Fractures of the femoral neck account for 25% of the total number of fractures of the femur. The vast majority of these fractures occur in the elderly. Most often, a fracture of the femoral neck occurs as a result of a fall on its side, in the region of the greater trochanter. There are medial and lateral femoral neck fractures. Medial include subcapital fractures, in which the fracture surface passes at the base of the head, and transdermal ; to lateral – fractures of the base of the femoral neck and transversal . The latter are often comminuted and are accompanied by fragments of the greater and lesser trochanters.
Symptoms of femoral neck fractures
The diagnosis of femoral neck ovary is established on the basis of anamnesis and clinical data: localized soreness; in the presence of displacement of fragments along the length of a shortened limb; impaired function: the patient may bend his leg, but is not able to tear off the heels from the horizontal plane (symptom of “Adhered heel”). Radiography in two projections confirms the diagnosis.
The peculiarity of the blood supply to the femoral neck, as well as its biomechanical features, determine the delayed dark fusion of fractures in this area. This is especially true for medial fractures, in which 6-12 months of fixation are sometimes necessary.
The blood supply to the neck and femoral head occurs mainly due to the terminal vessels, which penetrate the neck in the area of attachment of the joint bag to it. With a medial fracture of the neck, the blood vessels that feed the central fragment are broken, which leads to a violation of the trophism of the fracture site, especially of the central fragment, and as a result to delayed and insufficient corns formation . The vertical location of the plane of fracture of the femoral neck also turns out to be on the fusion of fragments, in which forces act not on the axis of the neck, but perpendicular to it, on the cut, acting on the fragments.
Treatment of femoral neck fractures
Conservative and surgical methods for treating femoral neck fractures are proposed. Conservative methods include the simultaneous reduction of Whitman fragments (after preliminary anesthesia) and fixation of the limb with a circular plaster cast in the position of internal rotation and abduction of the thigh. In this case, a plaster cast is applied from the costal arch to the entire damaged limb (leaving the toes free), as well as to healthy yoga to the knee joint. Strengthen the plaster cast with a wooden spacer.
If there are contraindications to the application of a plaster cast, skeletal traction is also used in the Whitman position.
The long periods of treatment with conservative methods and the frequent nonunion of fragments (false joints) have led to an increase in indications for surgical treatment of medial femoral neck fractures.
Currently, medial fractures of the femoral neck, in addition to knocked together, are treated by the method of extra-articular intraosseous osteosynthesis with the help of a trihedral or three-lobed nail made of high-quality stainless steel, which is driven through a small incision of soft tissues in the pretreatment region.
More than 100 special guiding devices have been proposed for the correct introduction of a trihedral nail, which often presents known difficulties. A three-lobed nail must be inserted into both fragments so that its end does not come out of the bone, but takes a central position in the femoral head. An incision is made on the outer surface of the thigh, in the undervert region. Using a guiding device or special calculations determine the direction of introduction of the nail. Preliminarily, an exact comparison of fragments with skeletal traction is necessarily achieved or the thigh is lowered on the operating table. Control over the state of the fragments and the holding of the rod is carried out using x-rays in the operating room.
During the operation, in addition to the correct position of the rod, it is necessary to achieve knocked together bone fragments for their better consolidation. After osteosynthesis, x-ray control is necessary (in two projections).
Surgical treatment allows you to raise patients early and begin to begin the functional load of the limb, which prevents the development of complications from the internal organs, especially in elderly patients, significantly reduces mortality, and shortens the duration of treatment. Currently, the surgical method for treating hip fractures is the main one. However, it should be emphasized that surgical treatment should be carried out only in those medical institutions where surgeons are well versed in the operation technique and have the necessary tools and equipment (three-lobed nails, guides, X-ray equipment, etc.).
A metal nail is removed only after complete coalescence of fragments, determined clinically and radiologically. The nail may not be removed.
The most common and effective treatment for sufficient lateral ( intertrochanteric and pertrochanteric ) of hip fractures is the method of skeletal traction. Skeletal traction for the distal end of the thigh, carried out with a load of up to 5-7 kg, with the allotted limb, the reduction of fragments is achieved (displacement along the length is eliminated, as well as the typical angular displacement-plow vara ). After b-7 weeks, skeletal traction is replaced by glue for another 2-3 weeks. Crutches are allowed after 2Va months, disability is restored on average after 4 months.
In recent years, for the treatment of lateral femoral neck fractures, which, like the medial ones, are found mainly in old age and life-threatening due to complications of pneumonia, hemocirculatory disorders, etc., an operational method of treatment is used. Fragments after reduction are fixed with a three-lobed nail with an additional plate on the diaphysis, which helps prevent secondary viral curvature of the cervical- diaphyseal region of the thigh.
Subtalar dislocation of the foot
Subtalar dislocation of the foot is very rare. The reason for this lies in the small functional requests for the talon-calcaneo-navicular joint in terms of range of motion and in a sufficiently strong ligamentous apparatus. The injury causing this dislocation is extremely severe: most often a fall from a height combined with twisting of the foot. In fact, it is not the foot that is dislocated, but the talus with the lower leg is displaced in relation to the foot.
Symptoms of subtalar dislocation of the foot
. Very pronounced deformation of the foot, most often in the position of varus and equinus, is noted . The head of the talus is palpated on the rear of the foot. On palpation, diffuse soreness occurs. The function of the foot is completely impaired. There are no active movements, passive – very sharply limited and painful.
Treatment of subtalar dislocation of the foot
Treatment in fresh cases, like all traumatic dislocations, consists in reposition, fixation and subsequent functional therapy. Fixation is carried out by the back gypsum splint to the knee joint for a period of 3 weeks. Full load is allowed no earlier than 1.5 months after the injury.
We are talking about the deviation of the axes of the legs of such a kind that when the medial ankles touch, there is a certain interval between the medial condyles of the femur.
Etiology of o-shaped legs
During the first two years of a child’s life, a physiological O-shaped position of the legs is observed. In the process of normal growth and development, the axes are straightened, and X-shaped legs are often formed. Due to incorrect ratios between loads and their ability to withstand varus curvature, they can increase. In addition, the O-shaped deformation of the legs can be the result of traumatic injuries. Previously, this phenomenon was often encountered against the background of rickets.
Clinic o-shaped legs
The degree of deviation from the normal axis is determined in centimeters by measuring the distance between the medial condyles of the femur with the reduced medial ankles. During the period of growth and formation of the skeleton, an interval reaching a maximum of 3 cm is considered physiological. Complaints and consequences are as described in the previous section.
O-shaped leg treatment
If spontaneous straightening did not occur at the time the child entered school, and the distance between the medial condyles exceeds 3 cm, then conservative treatment is first performed. With its failure or with the progression of the curvature, despite the treatment, corrective osteotomy is indicated, especially for the prevention of arthrosis of the knee joints.
Femoral condyles fractures
Fractures of the condyles of the thigh are intraarticular lesions and are quite rare. There are isolated fractures of one condyle and fractures of both condyles.
Symptoms of femoral condyle fractures
When one of the condyles is fractured, the clinical symptoms are limited, and often in the absence of condyle displacement, these fractures are erroneously diagnosed as sprains or ruptures of the knees. When the broken condyle is displaced, deformation in the area of the knee joint is determined (deviation of the shin outwards or inwards ).
With fractures of both condyles, the clinical picture is similar to the clinical picture of low hip diaphysis fractures. With the latter, there is a significant swelling in the knee joint, hemarthrosis, subcutaneous hemorrhage.
Treatment of femoral condyles fractures
. The main method for treating femoral condyle fractures is traction, which helps to eliminate deformity, compare fragments and carry out early movements in the knee joint.
For fractures of one of the condyles with a displacement, glue traction is applied to the lower leg in the straightened position of the limb (the angle of flexion in the knee joint should not exceed 10 °) using lateral loops and early movements.
If the conservative treatment is unsuccessful, an open reposition with fixation of the damaged condyles by heterogeneous bone or metal pins or screws is indicated.
Dosed load (on crutches) of an injured limb is allowed no earlier than 3.5-4 (months after the start of treatment. For fractures of both condyles with fragment displacement, skeletal traction is applied by a bracket placed on the condyles, which allows not only traction along the length, but also to compress the fragments.In the absence of a staple, traction can be applied to the spoke inserted into the tibial tuberosity region or through the calcaneus. In these cases, to disperse the condyles, they are used as in fractures of the condyles tibia, additional side loop or a special apparatus Novachenko . When marginal intra-articular fractures of the posterior section of the condyles only operative treatment: fixing pin fragments of bone or bone broth autoshtiftom .
Fractures of the greater and lesser trochanter
Isolated fractures of the greater trochanter are not common. They occur with a direct hit or fall on the region of the greater trochanter or separation due to a sharp uncoordinated contraction of the middle and small gluteal muscles. If the displacement of the greater trochanter is slightly expressed, you can limit yourself to fixing the limb in the position of maximum abduction with a plaster cast. In cases with a significant displacement of the greater trochanter, open reduction and osteosynthesis are indicated. The average treatment time is 6-7 weeks. With isolated fractures of the small skewer , due to a sharp reduction in w. ileo-psoas , glue traction is often used in the position of bending, bringing and turning the limb outwards.
Damage to the lateral ligaments of the knee joint
On the inner and outer surfaces, the capsule of the knee joint is reinforced with dense cords – the lateral ligaments of the knee joint. More often, the inner lateral ligament is damaged due to sharp tension (sometimes in combination with damage to the inner meniscus). Damage usually occurs when falling or jumping onto the allotted lower limb or when the limb abruptly abducts, when the knee joint is bent and the foot is fixed on a support (collision of players when playing soccer). The external lateral ligament is damaged due to excessive adduction of the lower leg when falling to the side, etc. At the time of damage to the ligament, the patient feels a sharp pain on the inner or outer surface of the joint. Swelling at the site of rupture of the ligament, hemorrhage, hemarthrosis, sharp pain on palpation according to the place of rupture of the lateral ligament is clinically determined. The pain intensifies with passive adherence, with damage to the external ligament and abduction of the lower leg with damage to the internal ligament. With a rupture of the inner ligament, the abduction of the lower leg is excessively expressed, and with a rupture of the external ligament, the reduction of the lower leg is increased (the study is performed with full extension of the lower leg). Treatment : rest, pressure bandage and fixation of the limb in a plaster cast for 4-6 weeks, followed by careful prescribing of therapeutic exercises, as well as massage and thermal procedures. In order to prevent lateral looseness in the knee joint, a removable device should be used after removing the plaster cast for 2-3 months. If failure of the damaged ligament occurs, surgical treatment is used. Make a side incision. The damaged ligament is plastically restored using a strip of broad fascia of the thigh, which is strengthened intraosseously to the thigh and lower leg. Some authors only hem the fascial graft to soft tissues. If the lateral ligaments are damaged, sometimes ossification occurs at the site of tearing of the ligament at the place of its attachment to the femoral condyle ( Shtida-Peligrini shadow ).
Cruciate Ligament Damage
Mutually intersecting anterior and posterior cruciate ligaments are located inside the knee joint, stretched obliquely between the condyles of the thigh and the articular surface of the tibia. The anterior cruciate ligament limits the displacement of the tibia in the ankle joint anteriorly, and the posterior one limits the displacement of the tibia posteriorly. Both ligaments limit the rotation of the lower leg.
The rupture of these ligaments is a serious damage, since in untreated cases it leads to instability of the knee joint and subluxation of the lower leg when walking.
The cruciate ligaments of the knee joint are damaged less frequently than the lateral ones. Most damaged anterior cruciate ligament during hyperextension limb at the knee joint and abduction tibia, the tibia when it is pushed in the direction of back to front, and so on. D. Posterior cruciate ligament rupture occurs when a sudden impact on the leg in the front-rear direction.
Significant hemarthrosis is formed immediately after damage to the ligaments. However, the diagnosis is made not on the basis of this symptom, but on the basis of excessive displacement of the articular ends in the front and in the afternoon direction (symptom of the anterior or posterior “drawer”). The indicated
displacement of the articular ends can be noted, naturally, only with complete or significant damage to the ligaments and is better detected with relaxed muscles.
To determine the symptoms of the anterior or posterior “drawer”, the limb is bent in the knee joint to a right angle and then the upper end of the lower leg is shifted anteriorly or posteriorly. If the anterior cruciate ligament is damaged, the tibia is excessively displaced anteriorly (a positive symptom of the anterior “drawer”). The reverse picture is observed with damage to the posterior cruciate ligament.
Treatment of cruciate ligament injuries
In fresh cases, cruciate ligament injuries are treated by puncture of the knee joint to remove spilled blood and fixation of the limb in the position of flexion of the knee joint at an angle of 150 ° for a period of 6 weeks. After this, the plaster cast is removed and a new one is applied when the knee joint is bent at an angle of 165-170 ° for a period of 1-l.5 months.
After 10-12 weeks from the moment of injury, the plaster cast is completely removed and cautious passive and active movements in the knee joint, muscle massage and thermal procedures are prescribed. To prevent knee joint looseness, it is necessary to use a removable splint for several months.
In case of incomplete rupture of the cruciate ligaments, fixation is carried out for 4-6 weeks, after which muscle massage and the development of movements are performed.
With chronic ruptures of the cruciate ligaments with a pronounced displacement of the knee joint in the sagittal plane, a plastic restoration of their integrity is shown using a graft from the wide fascia of the thigh ( Sitenko operation ) or a strip of the broad fascia of the thigh on the leg (Gay Groves ).
Recently, attempts are being made to use perlon for the plasticization of the cruciate ligaments.
With a bruised knee , swelling, pain during movement and pressure, and hemarthrosis are usually observed. In the future, a reactive synovial effusion in the joint may appear with an increase in its volume and ballot of the patella. Treatment: rest, tight bandaging of the knee joint, and with large bruises, fixation of the limb in the position of slight flexion in the knee joint for several days. Further therapeutic exercises are carried out. In the first 1-2 days, local cold is shown (ice bladder).
Dislocation of the foot
With dislocations of the foot, it can move in the ankle joint in all directions: outwards, inwards , anteriorly, posteriorly and upward. Quite often, these types of displacements are combined with each other. However, pure traumatic dislocation of the foot in the ankle joint is almost never found, which is associated with the presence of very strong ligaments in the region of this joint. Therefore, dislocations of the foot are observed with fractures of the ankles and marginal fractures of the anterior and posterior articular surfaces of the tibia. Dislocations of the foot up occur when a gap in the tibiofibular joint and a sharp divergence of the ankle fork, when the talus wedges into the resulting diastasis. Given that foot dislocations are always combined with the indicated injuries, it is advisable to talk about fractures and dislocations in the ankle joint and consider them when setting out the section for ankle fractures.