Pathologies in children: chest deformity. Malformations of the chest and organs of the chest cavity Congenital malformations of the chest
Congenital malformations of the chest occur in about 1 in 1,000 children. Most often, in 90% of cases in relation to all types of defects, funnel chest deformity (PEH) is detected. Among the more rare forms, keeled deformity, various anomalies in the development of the ribs, splitting of the sternum and combined variants should be distinguished.
The reasons for the formation of these defects have not been fully elucidated. There is no doubt that they are congenital dysplasia or aplasia of the cartilage, less often of the bone part of the chest. Morphological studies of the connective tissue revealed a violation of its structure. The change in the structure of the connective tissue, in turn, is associated with a violation of metabolic processes.
The hereditary factor is of great importance. According to many authors, up to 20% of children with chest deformity have relatives with a similar pathology. To date, a large number of syndromes have been described in which one of the constituent components is anomalies of the sternocostal complex. Marfan's syndrome is the most common. In this syndrome, against the background of connective tissue dysembryogenesis, asthenic structure, arachnodactyly, subluxation and dislocation of the lenses, dissecting aortic aneurysm, funnel-shaped and keeled deformity of the chest, clear biochemical changes in the metabolism of collagen, glycosaminoglycans are noted.
Knowledge of the signs of syndromes and their identification are important in terms of determining tactics and prospects for treatment. So, with the Ehlers-Danlos syndrome (fourth ecchymotic form), in addition to bone and cartilage pathology, there are violations of the structure of the vessel wall. During surgical treatment, complications associated with increased bleeding are possible. If a child has various kinds of osteochondral deformities, it is advisable to consult a geneticist.
Funnel chest deformity
External signs of funnel chest deformity are characterized by retraction of the sternum and the adjacent part of the ribs. The costal arches are somewhat deployed, the epigastric region bulges:
Funnel chest deformity in a 4-year-old child
Clinic and diagnostics. As a rule, the deformity is determined immediately after birth, with a characteristic symptom of the paradox of inspiration (retraction of the ribs and sternum during inspiration). In about half of the patients, as they grow, the deformity progresses and becomes fixed by the age of 3-5 years. Deformation may appear at a later date - usually during the period of accelerated growth of the child. It is noted that the most profound forms of deformation appear early. Deformations that occur during puberty are rarely pronounced.
When examining a child, it is possible to identify stigmas characteristic of a particular syndrome (increased joint mobility, flat back, reduced tissue turgor, poor vision, gothic sky, etc.).
Along with the inspection data, radiographic and functional research methods are important. An X-ray in direct projection reveals the degree of displacement of the heart (usually to the left), which indirectly makes it possible to judge the effect of deformation on heart function. With the help of a lateral radiograph, the depth of the depression of the sternum is determined, the thoracovertebral index or the Gizhitskaya index (IG) (1962) is measured.
a) by degree - I degree IG = 1-0.7; II degree IG = 0.7-0.5; III degree IG less than 0.5,
b) in shape - symmetrical, asymmetrical, flat.
Functional changes in external respiration and hemodynamics are detected with severe deformities and directly depend on its degree. Disturbances in external respiration are manifested by a decrease in maximum ventilation of the lungs, an increase in the minute volume of breathing and an indicator of oxygen consumption per minute. The coefficient of oxygen use is reduced. ECG changes are noted. However, the most informative study of the heart is echocardiography, which allows to clarify the morphological changes in the heart. This is important due to the fact that with funnel chest deformity, especially with syndromic pathology, mitral valve prolapse is common.
Treatment. There are no conservative treatments for pectus excavatum.
indications for surgery. Indications for surgery are determined on the basis of the degree and shape of pectus excavatum. Thoracoplasty is unconditionally indicated for pectus excavatum III degree and is indicated for VDKK II degree. With funnel chest deformity of the 1st degree (with the exception of flat forms), thoracoplasty, as a rule, is not performed. [Urmonas V.K., Kondrashin N.I., 1983]. The optimal age for the operation is 5 years. With great care, one should approach surgical treatment in children with syndromic forms of deformity. Only after a comprehensive examination and in the absence of contraindications can surgery be recommended.
Recently, the Paltia method has been most widely used. The operation consists in subperichondral excision of the curved costal cartilages, transverse wedge-shaped sternotomy and fixation of the sternum in the corrected position with a metal plate.
The results of surgical correction of pectus excavatum are good (according to different authors, in 80-95% of cases). Relapses occur with insufficient fixation of the sternum and more often in children with syndromal forms operated on at an early stage.
Keeled deformity of the chest
Keeled deformity of the chest, as well as funnel-shaped, is a malformation. Often there is a hereditary transmission of the defect, which can be an integral component of one of the syndromes.
Clinic and diagnostics. The deformity is usually detected at birth and increases with age. The sternum protruding forward and the ribs sinking along its edges give the chest a characteristic keeled shape. Deformation can be symmetrical or asymmetric. With an asymmetric shape, the cartilaginous sections of the ribs lift the sternum on one side, and it curves along the axis. There are combined forms, when the upper third of the sternum is raised, and the lower part with the xiphoid process falls sharply. At the same time, pairing of the IV and V ribs was noticed, and the IV rib is located above the V rib at the place of intersection with the sternum.
Functional disorders, as a rule, are not detected. With syndromic forms and with a pronounced decrease in the volume of the chest, there may be complaints of fatigue, shortness of breath, and palpitations during exercise. However, in most cases, children and their parents are concerned about a cosmetic defect.
Treatment. Indications for surgery occur mainly in children older than 5 years with a pronounced cosmetic defect. Several methods of surgical interventions have been proposed, based on subperichondral resection of the parasternal part of the ribs, transverse sternotomy, and cutting off the xiphoid process. Fixation of the sternum in the correct position is carried out by stitching the sternum with the perichondrium and the remaining ends of the ribs. The results of surgical treatment of keeled deformity are good.
Rib anomalies
Rib anomalies may include deformation or absence of individual costal cartilages, bifurcation and synostosis of the ribs, deformation of groups of costal cartilages, absence or wide divergence of the ribs.
A bifurcation of the thoracic ribs (Luschke's ribs) usually appears as a dense protruding mass next to the sternum. In rare cases, it is necessary to carry out a differential diagnosis with a tumor process. Treatment is required only for significant deformities for cosmetic purposes. It consists in the subchondral removal of deformed cartilage.
Cerebro-costo-mandibular syndrome. Rib defects (absence, bifurcation, pseudoarthrosis, etc.) are combined with non-closure of the upper palate or Gothic palate, hypoplasia of the lower jaw, micrognathia, glossoptosis, and microcephaly. Surgical treatment is indicated in extreme cases with a significant chest wall defect with paradoxical breathing.
Poland's syndrome is always characterized by a unilateral lesion, including aplasia or hypoplasia of the pectoralis major muscle, hypoplasia of the pectoralis minor muscle. It is often accompanied by the absence of part of the underlying costal cartilages and ribs, aplasia or hypoplasia of the nipple, aplasia of the mammary gland in girls, deformity of the arm and hand. Diagnosis is based on external examination. X-rays are used to clarify the condition of the ribs. In the presence of a significant defect with the formation of a pulmonary hernia, a rib defect is repaired using autotransplantation of the ribs from the healthy side. It is possible to use the above- and underlying ribs with their splitting and displacement towards the defect. Some surgeons have successfully used synthetic materials. To replace the missing muscles, a flap or the entire latissimus dorsi is moved. Operations for wide defects with paradoxical breathing are performed at an early age.
The splitting of the sternum is a rare malformation, which consists in the presence of a longitudinal gap located along the midline. The defect can vary in length and width up to complete splitting of the sternum. At the same time, a paradoxical movement of the mediastinal organs is noted, covered at the defect site only with a thinned layer of soft tissues and skin. The pulsation of the heart and large vessels is visible. The defect is detected in early infancy and increases as the child grows. Along with anatomical manifestations, functional disorders are also noted. Respiratory disturbances up to bouts of cyanosis are possible. Children usually lag behind in physical development.
The operation is performed at an early age. It consists in releasing the edges of the defect, which are sutured throughout with interrupted nylon sutures.
When examining children with malformations of the chest, attention should be paid to identifying stigmas of disembryogenesis, such as anomalies in the finger pattern, shortening of the fingers, etc. With medical genetic counseling for sporadic cases of the syndrome, the prognosis for the birth of a healthy child is favorable.
Congenital deformities of the chest depend on malformations of the spine, ribs, and sternum.
1. The absence or nonunion of the sternum is explained by the cessation of the development of the sternum: the rollers from which you form) the sternum, laid symmetrically at the medial ends of the ribs, do not fuse with each other. The ribs in such cases are interconnected by a fibrous plate. The chest may be completely absent, but more often you see) partial underdevelopment of its lower end or handle. The fibrous plate at the site of the sternum with this anomaly follows the respiratory movements, sharply drawn in when inhaling and protruding when exhaling. With age, the fibrous plate becomes denser, its fluctuations decrease. Children with clefts and a complete sternum defect may develop normally.
2. Funnel-shaped chest, in which part of the chest and upper abdominal walls are funnel-shaped deepened. This deformation was called the "shoemaker's chest".
3. Keeled chest, in which, on the contrary, the sternum protrudes anteriorly.
Malformations of the mammary gland
1. Amastia - the complete absence of the mammary glands.
2. Polymastia - an excess of mammary glands.
3. Polytellia - an excessive number of nipples. Additional mammary glands or nipples are usually located along the "milk line", which runs from the axilla, along the anterolateral surface of the chest and abdomen, to the inner thighs.
4. Genikomastiya - unilateral or bilateral enlargement of the mammary gland. In men, this pathology is rare, it is associated with hormonal disorders of the gonads, pituitary gland or adrenal cortex.
congenital diaphragmatic hernia
Diaphragmatic hernia is the protrusion of the abdominal organs into the chest through a hole in the diaphragm. There are three main types of congenital hernia of the diaphragm:
1. Hernia of the diaphragm proper:
True diaphragmatic hernia - the abdominal organs exit through a defect in the diaphragm along with the peritoneum, forming a hernial sac;
False diaphragmatic hernia - there is no hernial sac, and the abdominal organs that have moved into the chest cavity are in contact with the organs of the chest cavity;
2. hernia of the esophageal opening of the diaphragm - the cardia of the stomach or the stomach is completely displaced into the posterior mediastinum;
3. anterior diaphragmatic hernia - occur in the presence of an enlarged sternocostal triangle,
4. in which the abdominal organs are displaced into the pericardial cavity. Heart defects
Heart defects are divided into congenital and acquired. Congenital heart defects include:
1. atrial septal defect;
2. ventricular septal defect, which leads to the discharge of blood into the right ventricle through a defect in the muscular or membranous part of the septum;
3. unclosed ductus arteriosus (ductus arteriosus, Botallov). The ductus arteriosus most often connects the common trunk of the pulmonary artery with the lower semicircle of the aortic arch at the level of the orifice of the left subclavian artery. When it is not closed, part of the oxygenated blood from the aorta enters the pulmonary trunk, then into the lungs. This leads to an overload of the left atrium and ventricle, causing their hypertrophy;
4. coarctation of the aorta. With stenosis of the isthmus of the aorta, hypertension rapidly progresses in the vessels of the upper half of the body and the brain. Patients are at risk of cerebral hemorrhage and other severe consequences of the defect;
5. other defects (isolated stenosis of the pulmonary artery, triad, tetrad and pentad of Fallot, etc.).
Acquired - insufficiency of the aortic and mitral valves. Operations on the chest wall and organs of the chest cavity Operations on the mammary gland.
Classification of purulent mastitis:
1. superficial (premammary) mastitis, located in the peripapillary zone or above the stroma of the gland directly under the skin;
2. intramammary mastitis, located in the lobules of the gland itself;
3. retromammary mastitis, located under the deep sheet of the capsule of the mammary gland to the own fascia of the breast. Incisions for superficial mastitis are carried out paraoreolyarno or in the radial direction, without affecting the halo, dissecting the skin and subcutaneous tissue.
Incisions for intramammary mastitis are made at the site of greatest softening in the radial direction, 6-7 cm long, without affecting the halo.
1. dissection of the skin, subcutaneous tissue, gland tissue;
2. opening of the abscess;
3. destruction of partitions with neighboring abscesses until a single cavity is formed in a blunt way;
4. removal of necrotic tissues;
5. thorough washing of the abscess cavity with an antiseptic solution;
6. drainage (rubber strips are usually used).
To open a retromammary abscess, an incision is made along the lower transitional fold of the mammary gland. The skin and tissue are dissected in layers, the mammary gland is lifted and the pectoralis major muscle is peeled off from the fascia, and the abscess is opened. The abscess cavity is drained.
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Chapter V
BREAST
CHEST ANOMALIES
Congenital deformities of the chest depend on malformations of the spine, ribs and sternum. These deformities must be distinguished from a variety of acquired deformities of the chest.
Less common than others is the absence and non-closure of the sternum. This defect is explained by developmental arrest: the ridges from which the sternum is formed, laid symmetrically at the medial ends of the ribs, do not fuse with each other. The ribs in such cases are interconnected by a fibrous plate. The sternum may be completely absent, but more often there is a partial underdevelopment of its lower end or handle. With malformations of the sternum, an embryonic scar occurs on the skin, which goes down from the sternum along the midline of the abdomen to the navel. In addition, increased pigmentation is sometimes noted along the scar, which we observed in one patient. The fibrous plate at the site of the sternum follows the respiratory movements, sharply retracting when inhaling and protruding when exhaling. The pulsation of the heart is visible to the eye, which may be incorrectly located. With age, the fibrous plate becomes denser and its fluctuations are less. Children with clefts and a complete sternum defect may develop normally.
In addition to defects in the sternum, there is an anomaly called funnel chest, in which part of the chest and upper part of the abdominal wall are funnel-shaped deepened. The recess sometimes reaches large sizes. Previously, such a deformation was called the shoemaker's chest. If rachitic curvature is suspected, one must remember about the congenital funnel-shaped chest, in which there are no complaints from the patient.
In recent years, with a pronounced deformity on the basis of a funnel-shaped chest, a corrective operation has been performed.
Anomalies in the development of the ribs are more common. There are underdevelopment of the ribs, their complete absence, as well as their excessive formation - additional ribs. One or more ribs may be underdeveloped or absent altogether. In the absence of ribs, the ribs adjacent to the defect may be underdeveloped, deformed, and sometimes fused together. At the site of the defect, which goes from the spine to the sternum, the muscles are usually underdeveloped at the same time; when breathing in this place, a protrusion of the lung is visible. With large defects, when there are no 2-3 ribs, at the same time there is an abnormal development of the spine in the form of wedge-shaped vertebrae and scoliosis.
In the absence of ribs, it is necessary to apply active gymnastics and massage of the back muscles as soon as possible to prevent the development of scoliosis and to strengthen the muscles, which should compensate for the bone defect. Wearing a corset in these children is harmful by weakening the muscles. Treatment with gymnastics should be carried out systematically from year to year, following the development of the child.
Additional ribs are usually found in the cervical, occasionally in the lumbar, spine on one or both sides. Accessory ribs in children rarely cause complaints and do not require treatment.
In rare cases, pain may require surgical removal of an additional rib.
CONGENITAL DIAPHRAGMIC HERNIATION
Despite their relative rarity, congenital diaphragmatic hernias are of considerable interest. Diaphragmatic hernia is the protrusion of the abdominal viscera into the chest cavity through a hole in the diaphragm. In children, there are mainly congenital diaphragmatic hernias; acquired traumatic hernias are rare. So, in our clinic, out of 100 diaphragmatic hernias, 91 were congenital and only 9 were acquired.
The development of the diaphragm ends by the end of the second month of embryonic life. The diaphragm is laid in the cranial part of the embryo at the level of the third-fifth cervical segment. On the 4th week, its ventral section develops in the form of a fold, which only partially separates the pericardial cavity from the pleural sacs and the peritoneal cavity. This fold is called the septum transversum, or primitive diaphragm. The dorsal sections of the pleural cavities still communicate with the peritoneal cavity. At the end of the 6th week, folds protrude from the lateral and posterior walls of the body, which gradually move towards the septum transversum, fuse with it and form a chest-abdominal barrier. The side folds are called Uskov's pillars.
The diaphragm developed in this way is at first a connective tissue plate, into which muscles later grow. By the end of the 3rd month, the diaphragm gradually descends and takes its permanent place.
These brief embryological data explain the formation of congenital diaphragmatic hernias.
With the underdevelopment of Uskov's columns, defects are formed, usually located in the dorsal part of the diaphragm, less often in its central part. Depending on the degree of underdevelopment of one or another Uskov column, defects of various sizes and different locations are formed; sometimes the diaphragm is almost completely absent.
Hernia gates in congenital hernias are holes in the diaphragm, formed as a result of its underdevelopment. They can be of various sizes and shapes: either in the form of a slit, or rounded, sometimes very large, to the extent that the entire half of the diaphragm is almost completely absent. In such cases, only along the edge around the hole there is a narrow strip of the diaphragm.
Rice. 108. Typical localization of congenital defects of the diaphragm.
1-defect of the esophageal opening of the diaphragm: 2 - extensive defect of the diaphragm itself on the left; 3 - defect in the anterior part of the diaphragm.
Diaphragmatic hernias are more common on the left.
There are three main types of congenital hernia of the diaphragm: 1) a hernia of the diaphragm itself (its dome), 2) a hernia of the esophageal opening of the diaphragm, and 3) anterior diaphragmatic hernia. According to S. Ya. Doletsky from our clinic, the most common is a hernia of the diaphragm itself (61%), then a hernia of the esophagus (16%), and less often than others - anterior (Fig. 108) (12%); acquired hernias accounted for 9%.
Diaphragmatic hernias are distinguished true and false, depending on the presence of a hernial sac. It depends on the time of stopping the development of the diaphragm; if development is stopped at an early stage, his displaced abdominal organs will be located in direct contact with the lung. In late underdevelopment, the viscera protrude from the abdominal cavity through a defect in the diaphragm and form a hernial sac.
With all types of diaphragmatic hernias, there is some degree of movement of the abdominal organs into the chest, which causes compression of the lung and displacement of the heart. The stomach, omentum, small and large intestines, part of the liver, spleen, and less often the kidney are moved.
With each type of hernia, some symptoms characteristic of this type are observed. The clinical picture in certain forms of diaphragmatic hernia is expressed differently.
Clinic.
In some cases, a number of disorders are observed from the first days of life, in others, on the contrary, the disease is almost asymptomatic and is detected only in subsequent years of life.
One of the first, fairly frequent clinical symptoms that can be ascertained shortly after birth is cyanosis, which differs from cardiac in that it is intermittent in the form of attacks associated with eating or crying. There may be bouts of coughing and shortness of breath. Phenomena of a disorder of cardiac activity due to displacement of the heart are possible. From the gastrointestinal tract, a number of disorders are also observed. If the stomach is displaced into the pleural cavity and stretched by liquid and gases, then, in addition to shortness of breath, cyanosis and increased heart rate, there is also cough, vomiting and difficulty swallowing. Sometimes there is a sunken abdomen.
When examining a patient, percussion determines the displacement of the heart in the direction opposite to the hole in the diaphragm, tympanitis, and sometimes dullness; on auscultation, the absence or weakening of breathing. At attentive repeated listening it is possible to catch peristaltic noises of intestines.
This symptom immediately makes one suspect the presence of a diaphragmatic hernia.
In some cases, for a number of years, a hernia is asymptomatic and is detected by chance.
In the future, as the child grows, symptoms characteristic of certain types of hernia appear. The leading symptom in hernias of the diaphragm itself is respiratory distress and oxygen deficiency, which is expressed in bouts of cyanosis and shortness of breath. At times, vomiting and stool retention appear. On examination, in some patients, the sunken abdomen, which is called the scaphoid, attracts attention. With a careful examination, it is possible to listen to peristalsis in the left half of the chest and determine the change in percussion sound.
The borders of the heart are shifted to the right. This sometimes gives rise to an erroneous diagnosis of dextrocardia, which explains the existing disorders. 
Rice. 109. Developmental delay in a child (left) with diaphragmatic hernia (children aged 1 year 8 months); (according to Doletsky).
Esophageal hernias (hiatal hernias) are characterized by the development of anemia. There is vomiting of the color of coffee grounds or tarry stools. Gastric bleeding occurs as a result of ulceration in the esophagus and stomach due to their constant injury in the area of the hernia gate. Older children complain of pain in the epigastric region and rumbling. A clinical examination of a patient with an esophageal hernia may not detect pathological changes. Only a careful examination of the patient can reveal a weakening of breathing in the right lung field behind and a dull-tympanic percussion sound.
Anterior hernias are mostly revealed only with age. The leading symptom in older children is abdominal pain due to the movement of intestinal loops and their partial infringement. Children complain of paroxysmal pain in the abdomen and chest, stool retention.
With diaphragmatic hernias, chronic oxygen starvation and malnutrition are always observed. Violation of the correct activity of the heart, respiration and nutrition causes a lag in the overall development of a patient with diaphragmatic hernia. This lag can be expressed very differently, depending on the degree of oxygen deficiency, the size of the hernia and the degree of compression of the lung. Rice. 109 clearly shows this developmental disorder. After the operation of suturing the hernial opening in the diaphragm, children begin to develop normally.
Diagnostics
Diagnosis of congenital diaphragmatic hernia due to the diversity of the clinical picture is sometimes difficult. X-ray examination is of decisive importance. Chest x-ray often reveals the presence of abdominal viscera in the chest cavity. In order to avoid a diagnostic error, it should be remembered that the final solution to the issue is provided by repeated fluoroscopy using a contrast agent, which accurately determines which sections of the gastrointestinal tract are involved in hernias (Fig. 110a, 110b, 111, 112).
Prediction in this disease must always be made carefully. A significant proportion of children die in the first days and weeks of life. Sometimes, as has been pointed out, the disease does not give visible disorders and the child develops satisfactorily.
The most severe complication of a diaphragmatic hernia is strangulation, which can come on suddenly. In such cases, the phenomena of intestinal obstruction develop, not accompanied by bloating, but with severe violations of the chest organs. Absence of abdominal distension makes diagnosis difficult. You should always remember about diaphragmatic hernia and internal infringement. Prediction for a strangulated diaphragmatic hernia is even more difficult. According to statistics, without surgery, 75% of children with congenital diaphragmatic hernia die within the first month of life, and of the survivors, a significant proportion die by the end of the first year of life.
Treatment
In connection with the successes achieved by surgery of the chest cavity in recent years, it is necessary to expand the indications for surgical treatment of diaphragmatic hernia in newborns and young children in order to prevent their death.
As with all other types of hernias, with a diaphragmatic hernia, surgical treatment should be used without waiting for the hernia to be incarcerated. The operation should consist in setting the viscera into the abdominal cavity and sewing up the hole in the diaphragm. As the experience of our clinic has shown, the transperitoneal approach is the best, and not through the chest cavity. The latter path may be required only in individual cases.
With severe respiratory failure, children with large hernias of the dome of the diaphragm should be operated on in the first days of life, as they are under constant threat of death. 
Rice. 110a. Radiographs of congenital diaphragmatic hernia in a 4.5-year-old child.
Plain radiograph, which shows the high standing of the left diaphragm.
Rice. 1106. Radiographs of congenital diaphragmatic hernia in a 4.5-year-old child.
X-ray with barium: part of the colon is in the left half of the chest cavity (hernia of the diaphragm itself on the left.
Rice. 111. Hiatus hernia: it is seen that in the study with barium, a large part of the stomach, which has the shape of an hourglass, is located in the chest cavity above the diaphragm.
Rice. 112. Anterior diaphragmatic hernia.
a - with a survey radiograph, a shadow is visible above the diaphragm on the right, resembling a lung cyst; b - a loop of the colon, filled with a contrasting mass, lies in the anterior mediastinum.
Hiatus hernias do not give severe disorders in the first months of life, so these patients can be operated on after a year.
The operation for anterior diaphragmatic hernia is technically simpler and easier to tolerate by patients, therefore, once the diagnosis is established, it can be performed at any age.
In case of infringement or bleeding from the stomach and intestines, urgent surgical intervention is indicated.
Timely diagnosis and surgical treatment will certainly help save the lives of many children born with diaphragmatic hernia.
The operation staunchly cures the patient and ensures his normal further development, while children left without surgery lag behind in their development. In addition, the operation is not only a therapeutic, but also a preventive measure for severe complications that a diaphragmatic hernia can give.
Funnel chest. The deformity appears immediately after birth. A characteristic symptom of the "paradox of inspiration" is the retraction of the sternum and ribs during inspiration, which is most pronounced when screaming and crying.
At school and adolescence, changes caused by chest deformity are more pronounced. Violation of posture increases, thoracic kyphosis is pronounced, fatigue, tachycardia, pain behind the sternum, a distinct decrease in lung excursions, pneumonia, bronchiectasis, and displacement of the mediastinal organs develop.
Surgical treatment - more often resection of costal cartilage segments, T - shaped osteotomy of the sternum and after correction - fixation with metal or bone structures.
congenital heart defects.
There are 3 groups of congenital heart defects, depending on the mixing of arterial and venous blood and, accordingly, changes in the color of the skin and mucous membranes.
1. Skin color is normal. Arterial and venous blood do not mix. Defects: coarctation of the aorta, stenosis of the aorta, pulmonary artery.
2. White-type defects: atrial septal defects, non-closure of the ductus arteriosus.
3. Vices of the blue type - are characterized by the discharge of venous blood into the arterial bed.
Atrial septal defects.
They make up about 10% of all heart defects. There is a discharge of arterial blood from the left to the right atrium. Hypertension develops in the system of a small circle, children usually lag behind in development, shortness of breath, sometimes cyanosis, hypertrophy of the right heart.
The treatment is surgical, preferably up to 3-4 years.
Ventricular septal defect. According to the statistics of the Institute of Cardiovascular Surgery, this defect is observed in 17% of patients with congenital malformations.
Hemodynamic disturbances are associated with the reflux of arterial blood from the left ventricle into the right ventricle (arterial discharge).
Treatment is surgical.
Non-closure of the arterial (botallian duct).
The child lags behind in development, frequent pneumonia, pallor of the skin, systole - diastolic murmur.
Treatment is surgical.
Coarctation of the aorta (congenital stenosis of the isthmus of the aorta). According to statistics, it occurs from 6 to 14% of all birth defects. The average life expectancy with this defect is up to 30 years.
Most often, the hemodynamic picture includes two different modes: the upper one, including the coronary system of the shoulder - head vessels, and the lower one, including the trunk, lower limbs and internal organs.
The state of decompensation can develop already in children of 1 year of age. Surgical treatment from 3 to 10 years, but surgery is also performed at the 1st year of life.
Operation: resection and plasty of the site of narrowing..
Tetralogy of Fallot is a blue (cyanotic) type of defect.
The defect is a classic among all the defects of the cyanotic type. It makes up 14% of all birth defects and 75% of blue defects.
Anatomically:
1) narrowing of the pulmonary artery;
2) ventricular septal defect;
3) displacement to the right (dextraposition) of the aortic orifice and its location above both ventricles (aorta sitting astride the interventricular septum);
4) hypertrophy of the wall of the right ventricle.
The defect in 1888 was first described by the French pathologist Fallot. Cyanosis develops from the first days or weeks. Dyspnea. By the age of 2, the fingers are “drumsticks.” Children rest while squatting (a very characteristic symptom) - pressure in the upper aorta rises due to compression of the large arteries of the lower extremities, this makes the collaterals between the large and small circles of blood circulation work more intensively . During attacks - loss of consciousness.
All these defects have distinct external manifestations.
Upper sternal fissures are developmental defects caused by nonunion of the upper sternum. When straining, crying or coughing, the heart and large vessels seem to be located on the neck. Surgical treatment in the first weeks of a child's life.
Funnel chest - congenital deformity of the sternum and adjacent ribs, which form a funnel-shaped depression below the handle of the sternum. The depression of the sternum reduces the volume of the chest, disrupts the function of the organs located in it. Surgical treatment at the age of 2-3 years.
Keeled chest - a developmental defect in which the lower sternum, together with the cartilage of the ribs, protrudes forward in the form of a keel. Treatment (physiotherapy) begins in the neonatal period, since the defect usually progresses with the growth of the child.
Malformations of the lungs. Lobar emphysema is a malformation that is characterized by vivid clinical manifestations: severe shortness of breath with retraction of the anterior surface of the chest, cyanosis, wheezing, asymmetric increase in the size of the chest and its lagging during breathing. Above the altered lobe of the lung, a percussion sound of a tympanic shade is noted. The mediastinum and heart are displaced in the opposite direction. Treatment is operative.
Hypoplasia of the lung is an anomaly consisting in the underdevelopment of lung tissue. The diseased side lags behind when breathing, the mediastinum is displaced in the opposite direction. Often, clinical manifestations occur when an inflammatory process is attached. Treatment is mainly surgical.
Malformations of the esophagus. These types of defects belong to the group with severe clinical manifestations.
Esophageal atresia is often associated with a lower tracheoesophageal fistula. The clinical picture is typical. Usually, 2-3 hours after the birth of a child, the upper blind segment of the esophagus and nasopharynx overflow with mucus, as a result of which the child has abundant foamy discharge from the mouth. Part of the mucus is aspirated, bouts of cyanosis occur. The diagnosis is specified by catheterization of the esophagus. If the upper esophagus communicates with the trachea, then the clinical picture will be dominated by respiratory disorders, since the contents of the upper esophagus enter the trachea through the fistula. Surgical treatment in the first hours of a child's life.
With cardiospasm, the main symptoms are vomiting and persistent regurgitation immediately after feeding. The diagnosis is established by x-ray examination of the esophagus. Treatment is conservative. Feeding your baby in an upright position can reduce the backflow of stomach contents into the esophagus. In the future, with the maturation of the nervous structures of the esophageal wall and the restoration of its function, the child recovers.
3. Tactics of the doctor of the unit in identifying a patient with acute appendicitis. Treatment for acute appendicitis is only surgical.
At the prehospital stage, patients with acute appendicitis should not undergo any medical manipulations. The appointment of painkillers and sedatives can change the clinical picture and make diagnosis difficult. Food and water intake is also excluded. In the hospital (after examining patients, confirming the diagnosis of the disease, identifying complications, in the absence of a contraindication to surgery), the toilet of the surgical field and premedication are performed. The course of the operation for uncomplicated and complicated appendicitis is different.
In uncomplicated appendicitis, surgery is usually performed under local anesthesia using an oblique incision in the right iliac region of Volkovich-Dyakonov (McBurney) or pararectal access according to Linander.
After removal of the gangrenous appendix or its perforation, the operation ends with suturing the laparotomy wound to the aponeurosis. Provisional sutures are applied to the skin and subcutaneous tissue, which are tied on the 2nd-3rd day of the postoperative period in the absence of inflammatory changes in the wound.
In case of complicated appendicitis, the operation is performed under anesthesia using a wide median approach. This barks the opportunity to perform a full revision of the abdominal organs, to carry out the operation necessary in terms of volume. make proper sanitation of the peritoneal cavity and rationally drain it.
When diagnosing appendicular infiltrate during the admission of the patient to the hospital, the operation is not performed. Patients are prescribed complex conservative treatment using antibiotics and anti-inflammatory drugs. In the event of signs of abscessing of the infiltrate, an operation is performed, which is limited to opening and draining the abscess of the abdominal cavity. If the outcome of the appendicular infiltrate is diffuse peritonitis, the operation is performed using a median approach, and, in addition to treating the area of the source of peritonitis, it is necessarily accompanied by sanitation of the abdominal cavity and its drainage.
When an appendicular infiltrate is detected during surgery, surgical tactics are ambiguous. With a loose infiltrate, removal of the appendix is permissible. At the same time, the surgeon seeks to preserve the restrictive adhesion of the organs that form the infiltrate in order to prevent diffuse peritonitis. If a dense infiltrate is detected during the operation, the latter is delimited from the rest of the abdominal cavity with tampons. Persistent searches, attempts to isolate and remove the appendix in a dense infiltrate are a mistake. Tampons are brought to the stump of the appendix and in those cases, then with appendectomy there is uncertainty in hemostasis. This happens when the appendix is removed in conditions of loose appendicular infiltrate. In these cases it is very difficult to carry out a reliable ligation of vessels in the inflamed altered mesentery of the appendix.
After appendectomy, as early as possible, an active motor mode is advisable. It is prescribed taking into account the age, characteristic of the disease, its complications, the course of the postoperative period and other characteristics of the patient.
An indicator of the successful course of the early postoperative period in patients who underwent appendectomy is a gradual improvement in their well-being and objective condition, normalization of body temperature, pulse parameters, indicators of avisitis, mainly blood, restoration of intestinal motility, the appearance of appetite, etc. Recovery occurs after 4-5 and the day after the operation.
From the complication of acute appendicitis, due to surgery or the peculiarities of the course of inflammation in the appendix. In the early postoperative period, infiltrates and abscesses of the Douglas space deserve special attention. Of great importance in the diagnosis of this complication is a digital examination of the rectum. Through the rectum, an opening of the abscess of the Douglas space is also performed. In women, removal of pus with such a complication is also possible through the posterior fornix of the vagina.
Tension pneumothorax.
Valvular pneumothorax. Severe respiratory and circulatory disorders also occur with valvular pneumothorax. With each breath, air on the side of the injury is forced into the pleural cavity through the wound of the chest wall or bronchus, squeezing the lung more and pushing the mediastinum, because it cannot go out as a result of the valve mechanism. Thus, intrapleural compression occurs, rapidly leading to severe respiratory and cardiovascular failure.
Cl and diagn by the growth of pathological changes. Therefore, it is very important to know the mechanism of injury, the time elapsed since the injury, and the nature of care at the prehospital stage.
Pain of varying intensity on the side of the injury, aggravated by inhalation, coughing, changes in body position, often with a sharp limitation of respiratory movements, especially if the skeleton is damaged; shortness of breath and difficulty breathing, also worsening
during movements, which, together with pain, makes the victim take a forced position; hemodynamic changes of varying severity; hemoptysis of varying intensity and duration; emphysema in the tissues of the chest wall, mediastinum and adjacent areas; displacement of the mediastinum in the direction opposite to the site of injury; other physical changes.
Some of these signs are noted in the vast majority of victims (pain, shortness of breath), others are much less common (emphysema, hemoptysis).
examination, palpation, percussion, auscultation, study of the nature and localization of wounds, etc. On this basis, and in the absence of other research methods, it is often possible to determine the nature of the damage and take urgent therapeutic measures. Clinical data also serve as a rationale for choosing the type and sequence of clarifying diagnostic techniques.
In emergency situations, therapeutic and diagnostic puncture is very useful for detecting hemo- and pneumothorax, ongoing intrapleural bleeding or hemopericardium. Correctly executed methodically, it without much difficulty allows you to establish the presence of air or blood in the cavity of the pleura and pericardium, and if necessary, remove them for therapeutic purposes. The main role in clarifying the nature of the lesion belongs to the X-ray method, the implementation of which should be considered mandatory for all
chest injuries. have thoracoscopy, bronchoscopy, esophagoscopy, which, however, are often not decisive in the diagnosis of intrathoracic injuries.
Tympanitis is characteristic of pneumothorax. Percussion also manages to establish the boundaries of the lungs, heart, mediastinal displacement, etc. Absence or weakening of breathing is noted during auscultation. Plain radiographs reveal fractures of the chest skeleton, the presence of free gas and fluid in the pleural cavity, displacement of mediastinal organs, diaphragms, collapse or atelectasis of the lung, mediastinal emphysema, and other signs.
Chest injuries with valvular pneumothorax make up a small group (1-2%) of the total number of victims, but differ in the significant severity of functional changes. In these cases, most of the symptoms found in other types of penetrating chest wounds are observed during examination. During the examination of the victims, along with signs of hypoxia and hemodynamic disorders, a pronounced growing subcutaneous emphysema of the chest wall, often spreading to the neck, head, limbs, and abdomen, is striking. Physically, pneumothorax is detected with a sharp shift of the mediastinum in the opposite direction. diaphragm and a sharp shift of the mediastinum to the undamaged side. All patients with valvular pneumothorax require urgent surgical care, without which they quickly die due to the progression of respiratory and cardiovascular disorders.
In cases of very dangerous mediastinal emphysema, the subcutaneous air cushion first appears on the neck, in the region of the jugular notch, and from there spreads symmetrically to both halves of the body.
Basic principles of surgical care. In general, the staged treatment of victims with chest injuries is as follows.
All victims are administered analgesics, cardiac drugs and carried out on a stretcher, preferably in a semi-sitting position.
Enter analgesics, tetanus toxoid, broad-spectrum antibiotics, according to the testimony of cardiac drugs. In case of tension pneumothorax, the pleural cavity is punctured with a thick Dufo-type needle in the 2nd intercostal space along the mid-clavicular line, with its fixation to the skin with a plaster. A rubber valve made from the finger of a surgical glove is attached to the free end of the needle. If necessary, resort to artificial or assisted breathing.
In the cold season, the victim should be overlaid with heating pads and wrapped in a blanket. In cases of signs of bleeding and a drop in blood pressure, according to vital indications, infusion therapy is carried out (polyglucin, saline solutions, glucose), which, however, should not delay the wounded at this stage.
on the nature of the destruction of the intrathoracic.
