transport immobilization. Injuries of the wrist joint: complications, treatment

Immobilization for fractures is the main first aid tool that ensures the immobility of the bones. The fact is that the movements, whether they are arbitrary or not, that the victim makes during delivery to the doctor, cause him serious harm. Immobilization minimizes additional trauma to soft tissues and blood vessels from sharp bone fragments at the fracture site, and reduces the possibility of shock, significant bleeding, or the development of an infectious complication. The timing of immobilization depends on the distance to the medical institution and ranges from several hours to 2-3 days.

Types of fractures and the need for first aid

It is customary to distinguish between pathological fractures that occur with various bone diseases and traumatic fractures that occur as a result of a large dynamic load on the bone during injury. Chronic fractures occur somewhat less frequently, in the case when the loads on the bone were, although not excessive, but prolonged.

Traumatic fractures are usually divided into:

• closed;
• open, when in addition to a broken bone there is also a wound;
• intra-articular, in which blood accumulates in the joint capsule.

Each of the species, in turn, can be with or without displacement of bone fragments.

There are pronounced signs by which it is possible to determine the presence of a fracture in the victim:

• severe pain at the site of injury;
• with a limb injury - a change in shape and size in comparison with the uninjured one;
• bone mobility at the site of injury, which was not observed in the normal state;
• inability to move the injured limb.

Open fractures are also dangerous because pathogens can get into the wound and infection can develop. Damage to tissues by bone fragments causes bleeding, often significant. If the fracture is open, the bleeding is external, and if it is closed, internal bleeding develops, which is no less dangerous. If there are several fractures, or they are open and severe, traumatic shock often develops, requiring urgent medical measures. One of the important points in the treatment of fractures is qualified first aid, the main activities of which are:

• anesthesia;
• stop bleeding if the fracture is open:
• prevention of occurrence of shock or measures to combat it;
• ensuring the immobility of the injury site by immobilization, which reduces pain and prevents shock;
• urgent delivery of the victim to a medical facility.

Use of splints for fractures

Types of tires for fractures

Standard ready-to-use tires vary in size and design features. They are more often designed to immobilize the upper or lower limbs, and in some cases - to stretch them.

Standard tires are made from different materials:

• steel mesh or wire, such as Cramer flexible ladder bars;
• wood: from slatted wooden structures, such as Dieterichs tires;
• plastics;
• thick cardboard.

In the event that transport immobilization is required for a relatively long period, plaster bandages or splints are used. The peculiarity of such tires is that they are made individually for each victim. They fix bone fragments well and fit snugly to the body. A relative disadvantage of this option of immobilization can be considered the difficulty of transporting the victim in frosty weather, while the tire is still wet.

It often happens that ready-made standard tires are not at hand. In this case, it makes sense to use improvised materials nearby. Usually boards or thick rods are used, thin rods can be knitted in the form of a knit for convenience.

It must be borne in mind that if rescuers or a medical team are already on their way to help the victim, it is not necessary to build an impromptu splint from improvised material, it is more expedient to wait for professional help.

Immobilization splint rules

Algorithm for applying an immobilization splint to the upper limbs

• the injured arm is bent at an angle of 90 degrees;
• under the arm, in the axillary fold, you need to put a roller of clothes or soft material, about 10 cm in size;
• if a bone in the shoulder is broken, it is most convenient to use a flexible standard Cramer splint; in its absence, improvised rigid materials are used;
• fix the shoulder and elbow joints with one improvised rigid and solid splint, and the second with the elbow and wrist joints;
• the bent arm must be hung on a scarf.

In case of a fracture of the bones of the forearm, the elbow and wrist joints are fixed with a splint, a roller, 8-10 cm in size, is placed in the armpit. The arm is bent at an angle of 90 degrees and suspended on a scarf. Sometimes it happens that a solid object for making an impromptu tire cannot be found. In this case, the broken bone of the forearm can be fixed by bandaging it to the body.

It is better not to bandage the fingertips with a fracture of the upper limbs, so it is more convenient to control blood circulation.

Immobilization for other types of fractures

In case of a fracture of the femur, one splint is applied on the inside of the injured limb, fixing the knee and ankle joint. Such a splint should reach the groin, where a soft roller, about 10 cm in diameter, is necessarily placed. On the outside of the leg, the splint is laid so as to fix all three joints: femoral, knee and ankle. Joints should be grasped to exclude movement in them; otherwise it will be transferred to the area of ​​the broken bone. In addition, such fixation prevents dislocation of the head of the damaged bone.

This is how a splint is applied for a hip fracture

In case of a fracture of the lower leg, splints are also applied along the inner and outer surface of the injured limb, fixing the knee and ankle joint. If it is not possible to find improvised material for the device of the immobilization splint, the injured leg can be fixed by bandaging it to the uninjured leg. However, such a measure is considered insufficiently reliable, and is used in extreme cases.

It is unacceptable to transport victims with fractures, even for short distances, without immobilization.

In case of a fracture of the collarbone, you need to hang the victim's hand on a scarf bandage. If the medical facility is far enough to get, you need to apply a figure-eight bandage to pull the shoulder girdle back and fix it in this position.

If immobilization is required for fractures of the ribs, a tight fixing bandage is applied to the chest, having previously anesthetized the victim. The chest is bandaged on exhalation, while the tightened ribs make only minimal movements during breathing. This reduces pain, and removes the risk of additional soft tissue injury from debris. Uncomplicated fractures of the ribs heal quickly, but complications are serious if the internal organs are injured by broken ribs.

When the foot is broken, the Cramer's flexible splint is applied to the upper thirds of the lower leg, modeling it along the contour of the back surface.

First aid for severe fractures

Fractures of the pelvic bones are severe, life-threatening damage to the victim, characterized by sharp pains, the inability to walk, stand, and raise the leg. To provide first aid, the victim is placed on a rigid stretcher down with his back, while his legs are left in a half-bent state. Soft cushions should be placed under the knees.

The most severe injury is considered to be a fracture of the spine, which can occur with a strong blow to the back or during a fall from a height. The victim experiences acute pain, there is swelling, protrusion of damaged vertebrae.

When providing assistance, you need to be extremely careful, since the displacement of the vertebrae often leads to damage to the spinal cord and its rupture.

The victim is placed on a hard surface, doing this on command, while avoiding kinks in the spine. Then they are fixed with wide straps. In case of a fracture of the upper spine, it is necessary to place soft cushions in the neck area.

Immobilization- this is the creation of immobility (rest) of the damaged part of the body. Applies to:
- bone fractures:
- damage to the joints;
- nerve damage;
- extensive damage to soft tissues;
- severe inflammatory processes of the extremities;
- injuries of large vessels and extensive burns.
Immobilization is of two types:
- transport;
- medical.
Transport immobilization - carried out at the time of delivery of the patient to the hospital; this is a temporary measure (from several hours to several days), but it is of great importance for the life of the victim and for the further course and outcome of the damage. It is provided by means of special or improvised splints and by applying bandages.
Transport tires are divided into:
- fixing;
- Combining fixation with traction.
Of the fixing tires, the most common are:
- plywood, used for immobilization of the upper and lower extremities;
- wire (Cramer type), made of steel wire. Such tires are light, durable and widely used in practice;
- wire ladder;
- plank (Diterichs splint, designed by a Soviet surgeon to immobilize the lower limb. The splint is wooden, but at present it is made of lightweight stainless metal);
- cardboard.

26.1. Gypsum bandage

Performs the functions of both transport and therapeutic immobilization. Convenient in that it can be made in any shape. Immobilization with a plaster bandage is convenient in case of damage to the lower leg, forearm, shoulder. The inconvenience lies only in the fact that it takes time to dry and harden the bandage. Today, new modern materials are also used. For example, CELLON - plaster bandages, represented by a thin creamy structure, providing exceptionally good opportunities for modeling (Fig. 227). Bandages made of plaster bandage CELLON (Fig. 228) are thin, strong, uniform in thickness. After 30 minutes, a light load is acceptable. They transmit X-rays well. Synthetic bandages CELLAKAST Xtra are currently being produced, providing high-strength and stable fixation of the fracture with a very low weight of the bandage. The bandages are made of fiberglass threads impregnated with polyurethane resin. The dressing made of these bandages has an excellent X-ray transmission ability and ensures skin respiration. Bandages are available in beige, blue and green. Rice. 228. Applying a bandage from a CELLON bandage.

26.2. Principles of transport immobilization

Tires for transport immobilization are not always available at the scene of the incident, in which case it is necessary to use improvised material or improvised tires. For this purpose, sticks, planks, pieces of plywood, cardboard, umbrellas, skis, tightly rolled up clothes, etc. are used. You can also bandage the upper limb to the body, and the lower limb to the healthy leg (autoimmobilization).
Basic principles of transport immobilization:
- the tire must necessarily capture two, and sometimes three adjacent su;
- when immobilizing a limb, it is necessary to give it an average physiological position; if this is not possible, then the position in which the limb is least injured;
- in case of closed fractures, before the end of immobilization, it is necessary to carry out an easy and careful traction of the injured limb along the axis;
- in case of open fractures, reduction of bone fragments is not performed;
- with open fractures, a sterile bandage is applied to the wound and the limb is fixed in the position in which it is located;
- do not remove clothes from the victim;
- it is impossible to impose a hard tire directly on the body, it is necessary to put a soft bedding (cotton wool, hay, towel, etc.);
- an assistant should hold the injured limb while transferring the patient from the stretcher.
It must be remembered that improperly performed immobilization can be harmful as a result of additional tissue trauma. So, insufficient immobilization of a closed fracture can turn it into an open one, aggravating the injury and worsening its outcome.

26.3. Transport immobilization in case of neck injury

Immobilization of the neck and head is performed using a soft circle, cotton-gauze bandage or a special transport tire.
When immobilized with a soft backing circle, the victim is placed on a stretcher and tied to prevent movement. A cotton-gauze circle is placed on a soft bedding, and the victim's head is placed on the circle with the back of the head in the hole.
Immobilization with a cotton-gauze bandage - a "Schanz-type collar" - can be performed if there is no difficulty breathing, vomiting, or arousal. The collar should rest against the occiput and both mastoid processes, and from below - rest on the chest. This eliminates lateral movement of the head during transport.

26.4. Transport immobilization in case of spinal injury

Elimination of mobility of damaged vertebrae during transportation;
- unloading of the spine;
- Reliable fixation of the damaged area.
Transportation of a victim with spinal injury always poses a risk of being injured by a displaced vertebra of the spinal cord. Immobilization in case of damage to the spine is carried out on a stretcher, both in the position of the victim on the stomach with a pillow or folded clothing under the chest and head to unload the spine, and in the supine position with a roller under the back (Fig. 229).
An important point in the transportation of a patient with a spinal injury is his placement on a stretcher, which should be performed by 3-4 people.

26.5. Transport immobilization in case of damage to the shoulder girdle

In case of damage to the clavicle or scapula, the main goal of immobilization is to create rest and eliminate the effect of the gravity of the arm and shoulder girdle, which is achieved using a scarf or special splints. Immobilization with a scarf is carried out by hanging the arm with a roller placed in the armpit. You can make immobilization bandage Dezo (Fig. 230, 231).

26.6. Transport immobilization in case of damage to the upper limbs

In case of a fracture of the humerus (Fig. 232) in the upper third, immobilization is carried out as follows:
- the arm is bent at the elbow joint at an acute angle so that the hand lies on the nipple of the mammary gland from the opposite side;
- a cotton-gauze roller is placed in the armpit and bandaged through the chest to a healthy shoulder girdle;
- the forearm is hung on a scarf;
- the shoulder is fixed with a bandage to the body.

26.6.1. Immobilization with ladder and plywood rail

Carried out with a fracture of the diaphysis of the humerus. Stair rail for immobilization is wrapped with cotton wool and modeled on the patient's intact limb. The tire should fix three joints:
- shoulder;
- elbow;
- radiocarpal.

A cotton-gauze roller is placed in the axillary fossa of the injured limb. With bandages, the tire is fixed to the limb and torso. Sometimes the hand is hung on a scarf (Fig. 233). If the fracture is localized in the area of ​​the elbow joint, the tire should cover the shoulder and reach the metacarpophalangeal joints.
Immobilization with a plywood splint is carried out by imposing it on the inside of the shoulder and forearm. The tire is bandaged to:
- shoulder;
- elbow;
- forearm;
- brushes, leaving only fingers free.

26.6.2. When immobilized with improvised means

They use sticks, bundles of straw, branches, planks, etc. In this case, certain conditions must be observed:
- from the inside, the upper end of the tire should reach the armpit;
- its other end from the outside should protrude beyond the shoulder joint;
- the lower ends should protrude beyond the elbow.
After splinting, they are tied below and above the fracture site to the shoulder, and the forearm is hung on a scarf (Fig. 234).

26.6.3. Forearm injuries

When immobilizing the forearm, it is necessary to exclude the possibility of movements in the elbow and wrist joints. Immobilization is carried out with a ladder (Fig. 235) or mesh splint. To do this, it must be curved with a gutter and lined with soft bedding. The tire is applied along the outer surface of the affected limb from the middle of the shoulder to the metacarpophalangeal joints. The elbow joint is bent at a right angle, the forearm is brought to the middle position between pronation and supination, the hand is slightly unbent and brought to the stomach. A dense roller is put into the palm, the splint is bandaged to the limb and the hand is hung on a scarf. When immobilized with a plywood tire, in order to avoid bedsores, cotton must be underlain. For immobilization of the forearm, you can also use the material at hand, following the basic rules for creating immobility of the damaged limb.

26.6.4. Injuries to the wrist and fingers

In case of injuries in the area of ​​the wrist joint of the hand and injuries of the fingers, a ladder or mesh splint curved in the form of a groove is widely used, as well as plywood splints in the form of strips from the end of the fingers to the elbow. Tires are covered with cotton wool and applied from the palm side. It is bandaged to the hand, leaving the fingers free to monitor blood circulation. The brushes are given an average physiological position, and a dense roller is placed in the palm.

26.7. Transport immobilization in case of pelvic injury

Immobilization in case of pelvic injury is a difficult task, since even involuntary movements of the lower extremities can cause displacement of bone fragments. For immobilization in case of damage to the pelvic bones, the victim is placed on a rigid stretcher, giving him a position with half-bent and slightly spread legs, which leads to muscle relaxation and pain reduction. A roller is placed in the popliteal regions (Fig. 236): a blanket, clothes, a folded pillow, etc.

26.8. Transport immobilization for injuries of the lower extremities

Correctly performed immobilization in case of damage to the thigh (Fig. 237) captures three joints at once, and the splint should be applied from the armpit to the ankles.

26.8.1. Immobilization with a Dieterichs bus

This splint for proper immobilization in case of a fracture of the femur combines the necessary conditions:
- fixation;
- simultaneously stretching.
It is suitable for all levels of hip or tibia fracture. It consists of two wooden sliding bars of various lengths, a wooden footrest (“sole”) for stretching and a twist stick with a cord (Fig. 238). A long bar is applied to the outer surface of the thigh from the armpit, and a short bar is placed on the inner surface of the leg. Both slats have transverse struts at the top for stop.

Since the bars are sliding, they can be given any length depending on the height of the victim. A “sole” is bandaged to the foot (Fig. 239), which has a fastening for a cord; an emphasis with a hole through which the cord is passed is hinged on the inner bar of the tire. After applying the tire, the cord is twisted to tension. The tire is fixed to the body with soft bandages.

Attention! With simultaneous fractures of the ankles, injuries of the ankle joint and bones of the foot, the Dieterichs splint cannot be applied!

26.8.2. Immobilization with a ladder splint

For immobilization with a ladder tire (Fig. 240), 3 tires are taken for hip fractures;
- two of them are tied along the length from the armpit to the foot, taking into account its bending to the inner edge of the foot;
- the third tire is applied from the gluteal fold to the fingertips;
- in the presence of several tires, you can impose a fourth

Immobilization with plywood tires is carried out in the same way as with ladder tires.
Improvised splinting is carried out with various improvised devices.

26.9. Transport immobilization of the lower leg

Can be done with:
- special plywood tires;
- wire tires;
- ladder rails;
- tires Diterikhs;
- improvised tires.
For the correct application of the splint in case of fractures of the bones of the lower leg, it is necessary that the assistant lifts it by the heel and, as if removing the boot, begins to smoothly pull the leg. Immobilization is achieved by applying along the back surface of the limb - from the gluteal fold - a ladder splint well modeled along the contours of the limb (Fig. 241) with the addition of two plywood splints on the sides. Tires are bandaged from the outer and inner sides with the calculation that they go above the knee joint, and below - behind the ankle joint. The structure is fixed with a gauze bandage (Fig. 242).

Test tasks:

1. Specify a tire not intended for transport immobilization:
a. Pneumatic.
b. Diterichs.
c. Beler.
d. Kramer.
e. Mesh.
2. Add:
In case of a fracture of the limbs, it is necessary to immobilize at least _____________ nearby joints (the answer is entered as a number).
3. Add:
In case of a hip injury, it is necessary to immobilize the ________________ joint (answer
entered as a number).
4. Transport immobilization is used for:
a. Reducing the pain syndrome.
b. Reducing the likelihood of complications.
c. Prevention of further displacement of bone fragments.
d. Treatment of fractures and dislocations.
5. With an injury to the musculoskeletal system, pain reduction is achieved:
a. Comfortable position of the victim.
b. Stop bleeding.
c. Immobilization and anesthesia.
d. Applying a pressure bandage.
6. Transportation of the victim with a clavicle fracture:
a. In a sitting position, leaning back.
b. In a hard lying position, on the back.
c. In the frog position.
d. Lying on your stomach.
7. In case of a closed fracture of the leg at the scene, the following is performed in the first round:
a. Tire preparation.
b. Immobilization.
c. Anesthesia.
8. Traumatological patients should be activated:
a. from the first day after the injury.
b. From the second week after the injury.
c. An individual and timely approach is needed.
d. After the end of drug treatment and consultation of an exercise therapy doctor.

The wrist joint is formed by the ends of the ulna and radius and small bones of the wrist. Ligaments are located in large numbers around the articular capsule, which allows you to make movements of the hand in different directions.

The human hand consists of three parts. The wrist is formed by 8 bones, which are located in two rows, and 5 metacarpal bones extend from them, which form the basis of the hand. The phalanges of the fingers are attached to these metacarpals. In order for a person to make small movements with a brush, it has many tendons and nerves, it has an excellent blood supply.

Hand injuries are quite common, after each there is a risk of loss of hand function, therefore, before the doctor arrives, the victim can only be given first aid, and already qualified treatment will be prescribed by specialists.

Injury

Since the capsule of the wrist joint is not protected by muscles, it is always very painful. A bruised hand is characterized by a rapidly developing edema, often a hematoma (subcutaneous hemorrhage) is formed. These characteristic signs of a bruise are especially pronounced when the fingertip is injured - for example, when it is hit with a hammer. The bones of this part of the body are quite thin and break easily, therefore, with a severe bruise, it is imperative to do and exclude (or confirm).

After the puffiness decreases somewhat, you can carry out procedures for warming up the bruised area., but only if the doctor confirms the absence of an inflammatory process.

As a warm-up, you can use ointments with anti-inflammatory and analgesic effects, which include Fastum-gel. Often, with a bruise, blood accumulates under the nails of the injured hand - it must be removed in the surgical room of the outpatient institution, which will lead to significant relief of the condition and the disappearance of dull, aching pain.

compression

If the brush is compressed by any heavy object, then an extensive hemorrhage immediately occurs, damage to the muscles and skin occurs. First aid in case of such an injury consists in applying a tight bandage, applying cold. The injured hand must be given an elevated position. Compression is an injury that will definitely require qualified medical care!

Ligament injury

Injury to the ligaments of the wrist joint is possible with a sharp movement of large amplitude - for example, this often happens when you fall on your hand. The same statement applies to damage to the tendons on the hand, but in this case, there is often a detachment of small bone fragments to which the tendons are attached. The result of such an injury is a subluxation of the joint, and blood accumulates in its cavity.

Note: ligament damage is always accompanied by severe pain, swelling and impaired mobility in the affected joint. Often, with such an injury, pathological movements are observed - for example, the victim can bend the finger to the side, or take it to the opposite side: this will be a characteristic sign of a detachment of the bone fragment.

First aid for such injuries consists in applying cold, resting the affected joint and placing the hand on a hill. Be sure to seek qualified medical attention.

In order for the fingers to move, tendons are needed - extensor on the outer surface, flexors on the inner.

Symptoms will vary:

• If there is damage to the extensor, which is attached to the nail phalanx, then it stops straightening and “hangs down”.
• If the ligament leading to the lower phalanx is injured, then a double contracture is observed: the middle phalanx flexes, the nail phalanx hyperextends, and the finger takes the form of a zigzag.
• If a double contracture has occurred, then the treatment will proceed surgically, it is impossible to restore the functioning of the hand without an operation.
• Flexor tendons are most often affected by cut wounds of the palm. Such injuries are characterized by the inability to bend the fingers, to clench them into a fist. The victim must attempt such movements very carefully, because the ends of the tendons may diverge, which will complicate treatment.

First aid for such an injury consists in immobilizing the limb, when a tennis ball, foam rubber sponge is inserted into the injured palm. You should immediately seek help from a doctor in the trauma department - such injuries are treated only surgically.

Dislocation of the wrist joint

wrist joint occurs, as a rule, with an unsuccessful fall on the arm. With such an injury, the hand is displaced to the back, but the displacement of the palm is extremely rare. Dislocation causes compression of blood vessels and nerve bundles, which is manifested by acute pain, numbness of the entire hand, inability to make any movements, swelling and impaired blood circulation.

If the hand is displaced to the rear, then the deformity in the form of a step can be determined in the wrist joint. Palmar dislocation does not restrict movement in the hand and fingers. First aid for such an injury is to immobilize the hand - this is done using a fragment of a board or plywood, any solid object.

Note: in no case should you adjust the dislocation on your own, as this will lead to additional injury to the joint.

If happened dislocation of one of the bones of the wrist, then you can feel the bony protrusion at the top of the hand. This condition is accompanied by swelling of the hand and some movement disorders. Often, patients do not pay attention to such an injury at all, this can lead to a significant deterioration in the movement of the hand in the future, so you should put a splint on the injured arm and contact a medical facility.

Often found and dislocation of the metacarpal bones- this injury occurs when falling on a clenched fist, after which the surface of the hand immediately swells, its surface changes. The affected palm becomes shorter than the healthy one, and the fingers do not clench into a fist.

If there was a fall on a hand with a straightened thumb, then there is a high probability that there will be dislocation in the metacarpophalangeal joint. The finger in this case shifts to the back of the hand, strongly unbends, the nail phalanx becomes bent, and finger movements are impossible. First aid consists in fixing the finger in its original position (it must not be wrinkled or attempted to be set) - doctors will work on the dislocation, and the reduction procedure is carried out only under anesthesia.

hand fracture

Bone fractures can also occur during falls and impacts. The symptoms of such injuries are quite classic - pain, swelling, violation of the shape of the hand, shortening of the finger, inability to move the affected part of the hand. Since the symptoms of bruises and fractures are identical, you need to contact a medical institution and take an x-ray - this will clarify the diagnosis and carry out effective therapeutic measures.

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Hand wounds

Open damage can be of a different nature:

• pricking,
• cut,
• ragged,
• chopped,
• bruised.

Wounds are complicated, as a rule, by trauma to the tendons or blood vessels, separation of the phalanx or the whole finger.

The amount of first aid will depend on the type of wound:

If a hand wound has occurred, then there may be severe / intense bleeding. To stop it, it is necessary to put a tourniquet on the victim's hand just above the wound. In the summer, the tourniquet can remain in place for two hours, in the cold season - no more than an hour and a half. Be sure to put a note under the tourniquet with the specified time for applying the tourniquet!

Avulsion of the phalanx of the finger: first aid

When a phalanx or a completely finger is torn off, the first task is to stop the bleeding with a tourniquet. Then a sterile dressing is applied to the wound and the victim is immediately taken to a medical facility. The cut off fragment cannot be washed - it is wrapped in a clean napkin (it is highly desirable to do this with a sterile napkin) and placed in a plastic bag. The package with the fragment is placed in another bag with snow or cold water, and when transporting this container, it is necessary to ensure that there is no tissue compression.

If an incomplete detachment occurs, then the limb must be cooled and immobilized. Then the victim is urgently taken to a medical institution - the probability of recovery of the severed fragment depends on how quickly the victim is on the operating table.

Note:the viability of the brush at a temperature of +4 degrees is maintained for 12 hours, at a higher temperature - a maximum of 6 hours. With a finger injury, these figures correspond to 16 and 8 hours.

Splinting

If an injury to the wrist joint and hand occurs, then first of all it is necessary to immobilize the affected limb. To do this, you can use either standard medical splints or improvised means - for example, thick cardboard, boards, plywood. The brush is fixed as follows:

• fingers are slightly bent and a roller of fabric / foam rubber is inserted into the palm;
• the thumb is laid aside;
• the brush is slightly bent to the back.

The tire is bandaged to the palmar surface of the forearm from the elbow to the wrist, its end must necessarily protrude beyond the nail phalanges. It will be useful to apply cold to an already immobilized hand, while the hand must be laid on a scarf.

If a finger is damaged, then a regular ruler can be used as a splint - it is tied / bandaged to the damaged finger.

Bandages

You can bandage the wound with a regular bandage, adhesive tape, or use a small tubular bandage, on the packaging of which the parts of the body that can be bandaged are indicated.

A spiral bandage is applied to one finger. This is done as follows:

• take a bandage 2-3 cm wide and wrap it around the wrist several times;
• then, along the back of the hand, the bandage is lowered obliquely to the nail phalanx and they begin to bandage the injured finger in a spiral, rising to its base;
• if the bandage is wide, then you can twist it around the nail, which will ensure a good fixing of the bandage;
• you need to complete the procedure with circular tours on the wrist.

If it is necessary to bandage all fingers, then a spiral bandage is also applied. On the right hand, bandaging begins with the thumb, on the left - with the little finger. After bandaging one finger, make a circular tour around the wrist and return to the nail phalanx of the next finger.

To bandage the brush, put cotton or gauze swabs / napkins between the fingers. Use a wide bandage (at least 10 cm) for such bandaging and wrap all fingers with it at once, then return to the wrist. Then they make a circular fixation and again descend to the fingers - gradually the entire brush will be bandaged. The thumb should always be attached separately from the palm!

Note:if there is no bandage at hand, then a scarf can be used as a dressing. Of course, such a bandage will not stop arterial bleeding, but it will help keep the arm immobilized and prevent contamination.

Human hand since birth is in constant motion. The hand does not stop moving even during. Immobility is an unnatural state of the hand, to which it responds with an unfavorable reaction. Although immobilization of the hand for a short time in terms of treatment of its damaged tissues is extremely important, nevertheless, it must be reckoned with the fact that an immobile state for a long time can lead to reversible or permanent stiffness of the hand.

By M. J. Bruner, the immobilized arm resembles a caged bird that, after being imprisoned for a long time, can no longer fly. Contrary to the natural mobility and dynamic function of the hand, a static state with too long immobilization is detrimental and leads to rigidity; and if rigidity does not occur in a functional position, then the damage to the hand is aggravated.

Thoughtful immobilization the hand is in a “functional position”, the constant use of its undamaged sections, as well as the early function of the damaged parts, leads to favorable results. So, in hand surgery, the key to complete success is postoperative immobilization and expedient, systematic restoration of movements. There are three methods of immobilization: one of them prevents the development of deformities and rigidity, the second serves to correct the latter, and the third creates the rest necessary for wound healing.
Of course, timely immobilization in the correct position is more effective than corrective immobilization, since the prevention of rigidity is undoubtedly easier than its treatment.

Iselen expresses his regret that surgeons in the treatment of injuries and purulent diseases do not pay enough attention to the prevention of the development of ankylosis, although they can easily be prevented if simple preventive measures are observed.

Choosing a brush position during its immobilization is a difficult task, especially for a doctor who is not constantly involved in the treatment of hand injuries. In order to understand the relationship between the state of rest, the state of action and the position of grip, it is necessary to take into account the difference in function that exists between the wrist joint and the joints of the fingers. This difference is due to the constancy of the length of the flexors and extensors in a state of relaxation. With complete relaxation of the muscles, flexion of the wrist causes extension of the fingers, while extension of it is accompanied by flexion of the fingers.

The correct position of the hand should also be ensured during plastic surgery (stalked flap, pedicled flap).
Incorrect position of the hand (picture on the left): the hand is in a state of flexion, the forearm hangs, and the shoulder is adducted.
The correct position of the hand (figure on the right) makes it possible to reduce the number of complications that occur due to prolonged immobilization

Bruner expressed it this way: the degree of flexion of the wrist is inversely proportional to the degree of flexion of the fingers in the event that the muscle tone is the smallest. This principle of automatic action is used in the operation of tenodesis. The position of the knuckles of the fingers largely depends on the position of the wrist. According to Bunnell's work, the wrist joint is a joint of crucial importance for the muscular balance of the hand. With palmar flexion of the wrist joint, the hand assumes a "non-functional", and with dorsiflexion - a functional position.

So, at 20° wrist extension the knuckles of the fingers are bent. The volume of flexion of the fingers approaches 45-70 °. In contrast, when the wrist is flexed, the main and end joints of the fingers are almost completely extended. If the hand becomes rigid without immobilization, then it is fixed not in a functional position, but in the position of flexion of the wrist, the position of the fingers in the form of a claw with the adduction of the thumb. The wrist of the injured hand bends under the influence of its own gravity. This leads to extensor tension, flattening of the palm, hyperextension of the main phalanges of the fingers and adduction of the thumb. When the wrist is extended, the hand assumes a functional position.

FROM practical point of view it is very important that the hand, during its immobilization, be in the most favorable position for the most important functions. In this position, even with the onset of a slight stiffness of the joints, an advantageous half-bent position of the fingers is still preserved, which is necessary for the capture. Therefore, in each case (if there is no forced need) of immobilization of the hand, the wrist must be in the position of dorsiflexion in order for the joints of the fingers to assume the position of average flexion, that is, the functional position.

So, at hand immobilization in a functional position, the main requirement is dorsiflexion at the wrist joint. Bunnell and most hand surgeons consider dorsiflexion up to 20° to be the most favorable, according to Iselen it should be more pronounced. In addition, the wrist is abducted to the side of the elbow by 10 degrees, but this is often forgotten by many surgeons. When immobilized, the thumb should be placed in an opposing position. Failure to do so is a serious mistake. Often, instead of opposing, the finger is erroneously fixed in the given position.

Articular ligaments relax when extended (A) and tense when flexed (B) (Moberg)

Doctors often forget about need sufficient flexion at the carpal joint, despite the fact that this joint is prone to contracture, the correction of which is almost impossible.

If there are no compelling circumstances, brush must be fixed always in the functional position. However, after the operation, sometimes there is a need for immobilization in other positions of the hand, namely: immobilization in the position of flexion or extension. Such a need exists almost exclusively after suturing tendons and nerves.

Unfortunately, in the recent past, domestic periodical literature, and now in the daily practice of doctors, there are still indications that immobilization of the hand and fingers in an extended position is recommended and performed for other indications, such as panaritiums and other "minor" injuries of the fingers. Fixing the fingers in a straightened position is an irreparable mistake. A rigid finger in an extended position irreversibly loses its grip function. Immobilization of the fingers in a straightened position on a wooden splint or in another way leads to a loss of mobility in the joints in a short time, which is explained by the special structure of the collateral ligaments of the interphalangeal and metacarpophalangeal joints.

These ligaments run distally and palmarly from points of rotation of the joints of the fingers located proximally and on the back surface. Thus, when the fingers are in a straight position, the ligaments relax, and when bent, they tighten. From this it is clear that if the joints are fixed in an extended position with relaxed ligaments, the latter quickly wrinkle. Later, when bending is attempted, the shortened and loosened ligaments present an obstacle to bending.

In the event that there is the need for immobilization of the hand in a straightened position, you should remember the rules under which the risk of loss of joint function is reduced. Immobilization of the hand in a straightened position is required after the suture of the extensor tendons or after tendon transposition. In this case, the hand is also given a position of dorsiflexion up to 20 ° (the metacarpophalangeal joints are extended). It is necessary to pay attention to the fact that the metacarpophalangeal joints are not in the position of hyperextension, since after the rapid wrinkling of the joint capsule, the possibility of full restoration of the flexion function will be lost.

It is advisable if, with such a forced position of the metacarpophalangeal joints the possibility of bending at least up to 5 ° is provided. After applying the tendon suture proximal to the metacarpophalangeal joints, the interphalangeal joints are immobilized in a position of slight (20-30°) flexion. Thus, two or three joints of the hand are immobilized in a position close to functional, which creates hope for a complete restoration of finger flexion function. The metacarpophalangeal joints of intact fingers may be more flexed and left free at the first dressing change. A finger whose extensor tendon has been sutured should not remain immobilized for more than three weeks.

This period is quite sufficient for tendon fusion. If the extensor tendon is damaged along the length of the finger, immobilization is performed with extension in the middle joint of this finger and with slight flexion in the end joint. A rupture of the extensor tendon along the terminal phalanx requires special treatment, which we will discuss below. When suturing the flexor tendons during their transposition, as well as after the suture of the nerves, it may be necessary to immobilize in the flexion position in order to reduce the tension of the sutures. To do this, it is necessary to relax the flexors, which is achieved by flexion in the wrist joint.

A - fixing the hand and fingers on a wooden splint in an extended position is a serious mistake
B - the permissible position of the hand during immobilization in cases where after the operation it is required to keep it in an extended position
B - immobilization of the hand in the position of palmar flexion in the presence of forced circumstances
D - the wrong way to fix the brush in the flexion position

In the end brush immobilized in a resting position, that is, with slight flexion in the wrist joint and with extension of the fingers. With this position of the wrist, a stronger extension of the fingers leads to tension of the extensors. Immobilization of the hand in flexion is detrimental and therefore its duration should be as short as possible.

After paralysis, the first regeneration is very slow. During the regeneration period, it is necessary to protect the muscles from overstrain and immobilize the hand in such a position that the patient can safely use it when performing various functions.

AT regeneration period of the radial nerve the wrist, thumb and other fingers should be in an extended position (it is best to use a palmar or elastic splint for this). In this case, the patient can actively use his hand.

At median nerve palsy to compensate for the function of the muscles of the elevation of the thumb, the latter is set in the position of opposition to the middle finger.

During ulnar nerve regeneration metacarpophalangeal joints are immobilized in a position of slight flexion, which prevents hyperextension of the little finger and ring finger.

Normal brush function due to the mechanism of action of the own muscles of the hand and the coordination of the functions of the muscles of the hand - forearm. Simultaneous damage to the median and ulnar nerves, localized in the wrist, leads to paralysis of the interosseous, vermiform muscles, as well as the muscles of the eminence of the thumb and little finger. With paralysis of these muscles, excessive rotation occurs, as well as adduction of the thumb, at the same time, the function of opposition falls out, the concave surface of the palm changes.

Metacarpophalangeal joints overextension, and a flexion position occurs in the joints of the fingers. The flexion position of the wrist only increases the action of the extensor. In the absence of immobilization, the hand assumes a position called the “claw” position, which can become irreversible due to contracture of the fasciae, articular ligaments, and skin. This condition of the hand is called "intrinsic minus" deformity by Bunnell, and simply "minus" hand by Ballmer. Immobilization of the hand during dorsal flexion in the wrist joint until the restoration of nerve function or before corrective surgery prevents the development of irreversible hand contracture prone to intrinsic minus deformity.

Deformity of long fingers "intrinsic plus":
A) the characteristic position of the fingers,
B) excessive extension in the metacarpophalangeal joint prevents flexion,
C) flexion in the main joint creates an opportunity for flexion in the interphalangeal joints (based on the schemes of J. Byrne),
D) “intrinsic plus” hand in an elderly patient with rheumatoid arthritis

Opposite position intrinsic minus, with contracture of the autochthonous muscles of the hand and with shortening of the articular ligaments, the hand assumes the so-called “intrinsic plus” position. In a typical plus hand, the metacarpophalangeal joints are in flexion, the middle joints of the fingers are in hyperextension, and the end joints are also in flexion. The arch of the transverse arch of the hand is well expressed. The thumb in its main joint is somewhat bent, and the terminal phalanx is unbent; the metacarpal bone is brought to the side of the palm.

A hand in this position is sometimes called a hand, " counting coins". Immobilization alone is not enough to prevent this deformity. So, along with etiological treatment, prevention of wrinkling of the own muscles of the hand is necessary.

In connection with hand immobilization problem we must not forget about one important circumstance, which is often not taken into account. If the hand is immobilized only up to the main phalanges of the fingers or only one finger is immobilized distally to the main phalanx, then the plaster splint on the palmar surface should not go beyond the distal palmar fold (groove). Otherwise, an obstacle is created for the movements of the main phalanges. The distal crease of the palm is an important level: outward from it, the flexor tendons are located in a tight vagina, and their compression interferes with the flexion of the fingers. On the thumb above the main joint there are two flexion grooves, of which the proximally running one corresponds to the distal groove of the palm.

The human hand has a complex structure and performs various subtle movements. It is a working organ and, as a result, more often than other parts of the body is damaged.

Introduction.

The structure of injuries is dominated by occupational (63.2%), domestic (35%) and street (1.8%) types of injuries. Occupational injuries are usually open and account for 78% of all open injuries of the upper extremities. Damage to the right hand and fingers is 49%, and the left - 51%. Open injuries of the hand in 16.3% of cases are accompanied by combined damage to tendons and nerves due to their close anatomical location. Injuries and diseases of the hand and fingers lead to a violation of their function, temporary disability, and often to disability of the victim. The consequences of injuries of the hand and fingers occupy more than 30% in the structure of disability due to injuries of the musculoskeletal system. The loss of one or more fingers leads to professional and psychological difficulties. A high percentage of disability as a result of hand and finger injuries is explained not only by the severity of the injuries, but also by incorrect or untimely diagnosis and choice of treatment tactics. In the treatment of this group of patients, one should strive to restore not only the anatomical integrity of the organ, but also its function. Surgical treatment of injuries is carried out according to an individual plan and in accordance with the principles outlined below.

Features of the treatment of patients with injuries and diseases of the hand.

Anesthesia.

The main condition for the implementation of a subtle intervention on the hand is adequate anesthesia. Local infiltration anesthesia can be used only for superficial defects, its use is limited on the palmar surface of the hand due to low skin mobility.

In most cases, during operations on the hand, conduction anesthesia is performed. Blocking of the main nerve trunks of the hand can be carried out at the level of the wrist, elbow joint, axillary and cervical region. For finger surgery, anesthesia according to Oberst-Lukashevich or a block at the level of the intercarpal spaces is sufficient (see Fig. 1)

Fig.1 Points of injection of anesthetic during conduction anesthesia of the upper limb.

At the level of the fingers and wrist, it is necessary to avoid the use of prolonged anesthetics (lidocaine, marcaine), since, due to the prolonged resorption of the drug, compression of the neurovascular bundles and the occurrence of tunnel syndromes, and in some cases finger necrosis, may occur. For severe injuries of the hand, anesthesia should be used.

Bleeding of the surgical field.

Among the tissues soaked with blood, it is impossible to differentiate the vessels, nerves and tendons of the hand, and the use of tampons to remove blood from the surgical field causes damage to the sliding apparatus. Therefore, bleeding is mandatory not only for large interventions on the hand, but also for the treatment of minor injuries. To bleed the hand, an elastic rubber bandage or pneumatic cuff is applied to the upper third of the forearm or the lower third of the shoulder, in which pressure is pumped up to 280-300 mm Hg, which is more preferable, as it reduces the risk of nerve paralysis. Before using them, it is desirable to apply an elastic rubber bandage to the previously raised arm, which helps to expel a significant part of the blood from the arm. For surgery on the finger, it is sufficient to apply a rubber tourniquet at its base. If the surgical intervention lasts more than 1 hour, then it is necessary to release air from the cuff for several minutes with the limb raised, and then refill it.

Skin incisions on the hand.

The epidermis on the hand forms a complex network of lines, the direction of which is determined by the various movements of the fingers. On the palmar surface of the skin of the hand, there are many furrows, wrinkles and folds, the number of which is not constant. Some of them, which have a specific function and are landmarks of deeper anatomical formations, are called primary skin formations (Fig. 2).

Fig. 2 Primary skin formations of the hand.

1-distal palmar groove, 2-proximal palmar groove. 3 interphalangeal grooves, 4 palmar carpal grooves, 5 interdigital folds, 6 interphalangeal folds

From the base of the main furrows, connective tissue bundles vertically depart to the palmar aponeurosis and to the tendon sheaths. These grooves are the "joints" of the skin of the hand. The groove plays the role of the articular axis, and adjacent sections perform movements around this axis: approaching each other - flexion, distance - extension. Wrinkles and folds are reservoirs of movement and contribute to an increase in the skin surface.

A rational skin incision should be subjected to the least stretch during movement. Due to the constant stretching of the edges of the wound, hyperplasia of the connective tissue occurs, the formation of rough scars, their wrinkling and, as a result, dermatogenic contracture. Incisions perpendicular to the sulci undergo the greatest change during movement, while incisions parallel to the sulci heal with minimal scarring. There are areas of the skin of the hand that are neutral in terms of stretching. Such an area is the mid-lateral line (Fig. 3) along which stretching in opposite directions is neutralized.

Fig. 3 Midlateral line of the finger.

Thus, the optimal incisions on the hand are incisions parallel to the primary skin formations. If it is impossible to provide such access to damaged structures, it is necessary to choose the most correct acceptable type of incision (Fig. 4):

1. the incision parallel to the furrows is complemented by a straight or arcuate in the wrong direction,

2.The cut is made along the neutral line,

3. the cut perpendicular to the furrows is completed with a Z-shaped plastic,

4. The incision crossing the primary skin formations should be arcuate or Z-shaped to redistribute tensile forces.

Rice. fourA-Optimal cuts on the hand,B-Z-plastic

For optimal primary surgical treatment of hand injuries, it is necessary to expand the wounds by additional and lengthening incisions in the correct direction. (Fig. 5)

Fig.5 Additional and lengthening cuts on the brush.

Atraumatic technique of operation.

Hand surgery is sliding surface surgery. The surgeon must be aware of two dangers: infection and trauma, which eventually lead to fibrosis. To avoid it, a special technique is used, which Bunnel called atraumatic. To implement this technique, it is necessary to observe the strictest asepsis, use only sharp instruments and thin suture material, and constantly moisten the tissues. Injury to tissues with tweezers and clamps should be avoided, since micronecrosis is formed at the site of compression, leading to scarring, as well as leaving foreign bodies in the wound in the form of long ends of ligatures, large knots. It is important to avoid the use of dry swabs to stop blood and tissue preparation, as well as to avoid unnecessary drainage of the wound. The connection of the edges of the skin should be done with minimal tension and not interfere with the blood supply to the flap. The so-called “time factor” plays a huge role in the development of infectious complications, since too long operations lead to “fatigue” of tissues and a decrease in their resistance to infection.

After atraumatic intervention, the tissues retain their characteristic luster and structure, and in the healing process, only a minimal tissue reaction occurs.

Immobilization of the hand and fingers.

The human hand is in constant motion. A stationary state is unnatural for the hand and leads to serious consequences. The non-working hand assumes a resting position: slight extension in the wrist joint and flexion in the joints of the fingers, abduction of the thumb. The hand takes a resting position lying on a horizontal surface and in a hanging state (Fig. 6)

Fig.6 Hand in rest position

In the functional position (position of action), extension in the wrist joint is 20, ulnar abduction 10, flexion in the metacarpophalangeal joints - 45, in the proximal interphalangeal joints - 70, in the distal interphalangeal joints - 30, the first metacarpal bone is in opposition, and the large the finger forms an incomplete letter “O” with the index and middle, and the forearm occupies an intermediate position between pronation and supination. The advantage of the functional position is that it creates the most favorable starting position for the action of any muscle group. The position of the joints of the fingers depends on the position of the wrist joint. Flexion at the wrist joint causes extension of the fingers, and extension causes flexion (Figure 7).

Fig.7 Functional position of the hand.

In all cases, in the absence of forced circumstances, it is necessary to immobilize the hand in a functional position. Immobilization of the finger in a straight position is an irreparable mistake and leads to stiffness in the joints of the finger in a short time. This fact is explained by the special structure of the collateral ligaments. They run distal and volar from the pivot points. Thus, in the straightened position of the finger, the ligaments relax, and in the bent position they stretch (Fig. 8).

Fig. 8 Biomechanics of collateral ligaments.

Therefore, when the finger is fixed in an extended position, the ligament wrinkles. If only one finger is damaged, the rest should be left free.

Fractures of the distal phalanx.

Anatomy.

Connective tissue septa, stretching from the bone to the skin, form a cellular structure and participate in the stabilization of the fracture and minimize the displacement of fragments. (Fig. 9)

R Fig.9 Anatomical structure of the nail phalanx:1-attachment of collateral ligaments,2- connective tissue partitions,3-lateral interosseous ligament.

On the other hand, a hematoma that occurs in closed connective tissue spaces is the cause of a bursting pain syndrome that accompanies damage to the nail phalanx.

The tendons of the extensor and deep flexor of the finger, attached to the base of the distal phalanx, do not play a role in the displacement of fragments.

Classification.

There are three main types of fractures (according to Kaplan L.): longitudinal, transverse and comminuted (eggshell type) (Fig. 10).

Rice. 10 Classification of fractures of the nail phalanx: 1-longitudinal, 2-transverse, 3-comminuted.

Longitudinal fractures in most cases are not accompanied by displacement of fragments. Transverse fractures of the base of the distal phalanx are accompanied by angular displacement. Comminuted fractures involve the distal phalanx and are often associated with soft tissue injuries.

Treatment.

Fractures without displacement and comminuted fractures are treated conservatively. For immobilization, palmar or dorsal splints are used for a period of 3-4 weeks. When applying a splint, it is necessary to leave the proximal interphalangeal joint free (Fig. 11).

Fig. 11 Tires used to immobilize the nail phalanx

Transverse fractures with angular displacement can be treated both conservatively and surgically - closed reposition and osteosynthesis with a thin Kirschner wire (Fig. 12).

Fig.12 Osteosynthesis of the nail phalanx with a thin Kirschner wire: A, B - stages of the operation, C - Final type of osteosynthesis.

Fractures of the main and middle phalanges.

The displacement of fragments of the phalanges is primarily determined by muscle traction. With unstable fractures of the main phalanx, the fragments are displaced at an angle open to the rear. The proximal fragment assumes a bent position due to the traction of the interosseous muscles attached to the base of the phalanx. The distal fragment does not serve as a place of attachment for the tendons and its hyperextension occurs due to the traction of the central portion of the extensor tendon of the finger, which is attached to the base of the middle phalanx (Fig. 13).

Fig. 13 The mechanism of displacement of fragments in fractures of the main phalanx

In case of fractures of the middle phalanx, it is necessary to take into account two main structures that affect the displacement of fragments: the middle portion of the extensor tendon, which is attached to the base of the phalanx from the rear, and the tendon of the superficial flexor, which is attached to the palmar surface of the phalanx (Fig. 14)

Fig. 14. The mechanism of displacement of fragments in fractures of the middle phalanx

Particular attention should be paid to fractures with rotational displacement, which must be eliminated with particular care. In a bent position, the fingers are not parallel to each other. The longitudinal axes of the fingers are directed towards the navicular bone (Fig. 15)

In displaced phalangeal fractures, the fingers cross over, making it difficult to function. In patients with fractures of the phalanges, flexion of the fingers is often impossible due to pain, so rotational displacement can be established by the location of the nail plates in the half-flexed position of the fingers (Fig. 16)

Fig. 16 determination of the direction of the longitudinal axis of the fingers in case of fractures of the phalanges

It is extremely important that the fracture heal without permanent deformity. The sheaths of the flexor tendons run in the palmar groove of the phalanges of the fingers and any unevenness prevents the tendons from sliding.

Treatment.

Non-displaced fractures or impacted fractures can be treated with the so-called dynamic splinting. The damaged finger is fixed to the adjacent one and early active movements begin, which prevents the development of stiffness in the joints. Displaced fractures require closed reduction and fixation with a plaster splint (Fig. 17)

Fig. 17 the use of a plaster splint for fractures of the phalanges of the fingers

If after reposition the fracture is not stable, the fragments cannot be held with a splint, then percutaneous fixation with thin Kirschner wires is necessary (Fig. 18)

Fig. 18 Osteosynthesis of the phalanges of the fingers with Kirschner wires

If closed reposition is impossible, open reposition is indicated, followed by osteosynthesis of the phalanx with pins, screws, and plates. (Fig. 19)

Fig. 19 Stages of osteosynthesis of the phalanges of the fingers with screws and a plate

With intra-articular fractures, as well as multi-comminuted fractures, the best result of treatment is provided by the use of external fixation devices.

Metacarpal fractures.

Anatomy.

The metacarpal bones are not located in the same plane, but form the arch of the hand. The arch of the wrist passes into the arch of the hand, forming a semicircle, which is completed to a full circle with the first finger. Thus, the fingertips touch at one point. If the arch of the hand flattens due to damage to bones or muscles, then a traumatic flat hand is formed.

Classification.

Depending on the anatomical localization of damage, there are: fractures of the head, neck, diaphysis and base of the metacarpal bone.

Treatment.

Fractures of the metacarpal head require open reduction and fixation with thin Kirschner wires or screws, especially in the case of an intra-articular fracture.

Metacarpal neck fractures are a common injury. Fracture of the neck of the fifth metacarpal, as the most common, was called "fracture of the boxer" or "fracture of the fighter." Such fractures are characterized by displacement at an angle open to the palm, and are unstable due to the destruction of the palmar cortical plate (Fig. 20)

Fig.20 Fracture of the neck of the metacarpal bone with the destruction of the palmar plate of the cortical layer

With conservative treatment by immobilization with a plaster longuet, as a rule, it is not possible to eliminate the displacement. The bone deformity does not significantly affect the function of the hand, only a small cosmetic defect remains. To effectively eliminate the displacement of fragments, closed reposition and osteosynthesis with two intersecting Kirschner wires or transfixation with wires to the adjacent metacarpal bone are used. This method allows you to start early movements and avoid stiffness in the joints of the hand. The pins can be removed 4 weeks after the operation.

Fractures of the diaphysis of the metacarpal bones are accompanied by a significant displacement of fragments and are unstable. With the direct action of the force, as a rule, transverse fractures occur, with an indirect one - oblique. The displacement of fragments leads to the following deformations: the formation of an angle open to the palm (Fig. 21)

Fig.21 The mechanism of displacement of fragments in a fracture of the metacarpal bone.

Shortening of the metacarpal bone, hyperextension in the metacarpophalangeal joint due to the action of the extensor tendons, flexion in the interphalangeal joints caused by the displacement of the interosseous muscles, which, due to the shortening of the metacarpal bones, are no longer able to perform the extension function. Conservative treatment in a plaster splint does not always eliminate the displacement of fragments. In transverse fractures, transfixation with pins to the adjacent metacarpal bone or intramedullary pinning with a pin is most effective (Fig. 22)

Fig.22 Types of osteosynthesis of the metacarpal bone: 1-wires, 2-plate and screws

In oblique fractures, osteosynthesis is performed with AO miniplates. With these methods of osteosynthesis, additional immobilization is not required. Active movements of the fingers are possible from the first days after the operation after the swelling subsides and the pain syndrome decreases.

Fractures of the base of the metacarpal bones are stable and do not present difficulties for treatment. Immobilization with a dorsal splint, reaching the level of the heads of the metacarpal bones, for three weeks is quite sufficient for the healing of the fracture.

Fractures of the first metacarpal.

The peculiarity of the function of the first finger explains its special position. Most fractures of the first metacarpal are basal fractures. By Green D.P. these fractures can be divided into 4 types, and only two of them (Bennett's fracture-dislocation and Rolando's fracture) are intra-articular (Fig. 23)

Rice. 23 Classification of fractures of the base of the first metacarpal bone: 1 - Bennet's fracture, 2 - Rolando's fracture, 3,4 - extra-articular fractures of the base of the first metacarpal.

To understand the mechanism of damage, it is necessary to consider the anatomy of the first carpometacarpal joint. The first carpometacarpal joint is a saddle joint formed by the base of the first metacarpal bone and the trapezoid bone. Four main ligaments are involved in stabilizing the joint: anterior oblique, posterior oblique, intermetacarpal, and dorsal-radius. (Fig. 24)

Fig.24 Anatomy of the first metacarpophalangeal joint

The volar part of the base of the first metacarpal is somewhat elongated and is the site of attachment of the anterior oblique ligament, which is the key to joint stability.

For the best visualization of the joint, an x-ray is needed in the so-called "true" anteroposterior projection (Robert projection), when the hand is in the position of maximum pronation (Fig. 25)

Fig.25 Projection of Robert

Treatment.

Bennett fracture-dislocation is the result of direct trauma to the semi-flexed metacarpal. At the same time, it happens
dislocation, and a small triangular palmar bone fragment remains in place due to the strength of the anterior oblique ligament. The metacarpal bone is displaced to the radial side and to the rear due to the pull of the long abductor muscle (Fig. 26).

Fig. 26 Bennett fracture-dislocation mechanism

The most reliable method of treatment is closed reposition and percutaneous fixation with Kirschner wires to the second metacarpal or to the trapezius or trapezoid bone (Fig. 27)

Fig. 27 Osteosynthesis with Kirschner wires.

For reposition, finger traction is performed, abduction and opposition of the first metacarpal bone, at the moment of which pressure is applied to the base of the bone and reposition. In this position, the introduction of the spokes is carried out. After the operation, immobilization is performed in a plaster splint for a period of 4 weeks, after which the splint and wires are removed, and rehabilitation begins. In case of impossibility of closed reduction, resort to open reposition, after which osteosynthesis of both Kirschnen wires and thin 2 mm AO screws is possible.

Rolando's fracture is a T- or Y-shaped intra-articular fracture and can be classified as multi-comminuted fractures. The prognosis for recovery of function in this type of damage is usually unfavorable. In the presence of large fragments, open reposition and osteosynthesis with screws or wires are indicated. To preserve the length of the metacarpal bone in combination with internal fixation, external fixation devices or transfixation to the second metacarpal bone are used. In case of compression of the base of the metacarpal bone, primary bone grafting is necessary. If it is impossible to surgically restore the congruence of the articular surfaces, as well as in elderly patients, a functional method of treatment is indicated: immobilization for a minimum period to subside pain, and then early active movements.

Extra-articular fractures of the third type are the most rare fractures of the first metacarpal bone. Such fractures are perfectly amenable to conservative treatment - immobilization in a plaster splint in the position of hyperextension in the metacarpophalangeal joint for 4 weeks. Oblique fractures with a long fracture line may be unstable and require percutaneous pin fixation. Opening reposition for these fractures is extremely rare.

Fractures of the scaphoid

Navicular fractures account for up to 70% of all carpal fractures. They come when falling on an outstretched hand from overextension. According to Russe, horizontal, transverse and oblique fractures of the navicular bone are distinguished. (fig28)

Recognizing these fractures can be quite difficult. Important is local tenderness when pressing into the area of ​​the anatomical snuffbox, pain during dorsiflexion of the hand, as well as radiography in direct projection with some supination and ulnar abduction of the hand.

Conservative treatment.

It is indicated for fractures without displacement of fragments. Plaster immobilization in a bandage covering the thumb for 3-6 months. The cast is changed every 4-5 weeks. To assess the consolidation, it is necessary to carry out staged radiographic studies, and in some cases MRI (Fig. 29).

Fig. 29 1- MRI picture of a fracture of the navicular bone,2- immobilization for fractures of the navicular bone

Operative treatment.

Open reduction and screw fixation.

The navicular bone is opened from the access along the palmar surface. Then a guide pin is passed through it, along which a screw is inserted. The most commonly used screw is Herbert, Acutrak, AO. After osteosynthesis, plaster immobilization for 7 days. (Fig. 30)

Fig. 30 Osteosynthesis of the navicular bone with a screw

Nonunion of the scaphoid.

In case of nonunion of the navicular bone, bone grafting according to Matti-Russe is used. According to this technique, a groove is formed in the fragments into which the spongy bone taken from the iliac crest or from the distal radius (D.P. Green) is placed (Fig. 31). Plaster immobilization 4-6 months.

Fig. 31 Bone grafting with nonunion of the navicular bone.

Screw fixation with or without bone grafting can also be used.

Damage to the small joints of the hand.

Damage to the distal interphalangeal joint.

Dislocations of the nail phalanx are quite rare and, as a rule, occur in the back. More often, dislocations of the nail phalanx are accompanied by avulsion fractures of the places of attachment of the tendons of the deep flexor or extensor of the finger. In recent cases, open reduction is performed. After reduction, lateral stability is checked and a test for hyperextension of the nail phalanx. In the absence of stability, transarticular fixation of the nail phalanx is performed with a pin for a period of 3 weeks, after which the pin is removed. In cases where more than three weeks have passed since the injury, it is necessary to resort to open reduction, followed by transarticular fixation with a pin.

Damage to the proximal interphalangeal joint.

The proximal interphalangeal joint occupies a special place among the small joints of the hand. Even in the absence of movements in the remaining joints of the finger, with preserved movements in the proximal interphalangeal joint, the function of the hand remains satisfactory. When treating patients, it should be taken into account that the proximal interphalangeal joint is prone to stiffness not only in case of injuries, but also during prolonged immobilization of even a healthy joint.

Anatomy.

The proximal interphalangeal joints are blocky in shape and are strengthened by the collateral ligaments and the palmar ligament.

Treatment.

Damage to collateral ligaments.

Injury to the collateral ligaments results from the application of lateral force to an extended finger, which is most commonly seen in sports. The radial radial ligament is injured more often than the ulnar ligament. Collateral ligament injuries diagnosed 6 weeks after injury should be considered chronic. To make a diagnosis, it is important to check lateral stability and perform a stress x-ray. When evaluating the results of these tests, it is necessary to focus on the volume of lateral movements of healthy fingers. To treat this type of injury, the elastic splinting method is used: the injured finger is fixed to the adjacent one for 3 weeks with a partial rupture of the ligament and for 4-6 weeks with a complete rupture, then sparing the finger is recommended for another 3 weeks (for example, exclusion of sports loads). (Fig. 32)

Fig. 32 Elastic splinting for collateral ligament injuries

During the period of immobilization, active movements in the joints of the injured finger are not only not contraindicated, but absolutely necessary. In the treatment of this group of patients, the following facts must be taken into account: the full range of motion is restored in the vast majority of cases, while pain persists for many months, and an increase in the joint in volume in a number of patients throughout life.

Dislocations of the middle phalanx.

There are three main types of dislocations of the middle phalanx: dorsal, palmar and rotational (rotary). For diagnosis, it is important to take x-rays of each injured finger separately in direct and strictly lateral projections, since oblique projections are less informative (Fig. 33)

Fig. 33 Radiography with dorsal dislocations of the middle phalanx.

The most common type of injury is dorsal dislocation. It is easy to eliminate, often done by the patients themselves. For treatment, elastic splinting is sufficient for 3-6 weeks.

With a palmar dislocation, damage to the central portion of the extensor tendon is possible, which can lead to the formation of a boutonniere deformity (Fig. 34)

Fig. 34 Boutonniere deformity of the finger

To prevent this complication, a dorsal splint is used, fixing only the proximal interphalangeal joint for 6 weeks. During the period of immobilization, passive movements are made in the distal interphalangeal joint (Fig. 35)

Fig. 35 Prevention of boutonniere deformity

Rotational subluxation is easily confused with palmar. On a strictly lateral radiograph of the finger, you can see a lateral projection of only one of the phalanges and an oblique projection of the other (Fig. 36)

Fig.36 Rotational dislocation of the middle phalanx.

The reason for this injury is that the condyle of the head of the proximal phalanx is caught in a loop formed by the central and lateral portions of the extensor tendon, which is intact (Figure 37).

Fig. 37 rotational dislocation mechanism

Reduction is performed according to the Eaton method: after anesthesia, the finger is flexed in the metacarpophalangeal and proximal interphalangeal joints, and then, careful rotation of the main phalanx (Fig. 38)

Fig. 38 Reduction of rotator dislocation according to Eaton

In most cases, closed reduction is not effective and an open reduction must be resorted to. After reduction, elastic splinting and early active movements are performed.

Fracture-dislocation of the middle phalanx.

As a rule, a fracture of the palmar fragment of the articular surface occurs. This joint-destroying injury is successfully treated if diagnosed early. The simplest, non-invasive and effective method of treatment is the use of a dorsal extensor blocking splint (Fig. 39), which is applied after reduction of the dislocation and allows active flexion of the finger. Full reduction requires flexion of the finger at the proximal interphalangeal joint. Reduction is assessed by a lateral radiograph: the adequacy of reduction is assessed by the congruence of the intact dorsal part of the articular surface of the middle phalanx and the head of the proximal phalanx. The so-called V-sign proposed by Terri Light (Fig. 40) helps in assessing the radiograph.

Fig. 39 Dorsal extensor blocking splint.

Fig.40 V-sign to assess the congruence of the articular surface.

The splint is applied for 4 weeks, it is extended weekly by 10-15 degrees.

Damage to the metacarpophalangeal joints.

Anatomy.

The metacarpophalangeal joints are condylar joints that allow, along with flexion and extension, adduction, abduction and circular movements. The stability of the joint is provided by the collateral ligaments and the palmar plate, which together form a box shape (Figure 41)

Fig. 41 Ligament apparatus of the metacarpophalangeal joints

Collateral ligaments consist of two bundles - own and additional. The collateral ligaments are more taut in flexion than in extension. Palmar plates of 2-5 fingers are interconnected by a deep transverse metacarpal ligament

Treatment.

There are two types of dislocation of the fingers: simple and complex (irreducible). For the differential diagnosis of dislocations, it is necessary to remember the following signs of a complex dislocation: on the radiograph, the axis of the main phalanx and metacarpal bone are parallel, the location of sesamoid bones in the joint is possible, and there is a deepening of the skin on the palmar surface of the hand at the base of the finger. A simple dislocation is easily corrected by gentle pressure on the proximal phalanx, and traction is not required. Elimination of complex dislocation is possible only surgically.

Damage to the nail bed.

The nail gives the distal phalanx firmness during grip, protects the fingertip from injury, plays an important role in the implementation of the function of touch and in the perception of the aesthetic appearance of a person. Nail bed injuries are among the most common injuries of the hand and accompany open fractures of the distal phalanx and injuries of the soft tissues of the fingers.

Anatomy.

The nail bed is the layer of dermis that lies beneath the nail plate.

Rice. 42 Anatomical structure of the nail bed

There are three main zones of tissues located around the nail plate. The nail fold (the roof of the matrix), covered with an epithelial lining - the eponychium, prevents the uncontrolled growth of the nail up and to the sides, directing it distally. In the proximal third of the nail bed is the so-called germinal matrix, which ensures the growth of the nail. The growing part of the nail is delimited by a white crescent - a hole. If this zone is damaged, the growth and shape of the nail plate are significantly impaired. Distal to the socket is a sterile matrix that adheres tightly to the periosteum of the distal phalanx, which ensures the advancement of the nail plate during its growth and, thus, plays a role in the formation of the shape and size of the nail. Damage to the sterile matrix is ​​accompanied by deformation of the nail plate.

The nail grows at an average rate of 3-4 mm per month. After the injury, the advancement of the nail in the distal direction stops for 3 weeks, and then the growth of the nail continues at the same rate. As a result of the delay, a thickening is formed proximal to the injury site, which persists for 2 months and gradually becomes thinner. It takes about 4 months before a normal nail plate forms after an injury.

Treatment.

The most common injury is a subungual hematoma, which is clinically manifested by the accumulation of blood under the nail plate and is often accompanied by a pronounced pain syndrome of a pulsating nature. The method of treatment is the perforation of the nail plate at the site of the hematoma with a sharp instrument or the end of a paper clip heated on fire. This manipulation is painless and instantly relieves tension and, as a result, pain syndrome. After evacuation of the hematoma, an aseptic bandage is applied to the finger.

When part or all of the nail plate is torn off without damaging the nail bed, the separated plate is processed and put in place, fixing with a seam. (Fig. 43)

Fig.43 Refixation of the nail plate

The nail plate is a natural splint for the distal phalanx, a conduit for the growth of a new nail, and ensures that the nail bed heals to form a smooth surface. If the nail plate is lost, then it can be replaced with an artificial nail made of a thin polymer plate, which will ensure painless dressings in the future.

Wounds of the nail bed are the most complex injuries, leading in the long term to a significant deformation of the nail plate. Such wounds are subject to careful primary surgical treatment with minimal excision of soft tissues, accurate matching of fragments of the nail bed and suture with its thin (7\0, 8\0) suture material. The removed nail plate is refixed after treatment. In the postoperative period, immobilization of the phalanx is required for 3-4 weeks to prevent its traumatization.

Tendon injuries.

The choice of the method of tendon reconstruction is made taking into account the time elapsed since the injury, the prevalence of cicatricial changes along the course of the tendons, the condition of the skin at the site of the operation. The tendon suture is indicated if it is possible to connect the damaged tendon end-to-end, in the normal state of the soft tissues in the area of ​​operation. There is a primary tendon suture, performed within 10-12 days after the injury in the absence of signs of infection in the wound area and its incised nature, and a delayed suture, which is applied from 12 days to 6 weeks after the injury under less favorable conditions (torn-bruised wounds). In many cases, later suturing is not possible due to muscle retraction and significant diastasis between the ends of the tendon. All types of tendon sutures can be divided into two main groups - removable and submersible (Fig. 44).

Fig. 44 Types of tendon sutures (a - Bunnell, b - Verdun, c - Cuneo) d - intratruncal suture, e, f - adaptive sutures. Stages of suturing in the critical zone.

Removable sutures, proposed in 1944 by Bunnell S., are used to fix the tendon to the bone and in areas where early movement is not so necessary. The suture thread is removed after the tendon is sufficiently firmly fused with the tissues at the point of fixation. The dip sutures remain in the tissues, carrying the mechanical load. In some cases, additional sutures are used to provide a better alignment of the ends of the tendons. In chronic cases, as well as with a primary defect, tendon plasty (tendoplasty) is indicated. The source of the tendon autograft is tendons, the taking of which does not cause significant functional and cosmetic disorders, for example, the tendon of the long palmar muscle, superficial flexor fingers, long extensor toes, plantar muscle.

Finger flexor tendon injury.

Anatomy.

Flexion of 2-5 fingers is carried out due to two long tendons - superficial, attached to the base of the middle phalanx and deep, attached to the base of the distal phalanx. Flexion of 1 finger is carried out due to the tendon of the long flexor of 1 finger. The flexor tendons are located in narrow, complex bone-fibrous canals that change their shape depending on the position of the finger (Fig. 45).

Fig. 45 Change in the shape of the bone-fibrous canals of 2-5 fingers of the hand when they are bent

In places of greatest friction between the palmar wall of the canals and the surface of the tendons, the latter are surrounded by a synovial membrane that forms the sheaths. The tendons of the deep flexors of the fingers are connected by means of the worm-like muscles with the extensor tendon apparatus.

Diagnostics.

If the tendon of the deep flexor of the finger is damaged with a fixed middle phalanx, flexion of the nail is impossible, with combined damage to both tendons, flexion of the middle phalanx is also impossible.

Rice. 46 Diagnosis of flexor tendon injuries (1, 3 - deep, 2, 4 - both)

Flexion of the main phalanx is possible due to the contraction of the interosseous and vermiform muscles.

Treatment.

There are five zones of the hand, within which the features of the anatomy affect the technique and results of the primary suture of the tendons.

Fig.47 Brush zones

In zone 1, only the deep flexor tendon passes in the bone-fibrous canal, so its damage is always isolated. The tendon has a small range of motion, the central end is often held by mesotenon and can be easily removed without significant expansion of the damaged area. All these factors determine the good result of the imposition of the primary tendon suture. The most commonly used transosseous tendon suture is removed. Dip welds may be used.

Over the course of zone 2, the tendons of the superficial and deep flexors of the fingers cross over, the tendons are tightly adjacent to each other, and have a large range of motion. The results of the tendon suture are often unsatisfactory due to cicatricial adhesions between the sliding surfaces. This zone was called the critical or "no man's zone".

Due to the narrowness of the bone-fibrous canals, it is not always possible to suture both tendons; in some cases, it is necessary to excise the tendon of the superficial flexor of the finger and suture only the tendon of the deep flexor. In most cases, this avoids contractures of the fingers and does not significantly affect the function of flexion.

In zone 3, the flexor tendons of neighboring fingers are separated by neurovascular bundles and worm-like muscles. Therefore, tendon injuries in this area are often accompanied by damage to these structures. After the suture of the tendon, the suture of the digital nerves is necessary.

Within zone 4, the flexor tendons are located in the carpal tunnel along with the median nerve, which is located superficially. Tendon injuries in this area are quite rare and are almost always associated with damage to the median nerve. The operation involves the dissection of the transverse ligament of the wrist, the suture of the tendons of the deep flexors of the fingers, the tendons of the superficial flexors are excised.

Over the course of zone 5, the synovial sheaths end, the tendons of adjacent fingers pass close to each other and, when the hand is clenched into a fist, are displaced together. Therefore, cicatricial fusion of tendons with each other practically does not affect the volume of flexion of the fingers. The results of the tendon suture in this area are usually good.

Postoperative management.

The finger is immobilized with the help of a back plaster splint for a period of 3 weeks. From the second week after the edema subsides and the pain syndrome in the wound decreases, passive flexion of the finger is performed. After removing the plaster splint, active movements begin.

Injuries to the extensor tendons of the fingers.

Anatomy.

In the formation of the extensor apparatus, the tendon of the common extensor of the finger and the tendons of the interosseous and vermiform muscles, connected by many lateral ligaments, form a tendon-aponeurotic stretch (Fig. 48,49)

Fig.48 The structure of the extensor apparatus of the hand: 1 - Triangular ligament, 2 - the place of attachment of the extensor tendon, 3 - lateral connection of the collateral ligament, 4 - disk over the middle joint, 5 - spiral fibers, 5 - middle bundle of the long extensor tendon, 7 - lateral long extensor tendon bundle, 8 - attachment of the long extensor tendon on the main phalanx, 9 - disk above the main joint, 10 and 12 - long extensor tendon, 11 - worm-like muscles, 13 - interosseous muscles.

Rice. 49 Extensors of fingers and hands.

It must be remembered that the index finger and little finger, in addition to the common one, also have the tendon of their own extensor. The middle bundles of the extensor tendon of the fingers are attached to the base of the middle phalanx, unbending it, and the lateral bundles are connected to the tendons of the small muscles of the hand, attached to the base of the nail phalanx and perform the function of extending the latter. The extensor aponeurosis at the level of the metacarpophalangeal and proximal interphalangeal joints forms a fibrocartilaginous disc similar to the patella. The function of the small muscles of the hand depends on the stabilization of the main phalanx by the extensor of the finger. When the main phalanx is bent, they act as flexors, and when extended, together with the extensor of the fingers, they become extensors of the distal and middle phalanges.

Thus, one can speak of a perfect extensor-flexion function of the finger only with the integrity of all anatomical structures. The presence of such a complex interconnectedness of elements to some extent favors the spontaneous healing of partial injuries of the extensor apparatus. In addition, the presence of lateral ligaments of the extensor surface of the finger prevents the tendon from contracting when injured.

Diagnostics.

The characteristic position that the finger takes depending on the level of damage allows you to quickly make a diagnosis (Fig. 50).

Fig. 50 Diagnosis of damage to the extensor tendons

extensor at the level of the distal phalanx, the finger assumes a flexion position in the distal interphalangeal joint. This deformity is called the mallet finger. In most cases of fresh injuries, conservative treatment is effective. To do this, the finger must be fixed in a position overextended in the distal interphalangeal joint using a special splint. The amount of hyperextension depends on the level of mobility of the patient's joints and should not cause discomfort. The remaining joints of the finger and hand must be left free. The term of immobilization leaves 6-8 weeks. However, the use of tires requires constant monitoring of the position of the finger, the state of the elements of the splint, as well as the patient's understanding of the task facing him, therefore, in some cases, transarticular fixation of the nail phalanx with a pin for the same period is possible. Surgical treatment is indicated when the tendon is torn from its attachment site with a significant bone fragment. In this case, a transosseous suture of the extensor tendon is performed with fixation of the bone fragment.

When the extensor tendons are damaged at the level of the middle phalanx, the triangular ligament is simultaneously damaged, and the lateral tendon bundles diverge in the palmar direction. Thus, they do not unbend, but bend the middle phalanx. In this case, the head of the main phalanx moves forward through a gap in the extensor apparatus, like a button passing through a loop. The finger assumes a position bent at the proximal interphalangeal joint and overbent at the distal interphalangeal joint. This deformation is called "boutonniere". With this type of injury, surgical treatment is necessary - stitching together the damaged elements, followed by immobilization for 6-8 weeks.

Treatment of injuries at the level of the main phalanx, metacarpophalangeal joints, metacarpus and wrist is only surgical - the primary suture of the tendon, followed by immobilization of the hand in the extension position in the wrist and metacarpophalangeal joints and slight flexion in the interphalangeal joints for a period of 4 weeks, followed by the development of movements.

Damage to the nerves of the hand.

The innervation of the hand is provided by three main nerves - the median, ulnar and radial. In most cases, the main sensory nerve of the hand is the median, and the main motor nerve is the ulnar, which innervates the muscles of the little finger elevation, interosseous, 3 and 4 worm-like muscles and the muscle that adducts the thumb. Of great clinical importance is the motor branch of the median nerve, which departs from its lateral cutaneous branch immediately after exiting the carpal tunnel. This branch innervates the short flexor of the 1st finger, as well as the short abductor and opposing muscles of Many. the muscles of the hand have a double innervation, which preserves to some extent the function of these muscles when one of the nerve trunks is damaged. The superficial branch of the radial nerve is the least significant, providing sensation on the dorsum of the hand. If both digital nerves are damaged due to loss of sensitivity, the patient cannot use his fingers, their atrophy occurs.

The diagnosis of nerve damage should be made before surgery, as this is not possible after anesthesia.

Suturing the nerves of the hand requires the use of microsurgical techniques and adequate suture material (thread 6\0-8\0). In the case of fresh injuries, soft and bone tissues are first processed, after which they proceed to the suture of the nerve (Fig. 51)

Fig.51 Epineural nerve suture

The limb is fixed in a position that provides the least tension on the suture line for 3-4 weeks.

Soft tissue defects of the hand.

The normal function of the hand is possible only with the integrity of its skin. Each scar creates an obstacle to its implementation. The skin in the scar area has reduced sensitivity and is easily damaged. Therefore, one of the most important tasks of hand surgery is to prevent scarring. This is achieved by placing a primary suture on the skin. If, due to a skin defect, the imposition of a primary suture is impossible, then its plastic replacement is necessary.

With superficial defects, the bottom of the wound is represented by well-perfused tissues - subcutaneous adipose tissue, muscle or fascia. In these cases, transplantation of non-perfused skin grafts gives good results. Depending on the size and localization of the defect, split or full-thickness flaps are used. The necessary conditions for successful engraftment of the flap are: good blood supply to the bottom of the wound, the absence of infection and tight contact of the graft with the receiving bed, which is ensured by the application of a pressure bandage (Fig. 52)

Figure 52 Steps for applying a pressure bandage

The bandage is removed on the 10th day.

Unlike superficial defects, with deep wounds, tissues with a relatively low level of blood supply are tissues with a relatively low level of blood supply - tendons, bones, joint capsule. For this reason, the use of non-perfused flaps in these cases is ineffective.

The most common damage is tissue defects of the nail phalanx. There are many methods for closing them with blood-supplied flaps. In case of detachment of the distal half of the nail phalanx, plasty with triangular sliding flaps, which are formed on the palmar or lateral surfaces of the finger, is effective (Fig. 53)

Fig. 53 Plasty with a triangular sliding flap for a defect in the skin of the nail phalanx

Fig.54 Plasty with a palmar finger sliding flap

Triangular areas of the skin are connected to the finger by a leg, consisting of fatty tissue. If the soft tissue defect is more extensive, then a palmar finger sliding flap is used (Fig. 54)

For defects in the pulp of the nail phalanx, cross-flaps from the neighboring longer finger (Fig. 55), as well as a skin-fat flap of the palmar surface of the hand, are widely used.

Fig.55 Plastic surgery using a skin-fat flap from the palmar surface of the hand.

The most severe type of hand tissue defect occurs when the skin is removed from the fingers like a glove. In this case, the skeleton and tendon apparatus can be completely preserved. For the injured finger, a tubular pedicled flap is formed (Filatov's sharp stalk), while skeletonizing the entire hand, plastic surgery is performed with skin-fat flaps from the anterior abdominal wall (Fig. 56).

Fig. 56 Plastic surgery of a scalped wound of the middle phalanx with a “sharp” Filatov’s stalk

Tendon canal stenoses.

The pathogenesis of degenerative-inflammatory diseases of the tendon canals is not fully understood. Women 30-50 years old are more often ill. The predisposing factor is static and dynamic hand overload.

De Quervain's disease

1 bone-fibrous canal and the tendons of the long abductor thumb muscle and its short extensor are affected.

The disease is characterized by pain in the region of the styloid process, the presence of a painful induration on it, a positive Finkelstein symptom: acute pain in the region of the styloid process of the radius, which occurs during ulnar abduction of the hand, with 1 finger previously bent and fixed. (Fig. 57)

Fig. 57 Finkelstein's symptom

X-ray examination allows to exclude other diseases of the wrist joint, as well as to identify local osteoporosis of the apex of the styloid process and thickening of the soft tissues above it.

Treatment.

Conservative therapy involves local administration of steroid drugs and immobilization.

Surgical treatment is aimed at decompression of the 1st canal by dissecting its roof.

After anesthesia, a skin incision is made over the painful induration. Immediately under the skin is the dorsal branch of the radial nerve, it must be carefully taken to the rear. Making passive movements with the thumb, 1 canal and the site of stenosis are examined. Further along the probe, the dorsal ligament is carefully dissected and partially excised. After that, the tendons are exposed and examined, you should make sure that nothing prevents them from sliding. The operation ends with careful hemostasis and wound closure.

Stenosing ligamentitis of the annular ligaments.

The annular ligaments of the tendinous sheaths of the flexors of the fingers are formed by a thickening of the fibrous membrane and are located at the level of the diaphysis of the proximal and middle phalanges, as well as above the metacarpophalangeal joints.

It is still not clear what is affected primarily - the annular ligament or the tendon passing through it. In any case, the slip of the tendon through the annular ligament is difficult, which leads to the “snapping” of the finger.

Diagnosis is not difficult. Patients themselves show a “snapping finger”, a painful induration is palpated at the level of infringement.

Surgical treatment gives a quick and good effect.

The incision is carried out according to the rules described in the section “accesses to the brushes”. A thickened annular ligament is exposed. The latter is dissected along a grooved probe, and its thickened part is excised. Flexion and extension of the finger assesses the freedom of sliding of the tendon. In chronic processes, an additional opening of the tendon sheath may be required.

Dupuytren's contracture.

Dupuytren's contracture (disease) develops as a result of cicatricial degeneration of the palmar aponeurosis with the formation of dense subcutaneous cords.

Predominantly men (5% of the population) of the elderly suffer.

Diagnosis is usually not difficult. The disease usually develops over several years. Painless cords are formed, dense on palpation and causing limitation of active and passive extension of the fingers. Fingers 4 and 5 are most often affected, both hands are often affected. (fig.58)

Fig.58 Dupuytren's contracture 4 fingers of the right hand.

Etiology and pathogenesis.

Not exactly known. The main theories are traumatic, hereditary. There is a connection with the growth of endothelial cells of the vessels of the palmar aponeurosis and a decrease in the oxygen content, which leads to the activation of fibroplastic processes.

Often associated with Ledderhose's disease (cicatricial change of the plantar aponeurosis) and fibroplastic induration of the penis (Peyronie's disease).

Anatomy of the palmar aponeurosis.

1.m. palmaris brevis.2.m. palmaris longus.3. volar carpal ligament communis.4. volar carpal ligament proprius.5. Palmar aponeurosis.6. Tendon of palmar aponeurosis.7. Transverse palmar ligament.8. vaginae and ligaments of mm. flexor muscles.9. tendon of m. flexor carpi ulnaris.10. tendon of m. flexor carpi radialis.

The palmar aponeurosis has the shape of a triangle, the apex of which is directed proximally, the tendon of the long palmar muscle is woven into it. The base of the triangle breaks up into bundles going to each finger, which intersect with transverse bundles. The palmar aponeurosis is closely connected with the skeleton of the hand, separated from the skin by a thin layer of subcutaneous fatty tissue.

Classification.

Depending on the severity of clinical manifestations, 4 degrees of Dupuytren's contracture are distinguished:

Grade 1 - characterized by the presence of a seal under the skin, which does not limit the extension of the fingers. At this degree, patients tend to mistake this seal for "namin" and rarely go to the doctor.

2 degree. With this degree, there is a limitation of finger extension up to 30 0

3 degree. Extension limitation from 30 0 to 90 0 .

4 degree. The extension deficit exceeds 90 0 .

Treatment.

Conservative therapy is ineffective and can only be recommended for the first degree and as a stage of preoperative preparation.

The main treatment for Dupuytren's contracture is surgery.

A large number of operations have been proposed for this disease. The following are of primary importance:

Aponeurectomy- excision of the cicatricial altered palmar aponeurosis. It is made from several transverse cuts, which are made according to the rules described in the section “cuts on the brush”. The strands of the altered palmar aponeurosis are isolated and excised subcutaneously. This can damage the common digital nerves, so this step must be performed with extreme care. As the aponeurosis is excised, the finger is gradually removed from the flexion position. The skin is sutured without tension and a pressure bandage is applied, which will prevent the formation of a hematoma. A few days after the operation, they begin to bring the fingers into the extension position using dynamic splints.