pluripotent cells of the bone marrow stroma, as well as as a result of metaplasia of poorly differentiated mesenchymal cells of paraosseous tissues. In histology, it is customary to call bone formation in the place of fibrous connective tissue desmal: in the place of hyaline cartilage - enchondral, in the area of accumulation of proliferating cells of skeletogenic tissue - bone formation of the mesenchymal type. Stages of reparative bone regeneration:
- catabolism of tissue structures, dedifferentiation and proliferation of cellular elements,
- formation of blood vessels,
- formation and differentiation of tissue structures,
- mineralization and restructuring of the primary regenerate and bone restitution.
Practical scheme for bone tissue regeneration: proliferation of cellular elements, disruption of aerobic metabolism, loss of apatite, crystallization, osteoclasts and resorption, priority growth of bone tissue.
There are (T.P. Vinogradova, G.N. Lavrishcheva, V.I. Stetsula, E.Ya. Dubrov) three types of reparative regeneration of bone tissue:
- according to the type of primary,
- primary detainee,
- secondary bone fusion.
Primary fusion - diastasis up to 50-100 km, complete immobilization.
Primary delayed - complete absence of a gap, complete immobilization - fusion only along the Haversian tubules.
Secondary bone fusion - displacement of fragments, mobility - callus passes through the desmal and enchondral stages.
Clinical picture of the disease (symptoms and syndromes)
The clinical picture of damage to the musculoskeletal system is represented by the following symptoms: pain, swelling, deformation at the level of damage and dysfunction of the injured segment. Depending on the severity of the injury, the body’s compensatory response—traumatic shock—is expressed to a greater or lesser extent. The most shocking are: hip fractures, spinal fractures and pelvic injuries. In addition, it should be borne in mind that the development of shock may be due to the presence of damage to several less significant segments. Moreover, in conditions of polytrauma or combined trauma, a potentiation effect, or the so-called phenomenon of mutual aggravation, is observed. In other words, the severity of changes in the body's homeostasis is more pronounced than when simply summing up the changes caused by each specific injury.
Pathogenetic factors causing the development of traumatic shock are pain and blood loss. Bleeding due to damage to the musculoskeletal system can be either external (open injuries) or internal. Moreover, overestimation, as a rule, of external blood loss is accompanied by an underestimation of internal bleeding. It is not possible to determine the deficit of circulating blood volume in conditions of mass admissions of patients, especially in the source of an emergency. Therefore, data on the estimated volumes of blood loss in closed fractures are extremely important.
It is also necessary to take into account the fact that in case of bone fractures, especially the epimetaphyseal zone, bleeding usually continues for three days, so there is a lack of circulating blood volume without infusion therapy increases over time.
Local symptoms of damage to the musculoskeletal system, as a rule, make it possible to identify limb injuries without much difficulty and provide appropriate assistance. It should be noted that special attention is needed to the diagnosis of closed injuries of the great vessels. The clinical picture is presented by the following signs: absence of pulse in the peripheral segments of the extremities, pallor of the skin and decrease in temperature distal to the site of injury, absence of active movements, and after a few hours - joint contractures. The following types of vascular damage are possible:
- gap;
- contusion followed by thrombosis;
- compression of the vessel by displaced bone fragments.
Particular attention should be paid to fractures and dislocations of bones at the level where the arterial trunks most closely adhere to the elements of the musculoskeletal system.
Most often, trauma to the main arteries accompanies the following skeletal injuries:
- collarbone fracture - injury subclavian artery;
- fracture of the shoulder and dislocation of the forearm - damage to the brachial artery;
— fracture of the lower third of the femur and fracture dislocation at the level of the knee joint;
- damage to the popliteal artery.
Victims with suspected damage to the main arteries should be immediately evacuated to specialized departments, since the lack of blood circulation in the distal extremities for more than four hours may lead to the need for their amputation.
Diagnosis of the disease
Diagnosis of spinal injuries, especially at the prehospital stage, is quite difficult. The only symptom of an uncomplicated injury may be pain that worsens with movement. However, in emergency situations, often the victims themselves, and even medical personnel, do not attach much importance to this sign. Determining the mechanism of injury can provide some assistance in making a diagnosis. For example, sharp bending or throwing back of the head at the time of injury can lead to quite severe injuries at the level cervical region spine; falling from a height onto straight legs, fractures of the heel bones are often accompanied by damage to the lumbar spine. Therefore, in this situation, preference should be given to overdiagnosis.
Reliable and relative signs of a fracture.
- X-ray diagnostics
- Computer and NMR diagnostics of fractures.
Treatment of the disease
Urgent Care
Medical care for victims with damage to the musculoskeletal system includes the following elements:
— termination of the traumatic factor;
- stopping external bleeding;
— antishock therapy;
— application of an aseptic dressing;
- immobilization.
Extracting victims from under the rubble and destroyed vehicles often results in additional trauma. A surge of additional pain impulses when the body position changes in victims with injuries to the musculoskeletal system, resumption of stopped bleeding, getting into bloodstream toxic products in patients with long-term crush syndrome can lead to a sharp deterioration in the victim’s condition. Therefore, a preliminary assessment of the nature and severity of injuries, as well as pain relief, are necessary elements providing medical care at this stage. After removing a victim with existing external bleeding, it is necessary to stop it. Among the small arsenal of techniques and means used for these purposes, preference is given to applying a tourniquet or a pressure bandage, and if instruments are available, applying a clamp or ligating an artery in the wound.
It should be noted that applying a tourniquet in many cases is unjustified:
- firstly, the indication for applying a tourniquet is damage to large, main arteries - brachial, femoral and popliteal, open injuries of which are extremely rare. In all other cases, applying a pressure bandage is sufficient;
- secondly, the use of improvised means as a tourniquet leads to the application of a so-called venous tourniquet, which, creating venous stagnation with normal arterial inflow, leads to significant blood loss even from small superficial wounds.
After stopping the bleeding, the severity of the patient’s general condition is assessed and, if necessary, infusion anti-shock therapy is started, the main elements of which in traumatic shock are pain relief and restoration of circulating blood volume. Both general anesthesia with narcotic and non-narcotic analgesics and local blockade with weak anesthetic solutions in the fracture area are possible.
For infusion therapy, the use of any solutions, both saline and blood substitutes, is indicated. At this stage of medical care, the principle of restoring circulating blood volume is important. The main indicators of the adequacy of antishock therapy are a decrease in the frequency of respiratory movements, a decrease in tachycardia, and stabilization of blood pressure.
When applying aseptic dressings, it is advisable to use so-called wound preservatives, such as the aerosol preparation tsimezol, or water-soluble ointments - levosin, levomikol. The use of these drugs makes it possible to delay the development of infection in the wound for up to 24 hours, which allows delaying wound care or primary surgery. surgical treatment.
Pain relief is one of the main elements of antishock therapy. At this stage, the use of parenteral analgesics, both narcotic and non-narcotic, is mandatory. Along with central analgesia, it is also possible to use local anesthesia in the fracture area with weak anesthetic solutions. An indicator of the correct injection site for the anesthetic is the flow of blood into the syringe from the hematoma formed at the fracture site.
Immobilization, stopping or reducing the mobility of fragments at the level of injury, reduces pain impulses and reduces the risk of additional injury to soft tissues, blood vessels and nerves from bone fragments.
In our country, perhaps the only means used for immobilization during transportation of victims is the Kramer ladder splint. Quite primitive and easy to use, the Kramer splint, however, when applied correctly, provides reliable immobilization necessary for transporting the victim. To immobilize the lower extremities, Thomas and Dieterichs splints can be used. Pneumatic tires, which are put on a limb in the form of a stocking and then inflated using chemical reactions, have become widespread abroad. It is also possible to use improvised tires. In addition, in the absence of standard and improvised means for immobilization, the method of fixing one injured lower limb to the other and fixing the upper limb to the body is used. The main rule and necessary condition for transport immobilization for traumatic injuries of the extremities is the fixation of two joints adjacent to the segment of injury. For example:
— hip fracture: immobilization of the hip and knee joints;
— tibia fracture: immobilization of the knee and ankle joints;
- fracture of the shoulder: fixation of the shoulder and elbow joints;
— fracture of the forearm: fixation of the elbow and wrist joints.
It is especially necessary to dwell on immobilization in the so-called forced positions of the limbs. Such positions are usually found with dislocations. So, for example, with an axillary dislocation of the shoulder, the upper limb is raised above the head and held in this position by the healthy hand; with the most common posterior hip dislocation, the lower limb is bent at the hip and knee joints, adducted and internally rotated; for obturator dislocation of the hip - abducted outward to 90 degrees and rotated outward. In such situations, one should in no way try to restore the normal position of the limb, but should immobilize the limb in the existing forced position.
Immobilization in case of damage to the spine and pelvic bones is carried out by laying the patient on his back on a flat, hard surface. If the cervical spine is damaged, the patient is placed with the head tilted back slightly (a bolster under the back of the neck) to give the cervical spine an extension position.
If the pelvis is damaged lower limbs should be in a position of bending in the hip and knee joints at an angle of 30-40 degrees (the so-called frog pose), which leads to maximum relaxation of the muscles attached to the pelvic bones and a decrease in pain. Technically, this position is achieved by placing a bolster of the appropriate size under the knee joints.
Transportation of patients with injuries to the musculoskeletal system, especially if it continues for a long time, must be accompanied by analgesia (repeated administration of analgesics or repeated novocaine blockades), as well as, if necessary, infusion therapy.
Providing assistance to victims with injuries to the musculoskeletal system in a specialized hospital
Conservative treatment
When a patient is admitted to a specialized hospital against the background of ongoing anti-shock therapy (if necessary), an assessment of the severity of existing injuries and x-ray diagnosis of fractures are carried out. During a traumatic illness, two periods should be distinguished: hypocoagulation and hypercoagulation.
In the first three days, hypocoagulation syndrome occurs. This is caused by the fact that after an injury, heparin is released from damaged tissues. In addition, a decrease in the absolute amount of coagulation factors (due to their consumption for thrombosis of injured vessels) is combined with a decrease in their concentration in the circulating blood due to massive infusion therapy.
From the 4th-5th day the state of hypercoagulation increases, i.e. tendency to thrombus formation, which can cause thromboembolic complications.
This specificity of the course of the post-traumatic period should be taken into account in drug therapy. If in the first days it is necessary to use drugs that improve blood clotting, then from the 4-5th day - anticoagulants.
The system of treatment of isolated injuries of the musculoskeletal system is currently quite fully developed and is discussed only from the point of view of the preference given by one or another school to one or another method of treatment.
Regarding polytrauma, there is still no unified approach to the tactics of treating fractures. This is due to the presence of a large number of specific factors:
— serious condition the victim upon admission, which continues after recovery from shock;
- the need to combine two tasks - saving lives and rational treatment of fractures;
- frequent occurrence of local and general complications;
— the need to ensure the mobility of the victim for repeated diagnostic and therapeutic measures related to shifting and transporting the patient;
— level of technical equipment, experience of medical personnel and drug supply;
— correspondence of the number of victims to the forces and means of the medical institution.
Basic methods of treating fractures:
- closed reduction with application of a fixing bandage,
- skeletal traction, incl. damper,
- surgical therapeutic immobilization during surgical treatment.
Conservative treatment methods in polytrauma conditions have limited results.
Conservative treatment methods include skeletal traction and plaster casting. Skeletal traction can be successfully used for fractures of the femur, humerus, and lower leg bones. Providing the possibility of good comparison of fragments, the method allows for early development in the joints adjacent to the fracture site. In addition, traction can be used as a method of gradually reducing fragments with subsequent application of a plaster cast (fracture of the tibia, calcaneus, etc.).
Plaster immobilization as a method of treating fractures can be used in two cases:
- fractures without displacement or impacted fractures;
— fractures for which immediate manual reduction is possible.
The disadvantages of one of the most ancient methods of treatment (immobilization) include the possibility of secondary displacement of fragments, as well as immobilization contractures in the joints.
The choice of treatment method for a patient with damage to the musculoskeletal system in each specific case is based on personal experience and the skill of a specialist, since decision-making is influenced by a huge number of factors:
— high variability of damage to the musculoskeletal system, their combination with each other and with damage to other organs and systems;
— the severity of the victim’s condition;
- time elapsed since the injury;
— age of the victim;
- Availability necessary conditions and tools for implementing a particular treatment method;
— qualifications of the specialist providing assistance.
Nevertheless, it is advisable to consider the most common injuries of the musculoskeletal system, to characterize the indications and contraindications for certain treatment methods.
Upper limb injuries
Clavicle fracture. In the vast majority of cases, conservative treatment is carried out using Delbe rings or a figure-of-eight bandage as immobilization. The only absolute indication for open reduction is the threat of skin perforation by displaced bone fragments or damage to the elements of the brachial plexus and subclavian vessels.
Shoulder dislocation requires urgent closed reduction, which should be carried out under general anesthesia, followed by fixation with a Deso bandage.
Fractures of the humerus respond well to conservative treatment with permanent skeletal traction or functional plaster casts. However, in conditions of polytrauma, it is advisable to use surgical treatment. Fixation of fragments is carried out, as a rule, with plates. Another indication for open reduction is damage to the radial nerve at the level of the fracture, as well as displaced intra-articular fractures of the distal metaepiphysis of the humerus.
Forearm dislocation. Urgent closed reduction is indicated under general anesthesia, followed by fixation with a posterior plaster splint.
Fractures of the bones of the forearm. A fracture of one of the bones of the forearm, if closed reduction is possible, is immobilized with a plaster cast. For displaced fractures of both bones, especially in the middle third, it is advisable to use a surgical treatment method. Considering the high functional significance of the segment and the need for early restorative treatment, it is preferable to perform external osteosynthesis, which does not require additional external immobilization.
Lower limb injuries
Hip dislocation. Closed removal of the dislocation is necessary under conditions of general anesthesia with muscle relaxation, followed by unloading traction. In a situation where there is no clear clinical (at the time of closed reduction) or radiological data on the elimination of the dislocation, one should think about possible soft tissue or bone (in the case of fracture-dislocation) interposition, requiring open reduction.
Fracture femur. Fractures of the upper third of the femur, comminuted or oblique fractures of the middle and lower third are successfully treated with permanent skeletal traction. If it is necessary to stabilize the fracture surgically, preference should be given to external osteosynthesis with plates. Transverse fractures of the femoral shaft are an ideal location for intramedullary osteosynthesis. Simple and quick to perform, this method of osteosynthesis allows you to carry out loads on the injured limb in the early post-traumatic period. The absolute (from the point of view of the functional outcome of treatment) indication for open reduction is a comminuted, intra-articular fracture of the distal metaepiphysis of the femur. Osteosynthesis in this situation is carried out with metal plates (L-shaped or straight), which allows you to avoid additional external immobilization and begin early restoration of the function of the knee joint.
A popliteal fracture without a rupture of the extensor apparatus only requires immobilization. If the extensor apparatus is damaged, surgical treatment is indicated. The generally accepted method of osteosynthesis is the Weber operation, which allows, without immobilization in the postoperative period, to develop movements in the knee joint and to carry out loads on the injured limb.
Damage to the ligaments of the knee joint is an indication for surgical restoration in the event of an isolated injury. In patients with polytrauma, an immobilization method of treatment can be used, postponing the decision on surgical restoration of the ligamentous apparatus for 2-6 months.
Fracture of the leg bones. As a rule, in the case of isolated damage and the possibility of closed correction of displacement, a plaster cast is applied. It is possible to use skeletal traction as a method of gradual reduction of fragments over 3-7 days, followed by application of a plaster cast. Comminuted intra-articular fractures of the proximal and distal metaepiphysis of the tibia with displacement are an indication for open reduction and metal osteosynthesis. The latter can be produced either by screws or by plates. In the surgical treatment of diaphyseal fractures of the tibia, preference should be given to stable methods of osteosynthesis: external and intramedullary. The method of choice for oblique and helical fractures can be repositioning osteosynthesis with screws. For comminuted and open fractures of the tibia, extrafocal fixation is indicated, which can be carried out using both Ilizarov and rod devices.
Heel bone fracture. As a rule, in urgent conditions it requires plaster immobilization. It is possible to use the skeletal traction method followed by the application of a plaster cast.
Spinal column injuries
From an anatomical-functional and therapeutic-diagnostic point of view, the spine should be divided into three sections: cervical, thoracic and lumbar.
Pronounced physiological mobility in all planes at the level of the cervical spine determines the possibility of damage even with minor mechanical trauma. In addition, the anatomical feature of the structure of the cervical vertebrae determines the possibility of dislocations, which are casuistry in other parts of the spine. Without going into the intricacies of the variety of possible injuries at the level of the cervical spine, it should be noted that from a therapeutic point of view it is necessary to distinguish between stable and unstable injuries. Unstable injuries include fractures, fracture dislocations and dislocations of the cervical vertebrae, which tend to undergo secondary displacement. If for stable injuries at the level of the cervical spine, immobilization with a Shants collar is sufficient, then for unstable injuries, long-term immobilization with a thoracocranial plaster cast or surgical treatment is necessary.
Damage at the level of the thoracic spine is usually stable. Usually these are compression fractures of the vertebral bodies, requiring only bed rest (with 2-3 degrees of compression on reclining rollers) followed by the use of semi-rigid corsets as immobilization.
At the level of the lumbar spine, both stable injuries (compression fractures of the vertebral body, fracture of the spinous and transverse process, isolated fractures of the articular processes) and unstable injuries are also possible. For stable injuries, bed rest is observed (with reclination if necessary) for 6 weeks. In case of unstable injuries, it is advisable to use operative stabilization of the damaged segment.
In addition to the above, indications for surgery at any level of the spinal column are complicated spinal injuries, i.e. those injuries that cause spinal cord injury.
Pelvic fractures
Stable and unstable injuries of the pelvic ring should be distinguished. Stable fractures include: marginal fractures, avulsion fractures of the spines, fractures of the anterior semi-ring of the pelvis (fracture of the ischium and pubic bones on one or both sides) without damage to the posterior semi-ring, isolated fractures of the sacrum or ilium. Such injuries do not require additional immobilization provided bed rest is observed. It is advisable to use disciplinary traction in the position of maximum relaxation of the antagonist muscles - the Volkovich-Dyakonov position (frog pose).
Unstable pelvic injuries include vertical or diagonal pelvic fractures, synphysis tears, and sacroiliac joint ligament injuries. Such injuries, especially in conditions of polytrauma, require reliable stabilization, which can be achieved by applying a rod apparatus, using various types of orthoses, and metal osteosynthesis can also be used. For dislocations or fracture-dislocations of the pelvis, skeletal traction with large loads is indicated, and after eliminating the displacement, external or internal stabilization of existing injuries is indicated.
Surgery
IN Lately Even in conditions of isolated fractures, especially of long tubular bones, preference is given to the surgical method of treatment, which has a number of advantages:
— the possibility of ideal comparison of fragments, which is especially important for intra-articular fractures;
— the possibility of rapid rehabilitation of an injured limb, i.e. restoration of function in joints;
— reduction of periods of bed rest and hospital treatment.
Although it has significant advantages, the surgical method of treatment has a significant drawback - the risk of purulent complications, which, if they occur, can lead to serious consequences both for the injured limb and for the victim as a whole. The main indication for surgical treatment isolated fractures should be determined by the impossibility of adequate reduction and retention of fragments in the reduced position using a conservative method.
Surgical tactics for open and closed fractures have their own characteristics. Thus, for open bone injuries of type IIB-IIIB (according to the Kaplan-Markova classification), extrafocal stabilization of fragments is indicated, since the risk of purulent complications is quite high. In a situation where immediate elimination of existing displacements is possible, preference is given to rod devices, which have a number of advantages over Ilizarov devices:
— speed and ease of application;
— the possibility of unilateral insertion of rods, which significantly reduces the risk of additional injury to soft tissues, blood vessels and nerves;
— rod-based external fixation devices provide optimal care for open fracture wounds.
In addition, ensuring the fulfillment of the main task in urgent conditions - fracture stabilization, the rod apparatus, if necessary, in the post-traumatic period can be replaced with an Ilizarov apparatus.
Treatment of open fractures is carried out in compliance with all basic principles of wound treatment. The primary surgical treatment operation is aimed at excision of non-viable tissue, reducing the risk of purulent complications, and creating conditions for healing of an open fracture wound by primary intention. In cases where wound closure is impossible due to a large soft tissue defect, open wound management under ointment dressings is indicated. Preference should be given to water-soluble ointments (levosin, levomikol), especially in the first phase of the wound process.
In case of closed fractures of the bones of the extremities, surgical stabilization of the fragments is carried out using extramedullary or intramedullary osteosynthesis. The latter has great advantages in diaphyseal transverse fractures of the femur, since, providing sufficient stability, it allows early loading on the operated limb. Bone osteosynthesis with metal plates has now gained popularity all over the world. The plates developed in various lengths and shapes make it possible to achieve adequate reduction and reliable fixation of fragments in fractures of any location.
Concept of stable osteosynthesis.
Options for stable osteosynthesis. There are two main types of osteosynthesis: internal (submersible) and external (using devices). Internal osteosynthesis - conventional and compression. Intramedullary osteosynthesis with pins with fixation. Bone osteosynthesis - plates, screws, wire. KDO with rod and spoke devices.
Causes of fracture consolidation disorders.
- short-term, imperfect or frequently interrupted immobilization;
- lack of reposition of fragments, use of large loads during traction, incorrectly performed osteosynthesis;
- irrational removal of viable bone fragments and resection of the ends of fragments;
- circulatory disorders incl. associated with soft tissue trauma, as well as topographic and anatomical difficulties;
- interposition;
- tropho-neurotic disorders
- multiple fractures.
Modern osteosynthesis is a responsible operation that requires careful asepsis, the provision of a variety of structures to achieve strong fixation of the fracture and special training of trauma surgeons. At correct use the patient's stay in the hospital is reduced, precise adaptation of the fragments and their immobility are achieved, ensuring primary healing of the fracture.
External (transosseous) osteosynthesis
Even A. Lambott in 1907 used screws screwed transversely into the bone, connected above the skin by two plates. In 1917, Rosen proposed a T-shaped design with two fixing screws-nuts, with the help of which reduction and fixation of fractures in two planes was possible. In the 20-30s, a number of external fixation devices were developed (Anderson, Studer, Haynes, A.S. Pertsovsky, T.E. Gnilorybov). The device with cross-shaped insertion of the spokes was first proposed by R. Witmoser in 1949.
More than 50 modifications of external fixation devices are currently used abroad. In our country, the designs of K.M. Sivash, O.Sh. Gudushauri, G.A. Ilizarov, N.D. Florensky, V.N. Kalnberz, V.M. Demyanov, S.S. Tkachenko have been used. The greatest success was achieved by G.A. Ilizarov, who since 1952 has been promoting KDO as an antithesis to all other methods of treating fractures. The widespread use of EDT allowed G.A. Ilizarov to make the most important discovery: with prolonged and slow distraction, tissues respond with a growth reaction.
From here it became possible to grow bone, blood vessels, nerves, lengthen and expand a limb, replace traumatic defects and defects resulting from surgical interventions.
However, compared to other methods, the length of stay of the patient in the hospital increases by 2-3 times. The main enemy of the method was wire osteomyelitis, which, according to a number of authors, along with suppuration of wounds around the wires, reaches 42% (of which wire osteomyelitis - 6-15%).
Injuries or damage to the musculoskeletal system are one of the most common types of injuries that occur during various anatomical and functional disorders of tissues and organs resulting from the action of aggressive environmental factors (during a fall, awkward or unexpected movement, during car accidents or natural disasters).
Main types of injuries:
- Bruises;
- Sprained or torn ligaments;
- Dislocations;
- Fractures.
Bruises
Ushiba– the most common type of injury, which can occur either independently or accompany other more severe injuries (dislocations, fractures, damage to internal organs). A bruise is usually the result of a fall from a small height or a blow caused by a blunt object. With mild bruises that are not accompanied by bruises, swelling and pain disappear after 1-2 days; with bruises they persist for up to 6-12 days.
Sprains or torn ligaments
Damage to tissues with their partial rupture while maintaining anatomical continuity is called stretching. Most common joint sprain . The mechanism of this type of injury is caused by tissue stretching by two forces acting in opposite directions, with the body, organ or area fixed. This usually happens when falling, lifting weights, running, etc. Sprain – the most common injury to the musculoskeletal system encountered in everyday life. It manifests itself as pain in the joint area. Such pain during a sprain usually does not go away for a long time, although there are no external manifestations of the injury.
Torn muscle or tendon- a fairly rare injury. It requires excessive effort to occur. The rupture most often occurs in the muscles that experience the heaviest stress - the biceps of the arm or the triceps of the calf. Tendon rupture(the muscle tears extremely rarely) is manifested by the formation of a relief in the area of the shoulder or lower leg that is uncharacteristic for these parts of the body - hunching of muscles . This is accompanied by severe pain and immobility of the limb. If the acting force exceeds the resistance of the tissues, then ligaments, fascia, muscles, tendons, nerves, etc. rupture.
Dislocations
Dislocation- This is a displacement of the articular surfaces of bones in the articular joints. In this case, damage to the joint capsule with injury to blood vessels and nerve trunks is possible. Dislocations occur from excessive stress on the joints. The most common dislocations are the shoulder and elbow joints. Dislocations of the ankle and finger joints are less common. Dislocations of the knee and hip joints are extremely rare.
With dislocations and subluxations, the normal shape of the joint is disrupted, movements in it are limited or become impossible. These signs are combined with symptoms that occur with damage to the ligamentous apparatus and joint capsule.
Fractures
Bone fractures called a violation of their integrity. The cause of a fracture can be either an external force (impact or heavy load) or some diseases that reduce the strength of bones and make them brittle. The severity of the fracture depends on its location, size and type.
Read more about the main types of injuries to the musculoskeletal system and methods of their treatment in the relevant subsections.