The motion of exterior brokers on the organism (mechanical, thermal, radiation, psychological, and so on.) is known as a trauma, which follows with anatomic and practical violations in organs and tissues accompanied by native and common response of an organism.
Sorts of traumatism:
1. Traumas of a non-industrial character:
а) transport (railway, car, tram);
family;
sports activities;
others (traumas on account of pure accidents).
Industrial traumas (industrial and agricultural).
Deliberate traumas (family traumas, ill-intentioned assaults,suicide makes an attempt).
Relying upon the sort of agent inflicting the injury, traumas are divided into mechanical, electrical, radiation, psychological, operational, and so on.
The division of traumas in response to the character of injury has nice worth — they are often open and closed. In open damages the gaped wounds of the pores and skin or mucous membranes might present. Microbes can penetrate by the wound of the pores and skin or mucous, selling the event of early or late problems.
Penetrating accidents, when inner organs (abdomen, thorax, cranium, joints) might be affected and non-penetrating ones are distinguished.
With a easy trauma just one sort of tissue is injured, with a fancy one — totally different tissues are broken, for instance, the pores and skin, muscle groups and bone.
The trauma is homogeneous whether it is triggered solely by one issue. If the trauma was brought on by many components, for instance mechanical trauma along with a burn, it’s mixed, and simultaneous injury to totally different techniques (concussion and damaged shin bone) is known as a joint trauma.
Traumas might be direct and oblique (damages which develop at a distance from the causative agent motion).
Traumas might be single and a number of (polytrauma). Normally traumas are acute. Nonetheless in some circumstances it’s doable to talk about continual, brought on by the dangerous affect {of professional} components.
In sufferers with extreme traumas the signs develop in a short time, the situation often is severe, very often it’s worsened by traumatic shock. Thus the surgeon ought to rapidly specify the analysis and submit the required assist. Whereas gathering the anamnesis and goal examination of an injured affected person, some circumstances require particular consideration, in distinction to the same old investigation of the surgical affected person.
Firstly, the looks of a broken space doesn’t at all times inform in regards to the severity of the injury.
Secondly, not at all times trauma the signs of that are apparent threatens the lifetime of the affected person. Prognosis of a number of traumas in sufferers who’re unconscious, in severe shock or alcoholic intoxication is very troublesome.
Thirdly, the intense common phenomena might be noticed in trauma (shock, acute anemia, traumatic toxicosis) that are essential to estimate and render a corresponding support to the affected person.
In case of extreme traumas, the place the affected person’s life is below risk, to begin with it’s obligatory to offer emergency care, after which begin gathering the anamnesis and carry out the entire examination of the affected person.
Whereas analyzing the affected person it’s obligatory to search out out the complaints, how he felt in the mean time of the trauma and after it, which support he obtained. It’s obligatory to find out accompanying illnesses.
Whereas analyzing the affected person it’s obligatory to look at intimately the broken space to specify the analysis and get earlier illustration on the character of the trauma, appoint strategies of therapy and count on for doable problems.
CLOSED INJURIES TO SOFT TISSUE
Closed accidents to comfortable tissues are divided into blows, distortions and ruptures, concussions and compression. Closed damages of soppy tissues and organs situated in cavities are noticed.
Blow is an harm to tissues and organs with out infringement of the pores and skin integrity on account of quick and short-term motion from the injuring issue on any space of the physique.
The mechanism of a trauma might be numerous, for instance, falling down on an object or influence.
The severity of the injury is set by two components:
Character of the injuring agent, its weight, consistence, speedof motion.
Kind of broken tissues (pores and skin, muscle groups, fats, bones), their bodily situation.
The medical image is characterised by ache, swelling and violation of the perform of the injured organ or space. On account of a big power motion in touching path the displacement of the pores and skin from the underlying tissues might be noticed. Shock or paralysis of the realm innervated by a particular nerve can happen on account of huge nerves bruise; contusion of the joint causes infringement of its perform, of thorax and lungs — hypodermic emphysema.
Therapy. The duty of therapy in the course of the first interval after contusion is to cease the haemorrhages in tissues. The broken organ wants relaxation, a raised place. They apply chilly, a squeezing bandage. On the 2nd–third day, when the broken vessels have shaped clots, heat, physiotherapeutic procedures are administered for the resolving of haemorrhages. With the presence of hematoma — suction and introduction of antibiotics.
Distortions and Ruptures
Distortions are injury to comfortable tissues which is brought on by a power which strains however doesn’t disturb the anatomic construction of the tissue. Nonetheless, if in such trauma mechanism the working power overcomes the tissue resistance, a rupture of the ligament, fascia, muscle groups, tendons, nerves and so on. happens. Clinically rupture of the ligament is accompanied by robust ache, violation of actions, haemorrhages into comfortable tissues and swelling within the joints. On account of haemorrhages the fluctuation might be decided throughout palpation.
Therapy consists in relaxation, imposing of compacting bandages, longterm immobilization of the joint. After the resolving of the haemorrhages from the third week it’s doable to start cautious energetic actions, massages, medical workout routines. In sluggish resolving punction is carried out and antibiotics are given.
Ruptures — full and incomplete — occur seldom, usually on account of robust and quick muscle contractions, whereas lifting weights.
Clinically they seem with robust pains, haemorrhages, hypostasis, and restriction of mobility.
Therapy. With an incomplete rupture — immobilization, relaxation, chilly, then heat, physio-procedures. With a whole rupture — operation with the next immobilization for two–3 weeks.
Concussion ends in important infringements of tissue and organ features.
Lengthy-term and robust vibration of the higher extremities firstly causes infringement of their features, after which lead to morphological modifications within the muscle groups, nerves, bones, that are the rationale for the event of sclerotic processes, restriction of working means (vibrating illness).
Compression is noticed with injury to important organs (the guts, the mind, the lungs).
Traumatic toxicosis is a particular sort of injury, which is an unique syndrome noticed throughout lengthy compression of a giant space of soppy tissues, largely the extremities, with common and native phenomena. It happens throughout landslides, earthquakes, bombardments, railway accidents. The syndrome seems after the elimination of the compressing weights. The detailed description of this syndrome was made by A. Ya. Pitel (1941), M. M. Yelansky (1950).
The extremity launched from the stress is pale with cyanotic spots. The heart beat on it isn’t palpated, sensitivity is misplaced, and motion isn’t doable. In 3–5 h the image of extreme shock with violation of CNS features — excitation, worry, nervousness after which apathy, drowsiness, injury to haemodynamics develop. Plasmorrhea and poisonous injury of the liver and kidneys happens. In extreme circumstances degenerative modifications within the kidneys and liver can happen — oliguria, hematuria, protein, cylinders in urine, anuria, uremia, hypostasis of the mind, lungs. On the third–fifth day the extremity swells, turns into dense, paralyses develops. After demise throughout dissection extreme degenerative modifications within the kidneys, degeneration and fatty degeneration of the liver, hypostasis of the mind, lungs, and so on. are noticed.
The next is necessary within the pathogenesis of the syndrome:
Injury of the CNS (shock, hypostasis of the mind, and so on.).
Absorption of poisons, uric and phosphoric acids and potassiumfrom comfortable tissues.
Violation of the hepatic-renal barrier features.
Violation of haemodynamics (elevated permeability of vesselwalls with output of plasma into intertissue cavities), trophic disturbances.
Ischemic necrosis of the muscle groups.
Therapy. The essential duties regarding liquidation of traumatic toxicosis are following:
Lower in necrosis of the muscle groups.
Lower in intoxication.
These duties are solved with the assistance of the next actions:
The broken extremity is cooled with ice to scale back traumatichypostasis and slit the pores and skin and fascia to scale back the compression of the muscle groups. In extreme circumstances the extremity is amputated to avoid wasting the affected person’s life.
Bromides, hydrochloride, atropine, glucose, novocainic blockade are utilized to stop shock and angiospasms.
Alkaline reserve of the blood is restored by intravenous introduction of 20–25 g of soda and three l of isotonic resolution; the affected person is appointed loads of fluids.
They strengthen diuresis with the assistance of diuretic preparations.
The essential position in wrestle towards intoxication throughout traumatic toxicosis belongs to strategies of extracorporal detoxing. From the very starting the regional perfusion of the injured extremity below a tourniquet for decreasing endotoxification is carried out. Haemodialysis, haemofiltration (to liquidate acute renal insufficiency), haemosorption, plasmosorption, plasmapheresis (for combating towards acute hepatic insufficiency) are used after the trauma as quickly as doable.
Common Phenomena in Trauma
Traumatic damages, in addition to different pathological processes, are accompanied by common indicators on the a part of the central nervous system and different organs and techniques subordinated to its regulating affect. Such pathological situations are clinically noticed.
Unconciousness is a sudden and short-term mind ischemia, which is expressed by lack of consciousness and sensitivity infringements.
The rationale for unconciousness is neuro-psychological moments, which by the neuromotor heart trigger reflex contraction of the peripheral blood vessels and mind vessels.
Unconciousness can occur on account of fright, worry and so on., consequently, paleness, nausea, ringing within the ears, blackness within the eyes chilly sweats, dilation of pupils, pulse lower, shallow respiratory, pale mucous and integuments are noticed.
Therapy. The affected person ought to lay with raised legs, loosened garments, and good influx of contemporary air. The affected person is given steam from liquid ammonia to inhale; the face is moistened with cool water; when the affected person regains consciousness, it’s obligatory to present him valerian drops, espresso, wine.
Collapse is a brief situation of acute cardiac weak point and a lower in vascular tone that unexpectedly seems and is accompanied by a decline in all important features.
Collapse is noticed with bleedings, septic and infectious illnesses, poisoning, narcosis, sharp pains.
The medical image of collapse is just like the medical image of shock. It’s essential to do not forget that with shock the phenomena of oppression of the nervous system prevail.
Signs: paleness that out of the blue seems, cyanosis, small, frequent pulse, shallow respiratory, lower in blood stress, chilly sweat, drop within the physique temperature, chilly extremities and muscular leisure, consciousness is stored.
Therapy. They take away the explanations for collapse, enhance cardiac exercise and the facilities of the rectangular mind. With blood loss, haemotransfusion, isotonic resolution are administered; they provide the affected person scorching tea, espresso; enter camphor, caffeine hypodermically.
Shock is a extreme common situation of the affected person, which is expressed by the oppression of the nervous system and all physiological techniques.
Initially of the XVIII century, a French physician H. Le Dran described the fundamental options of traumatic shock and often used the time period “shock” in his works.
Initially of the XIX century P. Savenko (1834) appropriately outlined shock as extreme injury to the central nervous system of the affected person.
M. I. Pyrogov gave a classical description of the medical image of shock and proved that shock ought to be thought of as a particular situation. He allotted erectile and lethargic phases and decided the methods of shock prevention and therapy.
I. M. Sechenov, I. P. Pavlov, M. S. Vvedensky, and so on. made a contribution to the understanding of phenomena going down in an organism throughout shock.
The next is on the foundation of the shock classification:
1. After the explanations of improvement:
а) traumatic;
operation;
haemotransfusional;
psychological and anaphylactic shock.
2. After the severity of medical exhibitings:
а) extreme, average and delicate;
b) I diploma — with maximal arterial blood stress of 90 mmHg ІІ diploma — ABP of 90–70 mmHg
ІІІ diploma — ABP of fifty–70 mmHg
ІV diploma — ABP is decrease than 50 mmHg.
3. After the time of improvement:
а) main — in the mean time of injury or simply after it;
b) secondary — some hours after the trauma, when neuro-reflex
violations worsen by intoxication, diffusion of merchandise of tissue disintegration, extra trauma.
The erectile section of shock develops in the mean time of trauma, short-term. It’s characterised by the presence of motoric and psychological excitation of the affected person. This section passes into lethargic, characterised by the oppression, inhibition of the nervous system and sharp lower in all important finctions of an organism.
Scientific image. M. І. Pyrogov gave the classical definition of the medical image of erectile and lethargic phases of shock.
Acute motoric and lingual excitation seems as coarse shouts, unmotivated, inexpedient actions: the affected person is unsettled, jumpy, with out paying consideration which will render hurt to himself. Dilatation of the pupils, pink face, strained, the arterial blood stress is elevated. The erectile section of shock is just like narcotic intoxication or excitation.
Pyrogov additionally described the lethargic section of shock, which is characterised by an expressive lower within the response to stimuli, slackness, apathy, lower in reflexes, and suppression of the features of the central neural system (CNS) with preservation of consciousness.
Sharp deterioration within the exercise of the cardiovascular system, paleness, frequent pulse, lower within the physique temperature, dullness of cardiac tones and reduce in blood stress, which is the main symptom of shock, and in addition blood coagulation, violation of metabolism and features of all organs and techniques, perform of the kidneys (anuria), and oxygen hunger of the tissue are marked.
The analysis is straightforward to find out by the medical image, however with a number of damages differential analysis is often difficult. It’s obligatory to review rigorously the anamnesis and symptomatology, which is able to assist decide the proper analysis.
There are the next theories of shock improvement:
The poisonous concept (Kenu), in response to which extreme violationsin the organism are brought on by poisoning with merchandise of tissue disintegration, principally from the muscle groups. Intoxication causes trichangiestesia and enhance of their permeability, which ends up in the plasma exit into the tissues and congestion of the blood within the capillaries of organs. Subsequently, the blood quantity decreases, which turns into the rationale for cardiac standstill.
The vascular-motor concept (Kreil), in response to which traumacauses a reflex paralysis within the peripheral vessels, that ends in a lower of ABP and congestion of the blood within the venous system. Blood circulation within the important organs is broken.
The Henderson’s acapnia concept explains the event ofshock by the carbonic acid discount within the blood brought on by hyperventilation throughout ache. It ends in the infringement of blood circulation, congestion of the blood and the event of acidosis within the tissue.
The neuroreflex concept is essentially the most convincing, confirmed by experimental and medical knowledge.
Shock is the organism’s response wherein the supreme elements of the CNS participate immediately. Expertise testifies that the severity of shock is set not solely by extent of trauma but in addition it localization. It’s related with quantity of receptors on the injured space and in tissue, in addition to the extent of extra components participation, which deepen shock (cooling, exhaustion, fatigue, sleeplessness, anemia).
The essential duties in shock liquidation
Termination of the stream of nervous pulses from the periphery to the middle. This process is carried out with the assistance of novocainic blockades (sympathetic, paranephral, underperiosteal).
Discount of excitability of the CNS by the creation of absolute relaxation, morphine, bromides, alcohol administration.
Struggle with components which worsen the course of shock. Largedoses of options of glucose, blood substitutes, inhalation of oxygen, haemotransfusion, plasma, potassium chloride are launched to combat towards toxemia, anoxemia, plasm- and blood loss.
Struggle towards the results of shock, restoration of broken features, haemodynamic infringements (cardiac substances, heating, haemotransfusion, plasma, blood substitutes).
All means ought to be carried out concurrently and vigorously.
BONE FRACTURES AND DISLOCATIONS
Classification of Fractures
Fracture is a partial or full infringement of integrity of the bone, brought on by high-speed power, accompanied by injury to comfortable tissue.
Relying upon the origin, fractures are divided into congenital and bought. Every of those teams, in flip, is split into open and closed, and congenital fractures are divided into traumatic and pathological.
Intrauterine fractures are noticed seldom: usually in reference to inferiority, fragility of bones of the fetus. Acquired fractures are brought on by exterior forces, muscular contraction or in reference to pathological course of in bone tissue.
Open fractures are accompanied by injury to the integrity of soppy tissues and integuments.
In closed fractures the pores and skin and mucous are intact and function a barrier for the penetration of an an infection.
Traumatic fractures occur on account of the motion of mechanical power. After the mechanism of power utility, they’re divided into fractures on account of direct blow, compression, bending, twisting and abruption of bones.
In direct blow a traversal fracture with the displacement of peripheral fragments is noticed. Compression ends in a compression fracture of vertebrae after bending or falling. With bending there might be indirect or traversal fractures.
The twisting of a bone with one finish fastened ends in the event of coiled (spiral) fracture.
Fragmented fractures are noticed throughout sharp and robust muscular contraction, extra usually throughout makes an attempt to remain on the ft whereas falling.
After the localization of the injury, fractures are divided into epiphyseal, metaphyseal and diaphyseal. In keeping with the path of the road of injury — into traversal, angular, longitudinal, spiral, fragmental.
Fractures could also be full and incomplete. Easy, complicated and mixed fractures are distinguished, in addition to single and a number of.
Morphological Modifications in Completely different Phrases
after the Fracture. Formation of Bone Callous
The pathological modifications in fractures and their kniting might be divided into three durations:
а) modifications immediately related with trauma, aseptic irritation improvement;
the interval of osteogenesis;
the interval of transformation of the bone callous.
For the time being of the fracture and in the course of the first days on the realm of the trauma haemorrhages, destruction of the connective tissue of bones, improvement of aseptic inflammations and hypostasis are marked. Leukocytes migrate to the injury zone, inflammatory exudation is noticed.
The extra the tissue is broken in fracture the extra extent of manifestation of such phenomena. Aseptic irritation ends in resolving the broken tissue.
Concurrently with clearing the realm of fracture from lifeless cells and tissue, the method of osteogenesis takes place, which in the course of the first two weeks ends in the formation a callous.
The bone callous is shaped by copy of periosteum cells of the bone marrow, haversian canal and connective tissue. Every of those sources of osteogenesis ends in the event of a particular layer of the bone callous. A bone callous consists of a number of layers.
The periosteal (exterior) callous develops from periosteum cells, enveloping the bone ends from the surface, like a muff.
From the 2nd day on the fracture place the proliferation of cells on the facet of the cambial layer of the periosteum begins. As much as the third–4th day there are already loads of embryonic cells (fibroblasts, chondroblasts), younger once more shaped vessels and osteoblasts. These osteoblasts are the principle cells which kind new bone tissue.
Osteogenesis takes place by the use of direct improvement of the bone callous from ossiform tissue or earlier formation of cartilage.
The endosteal, or inner, layer of the bone callous develops from endosteum cells of the bone marrow of peripheral and central bone fragments. Younger cells, filling within the defect between the bone fragments, merge right into a single endosteal layer of the bone callous.
The middleman, or intermediate, layer of the bone callous develops from mobile components of the haversian canal of bone fragments and occupies an interval between periosteal and endosteal layers. The higher the reposition the smaller the layer, i.e. the denser the bone fragments adjoin to one another.
The paraoseal layer of the callous develops from tissue, which surrounds the fracture web site. The larger destruction across the tissues the extra it’s pronounced.
The next improvement of the bone callous happens by two methods:
direct formation of the bone callous and ossiform tissue;
earlier formation of hylin or fibrous cartilage from ossiformtissue, which additional turns into bone.
It’s proved that in a great stitching of the fragments and their full immobility, the direct formation of the bone callous from ossiform tissue takes place as a rule, however of their incorrect place the cartilage improvement is noticed extra usually. So, fibroblasts switch into osteoblasts and even into bone cells.
The phrases of accretion (consolidation) in bone fractures are totally different. The formation of the first bone callous, that’s the connecting of bone fragments with ossiform tissue, happens throughout 4–5 weeks. Then lime salts are deposited within the ossiform tissue, which begins the method of the secondary bone callous, continuing from 5–6 weeks to a number of months relying upon the sort of the bone.
Concurrently 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 excess of bone callous, renews the bone marrow canal, bone balks. Architectural reorganization is a course of which may final for years.
Scientific Image of Fractures
The medical image of fractures could be very numerous and never at all times properly pronounced. The essential signs of fracture are as follows:
Ache is felt without delay after the fracture; it fades throughout relaxation andincreases throughout any motion of the extremity; ache isn’t the principle symptom of fractures as a result of it additionally happens in blows and strains.
Violation of motor perform isn’t at all times a typical symptomfor fracture; a really attribute signal, for instance, for fracture of the decrease extremities is that if the affected person can not stand on them after the trauma.
Deformation on the fracture web site typically is sharply pronounced, however might be undistinguished, and it may be revealed solely on the roentgenogram; deformation is related with displacement of fragments.
The next sorts of displacement are distinguished:
— displacement below an angle when the axes of the fragments kind an angle on the fracture web site; the angle relies upon upon the path of the fragments;
— lateral displacement is noticed when the fragments break up within the path of its diameter;
— displacement by size; longitudinal shifting — essentially the most usually kind of displacement when one fragment is shifted alongside one other one;
— displacement by periphery happens on account of a flip of one among fragments, extra usually peripheral, round its lengthy axis.
Mobility of fragments alongside the bone is a real attribute of afracture. It’s properly pronounced in diaphyseal fractures.
Crepitation and irregular mobility of fragments are determinedif the bone is fastened with one hand above and the second hand beneath the fracture web site and cautiously transfer in the other way. The bone crunch is heard (crepitation).
First support in fractures is the start of therapy, as a result of it prevents such problems as shock, bleeding, and an infection. In closed fractures the fundamental process of first support is the prevention of subsequent shifting of the bone fragments and traumatizing tissue. Transport immobilization — imposing a transport splint is carried out.
Moreover the latter, in open fractures it’s obligatory to stop an infection by imposing aseptic bandage.
Ideas of Therapy, Reposition and Immobilization
The essential process of therapy of fractures is restoration of anatomic integrity of the injured bone and physiologic perform of the injured organ.
Hyppocrates (greater than 2 thousand years in the past) utilized reposition and unmovable splints. The primary purpose of fractures therapy is anatomic restoration of the integrity of the bone. Within the 50s of the earlier century M. І. Pyrogov used plaster bandages for the therapy of fractures. The research of the outcomes of utilizing plaster bandages proved {that a} lengthy placement of the extremities in plaster offers accretion of bones, however not at all times restors the perform of the injured extremity. Muscular atrophy, rigidity, joint immobility have been noticed.
Fashionable therapy of fractures is directed on the restoration of the anatomic construction and physiologic features of the fractured bone. For reaching this objective it’s obligatory to make use of persistently the next actions:
Reposition of bone fragments.
Protecting them within the appropriate place for accretion — immobilization (fixation).
Acceleration of the processes of accretion (consolidation).
Restoration of the perform of the injured organ (rehabilitation).
Useful therapy with the appliance of physiotherapy workout routines is used for rehabilitation of the injured organ; enchancment of the final situation of the affected person (diet, vitaminization, haemotransfusion).
Reposition. Reposition of fragments ought to be carried out instantly after the fracture and earlier than the event of traumatic hypostasis and reflex contraction of muscle groups. Bone fragments ought to be exactly put in appropriate place.
Fixating or immobilization of bone fragments within the appropriate place is carried out by totally different strategies:
— plaster bandage; — stretching; — operation.
The traction technique is broadly utilized for the therapy of fractures as a result of it permits to secure particular motion in joints and muscular perform with protecting immobilization of bone fragments. At this technique the extremities aren’t compressed by a bandage which doesn’t hinder blood circulation and accelerates the formation of a bone callous, prevents atrophy, decubitus, and so on. The extremity utterly is accessible for examination and supervision, and motion begins from the primary days of therapy.
Drawback of this technique: it requires the affected person to remain in mattress, which hinders X-ray management.
The tactic is carried out with the assistance of emplastic or skeletal traction.
Strategy of Plaster Traction
The pores and skin of the injured extremity is processed with spirit; the lateral surfaces are wiped with glue and a sticky plaster or items of flannel with the width of 6–8 cm are placed on, then as a loop are thrown over the joint and paste to the exterior floor, afterwards redressed.
With making use of plaster traction it’s essential to bear in mind the next options:
it ought to be utilized throughout the first hours after the fracture earlier than the incidence of muscular retraction and traumatic hypostasis;
strips of the sticky plaster are hooked up to the entire section of the extremity irregardless of the extent of fracture, that gives even muscular leisure;
joints stay cellular, which makes early actions (beginning on the 2nd–third day) doable.
Skeletal traction is carried out with the assistance of a metallic spoke which is pushed by the bone, holding the bone with a stirrup. This method permits to make use of a big weight (as much as 16 kg) to stretch muscle groups and repose fragments; driving the spokes by the tubercular of the tibia.
Spokes are pushed by the bone with particular drills after which an arch with apertures the place the twine is hooked up is fastened to the spoke. After fixing the extremity to the Beller’s, Chaklin’s or Bogdanov’s splint, the load of which is set by the diploma of muscular improvement (hip — 8–14 kg, shin — 4–8 kg) is suspended to the twine.
The operative technique permits to offer the reposition and fixation of bone fragments.
Such strategies of fragments fixation are utilized in surgical therapy: suturing collectively of fragments by silk or different suturs (principally, in pediatric follow), metalosteosynthesis (fixation with metallic plates, beams, screws; intramedullar osteosynthesis with the assistance of hinges), fixation with bone glue, ultrasonic welding of bones, compression-distraction osteosynthesis with the assistance of particular units — by G. Ilizarov, O. Gudushauri, and so on.
Dislocation
Dislocation is an irregular shifting of articulate surfaces in relation to one another. If the articulate surfaces stop to collide, dislocations thought of as full, partial collisions — incomplete or subluxation. Dislocations are often accompanied by breaks within the joint capsule and the exiting of 1 articulate floor by this break. Relying upon the injured joint they are often dislocations of the humeral joint, and so on.
It’s thought of that dislocations happen largely within the bone which articulate floor is situated distal regarding different bones, which participate within the formation of the particular joint. Dislocations of vertebrae are exceptions, on this case it’s thought of that the higher vertebra is dislocated in relation to the decrease one.
Congenital dislocations, which happen within the uterus, and bought, which develop on account of a trauma (traumatic dislocation) or pathological within the joint (pathological dislocation) are distinguished. Acquired traumatic dislocations are noticed in 80–90% of the circumstances.
The pathological image — dislocations are accompanied by a rupture within the joint capsule, the ligamentous equipment, tendons, nerves and enormous vessels, and so on.
Scientific image. Questioning the affected person permits to search out out circumstances of trauma, mechanism of injury, presence of ache within the joint that amplify throughout motion.
Numbness of the extremity happens when a nerve is compressed. Deformation of the joint is marked. The analysis of a dislocation is confirmed by X-ray examination.
Therapy. The affected person requires the pressing certified care. First support is imposing a transport splint or fixing bandage, the affected person ought to be given sedatives and instantly directed to the hospital. Repositioning is simpler and the outcomes are higher whether it is carried out in the course of the first hours after a trauma. The two–5-day dislocations are hardly cured, and in 3–4 weeks operative intervention is critical.
Repositioning of the dislocations ought to be carried out below anaesthesia. The mandatory situation for quick repositioning of the dislocation is full muscular leisure, which is achieved by anaesthesia. The appliance of tough bodily power ends in extra damages of the joint capsule and the dislocation relapses improvement (routine dislocation), often noticed in humeral and mandible joints.
For restoration of regular anatomic relations within the joint some strategies of dislocations reposition primarily based on muscular leisure of the joint web site and transposition of the dislocated articulate floor with utility of actions, attribute to every joint, are utilized. They’re as if repeat in reverse order actions which happen throughout a dislocation of an injured joint.
The Koher’s technique consists of 4 phases:
1st stage. Bending the injured hand on the ulnar joint with bringing the shoulder to the thorax.
2nd stage. The hand is prolonged downwards with simultaneous rotation of the shoulder.
third–4th phases. The hand is lifted upwards and on the similar time they rotate the shoulder whereas placing the hand on the wholesome shoulder.
The Janelidze’s technique is predicated on physiologic muscular leisure on account of exhaustion of an injured extremity by weight. Instantly after repositioning a management X-ray image is taken. The extremity is fastened for six–10 day in a functionally beneficial place by a bandage and additional the complicated of medical workout routines is indicated.
Pathological dislocations are the results of degenerative pathological processes, which consequence within the destruction of a capsule and tendons (tuberculosis, tumour, and so on.).
CLOSED INJURIES TO THE SKULL, THORACIC AND ABDOMINAL ORGANS
Closed Accidents to the Cranium
Closed accidents to the cranium, thoracic and belly organs are allotted right into a separate group in reference to the unique medical image and severity of the prognosis. Signs are decided by the sort and severity of the trauma in addition to by the physiologic options of the injured organ. In lots of circumstances exterior attributes of the trauma are absent, and it’s identified solely from the anamnesis. Generally on the contraty — with the presence of pronounced exterior damages (wounds, hematoma, and so on.) the interior organs, finding on the trauma web site, don’t endure.
The mind trauma is often noticed. Its important causes — road and transport accidents. Hippocrates, in due time, described the signs and medical coverage in case of the mind trauma.
In 1575 A. Pare gave a whole description of mind concussion and on the finish of the XVIII century L. Pti decided three sorts of mind damages: concussion, contusion and compression.
In 1986 a brand new classification of the medical types of injury to the cranium and mind was established:
Mind concussion.
Contusion of the mind of the delicate diploma.
Contusion of the mind of the average diploma.
Contusion of the mind of extreme diploma.
Compression of the mind towards a background of its blow.
Compression of the mind with out the accompanied contusion.
Peculiarities of the mind response to trauma consist in quick enhance in venous stress with the event of hypostasis and mind substance swelling.
Mind concussion is essentially the most usually sort of closed trauma. The mind tissue throughout a concussion suffers a bit.
Anemia of the mind and small dotted haemorrhages, hypostasis of the mind are noticed at post-mortem. On account of a trauma lymph and blood circulation of the mind, in addition to perform of the synapses are broken.
Clinically the mind concussion manifests itself as lack of consciousness in the mean time of the trauma, which might be short-term or lasts a number of hours or days. Retrograde amnesia (when the occasions which came about immediately earlier than the trauma disappear from the reminiscence) is noticed. Right now the affected person doesn’t react to something, doesn’t come into contact. The affected person is pale, shallow respiratory, weak pulse. The pupils are often constricted and don’t react to mild, pores and skin and tendon reflexes are weakened and don’t seem. In extreme circumstances vomiting is feasible, involuntary urination and defecation.
After the severity of medical indicators three levels of mind concussion are distinguished. In delicate circumstances consciousness comes again to the affected person in some minutes, and he orientates rapidly sufficient together with his environment. With average traumas, lack of consciousness is longer, and the affected person regains step by step, often by the excitation interval. In most extreme circumstances the affected person is unconscious for some days and regaining full consciousness happens slowly. Having regained consciousness the affected person complains of headache, nausea, vomiting. The physique temperature is dicreased. In extreme circumstances these complaints can final for a very long time, typically years.
Therapy. Strict mattress routine for two–3 weeks is appointed. The affected person is allowed to rise up in spite of everything complaints disappear. With a view to cut back the intracranial stress and hypostasis of the mind, hypertonic options (30–50 ml of a 40% options of glucose, 20–50 ml of a ten% resolution of sodium chloride, 10 ml of a 40% resolution of urotropin, 5–10 ml of a 25% resolution of magnesium sulfate), rheogluman (10 ml/kg), diuretics (lazex, furosemide — 2–6 ml) are given day by day. If there isn’t any enchancment in a number of days a lumbar puncture is carried out, which reduces the intracranial stress and promotes the development of the affected person’s subjective situation. Dexamethasone (4 mg) is introducted into the subarachnoidal cavity. As well as, a spinal puncture is fascinating for diagnostic functions: the presence of blood within the liquor specifies contusion of the mind, subarachnoidal haemorrhages or fracture to the cranium foundation.
Contusion of the mind is a extra severe trauma, accompanied by infringement to the integrity of the mind substance on a restricted web site.
Pathologic-anatomically small haemorrhages immediately within the mind substance in addition to softening and necrosis are noticed.
Scientific course. For the time being of blow the affected person loses consciousness for a very long time. The affected person’s complaints are the identical as for mind concussion however extra pronounced. The temperature is elevated. Neurological signs are noticed. They are often accompanied by disturbances to imitate, sight, talking, sensitivity, actions and coordination. Signs of injury to the craniocerebral nerves are extra usually noticed. Within the spinal liquid a small quantity of blood might be discovered.
Three levels of contusion might be distinguished — delicate, average, extreme. The therapy for mind contusion is identical as for concussions; nevertheless, mattress routine is longer — as much as 1 month.
Mind compression is the results of stress from bone fragments on the mind in case of fracture to the cranium in addition to intracranial haemorrhages.
Intracranial bleeding happens in 80% of the circumstances with injury to the center artery of the cranial membrane or its branches, and within the different 20% — venous sinuses, branches of vena jugularis or bones of the cranium. Signs of mind compression might be brought on by small hematomas. Blood can accumulate above it (epidural hematoma), or below the dura mater (subdural hematoma), in addition to within the mind tissue — intrabrain (intracranial) hematoma.
Scientific course. On the first second of the trauma the sufferer doesn’t lose consciousness (or unconsciousness is short-term), after the trauma the affected person can stroll and even begin to work. Complications rapidly disappear, then renew, enhance and change into often insupportable.
On the similar time with the complications there’s nausea, dizziness and stability infringement. It’s shallow respiratory, pulse is slowed, however of fine filling. On the facet of the compression — the pupils are dilated, and on the entire reverse facet — paralysis, reflexes disappear. Consciousness is imprecise or absent. If the affected person isn’t rendered medical care, terminal standing develops, then demise comes.
Therapy. Solely an pressing operation can save such sufferers. It’s essential to do cranial trepanation, if obligatory ligate the injured vessel, evacuate the hematoma and take away bone fragments which may entail mind compression. The localization of the hematoma is specified with the assistance of angiography or pc tomography, and electroencephalography is utilized for willpower of the mind injury. The situation of the affected person improves already in the course of the operation. Additional sufferers are handled as for a mind contusion.
In mind compression such problems as meningitis, arachnoiditis, abscess of the mind, traumatic epilepsy can develop; fixed complications, dizziness, roughly pronounced psychological retardation might seem.
Accidents to the Thorax and Thoracic Organs
In traumas to the thorax concussion, contusion or compression of the chest wall are distinguished; on the similar time closed ruptures of the lungs and bronchial tubes, injury to the guts and enormous vessels might be noticed.
Thorax concussion is noticed seldom, often on account of the blast motion. Thorax concussion is compensated attributable to its elasticity. Regardless of this, typically there are damages of the organs situated in it, particularly the guts.
Scientific image. The revealing of coronary heart concussion is difficult, as a result of clinically it is extremely comparable with traumatic shock. Simply after the trauma the affected person is pale or cyanotic pores and skin and mucous is noticed, dyspnea, chilly sweat, and in addition haemodynamic disturbances, in extreme circumstances quite a few petechia seem on the face, conjunctiva, anterior chest wall and organs of the mediastinum (traumatic asphyxia syndrome) and first cardiac arrest can happen.
Therapy. Mattress routine is indicated, half-sitting posture. Antishock substances, oxygen remedy are utilized. It’s essential to be prepared for cardiac fibrillation.
Contusion and compression of the thorax are often accompanied by ribs fracture, blood vessels rupture and pleura injury and lungs rupture, which may additional lead to such problems as pneumothorax, haemothorax and hypodermic emphysema.
Pneumothorax is an accrued air within the pleural cavity. It compresses the lungs and shifts the mediastinum to the wholesome facet. Normally pneumothorax is unilateral and extra usually develops after ribs fracture, lungs pleura and rupture. Nonetheless, it could occur spontaneously.
Open, closed and stress pneumothorax are distinguished.
Scientific image. As loads of air can compress the lungs and shift the mediastinum and the guts to the other facet, pronounced subjective and goal signs are noticed. With extreme pneumothorax dyspnea, cyanosis, accelerated pulse, pleuropneumonal shock can seem. Smoothing of the intercostals, arch-like growth of the thorax and restricted respiratory actions on the injured facet are typical. Throughout percussion pronounced box-like sound seems, throughout auscultation — weakened respiration.
Therapy. With closed pneumothorax a puncture throughout which the air is faraway from the pleural cavity is carried out. The puncture technique is utilized within the case of stress pneumothorax. If the puncture isn’t efficient, it’s essential to conduct drainage of the pleural cavity. The exterior finish of the drainage with a hard and fast valve from a finger of a rubber glove (by the kind of an underwater drainage) is put right into a receiver with an antiseptic resolution (Bulau drainage). It’s higher to make use of energetic drainage with the assistance of a pump.
Hemothorax is blood congestion within the pleural cavity; it will possibly develop throughout closed and open fractures.
Scientific image. With delicate haemothorax the blood flows down into pleural sinus and often doesn’t trigger particular complaints from the affected person, even goal signs are absent.
With giant and whole pneumothorax the lung is totally compressed, the mediastinum is shifted to the other facet, important infringements of haemodynamics and respiration happen. Dyspnea, cyanosis, accelerated pulse of weak filling, lower in arterial stress are noticed. Throughout percussion acute obtusion is set, throughout auscultation — important weakening in respiration. X-ray examination reveals the extent of liquid and in whole haemothorax even a homogeneous darkish patch is discovered. The pleural puncture confirms the analysis.
Therapy. The blood from the pleural cavity must be eliminated instantly (puncture or drainage of the pleural cavity), in any other case in due time coagulation happens and an infection of the blood.
If the blood loss by the siphon pleural drainage is bigger than 1 l a day and the bleeding proceeds, it have to be stopped by an emergency thoracotomy.
CLOSED INJURIES TO THE ORGANS OF THE ABDOMINAL CAVITY
The outcomes of a blunt trauma to the abdomen or the decrease a part of the thorax are closed damages to the organs of the belly cavity. The explanations for such traumas are blow or push to the abdomen, falling, street and transport accidents, and so on.
The character of the injury relies upon not solely upon the sort and power of the injuring agent but in addition upon different circumstances — elasticity of the belly cavity, muscular tone and the quantity of fats, diploma of filling of the cavity organs.
Scientific image. After the blunt trauma of the abdomen roughly pronounced shock is often noticed.
In case of injury to the cavitary organs (abdomen, small and enormous intestines, biliary and urinary bladder) a medical course of acute irritation of the peritoneum — peritonitis develops in sufferers at first of the illness.
Therapy. An emergency operation is critical. They take away the supply inflicting peritonitis. If the analysis is late, peritonitis develops, the medical image of uncared for diffuse peritonitis accompanied by meteorism, atony of the intestines, hiccups, vomiting develops; in a number of days the intoxication grows and the affected person dies. For the therapy of sufferers with peritonitis, the division of common surgical procedure on the Odessa State Medical College suggests a fancy of actions, which consists of peritoneal lavage, peritoneal dialysis, haemosorption, lymphosorption, intubation of the intestines, compelled diuresis.
Injury to the parenchymatous organs (the liver, the spleen, the kidneys) could be very harmful due to intracavitary bleeding. Already within the onset of the illness the symptomatology of acute anemia prevails. Throughout palpation the abdomen is painful, stress of the muscle groups of its partitions seems, and average signs of peritoneal irritation are noticed. Throughout percussion — obtusion within the decrease elements of the abdomen and in higher ones — thympanitis. Bleeding from the parenchymatous organs stops independently very seldom, due to this fact the operation is critical to cease it.
Injury to the liver is often stitched or tamponed with the large omentum (typically resection), the spleen is eliminated.
Organs of the belly cavity or retroperitoneal organs, might be broken with fractures of the ribs or pelvic bones. Blow with injury of the ribs could cause ruptured kidneys, liver and spleen, and in case of a fractured pelvis, bone fragments can wound the urinary bladder wall. Extreme traumas can change into the rationale for much more harmful thoracic-abdominal injures. With suspicion of injury to the genitalia, liver or spleen an emergency laparotomy is critical as a result of a delay can result in deadly penalties.