Infringement of the knee joint can also be caused by separation of the intercondylar eminence ( eminentia intercondilloidea ), to the anterior tubercle of which the anterior cruciate ligament is attached. The mechanism of damage is the same as with the rupture of the anterior cruciate ligament – over- extension of the knee joint. The diagnosis is made on the basis of the symptom of the anterior “drawer” and radiography data. Treatment : immobilization with a plaster cast for 6-8 weeks in the extension position. Recently, in the presence of a detachment of a massive section of the intercondylar eminence, surgical intervention with fixation of the intercondylar eminence with a bone pin or silk ( perlon ) thread conducted through canals in the tibia is preferred.
The anatomical and physiological characteristics of the hip joint (deep articular cavity, dense joint capsule and strong ligamentous apparatus, deep location of the joint protected by a thick layer of muscles, a large volume of possible movements with significantly less functional requests to the joint, etc.) determine the comparative rarity of traumatic dislocations of the hip ( 5-7% of the total number of dislocations).
Depending on the direction of displacement of the femoral head, the following main types of hip dislocations are distinguished: 1) iliac ( posterior ); 2) sciatic (posterior); 3) genuine ( anteroposterior ); 4) obturator (anteroposterior). Of these dislocations, the iliac is more common than others (80-85%).
Symptoms of dislocation in the hip joint
The main symptoms of traumatic dislocation of the thigh are deformation in the area of the damaged joint and a typical forced position of the limb. The posterior group of hip dislocations (iliac and sciatic) is characterized by hip flexion, adduction and internal rotation. Moreover, the lower the head is located (sciatic dislocation), the more flexion and adduction of the thigh are more pronounced. For front dislocations (obturator and supral ), limb flexion, abduction and external rotation are characteristic, and with suprapubic dislocation these components are moderate, and with obturator-more sharply.
With posterior dislocations, as a rule, a relative shortening of the lower limb is noted.
Normally, the greater trochanter is located at the level of the Roser-Nelaton line (the conditional line connecting the anteroposterior iliac spine and the top of the ischial tubercle). With posterior dislocations, the greater trochanter is located above this line. If you consider that with a dislocation of the femoral head, like. and with dislocations in other joints, there is sharp pain, lack of active movements in the hip joint, a positive symptom of “springy mobility”, the location of the head outside the acetabulum, etc., it becomes clear that the clinical diagnosis is not difficult. X-ray of the hip joint complements the data from a clinical study.
Hip dislocation treatment
. Depending on the prescription, there are fresh (up to 3 days old), stale (up to 3 weeks) and chronic (over 3 weeks> dislocations. Fresh dislocations should be repaired immediately upon the patient’s admission to a medical institution. You should also try to correct stale dislocations conservatively however manipulation should be carried out without the use of considerable strength and coarse techniques. Upon failure of conservative reposition shown operative (open) reduction.
diaplasis thigh performed under deep anesthesia or spinal anesthesia. Ned sufficiency of anesthesia does not cause complete muscle relaxation, reduction in such cases, painful and traumatic .
Of the many ways to reposition most widely used way to call Janelidze and the method of Kocher . diaplasis by Collin-Dzhanelidze follows.
The patient was placed on the table belly down so that the pelvis it was lying on the table, and the sore leg drooped freely, and under the influence of gravity, the leg was set at almost a right angle in the hip joint after 5-10 minutes. Then the surgeon, making sure that the anterior upper pelvic abuts against the table, bends the drooping leg in the knee joint to a right angle, takes it a little and turns it inward, then rests the knee on the lower leg of the drooping limb and, gradually pressing down on it , produces simultaneously hip rotation outwards.
The moment of entry of the femoral head into the acetabulum is accompanied by a characteristic click. An indicator of the reduction is the possibility of free movement in the hip joint.
In this way, you can fix the iliac, sciatic and obstructive dislocations. Bending dislocations should be adjusted according to the method of Kocher . The Kocher method , based on lever – like actions with a damaged limb, is more traumatic . Therefore, it should be used only in case of failure of the reduction according to the method of Kollen-Dzhanelidze or stale dislocations, as well as with obstructive dislocations.
The patient is laid on the table on his back, the assistant fixes the patient’s pelvis, and the surgeon, grabbing the shin with both hands, gradually bends at first and brings the hip. During the second stage of the board, the surgeon also gradually gives the hip, without reducing the adduction and flexion, the position of the maximum external rotation. The last stage consists in the rapid extension of the thigh with its simultaneous abduction and internal rotation.
After reduction in one way or another, the patient is placed on an orthopedic bed (with a shield), glue traction is applied to the thigh and lower leg. After 5-6 days, after the abatement of acute phenomena, they begin to make active-passive movements in the hip joint, massage the muscles, thighs and lower leg. After 10-12 days walking on crutches is allowed, by the end of the 3rd week, full load. Disability is restored 5-7 weeks after injury.
Dislocations of the lower leg
Traumatic dislocation of the lower leg is a very rare lesion. Depending on the mechanism of the injury, the lower leg may shift towards the articular end of the femur anteriorly, posteriorly, inwards and outwards. More often than others, front dislocations are observed. A complete dislocation of the lower leg, especially the anterior and posterior, is accompanied by compression of the neurovascular bundle and can be complicated, if not urgent reposition, by necrosis of the peripheral part of the limb. With lateral dislocations, the peroneal nerve can be damaged. Therefore, with dislocation of the lower leg, reduction should be done urgently.
Symptoms of dislocation of the leg
When examining the patient, a sharp typical deformation in the knee joint is noteworthy. Almost always it is possible to probe the articular ends of the femur and tibia, displaced in opposite directions. The skin in the joint is tense. The tibia axis passes depending on the type of dislocation anterior, posterior, outward or inward from the axis of the thigh. Active movements in the joint are impossible. It is necessary to differentiate the dislocations of the lower leg with hip epiphysiolysis (at a young age). During epiphysiolysis, in contrast to dislocation, sharp local (rather than spilled) pain is observed, small passive movements (flexion and extension) are preserved, which are completely absent during dislocation. During epiphysiolysis of the distal epiphysis of the femur (complete displacement of the anterior pituitary gland ) in the early days, a very characteristic symptom is observed: lying in bed with a fully extended limb, the patient, if he closes his eyes, says that his leg is bent at the knee (N.P. Novachenko ).
Shin dislocation treatment
Reduction is performed under deep anesthesia, with maximum muscle relaxation. In this case, the assistant traces along the length of the limb, and the surgeon produces pressure with both hands on the thigh and lower leg in opposite directions. After reposition, apply a circular plaster cast or back plaster splint from the groin to the ends of the toes for a period of 1.5 months. After this, a long course of functional treatment and physiotherapy is prescribed. Scarring processes in paraarticular tissues so fully compensate for damage to the ligamentous apparatus that joint laxity and instability after dislocation, provided proper treatment, are extremely rare.
Fractures of the patella are a relatively frequent lesion (1.5% in relation to all fractures), they occur mainly in adults and the elderly. Fracture of the patella can occur due to direct injury during a fall on a bent knee and a hit on a sharp object. In this case, stellate ( comminuted ), longitudinal or transverse fractures occur .
Symptoms of a patella fracture
. The diagnosis is made on the basis of swelling in the knee joint and pain on palpation, the presence of hemarthrosis, the gap between the fragments of the patella and the absence of active extension of the lower leg. Radiography data helps to diagnose.
Damage to the patella is often combined with a rupture of the lateral extensor apparatus – a tendon stretch of the quadriceps femoris. In these cases, there is a significant discrepancy in fragments of the patella.
Patella Fracture Treatment
If the fragment discrepancy is absent or does not exceed several millimeters and the congruence of the posterior surface of the patella is preserved, conservative treatment is used (lateral extensor apparatus is not broken): fixation of the limb with a gypsum splint for a period of 2-3 weeks in the position of full extension in the knee joint. Fragments of the patella in this case can be brought together by strips of sticky patch, and blood from the joint is removed by puncture. After 2-3 weeks, cautious movements in the knee joint are prescribed.
If there is a discrepancy of fragments more than 1 cm, surgery is indicated with the application of a silk purse-string suture around the patella. A torn lateral extensor apparatus is sewn with catgut sutures (Schulze operation). During surgery, blood clots are removed from the knee joint. The operation should be performed in the first 2 days or 8-10 days after the injury, since in the middle of this period the tissues are imbibed with blood and easily torn. After the operation, fixation is performed with a gypsum tire for a period of 2-3 weeks, then therapeutic gymnastics and limb massage are prescribed.
With multi-fragmented fractures of the patella, its complete removal is sometimes indicated.
Menisci are semilunar cartilages located between the articular surfaces of the condyles of the femur and tibia. With their thickened outer edges, the menisci are facing the inner wall of the joint capsule, and the inner free edges are towards its center. The inner meniscus is damaged several times more often than the outer one. The mechanism of meniscus damage can be direct and indirect (jump, fall from a height, accompanied by rotation, adduction or abduction of the lower leg and moderate flexion). The meniscus rupture line can extend longitudinally or transversely; it is possible to tear off the place of attachment of the meniscus to the joint capsule or tear off its posterior or anterior horn.
Meniscus Damage Clinic
With damage to the meniscus, hemarthrosis, joint pain is noted. When the meniscus is infringed, a blockage of the joint occurs (inability to straighten the limb in the knee joint). When feeling with one finger, localized pain is determined (at the level of the joint gap between the patellar ligament and the lateral ligament of the knee joint), sometimes here you can feel the torn end of the meniscus. In case of extinction-extensor movements in the knee joint, a clicking sound is sometimes heard. In the subsequent important diagnostic sign of meniscus damage is pinching it between the articular surfaces. In these cases, patients note that “something pops up” in the knee. They can neither bend nor straighten the lower leg. In order to eliminate meniscus displacement, patients produce maximum flexion of the knee joint with both hands. After such a blockade, a reactive effusion accumulates in the joint, and patients are forced to stay in bed for several days.
If the inner meniscus is damaged, the appearance of a hyperesthesia zone on the inside of the knee joint is sometimes noted ( Turner symptom ).
In men, especially in cases of repeated attacks of the disease, atrophy of the quadriceps muscle and Chaklin’s symptom are observed , consisting in the following: if the patient actively raises the damaged leg in the extension position, then flattening is observed m. vastus medialis and compensatory tailor muscle tension. Conventional radiographs do not provide any data for judging the presence of meniscus damage. Radiography with the introduction of a joint or air into the cavity sometimes facilitates the diagnosis.
Treatment of meniscus lesions
Treatment immediately after meniscus damage consists of rest, bandaging of the knee joint and fixation of the limb. In the presence of significant hemarthrosis, a joint puncture can be performed. If at the level of the gap of the knee joint the standing end of the meniscus is palpable or there is a blockage of the joint, the meniscus should be reduced. This reduction is carried out in the position of the patient on the back. The limb is bent at the knee joint. External rotation and abduction of the lower leg is performed, and then vigorous extension in the knee joint. After the meniscus is repositioned, movements in the joint become free.
With repeated blockade of the joint with infringement of the meniscus, surgical treatment, opening (arthrotomy) of the knee joint and removal of the meniscus, fixation of the limb with a splint for 10-12 days is indicated. Subsequently, the development of movements in the joint is carried out, thermal procedures are applied.
Hip fractures in newborns
Hip fractures are more often observed during the first birth in the case of the gluteal position of the fetus. In this case, the limb is passive, the thigh is significantly increased in volume, deformed and shortened. More often, the fracture is localized in the diaphysis, however, epiphysiolysis of the femoral head can also be observed . Significant displacements require immediate reduction. Hip fracture treatment can be done on an outpatient basis, but preferably in a hospital setting. To do this, use the traction system using flannel strips that are glued to the skin with glue . The Ukrainian Scientific Research Institute of Traumatology and Orthopedics named after MI Sitenko developed a special method of outpatient treatment of hip fractures in newborns, one feature of which is the original tire-bed, allowing to carry out a constant traction in the outpatient setting, without impeding childcare. Traction is carried out using flannel strips glued to the skin with cleol ; the leg is installed vertically but by Schede , the rods are attached to a special rod, the angular displacements are eliminated by the side adjusting loops. The fixation on the tire crib is recommended to continue up to 3-4 weeks.