Proximal phalanx of the finger. Treatment of closed fractures of the phalanges of the fingers of the hand How are the phalanges of the fingers connected?
Each toe consists of three phalanges - proximal (upper), middle and distal (lower), except for the big toe, which lacks the middle phalanx. The bones are short, tubular.
The proximal and middle phalanges have a head, which is the pineal gland, a body and a base with an articular surface.
Distal phalanges have flattened distal ends with tuberosity.
Causes and mechanisms
They arise due to the direct action of traumatic factors: falling on the toes of heavy weights, squeezing the fingers between hard objects, falling on the toes from a height, while jumping, etc.
Classification
Fractures can be:
- isolated(fracture of one phalanx of one finger);
- multiple(on one or more fingers) with localization in the area of the distal end of the diaphysis, the proximal end of the phalanx.
By nature, fractures are:
- transverse;
- oblique;
- longitudinal;
- fragmentation;
- intraarticular;
- combined;
- tears of the tuberosity of the nail phalanx with and without displacement.
In addition, there are closed and open fractures of the fingers.
Isolated fractures account for about 82%, and multiple fractures - about 18%. In terms of frequency, the first place is occupied by fractures of the distal phalanges, the second - the proximal and the third - the fractures of the middle phalanges.
With fractures of the phalanges, the displacement of fragments is most often in width and at an angle.
Symptoms
No offset
Clinical manifestations of non-displaced fractures: pain, defiguration of the finger depending on the magnitude of the edema, loss of active finger movements through pain.
Palpation and pressing along the axis of the finger in an extended state exacerbates pain at the fracture site, which never happens with bruises.
Offset
In the presence of displacement of fragments, a pronounced shortening of the finger, deformation of the phalanx is observed.
When the fragments are displaced outward in width, the angle of deformation is open outward. Angular displacements of fragments (in the sagittal plane) lead to deformation with an angle open to the rear, less often to the plantar side.
X-ray examination clarifies the nature of the fracture.
First aid
First of all, you should start by examining the injured area. If all joints are functioning normally (bending and unbending), then this is a severe injury.
If a violation of mobility is found, it is necessary to contact the emergency room.
First aid measures include applying a cold compress to relieve pain and reduce hematoma.
Ice cannot be applied directly to the skin; it must first be wrapped in a cloth, such as a towel.
Keep the ice for 10 minutes, then a 20-minute break, repeat 3-4 times.
If there is damage to the skin, it must be disinfected. It is not recommended to use iodine for this, as it has a warming effect.
Treatment
Fractures of the phalanges of the toes in most cases are treated conservatively.
No offset
Fractures without displacement or with slight displacement, which do not lead to impaired function, are treated by immobilization with a plaster plantar splint overlapping the injured toe and the adjacent one on the dorsum in the form of a visor.
This plaster cast provides immobilization during the entire period of adhesion (3 weeks). The ability to work is restored in 4-5 weeks.
Offset
Fractures of the phalanges with displacement of fragments with a transverse plane after anesthesia with 1% novocaine solution are simultaneously closed and matched.
With an oblique plane - after the closed juxtaposition of the fragments under X-ray control, they are fixed with wires, which are passed through the phalanx, the joint into the intact phalanx, preventing secondary displacement.
Additionally, a plantar plaster splint with a visor on the dorsum of the toe is applied to the foot.
In cases where the comparison fails (interposition, significant edema, stale fracture), an open comparison of the fragments with the osteosynthesis of their nails, which are passed through the phalanges into the head of the metatarsal bone into the medullary canal, or osteosynthesis with special plates is shown.
With beveled and helical planes
Skeletal traction or surgery is used.
Surgical treatment consists in open juxtaposition of the fragments with subsequent osteosynthesis with wires, plates or corresponding screws.
Special attention it is necessary to pay attention to the elimination of angular deformations, which cause the occurrence of hammer-shaped deformities of the fingers.
Left angular deformity causes subluxation in the metatarsophalangeal joint with contraction of the flexors of the fingers and the development of hammer-shaped deformities of the fingers.
Taking into account the static load of the foot, it is necessary to pay particular attention to the anatomical restoration of the I and V axis of the fingers.
The duration of disability for phalangeal fractures is 4-6 weeks.
Rehabilitation
After a fracture within 6-7 weeks, it is contraindicated to overextend the injured finger.
Long walks and, of course, sports should be excluded.
During the recovery period, the doctor prescribes therapeutic massage, physiotherapy, and special gymnastics.
The diet should include foods rich in protein and calcium.
The phalanges of human fingers have three parts: proximal, main (middle) and terminal (distal)... There is a clearly visible nail tuberosity on the distal part of the nail phalanx. All fingers are formed by three phalanges, called the main, middle and nail. The only exception is thumbs - they consist of two phalanges. The thickest phalanges of the fingers form the thumbs, and the longest form the middle fingers.
Structure
The phalanges of the fingers are short tubular bones and look like a small elongated bone, in the form of a half-cylinder, with the convex part facing the back of the hand. At the ends of the phalanges, there are articular surfaces that take part in the formation of interphalangeal joints. These joints are block-shaped. It is possible to perform extensions and flexions in them. The joints are well strengthened with collateral ligaments.
The appearance of the phalanges of the fingers and the diagnosis of diseases
In some chronic diseases of internal organs, the phalanges of the fingers are modified and take the form of "drumsticks" (spherical thickening of the terminal phalanges), and the nails begin to resemble "watch glasses". Such modifications are observed in chronic lung diseases, cystic fibrosis, heart defects, infective endocarditis, myeloid leukemia, lymphoma, esophagitis, Crohn's disease, liver cirrhosis, diffuse goiter.
Fracture of the phalanx of the finger
Fractures of the phalanges of the fingers are most often caused by a direct blow... Fracture of the nail plate of the phalanges is usually always fragmented.
Clinical picture: the phalanx of the fingers hurts, swells, the function of the injured finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. With fractures of the phalanges of the fingers without displacement, sprains or displacements are sometimes mistakenly diagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with injury, then you should definitely X-ray examination(fluoroscopy or radiography in two projections), which allows you to make the correct diagnosis.
Treatment of a fracture of the phalanx of the fingers without displacement is conservative. An aluminum splint or plaster cast is applied for three weeks. After that, physiotherapy treatment, massage and physiotherapy exercises are prescribed. Full mobility of the injured toe is usually restored within a month.
When the phalanges of the fingers are displaced, the bone fragments are compared (repositioned) under local anesthesia. Then a metal splint or plaster cast is applied for a month.
In case of a fracture of the nail phalanx, it is immobilized with a circular plaster cast or adhesive plaster.
The phalanges of the fingers hurt: causes
Even the smallest joints in the human body, the interphalangeal joints, can be affected by diseases that impair their mobility and are accompanied by excruciating pain. Such diseases include arthritis (rheumatoid, gouty, psoriatic) and osteoarthritis deformans. If these diseases are not treated, then over time they lead to the development of severe deformation of the damaged joints, a complete disruption of their motor function and atrophy of the muscles of the fingers and hands. Despite the fact that the clinical picture of these diseases is similar, their treatment is different. Therefore, if you have pain in the phalanges of the fingers, then you should not self-medicate.... Only a doctor, having carried out the necessary examination, can make the correct diagnosis and, accordingly, prescribe the necessary therapy.
Dislocations of the phalanges of the fingers make up from 0.5 to 2% of all injuries of the hand. The most common dislocations occur in the proximal interphalangeal joint - about 60%. Dislocations in the metacarpophalangeal and distal interphalangeal joints occur with approximately the same frequency. Dislocations in the joints of the fingers of the hand are more often observed on the right hand in people of working age in connection with a domestic injury.
Dislocations in the proximal interphalangeal joints. The proximal interphalangeal joint is characterized by two types of damage:
1) dislocation posterior, anterior, lateral;
2) fracture dislocation.
Posterior dislocations occur during overextension of the proximal interphalangeal joint. This injury is characterized by rupture of the palmar plate or collateral ligaments.
Lateral dislocations are a consequence of the impact on the finger of abductive or adductive forces when the finger is extended. The radial collateral ligament is damaged much more often by the ulnar ligament. As a rule, spontaneous reduction occurs with this damage. Reduction of fresh lateral and posterior dislocations is often not difficult and is performed in a closed manner.
Anterior dislocation occurs as a result of combined forces - leading or abducting - and a force directed anteriorly and displaces the base of the middle phalanx forward. In this case, the central bundle of the extensor tendon is detached from the attachment point to the middle phalanx. Palmar dislocations occur much less frequently than others, since there is a dense fibrous plate in the composition of the anterior wall of the capsule, which prevents the occurrence of this damage.
Clinically, with this type of injury in the acute period, edema and pain can mask the existing deformity or dislocation. On examination, patients with lateral dislocations show pain during the rocking test and tenderness on palpation on the lateral side of the joint. Lateral instability indicating complete rupture.
Radiographically, with a rupture of the collateral ligament or with severe swelling, a small fragment of bone is revealed at the base of the middle phalanx.
With fracture dislocations, there is a dorsal subluxation of the middle phalanx with a fracture of the palmar lip of the middle phalanx, which can cover up to 1/3 of the articular surface.
Dislocations in the distal interphalangeal joints.
The distal interphalangeal joints are stable in all positions, since the supporting apparatus consists of dense collateral accessory ligaments connected to the fibrous plate from the outer palmar side. Here, dislocations are also possible, both in the back and in the palmar side. Reduction of fresh dislocations is not difficult. The only inconvenience is the short reduction lever represented by the nail phalanx. Reduction of chronic dislocations in the interphalangeal joints is much more difficult, since contracture rapidly develops with cicatricial changes in the surrounding tissues and the organization of hemorrhage in the joint. Therefore, you have to resort to various methods of surgical treatment.
Dislocations in the metacarpophalangeal joints.
The metacarpophalangeal joints are condylar joints, which, in addition to flexion and extension, are characterized by lateral movement of at least 30 ° with the joint extended. Because of its shape, this joint is more stable in flexion when the collateral ligaments are taut than in extension, which allows lateral movement in the joint. The first finger suffers more often.
With old dislocations of the phalanges of the fingers of the hand, the main method of treatment is the imposition of compression-distraction devices. This method is often combined with open reduction. In other cases, if reduction is impossible and the articular surfaces are destroyed, arthrodesis of the joint is performed in a functionally advantageous position. Arthroplasty using biological and synthetic pads is also used.
Metacarpal fracture treatment
The main methods of restoring the function of the finger joints are open and closed repositions of fragments as soon as possible after trauma, arthroplasty using various auto-, homo- and alloplastic materials, treatment with external fixation devices of various designs. Recently, with the development of microsurgical techniques, many authors have proposed the use of vascularized grafts for total and subtotal destruction of articular surfaces, such as transplantation of a blood-supplied joint. However, these operations are lengthy, which is unfavorable for the patient, have a high percentage of vascular complications, and subsequent rehabilitation treatment is difficult due to prolonged immobilization.
For non-operative treatment of fractures and dislocation fractures, the most common method is the use of plaster casts, twists and splint-sleeve devices. In clinical practice, immobilization with splints and circular plaster casts is used. Recently, various types of plastic dressings have been increasingly used.
The terms of immobilization with plaster casts for fractures and dislocations of the phalanges of the fingers and metacarpal bones of the hand is 4-5 weeks.
When carrying out open reduction or reposition of fragments of the phalanges and metacarpal bones of the hand for osteosynthesis, various extraosseous and intraosseous fixators of various sizes are widely used - rods, pins, pins, screws made of various materials.
Especially great difficulties arise in the treatment of complex intra-articular fractures - at the same time the head and base of the bones in the same joint, with multiple comminuted fractures, accompanied by ruptures of the capsule and ligamentous apparatus of the joint and as a result of dislocation or subluxation. Often, these injuries are accompanied by the interposition of bone fragments with joint blockade. The authors also propose various methods of treatment: the imposition of external fixation devices, primary arthrodesis of the damaged joint. The most effective surgical treatment consists in open reduction and connection of fragments with various fixators.
There is an opinion that in case of severe damage to the joints of the fingers of the hand, one should not restore the integrity of the articular surfaces, but close the joint by primary arthrodesis, since the creation of a supporting finger when fixing the injured joint in a functionally advantageous position contributes to a faster and more complete rehabilitation of a patient whose profession is not associated with fine differentiated hand movements. Arthrodesis is widely used for injuries of the distal interphalangeal joints. Priority is given to this operation and for chronic damage to the joints with significant damage to the articular surfaces.
In the last decade, many technical solutions have been described related to the modernization of existing and the creation of new models of compression-distraction and hinge-distraction devices.
M.A. Boyarshinov developed a method for fixing the fragments of the phalanx of the finger with a structure of knitting needles, which is mounted like this. Through the proximal fragment of the phalanx, closer to the base, a Kirschner's wire is passed transversely, a thin wire is passed through the same fragment, but closer to the fracture line, and a pair of thin wires is also passed through the distal fragment. The protruding ends of the Kirschner wire, passed through the proximal fragment at the base of the phalanx, at a distance of 3-5 mm from the skin, are bent in the distal direction at an angle of 90 ° and placed along the finger. At a distance of 1 cm from the distal end of the damaged phalanx, the ends of the spoke are again bent counter to each other at an angle of 90 ° and twisted together. As a result, a one-plane rigid frame is formed. For it, thin wires are fixed with the effect of compression or distraction of the repressed phalanx fragments. Depending on the location and nature of the fracture, the technique for introducing the needles may be different. For transverse and close to them fractures, we use the fixation of fragments at the junction in the form of a lock using L-shaped curved needles according to E.G. Gryaznukhin.
To eliminate the contracture of the fingers in both interphalangeal joints, an external I.G. device can be used. Korshunov, equipped with an additional trapezoidal frame made of Kirschner spoke, and a screw pair from the top of the frame. The external apparatus consists of two arcs with a diameter of 3-3.5 cm, in the area of the ends of the arc there are holes: 0.7-0.8 mm in diameter - for carrying the needles and 2.5 mm in diameter - for threaded rods connecting the arcs to each other. One arc is fixed with a spoke to proximal phalanges e, the other - to the middle phalanx. A needle is passed through the distal phalanx at the level of the base of the nail, the ends of the spoke are bent towards the end of the phalanx and fastened together. The resulting frame is attached to the screw pair of the outer trapezoidal frame. In this case, a spring can be placed between the screw pair and the frame that fixes the end phalanx for a more gentle and efficient thrust.
With the help of screw pairs, distraction-extension of the phalanges is performed at a rate of 1 mm / day in the first 4-5 days, then up to 2 mm / day until full extension and creation of diastasis in the interphalangeal joints up to 5 mm. Straightening of the finger is achieved within 1-1 / 2 weeks. Distraction of the interphalangeal joints is maintained for 2-4 weeks. and longer depending on the severity and duration of the contractures. First, the distal phalanx is released and the distal interphalangeal joint is developed. After the restoration of active movements of the distal phalanx, the proximal interphalangeal joint is released. Final rehabilitation measures are carried out.
When using surgical treatment and osteosynthesis according to the AO technique, it is recommended to start early movements in the operated hand. But in the future, it is necessary to carry out repeated surgery to remove the metal structures. At the same time, when fixing fragments with wires, their removal does not present any technical difficulties.
In otropedo-traumatological practice, only some of the devices with originality and fundamentally significant differences are widely used: Ilizarov, Gudushauri devices, Volkov-Oganesyan articulated and repositioning devices, Kalnberz “stress” and “rigid” devices, Tkachenko's “frame” device. Many constructions were used only by the authors and did not find wide application in hand surgery.
The main advantage of the Ilizarov apparatus is the variety of layout options, as well as the simple technology of manufacturing the apparatus elements. The disadvantages of this device include the multi-subject set; the laboriousness and duration of the assembly processes, the imposition and replacement of elements on the patient; the possibility of fixed displacements in the apparatus; difficulties in eliminating rotational displacements; limited possibilities of precisely controlled and strictly dosed hardware reduction.
When using distraction devices, one should take into account the rather long duration of treatment, the impossibility of complete restoration of the articular surfaces. As a result, the range of their application is limited for various types of injuries to the finger joints.
To restore joint mobility, since the 40s of the last century, metal and plastic structures began to be widely used, which replaced various parts of the joints, articular ends and whole joints. The solution to the problem of endoprosthetics of the joints of the fingers of the hand went in two main directions:
development of hinged endoprostheses;
creation of endoprostheses from elastic materials.
An obligatory component in the complex of reconstructive and restorative treatment of patients with injuries of the bones of the hand is postoperative rehabilitation, which includes exercise therapy and a complex of physiotherapeutic measures. A set of measures is used in rehabilitation treatment, phototherapy has been actively used recently. These procedures help to improve trophism, reduce swelling and pain.
The loss of the first finger leads to a decrease in hand function by 40-50%. The problem of its recovery continues to be relevant today, despite the fact that surgeons have been doing this for more than a hundred years.
The first steps in this direction belong to French surgeons. In 1852 P. Huguier performed the first plastic surgery on the hand, later called phalangization. The point of this operation is to deepen the first board-to-board gap without increasing the length of 1 beam. In this way, only the key grip was restored. In 1886, Ouernionprez developed and performed an operation based on a completely new principle - the transformation of finger II into I. This operation was called pollicization. In 1898, the Austrian surgeon S. Nicoladom performed for the first time a two-stage transplant of the second toe. In 1906, F. Krause used the first toe for transplantation, considering it more suitable in shape and size, and in 1918, I. Joyce replanted the finger of the opposite hand to replace the lost toe. Methods based on the principle of two-stage transplantation on a temporary feeding stem have not become widespread due to technical complexity, low functional results, and prolonged immobilization in a forced position.
The method of skin and bone reconstruction of the first finger of the hand is also due to the emergence of C. Nicoladoni, who developed and described the operation technique in detail, but for the first time in 1909 the Nikoladoni method was applied by K. Noesske. In our country V.G. Shchipachev in 1922 performed phalangization of the metacarpal bones.
B.V. Parii, in his monograph, published in 1944, systematized all reconstruction methods known at that time and proposed a classification based on the source of the plastic material. In 1980 V.V. Azolov supplemented this classification with new, more modern methods of reconstruction of the first finger: distraction lengthening of the first ray using external fixation devices and microsurgical methods of free transplantation of tissue complexes.
With the development of microsurgery, it became possible to replant completely detached fingers of the hand. Obviously, replantation provides the most complete restoration of function, compared with any reconstruction operation, even with shortening and possible loss of movement in the finger joints.
All modern methods of restoration of the first finger of the hand can be divided as follows.
plastic with local tissues:
plastic with displaced flaps;
cross plastic;
plastic with flaps on the vascular pedicle:
plastic according to Holevich;
Littler plastic;
radial rotated flap;
2) distant plastic:
on a temporary supply leg:
sharp Filatov stem;
plastic according to Blokhin-Conyers;
free transplantation of tissue complexes with microsurgical techniques:
flap of the first interdigital space of the foot;
other blood-supplied tissue complexes.
Methods for restoring segment length:
heterotopic replantation;
pollicization;
transplant of II toe:
transplant of segment I of toe.
Methods that do not increase the segment length:
phalangization.
Methods for increasing segment length:
1) methods using tissues of the injured hand:
distraction lengthening of the segment;
pollicization;
bone-dermal reconstruction with a radial rotated bone-dermal flap;
2) distant plastic surgery using free transplantation of tissue complexes using microsurgical techniques:
opposite hand finger transplant;
second toe transplant;
transplant of segment III of the toe;
simultaneous skin and bone reconstruction using a free skin and bone graft.
The criteria for primary and secondary recovery is the time elapsed after the injury. Permissible terms in this case are the deadlines during which replantation is possible, i.e. 24 hours.
The main requirements for a reconstructed finger I are as follows:
sufficient length;
stable skin;
sensitivity;
mobility;
acceptable appearance;
the ability to grow in children.
The choice of the method for its restoration depends on the level of loss, in addition, gender, age, profession, the presence of injuries to other fingers of the hand, the patient's state of health, as well as his desire and the capabilities of the surgeon are taken into account. Traditionally, it is believed that the absence of the nail phalanx of the 5th toe is compensated damage and surgical treatment is not indicated. However, the loss of the nail phalanx of the first finger is the loss of 3 cm of its length, and, consequently, a decrease in the functional ability of the finger and the hand as a whole, namely, the inability to grasp small objects with the fingertips. In addition, nowadays more and more patients want to have a complete brush in aesthetic terms. The only acceptable reconstruction method in this case is the grafting of a part of the first toe.
The length of the stump of the 1st ray is a decisive factor in the choice of the method of surgical treatment.
In 1966, in the USA, N. Buncke performed the first successful one-stage transplant of the first toe to the hand in a monkey with microvascular anastomoses, and Cobben in 1967 was the first to perform such an operation in the clinic. Over the next two decades, the technique of performing this operation, indications, contraindications, functional results and consequences of borrowing the first toe from the foot were studied in detail by many authors, including in our country. Studies have shown that, in functional and cosmetic terms, the 1st toe is almost identical to the 1st toe. As for the function of the donor foot, here the opinions of surgeons differ. N. Buncke et al. and T. Mau, performing biomechanical studies of the feet, came to the conclusion that the loss of the first toe does not lead to significant gait restrictions. However, they noted that long-term healing of the donor wound is possible due to poor engraftment of a free skin graft, as well as the formation of gross hypertrophic scars on the dorsum of the foot. These problems, according to the authors, can be minimized by observing the rules of precision technique when extracting a toe and closing a donor defect, as well as with proper postoperative management.
Special studies carried out by other authors have shown that in the final stage of the step I toe drops to 45% of body weight. After its amputation, lateral instability of the medial part of the foot may occur due to dysfunction of the plantar aponeurosis. So, when the main phalanx of the 1st finger is displaced to the dorsiflexion position, the body weight moves to the head of the 1st metatarsal bone. In this case, the plantar aponeurosis is stretched, and the interosseous muscles through the sesamoid bones stabilize the metatarsophalangeal joint and raise the longitudinal arch of the foot. After the loss of the first toe, and especially the base of its proximal phalanx, the effectiveness of this mechanism decreases. The load axis is shifted laterally to the heads of the II and III metatarsal bones, which in many patients leads to the development of metatarsalgia. Therefore, when taking the first finger, it is advisable to either leave the base of its proximal phalanx, or firmly suture the tendons of the short muscles and the aponeurosis to the head of the first metatarsal bone.
Transplant I toe moans by Buncke
Preoperative planning.
The preoperative examination should include a clinical assessment of the blood supply to the foot: determination of arterial pulsation, Doppler sonography and arteriography in two projections. Angiography helps document the adequacy of the blood supply to the foot through the posterior tibial artery. In addition, hand arteriography should be performed if there is any doubt about the condition of potential recipient vessels.
The dorsal artery of the foot is an extension of the anterior tibial artery, which runs deep under the supporting ligament at the level of the ankle joint. The dorsal artery of the foot is located between the tendons of m. extensor hallucis longus medially, etc. extensor digitorum longus laterally. The artery is accompanied by commitant veins. The deep peroneal nerve is located lateral to the artery. Passing over the bones of the tarsus, the dorsal artery of the foot gives off the medial and lateral tarsal arteries and in the region of the base of the metatarsal bones forms an arterial arch that runs in the lateral direction. The second, third and fourth dorsal metatarsal arteries are branches of the arterial arch and run along the dorsum of the corresponding dorsal interosseous muscles.
The first dorsal metatarsal artery is an extension of the dorsal artery of the foot. It is usually located on the dorsum of the first dorsal interosseous muscle and supplies blood to the skin of the dorsum of the foot, I and II metatarsal bones and interosseous muscles. In the area of the first interdigital space, the first dorsal metatarsal artery is divided into at least two branches, one of which runs deep to the tendon of the extensor longus of the first toe, supplying blood to the medial surface of the first toe, and the other branch supplies the adjacent sides of the first and second toes.
The deep plantar branch departs from the dorsal artery of the foot at the level of the base of the first metatarsal bone and goes to the plantar surface of the foot between the heads of the first dorsal interosseous muscle. It connects to the medial plantar artery and forms the plantar arterial arch. The deep plantar artery also gives off branches to the medial side of the first toe. The first plantar metatarsal artery is a continuation of the deep plantar artery, which is located in the first intermetatarsal space and supplies blood to the adjacent sides of the I and II toes from the plantar side.
According to the group of studies, the dorsal artery of the foot is absent in 18.5% of cases. Nutrition from the anterior tibial artery system is carried out in 81.5% of cases. Of these, 29.6% have a predominantly dorsal type of blood supply, 22.2% have predominantly plantar blood supply, and 29.6% have a mixed blood supply. Thus, in 40.7% of cases, there was a plantar type of blood supply to the I and II toes.
Venous outflow is carried out through the veins of the dorsum of the foot, which flow into the dorsal venous arch, which forms the large and small saphenous systems. Additional outflow occurs through the veins that accompany the dorsal artery of the foot.
The dorsum of the toes is innervated by the superficial branches of the peroneal nerve, and the first interdigital space is innervated by the branch of the deep peroneal nerve and the plantar surface of the I-II toes - by the digital branches of the medial plantar nerve. All of these nerves can be used to re-innervate the transplanted complexes.
Usually, a toe on the side of the same name is used, especially if additional skin grafting is needed to cover the toe on the hand, which can be taken from the foot along with the toe being transplanted. The problem of soft tissue deficiency in the recipient area can be solved by traditional plastic methods, such as free skin grafting, grafting with a pedicle flap, and free tissue transplantation before or during toe reconstruction.
Highlight on the foot
Before the operation, the course of the great saphenous vein and the dorsal artery on the foot are marked. A tourniquet is applied to the lower leg. On the back of the foot, a straight, curved or zigzag incision is made along the dorsal artery of the foot, keeping saphenous veins, the dorsal artery of the foot and its continuation - the first dorsal metatarsal artery. If the first dorsal metatarsal artery is present and located superficially, then it is traced distally and all lateral branches are ligated. If the plantar metatarsal artery is the dominant artery, dissection begins from the first interdigital space in the proximal direction, making a longitudinal incision in the sole for a wider view of the metatarsal head. Allocation in the proximal direction is continued until an artery of sufficient length is obtained. Occasionally, the transverse metatarsal ligament has to be transected to mobilize the plantar metatarsal artery. If it is impossible to determine which of the vessels is dominant, then the selection begins in the first intermetatarsal space and is performed in the proximal direction. In the first interdigital space, the artery is ligated to the second finger and the first intermetatarsal artery is traced until it becomes clear how to select it - from the dorsal or plantar approach. The vascular bundle is not transected until the finger is convinced of the possibility of blood supply through it and the preparation of the hand for transplantation is completed.
Trace the dorsal artery of the foot to the short extensor of the first toe, cross it, raise and open the deep peroneal nerve located lateral to the dorsal artery of the foot. The deep peroneal nerve is isolated to restore it with the recipient nerve on the hand. The first metatarsal artery is traced to the interdigital space, keeping all branches going to the first toe, and tying up the rest. The superficial veins are isolated and mobilized so as to obtain a long venous leg. In the first interdigital space, the plantar digital nerve is isolated along the lateral surface of the finger and separated from the digital nerve leading to the second finger by carefully separating the common digital nerve. In the same way, the plantar nerve is isolated on medial surface I finger and mobilize it as much as possible. The length of the secreted nerves depends on the requirements of the recipient area. Sometimes nerve plastic surgery may be required. Determine the approximate required length of the tendons on the hand. The extensor longus tendon of the 1st finger is transected at the level of the supportive ligament or more proximally, if necessary. To expose the long flexor tendon of sufficient length, an additional incision is made on the sole. At the level of the sole, between the long flexor tendon of the first toe and the flexor tendons of the other fingers, there are bridges that prevent it from being separated from the incision behind the ankle. The finger is isolated from the metatarsophalangeal joint. If you need to restore the metacarpophalangeal joint on the hand, you can take the joint capsule with your finger.
The plantar surface of the head of the I metatarsal bone should be preserved, but the dorsum of it can be taken with a finger if an oblique osteotomy of the head is done. After removing the tourniquet, hemostasis is carefully performed on the foot. After ligation of the graft vessels and their intersection, their finger is transferred to the hand. The wound on the foot is drained and sutured.
Brush preparation.
The operation begins with the application of a tourniquet on the forearm. Two incisions are usually required to prepare the recipient site. A curved incision is made from the dorsal-radial surface of the stump of the 1st finger through the palm along the thenar fold, and, if necessary, it is extended to the distal part of the forearm, opening the canal of the wrist. An incision is made along the back of the hand in the projection of the anatomical snuffbox, continuing it to the end of the finger stump. The tendons of the long and short extensors of the 1st finger, the long abductor muscle of the 1st finger, the head vein and its branches, the radial artery and its terminal branch, the superficial radial nerve and its branches are isolated and mobilized.
Allocate the stump of the first finger. From the palmar incision, the digital nerves are mobilized to the 1st finger, the tendon of the long flexor, the adductor muscle of the 1st finger and the abductor short muscle, if possible, as well as the palmar digital arteries, if they are suitable for anastomosis. Now the tourniquet is removed and a thorough hemostasis is performed.
Actually transplanting a toe onto a hand.
The base of the main phalanx of the toe and the stump of the main phalanx of the toe are adapted, and osteosynthesis is performed with Kirschner wires.
The flexor and extensor tendons are repaired in such a way as to balance the forces on the transplanted toe as much as possible. T. Mau et al. proposed a scheme for the reconstruction of tendons.
Check the inflow through the recipient radial artery, and impose an anastomosis between the dorsal artery of the foot and the radial artery.
Anastomosis is applied to the head vein and the great saphenous vein of the foot. Usually one arterial and one venous anastomosis is sufficient. The lateral plantar nerve of the toe and the ulnar digital nerve of the toe, as well as the medial plantar nerve of the toe with the radial nerve of the toe, are sutured epineurally. If possible, the superficial branches of the radial nerve can be sutured to a branch of the deep peroneal nerve. The wound is sutured without tension and drained with rubber graduates. If necessary, use free skin graft plastics. Immobilization is performed with a plaster cast longitudinal bandage so as to avoid compression of the transplanted finger in the bandage and to ensure control over the state of its blood supply.
Transplant of a fragment of the first toe
In 1980 W. Morrison described a free vascularized complex tissue complex from the first toe, “wrapping” a traditional non-blood-supplied bone graft from the iliac crest for reconstruction of the lost I toe.
This flap includes the nail plate, dorsum, lateral and plantar skin of the first toe and is considered indicated for the reconstruction of the first toe when it is lost at or distal to the metacarpophalangeal joint.
The advantages of this method are:
restoration of the length, full size, sensitivity, movement and appearance of the lost toe;
only one operation is required;
preservation of the skeleton of the toe;
minimal gait disturbance and minor damage to the donor foot.
The disadvantages are:
the need for the participation of two teams;
potential loss of the entire flap due to thrombosis;
bone resorption capabilities;
the absence of the interphalangeal joint of the reconstructed finger;
the possibility of long-term healing of the donor wound due to the rejection of a free skin graft;
the inability to use it in children due to the lack of the ability to grow.
As with all microvascular foot surgeries, the adequacy of the first dorsal metatarsal artery must be assessed prior to surgery. On feet where it is absent, a plantar approach may be required to isolate the first plantar metatarsal artery. Before the operation, it is necessary to measure the length and circumference of the first finger of a healthy hand. Use the toe on the side of the same name to suture the lateral plantar nerve to the ulnar digital nerve of the hand. Two surgical teams are involved to expedite the operation. One team isolates the complex on the foot, while the other prepares the hand, takes a bone graft from the iliac crest and fixes it.
Operation technique
A skin-fat flap is isolated so that the entire I toe is skeletonized, with the exception of a strip of skin on the medial side and distal tip of the toe. The distal end of this strip should extend almost to the lateral edge of the nail plate. The width of this strip is determined by the amount of skin required to fit the size of a normal I toe. Usually a 1 cm wide strip is left. The flap should not extend too proximally to the base of the first toe. Enough skin is left in the interdigital space so that the wound can be sutured. The direction of the first dorsal metatarsal artery is noted. With the foot down and using a venous tourniquet, the appropriate dorsal veins of the foot are marked.
A longitudinal incision is made between the I and II metatarsal bones. The dorsal artery of the foot is identified. Then it is isolated distally to the first dorsal metatarsal artery. If the first dorsal metatarsal artery is deep in the intermetatarsal space, or if the plantar digital artery is dominant for the first toe, a plantar incision is made in the first interdigital space. The lateral digital artery is isolated in the first interdigital space, and its isolation is continued proximally through a linear incision. The vascular branches are tied to the II toe, keeping all branches to the flap. The branch of the deep peroneal nerve is traced, which runs next to the lateral digital artery to the first toe, and the nerve is divided proximally so that its length meets the requirements of the recipient zone.
Dorsal veins leading to the flap are isolated. The lateral branches are coagulated to obtain a vascular pedicle of the required length. If the plantar metatarsal artery is used, it may require plastic surgery with a venous graft to obtain a vascular pedicle of the required length.
Once the neurovascular pedicle is exposed, a transverse incision is made at the base of the toe, avoiding damage to the vein draining the flap. The toe flap is raised, unfolded, and the lateral plantar neurovascular bundle is identified. The medial neurovascular bundle is isolated and mobilized, keeping its connection with the medial skin flap.
Separate the flap of the toe under the nail plate by careful subperiosteal discharge, avoiding damage to the matrix of the nail plate. Remove with a flap approximately 1 cm of tuberosity of the nail phalanx under the nail plate. The paratenon is retained on the extensor longus tendon of the first toe to provide an opportunity to perform plastic surgery with a free split skin graft. The plantar part of the flap is raised, leaving the subcutaneous tissue along the plantar surface of the toe. The lateral plantar digital nerve is cut off from the common digital nerve at the appropriate level. If the lateral plantar digital artery is not the main feeding artery of the flap, then it is coagulated and transected.
At this stage, the flap retains its connection with the foot only due to the vascular bundle, consisting of the dorsal digital artery, which is a branch of the first dorsal metatarsal artery and veins flowing into the system of the great saphenous vein of the leg. The tourniquet is removed and the blood supply to the flap is made sure. It may take 30 to 60 minutes to restore blood flow in the flap. Wrapping with a napkin dipped in warm isotonic sodium chloride solution or lidocaine solution can help stop persistent vasospasm. When the flap turns pink and the preparation of the hand is complete, microclips are applied to the vessels, tied and crossed. Thoroughly perform plastic surgery of the first toe with a split skin graft. Removing 1 cm of the distal phalanx allows the tip of the toe to be wrapped in a medial skin flap. A free split skin graft is used to cover the plantar, dorsum and lateral surface of the toe. W. Morrison suggested using crossplasty to cover the donor defect on the first toe, but usually it is not required.
Brush preparation.
The hand preparation team should also take a cancellous cortical graft from the iliac crest and process it to the size of a healthy finger. Normally, the tip of the first finger of the hand in adduction to the second finger is 1 cm proximal to the proximal interphalangeal joint of the second finger. On the hand, two areas require preparation. This is the dorsal-ray surface slightly distal to the anatomical snuffbox and the amputation stump itself. A longitudinal incision is made under the tourniquet in the first interdigital space. Two or more dorsal veins of the hand are isolated and mobilized. Between the first dorsal interosseous muscle and the adductor I finger muscle, mobilize a. radialis. The superficial radial nerve is identified. The arterial pedicle is mobilized, highlighting it proximally to the level of the proposed anastomosis at the level of the metacarpal-carpal or metacarpophalangeal joint.
The skin on the stump of the first finger is dissected with a straight cut across its tip from the mid-medial to the mid-lateral line, highlighting the dorsal and palmar subperiosteal flap about 1 cm in size. The neuroma of the ulnar digital nerve is isolated and excised. The end of the stump is refreshed for osteosynthesis with a graft. A depression is created in the stump of the main phalanx of the first finger or in the metacarpal bone in order to place a bone graft in it and then fix it with Kirschner wires, a screw or a miniplate with screws. The flap is wrapped around the bone so that its lateral side lies on the ulnar side of the bone graft. If the bone graft is too large, then it must be reduced to the required size. The flap is fixed with interrupted sutures in place so as to position the nail plate on the rear and the neurovascular bundle in the first intercarpal space. Using optical magnification, an epineural suture is applied to the ulnar digital nerve of the 1st toe and the lateral plantar nerve of the toe with a 9/0 or 10/0 thread. The own digital artery of the finger is sutured to the first dorsal metatarsal artery of the flap. Arterial inflow is restored, and dorsal veins are sutured. The deep peroneal nerve is sutured with a branch of the superficial radial nerve. The wound is sutured without tension, and the space under the flap is drained, avoiding placing the drain near the anastomoses. Then apply a loose bandage and plaster cast so as not to squeeze the finger, and leave the end of it to monitor the blood supply.
Postoperative management is carried out according to the usual technique developed for all microsurgical operations. Active finger movements begin after 3 weeks. As soon as the wound on the foot heals, the patient is allowed to walk with support on the foot. No special footwear required.
Finger osteoplastic reconstruction
Composite insular radial flap of the forearm.
This operation has the following advantages: good blood supply to the skin and bone graft; the working surface of the finger is innervated by transplanting an insular flap on a neurovascular pedicle; one-stage method; there is no resorption of the bone part of the graft.
The disadvantages of the operation include a significant cosmetic defect after the removal of the forearm flap and the possibility of a fracture of the radius in the distal third.
Before the operation, angiography is performed to determine the consistency of the ulnar artery and the superficial palmar arch, which provides blood supply to all fingers of the injured hand. Revealing the predominant blood supply due to the radial artery or the absence of the ulnar artery excludes the possibility of performing this operation in the author's version, but free transplantation of a complex of tissues from a healthy limb is possible.
The operation is performed under the tourniquet. The flap is lifted from the palmar and dorsal-radial surface of the forearm, its base is positioned several centimeters proximal to the styloid process of the radial bone. The flap should be 7-8 cm long and 6-7 cm wide. After preparation of the distal part of the stump of the first toe, the flap is lifted based on the radial artery and its comitant veins. Special care must be taken not to damage the cutaneous branches of the radial nerve or disrupt the blood supply to the radial bone just proximal to the styloid process. Small branches of the radial artery are identified, going to the muscle of the square pronator and further to the periosteum of the radial bone. These vessels are carefully mobilized and protected, after which an osteotomy of the radius is performed and a fragment of the radius is raised using bone instruments. The length of the graft can vary depending on the length of the 1st toe stump and the planned lengthening. The bone graft must include a cortico-cancellous fragment of the lateral surface of the radius at least 1.5 cm wide, and must be lifted so that vascular connections to the flap are preserved. The radial vessels are ligated proximally, and the entire flap is mobilized as a complex complex to the level of the anatomical snuffbox. The tendon of the long abductor I finger muscle and the short extensor of the I finger is released proximally by dissecting the distal part of the first dorsal supportive ligament. A complex skin-bone graft is then carried out under these tendons to the dorsum to the distal wound of the stump of the first toe. The bone graft is fixed with the I metacarpal bone with the spongy part in the position of opposing the II finger. Fixation is carried out longitudinally or obliquely with knitting needles, or using a mini-plate. The distal end of the graft is processed to give it a smooth shape. The skin portion of the flap is then wrapped around the graft and the remainder of the metacarpal bone or base phalanx.
At this stage, an insular flap on a vascular pedicle is raised from the ulnar side of the III or IV finger and placed on the palmar surface of the bone graft to provide sensitivity. A full-thickness skin graft is used to cover the donor defect. A split or full-thickness skin graft is taken from the front of the thigh to cover the donor forearm after covering the radius defect with the muscles. After removing the tourniquet, it is necessary to check the blood supply to both flaps and, if there are any problems, to revise the vascular pedicle.
A plaster cast is applied, and sufficient portions of the flaps are left open to ensure constant monitoring of their blood supply. Immobilization is maintained for 6 weeks or more until signs of consolidation appear.
Second toe transplant.
The first successful transplantation of the second toe into the position of the second toe was performed by Chinese surgeons Yang Dong-Yue and Chen Zhang-Wei in 1966.The second toe is supplied with blood by both the first and second dorsal metatarsal arteries extending from the dorsal artery of the foot, and the first and the second plantar metatarsal arteries extending from the deep plantar arch. The first dorsal metatarsal artery runs in the first intermetatarsal space. Here it is divided into the dorsal digital arteries, going to fingers I and II. The deep branch of the dorsal artery of the foot goes between the I and II metatarsal bones, connecting with the lateral plantar artery, and forms a deep plantar arch. The first and second plantar metatarsal arteries extend from the deep plantar arch. On the plantar surface of each interdigital space, the plantar artery bifurcates and forms the plantar digital arteries to the adjacent toes. In the first interdigital space, the digital vessels of the I and II fingers are located. The second toe is transplanted either on the first dorsal metatarsal artery extending from the dorsal artery of the foot as a feeding artery, or on the first plantar metatarsal artery extending from the deep plantar arch. There are variants of the anatomy of the vessels of the toes, in which the second toe is supplied with blood mainly from the system of the dorsal artery of the foot and the plantar arch. Toe identification can be simple or difficult, depending on the anatomical features. Based on the technique proposed by S. Poncber in 1988, a method was developed for isolating the second toe on the foot, which allows one to isolate all vessels supplying the second toe from the dorsal approach.
Isolation of the graft on the foot. For transplantation, a finger from the side of the same name is preferable, since normally the toes on the foot have a deviation to the lateral side, and therefore the transplanted finger is easier to orient to the long fingers. Before the operation, the pulsation of the dorsal artery of the foot is determined and the course of the artery and great saphenous vein is marked. Then a tourniquet is applied to the limb.
On the back of the foot, a curved incision is made in the projection of the dorsal artery of the foot and the first intermetatarsal space. At the base of the second toe, a bordering incision is made with cutting out triangular flaps along the back and plantar surface of the foot. The size of the cut out flaps can be different. After separating the skin and providing wide access to the dorsal structures of the foot, veins are carefully isolated - from the great saphenous vein at the level of the ankle joint to the base of the triangular flap at the second toe. The tendon of the short extensor of the 1st toe is transected and retracted, after which the dorsal artery of the foot is isolated at the required length proximally and distally to the base of the 1st metatarsal bone. At this level I define! the presence of the first dorsal metatarsal artery and its diameter. If the first dorsal metatarsal artery is more than 1 mm in diameter, then it must be traced to the base of the second toe. After the isolation and intersection of the extensor tendons of the II finger, a subperiosteal osteotomy of the II metatarsal bone is performed in the region of its base, the interosseous muscles are exfoliated, and the II metatarsal bone is raised by flexion in the metatarsophalangeal joint. This allows you to open wide access to the plantar vessels and to trace the deep branch connecting the dorsal artery of the foot with the plantar arch. From the plantar arch, the plantar metatarsal arteries leading to the second toe are traced and evaluated. Usually, the medial plantar digital artery of the second toe is large in diameter and departs from the first plantar metatarsal artery in the first interdigital space perpendicular to the axis of the toe. With this variant of the anatomy, the first plantar metatarsal artery, departing from the plantar arch, goes in the first intermetatarsal space and goes under the head of the I metatarsal bone, where, giving off the lateral branches, it goes to the plantar surface of the I toe. It can be isolated only after the intersection of the intermetatarsal ligament and the muscles attached to the lateral side of the head of the first metatarsal bone. Excretion is facilitated by pulling the container onto the rubber grip. After mobilization of the artery, the branches going to the 1st finger are coagulated and crossed. If necessary, a second plantar metatarsal artery can be isolated, running in the second intermetatarsal space. Then, the common finger plantar nerves are isolated, the bundles going to the adjacent fingers are separated, and the digital nerves of the second finger are cut. The flexor tendons of the II finger are isolated and crossed. After crossing the vessels leading to the third finger, the second finger remains connected to the foot only by the artery and vein. Remove the tourniquet. It is necessary to wait for the full restoration of blood flow in the finger.
Selection on brushes. A tourniquet is applied to the forearm. An incision is made through the end of the stump of the 1st ray with a continuation to the rear and the palmar surface of the hand. All structures to be restored are highlighted:
dorsal saphenous veins;
extensors of the first finger;
the tendon of the long flexor of the first finger;
palmar digital nerves;
recipient artery;
remove scars and endplate of stump of I ray.
After removing the tourniquet, the presence of inflow through the recipient artery is checked.
Hand graft transplant... The graft is prepared for osteosynthesis. This moment of the operation depends on the level of the defect in the first finger of the hand. If the first metacarpophalangeal joint is intact, the second metatarsal bone is removed and the cartilage and cortical plate of the base of the main phalanx of the second finger are removed. In the presence of a stump at the level of the metacarpophalangeal joint, 2 options are possible - joint restoration and arthrodesis. When performing arthrodesis, the graft is prepared as described above. When restoring the joint, oblique osteotomy of the metatarsal bone is performed under the head at the level of attachment of the metatarsophalangeal joint capsule at an angle of 130 °, open to the plantar side. This eliminates the tendency to hyperextension in the joint after finger transplantation to the hand, since the metatarsophalangeal joint is anatomically an extensor joint. In addition, such an osteotomy can increase the amount of flexion in the joint.
In the presence of a stump of the first finger at the level of the metacarpal bone, the required length of the metatarsal bone is left in the graft. After preparation of the graft, osteosynthesis is performed with Kirschner wires. In addition, we fix the distal interphalangeal joint of the second finger in a state of extension with a wire in order to exclude the possibility of developing flexion contracture of the finger. When performing osteosynthesis, it is necessary to orient the transplanted finger on the existing long fingers of the hand to be able to perform a pinch grip. Next, the extensor tendons are sutured, while a prerequisite is the position of full extension of the finger. The flexor tendons are then sutured. The suture is applied with slight tension on the central end of the long flexor tendon to avoid the development of flexion contracture of the finger. Then the arteries and veins are anastomosed and the nerves are sutured epineurally. When suturing a wound, it is necessary to avoid skin tension to exclude the possibility of vascular compression. When transplanting a toe with a metatarsophalangeal joint, most often it is not possible to cover the lateral surfaces in the area of the joint. In such a situation, plastic is most often used with a free full-thickness skin graft. The rollers are not fixed to these grafts.
If there is a cicatricial deformity in the area of the stump of the 1st ray on the hand, or if a finger transplant with a metatarsal bone is planned, then additional skin grafting may be required, which can be performed either before the finger transplant or at the time of the operation. Immobilization is carried out with a plaster cast longuette.
Suturing the donor wound on the foot. After careful hemostasis, the intertarsal ligament is restored and the intersected muscles are sutured to the 1st finger. The metatarsal bones are brought together and fixed with Kirschner wires. After that, the wound is easily sutured without tension. The space between the I and II metatarsal bones is drained. Immobilization is carried out with a plaster cast longitudinal bandage on the back surface of the leg and foot.
Postoperative management is carried out as in any microsurgical operation.
Hand immobilization is maintained until consolidation occurs, on average 6 weeks. From the 5-7th day after the operation, you can begin the careful active movements of the transplanted finger in the bandage under the supervision of a doctor. After 3 weeks, the wire is removed to fix the distal interphalangeal joint. The immobilization of the foot is carried out for 3 weeks, after which the needles are removed, the plaster cast is removed. Within 3 months. after the operation, the patient is not recommended to fully load the leg. Within 6 months. after the operation, bandaging of the foot is recommended to prevent flattening anterior section feet.
Pollicization
The operation of tissue transposition, which turns one of the fingers of the injured hand into the first finger, has more than a century of history.
The first report on the true pollicization of the second toe with the isolation of the neurovascular bundle and the description of the transplant technique belongs to Gosset. A necessary condition for successful pollicization is the separation of the corresponding common palmar digital arteries from the superficial arterial arch.
Anatomical studies have established that in 4.5% of cases, some or all of the common digital arteries depart from the deep arterial arch. In this case, the surgeon must choose a donor finger to which the common palmar digital arteries extend from the superficial arterial arch. If all common palmar digital arteries depart from the deep arterial arch, then the surgeon can transpose the second finger, which, unlike other fingers, can be moved in this case.
Pollicization of II finger... Under the tourniquet, flaps are planned around the base of the second finger and over the second metacarpal bone. A racquet-shaped incision is made around the base of the II finger, starting with the palm at the level of the proximal finger fold and continuing around the finger, connecting with a V-shaped incision over the middle part of the metacarpal bone with a bend extending to the base of the metacarpal bone, where it deviates laterally to the stump area I metacarpal bone.
The skin flaps are carefully isolated, and the remnants of the second metacarpal bone are removed. In the palm of the hand, neurovascular bundles are isolated to the second finger and flexor tendons. Digital artery to the radial side of the third finger is identified and transected behind the bifurcation of the common digital artery. A careful division of the bundles of the common digital nerve to the II and III fingers is performed.
On the back, several dorsal veins are isolated to the II finger, mobilized by bandaging all the lateral branches that interfere with its movement. The transverse intermetacarpal ligament is transected and the interosseous muscles are divided. The extensor tendons of the second finger are mobilized. Further, the course of the operation changes depending on the length of the stump of the first ray. If the saddle joint is preserved, then the second finger is isolated in the metacarpophalangeal joint and the base of the main phalanx is resected, thus, the main phalanx of the second finger will perform the function of the I metacarpal bone. If the saddle joint is absent, only the polygonal bone is preserved, then the metacarpal bone is resected under the head, thus, the II metacarpophalangeal joint will perform the function of the saddle joint. The second finger now remains on the vascular bundles and tendons and is ready for transplantation.
Prepare the first metacarpal bone or, if it is small or absent, a polygonal bone for osteosynthesis. The bone marrow canal of the stump of the first metacarpal or trapezoidal bone is expanded, and a small bone nail taken from the removed part of the second metacarpal bone is inserted into the base of the proximal phalanx of the second finger, as soon as it is transferred to a new position, and fixed with Kirschner wires. It is important to position the finger to be moved in a position of sufficient abduction, opposition and pronation. If possible, the extensor tendons of the second finger are sutured with the mobilized stump of the long extensor of the first finger. Since the second finger is noticeably shortened, it may sometimes be necessary to shorten the flexor tendons to the second finger. The tourniquet is removed, the viability of the displaced finger is assessed. The skin wound is sutured after moving the lateral flap of the interdigital space into a new cleft between the moved finger and the third finger.
Immobilization of the first ray is maintained for 6-8 weeks, until fusion occurs. Additional surgical interventions are possible, including shortening of the flexor tendons, extensor tenolysis, opponoplasty, if the function of the thenar muscles is lost and satisfactory rotational movements in the saddle joint are preserved.
Pollicization of the IV finger.
Under the tourniquet, a palmar incision begins at the level of the distal palmar fold, continues on each side of the IV finger through the interdigital spaces and connects distally over the IV metacarpal bone approximately at the level of its middle. Then the incision is continued to the base of the IV metacarpal bone.
The flaps are separated and lifted and identified through the palmar incision, the neurovascular bundles are mobilized. The ligation of the ulnar digital arterial branch to the third finger and the radial finger arterial branch to the fifth finger is performed slightly distal to the bifurcation of the common digital artery in the third and fourth interdigital spaces, respectively. Under a microscope, the common digital nerves are carefully split to the III and IV fingers and to the IV and V fingers, which is required to move the finger through the palm without tension of the digital nerves or damage to the nerves to the III and V fingers.
The transverse intermetacarpal ligaments are dissected on each side, leaving sufficient length to allow the two ligaments to be connected after the IV toe transplant. The extensor tendon of the IV finger is transected at the level of the base of the IV metacarpal bone and is mobilized distally to the base of the proximal phalanx. The metacarpal bone is freed from the interosseous muscles attached to it, and the tendons of the short muscles to the 4th finger are cut distally. Then an osteotomy of the IV metacarpal bone is performed at the base level and removed. The flexor tendons are mobilized to the middle of the palm, and any remaining soft tissue attached to the fourth finger is transected in preparation for passing it through the subcutaneous tunnel in the palm.
The I metacarpal bone is prepared for the IV toe transplant, and if it is short or absent, then the articular surface of the polygonal bone is removed to a cancellous substance. It is possible to make a canal in the I metacarpal or in the trapezius bone for the introduction of the bone nail when fixing the transplanted finger. On the rear of the I metacarpal bone, an incision is made in the proximal direction to identify and mobilize the stump of the extensor longus tendon of the I finger. Scars in the area of the stump of the first toe are removed, leaving well-supplied skin to cover the brine after the toe transplant.
A tunnel is formed under the skin of the palmar surface of the hand for holding the 4th finger to the stump of the 1st ray. The finger is carefully passed through the tunnel. In its new position, the finger is rotated by 100 ° along the longitudinal axis to achieve a satisfactory position with minimal tension of the neurovascular bundles. The articular surface of the proximal phalanx of the IV finger is removed, and the bone is modeled to obtain the required length of the toe. Fixation is carried out with Kirschner needles. The use of a bone intramedullary nail through the bone contact is not necessary.
The operation is completed by suturing the extensor tendon of the 4th finger with the distal stump of the long extensor of the 1st finger. The tendon suture is performed with sufficient tension until full extension of the IV finger is obtained in the proximal and distal interphalangeal joints. The remainder of the tendon of the short abductor I finger muscle is connected to the remainder of the tendons of the interosseous muscles of the IV finger from the radial side. Sometimes it is possible to suture the remainder of the adductor tendon to the stumps of the short muscle tendon along the ulnar side of the transplanted toe. Since the outflow of blood is carried out mainly through the dorsal veins, and when the finger is removed and passed through the tunnel, they have to be crossed, it is often necessary to restore the venous outflow by suturing the veins of the transplanted finger with the veins of the back of the hand in a new position. The tourniquet is then removed to control blood flow and hemostasis.
The donor wound is sutured after the restoration of the transverse intercarpal ligament of the III and V fingers.
In the first interdigital space, the wound is sutured so that there is no splitting of the hand. When suturing the wound at the base of the transplanted toe, it may be necessary to perform multiple Z-plastics to prevent the formation of a circular compression scar that disrupts the blood supply to the transplanted toe.
Immobilization is maintained until bone fusion, approximately 6-8 weeks. Movements of the fourth finger begin in 3-4 weeks, although when the plate is fixed, the movements can be started earlier.
Two-stage pollicisation method.
It is based on the "prefabrication" method, which consists in a staged microsurgical transplantation of a blood-supplied tissue complex, including a vascular bundle with its surrounding fascia, into the proposed donor area to create new vascular connections between this vascular bundle and the future tissue complex. The fascia surrounding the vascular bundle contains a large number of small vessels, which, by the 5-6th day after transplantation, grow into the surrounding tissues and form connections with the vasculature of the recipient region. The "prefabrication" method allows you to create a new vascular bundle of the required diameter and length.
A two-stage pollicization can be indicated in the presence of hand injuries that exclude the possibility of classical pollicization due to damage to the superficial arterial arch or common digital arteries.
Operation technique... The first stage is the formation of the vascular pedicle of the selected donor finger. Preparing the brush... Scars on the palm are excised. An incision is made along the palmar surface of the main phalanx of the donor finger, which is connected to the incision in the palm. Then a small longitudinal incision is made along the rear of the main phalanx of the donor finger. Gently peel the skin along the lateral surfaces of the main phalanx of the finger to form a bed for the fascia of the flap. Next, an incision is made in the projection of the future recipient vessels in the area of the "anatomical snuffbox". The recipient vessels are mobilized and prepared for anastomosis.
Fascial flap formation... A radial fascial skin flap is used from the other limb in order to, in addition to forming the vascular pedicle of the donor finger, to replace the defect on the palmar surface of the hand. Any fascial flap with an axial type of blood supply can be used. The details of the operation are known. The length of the vascular pedicle of the flap is determined in each case by measuring from the edge of the defect or the base of the donor finger, if there is no defect, then to the recipient vessels.
Formation of the vascular pedicle of the donor finger... The flap is placed on the palm of the injured hand so that the distal fascial part of the flap is held under the skin of the main phalanx of the donor finger in a previously formed tunnel, wrapped around the main phalanx and sutured to itself in a palmar incision. If there is a skin defect on the hand, then the skin part of the flap replaces it. The vascular pedicle of the flap is brought out to the site of recipient vessels through an additional incision connecting the anastomosis area and the palmar wound. Then anastomoses are applied to the artery and veins of the flap and recipient vessels. The wound is sutured and drained. Immobilization is carried out with a plaster cast for 3 weeks.
Second phase... Actually pollicization of the donor finger to the position of the 1st finger. Preparing the stump. Scars at the end of the stump are excised, they are refreshed to prepare for osteosynthesis, and the skin is mobilized. The extensor tendons of the first finger and the dorsal veins are distinguished.
On the palmar surface, the digital nerves and the tendon of the long flexor of the first finger are mobilized.
Isolation of a donor finger on a pedicle... Initially, on the palmar surface, before the tourniquet is applied, the course of the vascular pedicle is marked by pulsation. A skin incision is made at the base of the donor finger, with triangular flaps cut out on the dorsum and palmar surface. On the dorsum of the finger, saphenous veins are isolated, and after marking, they are crossed. The finger extensor tendon is transected. An incision is made along the palmar surface from the apex of the triangular flap along the marked vascular pedicle. The digital nerves themselves are carefully isolated. Disarticulation of the finger in the metacarpophalangeal joint is performed by dissecting the joint capsule and cutting the tendons of the short muscles. The finger is lifted on the new vascular pedicle by carefully extracting it in the direction of the stump of the first toe.
Isolation of the vascular pedicle is continued until sufficient length is allocated for rotation without tension. At this stage, the tourniquet is removed and the blood supply to the finger is monitored. The incision along the palmar surface of the stump of the I ray is connected to the incision in the palm in the area of the selected vascular pedicle.
The vascular pedicle is unrolled and placed in the incision.
Fixation of the donor finger in positionIfinger... Resection of the articular surface of the base of the main phalanx of the donor finger is performed. The finger is rotated 100-110 ° in the palmar direction in order to position the palmar surface of the donor finger in a position of opposition to the remaining long fingers.
Osteosynthesis is performed with Kirschner wires, trying not to restrict movement in the interphalangeal joints of the transplanted finger. The extensor and flexor tendons are restored and the digital nerves themselves are sutured epineurally. If there are signs of venous insufficiency under a microscope, anastomoses are applied to 1-2 veins of the donor finger and the veins of the dorsum of the stump of the 1st finger.
On the dorsum of the stump, a skin incision is made to place a triangular flap in order to avoid a circular compression scar.
The wound is sutured and drained. Immobilization is carried out with a longitudinal plaster cast before the onset of consolidation.
| Hand | Hand fingers | Bumps in the palm of your hand | Hand lines | Vocabulary | Articles
This section looks at each finger in turn, analyzing factors such as length, width, marks and phalanges of each finger individually. Each finger is associated with a specific planet, each of which, in turn, is associated with classical mythology. Each finger is seen as an expression of a different facet of the human character. The phalanges are the length of the toes between the joints. Each finger has three phalanges: the main, middle and initial. Each phalanx is associated with a special astrological symbol and reveals certain personality traits.
The first, or forefinger, finger. In the ancient Roman pantheon, Jupiter was supreme deity and the ruler of the world - the equivalent of the ancient Greek god Zeus. In full accordance with this, the finger bearing the name of this god is associated with the ego, the ability to lead, ambition and status in the world.
Second, or middle, finger. Saturn is considered the father of Jupiter and corresponds to the ancient Greek god Kronos, the god of time. The Saturn finger is associated with wisdom, a sense of responsibility and a general attitude in life, for example, whether a person is happy or not.
Third, or ring, finger. Apollo, god of the Sun and youth in ancient Roman mythology; in Ancient Greece it was associated with a deity with the same name. Since the god Apollo is associated with music and poetry, Apollo's finger reflects a person's creativity and his sense of well-being.
The fourth finger, or little finger. Mercury, among the Greeks, the god Hermes, the messenger of the gods, and this finger is the finger of sexual intercourse; it expresses how clear a person is, that is, whether he is really as honest as he says about it.
Definition of phalanges
Length. In order to determine the phalanges, the palmist considers factors such as its length in comparison with other phalanges and overall length. In general, the length of the phalanx reflects how expressive a person is in a particular area. Insufficient length indicates a lack of intelligence.
Width. Width is also important. The width of the phalanx indicates how experienced and practical a person is in this area. The wider the finger, the more actively the person uses the special features guided by this phalanx.
Marks
These are vertical lines. As a rule, it is good signs as they channel the energy of the phalanx, but too many grooves can mean stress.
Stripes are horizontal lines across the phalanx that act in the opposite way to the grooves: they are believed to block the energy released by the phalanx.
The human hand has a complex structure and performs a variety of subtle movements. It is a working organ and, as a result, is more likely to be damaged than other parts of the body.
Introduction.
In the structure of injuries, industrial (63.2%), household (35%) and street (1.8%) types of injuries prevail. Work-related injuries are usually open and account for 78% of all open injuries of the upper limbs. Injuries to the right hand and fingers account for 49%, while the injuries to the left account for 51%. Open injuries of the hand in 16.3% of cases are accompanied by combined damage to tendons and nerves due to their close anatomical location. Injuries and diseases of the hand and fingers lead to impairment of their function, temporary disability, and often to disability of the victim. The consequences of hand and finger injuries account for more than 30% in the structure of disability due to injuries of the musculoskeletal system. The loss of one or more fingers leads to professional and psychological difficulties. A high percentage of disability as a result of injuries to the hand and fingers is explained not only by the severity of the injuries, but also by incorrect or untimely diagnosis and choice of treatment tactics. When treating this group of patients, one should strive to restore not only the anatomical integrity of the organ, but also its function. Surgical treatment of injuries is carried out according to an individual plan and in accordance with the principles outlined below.
Features of the treatment of patients with injuries and diseases of the hand.
Anesthesia.
Adequate pain relief is the main prerequisite for subtle hand intervention. Local infiltration anesthesia can be used only for superficial defects, its use is limited on the palmar surface of the hand due to low skin mobility.
In most cases, during operations on the hand, conduction anesthesia is performed. Blocking of the main nerve trunks of the hand can be carried out at the level of the wrist, elbow, axillary and cervical regions. For finger surgery, anesthesia according to Oberst-Lukashevich or a block at the level of the intercarpal spaces is sufficient (see Fig. 1)
Fig. 1 Anesthetic injection points during conduction anesthesia upper limb.
At the level of the fingers and wrist, it is necessary to avoid the use of prolonged anesthetics (lidocaine, marcaine), since, due to prolonged resorption of the drug, compression of the neurovascular bundles and the occurrence of tunnel syndromes and, in some cases, finger necrosis. For severe hand injuries, anesthesia should be used.
Exsanguination of the operating field.
Among the tissues soaked with blood, it is impossible to differentiate the vessels, nerves and tendons of the hand, and the use of tampons to remove blood from the operating field harms the sliding apparatus. Therefore, exsanguination is mandatory not only for major interventions on the hand, but also for treating minor injuries. To exsanguinate the hand, an elastic rubber bandage or pneumatic cuff is applied to the upper third of the forearm or lower third of the shoulder, in which the pressure is pumped up to 280-300 mm Hg, which is more preferable, since it reduces the risk of nerve paralysis. Before using them, it is advisable to apply an elastic rubber bandage to the previously raised arm, which helps to squeeze out a significant part of the blood from the arm. For finger surgery, it is sufficient to apply a rubber tourniquet at its base. If the surgery lasts more than 1 hour, then it is necessary to release the air from the cuff for a few minutes with the raised position of the limb, and then refill it.
Skin incisions on the hand.
The epidermis on the hand forms a complex network of lines, the direction of which is due to a variety of finger movements. On the palmar surface of the skin of the hand, there are many grooves, wrinkles and folds, the number of which is variable. Some of them, which have a certain function and are landmarks of deep-lying anatomical formations, are called primary skin formations (Fig. 2).
Fig. 2 Primary skin formations of the hand.
1-distal palmar groove, 2-proximal palmar groove. 3-interphalangeal grooves, 4-palmar grooves of the wrist, 5-interdigital folds, 6-interphalangeal folds
Connective tissue bundles extend vertically from the base of the main furrows to the palmar aponeurosis and to the tendon sheaths. These grooves are the "joints" of the skin of the hand. The groove plays the role of an articular axis, and adjacent areas perform movements around this axis: approaching each other - flexion, distance - extension. Wrinkles and folds are reservoirs of movement and contribute to the enlargement of the skin surface.
A rational skin incision should be subjected to the least amount of stretching during movement. Due to the constant stretching of the edges of the wound, hyperplasia of the connective tissue occurs, the formation of rough scars, their wrinkling and, as a result, dermatogenic contracture. Perpendicular incisions are most affected by movement, while incisions parallel to the grooves heal with minimal scarring. There are areas of the skin of the hand that are neutral in terms of stretching. This area is the mid-lateral line (Fig. 3) along which stretching in opposite directions is neutralized.
Fig. 3 Mid-lateral line of the finger.
Thus, the optimal incisions on the hand are incisions parallel to the primary skin lesions. If it is impossible to provide such access to damaged structures, it is necessary to choose the most correct permissible type of section (Fig. 4):
1.A cut parallel to the grooves is complemented by a straight or arcuate in the wrong direction,
2.the cut is made along the neutral line,
3.The incision perpendicular to the grooves is complemented by a Z-shaped plastic,
4. the incision crossing the primary skin lesions must be arcuate or Z-shaped to redistribute the tensile forces.
Fig. fourA-Optimal wrist incisions,B-Z-plastics
For optimal primary surgical treatment of hand injuries, it is necessary to expand the wounds by means of additional and lengthening incisions in the correct direction.
Fig. 5 Additional and lengthening cuts on the brush.
Atraumatic operation technique.
Hand surgery is a sliding surface surgery. The surgeon must be aware of two dangers: infection and injury, which ultimately lead to fibrosis. To avoid it, a special technique is used, which Bunnel called atraumatic. To implement this technique, it is necessary to observe the strictest asepsis, the use of only sharp instruments and thin suture material, constant moistening of tissues. Avoid tissue trauma with tweezers and clamps, as micronecrosis forms at the site of compression, leading to scarring, as well as being left in the wound foreign bodies in the form of long ends of ligatures, large knots. It is important to exclude the use of dry swabs to stop blood and dissection of tissues, and to avoid unnecessary drainage of the wound. The joining of the edges of the skin should be done with minimal tension and the blood supply to the flap should not be impeded. The so-called "time factor" plays a huge role in the development of infectious complications, since too long operations lead to "fatigue" of tissues, a decrease in their resistance to infection.
After atraumatic intervention, the tissues retain their characteristic luster and structure, and only a minimal tissue reaction occurs during the healing process.
Immobilization of the hand and fingers.
The human hand is in constant motion. The immobility condition is unnatural for the hand and has serious consequences. The non-working hand assumes a resting position: slight extension in the wrist joint and flexion in the finger joints, abduction of the thumb. The hand takes the resting position lying on a horizontal surface and hanging (Fig. 6)
Fig. 6 Hand at rest
In the functional position (position of action), extension in the wrist joint is 20, elbow abduction is 10, flexion in the metacarpophalangeal joints is 45, in the proximal interphalangeal joints - 70, in the distal interphalangeal joints - 30, the first metacarpal bone is in opposition, and the large the finger forms an incomplete letter "O" with the index and middle, and the forearm occupies an intermediate position between pronation and supination. The advantage of the functional position is that it creates the most favorable starting position for the action of any muscle group. The position of the finger joints depends on the position of the wrist joint. Flexion in the wrist joint causes extension of the fingers, and extension - flexion (Figure 7).
Fig. 7 Functional position of the hand.
In all cases, in the absence of forced circumstances, it is necessary to immobilize the hand in a functional position. Immobilizing the finger in a straightened position is an irreparable mistake and leads to stiffness in the joints of the finger in a short time. This fact is explained by the special structure of the collateral ligaments. They run distal and palmar from the pivot points. Thus, in the straightened position of the finger, the ligaments relax, and in the bent position they stretch (Fig. 8).
Fig. 8 Biomechanics of collateral ligaments.
Therefore, when the finger is fixed in an extended position, the ligament shrinks. If only one finger is damaged, the rest should be left free.
Fractures of the distal phalanx.
Anatomy.
Connective tissue septa, stretching from bone to skin, form a cellular structure and are involved in stabilizing the fracture and minimizing the displacement of fragments. (Fig. 9)
R Fig. 9 Anatomical structure of the nail phalanx:1-attachment of collateral ligaments,2- connective tissue partitions,3-lateral interosseous ligament.
On the other hand, a hematoma that occurs in closed connective tissue spaces is the cause of a bursting pain syndrome that accompanies damage to the nail phalanx.
The extensor and deep flexor tendons that attach to the base of the distal phalanx do not play a role in the displacement of the fragments.
Classification.
There are three main types of fractures (according to Kaplan L.): longitudinal, transverse and comminuted (eggshell type) (Fig. 10).
Fig. 10 Classification of fractures of the nail phalanx: 1-longitudinal, 2-transverse, 3-comminuted.
Longitudinal fractures in most cases are not accompanied by displacement of fragments. Transverse fractures of the base of the distal phalanx are accompanied by angular displacement. Comminuted fractures involve the distal phalanx and are often associated with soft tissue injuries.
Treatment.
Fractures without displacement and comminuted fractures are treated conservatively. For immobilization, palmar or back splints are used for 3-4 weeks. When applying a splint, it is necessary to leave the proximal interphalangeal joint free (Fig. 11).
Fig. 11 Splints used to immobilize the nail phalanx
Transverse fractures with angular displacement can be treated both conservatively and operatively - closed reduction and osteosynthesis with a thin Kirschner wire (Fig. 12).
Fig. 12 Osteosynthesis of the nail phalanx with a thin Kirschner wire: A, B - stages of the operation, C - Final type of osteosynthesis.
Fractures of the main and middle phalanges.
The displacement of fragments of the phalanges is primarily determined by muscle traction. With unstable fractures of the main phalanx, the fragments are displaced at an angle open to the rear. The proximal fragment assumes a bent position due to the traction of the interosseous muscles attached to the base of the phalanx. The distal fragment does not serve as an attachment site for the tendons and its hyperextension occurs due to the traction of the central portion of the finger extensor tendon, which is attached to the base of the middle phalanx (Fig. 13). 
Fig. 13 Mechanism of displacement of fragments in fractures of the main phalanx
In fractures of the middle phalanx, it is necessary to take into account two main structures that affect the displacement of fragments: the middle portion of the extensor tendon, which is attached to the base of the phalanx from the rear, and the superficial flexor tendon, which is attached to the palmar surface of the phalanx (Fig. 14)
Fig. 14 Mechanism of displacement of fragments in fractures of the middle phalanx
Particular attention must be paid to fractures with rotational displacement, which must be repaired with particular care. In the bent position, the fingers are not parallel to each other. The longitudinal axes of the fingers are directed to the scaphoid bone (Fig. 15)
With displaced phalanx fractures, the fingers intersect, which makes it difficult to function. In patients with phalangeal fractures, flexion of the fingers is often impossible due to pain, therefore rotational displacement can be established by the location of the nail plates in the bent position of the fingers (Fig. 16)
Fig. 16 Determination of the direction of the longitudinal axis of the fingers with fractures of the phalanges
It is extremely important that the fracture heals without permanent deformity. The flexor tendon sheaths run in the palmar groove of the phalanges and any unevenness prevents the tendons from sliding.
Treatment.
Non-displaced fractures or punctured fractures can be treated with what is known as dynamic splinting. The injured finger is fixed to the adjacent one and early active movements begin, which prevents the development of stiffness in the joints. Displaced fractures require closed reduction and fixation with a plaster cast (Fig. 17)
Fig. 17 the use of a plaster splint for fractures of the phalanges of the fingers
If after reduction the fracture is not stable, the fragments cannot be held with the help of a splint, then percutaneous fixation with thin Kirschner wires is necessary (Fig. 18)
Fig. 18 Osteosynthesis of the phalanges of the fingers with Kirschner wires
In case of impossibility of closed reduction, open reduction with subsequent osteosynthesis of the phalanx with wires, screws, plates is shown. (Figure 19)
Fig. 19 Stages of osteosynthesis of the phalanges of the fingers with screws and a plate
In case of intra-articular fractures, as well as multi-splinter fractures, the best treatment result is provided by the use of external fixation devices.
Fractures of the metacarpal bones.
Anatomy.
The metacarpal bones are not located in the same plane, but form the arch of the hand. The arch of the wrist passes into the arch of the hand, forming a semicircle, which is completed to a full circle with the first finger. Thus, the fingertips touch at one point. If the arch of the hand, due to damage to bones or muscles, flattens, then a traumatic flat hand is formed.
Classification.
Depending on the anatomical localization of damage, there are: fractures of the head, neck, diaphysis and base of the metacarpal bone.
Treatment.
Metacarpal head fractures require open reduction and fixation with thin Kirschner wires or screws, especially in the case of an intra-articular fracture.
Metacarpal neck fractures are a common injury. Fracture of the neck of the fifth metacarpal bone, as the most common, is called "boxer's fracture" or "fighter's fracture." Such fractures are characterized by a displacement at an angle open to the palm, and are unstable due to destruction of the palmar cortical plate (Fig. 20)
Fig. 20 Fracture of the metacarpal neck with destruction of the palmar plate of the cortical layer
With conservative treatment by immobilization with a plaster cast, it is usually not possible to eliminate the displacement. Deformation of the bone does not significantly affect the function of the hand, only a small cosmetic defect remains. To effectively eliminate the displacement of fragments, closed reduction and osteosynthesis with two crossing Kirschner wires or transfixation with wires to the adjacent metacarpal bone are used. This method allows you to start early movements and avoid stiffness in the joints of the hand. The pins can be removed 4 weeks after surgery.
Fractures of the diaphysis of the metacarpal bones are accompanied by significant displacement of fragments and are unstable. With the direct action of the force, as a rule, transverse fractures occur, with the indirect action - oblique. The displacement of the fragments leads to the following deformities: the formation of an angle open to the palm (Fig. 21)
Fig. 21 The mechanism of displacement of fragments in a fracture of the metacarpal bone.
Shortening of the metacarpal bone, hyperextension in the metacarpophalangeal joint due to the action of the extensor tendons, flexion in the interphalangeal joints caused by the displacement of the interosseous muscles, which, due to the shortening of the metacarpal bones, are no longer able to perform the extension function. Conservative treatment in a plaster cast does not always eliminate the displacement of the fragments. In transverse fractures, the most effective transfixation with wires to the adjacent metacarpal bone or intramedullary separation with a pin (Figure 22)
Fig. 22 Types of metacarpal bone osteosynthesis: 1- with wires, 2- with a plate and screws
For oblique fractures, osteosynthesis is performed with AO miniplates. With these methods of osteosynthesis, additional immobilization is not required. Active movements of the fingers of the hand are possible from the first days after the operation after the edema subsides and the pain syndrome decreases.
Metacarpal base fractures are stable and easy to treat. Immobilization with a dorsal splint, reaching the level of the heads of the metacarpal bones, for three weeks is sufficient for the fracture to heal.
Fractures of the first metacarpal bone.
The peculiarity of the function of the first finger explains its special position. Most fractures of the first metacarpal bone are base fractures. By Green D.P. these fractures can be divided into 4 types, and only two of them (Bennett's fracture-dislocation and Rolando's fracture) are intra-articular (Fig. 23)
Fig. 23 Classification of fractures of the base of the first metacarpal bone: 1- Bennet's fracture, 2- Rolando's fracture, 3,4 - extra-articular fractures of the base of the first metacarpal bone.
To understand the mechanism of injury, it is necessary to consider the anatomy of the first carpometacarpal joint. The first carpometacarpal joint is the saddle joint formed by the base of the first metacarpal bone and the trapezoid bone. Four main ligaments are involved in stabilizing the joint: anterior oblique, posterior oblique, intercarpal and dorsal-radial. (Fig. 24)
Fig. 24 Anatomy of the first metacarpophalangeal joint
The palmar part of the base of the first metacarpal bone is somewhat elongated and is the site of attachment of the anterior oblique ligament, which is the key to joint stability.
For the best visualization of the joint, X-ray is necessary in the so-called "true" anteroposterior projection (projection Robert), when the hand is in the position of maximum pronation (Fig. 25)
Fig. 25 Robert's projection
Treatment.
Bennett's fracture-dislocation is the result of direct trauma directed to the bent metacarpal bone. At the same time, her
dislocation, and a small palmar bone fragment of a triangular shape remains in place due to the strength of the anterior oblique ligament. The metacarpal bone is displaced to the radial side and to the rear due to the traction of the long abductor muscle (Fig. 26).
Fig. 26 Bennett's fracture-dislocation mechanism
The most reliable method of treatment is closed reduction and percutaneous fixation with Kirschner wires to the second metacarpal or to the trapezius or trapezium bone (Fig. 27)
Fig. 27 Osteosynthesis with Kirschner wires.
For reduction, traction is performed on the finger, abduction and opposition of the first metacarpal bone, at the moment of which pressure is applied to the base of the bone and reduction. In this position, the needles are introduced. After the operation, immobilization is performed in a plaster cast for a period of 4 weeks, after which the splint and spokes are removed, and rehabilitation begins. In case of impossibility of closed reduction, they resort to open reduction, after which osteosynthesis of both Kirschnen's wires and thin 2mm AO screws is possible.
A Rolando fracture is a T- or Y-shaped intra-articular fracture and can be classified as a multi-splinter fracture. The prognosis for restoration of function in this type of damage is usually poor. In the presence of large fragments, open reduction and osteosynthesis with screws or spokes are indicated. To maintain the length of the metacarpal bone in combination with internal fixation, external fixation devices or transfixation to the second metacarpal bone are used. In the case of compression of the base of the metacarpal bone, primary bone grafting is required. In case of impossibility of surgical restoration of the congruence of the articular surfaces, as well as in elderly patients, a functional method of treatment is indicated: immobilization for a minimum period for the pain to subside, and then early active movements.
Extra-articular fractures of the third type are the most rare fractures of the first metacarpal bone. Such fractures respond well to conservative treatment - immobilization in a plaster cast in the position of hyperextension in the metacarpophalangeal joint for 4 weeks. Oblique fractures with a length of the fracture line may be unstable and require percutaneous osteosynthesis with wires. Opening reduction with these fractures is used extremely rarely.
Scaphoid fractures
Scaphoid fractures account for up to 70% of all wrist fractures. They come when falling on an outstretched hand from overextension. According to Russe, horizontal, transverse and oblique fractures of the scaphoid are distinguished. (fig28)
These fractures can be difficult to recognize. Of great importance is local pain when pressing in the area of the anatomical snuffbox, pain during dorsiflexion of the hand, as well as radiography in direct projection with some supination and elbow abduction of the hand.
Conservative treatment.
It is indicated for fractures without displacement of fragments. Plaster immobilization in a bandage covering the thumb for 3-6 months. Plaster casts are changed every 4-5 weeks. To assess consolidation, it is necessary to conduct staged radiographic studies, and in some cases, MRI (Fig. 29).
Fig. 29 1- MRI picture of a scaphoid fracture,2- immobilization for scaphoid fractures
Surgical treatment.
Open reduction and screw fixation.
The navicular bone opens from access along the palmar surface. Then a guide pin is passed through it along which the screw is inserted. The most commonly used screw is Herbert, Acutrak, AO. After osteosynthesis, plaster immobilization for 7 days (Fig. 30)
Fig. 30 Osteosynthesis of the scaphoid with a screw
Nonunions of the scaphoid.
For nonunions of the scaphoid bone grafting according to Matti-Russe is used. Using this technique, a groove is formed in the fragments into which the cancellous bone is taken from the iliac crest or from the distal radius (D.P. Green) (Fig. 31). Plaster immobilization for 4-6 months.
Fig. 31 Bone grafting with nonunion of the scaphoid.
Fixation with a screw with or without bone grafting can also be used.
Damage to the small joints of the hand.
Damage to the distal interphalangeal joint.
Dislocations of the nail phalanx are quite rare and usually occur in the dorsum. More often, dislocations of the nail phalanx are accompanied by avulsion fractures of the attachment points of the deep flexor or extensor tendons of the finger. In fresh cases, open reduction is performed. After the reduction, the lateral stability and the overextension test of the nail phalanx are checked. In the absence of stability, transarticular fixation of the nail phalanx is performed with a wire for a period of 3 weeks, after which the wire is removed; otherwise, the immobilization of the distal interphalangeal joint in a plaster splint or a special splint is indicated for 10-12 days. In cases where more than three weeks have passed after the injury, it is necessary to resort to open reduction, followed by transarticular fixation with a wire.
Damage to the proximal interphalangeal joint.
The proximal interphalangeal joint occupies a special place among the small joints of the hand. Even in the absence of movements in the remaining joints of the finger, with preserved movements in the proximal interphalangeal joint, the function of the hand remains satisfactory. When treating patients, it should be borne in mind that the proximal interphalangeal joint is prone to stiffness not only with injuries, but also with prolonged immobilization of even a healthy joint.
Anatomy.
The proximal interphalangeal joints are block-shaped in shape and are strengthened by collateral ligaments and the palmar ligament.
Treatment.
Collateral ligament damage.
Collateral ligament injury occurs as a result of lateral force applied to a straightened toe, which is most commonly seen in sports. The radial ligament is injured more often than the ulnar ligament. Collateral ligament injuries diagnosed 6 weeks after injury should be considered chronic. To make a diagnosis, it is important to check lateral stability and perform a stress X-ray. When evaluating the results of these tests, it is necessary to focus on the volume of lateral movements of healthy fingers. For the treatment of this type of injury, the method of elastic splinting is used: the injured finger is fixed to the neighboring one for 3 weeks with a partial rupture of the ligament and for 4-6 weeks with a complete one, then, for another 3 weeks, finger sparing is recommended (for example, exclusion of sports loads) (Fig. 32)
Fig. 32 Elastic splinting for collateral ligament injuries
During the immobilization period, active movements in the joints of the injured finger are not only not contraindicated, but absolutely necessary. In the treatment of this group of patients, it is necessary to take into account the following facts: the full range of motion is restored in the overwhelming majority of cases, while the pain persists for many months, and the increase in the joint in volume in a number of patients and throughout life.
Dislocations of the middle phalanx.
There are three main types of dislocations of the middle phalanx: dorsal, palmar, and rotational (rotary). For diagnosis, it is important to make an X-ray of each injured finger separately in frontal and strictly lateral projections, since oblique projections are less informative (Fig. 33)
Fig. 33 Radiography with dorsal dislocations of the middle phalanx.
The most common type of injury is dorsal dislocation. It is easy to eliminate, often done by the patients themselves. For treatment, elastic splinting is sufficient for 3-6 weeks.
With palmar dislocation, damage to the central portion of the extensor tendon is possible, which can lead to the formation of a "boutonniere" deformity (Fig. 34)
Fig. 34 Boutonniere deformity of the toe
To prevent this complication, a dorsal splint is used, which fixes only the proximal interphalangeal joint for 6 weeks. During the period of immobilization, passive movements are performed in the distal interphalangeal joint (Fig. 35)
Fig. 35 Prevention of boutonniere deformation
Rotational subluxation is easily confused with palmar subluxation. On a strictly lateral radiograph of the finger, you can see a lateral projection of only one of the phalanges and an oblique projection of the other (Fig. 36)
Fig. 36 Rotational dislocation of the middle phalanx.
The reason for this damage is that the condyle of the head of the main phalanx falls into the loop formed by the central and lateral portions of the extensor tendon, which is intact (Fig. 37).
Fig. 37 mechanism of rotational dislocation
The adjustments are made according to the Eaton method: after anesthesia, the finger is flexed in the metacarpophalangeal and proximal interphalangeal joint, and then, a careful rotation of the main phalanx (Fig. 38)
Fig. 38 Reduction of rotator dislocation according to Eaton
In most cases, closed reduction is ineffective and open reduction must be used. After reduction, elastic splinting and early active movements are performed.
Fracture-dislocation of the middle phalanx.
As a rule, a fracture of the palmar fragment of the articular surface occurs. This damage to the joint can be successfully treated with early diagnosis... The simplest, non-invasive and effective method of treatment is the use of a dorsal extensor blocking splint (Fig. 39), which is applied after the dislocation has been repositioned and allows active finger flexion. Full reduction requires flexion of the finger in the proximal interphalangeal joint. Evaluation of reduction is carried out according to the lateral radiograph: the adequacy of reduction is assessed by the congruence of the intact dorsum of the articular surface of the middle phalanx and the head of the proximal phalanx. The so-called V-sign proposed by Terri Light helps in assessing the radiograph (Fig. 40)
Fig. 39 Dorsal extensor blocking splint.
Fig. 40 V-sign for assessing the congruence of the articular surface.
The splint is applied for 4 weeks, and it is extended by 10-15 degrees weekly.
Damage to the metacarpophalangeal joints.
Anatomy.
The metacarpophalangeal joints are condylar joints that allow, along with flexion and extension, adduction, abduction and circular movements. Joint stability is provided by collateral ligaments and the palmar plate, which together form a capsule shape (Figure 41)
Fig. 41 Ligamentous apparatus of the metacarpophalangeal joints
Collateral ligaments consist of two bundles - own and additional. The collateral ligaments are more taut when flexed than when extended. Palmar plates of 2-5 fingers are interconnected by a deep transverse metacarpal ligament
Treatment.
There are two types of dislocation of the fingers: simple and complex (irreducible). For differential diagnosis dislocations, the following signs of complex dislocation should be remembered: on the roentgenogram, the axis of the main phalanx and the metacarpal bone are parallel, the location of the sesamoid bones in the joint is possible, and there is a deepening of the skin on the palmar surface of the hand at the base of the finger. A simple dislocation can be easily corrected by gentle pressure on the main phalanx, without the need for traction. Elimination of complex dislocation is possible only by surgery.
Damage to the nail bed.
The nail gives the distal phalanx a firm grip, protects the fingertip from injury, plays an important role in the function of touch and in the perception of the aesthetic appearance of a person. Nail bed injuries are among the most common hand injuries and accompany open fractures of the distal phalanx and soft tissue injuries of the fingers.
Anatomy.
The nail bed is the layer of the dermis that lies under the nail plate.
Fig. 42 Anatomical structure of the nail bed
There are three main areas of tissue located around the nail plate. The nail fold (roof of the matrix), covered with an epithelial lining - eponychium, prevents the uncontrolled growth of the nail up and to the sides, guiding it distally. In the proximal third of the nail bed, the so-called embryonic matrix is located, which ensures the growth of the nail. The growing part of the nail is delimited by a white half moon - a hole. If this zone is damaged, the growth and shape of the nail plate is significantly impaired. A sterile matrix is located distal to the hole, tightly adhering to the periosteum of the distal phalanx, which ensures the advancement of the nail plate during its growth and, thus, plays a role in the formation of the shape and size of the nail. Damage to the sterile matrix is accompanied by deformation of the nail plate.
The nail grows at an average rate of 3-4 mm per month. After injury, the advancement of the nail in the distal direction is suspended for 3 weeks, and then the growth of the nail continues at the same rate. As a result of the delay proximal to the site of injury, a thickening is formed, which persists for 2 months and gradually becomes thinner. It takes about 4 months for a normal nail plate to form after an injury.
Treatment.
The most common injury is a subungual hematoma, which is clinically manifested by the accumulation of blood under the nail plate and is often accompanied by severe pain syndrome of a pulsating nature. The method of treatment is perforation of the nail plate at the site of the hematoma with a sharp instrument or the end of a paper clip hot on a fire. This manipulation is painless and instantly relieves stress and, as a result, pain. After evacuation of the hematoma, an aseptic bandage is applied to the finger.
When part or all of the nail plate is torn off without damaging the nail bed, the separated plate is processed and placed in place, fixing with a seam. (Figure 43)
Fig. 43 Refixation of the nail plate
The nail plate is a natural splint for the distal phalanx, a conduit for the growth of a new nail and ensures the healing of the nail bed with the formation of a smooth surface. If the nail plate is lost, then it can be replaced with an artificial nail made of a thin polymer plate, which will provide painless dressings in the future.
Wounds of the nail bed are the most complex injuries, leading in the long term to significant deformation of the nail plate. Such wounds are subject to careful primary surgical treatment with minimal excision of soft tissues, exact comparison of fragments of the nail bed and suture of its thin (7 \ 0, 8 \ 0) suture material. The removed nail plate is re-fixed after treatment. IN postoperative period phalanx immobilization is required for 3-4 weeks to prevent its trauma.
Tendon damage.
The choice of the tendon reconstruction method is made taking into account the time elapsed since the moment of injury, the prevalence of cicatricial changes along the tendons, the condition skin at the site of the operation. The tendon suture is shown when it is possible to connect the damaged tendon end to end, the normal condition of the soft tissues in the area of operation. A primary tendon suture is isolated, performed within 10-12 days after injury in the absence of signs of infection in the area of the wound and its cut nature, and a delayed suture, which is applied within 12 days to 6 weeks after injury with less favorable conditions(lacerated and bruised wounds). In many cases, in a later period, suturing is impossible due to muscle retraction and the occurrence of significant diastasis between the ends of the tendon. All types of tendon sutures can be divided into two main groups - removable and immersion (Fig. 44).
Fig. 44 Types of tendon sutures (a - Bunnell, b - Verdun, c - Cuneo) d - intra-trunk suture imposition, e, f - adaptive suture imposition. Stages of suturing in the critical zone.
The removable sutures, proposed in 1944 by Bunnell S., are used to fix the tendon to the bone and in areas where early movement is not so necessary. The suture is removed after the tendon is firmly attached to the tissue at the fixation point. The immersion seams remain in the tissue, bearing mechanical stress. In some cases, additional sutures are used to provide a more perfect alignment of the ends of the tendons. In old cases, as well as with a primary defect, tendon plasty (tendoplasty) is indicated. The source of the tendon autograft is tendons, the removal of which does not cause significant functional and cosmetic disorders, for example, the palmaris longus tendon, superficial flexors of the fingers, long extensors of the toes, plantar muscles.
Injuries to the flexor tendons of the fingers.
Anatomy.
Flexion of 2-5 fingers is carried out due to two long tendons - superficial, attaching to the base of the middle phalanx and deep, attaching to the base of the distal phalanx. Flexion of 1 toe is carried out by the tendon of the long flexor of 1 toe. The flexor tendons are located in narrow, complex-shaped osteo-fibrous canals, which change their shape depending on the position of the finger (Fig. 45)
Fig. 45 Changing the shape of the osteo-fibrous canals of 2-5 fingers of the hand during their flexion
In places of greatest friction between the palmar wall of the canals and the surface of the tendons, the latter are surrounded by the synovial membrane that forms the vagina. The deep flexor tendons of the fingers are connected through the worm-like muscles with the tendon extensor apparatus.
Diagnostics.
In case of damage to the tendon of the deep flexor of the finger with a fixed middle phalanx, flexion of the nail is impossible, with combined damage to both tendons, flexion of the middle phalanx is also impossible.
Fig. 46 Diagnosis of damage to the flexor tendons (1, 3 - deep, 2, 4 - both)
Flexion of the main phalanx is possible due to the contraction of the interosseous and vermiform muscles.
Treatment.
There are five zones of the hand, within which the anatomical features affect the technique and results of the primary tendon suture.
Fig. 47 Brush zones
In zone 1 in the osteo-fibrous canal, only the deep flexor tendon passes, so its damage is always isolated. The tendon has a small range of motion, the central end is often held by the mesotenon and can be easily removed without significantly widening the area of damage. All these factors determine the good result of the placement of the primary tendon suture. The most commonly used transosseous removable tendon suture. The use of submerged joints is possible.
During zone 2, the tendons of the superficial and deep flexors of the fingers intersect, the tendons are tightly adjacent to each other, have a large range of motion. Tendon suture results are often unsatisfactory due to scar fusion between sliding surfaces. This zone is called critical or "no-man's".
Due to the narrowness of the bone-fibrous canals, suture of both tendons is not always possible; in some cases, excision of the tendon of the superficial flexor of the finger and suture only on the deep flexor tendon is necessary. In most cases, this avoids finger contractures and does not significantly affect flexion function.
In zone 3, the flexor tendons of the adjacent fingers are separated by neurovascular bundles and vermiform muscles. Therefore, damage to the tendons in this area is often accompanied by damage to these structures. After the tendon suture, a digital nerve suture is required.
Within zone 4, the flexor tendons are located in the carpal tunnel along with the median nerve, which is located superficially. Tendon injuries in this area are quite rare and are almost always associated with damage to the median nerve. The operation involves dissection of the transverse ligament of the wrist, the suture of the deep flexor tendons of the fingers, the tendons of the superficial flexors are excised.
Throughout the 5th zone, the synovial sheaths end, the tendons of the adjacent fingers pass close to each other and when the hand is squeezed into a fist, they move together. Therefore, cicatricial fusion of the tendons with each other practically does not affect the volume of flexion of the fingers. Tendon suture results in this area are generally good.
Postoperative management.
The finger is immobilized using a back plaster splint for a period of 3 weeks. From the second week after the edema subsides and the pain syndrome in the wound decreases, passive flexion of the finger is performed. After removing the plaster splint, active movements begin.
Injuries to the extensor tendons of the fingers.
Anatomy.
In the formation of the extensor apparatus, the tendon of the common extensor of the finger and the tendons of the interosseous and vermiform muscles, connected by many lateral ligaments, forming a tendon-aponeurotic stretch (Fig. 48,49)
Fig. 48 The structure of the extensor apparatus of the hand: 1 - the triangular ligament, 2 - the place of attachment of the extensor tendon, 3 - the lateral connection of the collateral ligament, 4 - the disc above the middle joint, 5 - spiral fibers, 5 - the middle bundle of the long extensor tendon, 7 - lateral a bundle of the long extensor tendon, 8 - attachment of the long extensor tendon on the main phalanx, 9 - the disc above the main joint, 10 and 12 - the long extensor tendon, 11 - vermiform muscles, 13 - interosseous muscles.
Fig. 49 Extensors of fingers and hands.
It must be remembered that the index finger and little finger, in addition to the common one, also have their own extensor tendon. The middle bundles of the extensor tendon of the fingers are attached to the base of the middle phalanx, unbending it, and the lateral bundles are connected to the tendons of the small muscles of the hand, are attached to the base of the nail phalanx and perform the function of extending the latter. The extensor aponeurosis at the level of the metacarpophalangeal and proximal interphalangeal joints forms a fibrocartilaginous disc similar to the patella. The function of the small muscles of the hand depends on the stabilization of the main phalanx by the extensor of the finger. When the main phalanx is bent, they act as flexors, and when extended together with the extensor of the fingers, they become extensors of the distal and middle phalanges.
Thus, one can speak of a perfect extensor-flexion function of the finger only with the integrity of all anatomical structures. The presence of such a complex interconnection of elements to some extent favors the spontaneous healing of partial injuries of the extensor apparatus. In addition, the presence of lateral ligaments of the extensor surface of the finger prevents the tendon from contracting in the event of injury.
Diagnostics.
The characteristic position that the finger takes depending on the level of damage allows a quick diagnosis (Fig. 50).
Fig. 50 Diagnosis of damage to the extensor tendons
extensors at the level of the distal phalanx, the finger takes a flexion position in the distal interphalangeal joint. This deformation is called the mallet finger. In most cases of fresh lesions, conservative treatment is effective. To do this, the finger must be fixed in an over-extended position in the distal interphalangeal joint using a special splint. The amount of hyperextension depends on the level of mobility of the patient's joints and should not cause discomfort. The remaining joints of the finger and hand must be left free. The immobilization period is 6-8 weeks. However, the use of splints requires constant monitoring of the position of the finger, the state of the splint elements, as well as the patient's understanding of the task before him, therefore, in some cases, transarticular fixation of the nail phalanx with a wire for the same period is possible. Surgical treatment is indicated when the tendon is torn away from the insertion site with a significant bone fragment. In this case, a transosseous suture of the extensor tendon is made with fixation of the bone fragment.
When the extensor tendons are damaged at the level of the middle phalanx, the triangular ligament is simultaneously damaged, and the lateral tendon bundles diverge in the palmar direction. Thus, they do not unbend, but bend the middle phalanx. In this case, the head of the main phalanx is displaced forward through the slit in the extensor apparatus, like a button passing into a loop. The finger assumes a bent position in the proximal interphalangeal joint and over-extended position in the distal interphalangeal joint. This deformation is called "boutonniere". With this type of injury, it is necessary surgery- stitching of damaged elements with subsequent immobilization for 6-8 weeks.
Treatment of injuries at the level of the main phalanx, metacarpophalangeal joints, metacarpus and wrist is only surgical - the primary tendon suture followed by immobilization of the hand in the position of extension in the wrist and metacarpophalangeal joints and slight flexion in the interphalangeal joints for a period of 4 weeks, followed by the subsequent development of movements.
Damage to the nerves of the hand.
The innervation of the hand is provided by three main nerves - the median, ulnar and radial. In most cases, the main sensory nerve of the hand is the median, and the main motor nerve is the ulnar, which innervates the muscles of the eminence of the little finger, the interosseous, 3 and 4 vermiform muscles and the adductor thumb muscle. The motor branch of the median nerve extending from its lateral cutaneous branch immediately after exiting the carpal tunnel is of great clinical importance. This branch innervates the short flexor of 1 finger, as well as the short abductor and opposing muscles of many. the muscles of the hand have double innervation, which preserves to one degree or another the function of these muscles when one of the nerve trunks is damaged. The superficial branch of the radial nerve is the least significant, providing sensitivity on the dorsum of the hand. If both digital nerves are damaged due to loss of sensitivity, the patient cannot use the fingers, their atrophy occurs.
The diagnosis of nerve damage should be made prior to surgery, as this is not possible after anesthesia.
Suture on the nerves of the hand requires the use of microsurgical techniques and adequate suture material (thread 6 \ 0-8 \ 0). In the case of fresh injuries, the soft and bone tissues are first processed, after which they proceed to the nerve suture (Fig. 51)
Fig. 51 Epineural nerve suture
The limb is fixed in a position that provides the least tension in the suture line for 3-4 weeks.
Defects of soft tissues of the hand.
The normal function of the hand is possible only with the integrity of its skin. Each scar creates an obstacle to its implementation. The skin in the area of the scar has a reduced sensitivity and is easily damaged. Therefore, one of the most important tasks of hand surgery is to prevent scar formation. This is achieved by applying a primary suture to the skin. If, due to a skin defect, the imposition of a primary suture is impossible, then its plastic replacement is necessary.
With superficial defects, the bottom of the wound is represented by well-supplied tissues - subcutaneous fatty tissue, muscle or fascia. In these cases, good results are obtained by the transplantation of non-blood-supplied skin grafts. Depending on the size and localization of the defect, split or full-thickness flaps are used. The necessary conditions for successful engraftment of the flap are: good blood supply to the bottom of the wound, absence of infection and tight contact of the graft with the receiving bed, which is ensured by the imposition of a pressure bandage (Fig. 52)
Fig52 Stages of applying a pressure bandage
The bandage is removed for 10 days.
Unlike superficial defects, with a deep bottom of the wound, there are tissues with a relatively low level of blood supply - tendons, bones, capsule of joints. For this reason, the use of non-blood-supplied flaps is ineffective in these cases.
The most common damage is tissue defects in the nail phalanx. There are many methods for closing them with blood-supplied flaps. When the distal half of the nail phalanx is detached, plastic is effective with triangular sliding flaps, which are formed on the palmar or lateral surfaces of the finger (Fig. 53)
Fig. 53 Plastic surgery with a triangular sliding flap in case of a defect in the skin of the nail phalanx
Fig. 54 Plastic surgery with a palmar finger sliding flap
The triangular areas of the skin are connected to the toe by a leg made of adipose tissue. If the soft tissue defect is more extensive, then a palmar finger sliding flap is used (Fig. 54)
In case of defects in the pulp of the nail phalanx, cross flaps from the adjacent longer finger are widely used (Fig. 55), as well as a skin-fat flap of the palmar surface of the hand.
Fig. 55 Plastic surgery using a skin and fat flap from the palmar surface of the hand.
The most severe type of hand tissue defect occurs when the skin is peeled off the fingers like a glove. In this case, the skeleton and tendon apparatus can be completely preserved. For the injured finger, a tubular flap is formed on the leg (Filatov's sharp stalk); when skeletonizing the entire hand, plastic is performed with skin and fat flaps from the anterior abdominal wall (Fig. 56).
Fig. 56 Plasty of a scalped wound of the middle phalanx with the "sharp" stem of Filatov
Stenoses of the tendon canals.
The pathogenesis of degenerative-inflammatory diseases of the tendon canals is not fully understood. More often women 30-50 years old are ill. Static and dynamic brush overloads are a contributing factor.
De Quervain's disease
1 osteo-fibrous canal and the tendons of the long abductor thumb muscle and its short extensor are affected.
The disease is characterized by pain in the styloid process, the presence of a painful compaction on it, a positive Finkelstein symptom: acute pain in the area of the styloid process of the radial bone, arising in the ulnar abduction of the hand, with 1 finger pre-bent and fixed (Fig. 57)
Fig. 57 Finkelstein's symptom
X-ray examination makes it possible to exclude other diseases of the wrist joint, as well as to reveal local osteoporosis of the apex of the styloid process and compaction of soft tissues above it.
Treatment.
Conservative therapy involves the local administration of steroid drugs and immobilization.
Surgical treatment is aimed at decompression of the 1st canal by dissecting its roof.
After anesthesia, a skin incision is made over the painful lump. The dorsal branch of the radial nerve is located immediately under the skin and must be carefully pulled back to the rear. Making passive movements with the thumb, one canal and the site of stenosis are examined. Further along the probe, the dorsal ligament is carefully dissected and partially excised. After that, the tendons are exposed and examined, making sure that nothing interferes with their sliding. The operation ends with a thorough hemostasis and wound closure.
Stenosing ligamentitis of the annular ligaments.
The annular ligaments of the tendinous sheaths of the flexors of the fingers are formed by a thickening of the fibrous membrane and are located at the level of the diaphysis of the proximal and middle phalanges, as well as above the metacarpophalangeal joints.
It is still not clear what is affected primarily - the annular ligament or the tendon passing through it. In any case, it is difficult for the tendon to slide through the annular ligament, which results in a “snap” of the finger.
Diagnostics is straightforward. Patients themselves show a “snapping finger”, a painful seal is palpated at the level of infringement.
Surgical treatment gives a quick and good effect.
The incision is made according to the rules described in the section “Brush access”. The thickened annular ligament is exposed. The latter is dissected along a grooved probe, and its thickened part is excised. Flexion and extension of the finger assesses the freedom of sliding of the tendon. With old processes, an additional opening of the tendon sheath may be required.
Dupuytren's contracture.
Dupuytren's contracture (disease) develops as a result of cicatricial degeneration of the palmar aponeurosis with the formation of dense subcutaneous cords.
Mostly elderly men (5% of the population) are affected.
Diagnostics, as a rule, does not cause difficulties. The disease usually develops over several years. Cords are formed that are painless, dense on palpation and cause limitation of active and passive extension of the fingers. The 4th and 5th fingers are most often affected, and both hands are often affected. (fig. 58)
Fig. 58 Dupuytren's contracture 4 fingers of the right hand.
Etiology and pathogenesis.
Not exactly known. The main theories are traumatic, hereditary. There is a connection with the proliferation of endothelial cells of the vessels of the palmar aponeurosis and a decrease in the oxygen content, which leads to the activation of fibroplastic processes.
Often combined with Ledderhose disease (cicatricial changes in the plantar aponeurosis) and fibroplastic induration of the penis (Peyronie's disease).
Anatomy of the palmar aponeurosis.
1.m. palmaris brevis.2. m. palmaris longus.3.volar carpal ligament communis.4.volar carpal ligament proprius.5. Palmar aponeurosis.6. Tendon of palmar aponeurosis.7. Transverse palmar ligament.8.vaginae and ligaments of mm. flexor muscles.9. tendon of m. flexor carpi ulnaris.10.
tendon of m. flexor carpi radialis.
The palmar aponeurosis has the shape of a triangle, the apex of which is directed proximally, the tendon of the long palmar muscle is woven into it. The base of the triangle splits into bundles going to each finger, which intersect with transverse bundles. The palmar aponeurosis is closely connected with the skeleton of the hand; it is separated from the skin by a thin layer of subcutaneous fatty tissue.
Classification.
Depending on the severity clinical manifestations 4 degrees of Dupuytren's contracture are distinguished:
Grade 1 - characterized by the presence of thickening under the skin, which does not limit the extension of the fingers. At this degree, patients usually mistake this lump for "namin" and rarely see a doctor.
2nd degree. At this degree, there is a limited extension of the finger to 30 0
3 degree. Extension limitation from 30 0 to 90 0.
4 degree. Extension deficit exceeds 90 0.
Treatment.
Conservative therapy is ineffective and can be recommended only at the first degree and as a stage of preoperative preparation.
The main method of treating Dupuytren's contracture is operative.
A large number of operations have been proposed for this disease. The following are of primary importance:
Aponeurectomy- excision of the scar-altered palmar aponeurosis. It is made from several cross cuts, which are made according to the rules described in the section “cuts on the brush”. The strands of the altered palmar aponeurosis are isolated and excised subcutaneously. In this case, the common digital nerves can be damaged, so this stage must be performed with extreme care. As the aponeurosis is excised, the finger is gradually removed from the flexion position. The skin is sutured without tension and a pressure bandage is applied to prevent hematoma formation. A few days after the operation, the fingers are moved to the extension position using dynamic splints.
Upper limb injuries
The most common injuries to the upper limb are fractures of the radius in the lower third ...
The most common injuries to the upper limb are fractures of the radius in the lower third (a ray at a typical site) and fractures in the upper third of the shoulder (surgical neck)
fig. 127 Bones of the upper limb ( ossa membri superioris) right; front view.Finger bones (phalanges), ossa digitorum (phalanges) (see fig.,,,,), presented phalanges, phalanges shaped like long bones. The first, thumb, has two phalanges: proximal, phalanx proximalis, and distal, phalanx distalis... The rest of the fingers still have middle phalanx, phalanx media... In each phalanx, a body and two pineal glands are distinguished - proximal and distal.
Body, corpus, each phalanx is flattened from the front (palmar) side. The surface of the phalanx body is bounded laterally by small combs. It contains feeding hole extending distally feeding channel.
The superior, proximal, end of the phalanx, or basis, basis phalangis, thickened and has articular surfaces. The proximal phalanges are articulated with the bones of the metacarpus, and the middle and distal phalanges are connected with each other.
The lower, distal, end of the I and II phalanges has phalanx head, caput phalangis.
At the lower end of the distal phalanx, on the back side, there is a slight roughness - tuberosity of the distal phalanx, tuberositas phalangis distalis.
In the area of the metacarpophalangeal joints of the first, second and fourth fingers and the interphalangeal joint of the first finger on the palmar surface, in the thickness of the muscle tendons, there are sesamoid bones, ossa sesamoidea.
fig. 151. Bones of the hand, right (X-ray). 1 - radius bone; 2 - subulate process of the radius; 3 - lunate bone; 4 - scaphoid bone; 5 - bone trapezoid; 6 - trapezoidal bone; 7-1 metacarpal bone; 8 - sesamoid bone; 9 - proximal phalanx of the thumb; 10 - distal phalanx of the thumb; 11 - II metacarpal bone; 12 - proximal phalanx of the index finger; 13 - the base of the middle phalanx of the index finger; 14 - distal phalanx of the index finger; 15 - capitate bone; 16 - hook of the hook-shaped bone; 17 - hooked bone; 18 - pisiform bone; 19 - triangular bone; 20 - subulate process of the ulna; 21 - the head of the ulna. The phalanx of a human finger has 3 parts: proximal, main (middle) and terminal (distal). There is a clearly visible nail tuberosity on the distal part of the nail phalanx. All fingers are formed by 3 phalanges, called the main, middle and nail. The only exception is thumbs, they consist of 2 phalanges. The thickest phalanges of the fingers form the thumbs, and the longest form the middle fingers.
Our distant ancestors were vegetarians. Meat was not included in their diet. The food was low in calories, so they spent all the time in the trees, obtaining food in the form of leaves, young shoots, flowers and fruits. The fingers and toes were long, with a well-developed grasping reflex, thanks to which they were kept on the branches and deftly climbed the trunks. However, the fingers remained inactive in the horizontal projection. The palms and feet were poorly revealed in a plane with wide-spread fingers. The opening angle did not exceed 10-12 °.
At a certain stage, one of the primates tasted the meat and found that this food was much more nutritious. He suddenly had time to examine the world around him. He shared his discovery with his brothers. Our ancestors became carnivores and descended from trees to the ground and rose to their feet.
However, the meat had to be butchered. Then man invented the ax. Man is actively using modified versions of the hack even today. In the process of making this instrument and working with it, people began to change their fingers. On the hands, they became mobile, active and strong, and on the legs they shortened and lost mobility.
By prehistoric times, human fingers and toes had acquired an almost modern look. The opening angle of the fingers at the palm and on the foot has reached 90 °. People have learned to perform complex manipulations, play on musical instruments, draw, draw, engage in circus arts and sports. All these activities were reflected in the formation of the skeletal base of the fingers.
Development became possible due to the special structure of the human hand and foot. She, in technical terms, is all "pivot". Small bones are connected by joints in a single and harmonious shape.
Feet and palms have become mobile, they do not break when making reversal and eversion movements, bending and twisting. With fingers and toes modern man can crush, open, tear, cut and perform other complex manipulations.
Anatomy is a fundamental science. The structure of the hand and wrist is a topic that interests not only doctors. Knowledge of it is necessary for athletes, students and other categories of persons.
In humans, the fingers and toes, despite noticeable external differences, have the same phalanx structure. At the base of each toe are long, tubular bones called phalanges.
The toes and hands are the same in structure. They consist of 2 or 3 phalanges. Its middle part is called the body, the lower part is called the base or proximal end, and the upper part is called the block or distal end.
Each finger (except the thumb) consists of 3 phalanges:
- proximal (main);
- medium;
- distal (nail).
The thumb consists of 2 phalanges (proximal and nail).
The body of each phalanx of the fingers has a flattened upper back and small lateral combs. There is a feeding opening in the body, which passes into a canal directed from the proximal end to the distal end. The proximal end is thickened. It has developed articular surfaces that provide connection with other phalanges and with the bones of the metacarpus and foot.
The distal end of the 1st and 2nd phalanges has a head. On the 3rd phalanx, it looks different: the end is pointed and has a bumpy, rough surface on the back. The joint with the bones of the metacarpus and foot is formed by the proximal phalanges. The rest of the phalanges of the fingers provide a reliable connection of the bones of the finger to each other.
Sometimes a deformed phalanx of a finger becomes the result of pathological processes occurring in the human body.
If round thickenings appear on the phalanges of the fingers and the fingers become like drumsticks, and the nails turn into sharp claws, then the person probably has diseases internal organs, which may include:
- heart defects;
- dysfunctions of the lungs;
- infective endocarditis;
- diffuse goiter, Crohn's disease (severe disease of the gastrointestinal tract);
- lymphoma;
- cirrhosis of the liver;
- esophagitis;
- myeloid leukemia.
If such symptoms appear, you should immediately consult a doctor, because in a neglected state, these diseases can become a serious threat to your health and even life. It happens that the deformation of the phalanges of the fingers and toes is accompanied by painful, pulling pains and a feeling of stiffness in the hand and foot. These symptoms indicate that the interphalangeal joints are affected.
Diseases affecting these joints include:
- deforming osteoarthritis;
- gouty arthritis;
- rheumatoid arthritis;
- psoriatic arthritis.
In no case should you self-medicate, because due to illiterate therapy, you can completely lose the mobility of your fingers, and this will greatly reduce the quality of life. The doctor will prescribe examinations that will identify the causes of the disease.
Determining the causes will make it possible to make an accurate diagnosis and prescribe a treatment regimen. In the case of strict adherence to all the recommendations of the physician in such diseases, the prognosis will become positive.
If painful bumps appear on the phalanges of the fingers, then you are actively developing gout, arthritis, arthrosis, or deposited salts have accumulated. A characteristic feature of these diseases is the induration in the area of the cones. A very disturbing symptom, because it is such a seal that leads to immobilization of the fingers. With such a clinic, you should go to the doctor so that he prescribed a therapy regimen, compiled a set of gymnastic exercises, prescribed massage, applications and other physiotherapeutic procedures.
Injuries to joints and bone structures
Who among us has not pressed our fingers with doors, hit our nails with a hammer, or dropped some heavy object on our feet? Often such incidents end in fractures. These injuries are very painful. They are almost always complicated by the fact that the fragile body of the phalanx splits into many fragments. Sometimes the cause of the fracture can be a chronic disease that destroys the bone structure of the phalanx. Such diseases include osteoporosis, osteomyelitis, and other severe tissue damage. If you have a high risk of getting such a fracture, then you should take care of your arms and legs, because the treatment of such phalangeal fractures is troublesome and expensive.
Traumatic fractures by the nature of the damage can be closed and open (with traumatic ruptures and tissue damage). After a detailed examination and X-ray, the traumatologist determines if the fragments have moved. Based on the results obtained, the attending physician determines how he will treat this injury. Victims with open fractures always go to the doctor. After all, the sight of such a fracture is very unsightly and frightens a person. But closed fractures of the phalanges are often tried to endure. You have a closed fracture if, after an injury, you develop:
- pain on palpation (touch);
- swelling of the finger;
- restriction of movement;
- subcutaneous hemorrhage;
- deformity of the finger.
Go to a traumatologist immediately and get treatment! Dislocations of the phalanges, damage to tendons, ligaments can be combined with closed fractures of the fingers, so you cannot cope without the help of a specialist.
First aid rules
If the phalanx is damaged, even if it is just a bruise, it is worth immediately applying a splint or a tight polymer bandage. Any solid plate (wood or plastic) can be used as a tire. Pharmacies now sell latex splints, which are good at fixing a split bone. You can use the adjacent healthy finger together. To do this, bandage them tightly together or glue them with a plaster. This will immobilize the injured phalanx and allow you to calmly work with your hand. This will also help prevent the broken bones from moving.
Conservative treatment (wearing tight bandages and plaster cast) of fractures lasts about 3-4 weeks. During this time, the traumatologist performs X-ray examination twice (on days 10 and 21). After removing the plaster, the fingers and joints are actively developed for six months.
The beauty of the hands and feet is determined by the correctness of the shape of the phalanges of the fingers. You need to take care of your hands and feet regularly.