Complications of closed fractures and dislocations, their prevention. Injuries and their prevention Volkmann's ischemic contracture

Consolidation slowdown. The absence of clear signs of consolidation, the appearance of callus on the radiograph after 2 months. after reposition and fixation of fragments, it should be regarded as a slowdown in consolidation.

Common causes may be age, alimentary, endocrine disorders, beriberi, concomitant diseases (diabetes, endarteritis, atherosclerosis, etc.).

Local causes include unsatisfactory reposition, unstable fixation of fragments, impaired blood supply and innervation, interposition, bone defects, lymphostasis, and inflammatory processes in tissues.

Therapeutic tactics should be aimed at analyzing the causes that could lead to a slowdown in fracture consolidation, and their elimination. The patient is hospitalized to replace immobilization with a plaster cast for a more active, surgical method of treatment, for example, the use of a compression-distraction apparatus for external fixation.

False joint. Recognition of the formation of a false joint is based on radiological information: sclerosis of the end plates at the ends of bone fragments, a clearly traced fracture line, excessive growth of bone tissue at the ends of the main fragments (hypervascular joints) or, on the contrary, the complete absence of signs of consolidation and osteoporosis of the end sections of the fragments ( hypovascular joints). If double terms of the average duration of bone consolidation have passed, then the false joint is considered to be formed.

Signs: pain with axial load, with lateral and rotational loads, swelling of soft tissues. Mobility at the site of the former fracture may be subtle (tight pseudoarthrosis) or pronounced (dangling pseudoarthrosis).

In the hypervascular form, the skin in the area of neoarthrosis is thickened, hyperpigmented with a hint of hyperemia, warmer than the surrounding areas by 0.5...1.5 °C. In the hypovascular form, the skin is thinned, with a bluish tint, colder than the surrounding areas.

Prevention consists in the timely diagnosis of delayed consolidation, as well as in the correct choice of a fracture treatment method and its high-quality implementation. Early inclusion in the rehabilitation process of a dosed musculoskeletal load and the use of additional means of correcting metabolic processes are important.

Treatment of false joints is carried out mainly by surgical methods using bone autoplasty or alloplasty. G. A. Ilizarov’s compression-distraction devices have become widespread for the treatment of false joints (Fig. 197). The exception is false joints of the femoral neck. Modern treatment of this pathological condition is hip arthroplasty.

Contractures and ankylosis. Each limb injury may be accompanied by the development of contracture in one or more joints, temporary or permanent, limited or severe.

Causes: intra-articular and peri-articular injuries and fractures, post-traumatic arthritis and arthrosis, prolonged immobilization (more than 3-4 months) and prolonged forced position in case of pain syndrome. Lack of motor activity, congestive edema, inflammation disrupt the metabolic processes in the muscles, which leads to myodystrophy, a decrease in the contractility of muscle fibers and their replacement with connective tissue. In the first 3-4 weeks after an injury, there is an active healing of soft tissue wounds, the formation of scars, adhesions of fascio-muscular formations. If during this period there are no movements of muscles and tendons (at least passive and minimal), then scars and adhesions begin to form in the area of the sliding apparatus, which ultimately leads to the development of myofasciotenodesis. This is facilitated by elements of the periosseous wound and extensive hemorrhages. Ligaments and articular bags lose their elasticity and wrinkle. As a result of disorders of the venous and lymphatic outflow, edematous effusion and fibrin accumulate in the joints, which serve as the basis for the formation of intra-articular adhesions. Scars formed in their place

Rice. 197. Treatment of false joints of the diaphysis of the femur (a) and tibia (b) with a nail with proximal and distal blocking, transosseous fixation

Ilizarov apparatus (c)

(intermuscular, musculoskeletal, intra- and periarticular, tendon-vaginal) lead to persistent contractures. Destruction of articular cartilage due to trauma or dystrophic processes leads to the formation of strong scars and adhesions directly between the articular ends of the articulating bones. As a result, fibrous ankylosis is formed, with a very long inactivity of the joint - bone.

Signs of contracture: restriction of movements in the joint, with restriction of extension, the contracture is considered flexion, with restriction of flexion - extension, with restriction of flexion and extension - flexion-extension. In the presence of rocking movements in the joint, they speak of stiffness joint. Complete immobility in a joint is called ankylosis.

Treatment. They carry out active and passive exercise therapy, occupational therapy, massage, thermal procedures (paraffin, ozocerite), electrical muscle stimulation, phonophoresis of lidase and hydrocortisone, hydrotherapy. With myogenic contractures, exercises aimed mainly at relaxing and stretching the muscles are shown. With desmogenic contractures, active exercises are supplemented with passive ones through mechanotherapy. The therapeutic effect achieved by corrective exercises is fixed with fixation bandages and orthopedic means. Persistent contractures are successfully treated by redressing, external functional devices (Fig. 198-200), surgical interventions (myolysis, tenolysis, arthrolysis).

If you suspect the development of Volkmann's contracture, you should immediately remove the plaster cast, give the limb an elevated position

Rice. 198. Apparatus for passive mechanotherapy of the knee joint

Rice. 199. Articulated-distraction apparatus Volkov-Oganesyan on the knee joint

(prevention of edema), provide local hypothermia (15 ... 20 ° C), introduce vasodilators, antispasmodics and anticoagulants. Effective periarterial novocaine blockade, blockade of the cervical sympathetic node, fasciotomy.

Deformities and shortening of the limbs. Causes: delayed or inadequate treatment of fractures and dislocations in the acute period of injury, diagnostic defects, severe fractures, purulent complications.

The solution to the problem of limb length restoration and deformity correction without bone loss became possible only after the introduction of distraction methods using external bone fixation devices. The methods of G. A. Ilizarov allow correcting any deformities of the limbs and restoring the length of the bones, which is especially important for the lower limbs (Fig. 201-204).

Complications in traumatic dislocations and fracture-dislocations. Causes complications are predominantly: 1) treatment and diagnostic errors of the general plan and 2) errors in the treatment of injuries of one joint with its anatomical and functional features. These include the difficulties in diagnosing dislocation and fracture-dislocation associated with radiographic sub-

Rice. 200. Ilizarov apparatus for the development of the elbow (a) and knee (b) joints

hardening, non-compliance with the principle of immediate reduction of the dislocation, insufficient anesthesia during the reduction of the dislocation (traumatic reduction), non-compliance with the timing and nature of the fixation of the reduced segment, etc.

Dislocation of the clavicle (complete, incomplete). Incomplete dislocation of the acromial end of the clavicle. In case of non-surgical treatment, it is necessary to immobilize the upper limb in the position of shoulder abduction up to 90° and its deviation forward by 25° with a cotton-gauze pad pressing on the reduced end of the clavicle. In this position, the limb is stably held for 4 weeks. Failure to comply with these rules leads to a recurrence of incomplete dislocation.

At complete dislocation of the acromial end of the clavicle surgical treatment is indicated with mandatory immobilization of the arm with a plaster cast for 3-4 weeks. Early removal of metal structures also leads to recurrence of dislocation (Fig. 205). Wrong choice of metal structures, ways of their introduction without taking into account indications and contraindications lead to fixator migration, fracture, dislocation, appearance of ossifications in the surrounding tissues, deformation or fracture of the pin at the level of the acromioclavicular joint.

Dislocation of the humerus. Most often, diagnostic errors occur in case of untimely detected dislocation of the head of the shoulder with an undiagnosed fracture of the large tubercle of the humerus and damage to the nerves of the pleura.

Rice. 201. Correction of varus deformity of the femur

Rice. 202. Lengthening of the humerus according to G. A. Ilizarov

celiac plexus, especially in obese people and with chronic dislocations, when the patient for one reason or another did not seek help in a timely manner, as well as with a pronounced swelling of the shoulder area and the absence of x-ray control.

Rice. 203. Correction of a fracture of the 1st metacarpal bone and flexion contracture of the 1st finger (a), lengthening of the metacarpal bones (b) and phalanges (c) according to G. A. Ilizarov

Rice. 204. Treatment of chronic osteomyelitis of the leg with subsequent lengthening of the bone according to G. A. Ilizarov

Rice. 205. Recurrence of dislocation of the acromial end of the clavicle after early removal of the hardware

Of great importance for the diagnosis of complicated dislocations of the humerus are radiographs of the shoulder joint in two standard projections and in the transthoracic projection with a clear identification of all bone articular and extra-articular formations. Rough reduction and repeated attempts, especially with insufficient anesthesia, lead to muscle strain, contribute to the interposition of the articular capsule, infringement of the tendon of the long head of the biceps brachii, and injury to the axillary nerve.

Often, dislocations of the shoulder are accompanied by a detachment of the tendons of the rotator muscles (supraspinatus, infraspinatus and small round), which are attached to the large tubercle of the humerus, which subsequently leads to a violation of the shoulder abduction and its rotation outward. Diagnosing this damage immediately after injury is extremely difficult. Absence of active abduction in the shoulder joint after 3 weeks. indicates tendon rupture, which is one of the indications for surgical intervention.

Shoulder subluxation may occur after reduction of a dislocated humerus. The reason for this is stretching or partial rupture of the joint capsule, partial damage to the shoulder rotators, a decrease in the tone and strength of the muscles of the upper limb as a result of trauma to the axillary nerve during traumatic reduction of the dislocation of the head of the humerus. Shoulder bag stretching in the elderly may occur during the treatment of an impacted fracture of the surgical neck of the shoulder on a scarf, in a Dezo bandage.

The elimination of subluxation is carried out by immobilizing the limb on the abduction splint with active non-surgical treatment (exercise therapy, massage and FTL).

Mistakes associated with the treatment of dislocations include insufficiently effective pain relief, violation of the techniques for reducing the dislocation, short-term immobilization and prolonged immobilization in the position of bringing the shoulder to the body.

In case of fracture-dislocation of the shoulder, an important role after reduction is played by the assessment of the degree of displacement of the large tubercle. A slight displacement can be considered acceptable, since after consolidation the function of the joint is restored; with a significant displacement of the tubercle, when the fragment is located between the acromion and the head of the humerus, surgery is indicated - osteosynthesis.

Dislocations of the bones of the forearm. One of the first mistakes in this case will be the rejection of an x-ray examination of the elbow joint in two projections with a clear clinical picture, as well as its poor quality. It can lead to the failure to detect intra-articular fractures of the coronoid and ulnar processes of the ulna, as well as the condyle of the humerus, which can serve as an obstacle to the closed reduction of the dislocation. The latter may occur with interposition of the flexor tendons of the forearm, sometimes with part of the condyle of the humerus. Obstacles to the reduction of dislocation can be eliminated only with surgical intervention with careful hemostasis.

It is important to follow the rules of immobilization: in case of posterolateral dislocations, the limb is bent at the elbow joint at an angle of 95-100° and the forearm is placed in a middle position between supination and pronation. Deviations to the sides lead to the development of contractures. With an anterior dislocation of the forearm, the limb is immobilized in the position of flexion at the elbow joint at an obtuse angle.

Diagnosis of dislocation of the head of the radius (more common in children) is difficult, so the quality of the radiograph and styling plays an important role (Fig. 206). In case of a Monteggi or Galeazzi fracture, it is necessary to make an x-ray, simultaneously removing the elbow and wrist joints on the same film, and early closed reduction of the fracture dislocation.

Complications after reduction of dislocations of the bones of the forearm include limited mobility in the elbow joint, development of deformity, ankylosis, periarticular ossifications, and neurological disorders.

Complications are prevented by atraumatic reduction, control of limb edema and early functional treatment.

Dislocations in the joints of the hand. Errors in the diagnosis of dislocation of the lunate bone and perilunar dislocation lead to chronic dislocations, and the latter, of course, are reduced with difficulty and not always successfully. Open reduction is also fraught with significant difficulties and leads to the development of aseptic necrosis of the lunate bone. The latter is associated with a violation of its blood supply. Patients lose their ability to work. To prevent errors in diagnosis, a high-quality radiograph of the radiation is necessary.

Rice. 206. Untimely diagnosed isolated dislocation of the radial head

Rice. 207. Chronic dislocation of the lunate bone

metacarpal joint in two projections before and after closed reduction of dislocation (Fig. 207).

After reduction of the palmar dislocation of the lunate bone, pain in the joint may persist as a result of the median nerve compression syndrome. To eliminate it, an operation is indicated - dissection of the transverse ligament of the wrist. With a perilunar dislocation, the head of the capitate is dislocated from the articulation with the lunate bone to the back, and a bayonet-like deformity of the hand occurs. In the diagnosis of this dislocation, a clear radiograph of the wrist joint in a strictly lateral projection plays an important role.

Treatment - early closed reduction of dislocation.

The reduction of the dislocation of the first finger in the metacarpophalangeal joint, displaced to the back, is often difficult as a result of the interposition of the tendon of its long extensor between the head of the metacarpal bone and the proximal phalanx of the finger. Clinically, this condition is manifested by an apparent shortening and straightening of the first finger, which is clearly visible on radiographs in two projections. The interposition of the tendon can be eliminated only by surgery.

With dorsal dislocations of the distal phalanges of the fingers, tears of the extensor tendons of the fingers are possible, which must be taken into account in the treatment to prevent complications.

Dislocations of the hip. Mistakes in the diagnosis of subluxation of the femoral head with an avulsion fracture of the posterior edge of the acetabulum are more common, especially in people who are severely obese. This is played by an insufficient examination of the patient, an incompletely collected anamnesis without taking into account the mechanism of injury, an insufficiently well-produced radiograph of both (!) hip joints in standard and axial projections, and

reassessment of the obtained data by an orthopedic traumatologist. An error is the imposition of plaster immobilization after the reduction of hip dislocation, and not skeletal traction in the position of abduction of the limb. Errors can also be associated with the absence of control radiographs after reduction of the dislocation, with non-compliance with the timing of immobilization, especially in case of a fracture of the acetabulum (the period should not be less than 4-6 months), late functional treatment with traction or early load on the injured limb. The latter will contribute to the early occurrence of aseptic necrosis of the femoral head and the development of deforming arthrosis with pain. It should be borne in mind that before reducing a traumatic dislocation of the femur (posterior or anterior), it is necessary to check the function of the sciatic nerve in order to clearly determine the nature of the lesion.

Traumatic hip dislocation (anterior or posterior) should be reduced under anesthesia using muscle relaxants to relax the muscles and reduce their retraction at the time of reduction, so that gross manipulations do not damage the femoral head, the round ligament and its vessels that feed the articular cartilage, as well as the articular capsule, where pass the vessels supplying blood to the upper part of the neck of the femur and its head. Otherwise, this will contribute to the occurrence of aseptic necrosis of the femoral head and early deforming arthrosis. The latter can also develop after open reduction of an old dislocation of the femur.

Rice. 208. Recurrent hip dislocation with acetabular fracture

Rice. 209 Fracture of the acetabulum with central displacement of the femoral head

With a combination of posterior hip dislocation with a fracture of the posterior edge of the acetabulum (Fig. 208) and with recurrence of hip dislocation with separation of the edge of the acetabulum, non-surgical treatment is ineffective, since the unrepaired displacement of the posterior edge of the acetabulum creates instability of the head in the joint and deprives it of support. In this case, the patient is shown an open reduction of the dislocation with osteosynthesis of the posterior edge of the acetabulum and continued treatment by skeletal traction.

When a bone fragment is infringed in the joint cavity, surgical treatment is certainly indicated. With closed reduction of hip dislocation, a selective approach is necessary. So, with anterior superior (suprapubic) dislocation, it is preferable to use the Kocher method, and for anterior inferior (obturator) dislocation, the Janelidze method. With a central dislocation of the hip, skeletal traction should be carried out in two planes: first, mainly along the axis of the femoral neck (up to 10 kg), and then, after removing the femoral head, along the axis of the limb. This manipulation must be carried out under X-ray control (Fig. 209).

Dislocation of the leg. Mistakes in diagnosis at this localization are rare. More often skip subluxation of the bones of the lower leg in the absence of neurovascular disorders. This is due to the lack of x-ray examination of the damaged knee joint in two projections, when the orthopedist makes a diagnosis of knee sprain. However, with increasing pain, swelling and instability when walking, chronic subluxation of the lower leg should be suspected.

Complete dislocations of the lower leg are diagnosed without much difficulty, but they also require atraumatic reduction, and it is necessary to pay attention to the state of the neurovascular bundle in the popliteal fossa. After reduction, it is necessary to apply a circular plaster bandage from the fingertips to the inguinal region in a functionally advantageous position of the knee joint for up to 2 months. and timely start exercise therapy.

Fractured dislocations of the lower leg or subluxations require surgery - open reposition with osteosynthesis of the condyles - and a thorough restoration of the congruence of the articular surfaces. Subsequently, it is necessary to comply

Rice. 210. Untreated anterior tibial subluxation due to rupture of the anterior cruciate ligament, leading to the development of gonarthrosis

Rice. 211. X-ray of the ankle joint with load: a - normal; b - when the ligaments are torn, uneven joint space appears

terms of immobilization with a plaster bandage and early rehabilitation treatment.

Instability of the knee joint due to damage to the ligaments leads to the development of joint contracture and deforming arthrosis with the presence of pain, which is a common complication that reduces the patient's ability to work (Fig. 210).

Dislocations in the ankle and foot joints. Diagnostic errors in dislocations, subluxations and fracture-dislocations, as a rule, occur when doctors underestimate clinical and radiological data (especially the correct relationship of bones in the joints, taking into account the mechanism of injury) (Fig. 211). Medical errors mainly include unresolved subluxations in the ankle joint or untimely bringing the foot to the middle position with partial damage to the deltoid ligament, when the foot is initially placed in the varus position, as well as untimely load on the injured limb.

An unrecognized rupture of the tibiofibular syndesmosis with a rupture of the deltoid ligament causes an increase in the deformity of the ankle joint with the subsequent development of deforming arthrosis. With ruptures of the lateral ligament of the ankle joint with subluxation of the foot inward and the medial ligament and tibiofibular syndesmosis with subluxation of the foot outward, surgical intervention is required.

With dislocations in the joints of the foot in combination with bone fractures, as a rule, various operations are required, followed by the use of orthopedic products for the foot or the manufacture of orthopedic shoes. It should be borne in mind that errors in the diagnosis and treatment of dislocations and fracture-dislocations of the foot drastically impair the function of the latter and often reduce the patient's ability to work. Correction of developed disorders usually requires highly specialized surgical care.

There are several classifications of errors and complications in the treatment of patients with bone fractures (M. M. Giriorova, 1956; M. V. Volkova, O. N. Gudushauri, A. A. Ushakova, 1967, etc.).

It is advisable to adhere to the following classification:

1. Diagnostic errors and complications as their consequences.

2. Organizational errors in the treatment of bone fractures.

3. Errors in the application of one-time reposition of fragments and fixation with a plaster cast.

4. Errors and complications in the treatment of skeletal extraction.

5. Mistakes and complications in surgical treatment for bone fractures.

6. Errors and complications in the treatment of bone fractures with compression-distraction devices.

7. Fat embolism.

Diagnostic errors

Diagnostic errors in the treatment of patients with bone fractures are rare, but they occur most often in multiple bone fractures and concomitant trauma, especially with brain compression. Damage overlaps and obscures the signs of fractures of bones of other localization (bones of the foot, spinal column).

Less often, but there are diagnostic errors in the scattered examination of the patient, when the patient is not exposed, but only limited to the site of injury, which shows the patient or the most clinically pronounced. Sometimes there are errors in fractures without displacement of one of the paired bones (forearm, lower leg).

Mistakes that are allowed

1) do not use X-ray examination and are limited to the diagnosis of slaughter or sprain of the joint (in case of a fracture of the ankle, condyle of the tibia, a killed fracture of the surgical neck of the humerus or femur);

Mistakes and complications in the treatment of fractures by skeletal extraction

1. Wrong choice of location for the Kirschner wire. For example, passing a wire through the growth cartilage in children irritates or suppresses it, which can affect the growth of a bone segment. In case of fractures of the lower third of the femur, the pin, passed only through the distal metaepiphysis, does not always have the ability to set the fragments, and in case of low fractures, it contributes to their even greater displacement.

2. Carrying out the spokes only through the soft tissues or the cortical substance of the bone is complicated by the eruption of its pain and the inferiority of the extraction.

3. The passage of the needle through the joint cavity (olecranon instead of the olecranon, torsion of the knee) leads to reactive synovitis and adherent arthritis.

4. Non-perpendicular with respect to the axis of the segment, the direction of the drawn spoke makes it difficult to reduce and contributes to its movement and eruption.

5. Incorrect calculation of the load required for the reduction of fragments, and the lack of dynamic control over it, do not allow them to be repositioned in the first 2-3 days or lead to overstretching, the formation of diastasis and reparative osteogenesis.

6. The absence of a skeletal traction system (the main one along the axis of the segment and lateral corrective traction) makes it impossible to restore the physiological curvature of the segment in case of diaphyseal fractures (shin, thigh) and the axis of the limb in case of intraarticular fractures of the condyles.

7. Non-compliance with the basic principles of reduction of bone fragments, that is, the axis of the peripheral fragment to the axis of the central one, with a balanced tension of the antagonist muscles on standard splints, pillows, bandages (wrong axis, abduction, flexion, rotation, etc.).

8. Early removal of skeletal traction (before the formation of primary callus) can lead to secondary displacement of fragments, especially prolonged extraction negatively affects the formation of the callus structure and the general condition of the patient.

Mistakes and complications in surgical treatment for bone fractures

1. Unjustified expansion of indications for surgical treatment of patients with fractures. As a rule, this happens in cases where the surgeon does not have conservative methods or is testing the fixator.

2. An erroneous choice of the method of fixation of bone captures with an intramedullary nail, overlay plates, a compression-distraction apparatus, etc.

3. Incorrect surgical access, which contributes to the destruction of the main vessels and nerve trunks. With small incisions and exposure of fragments, hooks injure soft tissues, and with too large ones, they sometimes disrupt the blood supply and trophism of tissues.

4. Subperiosteal circular skeletonization of the ends of fragments disrupts their blood supply over a considerable distance and slows down regeneration.

5. Using the wrong rod size. Thin and short rods unreliably fix the fragments (micromovements in the “cut” fracture and delayed consolidation are possible), require additional fixation with a plaster cast or apparatus. Using a rod that is too rough can crack the bone.

6. Diastasis between fragments left after osteosynthesis, or perforation of the bone cortex with an incorrectly killed fixator. The use of non-standard, untested homemade fixatives often leads to suppuration, metallosis, fractures, corrosion, and fixative migration.

7. Application for fixation of fragments of suture material (threads of catgut, silk, nylon, lavsan, etc.) removed for use in traumatological practice, since they are not able to withstand reduced fragments.

8. Percutaneous fixation of open and marginal fractures (humeral epicondyles, etc.) with one Kirschner wire, which does not exclude the possibility of rotational movements of fragments on the wires.

9. Fixation of fragments in open fractures with various types of overlay plates, complicated by suppuration of the wound and, if this foreign body is not thrown out in a timely manner,.

Early postoperative complications

1. Suppuration of the surgical wound (due to violation of asepsis rules, imperfect PST of open fractures, skin defects, soft tissue injury, etc.).

2. Reactive inflammation of the joints as a reaction to a nearby foreign body.

3. Embolism and thromboembolic complications.

Late postoperative complications

1. Delayed union or nonunion of the fracture (in the absence of stable fixation of fragments, periosteum in the area of the fracture, circulatory disorders, suppuration, etc.).

2. Osteomyelitis is a consequence of inadequate or ineffective treatment of the inflammatory process and suppuration of the wound after surgery or an open fracture.

3. Migration or fracture of the fixator (with defects in its design and low-quality metal, the presence of micro-movements in the fracture, etc.). A one-time large acting force leads to a fracture of biological fixators and deformation (curvature) of the metal fixator.

Mistakes and complications in the treatment of bone fractures with compression-distraction devices

1. The use of hardware osteosynthesis by a doctor who does not have special theoretical training and practical skills.

2. Incorrect holding of paired spokes (in different planes) after tension causes eruption of soft tissues and bone, which leads to unstable fixation.

3. Insertion of wires or rods in the projections of the neurovascular bundles can lead to primary (or secondary) damage and bleeding due to the formation of decubituses or vascular erosion.

4. Unstable fixation of fragments with an insufficient number (less than 4) of the levels of wires or rods.

5. Lack of control of the device in the course of treatment, control and correction of fixation of bone fragments.

6. Insufficient care for the condition of the rods (spokes). Suppuration of the rods, improper treatment of suppuration and untimely rearrangement of the pins leads to pin osteomyelitis.

7. Lack of dosed and (at the stage of restructuring of the callus) full load of the limb in the apparatus.

8. Premature removal of the device (before the appearance of radiological signs of union of the fracture or false joint).

Volkmann's ischemic contracture

- one of the most dangerous complications in the treatment of patients with bone fractures, especially in the elbow joint. It was described by Volkman in 1881. With untimely recognition and provision of assistance aimed at prevention, the occurrence of contracture leads to irreversible changes in tissues and to disability, sometimes ending in limb amputation.

Causes:

1) primary damage to the main artery of the limb during injury, belated diagnosis and surgical treatment for rupture of the vessel or thrombosis in closed fractures;

2) prolonged infringement of the artery by a displaced fragment, tourniquet, etc.;

3) violation of arterial circulation due to excessive hematoma and tissue edema;

4) circulatory disorders due to tight plaster cast and increased swelling of the limb segment in the plaster cast.

Pathogenesis andclinical symptoms. Primary damage to the main artery during trauma is rare, which is caused by the lack of necessary professional vigilance among doctors. Therefore, belated diagnosis and surgical treatment are allowed.

Rupture of the main artery is clinically manifested by the absence of a pulse in the periphery, pallor of the skin, a disorder of all types of sensitivity, and also by the absence of movements of the fingers of the limb.

In fractures with displacement of fragments (for example, supracondylar extension (extension) fracture of the shoulder), pinching or damage to the central fragments of the artery (in the region of the cubital fossa) may occur.

Clinicalsymptoms depends on the degree of circulatory disorders. If you apply a tight plaster cast, especially a circular one, and the swelling of the limb increases, circulatory disorders develop gradually and with appropriate clinical manifestations. The time during which ischemic contracture develops depends on the rate of increase in edema and the degree of vascular compression.

First, the veins are compressed, which lie superficially, have thin and elastic walls. Clinically, this is manifested by cyanosis and a sharp increase in edema in the periphery. As the outflow of blood is obstructed, its arterial inflow decreases, and therefore tissue hypoxia develops. Hypoxia primarily affects highly differentiated tissues - nervous and muscular. Ischemic pain and paresthesia appear, sensitivity decreases and active finger movements are limited. If at this time the cause of circulatory disorders is eliminated, then there is hope for the restoration of tissue vital activity, and therefore it is advisable to call this period the reverse stage of ischemic contracture.

If the patient is not given timely assistance, then edema increases, pidepidermal blisters appear, and tissue hypoxia increases. Sensitivity is dulled and the pain decreases, and then all kinds of sensitivity completely disappear. Active finger movements are not possible. Due to ischemia, degenerative changes in the muscles, aseptic necrosis of muscle tissue occur. This is an irreversible stage of ischemic contracture. Despite the restoration of blood circulation at this stage (weakening or removal of the plaster cast, decompression of tissues, stitching of blood vessels, etc.), against the background of aseptic inflammation, necrotic muscles are replaced by scar tissue and lose their ability to contract. Over time, the scars thicken and lead to shortening of the muscles.

Due to scarring and muscle atrophy, the circumference of the affected limb segment sharply decreases, the limb becomes thinner, active movements are absent or sharply limited. For example, with ischemic contracture, the fingers are in the position of extension in the metacarpophalangeal joints and flexion in all interphalangeal joints. You can straighten them only with maximum flexion of the hand in the wrist joint, when the points of attachment of the muscles approach each other. When the hand is extended, the fingers again bend into a fist. This sign is known as the digitiruhic phenomenon in Volkmann's ischemic contracture.

As a result of degenerative changes in the nerves, innervation and tissue trophism suffer: the skin is thin, cold, with high humidity, the nails are also thin, cracked.
Excessive or prolonged disruption of blood supply to tissues can lead to necrosis of all tissues of the distal end of the limb, which proceeds as dry gangrene. The skin on the fingers becomes dark bluish in color, wrinkled, the fingers are insensitive, thinner, classical signs of necrosis gradually appear with increasing phenomena of the body.

Prevention of Volkmann's contracture

Prevention of Volkmann's contracture covers the following activities:

1. Timely diagnosis of damage or thrombosis of the main artery and immediate surgery to restore blood flow. Therefore, with all injuries, especially with bone fractures, when examining a patient, attention must be paid to the blood supply to the injured segment, by palpation determining the skin temperature and the pulse on the peripheral artery. Clarify the diagnosis of oscillography. If there is no clear pulsation of the vessels, although the blood supply to the tissues is sufficient, a puncture of the distal part of the artery is made with a conventional injection needle, from which, with an intact artery, blood flows out pulsatingly. Finally, the issue of damage to the artery and its degree is decided by arteriography. In doubtful cases, it is necessary to operate to revise the condition of the vessels. Any observation in dynamics is unacceptable, because it can end tragically.

2. Urgent reposition of the bones during the sealing of the artery of bone fragments, which restores the anatomical ratio and blood circulation.

3. In case of injuries and fractures of bones, especially in the area of the elbow joint, circular plaster bandages should not be used. All children with fractures in the elbow area, despite good reposition of fragments, should be hospitalized for 2-3 days for observation. If they refuse hospitalization, parents should be warned about the need to seek help at the first manifestations of circulatory disorders in the limb. In this case, it is necessary to open the entire bandage (to the skin) and loosen it somewhat. After that, circulation should be restored. If the phenomenon of ischemia does not go away, this indicates an interstitial hematoma and edema, which requires tissue decompression - opening of fibrous fascial cases. Hematoma puncture is ineffective and leads to the loss of precious time.

Under anesthesia, after processing the surgical field, small (4-5 cm) skin incisions are made in several places of the segment (along the flexor and extensor muscles). Then, through these incisions, the fascia is dissected subcutaneously with scissors in length along the entire length of the muscles. Apply an aseptic bandage. Wounds are sutured after swelling subsides.

Treatment. After eliminating the causes that caused circulatory disorders, physiotherapy (warm baths, exercise therapy, massage, electrical stimulation) and medication (B vitamins, prozerin, dibazol, etc.) treatment is prescribed, aimed at restoring trophism and muscle tone, innervation and trophism fabrics.

Treatment should be long-term, and its effectiveness depends on the degree of pathological changes in tissues resulting from ischemia. In severe cases, in addition to the indicated treatment, various corrective splints are used, which, during the period of muscle scarring, keep the hand in a functionally advantageous position.

With the current Volkmann's contracture of the upper limb, surgical methods of treatment are used to reduce and eliminate the contracture of the fingers. These methods consist in extending the tendons outside their sheath or bringing the points of attachment of the muscles closer together due to the shortening of the bones of the forearm, lowering the epicondyles with the place of attachment of the muscles to them, etc. To keep the hand in the mid-physiological position, an arthrodesis of the wrist joint is performed. However, these operations are palliative and are in no way able to improve the functional state of the hand. A person remains disabled for life, because the muscles have lost their ability to contract.

With ischemic contracture of the lower limb, surgical treatment (lengthening of the calcaneal tendon, tri-articular) significantly improves the static-dynamic function of the foot.

Fat embolism

Fat embolism is one of the early complications of bone fractures, which occurs especially often (up to 25%) after multiple injuries and reaches 44% among the number of deaths from skeletal fractures.

Among the existing theories of the occurrence of fat embolism, two dominate: mechanical and biochemical. The oldest mechanical theory explains the occurrence of fat embolism as a result of droplets of fat from damaged bone marrow entering the bloodstream. Currently, most surgeons consider the cause of fat embolism to be biochemical changes in the blood during traumatic disease. Soluble blood lipids and emulsified blood plasma fat, when homeostasis is disturbed and under certain conditions, can merge into drops and cause embolism.

Clinically distinguish pulmonaryand cerebral forms of fat embolism. In the pulmonary form, the main signs of embolism are respiratory disorders: shortness of breath, cough, cyanosis, tachycardia, and pulmonary heart failure. If 3/4 of the pulmonary circulation is excluded, the person dies. The cerebral form of fat embolism is manifested by cerebral disorders, loss of consciousness, convulsions. Small petechial hemorrhages in the skin of the abdomen, chest and inner surfaces of the upper extremities are considered pathognomonic symptom of fat embolism.

In the diagnosis of fat embolism, a laboratory study of urine and blood plasma for free fat drops helps.

Treatment of patients with consists in the use of drugs that normalize the state of blood plasma lipids (Lipostabil transfusion, ether inhalations, etc.), as well as complex treatment of the general condition of the patient (anti-shock therapy, infusion of Gemodez, rheopolyglucin, antihistamines, anticoagulants, oxygen inhalations etc.).

In patients with fat embolism, it is important to securely fix fragments of a fractured bone segment and not to carry out any manipulations (reduction) in the fracture area in the acute period, with the exception of hematoma puncture.

For closed fractures in some cases, skin necrosis develops as a result of direct trauma or pressure from bone fragments from the inside. As a result, a closed fracture can turn into an open one in a few days and is called secondary open.

Hematoma accumulation in the subfascial space with closed bone fractures often causes the development of subfascial hypertension syndrome with circulatory disorders and innervation of the distal limbs due to compression of the neurovascular bundle.

Subfascial hypertension syndrome, compression or damage to the main vessel by a bone fragment can lead to the development of gangrene of the limb, thrombosis of venous and arterial vessels, insufficient blood supply to the limb, Volkmann's contracture, and if the nerves are damaged, to paralysis, paresis. With closed fractures, suppuration of the hematoma rarely occurs.

For open fractures the most common complications are superficial or deep suppuration of the wound, osteomyelitis, anaerobic infection develops much less frequently.

In patients with multiple, combined injuries and open fractures, along with shock, fat embolism is possible.

For fractures, accompanied by prolonged crushing of the limb, there may be a syndrome of prolonged compression with combined damage to the main vessels - anemia.

to late complications. fractures include malunion of fragments, delayed union, non-united fractures and false joints. In peri- and intra-articular fractures, the most common complications are the formation of heterotopic para-articular ossifications, post-traumatic deforming arthrosis, contractures, and post-traumatic edema.

Dislocations. Under the influence of acute or chronic infection (osteomyelitis, tuberculosis), destruction of one or both articular surfaces can occur, as a result of which the articular head is displaced relative to the articular cavity, subluxation develops, and sometimes complete dislocation. The development of a tumor in the head of the bone or in the articular cavity also disrupts the normal ratio of the articular surfaces: the enlarged head cannot fit in the articular cavity and gradually leaves it. Sprain of the ligaments of the joint during its dropsy or after an injury leads to a violation of the normal position of the articular ends of the bone, and with a slight influence of an external force, the articular surfaces can easily be displaced. Violation of the muscular apparatus of the joint (paralysis and muscle atrophy) can also contribute to the development of pathological dislocations; dislocations or subluxations can also occur due to paralysis of one muscle group while maintaining the normal strength of the antagonists.

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

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

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

Stage II - the formation and differentiation of tissue structures.

Stage III - the formation of the bone structure.

Stage IV - restructuring of the primary regenerate.

There are the following types of callus:

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

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

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

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

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

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

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

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

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

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One of the complications of a closed fracture is blood loss. Bleeding from a broken bone lasts up to 3-5 days. For some reason, many surgeons associate bleeding and blood loss only with damage to the main vessel and external bleeding or bleeding into the cavity.

Bleeding always occurs with a closed fracture. According to the studies of Clark (1951), V.F. Pozharissky (1972), blood loss in case of a fracture of the posterior half-ring of the pelvis can reach 2-3 l, the anterior half-ring of the pelvis - 0.8 l, the femur - 0.5-2.5 l, shins - 0.5-1.0 l. Especially dangerous is bleeding in elderly and senile patients with fractures of the ilium and sacrum, subtrochanteric and pertrochanteric fractures of the femur, high fractures of the tibia. In patients with multiple fractures, blood loss can be 2-3 liters or more.

Fat embolism is a rare but serious complication of fractures. It occurs more often in those victims who have not been diagnosed with shock and therefore have not received antishock therapy. It is believed that fat embolism develops as a result of impaired tissue circulation during shock. Pathological deposition of blood in the capillaries, acidosis as a result of hypoxia, impaired blood chemistry are links in the pathogenetic chain. In the clinic, a mixed form of embolism is more often observed - both cerebral and pulmonary.

Clinically, fat embolism is manifested by a sudden deterioration in the patient's condition ("light interval" from several hours to 2 days). The first symptom is a change in the consciousness of the victim due to increasing hypoxia of the brain up to loss of consciousness. Important signs of a fat embolism are increased respiration, cyanosis of the skin and mucous membranes (hypoxia!), an increase in body temperature to 39 ° C and above (obviously, of central origin). There are scattered symptoms of damage to the cerebral cortex, subcortical formations and the trunk: smoothness of the nasolabial fold, tongue deviation, swallowing disorder, meningeal symptoms. On radiographs of the lungs, symptoms of edema are noted - a picture of a "snow blizzard".

It is very important to differentiate a fat embolism from a growing intracranial hematoma, since in both cases there is a “light gap”. With a hematoma, focal symptoms of damage to one hemisphere are more pronounced, symptoms of damage to the subcortical regions and the brain stem are less pronounced. Hematoma is also characterized by bradycardia, there is no such shortness of breath and hypoxia as with embolism. Special research methods help: a picture of a "snowstorm" on x-rays of the lungs, a shift in the median structures of the brain on echoencephalograms with a hematoma, an increase in the pressure of the cerebrospinal fluid and blood in the cerebrospinal fluid with a hematoma. Of great importance is the study of the fundus: drops of fat can be seen in the capillaries of the fundus during embolism; varicose veins and smoothness of the contours of the optic nerve with hematoma.

Along with the general complications of closed fractures, there may be local complications. First of all, they should include an internal bedsore, which often occurs with a complete displacement of fragments of the tibia. Internal decubitus significantly complicates the use of many methods of treatment.

The accumulation of hematoma in the subfascial space with closed bone fractures often causes the development of subfascial hypertension syndrome with circulatory disorders and innervation of the distal limbs due to compression of the neurovascular bundle.

Subfascial hypertension syndrome, compression or damage to the main vessel by a bone fragment can lead to the development of gangrene of the limb, thrombosis of venous and arterial vessels, insufficient blood supply to the limb, Volkmann contracture, and, if the nerves are damaged, to paralysis, paresis. With closed fractures, suppuration of the hematoma rarely occurs.

For open fractures

the most common complications are superficial or deep suppuration of the wound, osteomyelitis, anaerobic infection develops much less frequently.

In patients with multiple, combined injuries and open fractures, along with shock, fat embolism is possible.

For fractures, accompanied by prolonged crushing of the limb, there may be a syndrome of prolonged compression with combined damage to the main vessels - anemia.

to late complications.

fractures include malunion of fragments, delayed union, non-united fractures and false joints. Often, fractures are complicated by Zudek's syndrome. In peri- and intra-articular fractures, the most common complications are the formation of heterotopic para-articular ossifications, post-traumatic deforming arthrosis, contractures, and post-traumatic edema.

Dislocations.

Under the influence of acute or chronic infection (osteomyelitis, tuberculosis), destruction of one or both articular surfaces can occur, as a result of which the articular head is displaced relative to the articular cavity, subluxation develops, and sometimes complete dislocation. The development of a tumor in the head of the bone or in the articular cavity also disrupts the normal ratio of the articular surfaces: the enlarged head cannot fit in the articular cavity and gradually leaves it. Sprain of the ligaments of the joint during its dropsy or after an injury leads to a violation of the normal position of the articular ends of the bone, and with a slight influence of an external force, the articular surfaces can easily be displaced. Violation of the muscular apparatus of the joint (paralysis and muscle atrophy) can also contribute to the development of pathological dislocations; dislocations or subluxations can also occur due to paralysis of one muscle group while maintaining the normal strength of the antagonists.