Ankle fractures are very common, accounting for about 40% of all shin bone fractures. Ankle fractures are divided into typical and atypical. The first include: a) isolated fractures of one of the ankles; b) fractures of both ankles; c) fractures of the inner ankle with an ankle fracture of the fibula ( Dupuytren fracture); d) ankle fractures with marginal tibia fractures ( Desto fracture ). All other types of ankle fractures and their combinations relate to atypical fractures. The most common are external ankle fractures and Dupuytren fractures. Edge fractures of the tibia in the form of isolated lesions are extremely rare. Most often they are combined with biloben fractures. Due to the anatomical position and mechanical features of the ankle joint, ankle fractures are formed in the vast majority of cases under the action of a direct injury. This takes place in cases when the lateral and rotational movements of the foot go beyond the normal range of motion (tucking the foot inwards or outwards). In this case, movements in the direction of the dorsal and plantar flexion of the foot, as well as the forced rotation of the lower leg around the longitudinal axis, which almost always occurs during a fall with a relatively fixed foot, are also known. Ankle fractures with displacement, as well as marginal fractures of the tibia ( Desto fractures ) should be considered as fractures- dislocations. In this case, the foot is shifted, as a rule, outwards and very rarely inside . With a fracture of the posterior edge of the articular surface of the tibia, the foot is shifted posteriorly, with a fracture of its anterior surface, anteriorly. More often, the posterior edge of the articular surface of the tibia suffers
Symptoms of fractures of lodges
Swelling and hemorrhages occur, localized mainly in the fracture area. Sometimes swelling reaches a fairly significant size and captures the entire foot. When the joint between the tibia and tibia (ankle forks) ruptures, the supradermal region appears to be enlarged. In the presence of a subluxation of the foot, it is most often shifted outwards and backwards. In these cases, it deviates outward from the axis of the lower limb, and its posterior part (the back shoulder of the foot lever) appears to be enlarged. Palpation in the area of the fracture is always determined by localized pain. Movement in the ankle and subtalar joints is limited and painful.
The clinical picture of isolated fractures of the external ankle and both ankles without displacement is less typical, which leads in some cases to diagnostic errors: the fracture is mistaken for distortion or contusion. A differential diagnostic sign is the nature and localization of pain. With distortion, it is found under the ankle anterior and anterior to it, is more or less diffuse in nature, with fractures, soreness is determined in the region of the ankle itself and is more localized. Finally, the issue is solved by x-ray, made necessarily in two projections.
Treatment of fractures of lodges
Treatment of patients with ankle fractures without displacement is reduced to the reliable holding of fragments in the correct position. This is achieved by applying a U-shaped plaster cast.
Treatment of ankle fractures with displacement of fragments requires the most accurate anatomical reposition, since only under this condition a good anatomical and functional outcome is possible.
The reduction technique is as follows. Anesthesia is performed for 30-40 ml of a 1% solution of novocaine. The patient lies on his back. The tibia is held by the assistant, the foot by the surgeon. After traction along the length during a fracture of the inner ankle with displacement and subluxation of the foot to the outside, the latter is eliminated by pressure on the foot below the fracture area in the direction from the outside to the inside . With this foot, a varus position is attached , which eliminates the very typical external displacement of the inner ankle. Hypercorrection of foot displacements does not occur due to tension of the ligaments located in the outer part of the ankle joint and foot. An equally typical displacement of the foot anteriorly is eliminated by applying pressure with the thumb on its anteroposterior margin anteriorly to the back and giving the foot a back flexion position.
In case of fractures of the posterior edge of the articular surface of the tibia with a displacement accompanied by; subluxation of the foot backwards, reduction is carried out with a thrust of the foot on its axis in front and protivotyage tibia posteriorly. For traction of the lower leg, it is recommended to use a loop of bandage, one end of which is thrown over the lower leg over the ankle joint, the other falls almost to the floor and is pulled down by the surgeon’s note. After this, the foot is given the position of maximum dorsal flexion. Reduction occurs due to the tension of the joint bag, pressing the broken fragment to the mother’s bone.
In case of fracture of the anterior edge of the articular surface of the tibia with displacement and subluxation of the foot anterior, the latter, when repositioned, shifts posteriorly, the tibia anteriorly. After this, the foot is given the position of maximum plantar flexion. The reduction mechanism is the same as in the previous case. After the bone has been repositioned, a U-shaped plaster cast is applied. You can also apply a blank, unlined plaster cast to the knee. These types of fractures require especially careful anatomical reposition, otherwise the intraarticular step remaining due to incompletely eliminated displacement, violating the congruence of the articular surfaces, leads to deforming arthrosis and pain. If the fork of the ankle joint diverges, it is necessary to restore its normal relations, which is achieved by squeezing the lower leg at the level of both ankles. The specially created nonphysiological positions of the foot, which provide the reduction of fracture- dislocations ( varus , dorsum and plantar flexion), must be kept in a plaster cast for 3 weeks. After the specified period, the bandage is changed, and the foot is brought back to normal position. In order to prevent persistent edema, therapeutic gymnastics is appointed already in the 2nd week, consisting in a frequent change in the position of the leg: alternating its elevated position and complete lowering. The fixation period for a fracture of the outer ankle is 4 weeks, and the inner and both ankles are 6 weeks. In cases where, in addition to an ankle fracture, there is a fracture of the posterior edge of the articular surface of the tibia, in the first 3 weeks after reduction, the U-shaped plaster cast is supplemented with the posterior layer to prevent sagging of the heel and relapse of posterior displacement. During the period of fixation, it is very important to ensure that the bandage does not loosen. Upon removal of the plaster cast, dosed load, massage and movements in the ankle (but not in the subtalar ) joint are prescribed . Disability is restored with a fracture of the external ankle after 2 months, a fracture of the inner and both ankles after 3-3.5 months. In order to prevent the development of post-traumatic flatfoot with valgus of the foot, which is especially often observed during Dupuytren’s fractures, it is necessary to use orthopedic insoles for at least six months. In cases when simultaneous reposition fails, patients must be hospitalized for skeletal traction. In case of unsuccessful conservative reduction, as well as stale and chronic fractures, surgical treatment is used. In an open way, the displaced fragment is adjusted and fixed with a metal nail or screw. When the distal articulation of the shin bones diverges, an open reduction of the fibula is performed, followed by fixation with a metal screw.
The longitudinal axis of the legs is not a straight line, but curved so that when the medial condyles of the femur come into contact between the medial ankles there is a certain interval.
Etiology of x-shaped legs
At 2-6 years of life, often against the background of normal growth, a slightly pronounced X-shaped position of the legs may occur, which compensatory entails the development of an external clubfoot. With reduced elasticity of the ligamentous apparatus or with too much stress (for example, with excess body weight), physiological curvature of the leg may increase, sometimes significantly. In addition, X-shaped legs can also be the result of traumatic injuries.
Clinic x-shaped legs
The degree of deviation from the axis is determined in centimeters by measuring the distance between the medial ankles with the knee joints brought together. In childhood, an interval of up to 5 cm can be considered normal. In children and adolescents, complaints rarely occur. In adults, depending on the severity of the X-shaped position of the legs due to improper distribution of loads, degenerative changes in the knee joints ( gonarthrosis ) may develop . The specified deformation is observed on one and on both lower extremities.
Treatment in preschool age is necessary only when the distance between the ankles exceeds 5 cm, since in this case the spontaneous reverse development of the pathological process is excluded. First, conservative measures should be carried out: use shoe inserts correcting the external clubfoot to shift the direction of pressure loads on the inner side of the leg (for example, inserts with high edges), conduct therapeutic exercises to strengthen the muscles and ligaments, and also use night tires. With a pronounced pathology, surgical treatment (corrective osteotomy) may be required even during the period of growth and formation of the skeleton.
In adults, persistent deformities are usually observed, so only symptomatic treatment is carried out mainly for knee arthrosis.
Femur diaphysis fractures
The most common fractures are in the middle third of the thigh . According to our data, hip fractures at the mentioned level are noted in 24.9% of cases. Hip fractures in the upper third in frequency take second place, while hip fractures in the lower third are in last place.
Symptoms of femoral diaphysis fractures
Bruising and tearing of the tissues during hip fractures contribute to the occurrence of traumatic edema, leading to an increase in the volume of the thigh.
Large blood loss due to hemorrhage in the tissue, as well as significant pain irritation often lead to the development of shock in the victim. In such cases, therapeutic measures should primarily be aimed at removing the patient from this condition. The displacement of fragments during diaphyseal hip fractures can be very diverse: to the side, along the length, at an angle and rotational. It should be noted that the level of fracture of the femur and the nature of the displacement of the central and peripheral fragments are subject to certain patterns. So, with hip fractures in the upper third, the central fragment due to retraction m. ileo-psoas is shifted anteriorly, and due to retraction mm . glutaei med . et . min . – out. The distal fragment under the action of traction of the adductors is displaced inward, and under the influence of gravity is somewhat posterior. These displacements lead to typical breeches. With hip fractures in the middle third, there is no typical displacement, but fragment displacement along the length is especially strong sometimes. In fractures of the femur in the lower third, a typical displacement is observed: the central fragment due to traction of the adducting muscle group is displaced inwards , and the peripheral fragment under the influence of traction of the calf muscles is posterior. Depending on the nature of the action of external forces at the time of the injury, the position of the fragments of the femur may be atypical.
Diagnosis of femoral diaphysis fractures
In a clinical study of the patient, swelling in the fracture area, curvature of the axis of the thigh, rotation of the peripheral limb outward or inward , shortening of the limb, and mobility in an unusual place (along the bone) are determined . A patient cannot actively raise a straightened limb. Crepitus is sometimes found.
When examining a patient with a hip fracture, it should be remembered that the fracture may be accompanied by damage to a large vessel or nerve. This fundamentally changes the treatment plan.
A clinical examination of a patient with a hip fracture should result in radiography of the damaged segment. This will clarify the nature of the fracture and the degree of displacement of the fragments, which is important to know when choosing a treatment method.
Treatment of femoral diaphysis fractures
Treatment (patients with diaphyseal hip fractures can be conservative and operative.
Children can be given simultaneous reduction and hold fragments with a well-modeled plaster cast. In adults, depending on the indications, either skeletal traction or osteosynthesis should be used. A
needle or terminal is placed over the condyles of the thigh, glue traction on the lower leg. A damaged limb, placed so that the peripheral fragment was located on the axis of the proximal. So, with a fracture of the femoral diaphysis in the upper third of the sun I limb should be led to an angle of 120-130 ° to the bispinal line and bent at the knee and hip joints at an angle of 140 °. A thrust along the axis with a load of 8-10 kg within 2-3 days eliminates the displacement of fragments along the length, and giving the limb the necessary position and the use of a system of adjusting loops make it possible to eliminate other types of displacements.If the patient has a hip fracture in the lower third of the diaphysis ( supracondylar fracture), the needle is inserted either through the distal fragment, or with a very low fracture through the tibial tuberosity bones. A damaged limb must be given a flexion position in the knee joint at an angle of 60-70 °, at which the calf muscle, relaxing, reduces the effect on the distal, posteriorly displaced fragment. This position can easily be created by placing the lower leg on a wedge-shaped pillow. Complementing traction along the axis of the thigh with a system of additional loops, fragments are usually repositioned and consolidated. In case of a hip fracture in the middle third, when typical displacements are not observed, skeletal traction is applied, giving the injured limb a mid-physiological position: flexion in the knee and hip joints at an angle of 130-140 °, abduction 100 ° to the bispinal line, Maximum load on skeletal traction, as with hip fractures of other locations, it usually does not exceed 9-10 kg, on adhesive rods 2-3 kg. The method of skeletal traction in the treatment of patients with hip diaphysis fractures creates peace for the injured limb, allows early use of functional treatment, the average duration of skeletal traction is 3-4 weeks and the subsequent adhesive traction – 2-3 weeks. The average time for restoration of disability for individuals of physical labor is 5-6 months, for persons of mental labor – 4-5 months. Along with conservative treatment of patients with hip fractures, surgical intervention is widely used in the cases indicated. It is used both for fresh hip fractures (transverse fractures, double fractures, etc.), fractures with soft tissue interposition, open fractures, and for incorrectly fused fractures, pseudarthrosis , etc. During surgery, after exposure and reduction of fragments, or another fixator: in case of oblique and helical fractures, some authors put in circular circular seams (at least two!), with the transverse plane of the fracture, the fragments are often fixed with Klimov T-beam. The most common for fixing femoral fragments was a metal rod (of various designs), which is inserted into the medullary canal. To reposition fragments and conduct the rod, the fracture site is exposed. A metal rod is retrogradely introduced into the proximal fragment from the side of the wound, which is brought out through the intertrochanteric fossa and the skin incision above it. Then fragments are set in the wound and the rod is guided into the distal fragment. In the postoperative period, the limb is placed on the Belera splint or fixed with a plaster cast for 2-3 weeks, after which the patient is allowed to walk on crutches, and then with a stick and without additional support. The average period of incapacity for work for patients with a fracture of the femur in whom the method of intraosseous fixation of fragments with a metal pin was applied is 3-4 months.