IV. The Content of education

1. To the basic methods of treatment of fractures of bones concern: extension, a plaster bandage, operative treatment. These methods are applied in a complex with physiotherapy exercises, massage, mehanotherapy, a physiotherapy.

The real estate in situ fracture can be framed by three basic expedients:

1) a plaster bandage;

2) to stationary values extension,

3) osteometalosinthesis.

At fractures function of an extremity as a result of damage both the bone, and environmental is broken.

The real estate of an extremity worsens a circulation and lymphatic circulation, promotes formation of an edema, result is an arrest of development of muscles, an osteoporosis and tightly mobile joints.

Recommencing of function of an extremity and serviceability of the patient is reached by the functional treatment. The functional method of treatment perceive early application of the active, painless motions in joints (from intention a maximum quantity of joints), rhythmical cuttings and release phenomena of muscles immobilization a segment of an extremity at the full real estate of well deposited spalls their osteal accreting.

The functional method can be applied at treatment of fractures by different expedients: extension, a plaster bandage, an osteosynthesis. Constant extension is one of the most applied expedients of treatment of fractures.

2. Expedients of conservative treatment of fractures.

Treatment of fractures by means of plaster bandages.

Fractures without shift of spalls, or it is necessary for them to lead occluded reposition comparison of osteal spalls, their content in the real estate on a continuance of formation osteal callus, including early function of the defective segment are a subject to such treatment.

The success of comparison of osteal spalls depends on high-grade anesthesia which takes out reflex constriction. In the majority accidents the local anesthesia by a method of injection 0,5 - 1 % of a solution of Novocainum in a hematoma in a place of fracture is applied. For this purpose a band of fracture handle a solution of an iodine, infiltration a skin Novocainum (at fracture of a humeral bone, bones of shin bone), up to 30 ml (at fracture of a femur). If blood from a hematoma a needle refer in other direction as injection of Novocainum outside of a hematoma does not yield anesthetizing effect is not gained in a squirt gun. At an insufficient aboriginal anaesthesia apply the general anesthesia.

Repositional Spalls is their shift and exact comparison on a line of fracture. For elimination of rotatory shift the peripheric spall should be given the correct standing concerning a long axis of an extremity. At fractures of bones of a forearm in medial and inferior thirds of extremity the medial standing between about the nation and a supination is given. Elimination of an angle of displacement is reached by alignment of a distal spall and recommencing of a long axis of an extremity. Elimination of shift of spalls longwise sometimes requires the appreciable efforts to overcome traction of reflexly reduced muscles, especially at repositional and spalls of a femur. Shift of spalls longwise is simultaneously eliminated by counteraction of proximal and distal spalls also.

Summing up the above-stated technique of comparison of spalls it is necessary to ooze, that the philosophy is comparison of a distal spall in relation to proximal.

For the content of the compared spalls plaster bandages which were applied widely in 50th years of a before last century by M.I.Pirogov are imposed.

At putty plaster bandages of an extremity give a medial physiologic standing. For the inferior extremity - a flexion in thigh joint and patellar joints under an angle 140-150^о, for the upper extremity - abduction of a brachium under an angle 60^о, a flexion under an angle 30^о and a flexion of a forearm under an angle 90^о. The immobilization a plaster bandage prolongs by time of accreting of fracture.

Medial terms of accreting of fractures of bones.

Localization of fracture Term immobilization (day)

Clavicle 30-40

Scapula 50-55

Fibular bone 30-40

Humeral bone 60-70

Ulna 45-60

Radial bone 45-60

Both bones of a forearm (diaphis) 45-50

Whirl bone 60-85

Diaphysis of a femur 45-60

Shin a bone 100-120

Both bones of an anticnemion (diaphis) 80-100

Nick of a femur 90-100

Method of constant} elongation.

The method of constant elongation treats oblique, spiral, a joint, the open fractures of extremities with shift of spalls, and their content to formation osteal callus. Reposition of a distal spall it is necessary to refer on an axis proximal, gradually enlarging a load for strendhs muscles.

For skeletal elongation the tooling spoke Кirshner, manual, or electrical special instrument is necessary. Before carrying out of a spoke level-by-level anesthesia of a skin, a hypodermic fat, muscles, a periosteum of 0,5 % by a solution of Novocainum in a place of the admitted injection and a yield of a spoke is spent. At fracture of a femur a spoke spend through epicondilus or silling shin bones. Thus a spoke spend from the outside to the middle. At fractures of bones of an anticnemion - through heel a bone measuring on 2 sm, from top to bottom from vertex of an exterior ossicle and 1,5 sm back. At fracture of a humeral bone - through a ulnar process, acting on 2 sm from its vertex from the middle outside. After a yield of a spoke from a bone in a hypodermic fat a skin pierce manually that the spoke is not reeled skins, and in places of an inlet and a yield of a spoke fix sterile gauze globules. For the prevention of migration of a spoke it anchor special fixatives on arc Кirshner a spoke tension, that she did not hog and did not gash the soft tissues, the inferior extremity conclude in a physiologic standing on splint Belera, upper - hang on the apparatus №1. The mass of a load is defined by mass of the patient, development of muscles, quantity of shift of spalls. However at fractures of bones of an anticnemion - 10 %, or are equaled to the first digit of a weight of the patient, and at fracture of a femur still to add half of this value.

Sсeletal elongation allows to observe constantly of an extremity, to spend motions in joints, to refine a circulation in an extremity. This method is termed as functional.

At children till 5 years of elongation Zinc - gelatin is spent by Pasta Una by means of baffles which are fixed to a skin.

At fractures of a cervical department of a column loop Glissona, or the special plug for elongation for a head use.

Operative treatment of fractures.

Distinguish terrain clearance and relative displays for operative treatment of fractures. Terrain clearance indications - interposition the soft tissues between the spalls, the complicated fractures damage by osteal spalls of greater receptacles, nerves, main or a spinal cord, the open fractures with the appreciable damage of the soft tissues, intraarticulate fractures with disturbance congruention articulate surfaces.

The relative indications - spiral, skew, spalls fractures, cross-section fractures of a humeral bone, diaphisis fractures with shift of spalls on breadth.

For an osteosynthesis of spalls use metal hinges (intramedular an osteosynthesis or upboue), screws, apparatus of exterior bracing of spalls (behind source compression-distraction an expedient) which is used at the open fractures with a major defect of the soft tissues, concomitant inflammatory processes, artificial joints and another. Principles to an osteosynthesis: exact comparison of spalls, their stable content on all continuance of accreting, early medical gymnastics - rehabilitation treatment.

At the open fractures the primary surgical treatment of a wound, the active drainage of a wound with a constant lavage its aseptic solutions within 8-10 days, antibiotic therapy is spent.

For last decades the quantity of a grass has considerably grown, especially at road accident. In this connection the important place belongs to granting of the help not only at fractures and dislocations on be for hospital and early hospital stages. The doctor of any of a lateral view should be able to diagnose a dislocation, to assist in situ adventures, to set a dislocation, correctly to lead immobilization, to appoint rehabilitation treatment.

The dislocation terms the full shift of the articulate extremities of bones with damage of a sheath and ligaments of a joint. The subluxation is a particulate shift of the articulate extremities of bones. Always dislocation distal a segment of an extremity in relation to proximal. So, if there was a dislocation in a shoulder joint it is necessary to term it as a dislocation of a brachium, a dislocation in a ulnar joint - a dislocation of a forearm, a dislocation in thigh joint - a dislocation of a femur, a dislocation in a knee joint - a dislocation of an anticnemion. Vertebra dislocation upper in relation to inferior.

Pathological anatomy.

At a dislocation the sheath and ligaments of a joint always educes, there is a hemorrhage in a vacuity of a joint and environmental tissues. Exception is the dislocation of a mandible which is not accompanied by a disrupture of a sheath, and also nee dislocations. At a dislocation environmental tissues, nerves, vascular and absorbent vessels, muscles are injured.

Frequency of dislocations in different joints depends on anatomic and physiologic features of a joint, its shape, the dimensions, an elastance of an articulate sheath, arrangement and strength of ligaments, volume of the active and passive motions in joints. There is a dislocation in ball-shaped and blacks joints more often. The dislocation in a shoulder joint compounds 50-60 % of all dislocations. Its frequency caused by an anatomic constitution - a flat, small articulate surface and the appreciable dimensions a head of a brachium. The second place behind frequency borrows a dislocation of a forearm - 20 %. Distinguish: nee dislocations which result from disturbance of development of a joint; traumatic dislocations which parent are traumas; pathological - as a result of fracture of a joint by inflammatory process, a tumour; ordinarydislocations which often iterate at ordinary motions without a trauma.

Distinguish dislocations fresh - by 3-rd day after a trauma, stale - from 3 day by 2-nd weeks, become outdated - it is more 2-3-х than weeks.

The basic complaint at dislocations is the pain and limitation of a motion in a joint. At the survey of the patient the unusual forced standing of an extremity, or its segment, elastic motions in a joint, deconfiguration and strain of a joint is observed. Sometimes it is possible palpate dislocation the extremity of a bone. At a dislocation acromial the extremity of a clavicle there is a positive sign of a key (by pressing the distal extremity of a clavicle strain in a field clavio-acromial to make in park peters, and at annealing - occurs).

At survey of the patient with a dislocation it is necessary to define a pulsing of peripheral receptacles which can peter as a result of pressing or a disrupture of receptacles, to check disturbances of sensitivity and motions of segments of an extremity. Radiological survey allows to erect a standing of articulate surfaces and a view of a dislocation, presence of possible fractures of bones.

Plaster bandage. The bandage from a gypsum is well simulated, directly adjoins to a body of the patient, is prompt harden. Before applying of a plaster bandage, lake gips bandage alight in a basin with warm water on 1-3хв will not cease to be oozed yet from water of air traps. After that the wetted material take both arms and by easy stages compresed. At put wadding a plaster bandage it is necessary to prepare for cotton in the form of rollers that them it was possible to cover a body of the patient easily and promptly. For allay plaster bandages special gypseous tables, supports under a back, a basin, leg-takes and other inventory are necessary.

At applying a plaster bandage it is necessary to protect osteal performances from pressure, enclosing under a bandage in these places cotton wool-gauze pillows, precisely to simulate bandages in relation to acting contours of a body when the gypsum yet has not hardened.

At applying non wadding plaster bandages immediately on a body impose dilatational longett which then anchor circular courses of gypseous bandage.

At manufacturing wadding plaster bandages cotton which impose immediately on a body of the patient, all over again directly bandage ordinary bandage. Circular stratums of a plaster bandage are on duty with dilatational{longitudinal} lateral strips. Such locating of stratums provides to a plaster bandage strength.

Model operation of a bandage carry out all palm, especially in fields of osteal performances. Sustain an extremity at applying a plaster bandage also all palm to prevent by incompresion.

The induration of a plaster bandage descends already during its} manufacturing, in the proximate 5-10 days after applying a bandage. For a desiccation of a bandage 1-3 day is necessary term. It is possible to accelerate a desiccation of a bandage by warming by its different expedients. The Plaster bandage it is impossible to consider finished, if on it the specification not superimposed on the yielded fracture. On a plaster bandage binding following records:

1) at fracture of a bone - the diagrammatic representation x-ray to a picture with a sketch of primary shift;

2) date when there was a fracture;

3) date putt bandages (specify what time imposed);

4) date of the stipulated cast removal;

5) a surname of the doctor that has bandaged.

After applying a bandage it is necessary to execute control roentgenography. The picture in this period is more important, than to applying a plaster bandage when there is an opportunity clinically to erect shift of spalls. Doctors on duty and sisters should be consulted, that on a state of patients at the first o'clock and days after applying the dummy plaster bandage it is necessary to observe. At complaints to a pain narcotics to yield it is impossible. The sensation of squeezing of an extremity, narrowness „ crawling of ants ”, a numbness and also cyanotic, specify paleness, an edema and a cold snap of dactyls of the defective extremity disturbance of a circulation. Complaints to pressure in any place under a bandage formation of decubituses testifies to aboriginal disturbance of a trophicity. In such events a plaster bandage it is necessary immediately рассечь. Slit a plaster bandage special{express} scissors which lead along the soft{weak} tissue of a body, repelling them. Important correctly to hold and to lead scissors. Their cutting part should stand almost perpendicularly to a plaster bandage. Scissors move forward on distance up to 1 see Edges of the slited plaster bandage make a helpless gesture, forcepses. The student on a mockup or a moulage can to allow lead a spoke by means of special instrument that he could get skills in this manipulation. Sometimes for sceletal extention apply a stirrup.