Reliable (absolute) and probable (relative) signs of fracture and dislocation. Complications of closed and open fractures and dislocations, their prevention. Prevention of complications of fractures and dislocations during evacuation Mistakes and complications in the treatment of fractures

09.12.2021Heading: The buildings

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 may 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 is the case 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 bandage with the help of PPI, anesthesia from a syringe tube (1 ml of a 2% solution of promedol), transport immobilization with improvised means and the use of an antibiotic tablet (doxycycline).

First aid is carried out by a paramedic, who controls the correctness of the 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 (Fig. 23.13) or 4 ladder tires are used: 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 the indications, they are re-introduced penicillin, in case of pain - promedol, dressings soaked with blood are bandaged, and transport immobilization improves. Dieterikhs tires are reinforced with plaster rings. Then the wounded are sent to the evacuation tents.
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.

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, inflammatory process disrupt 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 in early dates- up to 1 month after the operation, 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 discharge appears from the wound and develops general reaction organism, 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. At large area pressure sore shows free and non-free skin plasty.

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 into 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. In case of crushing of soft tissues, inflow-from-precision drainage of the postoperative wound is indicated for 1-2 weeks, without crushing of 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.

Pelvic fractures are severe skeletal injuries. The severity of the injury is due to a large loss of blood flowing from fragments of the pelvic bones and soft tissues, as well as the development of shock due to pain and blood loss.

Pelvic fractures, according to modern traumatology, account for 4-7% of the total number of fractures. May be accompanied by damage to internal organs, aggravating the patient's condition and representing an immediate danger to his life.

Anatomy

Taz- a system of interconnected bones that are located at the base of the spine. The pelvis is a support for the skeleton, protects the internal organs located in the lower abdomen and serves as a link between the bones of the lower extremities and the trunk.

The pelvic ring is formed by three paired pelvic bones (pubic, iliac and ischial) and the sacrum located behind. Three pelvic bones on each side are separated from each other by thin bone sutures and are motionless relative to each other. Anteriorly, the pubic bones articulate to form the pubic symphysis. Posteriorly, the iliac bones are attached to the sacrum through the sacroiliac joints.

In the external-lateral region, all three pelvic bones are involved in the formation of the acetabulum (part of the hip joint).

There are various mechanisms of injury, but most pelvic fractures result from falls from heights, crushing from car accidents, building collapses, industrial accidents (eg, in a mine), and collisions with pedestrians. The type of fracture of the pelvic bones depends on many factors, including the direction (lateral, anteroposterior) and the degree of compression.

Classification

There are four groups of pelvic fractures:

Stable (fractures of the pelvic bones, not accompanied by a violation of the integrity of the pelvic ring). This group includes isolated and marginal fractures of the pelvic bones.
Unstable (fractures of the pelvic bones, accompanied by a violation of the integrity of the pelvic ring). Depending on the mechanism of injury, vertically unstable and rotationally unstable fractures may occur. With vertically unstable fractures of the pelvic bones, the integrity of the pelvic ring, as a rule, is violated in two places: in the posterior and anterior sections. Fragments are displaced in the vertical plane. With rotationally (rotationally) unstable fractures, the displacement of fragments occurs in the horizontal plane.
Fractures of the bottom or edges of the acetabulum. Sometimes accompanied by hip dislocation.
Fracture and dislocation of the pelvic bones. With this type of injury, a fracture of the pelvic bones is combined with a dislocation in the pubic or sacroiliac joint.

a - fracture of the pelvic bones without violating the integrity of the pelvic ring; b - fracture with violation of the integrity of the pelvic ring; c - diagram of a complex fracture-dislocation of the pelvic bones.

Collateral damage

Pelvic fractures are always accompanied by blood loss. At regional and isolated fractures, blood loss is relatively small (200-500 ml). At unstable vertical fractures, patients sometimes lose 3 or more liters of blood.

Heavy pelvic fractures can be accompanied by damage to the urethra and bladder, less often - the rectum and vagina. In this case, the contents of the internal organs enter the pelvic cavity and cause the development of infectious complications.

Outwardly, the deformation of the clavicle, swelling in the area of the fracture are clearly visible. With careful palpation of the fracture zone, sharp pain is noted. The outer part of the clavicle is usually displaced downward and anteriorly under the weight of the arm. Fractures of the clavicle may be accompanied by damage to the deeper vessels and nerves (brachial plexus). First aid consists in hanging the hand on a scarf, or bandaging it to the body while bending up to 90 degrees in the elbow joint. The patient is taken to the nearest medical institution for the reposition of fragments.

It usually occurs when falling from a height, compression of the chest, direct impact. The main symptom is sharp pain that occurs when breathing, coughing, changing body position. The patient tries not to take deep breaths, so breathing becomes superficial.

The main danger is the possible damage to the pleura and lung by the sharp edges of bone fragments. In case of lung damage, the patient may experience subcutaneous emphysema, i.e. air penetration into the subcutaneous tissue. In this case, smoothing of the intercostal spaces, similar to edema, is noticeable. However, unlike edema, when feeling the injury site, it is easy to determine the “crunching” that occurs under the fingers (as if small bubbles burst). First aid consists in adequate anesthesia of the victim and the imposition of a tight circular bandage on the chest. If a bandage is not enough to apply a bandage, you can use strips of cloth, a towel. The patient is transported to a medical institution in a sitting or reclining position with a raised head end.

Pelvic fracture

In terms of the number of concomitant injuries of internal organs and mortality, pelvic fractures are second only to skull fractures. This type of fracture can occur when the victim gets into a blockage, under a rockfall, when falling from a height, or a direct strong blow.

The main sign of a pelvic fracture is a very sharp pain with any attempt to change the position of the body. Sometimes, on examination, a change in the shape of the pelvis is noticeable. Sharp pains also occur when pressing on the pelvic bones with your hands. The patient usually lies in the "frog position": on his back, with legs spread apart, half-bent at the knee and hip joints. A hematoma is usually determined at the site of impact. It should be borne in mind that fractures of the pelvic bones are often accompanied by damage to internal organs: the bladder, rectum, urethra, etc., externally manifested by the release of blood in the urine or feces. An additional danger is created by the possible development of a traumatic shock in a patient. Remember that all unconscious patients with multiple injuries should be suspected of having a pelvic fracture unless proven otherwise.

The deterioration of the patient's condition can occur rapidly, so the main task of the tourist group is to evacuate the victim from the route as quickly as possible and deliver him to the nearest medical facility. Immobilization in this case cannot be imposed. The victim must be laid on a flat, hard surface and transported in the very “frog position” in which he usually is. To maintain this position during the transfer, a roll of clothing should be placed under the patient's knees. It is mandatory to conduct anesthesia (ketarol, if available - promedol)!

The position in which to transport the victim with a pelvic fracture

Types of fractures

Fractures - a violation of the integrity of the bone under the influence of a traumatic force that exceeds the elasticity of the bone tissue. There are traumatic fractures that usually occur suddenly under the action of a significant mechanical force on an unchanged, normal bone, and pathological fractures that occur in a bone altered by some pathological process with a relatively minor injury or spontaneously.

Traumatic fractures

All traumatic fractures are divided into closed, in which the integrity of the skin or mucous membranes is not broken, and open, accompanied by damage to them. The main difference between open and closed fractures is the direct communication of the bone fracture area with the external environment, as a result of which all open fractures are primarily infected (bacterially contaminated).

Depending on the nature of the fracture, the bones are divided into transverse, longitudinal, oblique, helical, comminuted, double, crushed, impacted, compression and avulsion fractures. In the region of the epiphyses or epimetaphyses, T- and V-shaped fractures are observed. Spongy bone is characterized by fractures, accompanied by the introduction of one bone fragment into another, as well as compression fractures, in which destruction and crushing of bone tissue occurs. With a simple fracture, two fragments are formed - proximal and distal. Under the influence of a traumatic force, two or more large fragments can separate along the bone, in these cases polyfocal (double, triple) or segmental fractures occur. Fractures with one or more fragments are called comminuted. If, as a result of a fracture, the bone over a considerable extent is a mass of small and large fragments, they speak of a comminuted fracture.

Fractures of long tubular bones according to localization are divided into diaphyseal, metaphyseal and epiphyseal. There are also intra-articular, peri-articular and extra-articular fractures. Often there are mixed types, such as metadiaphyseal or epimetaphyseal fractures. Intra-articular fractures may be accompanied by displacement of the articular surfaces - dislocations or subluxations. Such injuries are called fracture-dislocations. Most often they are observed in injuries of the ankle, elbow, shoulder and hip joints.

Depending on the place of application of the traumatic force, fractures are distinguished that occur directly in the zone of application of the traumatic force, for example, bumper fractures of the lower leg during a collision passenger car on a pedestrian, and away from the place of application of the traumatic force, for example, helical fractures of the lower leg as a result of a sharp turn of the body with a fixed foot.

Open fractures can be primary and secondary open. With a primary open fracture, the traumatic force acts directly on the area of damage, injuring the skin, soft tissues and bones. In such cases, open fractures often occur with a large skin wound, an extensive area of soft tissue damage, and a comminuted bone fracture. With a secondary open fracture, a wound of soft tissues and skin occurs as a result of a puncture by a sharp bone fragment from the inside, which is accompanied by the formation of a skin wound and a smaller area of damage to soft tissues.

pathological fractures

Pathological fractures, as a rule, occur under the influence of a small injury or occur spontaneously in a bone affected by some pathological process, most often of a destructive nature (with benign and malignant tumors or bone metastases). Pathological fractures are also observed in neurogenic dystrophic processes, such as syringomyelia, dorsal tabes. Increased bone fragility is noted in Paget's disease, hyperparathyroid osteodystrophy, osteogenesis imperfecta, and other systemic skeletal diseases. Rarely, pathological fractures occur when inflammatory diseases bones: osteomyelitis, tuberculosis, etc.” (MME)

To make a diagnosis of "fracture" allows the presence of certain criteria. A fracture is a diagnosis that is made clinically and only confirmed radiographically.

Relative signs of a fracture

Pain- increases at the fracture site when simulating an axial load. For example, when tapping on the heel, the pain in case of a fracture of the lower leg will increase sharply.

Edema- occurs in the area of damage, as a rule, not immediately. Provides relatively little diagnostic information.

Hematoma- appears in the fracture area (often not immediately). Pulsating hematoma indicates ongoing heavy bleeding.

Dysfunction of the injured limb - implies the impossibility of loading the damaged part of the body and a significant limitation of mobility.

Absolute signs of a fracture

Unnatural limb position.

Pathological mobility (with incomplete fractures it is not always determined) - the limb is mobile in the place where there is no joint.

Crepitus (a kind of crunch) - felt under the arm at the fracture site, sometimes heard by the ear. It is well audible when pressing with a phonendoscope on the injury site.

Bone fragments - with an open fracture, they can be seen in the wound.

Rice. 12.1. Immobilization with the help of improvised means: a, b - with a fracture of the spine; c, d – hip immobilization; d - forearms; e - collarbones; g - shins.

Transportation of victims

The most important task of first aid is the organization of fast, safe, gentle transportation (delivery) of a sick or injured person to a medical institution. Causing pain during transportation contributes to the deterioration of the victim, the development of shock. The choice of method of transportation depends on the condition of the victim, the nature of the injury or illness, and the capabilities of the first aid provider. Transfer and transportation without immobilization of the victims, especially those with fractures, even for a short distance, is unacceptable. this can lead to an increase in the displacement of bone fragments, damage to nerves and blood vessels located next to the movable bone fragments. With large wounds of soft tissues, as well as with open fractures, immobilization of the damaged part of the body prevents the rapid spread of infection, with severe burns (especially of the limbs), it contributes to their less severe course in the future. Transport immobilization occupies one of the leading places in the prevention of such a formidable complication of severe injuries as traumatic shock.

At the scene, most often you have to use improvised means for immobilization (for example, boards, branches, sticks, skis), to which the damaged part of the body is fixed (bandaged, strengthened with bandages, belts, etc.). Sometimes, if there are no improvised means, sufficient immobilization can be ensured by pulling the injured arm to the body, hanging it on a scarf, and in case of a leg injury, bandaging one leg to the other (Fig. 12.1.).

The main method of immobilization of the injured limb for the period of transportation of the victim to a medical institution is splinting. There are many different standard transport tires that are commonly used medical workers such as ambulance services. However, in most cases, with injuries, one has to use the so-called impromptu splints, which are made from improvised materials.
It is very important to carry out transport immobilization as early as possible. The tire is applied over the clothes. It is advisable to wrap it with cotton or some soft cloth, especially in the area of bony prominences (ankles, condyles, etc.), where the pressure exerted by the splint can cause abrasions and bedsores.

In the presence of a wound, for example, in cases of an open fracture of a limb, it is better to cut the clothes (it is possible at the seams, but in such a way that the entire wound becomes well accessible). Then a sterile bandage is applied to the wound and only after that immobilization is carried out (the straps or bandages fixing the splint should not press hard on the wound surface).

With severe bleeding from the wound, when there is a need to use a hemostatic tourniquet, it is applied before splinting and is not covered with a bandage. You should not strongly tighten the limb with separate tours of the bandage (or its substitute) for a “better” fixation of the splint, because. this can cause circulatory problems or nerve damage. If, after applying the transport splint, it is noticed that a constriction has nevertheless occurred, it must be cut or replaced by applying the splint again. In winter or in cold weather, especially during long-term transportation, after splinting, the damaged part of the body is wrapped warmly.

When applying impromptu splints, it must be remembered that at least two joints located above and below the damaged area of the body must be fixed. If the tire does not fit well or is not fixed enough, it does not fix the damaged area, slips and can cause additional injury.

In the absence of any transport, the victim should be transferred to a medical institution on a stretcher, including improvised ones (Fig. 12.2.). First aid has to be provided even in such conditions when there are no improvised means or there is no time to make an impromptu stretcher. In these cases, the patient must be transferred in his arms. First aid has to be provided even in such conditions when there are no improvised means or there is no time to make an impromptu stretcher. In these cases, the patient must be transferred in his arms. One person can carry the patient in his arms, on his back, on his shoulder (Fig. 12.3). Carrying in the way “on the hands in front” and “on the shoulder” is used in cases where the victim is very weak or unconscious. If the patient is able to hold on, then it is more convenient to carry him in the “on the back” way. These methods require great physical strength and are used when carrying over short distances. It is much easier to carry in the hands of two. The victim, who is in an unconscious state, is most conveniently transferred in the “one after the other” way (Fig. 12.4. a).

Rice. 12.2. Stretcher a - medical; b, c - improvised.

If the patient is conscious and can stand on his own, then it is easier to carry him on the “lock” of 3 or 4 hands (Fig. 12.4. b, c). The stretcher strap makes it much easier to carry on your hands or on a stretcher.
In some cases, the patient can overcome a short distance on his own with the help of an attendant, who throws the victim’s arm around his neck and holds it with one hand, while the other grabs the patient by the waist or chest.
The injured person can lean on a stick with his free hand. If it is impossible to independently move the victim and there are no assistants, it is possible to transport them by dragging on an impromptu dragger - on a tarpaulin, cape.

Thus, in a wide variety of conditions, the first aid provider can organize the transportation of the victim in one way or another. The leading role in the choice of means of transportation and the position in which the patient will be transported or transferred is played by the type and localization of the injury or the nature of the disease. To prevent complications during transport, the victim should be transported in a certain position according to the type of injury.

Rice. 12.3. Carrying the victim by one porter: a - on the hands; b - on the back; c - on the shoulder.

Very often, a correctly created position saves the life of the wounded and, as a rule, contributes to his speedy recovery. The wounded are transported in the supine position, on the back with bent knees, on the back with the head down and lower limbs raised, on the stomach, on the side. Victims with head wounds, injuries of the skull and brain, spine and spinal cord, fractures of the pelvic bones and lower extremities are transported in the supine position. In the same position, it is necessary to transport all patients in whom the injury is accompanied by the development of shock, significant blood loss or unconsciousness, even short-term, patients with acute surgical diseases (appendicitis, strangulated hernia, perforated ulcer, etc.) and injuries of the abdominal organs.

Rice. 12.4. Carrying the victim by two porters: a - the method “one after the other”; b - "lock" of three hands; c – “lock” of four hands.

Victims and patients who are unconscious are transported in the prone position, with rollers placed under the forehead and chest. This position is necessary to prevent asphyxia. A significant part of patients can be transported in a sitting or semi-sitting position. It is also necessary to monitor the correct position of the stretcher when going up and down the stairs (Fig. 12.5.).

Rice. 12.5. The correct position of the stretcher during the ascent (a) and descent (b).

When transporting in the cold season, measures must be taken to prevent the victim from cooling down, because. cooling in almost all types of injury, accidents and sudden illnesses sharply worsens the condition and contributes to the development of complications. In this regard, the wounded with applied hemostatic tourniquets, victims who are unconscious and in a state of shock, with frostbite require special attention.

During transportation, it is necessary to constantly monitor the patient, monitor breathing, pulse, do everything so that during vomiting there is no aspiration of vomit into the respiratory tract.

It is very important that the person who provides first aid, by his behavior, actions, conversations, spares the patient's psyche as much as possible, strengthens his confidence in the successful outcome of the disease.

Used Books:

Textbook "First Aid in Emergency Situations" V.V. Shakhovets, A.V. Vinogradov;
E.G. Machulin "Organization of medical care for victims with injuries".

Hematoma accumulation 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's 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. 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 may 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.

Bone regeneration. Types of callus. Tentative dates for consolidation.

When healing a bone wound, 4 successive stages of reparative osteogenesis are conditionally distinguished:

Stage I - the beginning of the proliferation of cellular elements under the influence of necrosis products of damaged cells and tissues.

Stage II - the formation and differentiation of tissue structures.

Stage III - the formation of the bone structure.

Stage IV - restructuring of the primary regenerate.

There are the following types of callus:

Periosteal (external) callus is formed mainly due to the periosteum;

Endostal (internal) callus is formed from the side of the endosteum;

The intermediary callus fills the gap at the junction of the compact layer of bone fragments.

All types of callus develop at each fragment, connecting with each other, form a common "coupling" of the callus, which holds the fragments together.

If the fragments are correctly and securely fixed, then the fusion occurs mainly due to the intermediary callus.

Periosteal and endosteal callus are temporary formations that do not indicate the fusion of fragments. The presence of immobility between the fragments leads to permanent traumatization of the regenerate and disruption of blood microcirculation in it. This slows down bone regeneration. Under such conditions, the development of cartilaginous tissue predominates in the regenerate.

Periosteal callus characterizes unstable fixation of fragments, and its dimensions reflect the degree of this instability. Cancellous bone always fuses at the expense of endosteal.

The first signs of corns on radiographs in the form of tender cloud-like foci

calcifications appear in adults at 3-4 weeks, and in children - at 7-10 days after the fracture. The fracture line disappears after 4-8 months. During the first year, the callus is modeled, the radiological beam structure of the bone appears after 1.5-2 years.

12098 0

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 serious 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.