Pathologies in children: chest deformation. Malformations of the chest and thoracic organs Congenital malformations of the chest
Congenital chest defects occur in approximately 1 in 1,000 children. Most often, in 90% of cases in relation to all types of defects, pectus excavatum deformity (PCD) is detected. Among the more rare forms, keeled deformity, various anomalies of rib development, cleft sternum and combined variants should be highlighted.
The reasons for the formation of these defects have not been fully elucidated. There is no doubt that they are congenital dysplasia or aplasia of the cartilaginous, less often the bone, part of the chest. Morphological studies of connective tissue revealed a violation of its structure. Changes in the structure of connective tissue, in turn, are associated with metabolic disorders.
The hereditary factor is of great importance. According to many authors, up to 20% of children with chest deformities have relatives with a similar pathology. To date, a large number of syndromes have been described in which one of the constituent components is anomalies of the sternocostal complex. The most common is Marfan syndrome. In this syndrome, against the background of connective tissue dysembryogenesis, asthenic constitution, arachnodactyly, subluxation and dislocation of the lenses, dissecting aortic aneurysm, funnel-shaped and keeled deformity of the chest, clear biochemical changes in the metabolism of collagen and glycosaminoglycans are noted.
Knowledge of the signs of syndromes and their identification are important from the point of view of determining tactics and treatment prospects. Thus, with Ehlers-Danlos syndrome (the fourth ecchymotic form), in addition to osteochondral pathology, there are disturbances in the structure of the vascular wall. During surgical treatment, complications associated with increased bleeding are possible. If various types of osteochondral deformities are detected in a child, it is advisable to consult a geneticist.
Funnel chest deformity
External signs of funnel chest deformity are characterized by retraction of the sternum and adjacent parts of the ribs. The costal arches are slightly deployed, the epigastric region bulges:
Pectus excavatum in a 4-year-old child
Clinic and diagnostics. As a rule, the deformity is determined immediately after birth, and the symptom of inhalation paradox (retraction of the ribs and sternum during inhalation) is characteristic. In approximately half of the patients, the deformity progresses as they grow and by 3-5 years it becomes fixed. The deformity may appear at a later date - usually during the period of accelerated growth of the child. It has been noted that the most profound forms of deformation appear early. Deformations that occur during puberty are rarely pronounced.
When examining a child, one can identify stigmas characteristic of a particular syndrome (increased joint mobility, flat back, decreased tissue turgor, poor vision, Gothic sky, etc.).
Along with examination data, radiological and functional research methods are important. An X-ray in a direct projection reveals the degree of displacement of the heart (usually to the left), which indirectly allows us to judge the effect of the deformation on the function of the heart. Using a lateral radiograph, the depth of depression of the sternum is determined, the thoracovertebral index or Gizhitskaya index I (IG) (1962) is measured. The latter is the ratio of the smallest distance between the posterior surface of the sternum and the anterior contour of the spine to the largest. This is the basis for the classification of pectus excavatum deformity
a) by degree - I degree IG = 1-0.7; II degree IH = 0.7-0.5; III degree IH less than 0.5,
b) in shape - symmetrical, asymmetrical, flat.
Functional changes in external respiration and hemodynamics are detected with severe deformation and directly depend on its degree. External respiration disorders are manifested by a decrease in maximum ventilation of the lungs, an increase in the minute volume of respiration and oxygen consumption per minute. The oxygen utilization rate is reduced. Changes are noted on the ECG. However, the most informative study of the heart is echocardiography, which makes it possible to clarify the morphological changes of the heart. This is important due to the fact that with pectus excavatum, especially with syndromic pathology, mitral valve prolapse is common.
Treatment. There are no conservative methods for treating pectus excavatum.
Indications for surgery. Indications for surgery are determined based on the degree and shape of the funnel chest deformity. Thoracoplasty is certainly indicated for stage III pectus excavatum and is indicated for stage II VDHA. In cases of stage 1 pectus excavatum (with the exception of flat forms), thoracoplasty is usually not performed. [Urmonas V.K., Kondrashin N.I., 1983]. The optimal age for performing the operation is considered to be 5 years. Great care should be taken when approaching surgical treatment in children with syndromic forms of deformity. Only after a comprehensive examination and in the absence of contraindications can surgery be recommended.
Recently, the Paltia method has been most widely used. The operation consists of subperichondral excision of curved costal cartilages, transverse wedge-shaped sternotomy and fixation of the sternum in the corrected position with a metal plate.
The results of surgical correction of pectus excavatum deformity are good (according to various authors, in 80-95% of cases). Relapses occur with insufficient fixation of the sternum and more often in children with syndromic forms operated on early.
Pileated chest deformity
The keeled deformity of the chest, like the funnel-shaped one, is a developmental defect. Hereditary transmission of the defect is often traced, which may be an integral component of one of the syndromes.
Clinic and diagnostics. The deformity is usually detected from birth and increases with age. The protruding sternum and the ribs falling along its edges give the chest a characteristic keeled shape. The deformation can be symmetrical or asymmetrical. With an asymmetrical form, the cartilaginous sections of the ribs lift the sternum on one side, and it bends along the axis. There are combined forms, when the upper third of the sternum is raised, and the lower part with the xiphoid process sharply sinks. In this case, pairing of the 4th and 5th ribs was noticed, with the 4th rib located above the 5th rib at the point where it meets the sternum.
Functional disorders, as a rule, are not detected. In syndromic forms and with a pronounced decrease in chest volume, there may be complaints of fatigue, shortness of breath, and palpitations during physical activity. However, in most cases, children and their parents are concerned about a cosmetic defect.
Treatment. Indications for surgery occur mainly in children over 5 years of age with a pronounced cosmetic defect. Several methods of surgical interventions have been proposed, based on subperichondral resection of the parasternal part of the ribs, transverse sternotomy, and cutting off the xiphoid process. Fixation of the sternum in the correct position is carried out by suturing the sternum with the perichondrium and the remaining ends of the ribs. The results of surgical treatment of carinatum deformity are good.
Rib abnormalities
Anomalies of the ribs may include deformation or absence of individual costal cartilages, bifurcation and synostosis of the ribs, deformation of groups of costal cartilages, absence or wide divergence of the ribs.
Split thoracic ribs (Luschke's ribs) usually appear as a firm, protruding mass near the sternum. In rare cases, it is necessary to make a differential diagnosis with a tumor process. Treatment is required only for significant deformities for cosmetic purposes. It consists of subchondral removal of deformed cartilage.
Cerebro-costo-mandibular syndrome. Defects of the ribs (absence, bifurcation, pseudarthrosis, etc.) are combined with cleft palate or gothic palate, hypoplasia of the lower jaw, micrognathia, glossoptosis, and microcephaly. Surgical treatment is indicated in extreme cases with a significant chest wall defect with paradoxical breathing.
Poland syndrome is always characterized by a unilateral lesion, including aplasia or hypoplasia of the pectoralis major muscle, hypoplasia of the pectoralis minor muscle. It is often accompanied by the absence of part of the underlying costal cartilage and ribs, aplasia or hypoplasia of the nipple, aplasia of the mammary gland in girls, and deformation of the arm and hand. Diagnosis is based on external examination. To clarify the condition of the ribs, radiography is used. If there is a significant defect with the formation of a pulmonary hernia, plastic surgery of the rib defect is performed using autotransplantation of ribs from the healthy side. It is possible to use the overlying and underlying ribs with their splitting and displacement towards the defect. Some surgeons successfully use synthetic materials. To replace missing muscles, a flap or the entire latissimus dorsi muscle is moved. Surgeries for wide defects with paradoxical breathing are performed at an early age.
Cleft sternum is a rare malformation, which consists of the presence of a longitudinal gap located in the midline. The defect can vary in length and width, up to complete clefting of the sternum. In this case, there is a paradoxical movement of the mediastinal organs, covered at the site of the defect only by a thin layer of soft tissue and skin. The pulsation of the heart and large vessels is visible. The defect is detected in early infancy and increases as the child grows. Along with anatomical manifestations, functional disorders are also noted. Breathing disturbances, including bouts of cyanosis, are possible. Children usually lag behind in physical development.
The operation is performed at an early age. It consists of releasing the edges of the defect, which are stitched along the entire length with interrupted nylon sutures.
When examining children with developmental defects of the chest, it is necessary to pay attention to identifying stigmas of disembryogenesis, such as abnormalities of the finger pattern, shortening of the fingers, etc. With medical and genetic counseling regarding sporadic cases of the appearance of the syndrome, the prognosis for the birth of a healthy child is favorable.
Congenital deformities of the chest depend on malformations of the spine, ribs, and sternum.
1. The absence or nonfusion of the sternum is explained by a stop in the development of the sternum: the ridges from which the sternum is formed, laid symmetrically at the medial ends of the ribs, do not fuse with each other. The ribs in such cases are connected to each other by a fibrous plate. The breast may be completely absent, but more often you observe) partial underdevelopment of its lower end or manubrium. The fibrous plate at the site of the sternum with this anomaly follows the respiratory movements, sharply retracting when inhaling and protruding when exhaling. With age, the fibrous plate becomes denser and its vibrations decrease. Children with clefts and complete sternum defects may develop normally.
2. Funnel chest, in which part of the chest and upper abdominal walls are funnel-shaped. This deformation was called “shoemaker’s chest.”
3. Keeled chest, in which, on the contrary, there is a protrusion anterior to the sternum.
Breast malformations
1. Amastia – complete absence of mammary glands.
2. Polymastia – excess number of mammary glands.
3. Polytellia – excessive number of nipples. Accessory mammary glands or nipples are usually located along the “milk line,” which runs from the armpit, along the anterolateral surface of the chest and abdomen, to the inner thighs.
4. Genicomastia – unilateral or bilateral enlargement of the mammary gland. In men, this pathology is rare; it is associated with hormonal disorders of the gonads, pituitary gland or adrenal cortex.
Congenital diaphragmatic hernia
A diaphragmatic hernia is the protrusion of abdominal organs into the chest cavity through a hole in the diaphragm. There are three main types of congenital diaphragmatic hernia:
1. Hernia of the diaphragm itself:
True diaphragmatic hernia - the abdominal organs emerge through a defect in the diaphragm along with the peritoneum, forming a hernial sac;
False diaphragmatic hernia - the hernial sac is absent, and the abdominal organs that have moved into the chest cavity come into contact with the organs of the chest cavity;
2. hiatal hernia – the cardiac part of the stomach or the entire stomach is displaced into the posterior mediastinum;
3. anterior diaphragmatic hernias – occur in the presence of an expanded sternocostal triangle,
4. in which the abdominal organs are displaced into the pericardial cavity. Heart defects
Heart defects are divided into congenital and acquired. Congenital heart defects include:
1. atrial septal defect;
2. ventricular septal defect, which leads to the discharge of blood into the right ventricle through a defect in the muscular or membranous part of the septum;
3. patent ductus arteriosus (ductus arteriosus, Botallov). The ductus arteriosus most often connects the common trunk of the pulmonary artery with the lower semicircle of the aortic arch at the level of the mouth of the left subclavian artery. When it is not closed, part of the oxygenated blood from the aorta enters the pulmonary trunk, then into the lungs. This leads to overload of the left atrium and ventricle, causing their hypertrophy;
4. coarctation of the aorta. With stenosis of the aortic isthmus, hypertension rapidly progresses in the vessels of the upper half of the body and brain. Patients are at risk of cerebral hemorrhage and other serious consequences of the defect;
5. other defects (isolated pulmonary artery stenosis, triad, tetralogy and pentade of Fallot, etc.).
Acquired - insufficiency of the aortic and mitral valves. Operations on the chest wall and organs of the thoracic cavity Operations on the mammary gland.
Classification of purulent mastitis:
1. superficial (premammary) mastitis, located in the areola or above the stroma of the gland directly under the skin;
2. intramammary mastitis, located in the lobules of the gland itself;
3. retromammary mastitis, located under the deep layer of the mammary gland capsule to the fascia of the breast. Incisions for superficial mastitis are made paraoreolarly or in a radial direction, without affecting the areola, cutting through the skin and subcutaneous tissue.
Incisions for intramammary mastitis are made at the site of greatest softening in the radial direction, 6-7 cm long, without affecting the areola.
1. dissection of the skin, subcutaneous tissue, gland tissue;
2. opening of the abscess;
3. destruction of partitions with adjacent ulcers until a single cavity is formed using a blunt method;
4. removal of necrotic tissue;
5. thorough rinsing of the abscess cavity with an antiseptic solution;
6. drainage (usually rubber strips are used).
To open a retromammary abscess, an incision is made along the lower transitional fold of the mammary gland. The skin and tissue are cut layer by layer, the mammary gland is lifted and peeled off from the fascia of the pectoralis major muscle, and the abscess is opened. The abscess cavity is drained.
Page 53 of 103
Chapter V
BREAST
ANOMALIES OF THE DEVELOPMENT OF THE CHEST
Congenital deformities of the chest depend on malformations of the spine, ribs and sternum. These deformities must be distinguished from various acquired deformities of the chest.
Less common than others is the absence and non-fusion of the sternum. This defect is explained by an arrest in development: the ridges from which the sternum is formed, laid symmetrically at the medial ends of the ribs, do not fuse with each other. The ribs in such cases are connected to each other by a fibrous plate. The breastbone may be completely absent, but more often there is partial underdevelopment of its lower end or manubrium. With malformations of the sternum, an embryonic scar occurs on the skin, which runs down from the sternum along the midline of the abdomen to the navel. In addition, increased pigmentation is sometimes noted along the scar, which we observed in one patient. The fibrous plate at the site of the sternum follows the respiratory movements, sharply retracting when inhaling and protruding when exhaling. The pulsation of the heart is visible to the eye, which may be incorrectly positioned. With age, the fibrous plate becomes denser and its fluctuations are less. Children with clefts and complete sternum defects may develop normally.
In addition to sternum defects, there is an anomaly called pectus excavatum, in which part of the chest and upper abdominal wall are deepened in a funnel-shaped manner. The depression sometimes reaches large sizes. Previously, this deformation was called a shoemaker's chest. If rachitic curvatures are suspected, one must remember about congenital funnel-shaped chest, in which there are no complaints from the patient.
In recent years, in cases of severe deformation due to pectus excavatum, corrective surgery has been performed.
Anomaly of rib development is more common. There are underdevelopment of the ribs, their complete absence, as well as their excessive formation - additional ribs. One or more ribs may be underdeveloped or completely absent. In the absence of ribs, the ribs adjacent to the defect may be underdeveloped, deformed, and sometimes fused to each other. At the site of the defect, which runs from the spine to the sternum, the muscles are usually simultaneously underdeveloped; When breathing, a protrusion of the lung is visible in this place. With large defects, when 2-3 ribs are missing, abnormal development of the spine in the form of wedge-shaped vertebrae and scoliosis is simultaneously observed.
In the absence of ribs, it is necessary to use active gymnastics and massage of the back muscles as early as possible to prevent the development of scoliosis and to strengthen the muscles that should compensate for the bone defect. Wearing a corset in these children is harmful, weakening the muscles. Treatment with gymnastics should be carried out systematically from year to year, monitoring the child’s development.
Accessory ribs are usually found in the cervical, occasionally in the lumbar, spine on one or both sides. Extra ribs in children rarely cause complaints and do not require treatment.
In rare cases, pain may require surgical removal of an additional rib.
CONGENAL DIAPHRAGMAL HERNIA
Despite their relative rarity, congenital diaphragmatic hernias are of considerable interest. A diaphragmatic hernia is a protrusion of abdominal viscera into the chest cavity through a hole in the diaphragm. In children, congenital diaphragmatic hernias occur mainly; acquired traumatic hernias are rare in them. So, in our clinic, out of 100 diaphragmatic hernias, 91 were congenital and only 9 acquired.
The development of the diaphragm ends by the end of the second month of embryonic life. The diaphragm is formed in the cranial region of the embryo at the level of the third to fifth cervical segment. At the 4th week, its ventral section develops in the form of a fold, which only partially separates the pericardial cavity from the pleural sacs and the peritoneal cavity. This fold is called the septum transversum, or primitive diaphragm. The dorsal sections of the pleural cavities still communicate with the peritoneal cavity. At the end of the 6th week, folds protrude from the lateral and posterior walls of the body, which gradually move towards the septum transversum, fuse with it and form a thoraco-abdominal barrier. The side folds are called Uskov's pillars.
The diaphragm developed in this way first represents a connective tissue plate into which muscles later grow. By the end of the 3rd month, the diaphragm gradually descends and takes its permanent place.
These brief embryological data explain the formation of congenital diaphragmatic hernias.
When Uskov's columns are underdeveloped, defects are formed, usually located in the dorsal part of the diaphragm, less often in its central part. Depending on the degree of underdevelopment of a particular Uskov column, defects of various sizes and different locations are formed; sometimes the diaphragm is almost completely absent.
Hernial orifices in congenital hernias are holes in the diaphragm, formed as a result of its underdevelopment. They can be of various sizes and shapes: either in the form of a slit, or round, sometimes very large, to the point that the entire half of the diaphragm is almost completely absent. In such cases, only along the edge around the hole there is a narrow strip of diaphragm.
Rice. 108. Typical localization of congenital defects of the diaphragm.
1 - defect of the esophageal opening of the diaphragm: 2 - extensive defect of the diaphragm itself on the left; 3 - defect of the anterior part of the diaphragm.
Diaphragmatic hernias are more common on the left.
There are three main types of congenital diaphragmatic hernia: 1) hernia of the diaphragm itself (its dome), 2) hiatal hernia and 3) anterior diaphragmatic hernia. According to S. Ya. Doletsky from our clinic, the most common hernia is the diaphragm itself (61%), followed by hiatal hernia (16%) and less often than others - the anterior hernia (Fig. 108) (12%); acquired hernias accounted for 9%.
There are true and false diaphragmatic hernias depending on the presence of a hernial sac. This depends on the time at which the development of the diaphragm stops; if development stops at an early stage, its displaced abdominal organs will be located in direct contact with the lung. With late underdevelopment, the viscera from the abdominal cavity protrude into the peritoneum through a defect in the diaphragm and form a hernial sac.
With all types of diaphragmatic hernia, there is some degree of movement of the abdominal organs into the chest cavity, which causes compression of the lung and displacement of the heart. The stomach, omentum, small and large intestines, part of the liver, spleen, and less often the kidney move.
With each type of hernia, some symptoms characteristic of this type are observed. The clinical picture for certain forms of diaphragmatic hernia is expressed differently.
Clinic.
In some cases, a number of disorders are observed from the first days of life, in others, on the contrary, the disease is almost asymptomatic and is detected only in subsequent years of life.
One of the first, quite common clinical symptoms that can be noted soon after birth is cyanosis, which differs from cardiac in that it is intermittent in the form of attacks associated with eating or crying. Attacks of coughing and shortness of breath may occur. Possible phenomena of cardiac dysfunction due to heart displacement. A number of disorders are also observed in the gastrointestinal tract. If the stomach is displaced into the pleural cavity and distended by liquid and gases, then, in addition to shortness of breath, cyanosis and increased heart rate, there is also coughing, vomiting and difficulty swallowing. Sometimes there is a sunken stomach.
When examining a patient, percussion reveals a displacement of the heart to the side opposite the hole in the diaphragm, tympanitis, and sometimes dullness; on auscultation - absence or weakening of breathing. With careful repeated listening, it is possible to detect peristaltic sounds of the intestines.
This sign immediately makes one suspect the presence of a diaphragmatic hernia.
In some cases, the hernia is asymptomatic for a number of years and is discovered by chance.
Later, as the child grows, symptoms characteristic of certain types of hernia appear. The leading symptom of hernia of the diaphragm itself is respiratory distress and oxygen deficiency, expressed in attacks of cyanosis and shortness of breath. At times, vomiting and stool retention occur. When examined in some patients, attention is drawn to a sunken abdomen, which is called scaphoid. With a careful examination, it is possible to listen to peristalsis in the left half of the chest and determine the change in percussion sound.
The borders of the heart are shifted to the right. This sometimes gives rise to the erroneous diagnosis of dextrocardia, which explains the existing disorders. 
Rice. 109. Developmental delay of a child (left) with a diaphragmatic hernia (children aged 1 year 8 months); (according to Doletsky).
Esophageal hernias (hiatal hernias) are characterized by the development of anemia. There is vomit the color of coffee grounds or tarry stools. Gastric bleeding occurs as a result of ulceration in the esophagus and stomach due to their constant trauma in the area of the hernial orifice. Older children complain of pain in the epigastric region and rumbling. A clinical examination of a patient with an esophageal hernia may not reveal pathological changes. Only with a careful examination of the patient can one detect weakened breathing in the right pulmonary field behind and a dull tympanic percussion sound.
Anterior hernias are mostly detected only with age. The leading symptom in older children is abdominal pain due to movement of intestinal loops and their partial infringement. Children complain of paroxysmal pain in the abdomen and chest, and stool retention.
With diaphragmatic hernias, chronic oxygen starvation and nutritional disorder are always observed. Violation of the proper functioning of the heart, breathing and nutrition causes a lag in the overall development of a patient with a diaphragmatic hernia. This lag can be expressed very differently, depending on the degree of oxygen deficiency, the size of the hernia and the degree of compression of the lung. Rice. 109 clearly shows this developmental disorder. After the operation of suturing the hernial hole in the diaphragm, children begin to develop normally.
Diagnostics
Diagnosis of congenital diaphragmatic hernia is sometimes difficult due to the diversity of the clinical picture. X-ray examination is crucial. Chest X-ray often reveals the presence of abdominal viscera in the chest cavity. To avoid a diagnostic error, it should be remembered that the final solution to the issue is provided by repeated fluoroscopy using a contrast agent, which accurately determines which parts of the gastrointestinal tract are involved in hernias (Fig. 110a, 110b, 111, 112).
Prediction for this disease should always be made with caution. A significant proportion of children die in the first days and weeks of life. Sometimes, as stated, the disease does not cause visible disorders and the child develops satisfactorily.
The most severe complication of a diaphragmatic hernia is strangulation, which can occur suddenly. In such cases, intestinal obstruction develops, not accompanied by bloating, but with severe disturbances in the chest organs. The absence of abdominal bloating makes diagnosis difficult. You should always remember about diaphragmatic hernia and internal strangulation. The prognosis for a strangulated diaphragmatic hernia is even more difficult. According to statistics, without surgery, 75% of children with congenital diaphragmatic hernia die within the first month of life, and of those who survive, a significant proportion die by the end of the first year of life.
Treatment
In connection with the progress that thoracic surgery has achieved in recent years, the indications for surgical treatment of diaphragmatic hernia in newborns and young children should be expanded in order to prevent their death.
As with all other types of hernia, diaphragmatic hernia should be treated surgically without waiting for the hernia to be strangulated. The operation should consist of repositioning the viscera into the abdominal cavity and suturing the hole in the diaphragm. As the experience of our clinic has shown, the best is a transperitoneal approach, rather than an access through the chest cavity. The latter path may be required only in individual cases.
In case of severe breathing problems, children with large hernias of the diaphragm should be operated on in the first days of life, as they are under constant threat of death. 
Rice. 110a. Radiographs of a congenital diaphragmatic hernia in a 4.5 year old child.
A survey radiograph showing the high position of the left diaphragm.
Rice. 1106. Radiographs of a congenital diaphragmatic hernia in a 4.5 year old child.
Barium X-ray: part of the colon is located in the left half of the chest cavity (hernia of the diaphragm proper on the left.
Rice. 111. Hiatal hernia: It is seen that on barium examination, most of the stomach, which has an hourglass shape, is located in the chest cavity above the diaphragm.
Rice. 112. Anterior diaphragmatic hernia.
a - a plain radiograph shows a shadow above the diaphragm on the right, resembling a lung cyst; b - a loop of the colon, filled with a contrast mass, lies in the anterior mediastinum.
Hiatal hernias do not cause severe disturbances in the first months of life, so these patients can undergo surgery after a year.
Surgery for anterior diaphragmatic hernia is technically simpler and easier to tolerate for patients, so once a diagnosis is made, it can be performed at any age.
In case of strangulation or bleeding from the stomach and intestines, emergency surgery is indicated.
Timely diagnosis and surgical treatment will certainly help save the lives of many children born with a diaphragmatic hernia.
The operation permanently cures the patient and ensures his normal further development, while children left without surgery are sharply retarded in their development. In addition, the operation is not only therapeutic, but also a preventive measure for severe complications that a diaphragmatic hernia can cause.
Funnel-shaped chest. The deformity appears immediately after birth. A characteristic symptom is the “paradox of inhalation” - retraction of the sternum and ribs during inhalation, which is most clearly manifested during screaming and crying.
At school and adolescence, changes caused by chest deformation are more pronounced. Poor posture increases, thoracic kyphosis, fatigue, tachycardia, chest pain, a clear decrease in lung excursions are expressed, pneumonia, bronchiectasis, and displacement of mediastinal organs develop.
Treatment is surgical - most often resection of segments of costal cartilage, T-shaped osteotomy of the sternum and after correction - fixation using metal or bone structures.
Congenital heart defects.
There are 3 groups of congenital heart defects depending on the mixing of arterial and venous blood and, accordingly, changes in the color of the skin and mucous membranes.
1.Skin color is normal. Arterial and venous blood do not mix. Defects: coarctation of the aorta, stenosis of the aorta, pulmonary artery.
2. White type defects: atrial septal defects, patent ductus arteriosus.
3. Blue type defects are characterized by the discharge of venous blood into the arterial bed.
Atrial septal defects.
They make up about 10% of all heart defects. There is a discharge of arterial blood from the left to the right atrium. Hypertension develops in the pulmonary circulation system, children are usually developmentally delayed, shortness of breath, sometimes cyanosis, hypertrophy of the right heart.
Treatment is surgical, preferably up to 3–4 years of age.
Ventricular septal defect. According to statistics from the Institute of Cardiovascular Surgery, this defect is observed in 17% of patients with congenital defects.
Hemodynamic disorders are associated with the reflux of arterial blood from the left ventricle into the right (arterial shunt).
Treatment is surgical.
Non-closure of the arterial duct (ductus arteriosus).
The child is developmentally delayed, has frequent pneumonia, pale skin, systole-diastolic murmur.
Treatment is surgical.
Coarctation of the aorta (congenital stenosis of the aortic isthmus). According to statistics, from 6 to 14% of all congenital defects occur. The average life expectancy for this defect is up to 30 years.
Most often, the hemodynamic picture includes two different modes: the upper one, which includes the coronary system of the brachial and cephalic vessels, and the lower one, which includes the torso, lower extremities and internal organs.
The state of decompensation can develop in children as young as 1 year of age. Surgical treatment is from 3 to 10 years, but surgery is also performed at the 1st year of life.
Operation: resection and plastic surgery of the narrowing site..
Tetralogy of Fallot is a blue (cyanotic) type of defect.
The defect is classic among all cyanotic type defects. Accounts for 14% of all congenital defects and 75% of blue defects.
Anatomically:
1) narrowing of the pulmonary artery;
2) ventricular septal defect;
3) displacement to the right (dextraposition) of the aortic mouth and its location above both ventricles (aorta sitting astride the interventricular septum);
4) hypertrophy of the wall of the right ventricle.
The defect was first described in 1888 by the French pathologist Fallot. Cyanosis develops from the first days or weeks. Dyspnea. By the age of 2, the fingers are “drumsticks.” Children rest while squatting (a very characteristic symptom) - the pressure in the upper aorta increases due to compression of the large arteries of the lower extremities, this forces the collaterals between the systemic and pulmonary circulation to work more intensively . During attacks - loss of consciousness.
All these defects have distinct external manifestations.
Superior sternal fissures are developmental defects caused by non-fusion of the upper sternum. When tense, crying or coughing, the heart and large vessels seem to be located in the neck. Treatment is surgical in the first weeks of the child’s life.
Pectus excavatum is a congenital deformity of the sternum and adjacent ribs, which form a funnel-shaped depression below the manubrium of the sternum. Depression of the sternum reduces the volume of the chest and disrupts the function of the organs located in it. Surgical treatment at the age of 2-3 years.
Keeled chest is a developmental defect in which the lower part of the sternum, together with the cartilages of the ribs, protrudes forward in the form of a keel. Treatment (physical therapy) begins during the neonatal period, since the defect usually progresses as the child grows.
Lung malformations. Lobar emphysema is a developmental defect that is characterized by striking clinical manifestations: severe shortness of breath with retraction of areas of the anterior surface of the chest, cyanosis, wheezing, asymmetrical increase in the size of the chest and its lag during breathing. A percussion sound of a tympanic hue is noted above the altered lobe of the lung. The mediastinum and heart are shifted to the opposite side. Treatment is surgical.
Lung hypoplasia is an anomaly consisting in underdevelopment of lung tissue. The affected side lags behind in breathing, the mediastinum is shifted to the opposite side. Often clinical manifestations occur when an inflammatory process occurs. Treatment is mainly surgical.
Malformations of the esophagus. These types of defects belong to the group with pronounced clinical manifestations.
Esophageal atresia is often combined with a lower tracheoesophageal fistula. The clinical picture is typical. Usually, 2-3 hours after the birth of a child, the upper blind segment of the esophagus and nasopharynx become overfilled with mucus, as a result of which the child develops copious foamy discharge from the mouth. Part of the mucus is aspirated, and attacks of cyanosis occur. The diagnosis is confirmed by catheterization of the esophagus. If the upper segment of the esophagus communicates with the trachea, then the clinical picture will be dominated by breathing disorders, since the contents of the upper segment of the esophagus enters the trachea through the fistula. Treatment is surgical in the first hours of the child’s life.
With cardiospasm, the main symptoms are vomiting and persistent regurgitation immediately after feeding. The diagnosis is made by X-ray examination of the esophagus. Treatment is conservative. Feeding the baby in an upright position reduces the reflux of stomach contents into the esophagus. Subsequently, when the nervous structures of the esophageal wall mature and its function is restored, the child recovers.
3. Tactics of a unit doctor when identifying a patient with acute appendicitis. Treatment for acute appendicitis is only surgical.
At the prehospital stage, patients with acute appendicitis should not undergo any medical manipulations. Prescribing painkillers and sedatives may change the clinical picture and complicate diagnosis. Eating food and water is also excluded. In the hospital (after examining the patients, confirming the diagnosis of the disease, identifying complications, in the absence of a contraindication to surgery), the surgical field is cleaned and premedicated. The course of the operation for uncomplicated and complicated appendicitis is different.
For uncomplicated appendicitis, the operation is usually performed under local anesthesia using an oblique incision in the right iliac region of Volkovich-Dyakonov (McBurney) or pararectal access according to Linander.
After removal of the gangrenous vermiform appendix or its perforation, the operation ends with suturing of the laparotomy wound to the aponeurosis. Provisional sutures are placed on the skin and subcutaneous tissue, which are tied on the 2-3rd day of the postoperative period in the absence of inflammatory changes in the wound.
In case of complicated appendicitis, the operation is performed under general anesthesia using a wide median approach. This makes it possible to perform a full-fledged examination of the abdominal organs and carry out the necessary operation in terms of volume. make proper sanitation of the peritoneal cavity and rationally drain it.
If appendiceal infiltrate is diagnosed during the patient's admission to the hospital, surgery is not performed. Patients are prescribed complex conservative treatment using antibiotics and anti-inflammatory drugs. If signs of abscess formation of the infiltrate appear, an operation is performed, which is limited to opening and draining the abdominal abscess. If the outcome of appendiceal infiltration is diffuse peritonitis, the operation is performed using a median approach, and, in addition to treating the source area of peritonitis, is necessarily accompanied by sanitation of the abdominal cavity and its drainage.
If an appendiceal infiltrate is detected during surgery, surgical tactics are ambiguous. In case of loose infiltration, removal of the appendix is permissible. At the same time, the surgeon strives to maintain the delimiting adhesion of the organs that form the infiltrate in order to prevent diffuse peritonitis. If a dense infiltrate is detected during surgery, the latter is delimited from the rest of the abdominal cavity with tampons. Persistent searches, attempts to isolate and remove the vermiform appendix in a dense infiltrate are a mistake. Tampons are brought to the stump of the appendix and in those cases, then during appendectomy there remains uncertainty about hemostasis. This happens when the appendix is removed in conditions of loose appendiceal infiltrate. In these cases, it is very difficult to achieve reliable ligation of vessels in the inflamed mesentery of the appendix.
After appendectomy, as early as possible, an active motor regimen is advisable. It is prescribed taking into account the age, characteristics of the disease, its complications, the course of the postoperative period and other characteristics of the patient.
An indicator of a successful course of the early postoperative period in patients who have undergone appendectomy is a gradual improvement in their well-being and objective condition, normalization of body temperature, pulse parameters, avisit parameters, mainly blood, restoration of intestinal motility, appearance of appetite, etc. Recovery occurs in 4-5 -and the day after surgery.
From complications of acute appendicitis caused by surgical intervention or the peculiarities of the course of inflammation in the appendix. In the early postoperative period, infiltrates and abscesses of the Douglas pouch deserve special attention. Digital examination of the rectum is of great importance in the diagnosis of this complication. The abscess of the pouch of Douglas is also opened through the rectum. In women, removal of pus with this complication is also possible through the posterior vaginal fornix.
Tension pneumothorax.
Valvular pneumothorax. Severe respiratory and circulatory disorders also occur with valvular pneumothorax. With each inhalation, air on the injured side is forced into the pleural cavity through a wound in the chest wall or bronchus, increasingly compressing the lung and pushing back the mediastinum, since as a result of the valve mechanism it cannot escape out. Thus, intrapleural compression occurs, quickly leading to severe respiratory and cardiovascular failure.
CL and diagnosis of increasing pathological changes. Therefore, it is very important to know the mechanism of injury, the time that has passed since the injury, and the nature of prehospital care.
Pain of varying intensity on the side of the injury, intensifying with inhalation, coughing, changing body position, often with a sharp limitation of respiratory movements, especially when the skeleton is damaged; shortness of breath and difficulty breathing, also getting worse
during movements, which, together with pain, forces the victim to take a forced position; hemodynamic changes of varying severity; hemoptysis of varying intensity and duration; emphysema in the tissues of the chest wall, mediastinum and adjacent areas; displacement of the mediastinum to the side opposite to the site of injury; other physical changes.
Some of these signs are observed in the vast majority of victims (pain, shortness of breath), others are much less common (emphysema, hemoptysis).
examination, palpation, percussion, auscultation, study of the nature and location of wounds, etc. On this basis and in the absence of other research methods, it is often possible to determine the nature of the damage and take immediate treatment measures. Clinical data also serve as a justification for choosing the type and sequence of clarifying diagnostic techniques.
In emergency situations, therapeutic and diagnostic puncture is very useful to identify hemo- and pneumothorax, ongoing intrapleural bleeding or hemopericardium. Methodically correctly performed, it can easily establish the presence of air or blood in the cavity of the pleura and pericardium, and, if necessary, remove them for therapeutic purposes. The main role in clarifying the nature of the lesion belongs to the x-ray method, the implementation of which should be considered mandatory in all cases.
chest injuries. have thoracoscopy, bronchoscopy, esophagoscopy, which, however, often are not decisive in the diagnosis of intrathoracic injuries.
Tympanitis is characteristic of pneumothorax. Percussion is also possible to establish the boundaries of the lungs, heart, displacement of the mediastinum, etc. During auscultation, the absence or weakening of breathing is noted. Plain radiographs reveal fractures of the chest skeleton, the presence of free gas and fluid in the pleural cavity, displacement of the organs of the mediastinum, diaphragm, collapse or pulmonary atelectasis, mediastinal emphysema and other signs.
Chest wounds with valvular pneumothorax make up a small group (1-2%) of the total number of victims, but are characterized by a significant severity of functional changes. In these cases, upon examination, most of the symptoms encountered in other types of penetrating chest wounds are observed. During the examination of the victims, along with signs of hypoxia and hemodynamic disorders, a sharply pronounced growing subcutaneous emphysema of the chest wall, often spreading to the neck, head, limbs, and abdomen, is striking. Physically, a pneumothorax is detected with a sharp shift of the mediastinum to the opposite side; a collapse of the lung, prolapse of the dome is logically detected diaphragm and a sharp shift of the mediastinum to the undamaged side. All patients with valvular pneumothorax require emergency surgical care, without which they quickly die due to the progression of respiratory and cardiovascular disorders.
In cases of very dangerous mediastinal emphysema, the subcutaneous air cushion first appears in the neck, in the area of the jugular notch, and from there spreads symmetrically to both halves of the body.
Basic principles of surgical care. In general, the staged treatment of victims with chest injuries is as follows.
All victims are administered analgesics and cardiac drugs and carried out on a stretcher, preferably in a semi-sitting position.
Analgesics, tetanus toxoid, broad-spectrum antibiotics, and cardiac medications if indicated are administered. In case of tension pneumothorax, the pleural cavity is punctured with a thick Dufaux-type needle in the 2nd intercostal space along the midclavicular line, with its fixation to the skin with a plaster. A rubber valve made from the finger of a surgical glove is attached to the free end of the needle. If necessary, resort to artificial or assisted respiration.
In the cold season, the victim should be covered with heating pads and wrapped in a blanket. In cases of signs of bleeding and a drop in blood pressure, infusion therapy (polyglucin, saline solutions, glucose) is carried out for vital reasons, which, however, should not cause a delay in the wounded at this stage.
on the nature of intrathoracic destruction.
