TRAUMATOLOGY

The action of external agents on the organism (mechanical, thermal, radiation, mental, etc.) is referred to as a trauma, which follows with anatomic and functional violations in organs and tissues accompanied by local and general reaction of an organism.

Kinds of traumatism:

1. Traumas of a non-industrial character:

а) transport (railway, automobile, tram);

household;

sports;

others (traumas as a result of natural accidents).

Industrial traumas (industrial and agricultural).

Deliberate traumas (household traumas, ill-intentioned attacks,suicide attempts).

Depending upon the kind of agent causing the damage, traumas are divided into mechanical, electric, radiation, mental, operational, etc.

The division of traumas according to the character of damage has great value — they can be open and closed. In open damages the gaped wounds of the skin or mucous membranes may show. Microbes can penetrate through the wound of the skin or mucous, promoting the development of early or late complications.

Penetrating injuries, when internal organs (stomach, thorax, skull, joints) can be affected and non-penetrating ones are distinguished.

With a simple trauma only one kind of tissue is injured, with a complex one — different tissues are damaged, for example, the skin, muscles and bone.

The trauma is homogeneous if it is caused only by one factor. If the trauma was caused by many factors, for example mechanical trauma together with a burn, it is combined, and simultaneous damage to different systems (concussion and broken shin bone) is called a joint trauma.

Traumas can be direct and indirect (damages which develop at a distance from the causative agent action).

Traumas can be single and multiple (polytrauma). Usually traumas are acute. However in some cases it is possible to speak about chronic, caused by the harmful influence of professional factors.

In patients with severe traumas the symptoms develop very quickly, the condition frequently is serious, quite often it is worsened by traumatic shock. Thus the surgeon should quickly specify the diagnosis and submit the necessary help. While gathering the anamnesis and objective examination of an injured patient, some circumstances require special attention, in contrast to the usual investigation of the surgical patient.

Firstly, the appearance of a damaged area does not always tell about the severity of the damage.

Secondly, not always trauma the symptoms of which are obvious threatens the life of the patient. Diagnosis of multiple traumas in patients who are unconscious, in serious shock or alcoholic intoxication is especially difficult.

Thirdly, the serious general phenomena can be observed in trauma (shock, acute anemia, traumatic toxicosis) which are necessary to estimate and render a corresponding aid to the patient.

In case of severe traumas, where the patient’s life is under threat, first of all it is necessary to provide emergency care, and then start gathering the anamnesis and perform the complete examination of the patient.

While examining the patient it is necessary to find out the complaints, how he felt at the moment of the trauma and after it, which aid he obtained. It is necessary to determine accompanying diseases.

While examining the patient it is necessary to examine in detail the damaged area to specify the diagnosis and get previous representation on the character of the trauma, appoint methods of treatment and expect for possible complications.

CLOSED INJURIES TO SOFT TISSUE

Closed injuries to soft tissues are divided into blows, distortions and ruptures, concussions and compression. Closed damages of soft tissues and organs located in cavities are observed.

Blow is an injury to tissues and organs without infringement of the skin integrity as a result of fast and short-term action from the injuring factor on any area of the body.

The mechanism of a trauma can be various, for example, falling down on an object or impact.

The severity of the damage is determined by two factors:

Character of the injuring agent, its weight, consistence, speedof action.

Type of damaged tissues (skin, muscles, fat, bones), their physical condition.

The clinical picture is characterized by pain, swelling and violation of the function of the injured organ or area. As a result of a large force action in touching direction the displacement of the skin from the underlying tissues can be observed. Shock or paralysis of the area innervated by a definite nerve can occur as a result of big nerves bruise; contusion of the joint causes infringement of its function, of thorax and lungs — hypodermic emphysema.

Treatment. The task of treatment during the first period after contusion is to stop the haemorrhages in tissues. The damaged organ needs rest, a raised position. They apply cold, a squeezing bandage. On the 2nd–3rd day, when the damaged vessels have formed clots, warm, physiotherapeutic procedures are administered for the resolving of haemorrhages. With the presence of hematoma — suction and introduction of antibiotics.

Distortions and Ruptures

Distortions are damage to soft tissues which is caused by a force which strains but does not disturb the anatomic structure of the tissue. However, if in such trauma mechanism the working force overcomes the tissue resistance, a rupture of the ligament, fascia, muscles, tendons, nerves etc. occurs. Clinically rupture of the ligament is accompanied by strong pain, violation of movements, haemorrhages into soft tissues and swelling in the joints. As a result of haemorrhages the fluctuation can be determined during palpation.

Treatment consists in rest, imposing of squeezing bandages, longterm immobilization of the joint. After the resolving of the haemorrhages from the 3rd week it’s possible to begin cautious active movements, massages, medical exercises. In slow resolving punction is performed and antibiotics are given.

Ruptures — complete and incomplete — happen seldom, generally as a result of strong and fast muscle contractions, while lifting weights.

Clinically they appear with strong pains, haemorrhages, hypostasis, and restriction of mobility.

Treatment. With an incomplete rupture — immobilization, rest, cold, then warm, physio-procedures. With a complete rupture — operation with the following immobilization for 2–3 weeks.

Concussion results in significant infringements of tissue and organ functions.

Long-term and strong vibration of the upper extremities firstly causes infringement of their functions, and then result in morphological changes in the muscles, nerves, bones, which are the reason for the development of sclerotic processes, restriction of working ability (vibrating disease).

Compression is observed with damage to vital organs (the heart, the brain, the lungs).

Traumatic toxicosis is a special kind of damage, which is an original syndrome observed during long compression of a large area of soft tissues, mostly the extremities, with general and local phenomena. It occurs during landslides, earthquakes, bombardments, railway accidents. The syndrome appears after the removal of the compressing weights. The detailed description of this syndrome was made by A. Ya. Pitel (1941), M. M. Yelansky (1950).

The extremity released from the pressure is pale with cyanotic spots. The pulse on it is not palpated, sensitivity is lost, and movement is not possible. In 3–5 h the picture of severe shock with violation of CNS functions — excitation, fear, anxiety and then apathy, drowsiness, damage to haemodynamics develop. Plasmorrhea and toxic damage of the liver and kidneys occurs. In severe cases degenerative changes in the kidneys and liver can occur — oliguria, hematuria, protein, cylinders in urine, anuria, uremia, hypostasis of the brain, lungs. On the 3rd–5th day the extremity swells, becomes dense, paralyses develops. After death during dissection severe degenerative changes in the kidneys, degeneration and fatty degeneration of the liver, hypostasis of the brain, lungs, etc. are observed.

The following is important in the pathogenesis of the syndrome:

Damage of the CNS (shock, hypostasis of the brain, etc.).

Absorption of toxins, uric and phosphoric acids and potassiumfrom soft tissues.

Violation of the hepatic-renal barrier functions.

Violation of haemodynamics (increased permeability of vesselwalls with output of plasma into intertissue cavities), trophic disturbances.

Ischemic necrosis of the muscles.

Treatment. The basic tasks concerning liquidation of traumatic toxicosis are following:

Decrease in necrosis of the muscles.

Decrease in intoxication.

These tasks are solved with the help of the following actions:

The damaged extremity is cooled with ice to reduce traumatichypostasis and slit the skin and fascia to reduce the compression of the muscles. In severe cases the extremity is amputated to save the patient’s life.

Bromides, hydrochloride, atropine, glucose, novocainic blockade are applied to prevent shock and angiospasms.

Alkaline reserve of the blood is restored by intravenous introduction of 20–25 g of soda and 3 l of isotonic solution; the patient is appointed plenty of fluids.

They strengthen diuresis with the help of diuretic preparations.

The basic role in struggle against intoxication during traumatic toxicosis belongs to methods of extracorporal detoxification. From the very beginning the regional perfusion of the injured extremity under a tourniquet for reducing endotoxification is conducted. Haemodialysis, haemofiltration (to liquidate acute renal insufficiency), haemosorption, plasmosorption, plasmapheresis (for fighting against acute hepatic insufficiency) are used after the trauma as soon as possible.

General Phenomena in Trauma

Traumatic damages, as well as other pathological processes, are accompanied by general signs on the part of the central nervous system and other organs and systems subordinated to its regulating influence. Such pathological conditions are clinically observed.

Unconciousness is a sudden and temporary brain ischemia, which is expressed by loss of consciousness and sensitivity infringements.

The reason for unconciousness is neuro-psychological moments, which through the neuromotor center cause reflex contraction of the peripheral blood vessels and brain vessels.

Unconciousness can happen as a result of fright, fear etc., consequently, paleness, nausea, ringing in the ears, blackness in the eyes cold sweats, dilation of pupils, pulse decrease, shallow breathing, pale mucous and integuments are observed.

Treatment. The patient should lay with raised legs, loosened clothes, and good inflow of fresh air. The patient is given steam from liquid ammonia to inhale; the face is moistened with cool water; when the patient regains consciousness, it is necessary to give him valerian drops, coffee, wine.

Collapse is a temporary condition of acute cardiac weakness and a decrease in vascular tone that unexpectedly appears and is accompanied by a decline in all vital functions.

Collapse is observed with bleedings, septic and infectious diseases, poisoning, narcosis, sharp pains.

The clinical picture of collapse is similar to the clinical picture of shock. It is necessary to remember that with shock the phenomena of oppression of the nervous system prevail.

Symptoms: paleness that suddenly appears, cyanosis, small, frequent pulse, shallow breathing, decrease in blood pressure, cold sweat, drop in the body temperature, cold extremities and muscular relaxation, consciousness is kept.

Treatment. They remove the reasons for collapse, increase cardiac activity and the centers of the oblong brain. With blood loss, haemotransfusion, isotonic solution are administered; they give the patient hot tea, coffee; enter camphor, caffeine hypodermically.

Shock is a severe general condition of the patient, which is expressed by the oppression of the nervous system and all physiological systems.

At the beginning of the XVIII century, a French doctor H. Le Dran described the basic features of traumatic shock and regularly used the term “shock” in his works.

At the beginning of the XIX century P. Savenko (1834) correctly defined shock as severe damage to the central nervous system of the patient.

M. I. Pyrogov gave a classical description of the clinical picture of shock and proved that shock should be considered as a special condition. He allocated erectile and torpid phases and determined the ways of shock prevention and treatment.

I. M. Sechenov, I. P. Pavlov, M. S. Vvedensky, etc. made a contribution to the understanding of phenomena taking place in an organism during shock.

The following is at the basis of the shock classification:

1. After the reasons of development:

а) traumatic;

operation;

haemotransfusional;

psychological and anaphylactic shock.

2. After the severity of clinical exhibitings:

а) severe, moderate and mild;

b) I degree — with maximal arterial blood pressure of 90 mmHg ІІ degree — ABP of 90–70 mmHg

ІІІ degree — ABP of 50–70 mmHg

ІV degree — ABP is lower than 50 mmHg.

3. After the time of development:

а) primary — at the moment of damage or just after it;

b) secondary — some hours after the trauma, when neuro-reflex

violations worsen by intoxication, diffusion of products of tissue disintegration, additional trauma.

The erectile phase of shock develops at the moment of trauma, short-term. It is characterized by the presence of motoric and mental excitation of the patient. This phase passes into torpid, characterized by the oppression, inhibition of the nervous system and sharp decrease in all vital finctions of an organism.

Clinical picture. M. І. Pyrogov gave the classical definition of the clinical picture of erectile and torpid phases of shock.

Acute motoric and lingual excitation appears as coarse shouts, unmotivated, inexpedient movements: the patient is unsettled, jumpy, without paying attention that may render harm to himself. Dilatation of the pupils, red face, strained, the arterial blood pressure is increased. The erectile phase of shock is similar to narcotic intoxication or excitation.

Pyrogov also described the torpid phase of shock, which is characterized by an expressive decrease in the reaction to stimuli, slackness, apathy, decrease in reflexes, and suppression of the functions of the central neural system (CNS) with preservation of consciousness.

Sharp deterioration in the activity of the cardiovascular system, paleness, frequent pulse, decrease in the body temperature, dullness of cardiac tones and decrease in blood pressure, which is the leading symptom of shock, and also blood coagulation, violation of metabolism and functions of all organs and systems, function of the kidneys (anuria), and oxygen starvation of the tissue are marked.

The diagnosis is easy to determine by the clinical picture, but with multiple damages differential diagnosis is frequently complicated. It is necessary to study carefully the anamnesis and symptomatology, which will help determine the correct diagnosis.

There are the following theories of shock development:

The toxic theory (Kenu), according to which severe violationsin the organism are caused by poisoning with products of tissue disintegration, basically from the muscles. Intoxication causes trichangiestesia and increase in their permeability, which results in the plasma exit into the tissues and congestion of the blood in the capillaries of organs. Therefore, the blood volume decreases, which becomes the reason for cardiac standstill.

The vascular-motor theory (Kreil), according to which traumacauses a reflex paralysis in the peripheral vessels, that results in a decrease of ABP and congestion of the blood in the venous system. Blood circulation in the vital organs is damaged.

The Henderson’s acapnia theory explains the development ofshock by the carbonic acid reduction in the blood caused by hyperventilation during pain. It results in the infringement of blood circulation, congestion of the blood and the development of acidosis in the tissue.

The neuroreflex theory is the most convincing, proven by experimental and clinical data.

Shock is the organism’s reaction in which the supreme parts of the CNS take part directly. Experience testifies that the severity of shock is determined not only by extent of trauma but also it localization. It is connected with amount of receptors on the injured area and in tissue, as well as the extent of additional factors participation, which deepen shock (cooling, exhaustion, fatigue, sleeplessness, anemia).

The basic tasks in shock liquidation

Termination of the stream of nervous pulses from the periphery to the center. This task is carried out with the help of novocainic blockades (sympathetic, paranephral, underperiosteal).

Reduction of excitability of the CNS by the creation of absolute rest, morphine, bromides, alcohol administration.

Fight with factors which worsen the course of shock. Largedoses of solutions of glucose, blood substitutes, inhalation of oxygen, haemotransfusion, plasma, potassium chloride are introduced to fight against toxemia, anoxemia, plasm- and blood loss.

Fight against the consequences of shock, restoration of damaged functions, haemodynamic infringements (cardiac substances, heating, haemotransfusion, plasma, blood substitutes).

All means should be conducted simultaneously and vigorously.

BONE FRACTURES AND DISLOCATIONS

Classification of Fractures

Fracture is a partial or complete infringement of integrity of the bone, caused by high-speed force, accompanied by damage to soft tissue.

Depending upon the origin, fractures are divided into congenital and acquired. Each of these groups, in turn, is divided into open and closed, and congenital fractures are divided into traumatic and pathological.

Intrauterine fractures are observed seldom: generally in connection with inferiority, fragility of bones of the fetus. Acquired fractures are caused by external forces, muscular contraction or in connection with pathological process in bone tissue.

Open fractures are accompanied by damage to the integrity of soft tissues and integuments.

In closed fractures the skin and mucous are intact and serve as a barrier for the penetration of an infection.

Traumatic fractures happen as a result of the action of mechanical force. After the mechanism of force application, they are divided into fractures as a result of direct blow, compression, bending, twisting and abruption of bones.

In direct blow a traversal fracture with the displacement of peripheral fragments is observed. Compression results in a compression fracture of vertebrae after bending or falling. With bending there can be oblique or traversal fractures.

The twisting of a bone with one end fixed results in the development of coiled (spiral) fracture.

Fragmented fractures are observed during sharp and strong muscular contraction, more often during attempts to stay on the feet while falling.

After the localization of the damage, fractures are divided into epiphyseal, metaphyseal and diaphyseal. According to the direction of the line of damage — into traversal, angular, longitudinal, spiral, fragmental.

Fractures may be complete and incomplete. Simple, complex and combined fractures are distinguished, as well as single and multiple.

Morphological Changes in Different Terms

after the Fracture. Formation of Bone Callous

The pathological changes in fractures and their kniting can be divided into three periods:

а) changes directly connected with trauma, aseptic inflammation development;

the period of osteogenesis;

the period of transformation of the bone callous.

At the moment of the fracture and during the first days on the area of the trauma haemorrhages, destruction of the connective tissue of bones, development of aseptic inflammations and hypostasis are marked. Leukocytes migrate to the damage zone, inflammatory exudation is observed.

The more the tissue is damaged in fracture the more extent of manifestation of such phenomena. Aseptic inflammation results in resolving the damaged tissue.

Simultaneously with clearing the area of fracture from dead cells and tissue, the process of osteogenesis takes place, which during the first two weeks results in the formation a callous.

The bone callous is formed by reproduction of periosteum cells of the bone marrow, haversian canal and connective tissue. Each of these sources of osteogenesis results in the development of a special layer of the bone callous. A bone callous consists of several layers.

The periosteal (external) callous develops from periosteum cells, enveloping the bone ends from the outside, like a muff.

From the 2nd day on the fracture place the proliferation of cells on the side of the cambial layer of the periosteum begins. Up to the 3rd–4th day there are already plenty of embryonic cells (fibroblasts, chondroblasts), young again formed vessels and osteoblasts. These osteoblasts are the main cells which form new bone tissue.

Osteogenesis takes place by way of direct development of the bone callous from ossiform tissue or previous formation of cartilage.

The endosteal, or internal, layer of the bone callous develops from endosteum cells of the bone marrow of peripheral and central bone fragments. Young cells, filling in the defect between the bone fragments, merge into a single endosteal layer of the bone callous.

The intermediary, or intermediate, layer of the bone callous develops from cellular elements of the haversian canal of bone fragments and occupies an interval between periosteal and endosteal layers. The better the reposition the smaller the layer, i.e. the denser the bone fragments adjoin to each other.

The paraoseal layer of the callous develops from tissue, which surrounds the fracture site. The greater destruction around the tissues the more it is pronounced.

The subsequent development of the bone callous occurs by two ways:

direct formation of the bone callous and ossiform tissue;

previous formation of hylin or fibrous cartilage from ossiformtissue, which further turns into bone.

It is proved that in a good stitching of the fragments and their full immobility, the direct formation of the bone callous from ossiform tissue takes place as a rule, but in their incorrect position the cartilage development is observed more often. So, fibroblasts transfer into osteoblasts and even into bone cells.

The terms of accretion (consolidation) in bone fractures are different. The formation of the primary bone callous, that is the connecting of bone fragments with ossiform tissue, occurs during 4–5 weeks. Then lime salts are deposited in the ossiform tissue, which starts the process of the secondary bone callous, proceeding from 5–6 weeks to several months depending upon the kind of the bone.

Simultaneously with osteogenesis and calcium salts deposits in ossiform tissue, the architectural reorganization of the bone callous begins: the osteoblast diffuses the ends of the bone fragments and the surplus of bone callous, renews the bone marrow canal, bone balks. Architectural reorganization is a process which can last for years.

Clinical Picture of Fractures

The clinical picture of fractures is very diverse and not always well pronounced. The basic symptoms of fracture are as follows:

Pain is felt at once after the fracture; it fades during rest andincreases during any movement of the extremity; pain is not the main symptom of fractures because it also occurs in blows and strains.

Violation of motor function is not always a typical symptomfor fracture; a very characteristic sign, for example, for fracture of the lower extremities is if the patient cannot stand on them after the trauma.

Deformation on the fracture site sometimes is sharply pronounced, but can be undistinguished, and it can be revealed only on the roentgenogram; deformation is connected with displacement of fragments.

The following kinds of displacement are distinguished:

— displacement under an angle when the axes of the fragments form an angle at the fracture site; the angle depends upon the direction of the fragments;

— lateral displacement is observed when the fragments split in the direction of its diameter;

— displacement by length; longitudinal shifting — the most often type of displacement when one fragment is shifted along another one;

— displacement by periphery occurs as a result of a turn of one of fragments, more often peripheral, around its long axis.

Mobility of fragments along the bone is a true attribute of afracture. It is well pronounced in diaphyseal fractures.

Crepitation and abnormal mobility of fragments are determinedif the bone is fixed with one hand above and the second hand below the fracture site and cautiously move in the opposite direction. The bone crunch is heard (crepitation).

First aid in fractures is the beginning of treatment, because it prevents such complications as shock, bleeding, and infection. In closed fractures the basic task of first aid is the prevention of subsequent shifting of the bone fragments and traumatizing tissue. Transport immobilization — imposing a transport splint is performed.

Besides the latter, in open fractures it’s necessary to prevent infection by imposing aseptic bandage.

Principles of Treatment, Reposition and Immobilization

The basic task of treatment of fractures is restoration of anatomic integrity of the injured bone and physiologic function of the injured organ.

Hyppocrates (more than 2 thousand years ago) applied reposition and unmovable splints. The main aim of fractures treatment is anatomic restoration of the integrity of the bone. In the 50s of the previous century M. І. Pyrogov used plaster bandages for the treatment of fractures. The study of the results of using plaster bandages proved that a long placement of the extremities in plaster provides accretion of bones, but not always restors the function of the injured extremity. Muscular atrophy, rigidity, joint immobility were observed.

Modern treatment of fractures is directed on the restoration of the anatomic structure and physiologic functions of the fractured bone. For reaching this purpose it is necessary to use consistently the following actions:

Reposition of bone fragments.

Keeping them in the correct position for accretion — immobilization (fixation).

Acceleration of the processes of accretion (consolidation).

Restoration of the function of the injured organ (rehabilitation).

Functional treatment with the application of physiotherapy exercises is used for rehabilitation of the injured organ; improvement of the general condition of the patient (nutrition, vitaminization, haemotransfusion).

Reposition. Reposition of fragments should be performed immediately after the fracture and before the development of traumatic hypostasis and reflex contraction of muscles. Bone fragments should be precisely put in correct position.

Fixating or immobilization of bone fragments in the correct position is carried out by different methods:

— plaster bandage; — stretching; — operation.

The traction method is widely applied for the treatment of fractures because it allows to safe definite movement in joints and muscular function with keeping immobilization of bone fragments. At this method the extremities are not compressed by a bandage which does not hinder blood circulation and accelerates the formation of a bone callous, prevents atrophy, decubitus, etc. The extremity completely is accessible for examination and supervision, and movement begins from the first days of treatment.

Disadvantage of this method: it requires the patient to stay in bed, which hinders X-ray control.

The method is carried out with the help of emplastic or skeletal traction.

Technique of Plaster Traction

The skin of the injured extremity is processed with spirit; the lateral surfaces are wiped with glue and a sticky plaster or pieces of flannel with the width of 6–8 cm are put on, then as a loop are thrown over the joint and paste to the external surface, afterwards redressed.

With applying plaster traction it is necessary to take into account the following features:

it should be applied within the first hours after the fracture before the occurrence of muscular retraction and traumatic hypostasis;

strips of the sticky plaster are attached to the whole segment of the extremity irregardless of the level of fracture, that provides even muscular relaxation;

joints remain mobile, which makes early movements (starting on the 2nd–3rd day) possible.

Skeletal traction is carried out with the help of a metal spoke which is driven through the bone, holding the bone with a stirrup. This technique allows to use a significant weight (up to 16 kg) to stretch muscles and repose fragments; driving the spokes through the tubercular of the tibia.

Spokes are driven through the bone with special drills and then an arch with apertures where the twine is attached is fixed to the spoke. After fixing the extremity to the Beller’s, Chaklin’s or Bogdanov’s splint, the weight of which is determined by the degree of muscular development (hip — 8–14 kg, shin — 4–8 kg) is suspended to the twine.

The operative method allows to provide the reposition and fixation of bone fragments.

Such methods of fragments fixation are applied in surgical treatment: suturing together of fragments by silk or other suturs (basically, in pediatric practice), metalosteosynthesis (fixation with metal plates, beams, screws; intramedullar osteosynthesis with the help of hinges), fixation with bone glue, ultrasonic welding of bones, compression-distraction osteosynthesis with the help of special devices — by G. Ilizarov, O. Gudushauri, etc.

Dislocation

Dislocation is an abnormal shifting of articulate surfaces in relation to each other. If the articulate surfaces cease to collide, dislocations considered as complete, partial collisions — incomplete or subluxation. Dislocations are usually accompanied by breaks in the joint capsule and the exiting of one articulate surface through this break. Depending upon the injured joint they can be dislocations of the humeral joint, etc.

It is considered that dislocations occur mostly in the bone which articulate surface is located distal concerning other bones, which take part in the formation of the definite joint. Dislocations of vertebrae are exceptions, in this case it is considered that the upper vertebra is dislocated in relation to the lower one.

Congenital dislocations, which occur in the uterus, and acquired, which develop as a result of a trauma (traumatic dislocation) or pathological in the joint (pathological dislocation) are distinguished. Acquired traumatic dislocations are observed in 80–90% of the cases.

The pathological picture — dislocations are accompanied by a rupture in the joint capsule, the ligamentous apparatus, tendons, nerves and large vessels, etc.

Clinical picture. Questioning the patient allows to find out circumstances of trauma, mechanism of damage, presence of pain in the joint that amplify during movement.

Numbness of the extremity occurs when a nerve is compressed. Deformation of the joint is marked. The diagnosis of a dislocation is proven by X-ray examination.

Treatment. The patient requires the urgent qualified care. First aid is imposing a transport splint or fixing bandage, the patient should be given sedatives and immediately directed to the hospital. Repositioning is easier and the results are better if it is carried out during the first hours after a trauma. The 2–5-day dislocations are hardly cured, and in 3–4 weeks operative intervention is necessary.

Repositioning of the dislocations should be carried out under anaesthesia. The necessary condition for fast repositioning of the dislocation is complete muscular relaxation, which is achieved by anaesthesia. The application of rough physical force results in additional damages of the joint capsule and the dislocation relapses development (habitual dislocation), frequently observed in humeral and mandible joints.

For restoration of normal anatomic relations in the joint some methods of dislocations reposition based on muscular relaxation of the joint site and transposition of the dislocated articulate surface with application of movements, characteristic to each joint, are applied. They are as if repeat in opposite order movements which occur during a dislocation of an injured joint.

The Koher’s method consists of 4 stages:

1st stage. Bending the injured hand at the ulnar joint with bringing the shoulder to the thorax.

2nd stage. The hand is extended downwards with simultaneous rotation of the shoulder.

3rd–4th stages. The hand is lifted upwards and at the same time they rotate the shoulder while putting the hand on the healthy shoulder.

The Janelidze’s method is based on physiologic muscular relaxation as a result of exhaustion of an injured extremity by weight. Immediately after repositioning a control X-ray picture is taken. The extremity is fixed for 6–10 day in a functionally favourable position by a bandage and further the complex of medical exercises is indicated.

Pathological dislocations are the result of degenerative pathological processes, which result in the destruction of a capsule and tendons (tuberculosis, tumour, etc.).

CLOSED INJURIES TO THE SKULL, THORACIC AND ABDOMINAL ORGANS

Closed Injuries to the Skull

Closed injuries to the skull, thoracic and abdominal organs are allocated into a separate group in connection with the original clinical picture and severity of the prognosis. Symptoms are determined by the kind and severity of the trauma as well as by the physiologic features of the injured organ. In many cases external attributes of the trauma are absent, and it is known only from the anamnesis. Sometimes on the contraty — with the presence of pronounced external damages (wounds, hematoma, etc.) the internal organs, locating at the trauma site, do not suffer.

The brain trauma is frequently observed. Its main reasons — street and transport accidents. Hippocrates, in due time, described the symptoms and medical policy in case of the brain trauma.

In 1575 A. Pare gave a complete description of brain concussion and at the end of the XVIII century L. Pti determined three kinds of brain damages: concussion, contusion and compression.

In 1986 a new classification of the clinical forms of damage to the skull and brain was established:

Brain concussion.

Contusion of the brain of the mild degree.

Contusion of the brain of the moderate degree.

Contusion of the brain of severe degree.

Compression of the brain against a background of its blow.

Compression of the brain without the accompanied contusion.

Peculiarities of the brain reaction to trauma consist in fast increase in venous pressure with the development of hypostasis and brain substance swelling.

Brain concussion is the most often kind of closed trauma. The brain tissue during a concussion suffers a little.

Anemia of the brain and small dotted haemorrhages, hypostasis of the brain are observed at autopsy. As a result of a trauma lymph and blood circulation of the brain, as well as function of the synapses are damaged.

Clinically the brain concussion manifests itself as loss of consciousness at the moment of the trauma, which can be short-term or lasts several hours or days. Retrograde amnesia (when the events which took place directly before the trauma disappear from the memory) is observed. At this time the patient does not react to anything, does not come into contact. The patient is pale, shallow breathing, weak pulse. The pupils are usually constricted and do not react to light, skin and tendon reflexes are weakened and do not appear. In severe cases vomiting is possible, involuntary urination and defecation.

After the severity of clinical signs three degrees of brain concussion are distinguished. In mild cases consciousness comes back to the patient in some minutes, and he orientates quickly enough with his surroundings. With moderate traumas, loss of consciousness is longer, and the patient regains gradually, frequently through the excitation period. In most severe cases the patient is unconscious for some days and regaining full consciousness occurs slowly. Having regained consciousness the patient complains of headache, nausea, vomiting. The body temperature is dicreased. In severe cases these complaints can last for a long time, sometimes years.

Treatment. Strict bed regimen for 2–3 weeks is appointed. The patient is allowed to get up after all complaints disappear. In order to reduce the intracranial pressure and hypostasis of the brain, hypertonic solutions (30–50 ml of a 40% solutions of glucose, 20–50 ml of a 10% solution of sodium chloride, 10 ml of a 40% solution of urotropin, 5–10 ml of a 25% solution of magnesium sulfate), rheogluman (10 ml/kg), diuretics (lazex, furosemide — 2–6 ml) are given daily. If there is no improvement in several days a lumbar puncture is conducted, which reduces the intracranial pressure and promotes the improvement of the patient’s subjective condition. Dexamethasone (4 mg) is introducted into the subarachnoidal cavity. In addition, a spinal puncture is desirable for diagnostic purposes: the presence of blood in the liquor specifies contusion of the brain, subarachnoidal haemorrhages or fracture to the skull basis.

Contusion of the brain is a more serious trauma, accompanied by infringement to the integrity of the brain substance on a limited site.

Pathologic-anatomically small haemorrhages directly in the brain substance as well as softening and necrosis are observed.

Clinical course. At the moment of blow the patient loses consciousness for a long time. The patient’s complaints are the same as for brain concussion but more pronounced. The temperature is increased. Neurological symptoms are observed. They can be accompanied by disturbances to mimic, sight, speaking, sensitivity, movements and coordination. Symptoms of damage to the craniocerebral nerves are more often observed. In the spinal liquid a small amount of blood can be found.

Three degrees of contusion can be distinguished — mild, moderate, severe. The treatment for brain contusion is the same as for concussions; however, bed regimen is longer — up to 1 month.

Brain compression is the result of pressure from bone fragments on the brain in case of fracture to the skull as well as intracranial haemorrhages.

Intracranial bleeding occurs in 80% of the cases with damage to the middle artery of the cranial membrane or its branches, and in the other 20% — venous sinuses, branches of vena jugularis or bones of the skull. Symptoms of brain compression can be caused by small hematomas. Blood can accumulate above it (epidural hematoma), or under the dura mater (subdural hematoma), as well as in the brain tissue — intrabrain (intracranial) hematoma.

Clinical course. At the first moment of the trauma the victim does not lose consciousness (or unconsciousness is temporary), after the trauma the patient can walk or even start to work. Headaches quickly disappear, then renew, increase and become frequently intolerable.

At the same time with the headaches there is nausea, dizziness and balance infringement. It is shallow breathing, pulse is slowed, but of good filling. On the side of the compression — the pupils are dilated, and on the whole opposite side — paralysis, reflexes disappear. Consciousness is vague or absent. If the patient is not rendered medical care, terminal status develops, then death comes.

Treatment. Only an urgent operation can save such patients. It is necessary to do cranial trepanation, if necessary ligate the injured vessel, evacuate the hematoma and remove bone fragments which can entail brain compression. The localization of the hematoma is specified with the help of angiography or computer tomography, and electroencephalography is applied for determination of the brain damage. The condition of the patient improves already during the operation. Further patients are treated as for a brain contusion.

In brain compression such complications as meningitis, arachnoiditis, abscess of the brain, traumatic epilepsy can develop; constant headaches, dizziness, more or less pronounced mental retardation may appear.

Injuries to the Thorax and Thoracic Organs

In traumas to the thorax concussion, contusion or compression of the chest wall are distinguished; at the same time closed ruptures of the lungs and bronchial tubes, damage to the heart and large vessels can be observed.

Thorax concussion is observed seldom, usually as a result of the blast action. Thorax concussion is compensated due to its elasticity. Despite this, sometimes there are damages of the organs located in it, especially the heart.

Clinical picture. The revealing of heart concussion is complicated, because clinically it is very similar with traumatic shock. Just after the trauma the patient is pale or cyanotic skin and mucous is observed, dyspnea, cold sweat, and also haemodynamic disturbances, in severe cases numerous petechia appear on the face, conjunctiva, anterior chest wall and organs of the mediastinum (traumatic asphyxia syndrome) and primary cardiac arrest can occur.

Treatment. Bed regimen is indicated, half-sitting posture. Antishock substances, oxygen therapy are applied. It is necessary to be ready for cardiac fibrillation.

Contusion and compression of the thorax are frequently accompanied by ribs fracture, blood vessels rupture and pleura damage and lungs rupture, which can further result in such complications as pneumothorax, haemothorax and hypodermic emphysema.

Pneumothorax is an accumulated air in the pleural cavity. It compresses the lungs and shifts the mediastinum to the healthy side. Usually pneumothorax is unilateral and more often develops after ribs fracture, lungs pleura and rupture. However, it may happen spontaneously.

Open, closed and tension pneumothorax are distinguished.

Clinical picture. As plenty of air can compress the lungs and shift the mediastinum and the heart to the opposite side, pronounced subjective and objective symptoms are observed. With severe pneumothorax dyspnea, cyanosis, accelerated pulse, pleuropneumonal shock can appear. Smoothing of the intercostals, arch-like expansion of the thorax and restricted respiratory movements on the injured side are typical. During percussion pronounced box-like sound appears, during auscultation — weakened respiration.

Treatment. With closed pneumothorax a puncture during which the air is removed from the pleural cavity is conducted. The puncture method is applied in the case of tension pneumothorax. If the puncture is not effective, it is necessary to conduct drainage of the pleural cavity. The external end of the drainage with a fixed valve from a finger of a rubber glove (by the type of an underwater drainage) is put into a receiver with an antiseptic solution (Bulau drainage). It is better to use active drainage with the help of a pump.

Hemothorax is blood congestion in the pleural cavity; it can develop during closed and open fractures.

Clinical picture. With mild haemothorax the blood flows down into pleural sinus and usually does not cause special complaints from the patient, even objective symptoms are absent.

With large and total pneumothorax the lung is completely compressed, the mediastinum is shifted to the opposite side, significant infringements of haemodynamics and respiration occur. Dyspnea, cyanosis, accelerated pulse of weak filling, decrease in arterial pressure are observed. During percussion acute obtusion is determined, during auscultation — significant weakening in respiration. X-ray examination reveals the level of liquid and in total haemothorax even a homogeneous dark patch is found. The pleural puncture confirms the diagnosis.

Treatment. The blood from the pleural cavity needs to be removed immediately (puncture or drainage of the pleural cavity), otherwise in due time coagulation occurs and infection of the blood.

If the blood loss through the siphon pleural drainage is larger than 1 l a day and the bleeding proceeds, it must be stopped by an emergency thoracotomy.

CLOSED INJURIES TO THE ORGANS OF THE ABDOMINAL CAVITY

The results of a blunt trauma to the stomach or the lower part of the thorax are closed damages to the organs of the abdominal cavity. The reasons for such traumas are blow or push to the stomach, falling, road and transport accidents, etc.

The character of the damage depends not only upon the kind and force of the injuring agent but also upon other circumstances — elasticity of the abdominal cavity, muscular tone and the amount of fat, degree of filling of the cavity organs.

Clinical picture. After the blunt trauma of the stomach more or less pronounced shock is usually observed.

In case of damage to the cavitary organs (stomach, small and large intestines, biliary and urinary bladder) a clinical course of acute inflammation of the peritoneum — peritonitis develops in patients at the beginning of the disease.

Treatment. An emergency operation is necessary. They remove the source causing peritonitis. If the diagnosis is late, peritonitis develops, the clinical picture of neglected diffuse peritonitis accompanied by meteorism, atony of the intestines, hiccups, vomiting develops; in several days the intoxication grows and the patient dies. For the treatment of patients with peritonitis, the department of general surgery at the Odessa State Medical University suggests a complex of actions, which consists of peritoneal lavage, peritoneal dialysis, haemosorption, lymphosorption, intubation of the intestines, forced diuresis.

Damage to the parenchymatous organs (the liver, the spleen, the kidneys) is very dangerous because of intracavitary bleeding. Already in the onset of the disease the symptomatology of acute anemia prevails. During palpation the stomach is painful, pressure of the muscles of its walls appears, and moderate symptoms of peritoneal irritation are observed. During percussion — obtusion in the lower parts of the stomach and in upper ones — thympanitis. Bleeding from the parenchymatous organs stops independently very seldom, therefore the operation is necessary to stop it.

Damage to the liver is usually stitched or tamponed with the big omentum (sometimes resection), the spleen is removed.

Organs of the abdominal cavity or retroperitoneal organs, can be damaged with fractures of the ribs or pelvic bones. Blow with damage of the ribs can cause ruptured kidneys, liver and spleen, and in case of a fractured pelvis, bone fragments can wound the urinary bladder wall. Severe traumas can become the reason for even more dangerous thoracic-abdominal injures. With suspicion of damage to the genitalia, liver or spleen an emergency laparotomy is necessary because a delay can lead to fatal consequences.