28.06.2017
Diseases of the musculoskeletal system | Osteoarticular system
What ensures the mobility of our skeleton? First of all, joints, muscles, ligaments and nerves. You should also not ignore the heart and blood vessels (how will muscles work without nutrition and oxygen?), and other organs and tissues make a significant contribution to the possibility of movement.
What types of movements are there?
- Active and passive. A person does the first of his own free will. The second is someone else (for diagnostic or therapeutic purposes), and no effort is required from the person himself.
- Natural - harmonious, inherent in a healthy body, and pathological - performed in ranges and planes unusual for a healthy body.
- Rotational and planar (adduction-abduction, flexion-extension).
- Free and limited.
An example of movement limitation (both passive and active) is contracture. This term comes from Latin words meaning “constriction, contraction.” They can be inherent in the body from birth (for example, torticollis, clubfoot, etc.) or result from injuries and diseases of the nervous and musculoskeletal systems.
Causes of post-traumatic contracture of the shoulder, elbow, knee and other joints
As the name suggests, restriction of movement occurs due to traumatic damage to components of the musculoskeletal system - bones, tendons, fascia, joints, ligaments, muscles and/or surrounding tissues, such as skin and subcutaneous tissue, blood vessels and nerves. According to statistics, limb injuries lead to the development of contractures in seventy percent of cases.
By nature, these can be knife and gunshot wounds, bruises, fractures, dislocations, burns; injuries of the skull and spine. For example, when the integrity of the skin and deeper connective tissue structures - muscles, ligaments, tendons - is violated, limited mobility occurs due to scar changes over the joint. Scars tighten tissues and promote the formation of adhesions; the latter create the so-called additional fixation points are obstacles to free movement.
Contractures due to gunshot injuries are considered the most difficult. Because in this case, along with the integumentary and musculoskeletal structures, blood vessels and nerves are damaged.
Impaired blood circulation in tissues is a significant factor in the formation of contractures. It can be a consequence of edema, disruption of the integrity of large vessels, compression of them with a tourniquet or plaster cast, etc. This type of movement restriction develops very quickly (within a few hours) in contrast to scar deformities, which take months to form.
Another important factor is pain - a provocateur of protective contractures. It can lead to long-term limitation of movement even in the absence of serious tissue damage.
Limitation of mobility in one or more joints can also be caused by prolonged forced immobilization of the injured limb. In this case, changes occur in the joint capsule (loss of elasticity, wrinkling, thickening, adhesions, etc.), replacement of muscles with connective tissue, etc.
Contracture is not only provoked by tissue damage, but also causes it (muscle atrophy, growth retardation, subluxation, deformation of bone and joint structures).
Often, mobility impairments develop over time in the joints adjacent to the initially damaged joint and are compensatory in nature. According to this mechanism, for example, contracture of the knee joint occurs due to hip injury.
Fractures of the bones of the hand
This type of fracture of the hand bones is rare in traumatology. Due to some anatomical features of the structure of the hand, the most common in this group are fractures of the scaphoid bone. Less common are fractures of the lunate and pisiform bones. Other types of hand fractures in this area occur very rarely. In some cases, a combination of dislocations and fractures of the wrist bones is observed.
Scaphoid fracture
The cause of injury is a fall on a bent hand, a blow with a clenched fist on a hard object, or a direct blow to the palm. Typically, the scaphoid bone breaks into two fragments. Intra- and extra-articular damage is possible. Extra-articular fractures include avulsion of the tubercle of the scaphoid. A fracture of the scaphoid can be combined with a dislocation of the lunate (de Quervain's fracture dislocation).
Symptoms of a scaphoid fracture
The wrist joint on the side of the first finger is swollen and painful. The pain intensifies with load on the first and second fingers. Clenching the hand into a fist is impossible due to pain. To confirm a scaphoid fracture, x-rays are performed in three projections. Sometimes the fracture line cannot be seen on photographs. In such cases, if there are clinical signs of a scaphoid fracture, the patient is given a plaster cast, and after 10 days another series of radiographs is taken. During this time, the area of bone near the fracture line dissolves and the damage becomes more noticeable.
Treatment of a scaphoid fracture
The easiest injury to the scaphoid is avulsion of the tubercle. To heal such a fracture, immobilization for a period of 1 month is usually sufficient. In cases where the fracture line runs along the body of the scaphoid, it may take about six months for complete healing of the fragments. If one of the fragments does not receive enough nutrition, it may be reabsorbed. Pseudarthrosis often forms at the fracture site. Cysts may form in the body of the bone.
In case of a fracture of the scaphoid without displacement, the traumatologist applies a plaster splint for a period of 10-12 weeks. Then the plaster is removed and control radiographs are taken. If the photographs show no signs of fusion, another splint is applied for up to 2 months. In case of a displaced fracture of the scaphoid, osteosynthesis of bone fragments is performed using knitting needles or screws. Sometimes external osteosynthesis devices are installed. The period of immobilization after surgery is 2 months. For all fractures of the scaphoid bone, the patient is prescribed exercise therapy. For false joints and ununited fractures, osteosynthesis is performed in combination with bone grafting, arthrodesis of the wrist joint, or removal of a bone fragment that is not receiving nutrition.
Lunate fracture
A rare type of hand fracture. Occurs from a direct blow or fall on the hand. There is slight or moderate swelling of the injured area, pain that intensifies with axial load on the third-fourth fingers and an attempt to straighten the hand to the back. Radiographs are taken to confirm a lunate fracture.
Treatment of a lunate fracture
A plaster splint is applied to the damaged hand for 1.5-2 months. Lunate fractures usually heal without complications.
Pisiform bone fracture
This type of hand bone fracture is quite rare. The cause of injury is a direct blow to the injured area or a blow with the edge of the hand on a hard object. There is pain in the area of the wrist joint on the side of the little finger, which intensifies when trying to squeeze the hand or bend the little finger. To confirm a fracture of the pisiform bone, radiographs are taken in special projections. Immobilization is indicated for a period of 1 month.
Treatment of post-traumatic contracture
“Prevention is easier than cure.” Prevention of contractures is important and effective.
- An effective measure is correct fixation of the injured limb (in a natural position without excessive compression of blood vessels and nerves). Some doctors have experience in providing conditions for rapid healing of fractures without applying a plaster cast.
- Promoting mobility of the joints of the injured limb as quickly as possible (passive and active gymnastics improves blood supply and nerve trophism, accelerates healing, and prevents the formation of scar tissue). If real movement is not possible, visualization of a variety of movements gives good results. Experiments have shown that people who did not stop training in their imagination recovered much faster and more fully, even after very serious injuries and a long period of complete immobility.
- Timely relief of pain and prevention of the development of edema and insufficient blood supply to tissues are the most important factors in the aggravation of contractures (pain relief, physiotherapy).
- If the injury does not require emergency hospitalization (and surgery), an osteopathy session (or sessions) provides an excellent effect. In this section of medicine there is the so-called. 72-hour rule: it is after this period that the injury is fixed in the tissues. Within three days from the moment of injury, there is a real opportunity to reconfigure the tissues to the “health matrix” and create conditions for the rapid and correct restoration of the integrity of the structures and their natural mobility.
Finger fracture
The treatment plan depends on the type and nature of the damage. When choosing a tactic, a prerequisite is the ability to reliably restore normal relationships between all anatomical structures of the finger. For closed, stable extra- and intra-articular fractures of the fingers without displacement, apply a plaster or polymer bandage from the tips of the fingers to the middle third of the forearm, fixing the damaged finger in a state of slight or moderate flexion.
For some fractures of the middle and nail phalanges, an adhesive plaster or plastic bandage is used only on the finger, without fixing the forearm and wrist joint. If possible, healthy fingers are left free for active movements. To reduce swelling, the patient is advised to maintain an elevated position of the limb. To prevent the development of stiffness, it is advised to regularly move your healthy fingers several times a day.
As a rule, closed fractures of the fingers with displacement are well reduced, and the fragments after reposition are reliably held in the correct position using a regular plaster cast, so in most cases, when the fragments are displaced, the usual simultaneous reduction is performed under local anesthesia. An exception is some oblique and comminuted fractures of the middle and main phalanges, which are prone to secondary displacement. In case of oblique fractures, after reduction, percutaneous fixation is performed with a pin; in case of splintered injuries, either skeletal traction is applied to the finger, or surgical intervention is performed - open reduction and osteosynthesis with a pin, or (less often) with screws.
With intra-articular fractures with the formation of small triangular fragments, the formation of subluxation, rotation of the fragment or its entrapment in the joint is possible. In such cases, surgery is also necessary to prevent the development of contracture, ankylosis or post-traumatic deforming arthrosis. A particularly unfavorable option is crushed periarticular and intra-articular fractures of the phalanges, in which the congruence of the articular surfaces cannot be restored due to their significant destruction. In such cases, immobilization is carried out in a functionally advantageous position (slight flexion position).
For all open fractures of the finger (both displaced and non-displaced), PSO is performed. The wound is washed, the tendons are sutured if possible, sutures are placed on the skin, and drainage is carried out with a rubber graduate. A stable open fracture is fixed with plaster; for unstable injuries, skeletal traction is applied to the nail phalanx. If the tendons cannot be restored due to the age of the injury (more than 6 hours before admission), tendon repair is performed routinely after healing of the fracture.
For closed fractures of the nail phalanges of the II-V toes without displacement, an adhesive bandage is used; for damage to the middle and main phalanges, a plantar plaster splint is applied. If the first finger is fractured, a plaster boot is used from the tips of the fingers to the upper third of the shin. In case of displacement, reposition is carried out before applying plaster. Unstable oblique fractures, if necessary, are additionally fixed with a wire. Unstable splintered injuries are immobilized using skeletal traction on the nail phalanx. Fractures of the main phalanx of the first toe, especially intra-articular ones, may require surgical treatment. The fragments are compared through the incision and fixed with knitting needles, the wound is sutured, and a plaster is applied.
Surgical treatment of metacarpal fractures
If there is a displacement of fragments along the length, width or angular deformation of the bone, then osteosynthesis is indicated - fixation of fragments using a plate, screws or pins. If the diaphysis of the metacarpal bone is fractured, it is fixed with a plate and/or screws; it is also possible to install a pin inside the bone . If the plate causes discomfort to the patient, it can be removed, but not earlier than after a year. However, in most cases, metal fixatives are not removed. The pin is installed intramedullary (inside the medullary canal) for approximately 4-6 weeks. This fixator is removed based on the results of a control x-ray - as the bone heals.
It is possible to fix the fragments using knitting needles through small punctures of the skin if adequate closed reposition (comparison) of the fragments is possible. The ends of the needles usually protrude above the skin, but can also be buried under the skin. These metal anchors are removed after the fracture has healed, approximately 6 weeks after placement. The main advantage of this method is the absence of skin incisions during the operation. Regardless of the chosen method of fixation, the patient usually begins to develop movements in the joints of the fingers a few days after the operation.
The final choice of osteosynthesis method remains with the attending physician, based on medical indications, the nature of the displacement of fragments, and the functional requirements for the hand.
After the operation, a plaster splint is applied for up to 2-3 weeks. Postoperative sutures (if any) are removed 14 days after surgical treatment; until this point, dressings are performed on an outpatient basis every other day. If the patient has undergone osteosynthesis with knitting needles, then dressings are done every other day for about 1.5 months. Limiting the load on the hand averages 3 months.
The average length of hospitalization for a fracture of the metacarpal bones is 5 days