Diaphyseal fractures account for about 30% of the total number of fractures of the lower leg bones. Among the diaphyseal fractures of the lower leg bones, fractures of both bones predominate. Isolated fractures of the tibia are observed less frequently, fractures of the fibula are especially rare. With diaphyseal fractures of the leg bones, displacements of fragments in width, then displacements in length, at an angle, and finally around its axis, are most often encountered. Among the displacements in width, the displacements of the distal fragment posteriorly and outwardly prevail. The unrepaired displacement of fragments in width has an adverse effect on the course of the process of fracture fusion. When the fragments are shifted in width by 1 / 2-2 / 3 of the cross-sectional area of the bone, the period of consolidation of the fragments slows down, and more significant displacements that disrupt the contact between the fragments can cause a fracture to not heal . Displacements of fragments along the length are relatively rarely greater than 1.5-2 cm, however, their removal is still necessary to achieve good adhesion of fragments and restore the functional length of the limb. Unrepaired displacements at an angle open anteriorly make it possible to load a damaged limb only under conditions of recurrence of the knee joint. Unrepaired displacements at an angle open outwards cause excessive load on the inner edge of the foot, which contributes to the development of flat feet. No less adverse are the displacements of fragments around its axis.
Symptoms of diaphyseal fractures of the lower leg
The degree and nature of deformation during diaphyseal fractures of the lower leg bones depends on the features of the displacement of the fragments. With a careful examination of the limbs, it is possible to note the angular curvature of the axis of the leg, rotation of its distal section.
The most constant signs of diaphyseal fractures of the leg bones should be recognized as local pain and the impossibility of resting on the injured leg, which are especially important for isolated fractures of the tibia and fractures of both bones of the leg without displacement. For isolated fractures of the fibula, the most characteristic sign is local pain along the fibula. The support function and function of adjacent joints during these fractures may not be impaired.
Other signs of diaphyseal fractures of the lower leg bones include swelling, an increase in local temperature, and rapid bruising, the occurrence of which is associated with the surface location of the lower leg bones. Quite often, with diaphyseal fractures of the leg bones, bubble formation is observed in connection with the onset of a sharp violation of the lymph and blood circulation in the limb.
Prognosis of diaphyseal fractures of the lower leg bones
The prognosis of diaphyseal fractures of the leg bones largely depends on the age of the patient: the healing of fractures in children occurs much faster than in adults. The period of consolidation of fractures of both lower leg bones is longer than fractures of the tibia and especially of the tibia. The degree of damage to surrounding tissues, especially the periosteum, is also of great importance for the healing of fractures.
Treatment of diaphyseal fractures of the lower leg bones
When adjusting the diaphyseal fractures of the lower leg bones, the greatest attention is paid to eliminating the displacements of the fragments at an angle and around its axis, which most sharply affect the function of the limb. When eliminating the displacement of fragments across the width, it is planned to create a good contact between the fragments, which is necessary for the normal course of the bone tissue regeneration process. The reduction of diaphyseal fractures of the lower leg bones is achieved by various methods. The most commonly used is simultaneous manual reduction, which is indicated by fresh transverse fractures, fresh oblique, screw-shaped and multi-fragmented fractures that are not accompanied by a significant displacement along the length, angular displacement fractures and all leg fractures in children. Manual simultaneous reduction is performed under local anesthesia, for which 20-30 ml of 1% novocaine solution is injected into the fracture area. The patient is laid on the table in a supine position. A damaged limb is given a bent position, to ensure which a wedge-shaped stand is placed under the thigh. The first assistant grabs the heel and the adjacent part of the Achilles tendon with his right hand, and the rear of the foot with his left; the second assistant fixes the area of the knee joint with both hands. Through traction and protivotyagu , assistants gradually eliminate the offset length, as determined by measuring the comparative tibial length. After that, the first assistant, giving the foot the correct position, eliminates the displacement of fragments around the axis by pressure and back pressure with the hands in the opposite direction. The doctor also eliminates the displacement at an angle: for this, he creates an emphasis with his hand in the region of the apex of the curvature while simultaneously deflecting the distal part of the leg in the same direction. A plaster cast is applied to hold the fragments in the adjusted position. In case of diaphyseal fractures of the leg bones, it is most advisable to fix fragments using a U-shaped plaster bandage to the knee joint (fractures in the lower and middle third of the leg) or a circular unlined dressing to the middle third of the thigh, if there is a bone fracture in the upper third of the leg. If simultaneous reduction fails, the use of skeletal traction is indicated. Skeletal traction is carried out using the terminal for the ankles of the lower leg or knitting needle inserted into the calcaneus or lower tibia megaphysis . The lower leg is placed on an orthopedic pillow or a metal splint when bending the knee joint at an angle of 150 °. The initial load of 3 kg is gradually increased during the first 2-3 days to 5-8 kg. After eliminating the displacement of fragments along the length, the displacement in width and at an angle is eliminated with the help of side adjusting loops providing a gradual and very gentle effect on the fracture area. Upon reaching the reduction using constant skeletal traction, the skeletal load is gradually reduced to 3 kg. At this level, it is left until the initial consolidation (3-4 weeks), then, without removing the skeletal traction, a plaster cast is applied. The needle is removed when the plaster cast hardens. When applying a circular, non- laying gypsum dressing, it is recommended to gypsum the stirrup and allow walking with a load on the limb. When using a U-shaped plaster cast, a gypsum sheet is initially applied on the side surfaces of the lower leg from the joint space of the knee joint on the outer surface, enveloping the plantar surface of the foot, to the joint space of the knee joint on the inner surface. Gypsum rings are placed taking into account the fracture level so that one of the rings well covers the fracture area. After applying a plaster cast, the patient is prescribed bed rest and an elevated position for a damaged limb. Pay attention to the tightness of the dressing. With an increase in edema or a decline , 1-2 rings or all three are replaced. In recent years, an operative method of treating fractures has attracted considerable interest, which, along with absolute indications, is also currently used for relative indications. Absolute indications for surgical treatment of diaphyseal fractures of the lower leg bones include interposition of soft tissues and inefficiency of other reduction methods. Relative indications include oblique and helical fractures, in which the precise anatomical comparison of the fragments is easier to achieve operatively and the conditions for the earliest functional load of the injured limb are ensured. It is advisable to combine open reduction with diaphyseal fractures of the lower leg with osteosynthesis of the tibia . Osteosynthesis of the tibia is carried out using a bone graft, a metal plate (Lena, K.M. Klimova, N.V. Novikova), a metal rod and wire. Considering the anatomical and physiological features of the tibia, the simplest and most gentle method of osteosynthesis of this bone is the imposition of circular circular sutures that ensure the holding of fragments in the vira in a captive position until the onset of fusion. After that, it is advisable to fix the damaged shin with a plaster bandage in order to prevent possible angular displacements in connection with early active functional therapy. Fixation stops only after the patient begins to fully load the injured limb: on average, after a month with isolated fractures of the tibia and after 3-4 months with isolated fractures of the tibia and fractures of both bones of the leg. After removing the plaster cast, the patient is prescribed warm foot baths, therapeutic exercises and massage. In the presence of pronounced residual phenomena after the fracture (limitation of movements in the ankle joint, atrophy of soft tissues, swelling), more energetic thermal procedures are prescribed up to mud therapy. Depending on the timing of the fusion of fractures, the terms of disability of patients are established. In case of isolated fractures of the tibia, the period of incapacity for work for patients is 5 weeks, for isolated fractures of the tibia and for fractures of both bones of the lower leg for 3-4 months. Persons engaged in heavy physical labor, after a fracture of the tibial or both bones of the lower leg, begin to work 2-3 weeks later than the specified time.
Calcaneus fractures
erelomy calcaneus make up 3-4% of the total number of fractures. The mechanism of injury in most cases is direct. Most often this is a fall from a height on the heels. The following fractures should be distinguished: 1) the body of the calcaneus; 2) its anterior process; 3) calcaneal tuber. With these fractures, a rather characteristic type of displacement in the form of a duck beak should be especially noted.
Symptoms of calcaneus fractures
Characteristic clinical signs are changes in the contours of the heel: it is flattened, widened and swollen, which is especially clearly seen during a comparative examination of both feet from behind. The hemorrhage is located mainly in the epigastric regions, more on the inside. The heel is usually premium, the longitudinal arch is noticeably flattened. Soreness is especially pronounced during palpation of the heel from the sides and when it is compressed. The heel load is not possible due to sharp pains. A very characteristic sign is the almost complete absence of active movements and sharp pains with passive movements in the subtalar joint. In fractures of the calcaneal tuber with the displacement of fragments in the proximal direction, the restriction and weakening of the plantar flexion of the foot is characteristic. For a final diagnosis, identifying the nature of the fracture and choosing a method of treatment, an X-ray examination is necessary (in two or even three projections).
Heel fracture treatment
Treatment varies by fracture type. In case of calcaneus fractures without displacement, the foot and lower leg are fixed with a circular plaster cast to the knee joint for a period of 3-6 weeks. In the future, physiotherapeutic treatment, massage and physiotherapy are prescribed. In fractures with displacement of fragments and, therefore, with violation of the arches of the foot, treatment should be aimed at restoring the latter. In multi-fragmented fractures, this is achieved by reposition of fragments on the wedge or Schultz redressor . Reduction is performed under local anesthesia with 1% novocaine solution or under general anesthesia. To relax the triceps muscle of the leg, the leg is bent at the knee joint, and the foot is given the position of plantar flexion. When repositioning fragments and applying a cast, it is very important to model the longitudinal arches of the foot well. The period of fixation with a plaster cast is 8 weeks. The load of the foot is allowed no earlier than 3 months after the fracture, with the mandatory condition of wearing arch support for at least six months. In case of calcaneal fractures with a significant displacement of its posterior section, skeletal traction beyond the calcaneal tubercle is used. After 40-45 days, skeletal traction is replaced by a circular gypsum dressing with good modeling of the arch of the foot, applied for a period of 1 – P / 2 months. Upon removal of the bandage, a gradual load of the foot is permitted provided that the arch support is used. Disability is restored after 4-5 months. In case of fractures of the “duck beak” type with significant displacement, an open comparison of fragments with their fixation with a metal nail or screw is used. Some authors use fixation of fragments in fractures of the calcaneus with knitting needles.
Talus fracture
Fractures of the talus are rare. It should be noted that not a single muscle is attached to the talus. Bone fractures usually occur when falling from a height. Fractures of the neck of the talus most often occur, which for the most part are not accompanied by a significant displacement of fragments, less often – fractures of her body and posterior process. In some cases, as a result of severe violence, not only the displacement of the broken body of the talus bone can occur, but also its complete dislocation, accompanied by a rupture of the posterior ligaments and ankle bags. The body of the talus dislocated posteriorly and located behind the tibia sharply stretches the Achilles tendon and presses the skin inside or out of the Achilles tendon, which can cause ischemia and even necrosis.
Symptoms of talus fractures
In the area of the foot and ankle joint, swelling and hemorrhage are determined, especially pronounced in the inner ankle. Characteristic is a small plantar flexion and adduction of the foot. In fractures with displacement of fragments, deformation is detected, sharp pain along the joint gap is determined by palpation . With a fracture of the neck, it is more pronounced in the front, with fractures of the posterior process, posterior and external;
from the Achilles tendon. With dislocations of the body of the talus, the latter is felt in the region of the Achilles tendon inside and out of it. Active foot movements are usually difficult, passive – sharply limited and painful, especially with back flexion. The pathognomonic sign is the soreness of the passive back flexion of the first finger, which is explained by the location of the tendon of the long flexor of the thumb, on which the talus is suspended. To clarify the diagnosis, x-ray is required in two projections (it is necessary to remember the extra bone – os tibiale externum ).
Treatment of talus fractures
. In case of talus fractures without displacement of fragments, treatment is reduced to immobilization of the foot with the back gypsum splint for a period of 4-5 weeks. However, in order to avoid stiffness in the ankle joint, it is necessary to remove the limb from the tire in 2-3 weeks and to appoint active movements in the ankle joint. It is possible to load the foot only if there is an orthopedic insole and not earlier than after 7-8 weeks. Disability is restored after 2.5-3 months.
With an isolated fracture of the posterior process, the posterior gypsum splint is applied for 2-3 weeks. In the presence of pain and functional impairment, the question may arise of removing the broken fragment.
In case of fractures with a displacement, an attempt to close reduction should not be made. It is necessary to conduct an open reduction of fragments. After surgery, skeletal traction for the calcaneus is applied with the early appointment of therapeutic exercises. In severe cases of fractures with dislocation of the body of the talus, the most appropriate operation is the complete removal of the entire talus, and not just the dislocated fragment ( astragalectomy ) with a shift of the foot posteriorly.
Toe deformity
Hallux valgus ( Hallux valgus )
We are talking about the deviation of the big toe in the metatarsophalangeal joint in the lateral direction. In this regard, the tendon of the muscle leading to the toe moves from the inner to the plantar side.
Etiology of hallux valgus
Hallux valgus is a consequence of transverse flatfoot. The more pronounced the deviation of the thumb from the axis, the more the direction of traction of the flexors and extensors of the finger changes.
Hallux Valgus Clinic
Patients primarily complain of pain arising from pressure in the head region of the first metatarsal bone. The stronger the thumb is curved, the greater the deviation of the tendon of the muscle leading it to the plantar side. As a result of this, the soft tissue lining in the area of this bone is significantly reduced , and with continuing loads, a mucous bag forms here. The skin above the prominent head of the metatarsal bone is thinning, becoming atrophic and sensitive to cold. The said deformation causes the displacement of the II and III fingers either above or below the I finger. In the places where the fingers touch, corns are formed.
Treatment for hallux valgus
Treatment is initially carried out conservatively, its main task is to prevent hallux valgus deformity or its further development. For these purposes, therapeutic gymnastics of the foot, walking barefoot, the use of inserts and night tires are indicated. It is possible to provide orthopedic shoes. In many cases, the progression of the disease cannot be stopped, then surgical treatment becomes necessary. Depending on age, degree of deformation, degenerative changes in the joint of the thumb, various methods of surgical interventions are offered.
Hammer toe
Hammer-like deformity is characterized by strong flexion of the big toe in the interphalangeal and extension of the toe in the metatarsophalangeal joints. Etiology. This deformation, apparently, is due to the increased tension of the flexors of the big toe due to the flattening of the longitudinal arch.
Clinical Foot Deformity Clinic
Pain occurs both in the area of the interphalangeal joint from the dorsal side and on the terminal phalanx of the thumb when wearing ordinary shoes. In places under pressure from shoes, corns form.
Treatment of deformity of the big toe
With position defects, you can try to relieve the tension of the flexors with the help of liners. In addition, orthopedic gymnastics for the foot is necessary. If the deformation cannot be passively corrected, surgical treatment is indicated.
Rigidity of the metatarsophalangeal joint of the big toe
We are talking about rigidity of the metatarsophalangeal joint of the big toe.
Etiology. The disease develops as a result of degenerative changes in the metatarsophalangeal joint of the big toe (deforming arthrosis) or injuries. Clinic. When the foot rolls from heel to toe, pain occurs. Additionally, inflammatory reactions may develop in this area. Treatment. Special insoles, orthopedic shoes or accessories are used for commercially available shoes. Short-wave irradiation and events that improve blood circulation in this area are prescribed. In the absence of the desired effect, surgical treatment is indicated.
Hammerlike and clawlike toes
Speaking of hammer-like toes, they mean the position of the flexion of the fingers in the distal and extension in the interphalangeal and metatarsophalangeal joints. Clinic. Clinic of pain in the distal joints from the dorsal side and in the tips of the toes, as well as corns due to mechanical irritations. Treatment. Treatment for defects in position is carried out conservatively: therapeutic gymnastics, inserts in the shoes are prescribed, walking barefoot is recommended. With persistent deformation, surgical treatment is necessary.
Metatarsal Fractures
These fractures account for about 2% of all fractures, and among the fractures of the bones of the foot, they take first place. As a rule, they are the result of direct trauma, most of all falling to the rear moans of gravity, compression of the foot with the wheel, etc. Significant displacements of fragments are observed quite rarely, which is explained by the presence of other intact metatarsal bones, which play the role of a natural tire and protect fragments from significant displacements in width and especially in length. Only with a fracture of several: bone displacements of fragments can be significant.
Symptoms of metatarsal fractures
. The clinical picture depends on the nature of the injury, the number of broken bones and the presence or absence of displacement of fragments. Constantly occurring symptoms: swelling of the back of the foot, bruising, localized soreness. The symptom of Jacobson is considered pathognomonic: when pressure is applied to the head of the metatarsal bone from the side of the sole, localized pain at the fracture site is revealed.
For diagnosis, radiography should also be used. Fractures of the base of the metatarsal bones, especially III and IV, are also not always detected on the radiograph due to overlapping shadows of the base of these bones. Therefore, when radiography, the foot must be removed in the pronation position at an angle of 45 °, which eliminates overloading.
Metatarsal Fracture Treatment
Fractures of the metatarsal bones without displacement or with a slight displacement are treated by unloading the diseased limb and fixing the Beler wire splint (for fractures of one bone) and the posterior gypsum splint with good modeling of the arch (for multiple fractures). The fixation period is on average about 3 weeks.
The displacement of fragments, if significant, must be eliminated, since, forming a protrusion in the back or, even worse, in the plantar side, they cause pain during exercise and interfere with the wearing of shoes.
The reduction technique is as follows. The plaster back tire is made. Each broken metatarsal bone is anesthetized with 1% novocaine solution. The limb is bent at the knee joint, the back of the foot is set with the plantar surface at the edge of the table. Reposition is carried out by sipping with one hand the corresponding finger, with the other hand local impact on the fragments is performed, the assistant at this time provides a traction , fixing the lower leg and foot of the patient. When the reduction is achieved, a plaster cast is applied to the knee. The fixation period is on average 3-4 weeks. Upon termination of fixation, warm baths, massage and physiotherapy exercises for the ankle joint are prescribed. After 4-5 weeks, a light load is indicated. Full load can only be permitted with an orthopedic insole. Disability with isolated fractures is restored after 40 days, with multiple fractures – after 2 months.