Clavicle fracture. Technique for applying 8-shaped plaster casts to both shoulder girdles

Most patients with clavicle fractures are treated on an outpatient basis, but X-ray monitoring of the position of the fragments is required. If such control is impossible, the patient is sent to a hospital. When treating clavicle fractures, the general principles of fracture treatment are followed. Depending on the nature of the displacement of fragments, the appropriate method is used. There are three main groups of fractures:

1) without displacement of fragments;

2) with angular displacement of fragments, but without separating them;

3) with offset in width, length and angle.

Treatment of non-displaced fractures, which are most often observed in children and are usually subperiosteal, consists of fixing the arm to the chest with a Deso bandage or on a wedge-shaped pillow. Fusion of fragments in subperiosteal fractures occurs quickly, so fixation of the limb should be short-lived, no more than 8-10 days. After this period, the fixing bandage is removed and the patient is allowed active movements. Usually, after 21/2-3 weeks, good consolidation occurs, the callus is determined by radiological and palpation, and the function of the upper limb is restored.

Rice. 6. Delbe ring straps.

Much more difficult treatment of clavicle fractures with angular displacement, as well as in width and length. The greatest difficulties arise in the treatment of comminuted fractures with significant displacement of the fragment, especially when rotating it around its axis, when it is located perpendicular to the axis of the clavicle.

There is a large number various types bandages, devices and splints for matching and holding fragments of a broken collarbone. Currently, the most common soft ring straps are Delbe rings (Fig. 6) and an eight-shaped bandage with fixation of the shoulder girdle (Fig. 7).

Rice. 7. Figure-of-eight bandage.

Before applying any fixing bandage or splint, it is necessary to numb the fracture site well. For this, the patient is seated on a chair or laid on a table. The skin in the collarbone area is first washed with a 0.5% ammonia solution (ammonia), dried well, then wiped with alcohol and lubricated with an alcohol solution of iodine. The skin is infiltrated with a thin needle, and then the skin is pierced with a thicker and longer needle placed on a 10-gram syringe and the needle is brought to the collarbone. 20-25 ml of a 1% novocaine solution is injected into the fracture area and on both sides of it. Anesthesia is performed with one injection, without removing the needle. After 5-7 minutes, the fracture area is anesthetized, allowing the necessary manipulations to be performed painlessly.

To perform immediate reposition of fragments, the patient is seated on a chair so that he rests firmly on the back of the chair. Comparison of fragments and application of a bandage is carried out by two people. The assistant stands behind the patient and with both hands spreads his shoulder girdles so that the inner edges of the shoulder blades come closer to the spine. At this time, the surgeon presses with his thumb on the top of the angle formed by the fragments of the clavicle. This must be done slowly and carefully so as not to displace the fragments in the opposite direction. When the displacement of the fragments has been eliminated, which is determined by restoring the axis of the clavicle, they begin to apply a fixing soft bandage.

Applying ring straps(Delbe rings). Ring straps are made in advance from thick fabric, wrapped in a thick layer of cotton wool and lined with flannel. The rings are put on both shoulder girdles of the patient, pulled and tied with braid on the back in the interscapular area. While putting on and fixing the ring straps, the assistant keeps the shoulder girdles in a spread position at all times. After applying the ring straps, an x-ray is taken for verification of comparison of fragments.

Applying a figure-of-eight bandage. In the interscapular area, a thick cotton pad is glued with cleol. Comparison of fragments is carried out in the same way as when applying ring straps. Then flat cotton rolls are placed on the shoulder girdles and armpits and an eight-shaped gauze bandage is applied. Bandaging should be done quite tightly, since in the future the cotton pad strengthened in the interscapular area and the cotton rolls on the shoulder girdle and in the axillary area become compacted and the bandage may weaken. The alignment of the fragments must be checked x-ray.

After applying soft bandages, the patient should remain under the supervision of the doctor who applied the bandage for 2-3 hours. It is necessary to make sure that the bandage does not compress the vessels and nerves and does not cause numbness of the upper extremities. If the above phenomena are present, you need to cut the edges of the bandages coming out of the armpits. If the bandage does not cause any discomfort, then the victim can be sent home.

The most widely used plaster cast is the Smirnov-Weinstein bandage, which consists of two plaster strips. One of them covers the forearm of the injured limb and the healthy upper arm, the second surrounds the chest and fixes the shoulder laid back.

After applying any fixing bandage or splint, the patient must be examined daily for 3 to 4 days. After a week, you should take a control radiograph, if necessary, correct the position of the fragments and put the bandage in order, strengthening it with several rounds of bandage.

Physical therapy classes begin from the first days; it is better to conduct them in a special room, repeating the movements at home several times a day. Therapeutic exercises help improve blood supply to the limb, prevent muscle atrophy and joint contracture.

The duration of treatment and periods of disability for closed clavicle fractures depend on a number of reasons. Fusion of clavicle fragments in children, especially with subperiosteal fractures, occurs quickly. 7-10 days after the fracture, small children can freely raise their arm. In older children, the collarbone fuses within 10-15 days. In adults, healing of a broken collarbone occurs more slowly. The fragments should be considered healed if good callus is visible on the x-ray (usually at 5-6 weeks).

When deciding on the period of disability for clavicle fractures, it is necessary to take into account the profession and work performed by the victim. For people doing heavy physical work, they are higher than for people doing light work. It is a mistake to determine the time of incapacity for work depending on the average consolidation period without taking into account individual characteristics.

Most patients with clavicle fractures are treated on an outpatient basis from the moment they see a doctor until full restoration of their ability to work. However, in some cases, it is impossible to cure patients with conservative methods, in particular in the presence of fractures, in which none of the conservative methods can be used to keep the fragments in the correct position.

Surgical treatment indicated for interposition of soft tissues and comminuted fractures of the clavicle, when one of the fragments takes a vertical position, resulting in a threat of skin perforation or damage to the neurovascular bundle. Such patients must be sent to a traumatology or surgical department, and the reasons why outpatient treatment is impossible should be indicated. Indications for surgical treatment can be established not only in the first days after a fracture, but also at a later date, when there is a threat of non-union of fragments or secondary displacements are detected.

Almost always, patients with clavicle fractures who were treated in a hospital with various methods are sent to outpatient clinics or clinics to continue treatment. In order to ensure continuity of treatment, the doctor at the clinic or outpatient clinic must obtain a detailed extract from the medical history, as well as the latest radiograph of the patient discharged from the hospital. If there is no radiograph, then to get a clear idea of ​​the condition of the fragments and the process of consolidation, it is necessary to take an X-ray at the first examination. The accompanying document must indicate what treatment plan was outlined by the doctor who treated the patient in the hospital. If there is no such data in the extract from the medical history, then the doctor at the outpatient clinic or clinic himself draws up a plan for further treatment, which should be aimed at continuing fixation of the fragments until complete consolidation and restoration of mobility in the shoulder joint.

Persistent disability due to clavicle fractures, if the fracture is not complicated and is not accompanied by other injuries, is extremely rare. Usually, after completion of treatment, patients return to their previous place of work.

Errors may be made when treating patients with clavicle fractures at the beginning, during and at the end of treatment. A serious mistake is fixing the shoulder girdle without first comparing the clavicle fragments. The idea that the fusion of fragments in the wrong position will not affect the function of the shoulder girdle is erroneous, since shortening the clavicle leads to deformation, weakening of the muscle strength of the shoulder girdle and decreased ability to work. Improper fusion of clavicle fragments in children disrupts the statics of the torso and can cause the development of scoliosis and dysfunction of the entire upper limb.

Mistakes should also include the reduction of fragments without sufficient anesthesia of the fracture site, since manipulations with fragments in the presence of pain cause a defensive response - muscle retraction, which does not allow correct comparison of the fragments. You should not apply a fixing bandage with complete immobilization of the shoulder joint in people over 50 years of age, since long-term immobilization leads to wrinkling of the joint capsule and the development of arthrosis, as a result of which the function of the shoulder joint is sharply limited in the future. Finally, failure to perform active movements in all joints of the limbs during the treatment period should be considered a mistake. Therapeutic exercise improves blood circulation in the injured limb, which promotes more active callus formation and faster fusion of fragments.

Dubrov Ya.G. Outpatient traumatology, 1986

The student must know the technique of applying plaster casts:

Plaster casts are applied in a special room - a plaster room, where there is a cabinet for storing plaster and plaster bandages, a table for preparing plaster splints, basins for soaking plaster bandages, tools for removing and cutting plaster casts, a couch or a special orthopedic table.
Plaster bandages are either factory-made or made on site by rubbing plaster powder into regular edgeless gauze bandages (Figure 1).

To make a plaster cast, plaster bandages or plaster splints are lowered deep into a basin of warm water (Fig. 2) . Wetting of the bandage is determined by the cessation of air bubbles. Remove the bandage, grasping it at both ends so that the plaster does not leak out. Bringing your hands together, squeeze out the excess water.

Plaster casts are applied without lining directly to the skin, covering the bony protrusions with special cotton pads (Fig. 3) ; Sometimes in orthopedic practice thin layers of cotton wool are used.
To apply a plaster cast, plaster splints are often used, prepared from 6-8 layers of soaked plaster bandage. The length of the splint is 60 cm - 1 m. The splint is secured with plaster or regular gauze bandage. They bandage without excessive tension and constrictions, rolling out the head of the plaster bandage in a circular motion in an upward or downward direction, covering the previous round with the next round of the bandage by at least half of its width, while straightening the folds and smoothing out the rounds of the bandage. At all times, it is necessary to carefully model the wet bandage along the contours of the body. After applying a plaster cast, it is necessary to carefully monitor the state of blood circulation in the limb, paying special attention to the fingertips: pain, loss of sensitivity, coldness, swelling, discoloration with pallor or cyanosis indicate compression of the blood vessels and the need to change the bandage.

Types of plaster casts

The student must know main types of plaster casts for the upper and lower extremities.

For immobilization, different types of plaster casts are used - circular, fenestrated, bridge-like, hinged, crib, coxite, splints, splints. The plaster bed is used for diseases of the spine. 5-6 large splints are made in two layers each, length from the crown to the middle of the thighs and a width slightly greater than 1/2 of the chest circumference. The patient is placed on his stomach. Bone protrusions are protected with cotton wool, and the head, back, and hips are covered with two layers of gauze. A plaster splint is placed on top of the gauze and modeled well (Fig. 4) . Then subsequent layers are applied one by one. After hardening, the plaster bed is removed and cut so that the patient’s head fits into it to the middle of the crown, and the ears remain open; from the side, the edges should reach the crests of the iliac bones and axillary cavities, but in such a way that movements in the shoulder joints are not limited. An oval notch is made in the perineal area for ease of use of the vessel (Fig. 5). After cutting, the edges of the plaster crib are covered with gauze and rubbed with plaster slurry. The dried plaster crib is covered with soft material from the inside.
A plaster corset is applied for diseases and injuries of the spine. The type of corset is determined by the location of the lesion (Fig. 6). The corset is applied on a special orthopedic table or in a frame, which allows you to relieve the spine and eliminate deformity (Fig. 7) .

The iliac crests, spinous processes of the vertebrae, shoulder blades, and collarbones are first protected with quilted pads. For a corset, wide plaster bandages or specially cut splints are used; they are alternately applied in 4 layers at the back and front, carefully modeling. The bandage is strengthened with 1-2 layers of plaster bandage. The corset contains about 20 bandages 25 cm wide. A correctly applied corset has 3 points of support at the bottom - the crests of the iliac bones and the pubis, at the top in front it rests on the sternum. A window is usually cut out in the abdomen to make breathing easier. When applying a corset-collar, the patient's mouth should be open. The collar corset is cut so that at the top it ends slightly above the back of the head, below the ears and at the level of the chin, at the bottom - at the level of the XI-XII thoracic vertebrae.
In the area of ​​the shoulder girdles and armpits, the corset is cut so that movements in the shoulder joints are not limited.

The hip, or so-called coxitis, bandage (Fig. 8) is used for disease or damage to the hip joint or femur. For a coxite bandage, you need wide plaster bandages, plaster splints 60 or 1 mm long, and cotton pads for laying in the area of ​​the sacrum and iliac crests. The first 2-3 long splints are placed around the abdomen and pelvis and secured with circular rounds of plaster bandage. Then two meter long splints are applied along the back and outer surfaces of the lower limb to the lower third of the lower leg and fixed with a plaster bandage. Two short splints are used to strengthen the anterior and inner surfaces of the hip joint; one of them runs obliquely, forming the perineal part of the bandage. Short splints are applied in front from the lower third of the thigh to the ankle joint and in the back from the middle third of the shin to the fingertips. All splints are reinforced with rounds of plaster bandages. The bandage can be made from a smaller number of splints, but using a larger number of bandages. Particular strength is required in the groin area, where bandages often break.

A thoracobrachial bandage (Fig. 9) is applied for fractures in the area of ​​the shoulder joint and humerus. They begin by applying a plaster corset, then place a long splint along the inner surface of the arm from the hand to the axillary cavity, transitioning to the corset. The second splint is applied along the posterior outer surface from the hand through the elbow and shoulder joints to the corset. The splints are fixed with a plaster bandage and the bandage is strengthened with additional splints at the shoulder joint. A wooden stick - a spacer - is placed in plaster between the corset and the elbow joint.
Circular plaster casts are widely used for fractures of extremity bones (Fig. 10, 11, 12). A circular plaster cast applied directly to the wound is called a blind plaster cast. Along with the immobilization of fragments, such a bandage protects the wound from secondary infection, protects against drying out and cooling,
eliminates the need for dressings, providing optimal conditions not only for the fusion of bone fragments, but also for the healing of soft tissue wounds. A blind plaster cast is widely used for the treatment of gunshot injuries and facilitates the transportation and care of the wounded.
To observe the wound or the site of damage, a window is sometimes made in a circular plaster cast - a fenestrated bandage. It is cut out with a knife in a bandage that has not yet hardened in the intended area. To make it easier to cut out the window from the inside, a cotton pad is placed, and the plaster cast in this place is made thinner. The edges of the window are rubbed with plaster slurry.
A bridge bandage is a type of window bandage, when to strengthen the bandage, metal or cardboard-plaster arches plastered into the bandage are thrown through the window.
A circular bandage that covers only one of the joints of a limb is called a splint, and one that does not cover any joints is called a sleeve. The latter is applied mainly as part of complex dressings.
In case of damage and disease of the joints, most often the knee and elbow, a splint is applied, which creates complete rest for the joint. It should cover the overlying part of the limb to the upper third and the underlying part to the lower third. The splint is based on a plaster splint, over which it is bandaged with plaster bandages.
A removable plaster splint is made from a wide plaster cast, which should cover 2/3 of the circumference of the limb. The splint is well modeled on the limb and fixed with a gauze bandage. If necessary, you can easily remove the bandage by unwinding the bandage. A removable plaster splint is widely used in pediatric practice.
To gradually eliminate some forms of deformities and contractures, a staged bandage is used. There are several types of such a bandage. For example, when treating congenital clubfoot in young children, the foot is removed from the vicious position as much as possible and a plaster cast is applied to it in this form. After some time, the bandage is removed, the vicious position is eliminated again and a plaster cast is applied. So gradually, gradually changing the plaster casts, the foot is brought to its natural position. Another type of staged bandage, used to eliminate contractures in joints and angular deformations of bones, is a circular plaster cast with a cutout above the area to be corrected. The direction of the cut should be opposite to the deformation angle. Gradually reducing the size of the cutout using levers plastered in a bandage eliminates the deformity.
After treatment is completed, the plaster cast is removed. There is a special set of tools for this purpose. When cutting a plaster cast with special scissors, the inner branch must be parallel to the bandage at all times. In areas with pronounced curvature, it is better to use a saw. After cutting, the edges of the bandage are pulled apart and the casted part of the body is released. Remains of plaster are removed with warm water and soap. Other types of plaster casts: Turner plaster cast, Smirnov-Weinstein plaster cast, Chizhin frame, plaster cast for supracondylar fracture of the humerus or damage to the elbow joint, plaster cast for fractures of the forearm bones, plaster cast for damage to the bones of the phalanges of the fingers, plaster cast for fixation of the knee joint and the upper third of the leg bones, a plaster cast for a fracture of the middle third of the leg, a plaster cast for a fracture of the ankles, a plaster cast for a fracture of the foot bones.

The clavicle is the only bone connecting the upper limb to the torso. It is an S-shaped tubular bone. The absolute length of the clavicle of an adult is 12-16 cm. The clavicle consists of a body (middle part) and two ends: acromial and sternal. The latter are somewhat thickened and form articulations with the scapula and sternum.

The acromioclavicular joint is characterized by low mobility. It has a dense fibrous capsule into which the acromioclavicular ligament is woven. Another stronger ligament that holds the articulation of the clavicle with the acromion, the coracoclavicular ligament, consists of two portions: trapezoidal and conical.

The sternoclavicular joint is spherical in shape. Its fibrous capsule is strengthened by the anterior and posterior sternoclavicular ligaments. In addition, there are costoclavicular and interclavicular ligaments that protect the articulating bones from separation.

There are 5 muscles attached to the collarbone. In the area of ​​the sternal end, the sternocleidomastoid muscle is attached to the upper outer edge, and the clavicular part of the pectoralis major muscle is attached to the inferoanterior edge. In the area of ​​the acromial end, the trapezius muscle is attached to the anterosuperior surface, and the deltoid muscle is attached to the anterior-inferior edge. The fifth muscle - the subclavian - is attached along the back surface of the clavicle in its middle part. It should be remembered that under this muscle are the clavicular artery, vein and nerves of the brachial plexus. Somewhat more medially, at the level of the sternoclavicular plexus, the brachiocephalic trunk and the common carotid artery are located on the right, the subclavian artery on the left, and the vagus nerve on both sides.

From a physiological point of view, the clavicle is a kind of springy “spacer” between the sternum and the shoulder joint, which does not allow the latter to take a more medial position. Shoulder support and mobility in the clavicle joints contribute to a significant range of motion of the shoulder and shoulder girdle. Important role The muscles attached to the collarbone play a role in the biomechanics of these movements. In addition, the collarbone protects the neurovascular bundle. Clavicle fractures. These fractures account for about 3% of violations of the integrity of all skeletal bones and are more common in young people.

The mechanism of injury is predominantly indirect: a fall on the abducted arm, on the elbow, shoulder joints, compression of the shoulder girdle. A direct mechanism of injury is also possible - a blow to the collarbone area with some object or during a fall.

Clavicle fractures are diagnosed without difficulty, since the bone is located under the skin and is accessible for examination. The patient's appearance is characteristic: the head is turned and tilted towards the injury, the shoulder girdle is lowered and shifted anteriorly, and the medial edge of the scapula and its lower corner extend from the chest - the absence of a “spacer”, which was the clavicle. The victim supports the arm on the side of the injury, the shoulder is lowered, pressed against the body and internally rotated. The subclavian fossa is smoothed. Often, swelling is visible in the clavicle area due to the protruding central fragment. Palpation reveals a violation of bone continuity; it is possible (but not advisable!) to determine pathological mobility and crepitus.

Very often, clavicle fractures are accompanied by displacement of fragments, especially if the fracture line goes obliquely and passes through the middle of the bone. Due to an imbalance in the physiological balance of the muscles, the fragments are displaced and occupy a typical position. The central fragment, under the action of the sternocleidomastoid muscle, is displaced upward and posteriorly, the peripheral fragment - downward, anteriorly and inwardly. The reason for the dislocation of the distal fragment lies in the disappearance of the support between the shoulder joint and the sternum. The traction of the deltoid muscle and the own weight of the limb displaces the peripheral fragment downward. Traction of the pectoralis major and minor muscles rotates the shoulder medially, brings the limb closer to the body and not only increases the downward displacement, but also moves the fragment inward: the fragments seem to come one after another. The medial displacement of the peripheral fragment is aggravated by contraction of the subclavian muscle.

X-rays of the clavicle are performed, as a rule, in one direct anteroposterior projection and very rarely, in case of comminuted fractures, in order to clarify the location of the intermediate fragment, in a lateral projection.

There are conservative and surgical methods of treatment. Most often, conservative treatment consists of immediate reposition and stable fixation of fragments.

Local anesthesia. 10-20 ml of 1% novocaine solution is injected into the fracture area. After waiting 5-7 minutes, they begin manipulation. The purpose of reposition is to bring the peripheral fragment to the central one by lifting the shoulder girdle and moving it outward and backward. There are several ways to compare clavicle fragments. First way. The patient is placed on his back on the edge of the table with a high cushion placed between the shoulder blades. The arm on the fractured side is hung from the table. After 10-15 minutes, the surgeon’s assistant stands at the patient’s head, grasping the armpits with his hands, and shifts the shoulder girdle upward and backward. The surgeon, standing facing the patient, fixes the shoulder joint with one hand, and reduces and holds the fragments with the other. Second way. This method is similar to the first, but is performed with the patient in an upright position, who is seated on a low stool. The assistant surgeon stands behind the victim, grabs the armpits from the front and, resting his knee on the patient’s back, lifts and spreads the shoulder girdle as much as possible. The surgeon performs reduction directly at the fracture site.

Third way. Used in the absence of an assistant. Two stools are placed nearby, and the patient and the surgeon sit on them sideways to each other. The latter places his forearm into the patient’s armpit, and at the same time uses his chest to hold the victim’s shoulder and elbow joint in the adducted position. Then the doctor lifts the patient’s shoulder girdle with his forearm and, acting like a lever, moves it backwards. With his free hand he compares the fragments.

When performing any of the reduction methods, you should not abduct the shoulder, since this stretches the pectoralis major muscle and adducts the shoulder joint, which makes it difficult to compare the fragments.

At the end of the manipulation, without weakening the traction, it is necessary to fix the shoulder girdle and shoulder on the affected side in the position achieved by reposition. A plaster cast is best suited for this. Of the many proposed, the Smirnov and Weinstein bandage has stood the test of time and earned recognition (Fig. 4.1). When performing immobilization, be sure to place a cotton-gauze roll in the armpit. Reliable fixation of fragments is achieved with a Kuzminsky splint (Fig. 4.2). If immediate reduction fails, this splint can be used for gradual (over 2-3 days) comparison of fragments. Correct installation of the segments of the body of the humerus and correction of traction by moving the belts allow the splint to be used as a reduction device. Tires by Böhler, Rakhmanov, Tikhomirov, Chizhin, etc. are currently practically not used and have only historical meaning.

Titova's method gives good results when used correctly. The author carries out treatment using a certain size and shape of an “oval” placed in the patient’s armpit. The hand is suspended on a scarf. Early functional treatment is used.

Soft tissue bandages are unsuitable for fixing clavicle fragments: 8-shaped, Delbe rings, since they do not create a lift of the shoulder girdle, but only move it posteriorly, and the scarf, Deso and Velpeau bandages do not secure the fragments in the desired position. In addition, after 1-2 days the bandage weakens and the bandage ceases to play a fixing role. As an exception, these dressings can be used in children with subperiosteal fractures and in elderly and senile people. Clavicle fractures are often part of polytrauma, and the listed treatment methods become unacceptable due to the forced lying position of the patient. In such situations, the Couteau method should be included in the arsenal of disaster medicine. The patient lies on his back closer to the edge of the bed with his arm hanging for 24 hours. Then the arm, bent at the elbow joint, is placed on a low side stool for 14-21 days. Surgical treatment of clavicle fractures is performed according to strict indications. Such indicators are damage to the neurovascular bundle, open fractures, comminuted fractures with the threat of damage to blood vessels and nerves, interposition of soft tissues, and the threat of skin perforation from a sharp fragment. If a fragment with a sharp edge survives significantly, and the skin at the site of the protrusion is anemic (white), a soft tissue pressure sore should not be expected. It is necessary to operate on the patient, which will make it possible to make an incision in the desired projection and under aseptic conditions.

Surgical treatment consists of exposing the fragments, open reduction and fixation of bone fragments using one of the methods. The most commonly used is intraosseous osteosynthesis with a metal pin. The fixator can be introduced from the side of the central fragment or retrogradely, when the pin is punched into the peripheral fragment until it goes beyond the acromion, and then, having aligned the bone fragments, the pin is inserted into the central fragment, moving it in the opposite direction. External osteosynthesis with a plate is also possible. After the operation, a plaster cast is applied. Currently, external fixation devices are also used to treat clavicle fractures.

Regardless of the method of treatment and type of fixation device, immobilization should continue for at least 4-6 weeks. From the 3-4th day, UHF is prescribed for the fracture area and exercise therapy for non-immobilized joints. On the 7-10th day, static contractions of the muscles of the forearm and shoulder begin. After the immobilization period has expired, the plaster cast is removed and X-rays are taken. If consolidation has occurred, they begin restorative treatment: exercise therapy for the joints of the upper limb, massage of the shoulder girdle and shoulder, hydrotherapy in the pool, etc. Working capacity is restored in 6-8 weeks.

Clavicle dislocations. They make up 3-5% of all dislocations. Clavicle dislocations occur mainly as a result of an indirect mechanism of injury: a fall on the shoulder girdle or an abducted arm, a sharp compression of the shoulder girdle in the frontal plane. There are dislocations of the acromial and sternal ends of the clavicle, with the former occurring 5 times more often. It is very rare for both ends of the clavicle to dislocate at the same time.

Dislocation of the acromial end of the clavicle. On the outer side, the collarbone is held in place by ligaments, depending on the rupture of which, complete and incomplete dislocations are distinguished.

If one acromioclavicular ligament is torn, the dislocation is considered incomplete, and if the coracoclavicular ligament is also torn, it is considered complete. The history shows a characteristic mechanism of injury. Complaints of pain in the area of ​​the acromioclavicular joint, moderately limiting movement in the shoulder joint. Swelling and deformation are noted at the site of injury, the severity of which depends on whether the dislocation is complete or incomplete. With complete dislocation, the acromial end will stand out significantly, its outer surface can be felt under the skin, and when moving the scapula, the collarbone remains motionless. In case of incomplete dislocation, the clavicle remains connected through the coracoclavicular ligament and moves along with the scapula; the outer end of the clavicle cannot be felt. Palpation is painful in all cases. When you press on the collarbone, the dislocation is quite easily eliminated, but if you stop pressing, it appears again. This is the so-called key symptom, which serves as a reliable sign of rupture of the acromioclavicular ligament.

Radiography makes the diagnosis easier. When reading a radiograph, you should pay attention not so much to the width of the joint space (its size is variable, especially with incorrect placement), but to the position of the lower edge of the clavicle and its acromial end. If they are at the same level, it means that the ligamentous apparatus is intact and there is no dislocation, but if the collarbone has moved upward, the boundaries of the levels change (Fig. 4.3).

There are conservative and surgical methods of treatment. Reducing the dislocated acromial end of the clavicle is not difficult, but keeping it in the desired position using conservative methods is quite difficult. For fixation, a variety of bandages, splints and devices, supplemented with a pelot, are used.

An example of a soft tissue device is the Volkovich bandage. After anesthesia of the injury site with 20-30 ml of 1% novocaine solution, the clavicle is reduced. A cotton-gauze pad is applied to the area of ​​the acromioclavicular joint, which is fixed with a strip of adhesive plaster from the acromial end through the shoulder girdle backwards and downwards, then along the back surface of the shoulder, around the elbow joint and back along the front surface of the shoulder to the starting point. The bandage is applied with the shoulder retracted outward and posteriorly. A small roller is inserted into the axillary area, the arm is lowered and secured with a scarf.

Another way to fix the pelota is to apply an adhesive bandage with the shoulder abducted from the shoulder girdle to the lower third of the shoulder along the outer surface. Reinforce with a second strip running perpendicular to the first (crosswise). The hand is lowered, which increases the tension of the patch and the retention of the collarbone. It is advisable to reinforce both adhesive bandages by applying a Deso bandage.

Soft tissue bandages as a method of fixation are acceptable in the treatment of patients with incomplete ruptures of the acromioclavicular joint.

A plaster cast is most often used for fixation. Various modifications of thoracobrachial bandages are used, but with the obligatory abduction of the shoulder by 95-105° and the use of a pelot in the form of a roller, belt, etc. The original solution was found by A. N. Shimbaretsky, who supplemented the thoracobrachial plaster cast with a screw pelot.

In order to hold the reduced acromial end of the clavicle, a Kuzminsky splint or a specially designed Kozhukeev splint can be used. The immobilization period for all conservative methods is 4-6 weeks.

For chronic dislocations, surgical treatment is indicated. Its essence is to create acromioclavicular and coracoclavicular ligaments from autologous tissues, allo-tissues or synthetic materials (silk, nylon, lavsan). The most common operations are performed using the Bohm, Bennel, Watkins-Kaplan method (Fig. 4.4). After surgery, a plaster thoracobrachial bandage is applied for a period of 6 weeks.

The operations of restoring the acromioclavicular joint with knitting needles, screws, stitching, etc., captivating with their simplicity, should not be performed without plastic surgery of the coracoclavicular ligament due to the large number of complications.

Dislocation of the sternal end of the clavicle. It occurs as a result of an indirect mechanism of injury: excessive deviation of the shoulder and shoulder girdle posteriorly or anteriorly. Depending on the displacement of the inner end of the clavicle, presternal, suprasternal and retrosternal dislocations are distinguished. The last two are extremely rare. I am worried about pain in the sternoclavicular joint area. In the upper part of the sternum there is a protrusion (excluding retrosternal dislocation), which moves when the shoulder girdles are brought together and spread apart, and deep breathing. The tissues are swollen and painful on palpation. The shoulder girdle on the side of the injury is shortened.

X-rays of both sternoclavicular joints are taken in a strictly symmetrical position. When dislocated, the sternal end of the clavicle moves upward and towards the midline of the body. On an x-ray, its shadow overlaps the shadow of the vertebrae and is projected higher than on the healthy side.

The best anatomical and functional results are achieved with surgical treatment. The most common procedure is the Marxer operation: the clavicle is fixed to the sternum with a U-shaped transosseous suture. An abduction splint or thoracobrachial plaster cast is applied for 3-4 weeks.

For injuries, plaster retainers are often used. This method of immobilization has a number of advantages - they are convenient to use, easy to apply and promote proper fusion of bone tissue.

There are several types of plaster casts:

• With cotton-gauze, flannel or knitted lining. They have their drawbacks: cotton wool gets lost, causing discomfort; bone fragments are often not fixed rigidly enough. Often dressings are made with a knitted bandage or stocking as lining fabric. Both options protect the skin from damage.
• Without lining, which is applied directly to the skin.

Gypsum fixators are often used for various pathologies of the musculoskeletal system. They are prohibited from being used when:

• ligation of large vessels of the circulatory system;
• infections of anaerobic origin;
• purulent processes;
• phlegmon;
• somatic pathologies, etc.

Types of plaster casts vary in the method of application and the part of the body covered. A circular plaster cast is applied in a spiral shape to the injured area, while a splint bandage covers only one side.

Circular plaster casts come in the following types:

• Fenestrated. A hole is cut out on the fixator above the wound and drainage; the edges of the cut window should not injure the soft tissue.
• Bridges - are applied when there is a circular violation of the integrity of the skin. Circular bandages are made above and below the wound, which are additionally strengthened together with U-shaped metal parts.

The classification of plaster casts is based on the areas they are applied to. They are:

• split;
• tire;
• langetal;
• langet-circular;
• thoracobrachial (applied to the arms and chest);
• coxitis (on the legs, pelvis and abdomen with part of the chest);
• purulent (covers the legs, pelvis, border reaches the navel);
• corsets;
• cribs

For minor injuries to the collarbone, use the Deso bandage. Immobilization is carried out with a bandage, less often with plaster. If your clavicle is broken, you can use a bandage instead of a bandage.

Equipment and tools

Plaster casts are applied in a specially equipped room with the necessary set of tools. Required:

• table for preparing dressings;
• orthopedic or special table with a pelvis holder;
• apparatus for applying corsets;
• scissors for cutting plaster;
• beak tongs for bending plaster casts;
• plaster expander for pushing apart the edges of the plaster;
• spare materials for dressing.

Plaster casting

When applying a plaster cast, technique must be followed.

The rules for applying plaster casts are as follows:

• ensure immobility of the broken and two nearby joints;
• provide free access to the injured limb;
• in the process of applying a plaster cast, control the correct fit of the dressing material (strongly pressing bandages interfere with blood circulation in the injured area and can lead to the development of bedsores and necrosis of soft tissues);
• for any type of fracture, do not cover the fingers with a plaster bandage;
• it is necessary to control the behavior of bone fragments (repeated displacement is unacceptable);
• A soft bandage made of gray cotton wool is placed under the bone protrusions (it does not absorb moisture like white wool).

When applying a cast, the possible development of joint stiffness should be taken into account. Therefore, when dressing, it is necessary to give the joints a favorable functional position: there should be an angle of 90° between the lower leg and foot; knee bent 165°; hip – fully extended; fingers - in a slightly bent position, hand at an angle of 45°, shoulder - 15-20° (a gauze roll is placed under the arm).

The patient's bed should be orthopedic or a shield should be placed under the mattress. All dressing procedures are performed by an orthopedist or traumatologist. Before the procedure, the plaster bandage is soaked in water, wrung out and placed on the limb in a perfectly straightened state, paying special attention to the joint area. After the plaster has dried, it is bandaged, but not too tightly. This plaster cast algorithm is similar for all types of injuries that require rigid fixation of the injury area.

When swelling appears, the plaster cast is cut along the front part, and after normalization, the integrity of the fixator is restored (plastered).

A plaster cast takes the shape of a body part when applied. And this property is widely used in traumatology and orthopedics. For open fractures, a plaster cast is also applied. It is applied directly to the injury and does not interfere with wound drainage.

Overlay technique

Plaster casts are applied in the following sequence:

• All required materials are prepared.
• The fracture zone is immobilized with 2-3 nearby joints.
• To ensure immobility of the joint, plaster is applied to this joint and to fragments of the limb.
• A wide bandage is applied along the edges of the cast, which is subsequently folded over the edge of the plaster cast.
• If loss of motor function of the joint is suspected, it is placed in a comfortable position.
• When applying plaster, the joint is kept motionless.
• The application of a plaster cast is carried out in a circular motion around the damaged area, starting from the periphery and moving towards the center. The bandage is not bent; when changing direction, it is cut from the reverse side and straightened.
• Areas subject to greater stress are further strengthened (joints, feet).
• To more accurately model the contours of the limb, each layer is smoothed until the hand feels the contours of the body under the plaster. Particular attention is paid to bony protrusions and arches. The plaster must exactly follow the anatomical contours of the area on which it is applied.
• During dressing, the limb is supported with a brush (fingers can leave marks on the uncured plaster). The plaster bandage is applied in layers.
• Before the plaster has completely hardened, try not to touch it, so as not to disrupt the integrity of the fixing material.
• The edges of the bandage are strengthened, after the plaster has hardened, the edge is cut in a circle by 2 cm, then a lining is folded over it, which is fixed with plaster.
• Strong fixation is achieved with at least 5 layers of plaster bandage.
• After the application of the plaster cast is completed, it is marked (the dates of the injury, the application and removal of the plaster, and the name of the traumatologist are written down).

The plaster dries 15-20 minutes after soaking, so if the application area is large, the bandages are soaked gradually as needed.

After applying a circular bandage, the patient's condition is monitored for 2 days (swelling of the limb is possible).

When applying splints, the length and width of the healthy limb are measured in advance. Cut wide strips of plaster bandage. After soaking, the bandage is smoothed by weight. Where the joint bends, the edges are cut and placed on top of each other. To fix the splint, it is bandaged with a gauze bandage.

The plaster is removed using special tools (scissors, file, forceps, spatula), after moistening the incision site with hot water or special solutions. To remove the splint, cut the bandage.

A clavicle fracture is a pathological condition manifested by a violation of the anatomical integrity of the clavicle. Most often, fractures occur in the middle third, at the border of the outer and middle thirds of the clavicle, on its most curved and thinned part.

Epidemiology Accounts for 2.6-12% of the total number of fractures. In 80% of cases, the fracture occurs in the middle third, 15% - a fracture of the acromial end of the clavicle, 5% - sternal. Fractures of the clavicle almost always occur with displacement of fragments. The exception is fractures in children, which occur according to the “green stick” type. The bone breaks, but due to its elasticity, the fragments do not move, but remain attached, as happens when a green branch is broken.

Mechanism of injury: this is, as a rule, a fall on the side of the shoulder, on an outstretched arm, a direct blow to the collarbone, or a birth injury.

Fracture clinic. The collarbones are paired bones that serve as spacers between the shoulders and sternum. If they were not there, then the shoulders could be brought together in front until they touch. This is counteracted by the collarbones. When they are fractured, the shoulder on the side of the fracture moves anteriorly; the patient supports the forearm with his healthy hand to reduce pain. Pain at the fracture site, swelling, deformation, hemorrhage and shortening of the shoulder girdle are determined, the shoulder is lowered and displaced anteriorly. The peripheral fragment, together with the upper limb, under the influence of its weight and contraction of the pectoralis major and subclavian muscles, moves down, forward and inward. The central fragment is displaced upward and posteriorly under the influence of the sternoclavicular muscle. The fragments come closer together and overlap one another. Thus, the symptoms of a clavicle fracture:

Pain at the fracture site. The nature and intensity of pain depends on the type of fracture, from mild to unbearable.

Movement in the shoulder girdle and shoulder joint is limited.

The patient's head is tilted towards the injury, and the shoulder girdle is shortened.

There is also a crunching of fragments (crepitus) when palpating or attempting to move and a visible deformation of the collarbone.

Swelling in the area of ​​the fracture (the supraclavicular fossa is smoothed).

The patient holds the forearm and elbow of the injured limb with his healthy hand, pressing it to the body. Movement in the shoulder joint is limited due to pain. When palpating the fracture site, pathological mobility and crepitus of the fragments can be determined.

Here is an x-ray picture of a displaced clavicle fracture:

Conservative treatment: involves juxtaposing fragments and keeping them in the juxtaposed state. If the comparison does not pose any particular difficulties, then retaining the fragments using known methods is almost impossible. It is carried out using special bandages. Quite a lot of them have been invented, but they are not convenient and none of them guarantee immobilization. It is characteristic that as soon as the bandage becomes comfortable, it immediately completely loses its effectiveness. Therefore, all dressings require daily tightening to maintain their effectiveness.

eight-shaped bandage, see fig. Below is the simplest bandage for these purposes, quite effective for daily tightening, although not comfortable. It is applied with the shoulder blades brought together as closely as possible and the chest protruded.

Delbe rings, see fig. below. Unfortunately, the picture shows it incorrectly applied. Here the Delbe rings are brought together and there is no possibility of tightening them, although this must be done daily. They are simply too big for a child. By making them smaller and leaving a gap between them for tightening, all the shortcomings will be eliminated.

dressings according to Weinstein (a), Kaplan (b), see pictures below:

Deso's bandage is not suitable for immobilizing a fracture after reduction and is not given here. It is used only for transport immobilization of a clavicle fracture

Orthotic bandages of various designs have been developed recently; they are quite comfortable and effective, they are sold in orthopedic salons, although they are quite expensive.

Surgical treatment: currently, many trauma surgeons perceive conservative and surgical treatment methods as alternative, although we cannot agree with this. These are mutually complementary methods and each of them has every right to exist and has its own indications and contraindications. The failure of conservative treatment is an absolute indication for surgery. I am deeply opposed to starting the treatment of fractures with surgery. In this case, if there is no result, this is a guaranteed disability

extramedullary osteosynthesis with plates, the fracture is immobilized using special metal plates. The question is often asked about their quality, which ones are better. In order not to mislead the patient, the quality of the plates does not affect the final results of treatment. Large monetary costs (10-15 thousand Russian rubles) in this case are not justified. See fig. below.

intraosseous osteosynthesis with knitting needles, a rod, in which a metal structure (rod, pin) is inserted into the medullary canal of the clavicle, where it remains until complete recovery and is removed a year after its installation, as well as external fixation with devices (on the right)

Conditionally favorable, with adequate treatment, complete restoration of the anatomical integrity of the bone occurs, and working capacity is fully restored.

Plaster casts on certain areas of the body

Bandage for the key keeper. For fractures and dislocations of the collarbone, plaster casts have recently been rarely applied. These injuries are treated surgically, and after surgery the limb is suspended on a scarf.

Weinstein, which firmly fixes the compared fragments and makes it possible to carry out functional treatment. When applying the Smirnov-Weinstein bandage (Fig. 128, a, b), the arm is bent at the elbow joint at a right angle, the shoulder is retracted posteriorly at an angle of 45° with an outward rotation and raised. A cotton-gauze roller is placed in the axillary area, and a cotton-gauze pad is placed on the upper arm of the healthy side to prevent the pressure of the bandage on the shoulder girdle and neck. The shoulder girdle is fixed with damp, smoothed splints: one around the torso and shoulder of the injured side in a circular manner, the second obliquely through the middle third of the forearm and the shoulder girdle of the healthy side. The length of the splints should be such that their ends overlap each other by 10 cm. Additionally, the splints are fixed with a plaster bandage in the direction

yam longet. The bandage allows movement of the hand on the injured side and almost does not restrict movement in the healthy hand.

Shoulder bandage. For fractures of the neck of the scapula, neck of the humerus without displacement of fragments, for avulsions of the greater tuberosity, for fractures of the humerus in elderly patients, for fractures in the lower third of the shoulder, after reduction of a dislocated shoulder, after surgical interventions on these parts, immobilization of the upper limb is carried out with a posterior plaster splint of 6-8 layers from the metacarpophalangeal joint to the inner edge of a healthy scapula. The limb is bent at the elbow joint at an angle of 90°, the forearm is placed in the middle position between pronation and supination, the shoulder is moved to the side and forward by 45-50°. To abduct the shoulder, a wedge-shaped cotton-gauze pad is placed in the axillary fossa. The splint is placed across the back, capturing the scapula and shoulder joint of the diseased upper limb, and, moving to its outer-posterior surface, the elbow and wrist joints are fixed. The splint in the area of ​​the elbow joint is cut from the sides so that the edges on the fold extend one after the other.

the other is bandaged with spiral passages of gauze bandage to the forearm and shoulder, and reinforced in the area of ​​the shoulder joint with a spica-shaped soft bandage.

In case of fractures of the humeral diaphysis with displacement of the fragments, a one-stage reduction is performed, followed by fixation of the shoulder girdle with a plaster thoracobrachial bandage (Fig. 129).

The bandage is applied to the patient in a sitting or standing position. The injured upper limb is bent at the shoulder joint to an angle of 45° with external rotation of up to 30-45°. The degree of abduction depends on the level of the shoulder fracture (from 45 to 90°). The forearm is bent at the elbow joint to a right angle and placed in an average position between pronation and supination, the hands are placed in a position of slight dorsiflexion and abduction towards the elbow. The entire upper limb and torso are covered with soft bedding

coy. Plaster bandages are evenly distributed over all parts of the bandage with some increase in the shoulder joint. On the arm and torso, the bandage is bandaged with a plaster bandage in spiral motions, and on the shoulder joint it is applied as a spica bandage.

After applying 3-5 layers of plaster bandage, the bandage is strengthened with three splints: one goes from the chest through the shoulder joint to the shoulder in front, the other from the back through the shoulder joint to the shoulder at the back, and the third along the inner surface of the shoulder through the armpit to the torso. Splints are well modeled, ironed and fixed with plaster bandages. To prevent the bandage from breaking, it is advisable to plaster a wooden spacer between the shoulder and torso. Both ends of the spacer are well secured with several passes of plaster bandage. The hand is bandaged up to the heads of the metacarpal bones.

Forearm bandage. To immobilize the forearm, a plaster splint or circular plaster cast is used. The position of the forearm depends on the level of damage. Fractures in the lower third of the forearm are fixed in a position of pronation, in the middle third - between supination and pronation, in the upper third - in supination. These features of fixation are due to the nature of the displacement of fragments.

In case of closed fractures of the diaphysis of the forearm bones without displacement, to immobilize the limb, a deep dorsal plaster splint is applied to it from the metacarpophalangeal joint to the upper third of the shoulder. It can be made by rolling out plaster bandages directly on the hand or according to pre-taken measurements on the table. The forearm at the elbow joint is bent at an angle of 90°, the hand is extended at the wrist joint at an angle of 15°. A layer of cotton wool is placed in the area of ​​the elbow bend and in the first interdigital space. The splint is placed on the arm, carefully modeled and bandaged with spiral passages of gauze bandage.

In case of fractures of the forearm bones with displacement of the fragments, a one-step reposition of the fragments is performed with immobilization with a deep dorsal plaster cast. The elbow joint is bent at an angle of 90°, the position of the forearm depends on the level of damage. After reduction of the fragments, the forearm is fixed with a dorsal plaster splint from the metacarpophalangeal

articulation to the upper third of the shoulder with strengthening it with spiral moves of plaster bandage (3-5 layers).

Wrist bandage. View

The dressing depends on the location and characteristics of the injury. For fractures of the phalanges of the finger, after repositioning the fragments, a splint plaster cast is applied. The upper edge of the splint ends at

level of the middle third of the forearm, the lower one protrudes beyond the end of the finger by 0.5-1 cm. It is applied from the palmar surface, carefully modeled, giving the finger and hand a functional position, and fixed with a gauze bandage (Fig. 130, o, b).

In case of fractures of the wrist bones, immobilization is carried out with a plaster splint from the metacarpophalangeal joint to the elbow. In this case, the hand is placed in a position of slight dorsiflexion, and the fingers are bent.

Sometimes, for hand injuries, a circular plaster cast is used. In case of a fracture of the metacarpal bones, the hand and forearm are covered with a soft pad and, after repositioning the fragments, a bandage is applied in circular motions with a plaster bandage, starting from the hand. The traverses of the bandage are directed proximally, smoothing and modeling them along the contours of the arm. The bandage consists of 4-5 layers of plaster bandage, its distal end is sealed at the level of the proximal interphalangeal joints.

To immobilize the base of the first metacarpal bone, a bandage is applied after reduction of the fracture. The first metacarpal bone is placed in the abduction position and the thumb is cast down to the nail phalanx, carefully modeling the bandage and making sure that the first interdigital space is as wide apart as possible.

In case of a fracture of the scaphoid bone, a circular plaster cast is applied for immobilization, extending from the distal palmar fold and the interphalangeal joint of the first finger to the upper third of the forearm. The hand is placed in the longitudinal axis of the forearm and retracted as far as possible to the radial side. Big

the finger is placed in a position of full abduction.

Large splint. Used for immobilization in case of hip fractures, as well as in cases of damage to the hip joint (Fig.

The patient is placed on an orthopedic table: the sacrum is on a pelvic holder, the head and shoulders are on a stand. To apply this bandage, 3-4 assistants are needed. One of them holds the diseased limb in the desired position until the plaster hardens: slight flexion in knee joint; slight abduction and flexion at the hip joint; the foot is at a right angle to the shin; patella in a strictly horizontal plane.

The torso, starting from the 5th-6th ribs in front, the pelvis and the affected limb, especially in the area of ​​the knee and ankle joints, is covered with cotton-gauze pads. An oilcloth flat pillow or folded sheet is placed on the upper abdomen, which is removed after the bandage has hardened. Splints are prepared in 6-8 layers. One splint is applied from the tips of the toes to the posterior edge of the costal arch, the second - from the dorsum of the foot to the anterior edge of the costal arch, the third (the so-called “lock”) - around the groin and buttock area. While applying the bandage, you should monitor the position of the pelvis to avoid distortion. To do this, the healthy limb is abducted and fixed with an orthopedic table leg holder in accordance with the position of the injured limb. The bandage is applied in spiral strokes of a plaster bandage, starting from the ankles and ending at the costal arch, in 3-5 layers, after which the back and front splints and “lock” are applied to the hip joint. The splints are again fixed with spiral passages of a plaster bandage. The joints are fixed especially carefully. As the bandage is applied, it is carefully modeled according to the contours of the body.

To immobilize the upper thigh when drying is needed

If the abduction of the leg is injured, it is better to apply a plaster cast with the so-called “pants leg on the second leg.” A wooden spacer can be placed in plaster between the legs (Fig. 132).

In the elderly and senile, immobilization with a large coxite bandage is fraught with serious complications (bedsores, pneumonia, circulatory disorders, etc.). Therefore, it should not be used in such patients.

For injuries and inflammatory diseases in the area of ​​the knee joint, coxite and splint plaster casts are used: The latter can be applied with or without a foot, with or without a pelvic half-ring. In the latter case, the upper edge of the splint ends at the level of the gluteal fold. To apply the bandage, the patient is placed on his stomach. A cushion is placed under the lower third of the shin to give slight flexion to the knee joint. The foot is placed at a right angle to the shin. The back and side surfaces of the leg are covered with gauze, on top of which 5-6 layers of plaster bandage are rolled out, forming a splint, and carefully modeled. The splint is fixed to the leg with a gauze bandage.

Shin bandage. It is often applied for ankle fractures, diaphyseal fractures without displacement of fragments, as well as isolated fractures of the fibula.

For high fractures of the leg bones, the plaster cast should start from the toes and reach the upper third of the thigh; for fractures above the level of the ankles, up to the middle of the thigh. The lower leg and thigh should be in a slightly flexed position. For diaphyseal fractures, a circular or splint-circular unlined plaster cast is applied.

The circular bandage begins with circular and spiral strokes of the plaster bandage and is applied evenly throughout from the periphery to the center. The thickness of the bandage is 6-8 layers of plaster bandage.

When using a longitudinal-circular plaster cast, a splint is initially applied along the back surface of the lower leg in 6-8 layers.

In cases of ankle fractures with dislocation of the talus (pronation fractures), a long plaster splint equal to two distances from the heel to the middle third of the thigh is first prepared. It is applied in a U-shape, placing the middle across the foot in the form of a stirrup, and the ends along the inner and outer surfaces of the lower leg and thigh. The splint is strengthened with spiral passes of a plaster bandage in 3-5 layers, starting from the heel area and ankle joint and ending with the femoral part of the bandage. The toes are left free.

For an isolated fracture of the ankles or fibula without displacement of the fragments, an 11-shaped Volkovich splint cast or a plaster boot is applied.

When applying the Volkovich bandage (Fig. 133), first apply a plaster splint in 6-8 layers from the inner condyle of the tibia along the medial surface of the tibia, through the foot in the form of a stirrup, along the outer surface of the tibia to the head of the fibula. At the same time, it is carefully modeled to the arch of the foot, ankles, condyles of the leg, to the head of the fibula and bandaged with spiral passages of gauze bandage from the ankle to the knee. After the plaster has hardened, the gauze bandage is cut and removed, and the splint is fixed with three rings. The rings are applied in circular passes with a narrow plaster bandage in 3-4 layers.

The lower ring is placed above the ankle joint, the upper one - at the level of the tibial tuberosity and head of the fibula, the middle one - in the middle of the lower leg. When applying a bandage, you must ensure that it does not limit flexion in the knee joint. The advantages of this bandage are that it is lighter than a circular one, and as the swelling decreases, it can be strengthened by changing the rings without the risk of secondary displacement of the fragments.

A plaster cast in the form of a boot (Fig. 134) provides more reliable fixation of the ankle joint and is more comfortable to walk in. A boot is applied in the form of a longo-circular bandage. Prepare a splint with 6-8 layers of plaster bandage. It is applied from the tips of the toes along the plantar surface of the foot and the back surface of the shin to its upper third, carefully modeled and strengthened with circular and spiral strokes of a plaster bandage in 3-5 layers. In this case, the foot is fixed at a right angle to the shin, and the toes are left open. For convenience when walking, a small heel is attached to the heel area.

Rice. 134 For calcaneal fractures, plus

On the new bones and phalanges of the toes, a posterior plaster splint is applied without displacement from the tips of the toes to the upper third of the leg or a plaster boot, the application technique of which is described above.

Plaster corsets. Corsets, which are circular plaster casts, are used for fixation, unloading and reclination of the spine during inflammatory and degenerative processes, with injuries, curvatures of the spine and in the postoperative period.

Plaster corsets can be low with hangers (see Fig. 127, b) or without them (see Fig. 127, a), as well as with a collar (see Fig. 127, c). The support points for them are the back of the head, the shoulder girdle, the chest, and the crests of the pelvic bones. If the vertebrae below the VIII thoracic vertebra are affected, a low plaster corset is used; above the VIII thoracic vertebrae, a corset with a collar is used.

A plaster corset is usually applied with the patient standing or sitting with the arms or head stretched. This allows you to apply a corset with some stretching and unloading of the spine.

The patient's torso and the upper third of the thighs, front and back, are covered with a piece of gauze with a hole cut in the center for the head. On top of the gauze, the body is covered with cotton wool, which is reinforced with a gauze bandage. When making a corset with

With a collar-head holder, a cotton-gauze pad is placed on the neck and lower part of the head, and a rolled-up bandage 2-3 cm thick is placed between the teeth so that the patient can open his mouth.

Bandaging begins with spiral moves of the plaster bandage from the bottom up, covering the previous move by half the width. Bandage tightly in the pelvis and waist and loosely on the chest. As the bandage is applied, the bandage is smoothed and shaped, especially carefully in the area of ​​the iliac crests, greater trochanters of the femurs, sacrum, waist and lower chest. At the top, the manufacture of a corset with shoulder pads is completed with eight-shaped passes of the bandage through both shoulder pads. The bandage is applied tightly so that the shoulder pads fit snugly to the patient’s body.

When making a corset with a head collar, plaster bandages are applied circularly to the neck and lower part of the head. The edges are trimmed, the cotton-gauze lining is wrapped on the outer surface and plastered. A “window” is cut out on the front surface of the corset above the epigastric region.

The upper edge of the corset with a collar is located in front 1-2 cm above the lower edge of the horizontal branches of the lower jaw, on the sides - below the earlobe, in the back - at the level of the occipital protuberance. The lower edge is located on the sides at the level of the greater trochanters of the thighs, in the front - above the pubis, in the back - at the same level as on the sides. The lower edge of a collar with shoulder pads used for immobilization cervical region of the spine, in front it is located at the level of the third rib, in the back - at the level of the spinous processes of the fourth thoracic vertebra, on the sides - above the acromial clavicular joints.

The corset can be made from gypsum layers. Gauze for layers is cut according to the measurements taken. To do this, when making a corset with shoulder pads, the patient’s torso is measured in length from the collarbone through the shoulder girdle along the back to the desired level below, in width between the anterior axillary lines at the level of the lower corners of the shoulder blades. The corset requires 4-6 two-layer layers, which are soaked, smoothed on the table, applied to the patient’s torso, covered with a cotton gauze pad, in front and behind so that their edges on the sides and in the area of ​​the shoulder girdle overlap one another. Layers

modeled to the patient’s body and fastened with one or two circular and spiral strokes of a plaster bandage from bottom to top along its entire length.

For uncomplicated compression fractures of the lower thoracic and upper lumbar vertebrae, they are immediately straightened by forced hyperextension between two tables, and in this position a plaster reclining corset is applied. If gradual straightening is necessary compression fracture vertebra, the patient is placed on a bed with a wooden board and mattress, and a small dense cushion is placed under the lower back. The next day, a larger cushion is placed, and after 1-2 days it is replaced with an even larger one - 12-20 cm wide, 7-10 cm high. On the 8-15th day after straightening the vertebra, a plaster corset is applied.

With immediate straightening, the corset is applied in the position of the patient sagging between two tables, with gradual straightening - in the position of hanging from the lower back. A cotton-gauze pad is placed on the body, on top of which plaster bandages are rolled out, carefully modeling them along the contours of the body. After applying six layers of plaster bandage, an oval hole is cut out on the front surface of the corset (Fig. 135, a, b, c).

CHAPTER 15 REDUCTION AND CONSERVATIVE TREATMENT OF DISLOCATIONS

Dislocation (luxatio) called persistent separation of articulating surfaces as a result of physical violence or a pathological process. Dislocation gets its name from the damaged joint, or the underlying segment is considered dislocated (except for the collarbone and vertebrae); such as a shoulder dislocation or shoulder dislocation. In the case where the congruence of the joint is disrupted, but the contact of the articulating surfaces remains, a conclusion is made about subluxation in the joint.

15.1. CLASSIFICATION OF TRAUMATIC DISLOCATIONS

Based on the presence of damage to joint tissue:

Based on time elapsed since injury:

According to the presence of complications:

With damage to the neurovascular bundle;

With tendon rupture;

With fractures of the articular parts of the bones;

The most common are traumatic dislocations, which account for 2 to 4% of all skeletal injuries and 80-90% of all other dislocations. Dislocations occur in all age groups, but mainly in older men, who account for 60-75% of injuries.

The occurrence of dislocations is characterized by an indirect (lever) mechanism of injury; this can be any violent movement that exceeds the functionality of the joint, usually causing damage to the joint capsule and ligamentous apparatus.

In some cases, injuries damage all the tissues of the joint area, from the skin to the synovium. If tissue damage

joint occurred due to exposure to a traumatic factor, then the dislocation is classified as primarily open. When tissues are damaged due to the traumatic effect of the bones forming the joint or their fragments, then in such cases they speak of a secondary open dislocation. In addition, dislocations can be complicated by joint fractures (fracture-dislocation). The last two types are classified as complicated dislocations. According to the time that has passed since the violation of the congruence of the joint, dislocations are divided into fresh, stale and old. Dislocations are considered fresh when no more than three days have passed since the injury, stale - from three days to three weeks, old - three weeks or more.

Algorithm for diagnosing dislocations

History of trauma.

Complaints of severe pain and severe limitation of movements in the joint.

Deformations or disruption of the contours of the joint.

When examining the joint, a sharp limitation of movements in the joint is determined.

A survey radiograph of the damaged joint shows varying degrees of disruption of the congruence of the articulating surfaces, characteristic of each joint.

Algorithm for providing prehospital care for dislocations

First medical aid should be provided immediately as soon as possible.

Administration of painkillers (intramuscular, subcutaneous).

Adequate immobilization of the damaged joint with mandatory capture of adjacent limb segments.

Emergency transportation of the patient to a hospital or trauma center, depending on the damaged joint and the patient’s condition.

There are two ways to treat dislocations: conservative and surgical.

The conservative method of treatment, or the closed method of reducing a dislocation, is the main one.

Surgical treatment is used if closed reduction of the dislocation is impossible.

Algorithm for the treatment of fresh dislocations

Reduction of fresh dislocations is an emergency measure and is performed immediately after X-ray confirmation of the established diagnosis.

Removal of dislocation should be performed under general (intravenous) anesthesia, with the exception of certain cases when reduction is performed under local anesthesia or intubation anesthesia.

The dislocated segment of the limb is adjusted in the most gentle way possible, without brute force.

After reduction of the dislocation, the joint is immobilized with a plaster cast or skeletal traction.

Upon completion of immobilization, it is necessary to carry out rehabilitation measures: therapeutic exercises, physiotherapy, hydrotherapy, mechanotherapy aimed at relieving pain, normalizing blood circulation, and increasing the elasticity of soft tissues.

Algorithm for the effectiveness of dislocation reduction

The moment of reduction of the dislocation is usually accompanied by a click of varying severity.

Joint deformity is eliminated.

The amplitude and all types of movement depending on the joint are completely restored: extension, flexion, abduction, adduction, external and internal rotation.

Movements in the joint are free and smooth.

On the control radiograph, the dislocation was eliminated and the uniformity of the joint space was restored.

15.2. TREATMENT OF CLAVILA DISLAXATION

Treatment of dislocation of the acromial end of the clavicle

First aid

Prehospital care for dislocation of the acromial end of the clavicle (Fig. 15-1) consists of the administration of painkillers (Promedol 2% - 1.0 IM, SC); transport immobilization is carried out with a Kramer splint applied from the opposite shoulder girdle to the fingers, while the arm is in an adducted position with flexion at the elbow joint at an angle of 90 °.

Rice. 15-1. Dislocation of the acromial end of the clavicle

If there is no splint, it can be replaced with a Deso, Velpo bandage, or Kramer splint; as a last resort, a simple scarf bandage is used (Fig. 15-2 a, b).

Rice. 15-2. Fixation of the injured shoulder girdle using a Kramer splint (a, b)

Anesthesia. Local anesthesia - injection of a 1% novocaine solution into the joint cavity.

Reducing a dislocation of the acromial end of the clavicle usually does not present great difficulties.

Immobilization of the reduced end of the clavicle is carried out with a variety of plaster casts with pelots, splints and devices for holding the end of the clavicle in the reduced state (Fig. 15-3). Taking into account the fact that it is almost impossible to maintain the reduced acromial end using the proposed means, surgical treatment is usually resorted to.

Treatment of dislocation of the sternal end of the clavicle

First aid

Prehospital care for dislocation of the sternal end of the clavicle (Fig. 15-4) consists of the administration of painkillers (Promedol 2% - 1.0 ml IM,

Rice. 15-3. Smirnov-Weinstein bandage for temporary immobilization of the shoulder girdle in case of dislocation of the acromial end of the clavicle

Rice. 15-4. Dislocation of the sternal end of the clavicle

PC); transport immobilization is carried out with a Kramer splint applied from the opposite shoulder girdle to the fingers, while the arm is in an adducted position with flexion at the elbow joint at an angle of 90 °. If a splint is not available, it can be replaced with a Deso or Velpo bandage; as a last resort, a simple scarf bandage is used.

Transportation to a specialized department; in the absence of one - to the surgical department.

Reduction of a dislocated sternal end of the clavicle is usually performed. As a rule, treatment is surgical.

Immobilization of the shoulder girdle on the side of the damage to the clavicular-sternal joint is carried out as in the case of damage to the acromioclavicular joint.

15.3. TREATMENT OF HUMERAL DISLOCATION

Based on the dislocation of the head of the humerus, dislocations are distinguished into anterior (subcoracoid, intracoracoid, axillary), lower (subarticular) and posterior (subacromial, infraspinatus). The most common dislocations are anterior (75%) and axillary (24%), the rest account for 1% (Fig. 15-6).

Rice. 15-5. Anterior humeral dislocations

First aid

Prehospital care consists of administering painkillers (Promedol 2% -1.0 ml IM, SC, IV); transport immobilization is carried out with a Kramer splint, applied from the opposite shoulder girdle to the fingers, while the arm is in an adducted position with flexion at the elbow joint at an angle of 90 ° (Fig. 15-6, 15-7, 15-8).

Rice. 15-6. Applying a ladder splint for dislocations of the humerus - preparing the splint

Rice. 15-7. Application of a scalene splint for humeral dislocations - application

Rice. 15-8. Application of a ladder splint for dislocations of the humerus - hanging the arm on a scarf

Method Yu.S. Dzhanelidze is considered the most physiological and atraumatic. It is based on muscle relaxation by traction of the affected limb by gravity. The patient is placed on the dressing table on his side with the expectation that the dislocated arm hangs over the edge of the table, and a high table or bedside table is placed under the head (Fig. 15-9 a, b).

Rice. 15-9. Stages of shoulder reduction using the Dzhanelidze method

The body is fixed with rollers, especially in the area of ​​the shoulder blades, and left in place. Muscle relaxation occurs. The surgeon, grasping the patient's bent forearm, performs traction down along the arm (outward), followed by outward and inward rotation. Shoulder reduction can be determined by a characteristic click and restoration of movement in the joint.

Kocher's method. The most famous, but most traumatic method. The patient sits on a chair (Fig.a-d). A towel in the form of an 8-shaped loop is used to cover the damaged shoulder joint, creating countertraction. The doctor places his hand, the same as the dislocated arm, on top of the elbow bend and covers it. The second hand holds the wrist joint, bending the limb at the elbow joint at a right angle. Next, the doctor’s actions consist of four smoothly successive stages.

Rice. 15-10. Stages of reduction of shoulder dislocation according to Kocher (a-d)

Extension along the axis of the limb and bringing the shoulder to the body.

Continuing the movements of the first stage, rotate the shoulder outward by deflecting the forearm in the same direction.

Without changing the achieved position and traction, the elbow joint is moved anteriorly and inwardly, bringing it closer to the midline of the body.

The shoulder is internally rotated by the forearm, moving the hand onto the healthy forearm.

Meshkov's method also belongs to the category of atraumatic; it is convenient for eliminating anterior and especially lower dislocations.

The patient is placed on the table on his back. The assistant moves the dislocated limb upward and anteriorly at an angle of ° and holds it in this position without performing any actions for a period of time in order to tire and relax the muscles. The surgeon creates counter support with one hand by pressing on the acromion, and with the other he pushes the head of the humerus out of the armpit upward and backward in case of anterior dislocations and only upward in case of inferior dislocations.

Hippocrates' method. The patient lies on the couch on his back (Fig. 15-11). The doctor places the heel of his unshod leg, which is the same as the patient’s dislocated arm, in the patient’s axillary region. Having grabbed the victim's hand, traction is applied along the long axis of the arm with simultaneous gradual adduction and pressure with the heel on the head of the humerus outward and upward. When pushing the head, it is reduced.

Rice. 15-11. Shoulder reduction according to the Hippocratic method

A posterior plaster splint is applied from the armpit to the fingertips with the limb flexed at an angle of 90°. For the purpose of immobilization, a Deso bandage with a reclinator in the axillary area is used.

Rice. 15-12. Bandage bandage with a reclinator in the axillary region for immobilization of the shoulder girdle after repair of a shoulder dislocation

15.4. TREATMENT OF DISLOCATION OF FOREARM BONES

Dislocations of the forearm bones account for 18-27% of all dislocations (Fig. 15-13, 15-14).

The following types of dislocations occur in the elbow joint:

Dislocation of both forearm bones:

Dislocation of both bones posteriorly;

Dislocation of both bones anteriorly;

Dislocation of both bones outwards;

Dislocation of both bones medially;

Divergent dislocation of both bones of the forearm.

Rice. 15-13. Anterior forearm dislocation

Rice. 15-14. Posterior forearm dislocation

Isolated dislocation of the radius and ulna:

Dislocation of the radius anteriorly;

Posterior dislocation of the radius;

Dislocation of the radius outward;

Dislocation of the ulna.

First aid

Prehospital care consists of administering painkillers (Promedol 2% - 1.0 ml IM, SC); transport immobilization is carried out with a Kramer splint applied from the shoulder joint to the fingers, while the arm is in an adducted position with flexion at the elbow joint at an angle of 90°. If a splint is not available, it can be replaced with a Deso or Velpo bandage. As a last resort, a simple scarf bandage is used (Fig. 15-15, 15-16).

Rice. 15-15. Applying a ladder splint for forearm dislocations:

a - tire preparation; b - applying a splint and fixing the splint with a bandage; c - hanging a hand on a scarf; d - fixation of the injured limb with a modern PC scarf

Rice. 15-16. Fixation of an injured limb with a modern PC bandage

Anesthesia. Intravenous anesthesia, local anesthesia by injecting a 1% novocaine solution into the joint cavity.

Posterior dislocation of both forearm bones

The patient is placed on the couch in a supine position, the affected arm is abducted and slightly extended at the elbow joint. The doctor, being outward from the abducted shoulder, covers the shoulder in the lower third with both hands so that the thumbs lie on the protruding olecranon (Fig. 15-17). The assistant is located on the doctor's side and holds the hand.

Rice. 15-17. Repair of posterior forearm dislocation

Traction is applied along the axis of the limb, and the doctor uses his thumbs to move the olecranon and the head of the radius anteriorly while simultaneously pulling the shoulder back and using it as a fulcrum. If the forearm is straightened, free passive movements appear. With a posterolateral dislocation of the forearm, the doctor applies pressure with his thumb on the olecranon process and the head of the radius not only anteriorly, but also inwardly.

Anterior dislocation of both forearm bones

As with a posterior dislocation, the patient’s forearms are placed on the couch. The doctor moves the arm to a right angle, and the assistant fixes and counterextends the shoulder. The doctor, pulling the forearm with one hand and pressing on the upper third of the forearm downwards, outwards and backwards, bends the forearm at the elbow joint with the other hand.

Dislocation of both bones of the forearm medially

Position the patient on his back. One of the doctor’s assistants abducts the shoulder to a right angle, fixes and holds the shoulder, and the other assistant pulls the forearm along the axis of the limb. The doctor presses with one hand on the upper third of the forearm from the inside out, and with the other hand simultaneously presses on the external condyle of the shoulder from the outside in.

Dislocation of both forearm bones outwards

The patient's position is the same. The doctor's assistant fixes the abducted shoulder, and the doctor tractions the forearm with one hand, and with the other presses the upper third of the forearm inward and backward, bending the elbow joint.

A posterior plaster splint is applied from the armpit to the tips of the fingers with the limb bent at an angle of 90° (Fig. a, b).

Rice. 15-18. Plaster splint for immobilization of the bones of the elbow joint (a, b)

15.5. TREATMENT OF HAND DISLOCATION

15.5.1. TREATMENT OF DISLOCATION IN THE WRIST JOINT

True dislocations of the hand are dislocations characterized by complete displacement of the articular surfaces of the proximal row of carpal bones together with the hand relative to the articular surface of the radius. Perilunar injuries mainly predominate, which account for up to 90% of all dislocations in the area of ​​the hand joint (Fig. 15-19, 15-20).

With all of these dislocations, with the exception of true dislocation of the hand, the lunate, scaphoid, lunate, triquetrum, and lunar bones remain in place and are in contact with the radius.

Rice. 15-19. Dislocations of the hand.

a - peritrehedral-lunar; b - true; c - perilunar

Rice. 15-20. Dislocations of the hand (perilsavicular-lunar)

First aid

Prehospital care consists of administering painkillers (Promedol 2% - 1.0 ml IM, SC); transport immobilization is carried out with a Kramer splint applied from the elbow joint to the fingers. If a splint is not available, it can be replaced with a Deso bandage or a simple scarf.

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia, local anesthesia by injecting 20 ml of a 1% novocaine solution into the joint cavity or conduction anesthesia.

We will illustrate the reduction of these hand dislocations using the example of a technique for eliminating perilunar dislocation. The patient lies on the couch in a supine position. The assistant holds the limb by the shoulder, and the doctor performs traction along the axis of the forearm with a flexion angle at the elbow joint of 90 ° and stretches the wrist joint; in this case, one hand of the doctor performs traction on the first finger of the hand, and the second - on the other four. After stretching the wrist joint to eliminate displacement along the length, the doctor, using the thumbs of his hands, applies pressure on the back of the hand in the distal and palmar directions, and with the remaining fingers applies pressure on the distal forearm in the dorsal direction. After reduction, a click is noted.

A dorsal plaster splint is applied from the heads of the metacarpal bones to the elbow joint in the position of palmar flexion of the hand at an angle of 135 ° (Fig. 15-21).

Rice. 15-21. Immobilization of the wrist joint with a plaster splint

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint, applied from the upper third of the forearm to the tips of the fingers, or with a scarf bandage.

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia, conduction anesthesia or local anesthesia by injecting a 5-10% novocaine solution into the joint cavity.

The patient lies on the couch in a supine position. The physician's assistant flexes the upper limb at the elbow and secures the distal forearm. The doctor carries out traction of the first metacarpal bone along its axis by the first finger (you can use a fixing loop from a bandage) with simultaneous pressure on the base of the first metacarpal bone in the direction opposite to the displacement.

The hand and forearm are fixed with a plaster cast with the grip of the carpal joint from the upper third of the forearm to the heads of the II-V metacarpal bones in the position of abduction and opposition of the first finger, which is fixed with the capture of the distal phalanx (Fig. 15-22).

Rice. 15-22. Immobilization after repair of dislocation of the first metacarpal bone

15.5.2. TREATMENT OF METHAPLAR BONE DISLOCATIONS

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint applied from the upper third of the forearm to the tips of the fingers.

Transportation to a specialized department; in the absence of one - to the surgical department.

The patient lies on the couch in a supine position. The physician's assistant flexes the upper limb at the elbow and secures the distal forearm. The doctor applies traction along the axis of the metacarpal bones by their heads and corresponding toes. The second assistant applies pressure to the bases of the metacarpal bones in the distal and palmar directions.

The hand and forearm are fixed with a dorsal plaster splint, applied from the upper third of the forearm to the fingertips.

Treatment of dislocations in the metacarpophalangeal joints

We will consider the treatment of dislocations in the metacarpophalangeal joints using the example of a dislocation of the first finger. As a rule, the main phalanx of the first finger is dislocated posteriorly and to the rear (Fig. a, b).

Rice. 15-23. Dislocation of the main phalanx (first finger) of the hand (a, b)

First aid

Prehospital care consists of administering analgesics; transport immobilization is carried out with a Kramer splint applied from the upper third of the forearm to the tips of the fingers. If a splint is not available, it can be replaced with a simple scarf.

Transportation to a trauma center or a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia, local anesthesia by injecting 5-10 ml of a 1% novocaine solution into the joint cavity or conduction anesthesia.

A loop of twisted bandage is placed on the terminal phalanx of the first finger, using the ends of which the doctor applies traction along the length of the finger and increases hyperextension of the main phalanx to an acute angle. Using the thumb of the second hand, the doctor moves the proximal part of the main phalanx so that it slides along the metacarpal bone, and as soon as contact between the edges of the articular surfaces occurs, the finger is bent

(Fig. 15-24, 15-25, 15-26).

Rice. 15-24. The first stage of reduction of the dislocation of the main phalanx of the first finger

Rice. 15-25. The second stage of reduction of the dislocation of the main phalanx of the first finger

Rice. 15-26. The third stage of reduction of the dislocation of the main phalanx of the first finger

A plaster splint is applied from the upper third of the forearm to the nail phalanx of the first finger, the remaining fingers are free, starting from the heads of the metacarpal bones (Fig. 15-27).

Rice. 15-27. Immobilization of the hand and fingers after reduction of dislocation in the metacarpophalangeal and interphalangeal joints

15.5.3. TREATMENT OF DISLOCATION OF THE PHALANGES OF THE FINGERS

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint, applied from the middle third of the forearm to the fingers. If a splint is not available, it can be replaced with a simple scarf.

Transportation to a trauma center or a specialized department; in the absence of one - to the surgical department.

Anesthesia. Local anesthesia - injection of 2-3 ml of a 1% solution of procaine (novocaine) into the joint cavity, conduction anesthesia or intravenous anesthesia.

The patient lies on the couch. Reduction of the dislocation is achieved by traction on the dislocated phalanx, similar to the method for reducing the dislocation of the main phalanx of the first finger (see Fig. 26).

Immobilization is carried out with a dorsal plaster splint from the nail phalanx to the middle third of the forearm (see Fig. 15-27).

15.6. TREATMENT OF DISLOCATIONS IN THE HIP JOINT

There are four main types of dislocations (Fig. 31):

Rice. 15-28. Classic variants of hip dislocations and positions of the lower extremities - posterosuperior (iliac)

Rice. 15-29. Classic variants of hip dislocations and positions of the lower extremities - posteroinferior (sciatic)

Rice. 15-30. Classic variants of hip dislocations and positions of the lower extremities - anterosuperior (suprapubic)

Rice. 15-31. Classic variants of hip dislocations and positions of the lower extremities - anterioinferior (obturator)

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out by two Kramer splints, applied from the level of the nipple line along the anterior and posterior surfaces of the chest and lower limb to the toes. Immobilization is allowed with one Kramer splint, applied from the level of the nipple line along the back

the surface of the chest and lower limb to the toes, shaping the splint according to the position of the lower limb.

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia, conduction anesthesia, in rare cases - anesthesia.

In practical traumatology, hip dislocation is eliminated mainly in two ways - Kocher and Janelidze.

Kocher's method. This method is preferable for eliminating anterior hip dislocations, as well as for reducing old dislocations, regardless of type (Fig. a, b, c).

Rice. 15-32. Stages of hip reduction using the Kocher method (a, b, c)

The patient is placed on the floor on his back, the doctor's assistant fixes the pelvis with both hands, the doctor bends the patient's limb at a right angle at the knee and hip joints and performs a slowly increasing traction along the axis of the thigh over a period of minutes.

Modification N.I. Kefera: the doctor kneels, bends the other leg at a right angle and brings it into the patient’s popliteal fossa. Grasping the shin with his hand in the supramalleolar region, the doctor presses on it posteriorly and, like a lever, stretches the thigh. After traction, the hip is adducted, and then externally rotated and abducted. Reduction begins.

Method Yu.Yu. Dzhanelidze. The patient lies on the table in a prone position, the injured limb hangs from the table. The patient is left in this position. Then the injured leg is bent at the hip and knee joints at an angle of 90° and abducted slightly. The doctor grabs the distal part of the lower leg and presses on the patient’s lower leg with his knee, while simultaneously performing traction along the femoral axis and rotational movements (Fig. a, b).

Rice. 15-33. Stages of hip reduction using the Dzhanelidze method (a, b)

As a rule, skeletal traction is performed on the supracondylar region of the femur. In exceptional cases, a plaster hip bandage or a plaster splint is applied as a temporary aid from the level of the nipple line to the toes (Fig. 15-34).

Rice. 15-34. Plaster hip bandage for fixation of the hip joint

15.7. TREATMENT OF A DISCOVERED LIP

Dislocation of the lower leg posteriorly, anteriorly and outwardly is equally rare (Fig. 15-35).

Rice. 15-35. Dislocation of the tibia medially and posteriorly

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint, applied from the lumbar region to the fingertips of the injured limb (Fig. 15-36).

Rice. 15-36. Applying a ladder splint for dislocations in the knee and ankle joints

Due to the existing real danger of impaired blood supply in the lower leg, caused by the pressure of the proximal end of the tibia on the vascular bundle, emergency transportation of the victim to a specialized department for urgent removal of the dislocation is necessary.

Anesthesia. Intravenous anesthesia or conduction anesthesia. Before realigning the lower leg, check the pulsation of the branches of the popliteal artery in the foot.

The patient lies on the couch in a supine position. The doctor's assistant applies traction to the limb bent at the hip joint by the shin until the articular ends of the femur and tibia are separated, after which the doctor applies pressure simultaneously to the condyles of the femur and tibia until the axis of the limb is restored and the dislocation is eliminated, which is confirmed by the restoration of free smooth movement in the joint.

A posterior plaster splint is applied from the groin area to the fingertips with dynamic control over the state of the blood supply to the lower leg (Fig. 15-37).

Rice. 15-37. Immobilization of the knee joint after repair of a dislocated leg

15.8. TREATMENT OF PATELLA DISLOCATION

In clinical practice, lateral external dislocation of the patella is encountered mainly. The so-called rotational and vertical dislocations are largely theoretical.

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint applied along the back surface of the limb from the groin area to the fingertips.

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia or conduction anesthesia.

The patient lies on the couch in a supine position. Reduction of the dislocation is carried out with a bent

in the hip joint of the limb to relax the quadriceps muscle by moving the patella inward or outward.

The limb is fixed with a plaster cast from the groin area (from the gluteal fold) to the tips of the toes (Fig. 15-38).

Rice. 15-38. Immobilization of the knee joint after repair of patellar dislocation

15.9. TREATMENT OF DISLOCATION IN THE ANKLE JOINT

We do not consider dislocations in the ankle joint, since they are always combined with fractures of the ankles and the anterior and posterior edges of the tibia.

Treatment of subtalar foot dislocation

There are posterointernal and internal dislocations of the foot in the subtalar joint.

First aid

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia or conduction anesthesia.

Closed reduction of this dislocation is not always successful; in this case, open reduction is resorted to.

The patient lies on the couch in a supine position. The physician's assistant flexes the limb at the knee joint and fixes the distal part of the lower leg. The doctor performs traction on the foot at its heel and distal parts; simultaneously increases supination, adduction and plantar flexion of the foot. Having achieved the reduction of the foot, the doctor presses on the foot from the inside out and performs the reverse actions - pronation, abduction and dorsiflexion.

The foot and lower leg are fixed with a posterior plaster splint from the upper third of the lower leg to the fingertips (Fig. 15-39).

Rice. 15-39. Immobilization of the foot and ankle joint with a posterior plaster splint

Treatment of metatarsal dislocation

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint, applied from the upper third of the lower leg to the fingertips.

Transportation to a specialized department; in the absence of one - to the surgical department.

Anesthesia. Intravenous anesthesia or conduction anesthesia.

Closed reduction of complete metatarsal dislocation (Lisfranc joint dislocation) is not always successful; in this case, open reduction is resorted to.

The patient lies on the couch in a supine position. The physician's assistant flexes the limb at the knee joint and fixes the distal part of the lower leg. The doctor applies traction along the axis of the metatarsal bones by their heads and corresponding toes. The second assistant applies pressure to the bases of the metatarsals in the distal and plantar directions.

The foot and lower leg are fixed with a posterior plaster splint from the upper third of the lower leg to the tips of the fingers (Fig. 15-40).

Rice. 15-40. Immobilization of the foot and ankle with a posterior plaster splint after correction of a dislocation in the Lisfranc joint

15.10. TREATMENT OF DISLOXED TOES

The first finger is dislocated more often, mainly posteriorly.

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint applied along the back surface of the lower leg from its upper third to the tips of the fingers.

Transportation to a trauma center or a specialized department; in the absence of one - to the surgical department.

Anesthesia. Local anesthesia - injection of 5-10 ml of 1% novocaine solution into the joint cavity, conduction anesthesia or intravenous anesthesia.

The patient lies on the couch in a supine position. The doctor's assistant fixes the foot, the doctor extends the first toe along the axis of the metatarsal bone with increased dorsal flexion of the toe (in case of dorsal dislocation of the toe). Having achieved separation of the bones, the doctor, against the background of ongoing distraction, performs plantar flexion of the finger until the dislocation is eliminated.

The foot and finger are fixed with a posterior plaster splint from the middle third of the leg to the tips of the fingers (Fig. 15-41).

Rice. 15-41. Immobilization of the foot and ankle joint with a posterior plaster splint after correction of dislocation in the metatarsophalangeal joints

15.11. TREATMENT OF DISLOXATION OF PHALANGES OF THE TOES

First aid

Prehospital care consists of administering painkillers; transport immobilization is carried out with a Kramer splint applied along the back surface of the lower leg from its middle third to the fingertips.

Transportation to a trauma center or a specialized department; in the absence of one - to the surgical department.

Anesthesia. Local anesthesia - injection of 2-3 ml of 1% novocaine solution into the joint cavity, conduction anesthesia or intravenous anesthesia.

The patient lies on the couch. Reduction of the dislocation is achieved by traction on the dislocated phalanx.

The foot and toe are fixed with a posterior plaster splint from the middle third of the leg to the tips of the toes.