Radial head fracture

Ankle fracture

Reposition and plaster immobilization

The main task in the treatment of ankle injuries is the accurate restoration of the disrupted anatomical relationships between the various elements of the ankle joint, since without such restoration the normal functioning of the joint is impossible.
For non-displaced fractures, the relationship between the elements of the joint is not disturbed, so it is enough to apply a plaster cast for a period of 4-8 weeks. For displaced fractures, a one-stage closed reduction is performed. Reposition is carried out under local anesthesia in a hospital setting. When a joint is subluxated outwards, the traumatologist presses on the outer surface of the joint with one hand, and with the other on the inner surface of the lower leg above the ankle. After reducing the subluxation, he compresses the ankle joint, eliminating the discrepancy of the tibia. When a joint is subluxated medially, similar manipulations are performed, but the traumatologist’s hands are positioned the other way around: one on the inner surface of the joint, the second on the outer surface of the lower leg above the ankle.

If the posterior edge of the tibia is damaged, the foot is brought forward, producing dorsiflexion; if the anterior edge is damaged, the foot is brought back, producing plantar flexion. Then a plaster boot is placed on the leg in the hypercorrection position and control photographs are taken. The patient is prescribed painkillers and UHF. After the swelling subsides, the plaster is circulated. The period of immobilization depends on the nature of the injury and is 4 weeks for single-ankle fractures, 8 weeks for bimalleolar fractures and 12 weeks for trimalleolar fractures.

Surgery

Indications for surgical intervention are irreparable displacement of the ankles, subluxation of the foot and divergence of the joint, as well as the inability to keep the fragments in the correct position. In addition, operations are performed for ununited fractures, intense pain, severe dysfunction and statics. For fresh injuries, surgical intervention is usually carried out 2-5 days after the injury, for old ones - as planned.

The inner ankle is secured with a double-blade nail or screws. In case of ruptures of the tibiofibular syndesmosis, the tibia bones are brought together using a long screw or a special bolt. A nail or knitting needle is used to fix the outer ankle. For fractures of the posterior and anterior edges, osteosynthesis of the ankles is performed with a screw or nail. Then the wound is sutured and drained layer by layer, and a plaster cast is applied to the leg. In the postoperative period, antibiotic therapy is administered, analgesics, UHF and physical therapy are prescribed. After removing the plaster, measures are taken to develop the joint.

Itchy skin

Itching is one of the most common dermatological complaints, and it can occur not only in patients with dermatoses, but also in a wide range of general diseases. This is an unpleasant sensation, which is accompanied by a continuous need for response mechanical irritation of the skin. Itching can significantly affect the general condition and quality of life of patients, causing insomnia, anxiety, and in severe cases even lead to depression and suicidal thoughts.

Itching is one of the forms of the skin analyzer, close to other types of skin sensation (touch, pain). Unlike pain, which causes a “withdrawal, avoidance” reflex, with itching a “processing” reflex occurs. Scratching, rubbing, kneading, warming, pinching itchy areas leads to instant, but not long-term, satisfaction. This is due to the fact that during the scratching process, stronger impulses are simulated in the nerve endings, which suppress the conduction of weaker itching signals from the affected areas. Severe itching is relieved only through severe self-harm, leading to the replacement of the sensation of itching with a feeling of pain. If itching exists for a long time, then a focus of pathological excitation is formed in the cerebral cortex and itching from a defensive reaction turns into a standard skin reaction to various external and internal stimuli. At the same time, in response to prolonged scratching, the state of peripheral nerve receptors also changes, which leads to a decrease in the threshold for the perception of itching. Thus, a “vicious circle” is formed, the presence of which explains the difficulties in treating itching.

Itching is caused by mechanical, thermal, electrical or chemical stimulation of unmyelinated nerve fibers, the free nerve endings of which lie at the border of the epidermis and dermis. They are excited either directly or indirectly, through the release of various mediators (histamine, serotonin, proteases, neuropeptides, etc.).

Physiological itching occurs in response to environmental irritants (crawling insects, friction, temperature changes, etc.) and disappears after the cause is eliminated. Pathological itching is caused by changes in the skin or throughout the body and causes a strong need to get rid of the itching by scratching or other means.

Itching can be a symptom of various dermatoses (scabies, pediculosis, atopic dermatitis, allergic dermatitis, eczema, mycoses, psoriasis, lichen planus, etc.) or occur on intact skin due to diseases of the internal organs. Endogenous causes of skin itching are very diverse:

• endocrine and metabolic disorders (diabetes mellitus, hyperthyroidism, hypothyroidism, menopause, hyperparathyroidism);
• liver diseases (biliary cirrhosis, extrarenal cholestasis, hepatitis of various etiologies, etc.);
• chronic renal failure;
• blood diseases (iron deficiency anemia, polycythemia vera, lymphogranulomatosis, leukemia, mastocytosis);
• tumors of internal organs, melanoma;
• autoimmune diseases;
• infectious and parasitic (HIV infection, helminthiasis);
• neurological diseases;
• psychoneuroses;
• pregnancy;
• taking medications;
• age (senile itching).

If the cause of the itching, even with a thorough examination, cannot be identified, then it is defined as itching of unknown origin (pruritus sine materia).

To accurately assess itching, it is necessary to carefully collect anamnesis and question the patient. You should pay attention to the following characteristics of itching: time of occurrence, provoking factors, intensity, course, localization, character.

The intensity of itching can vary - from mild to very severe. For a more objective assessment, you should clarify: does itching interfere with falling asleep; whether the patient wakes up from itching; Does itching interfere with daily work? Itching leading to sleep disturbance is considered severe.

Depending on the time of occurrence, they are distinguished - nocturnal, daytime, permanent, seasonal. For example, with scabies and widespread eczema, the itching intensifies when patients go to bed; anal itching caused by pinworms occurs between two and three o'clock in the morning; in psychoneuroses - permanent.

Limited itching of the skin in one anatomical area, as a rule, is caused by local causes. The presence of widespread and symmetrical itching suggests its internal nature.

The itching sensation can be “deep” or “superficial”, it can have a hint of burning, tingling (for example, dermatitis herpetiformis is characterized by burning itching, especially of the scalp). Itching - parasthesia is a feeling of tingling, mild burning, crawling, etc., develops with increased pain sensitivity of the skin and decreases with stroking or light pressure on the itching area. Biopsy itch leads to deep damage to the skin.

As a result of prolonged itching and scratching, excoriation, pigmentation, scars, lichenification, and pyoderma occur. The free edge of the nail plates wears off, leaving the nails looking polished. Objective signs are not necessary to make a diagnosis of itchy skin.

Features of itching in syndromes of different origins

Cholestatic (liver) itching is one of the most painful and persistent symptoms of chronic cholestasis. It occurs in 100% of patients with primary biliary cirrhosis and in almost 50% is a reason to consult a doctor. Most often precedes all other symptoms of cirrhosis. Usually generalized, more pronounced on the limbs, thighs, abdomen, and with obstructive jaundice - on the palms, soles, interdigital folds of the hands and feet, under tight clothing.

Uremic itching, in chronic renal failure, can be local or diffuse, more pronounced on the skin of the neck, shoulder girdle, limbs, genitals, and nose. Intense, worse at night or immediately after dialysis, as well as in the summer months.

Diabetic itching most often occurs in the anogenital area, ear canals, and in some patients it is diffuse in nature.

Hyperthyroid itching is observed in 4–10% of patients with thyrotoxicosis, diffuse, faint, and inconsistent.

Hypothyroid itching is caused by dry skin, generalized, sometimes very intense, even excoriation.

Menopausal itching is observed mainly in the anogenital area, in the axillary folds, on the chest, tongue, palate, and often has a paroxysmal course.

Itching in hematological and lymphoproliferative diseases . Generalized or local: Hodgkin's disease - above the lymph nodes, anogenital - with iron deficiency anemia, with polycythemia - on the head, neck, limbs. With polycythemia, stabbing, burning, aquatic itching may precede the disease by several years.

Paraneoplastic itching sometimes appears several years before the onset of the disease. Can be local or generalized, of varying intensity. For some forms of cancer, a specific localization of itching is observed: for prostate cancer - itching of the scrotum and perineum; for cervical cancer - vaginal itching; for rectal cancer - perianal area; with a brain tumor infiltrating the bottom of the fourth ventricle, itching in the nostril area.

Psychogenic itching is often associated with depression and anxiety. It is characterized by: absence of skin changes, widespread or limited to some symbolic, significant area for the patient, intensifies in stressful situations, conflicts, sleep, as a rule, is not disturbed, patients often describe their sensations in a whimsical, exaggerated manner. Itching is relieved by taking sedatives or antipruritic drugs, and is much less easily relieved by external means. The presence of deep excoriations, bizarre self-harm, and parasitophobia is more likely to indicate the presence of psychosis rather than neurosis. A conclusion about the psychogenic cause of itching is possible only after excluding skin and systemic diseases.

Senile itching occurs in almost 50% of people over 70 years of age, more often in men and occurs in the form of night attacks. The causes of senile itching are mainly endocrine disorders, atherosclerosis, and dry skin. Senile itching is a diagnosis of exclusion; to make it, you must reject another cause of itching.

Localized itching

Itching of the anus is an extremely painful suffering, observed almost exclusively in men, especially after 40 years. It is often complicated by the appearance of painful cracks, streptococcal or candida intertrigo, the formation of boils, and hidradenitis. Causes: untidiness, hemorrhoids, helminthic infestation (enterobiasis), diabetes mellitus, constipation, proctitis, prostatitis, vesiculitis, intestinal dysbiosis.

Genital itching . It occurs in women over 45 years of age in the area of ​​the external genitalia, less commonly in the vagina. The itching is painful, accompanied by the appearance of excoriations and skin dyschromia. Causes: leucorrhoea, urogenital infections, endocrine disorders (menopause), inflammatory diseases of the genital organs, sexual neuroses. In girls, genital itching is observed with enterobiasis.

Itching of the scalp is often a manifestation of seborrheic dermatitis or psoriasis, and can also be a sign of diabetes. Excoriation and bloody crusts, as well as impetiginous elements as a result of a secondary infection, are usually observed on the scalp.

Itching of the ears and external auditory canals can be observed with eczema, seborrheic and atopic dermatitis, and psoriasis.

Itching of the eyelids can occur when exposed to volatile irritants, allergic dermatitis to cosmetics, and also as a result of parasitism of the Demodex mite in the hair follicles of the eyelashes.

An itchy nose can be a manifestation of hay fever, as well as intestinal helminthiasis in children.

Itching of the fingers is observed with eczema, scabies, and bird mite infestation.

Itching of the skin of the lower extremities can be caused by varicose veins, varicose eczema, and dry skin.

Diagnostics

Diagnosis of skin itching requires special attention, since it can precede the manifestation of serious diseases. At the first stage, a physical examination is carried out with an in-depth study of the skin condition and, in the presence of skin manifestations, an in-depth dermatological examination. Every patient suffering from itching should be tested for dermatozoonoses. In cases where itching cannot be associated with any dermatosis, other causes should be sought. Screening for a patient with pruritus should include:

• clinical blood test, ESR;
• general urine analysis with determination of protein, sugar, sediment;
• biochemical blood test (functional liver tests: ALT, bilirubin, alkaline phosphatase; fasting glucose level; cholesterol level; urea, uric acid, creatinine, acid phosphatase; determination of total protein and protein fractions; iron level and iron-binding capacity of serum, saturation of erythrocytes with iron) ;
• stool analysis for occult blood, helminths and their eggs;
• chest x-ray;
• functional examination of the thyroid gland, thyroxine level.

At the second stage, additional laboratory, ultrasound, X-ray, endoscopic, and histological studies are carried out, based on feasibility.

Patients with unexplained itching should be re-evaluated periodically, as the disease causing the itching may appear later.

Treatment

The most effective treatment for itching is to treat the underlying condition. Unfortunately, this is not always possible, so in such cases symptomatic therapy is prescribed. General therapy includes the use of sedatives, antihistamines, mast cell membrane stabilizers (ketotifen), hyposensitizing agents (calcium preparations and sodium thiosulfate), sequestrants and enterosorbents, salicylates. A wide range of physiotherapeutic methods are used: electrosleep, adrenal inductothermy, contrast showers, sulfur and radon baths, sea bathing. External therapy plays a major role in the treatment of itching, but most local drugs act for a short time. They are prescribed in the form of powders, alcohol and aqueous solutions, shaken mixtures, pastes, and ointments. For dry skin, antipruritic agents based on ointments and oils are more suitable. Antipruritic effects have: corticosteroid ointments, 5–10% anesthesin, 1–2% phenol, 5–10% Diphenhydramine solution, water with table vinegar (3 tablespoons of vinegar per 1 glass of water), lemon juice, chamomile infusion (10 –20 flowers per 1 glass of water), etc.

Also, for itching of any origin, it is necessary to eliminate provocative factors, such as dry skin, contact with irritating substances, degreasing the skin (rough, alkaline soap), consumption of certain products (alcohol, spices), as well as environmental temperature changes.

In conclusion, I would like to emphasize that, despite the wide range of therapeutic methods and agents, treating itching remains a difficult task.

Literature

1. Adaskevich V.P., Kozin V.M. Skin and venereal diseases. M.: Med. lit., 2006, p. 237–245.
2. Romanenko I.M., Kulaga V.V., Afonin S.L. Treatment of skin and venereal diseases. T. 2. M.: Medical Information Agency LLC, 2006, p. 342–34.
3. Skin itching. Acne. Urogenital chlamydial infection. Under. ed. E. V. Sokolovsky. SPb: Sotis. 1998, p. 3–67.

I. B. Mertsalova , Candidate of Medical Sciences

RMAPO, Moscow

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