Home Tooth pain Distal phalanges of the toes. Thickening of the phalanges of the fingers

Tooth pain

Distal phalanges of the toes. Thickening of the phalanges of the fingers

Lower limb

Bones lower limb are divided into four main groups: (1) foot, (2) lower leg, (3) thigh (femur), (4) hip joint. This chapter provides a detailed overview of the radioanatomy and setup for three of them: feet, lower legs, middle And distal femur, including ankle And knee joints.

FOOT

The bones of the foot are generally similar to the bones of the hand and wrist studied in Chapter 4. The 26 bones of one foot are divided into four groups

Phalanges (toes) 14

Metatarsal bones (instep) 5

Tarsal bones 7

Phalanges of the toes

The distal part of the foot is represented by phalanges, forming fingers. The five toes of each foot are numbered first through fifth, respectively, if counted from the medial edge or from the big toe. Note that the first, or thumb, finger has only two phalanges, proximal and distal, as well as the thumb. The second to fifth toes of each foot also have medial phalanx. Thus, two phalanges of the thumb and three in each finger from the second to the fifth make up a total 14 phalangeal bones.

The similarity with the hand in this case is obvious, since each hand also has 14 phalanges. However, the phalanges of the foot are shorter than the phalanges of the hand, and their range of motion is significantly less.

When describing any bone or joint, it is necessary to indicate which toe and which foot it belongs to. For example, the description - the distal phalanx of the first toe of the right foot - gives the exact location of the bone.

The distal phalanges of fingers 2-5 are so small that it is quite difficult to see them as separate bones on an x-ray.

Metatarsus bones

Five metatarsal bones form the instep of the foot. They are numbered in the same way as the fingers, from one to five, counting from the medial edge to the lateral.

Each metatarsal bone has three parts. The small rounded distal part is called head. The elongated thin middle part is called body. The slightly expanded proximal end of each metatarsal bone is called basis.

Lateral division base of the fifth metatarsal has a protruding uneven tuberosity, which is the site of attachment of the tendon. The proximal fifth metatarsal and its tuberosity are usually clearly visible on radiographs, which is important because this area of the foot is often injured.

(5-6-7) 1, 2, 3 Cuneiformia

The resemblance of the tarsus to that of the upper limb is not so obvious because the tarsus has seven bones, as opposed to the eight bones of the carpus. In this case, the tarsal bones are larger than the carpal bones and less mobile, since they form the basis for supporting the body in an upright position.

The seven bones of the tarsus are sometimes classified as bones of the ankle joint, although only one bone, the talus, directly belongs to this joint. Each of the tarsal bones will be further considered separately, along with all the bones with which it has articulations.

Heel bone (Calcaneus)

The heel bone is the largest and strongest bone in the foot. Its posteroinferior section is formed by a well-defined process - tubercle of the calcaneus. Its uneven, rough surface is the site of attachment of muscle tendons. The lower expanded section of the tubercle passes into two small rounded processes: the larger one lateral and the smaller, less frequently mentioned, medial process.

On the lateral surface of the calcaneus there is fibular block, which can have different sizes and shapes and is visualized laterally in the axial projection image. On the medial surface, in its anterior section, there is a large protruding process - support of the talus.

Articulations. The calcaneus articulates with two bones: in the anterior part with the cuboid and in the upper part with the talus. The connection with the talus forms an important subtalar joint. This articulation involves three articular surfaces that provide redistribution of body weight to maintain it in an upright position: this is an extensive posterior articular surface and two smaller ones - anterior and middle articular surfaces.

Note that the medial articular surface is the superior part of the protruding buttress of the talus, which provides medial support for this important supporting joint.

The depression between the posterior and middle articular surfaces is called groove of the calcaneus(Fig. 6-6). In combination With similar to the groove of the talus, it forms an opening for the passage of the corresponding ligaments. This hole, located in the middle of the subtalar joint, is called sinus tarsus(rice. 6-7).

Talus

The talus is the second large bone of the tarsus, it is located between the lower part of the tibia and the heel bone. Together with the ankle and talocalcaneal joints, it participates in the redistribution of body weight.

Articulations. The talus articulates with four bones: top with tibia and tibia, from below with calcaneal and in front with scaphoid.

Arches of the feet

Longitudinal arch of the foot. The bones of the foot form longitudinal and transverse arches, providing powerful spring-type support for the weight of the entire body. The springy longitudinal arch is formed by medial and lateral components and is located mostly at the medial edge and center of the foot.

The transverse arch runs along the plantar surface of the distal tarsus and tarsometatarsal joints. The transverse arch is formed mainly by the sphenoid bones, especially the short second, in combination with the largest sphenoid and cuboid bones (Fig. 6-9).

ANKLE JOINT

Front view

Ankle joint formed by three bones: two long bones of the lower leg, tibial and fibular and one tarsal bone - the talus. The expanded distal part of the thin fibula extending onto the talus is called the external (lateral) ankle.

The distal portion of the larger and more powerful tibia has a widened articular surface for articulation with an equally wide superior articular surface of the talus. The medial elongated process of the tibia, extended along the medial edge of the talus, is called the internal (medial) ankle.

The inner parts of the tibia and fibula form a deep U-shaped cavity, or joint space, covering the block of the talus on three sides. However, it is impossible to examine all three parts of the gap in a direct (posterior) projection, since the distal parts of the tibia and fibula are covered by the talus. This is because the distal fibula is located somewhat posteriorly, as shown in the pictures. Posterior projection with an inward rotation of the foot by 15°, called projection of the joint space 1 and shown in Fig. 6-15, allows a full view of the open articular space above the talus.

Anterior tubercle- a small expanded process located laterally and anteriorly in the lower part of the tibia, articulates with the upper lateral part of the talus, while partially overlapping the fibula in front (Fig. 6-10 and 6-11).

Distal articular surface of the tibia forms the roof of the fork and is called the ceiling of the tibia. In some types of fractures, especially in children and adolescents, damage to the distal epiphysis and ceiling of the tibia occurs.

Side view

In Fig. 6-11 shown ankle joint in a true lateral view, which shows that the distal fibula is located approximately 1 cm posterior to the tibia. This relative position becomes important in determining the true lateral position of the lower leg, ankle joint and foot. The main mistake when placing the ankle joint laterally is slight rotation of the joint, as a result of which the medial and lateral malleoli practically overlap each other. However, this will result in the ankle joint being depicted in an oblique projection, as shown in the figures. Thus, with true lateral projection lateral malleolus located approximately at 1 cm posterior from the medial malleolus. In addition, the lateral malleolus is also longer adjacent - medial approximately on 1 cm (this is better seen in the frontal projection, Fig. 6-10).

Axial (axial) view

An axial view of the inner edge of the distal fibula and tibia is shown in Fig. 6-12. The roof of the lower surface of the tibia (the roof of the tibia) is shown in this figure from the inside, in the end view of the ankle joint. The relationship is also visible lateral and medial malleolus fibula and tibia, respectively. Smaller, fibula located more posteriorly A line drawn through the center of both ankles is at an angle of approximately 15-20° to the frontal plane (parallel to the front surface of the body). Consequently, in order for the intermalleolar line to become parallel to the frontal plane, the shin and ankle

This joint should be rotated 15-20°. This relationship of the distal tibia and fibula is important when positioning the ankle joint or ankle slot in various projections, as described in the positioning sections of this chapter.

Ankle joint

The ankle joint belongs to the group block-type synovial joints, in which only flexion and extension movements are possible (dorsial flexion and plantar flexion). This is facilitated by strong collateral ligaments that pass from the medial and lateral malleolus to the calcaneus and talus. Significant lateral pressure can cause sprain of the ankle joint, accompanied by stretching or rupture of the lateral ligaments and rupture of the muscle tendons, which leads to expansion of the intra-articular space on the side of the injury.

1 Frank ED et al: Radiography of the ankle mortise, Radiol Technol 62-65: 354-359, 1991.

EXERCISES ON RADIOGRAMS

The following radiographs of the foot and ankle in the three most common projections provide an anatomical overview of the bones and joints. To conduct a review test, you are asked to name (or write down) all the parts marked in the pictures, having previously closed the answers given below.

Left foot, lateral view (Fig. 6-13)

A. Tibia.
B. Heel bone.

B. Tubercle of the calcaneus.
D. Cuboid bone.

D. Tuberosity of the fifth metatarsal bone.

E. Superimposed sphenoid bones. G. Scaphoid bone.

3. Subtalar joint. I. Talus.

Oblique projection of the right foot(rice. 6-14)

A. Interphalangeal joint of the first toe of the right foot.
B. Proximal phalanx of the first toe of the right foot.

B. Metatarsophalangeal joint of the first toe of the right foot.
D. Head of the first metatarsal bone.

D. Body of the first metatarsal bone. E. Base of the first metatarsal bone.

G. Second, or intermediate, sphenoid bone (partially overlapped by the first, or medial, sphenoid bone). 3. Scaphoid bone. I. Talus. K. Tubercle of the calcaneus. L. Third, or lateral, sphenoid bone. M. Cuboid bone.

N. Tuberosity of the base of the fifth metatarsal bone. O. The fifth metatarsophalangeal joint of the right foot. P. Proximal phalanx of the fifth toe of the right foot.

Projection of the joint space of the right ankle joint(Fig. 6-15)

A. Fibula.
B. Lateral malleolus.

B. Open joint space of the ankle joint.
G. Talus.

D. Medial malleolus.

E. The lower articular surface of the tibia (the articulating surface of the epiphysis).

Lateral projection of the ankle joint(rice. 6-16)

A. Fibula.
B. Heel bone.

B. Cuboid bone.

D. Tuberosity of the base of the fifth metatarsal bone. D. Scaphoid bone.

E. Talus. G. Sinus of the tarsus.

3. Anterior tubercle. I. Tibia.

TIBIAL AND FIBAL BONES

The next group of bones of the lower limb, which will be discussed in this chapter, includes two bones of the lower leg: tibia And fibular

Tibia

The tibia is one of the largest bones in the human skeleton and serves as the supporting bone of the lower leg. It can be easily felt through the skin in the anteromedial part of the leg. It has three parts: central body And two ends.

Proximal section. The expanded lateral sections of the upper, or proximal, end of the tibia form two powerful processes - medial And lateral condyle.

On the upper surface of the head of the tibia, between the two condyles, is located intercondylar eminence, in which two small tubercles are distinguished, medial And lateral intercondylar tubercles.

The upper articular surface of the condyles has two concave articular surfaces, often called tibial plateau, which form an articulation with the femur. On the lateral projection of the lower leg it can be seen that The tibial plateau has an inclination of 10° to 20° in relation to a line perpendicular to the long axis of the bone (Fig. 6-18) 1. This important anatomical feature must be taken into account when positioning to obtain a straight posterior projection of the knee joint, the central ray should run parallel to the plateau and perpendicular to the cassette. In this case, the joint space will appear open in the image.

In the proximal part of the bone, on its anterior surface, immediately behind the condyles, there is a rough protrusion - tibial tuberosity. This tuberosity is the attachment site of the patellar ligament, which contains the tendons of the large muscle of the anterior surface of the thigh. Sometimes adolescents experience separation of the tibial tuberosity from the shaft of the bone, a condition known as Osgood-Schlatter disease(see clinical indications, p. 211).

The body of the tibia is the long middle part of the bone located between its two ends. Along the anterior surface of the body, between the tibial tuberosity and the medial malleolus, there is a pointed crest, or leading edge tibia, which can be easily felt under the skin.

Diet department. The distal part of the tibia is smaller than the proximal one, it ends in a short process of a pyramidal shape, medial malleolus, which can be easily palpated in the medial area of the ankle joint.

On the lateral surface of the lower end of the tibia there is a flat, triangular shape fibular notch, to which the lower end of the fibula is adjacent.

Fibula

The fibula is smaller and located laterally to the back in relation to the larger tibia. The upper, or proximal, part of the bone forms an expanded head, which articulates with the outer surface of the posteroinferior part of the lateral condyle of the tibia. The upper end of the head is pointed, it is called top head of the fibula.

Body The fibula is the long thin part between its two ends. Expanded distal fibula

1 Manager Bj: Handbooks in radiology, ed. 2, Chicago, 1997, Year Book Medical Publishers, Inc.

FEMUR

The femur, or femur, is the longest and most powerful of all the tubular bones of the human skeleton. It is the only long bone between the hip and knee joints. The proximal femur will be described in Chapter 7, along with the hip joint and pelvic bones.

Middle and distal femur, anterior view(rice. 6-19)

As with all tubular bones, the body of the femur is an elongated and thinner part. On the front surface of the lower thigh bone lies the patella, or kneecap. Patella, largest sesamoid bone skeleton, located anterior to the distal femur. Note that in the frontal view, with the leg fully extended, the lower edge of the patella is approximately 1.25 cm above, or proximal to, the knee joint itself. It is important to remember this when positioning the knee joint.

The small, smooth, triangular-shaped depression on the front surface of the lower part of the femur is called the patellar surface (Figure 6-19). This depression is also sometimes called the intercondylar groove. In the literature, the definition of trochlear groove is also found (meaning a block-shaped formation, reminiscent of a spool of thread, which consists of the medial and lateral condyles with a depression between them). It is necessary to know all three terms as they relate to this recess.

With the leg straightened, the patella is located slightly above the patella surface. Lying deep within the muscle tendon, the patella, when the knee is bent, moves downward, or distally, along the patellar surface. This is clearly visible in Fig. 6-21, p. 204, which shows the knee joint in a lateral view.

Middle and distal femur, posterior view (Fig. 6-20)

On the posterior surface of the distal femur are two rounded condyles, separated in the distal posterior portion by a deep intercondylar fossa, or notch, above which the popliteal surface is located (see p. 204).

In the distal parts of the medial and lateral condyles there are smooth articular surfaces for articulation with tibia. When the femur is in a vertical position, the medial condyle is located slightly lower, or distal, to the lateral one (Fig. 6-20). This explains why the CL must be angled 5-7° cranially when performing a lateral view of the knee, which projects the condyles onto each other and the femur parallel to the cassette. An explanation for this is given additionally in Fig. 6-19, which shows that in a vertical anatomical position, when the condyles of the distal femur are parallel to the lower plane of the knee joint, the body of the femur in an adult is deviated from the vertical by approximately 10°. The magnitude of this angle ranges from 5° to 15°". In short people with a wide pelvis, this angle will be larger, and in tall patients with narrow pelvis, respectively, less. Thus, the magnitude of this angle in women is, as a rule, greater than in men.

Characteristic difference between the medial and lateral condyles is the presence of the adductor tubercle, a slightly protruding area to which the adductor tendon attaches. This tubercle is located in the posterior

Keats TE et al: Radiology, 87:904, 1966.

Patella

Patella(patella) - a flat, triangular-shaped bone, approximately 5 cm in diameter. The patella appears upside down because its pointed apex forms an inferior edge, and rounded base- upper. Outer side anterior surface convex and rough, and the inner one is oval in shape back surface, articulating with the femur, smooth. The patella protects the front of the knee joint from injury, in addition, it acts as a lever that increases the lifting force of the quadriceps femoris muscle, the tendon of which is attached to the tibial tuberosity of the leg. The patella in its upper position with a fully straightened limb and a relaxed quadriceps muscle is a mobile and easily displaced formation. If the leg is bent at the knee joint and the quadriceps muscle is tense, the patella moves down and is fixed in this position. Thus, it can be seen that any displacement of the patella is associated only with the femur and not with the tibia.

KNEE-JOINT

The knee joint is a complex joint that includes, first of all, femorotibial the joint between the two condyles of the femur and their corresponding condyles of the tibia. Also involved in the formation of the knee joint femoral-patellofemoral nickname joint, because the patella articulates with the anterior surface of the distal femur.

Menisci (articular discs)

The medial and lateral menisci are flat intra-articular cartilage discs between the superior articular surface of the tibia and the femoral condyles (Fig. 6-27). The menisci are crescent-shaped, their thickened peripheral edge gently declines towards the thinned central part. The menisci are a kind of shock absorbers that protect the knee joint from shock and pressure. It is believed that the menisci, together with the synovial membrane, are involved in the production of synovial fluid, which plays the role of lubricating the articular surfaces of the femur and tibia, covered with elastic and smooth hyaline cartilage.

I L A V A O

LOWER LIMB

Straight posterior projection of the lower leg (Fig. 6-29)

A. Medial condyle of the tibia.
B. Body of the tibia.

B. Medial malleolus.
D. Lateral malleolus.

D. Body of the fibula. E. Neck of the fibula. G. Head of the fibula. 3. Apex (styloid process) of the fibular head

I. Lateral condyle of the tibia. K. Intercondylar eminence (tibial crest

Lateral projection of the lower leg (Fig. 6-30)

A. Intercondylar eminence (tibial crest
bones).

B. Tibial tuberosity.

B. Body of the tibia.
D. Body of the fibula.

D. Medial malleolus. E. Lateral malleolus.

Straight posterior view of the knee joint (Fig. 6-31)

A. Medial and lateral intercondylar tubercles; you
stupas of the intercondylar eminence (crest of the tibia
cervical bone).

B. Lateral epicondyle of the femur.

B. Lateral femoral condyle.

D. Lateral condyle of the tibia. D. Upper articular surface of the tibia.

E. Medial condyle of the tibia. G. Medial condyle of the femur.

3. Medial epicondyle of the femur.

I. Patella (visible through the femur).

Lateral view of the knee joint (Fig. 6-32)

A. Base of the patella.
B. Apex of the patella.

B. Tibial tuberosity.
D. Neck of the fibula.

D. Head of the fibula. E. Apex of the head (styloid process) of the fibula

bones. G. Medial and lateral condyles superimposed on each other

3. Patellar surface (intercondylar, or trochlear, groove).

Lateral projection of the knee joint (with slight rotation) (Fig. 6-33)

I. Tubercle of the adductor muscle. K. Lateral condyle. L. Medial condyle.

Tangential view (patellofemoral joint) (Fig. 6-34)

A. Patella.

B. Patellofemoral joint.

B. Lateral condyle.

D. Patellar surface (intercondylar, or trochlear, groove). D. Medial condyle.

The only exception to the group of synovial joints is distal tibiofibular joint, related to fibrous compounds, in which the articulation between the articular surfaces of the tibia and fibula occurs with the help of connective tissue. It refers to syndesmoses and is continuous motionless, or inactive joint (amphiarthrosis). The most distal part of this joint is smoothed and covered by the common synovial membrane of the ankle joint.

SURFACES AND PROJECTIONS OF THE FOOT Surfaces. Determining the surface of the foot can sometimes cause some difficulties, since the foot rear called top part. Dorsum usually refers to the back parts of the body. In this case we mean dorsum of the foot, which is the upper, or opposite to the sole, surface. The sole of the foot is rear, or plantar, surface.

Projections. Posterior projection of the foot is plantar projection. Less commonly used anterior projection may also be called rear projection. Radiologists should be familiar with each of these terms and have a good understanding of the specific projection they are performing.

LAYINGS

General issues

X-rays of the lower extremity are usually performed on an imaging table, as shown in Fig. 6-38. Patients with severe trauma are often examined directly on a stretcher or gurney.

DISTANCE

The X-ray source/receiver distance (XRD) for radiography of the lower extremity is usually 100 cm. If the image is taken on a cassette located on the table deck, it should be taken into account that the distance from the table deck to the cassette holder is usually 8-10 cm, and therefore the emitter should raise further. When taking x-rays on a gurney or stretcher, use the depth gauge, usually located on the depth diaphragm of the machine, to set the RIP = 100 cm.

Radiation protection

When radiography of the lower extremity, gonadal protection is desirable, since the gonads are in close proximity to the irradiation zone. The gonad area can be protected with any leaded vinyl cover 1 . And although the requirements for radiation protection of gonads apply only to patients of reproductive age and only when the gonads are directly located in the area of the direct beam, it is recommended to apply it in all cases.

DIAPHRAGM

The rules for diaphragming are always the same - the boundaries of the diaphragm area should be visible on all four sides of the image, but the images of the organs being examined should not be cut off. The minimum size cassette should be used to obtain an image of the area of interest. Note that when radiography of the lower limb, small cassettes are most often used.

Several projections can be performed on one cassette for radiography of the lower extremity, so careful attention should be paid to diaphragm setting.

When using digital X-ray imaging receivers (particularly computed radiography systems with memory phosphor plates), cover the unused area of the cassette with a sheet of leaded vinyl. The phosphor is very sensitive to scattered radiation, which can cause severe fog on subsequent radiographs.

If the aperture boundaries are visible from all four sides, then this makes it easier to find the center of the image - at the intersection of the diagonals.

GENERAL PRINCIPLES OF LAYING

For the upper and lower limbs when laying, the same rule applies - the long axis of the limb being examined should

Rice. 6-38. Exemplary placement for the mediolateral projection of the lower limb:

Correct direction of the CL;

Correct aperture;

Correct use of radiation protection;

Diagonal placement of the lower limb allows you to get
X-ray image of both joints

not located along the long axis of the cassette. If you need to perform several projections, then When taking multiple images on one cassette, the orientation of the limb must be maintained.

The exception is the adult shin. It is usually laid diagonally across the cassette so that the knee and ankle joints enter, as shown in Fig. 6-38.

CORRECT CENTERING

Accurate centering and positioning of the body part being examined, as well as the correct direction of the CL, are very important when radiography of the upper and lower extremities. The photographs should show open joint spaces and there should be no geometric distortions of the shape of the bones, that is, the part of the body being removed should be parallel to the plane of the cassette, and the CL should be directed perpendicular to the limb being removed. Follow the directions on the styling pages.

EXPOSURE SETTINGS

Exposure parameters for radiography of the lower limb:

1. Low or medium kV (50-70).

2. Short exposure time.

3. Small focus.

Correctly exposed radiographs of the lower extremity should show both soft tissue contours and clear trabecular bone structure.

RADIOGRAPHY IN PEDIATRICS

Firstly, you should speak to the child in a language he understands. Parents often assist in restraining the child, especially if it is not a case of trauma. At the same time, care should be taken to ensure their radiation protection. Braces are useful in many cases because they help the child keep the limb still and in the desired position. Soft pillows for ease of laying and straps for fixation are common tools. Sand cushions should be used carefully as they are heavy. Measuring body thickness is an important factor in determining optimal exposure parameters.

In general, reduced exposure parameters are used in pediatrics due to the small size and low density of the limbs being examined. Use short exposure times, increasing the current (mA), - this reduces the dynamic blur of the image.

RADIOGRAPHY IN GERIATRICS

Elderly patients should be positioned for imaging with caution, and radiography of the lower extremity is no exception. Pay attention to signs of a hip fracture (leg excessively twisted). Routine positioning should be adjusted to suit the patient’s ability to bend limbs and personal pathology. When positioning the limb, pillows and supports should be used to ensure patient comfort.

Exposure parameters should be selected taking into account possible osteoporosis or osteoarthritis. Using short exposure times, increasing the current (mA), this reduces the dynamic blur of the image due to voluntary and involuntary movements.

ARTHROGRAPHY

Arthrography is commonly used to visualize large synovial joints such as the knee. It is performed by introducing contrast agents into the joint cavity under sterile conditions. Arthrography reveals diseases and injuries of the menisci, ligaments and tendons (see Chapter 21).

RADIONUCLIDE DIAGNOSTICS

Radionuclide scanning is intended for the diagnosis of osteomyelitis, metastatic processes in bones, impacted fractures, as well as inflammatory diseases subcutaneous tissue. The organ being examined is assessed within 24 hours from the start of the study. Radionuclide testing is more informative than radiography, since it allows you to assess not only the anatomical, but also the functional state of the organ.

Clinical indications

Radiologists should be familiar with the most common clinical indications for lower extremity radiography, which are (the attached list is not complete):

Bone cysts- benign tumor-like formations, which are a cavity filled with serous fluid. They most often develop in children and are located mainly in the knee joint.

Chondromalacia patella- often called runner's knee. The pathology is based on dystrophic changes (softening) of the cartilage, leading to its wear; accompanied by pain and constant irritation of the affected area. Runners and cyclists are often affected.

Chondrosarcoma- malignant tumor bones. The predominant localization is the pelvis and long tubular bones. It is more common in men over 45 years of age.

Ewing's sarcoma- primary malignant bone tumor is usually observed in childhood, from 5 to 15 years. The tumor is usually localized in the diaphysis of long tubular bones. The clinical picture includes pain, increased body temperature at the onset of the disease, and leukocytosis.

Exostosis, or osteochondroma- a benign tumor-like bone lesion, the essence of which is the overproduction of bone substance (the knee joint area is often affected). The tumor grows in parallel with the growth of the bone, moving away from the adjacent joint.

The phalanx of human limbs consists of three parts: the body - the base, the proximal and distal ends, on which the nail tuberosity is located.

Each human finger consists of three phalanges, except (it consists of two). Three phalanges: main, middle and nail. The phalanges on the toes are shorter than those on the fingers. The longest of them is on the middle finger, the thickest is on the thumb.

The structure of the phalanx of the fingers: an elongated bone, in the middle part having the shape of a semi-cylinder. Its flat part is directed towards the side of the palm, the convex part - towards back side. At the end of the phalanx there are articular surfaces.

By modifying the phalanx of the fingers, certain diseases can be diagnosed. The symptom of drumsticks is thickening of the terminal phalanx of the fingers and toes. With this symptom, the fingertips resemble a flask, and the nails resemble watch glasses. The muscle tissue that is located between the nail plate and the bone is spongy in nature. Because of this, when pressing on the base of the nail, the impression of a movable plate is created.

Drum fingers are not an independent disease, but only a consequence of serious internal changes. Such pathologies include diseases of the lungs, liver, heart, gastrointestinal tract, and sometimes - diffuse goiter and cystic fibrosis.

A phalanx fracture occurs from a direct blow or injury and is often open. It can also be diaphyseal, periarticular or intraarticular. The fracture is usually comminuted.

The clinical picture of the fracture is characterized by pain, swelling and limited finger function. If there is internal displacement, then deformation is noticeable. If there is no displacement, a bruise or sprain may be diagnosed. In any case, an X-ray examination must be performed for a final diagnosis.

Treatment of a fracture of the phalanx of the fingers without displacement is carried out with a plaster or an aluminum splint, which is applied when the nail phalanx is bent to 150, medium - up to 600, main - up to 500. The bandage or splint is worn for 3 weeks. After removing the material, therapeutic exercises are performed with physiotherapy. After a month, the working capacity of the phalanx is completely restored.

In case of displaced phalangeal fractures, a comparison of the fragments is carried out. After this, a plaster or metal splint is applied for 3-4 weeks. For fractures of the nail phalanges, the finger is immobilized with an adhesive plaster or a circular plaster cast.

The phalanges of the toes often suffer from dislocations in the metatarsophalangeal and interphalangeal joints. Dislocations are directed towards the back of the foot, the sole and to the side.

This problem is diagnosed by a characteristic deformation, shortening of the finger or limitation of its movement.

The largest number of dislocations occurs on the phalanx of the first finger, its distal part. In second place are dislocations of the fourth finger. The middle toes are much less affected due to their location in the center of the foot. In direction, dislocations are usually observed to the rear and to the side. The dislocation is reduced before swelling develops. If swelling has already formed, it is much more difficult to insert the phalanx into the joint.

Closed dislocations are reduced after local anesthesia. If it is difficult to reduce using the usual method, then use the insertion of a pin through the distal phalanx or the use of a pin. The procedure is simple and safe. Then they apply traction along the length of the damaged finger and countertraction (which is carried out by an assistant) at the ankle joint. By pressing on the base of the displaced phalanx, the dislocation is reduced.

For old dislocations, surgical intervention is required.

Sometimes such thickening is hereditary or occurs without visible reasons, but often accompanies various diseases, including congenital cyanotic heart defects, infective endocarditis, lung diseases (lung cancer, lung metastases, bronchiectasis, lung abscess, cystic fibrosis and pleural mesothelioma), as well as some gastrointestinal diseases (Crohn's disease, ulcerative colitis and cirrhosis of the liver).

The reasons for the development of drumstick symptom are unclear; perhaps it is caused by dilation of the vessels of the distal phalanges of the fingers under the influence of humoral factors. In patients with lung cancer, pulmonary metastases, pleural mesothelioma, bronchiectasis, and liver cirrhosis, the drumstick symptom may be combined with hypertrophic osteoarthropathy. In this condition, periosteal bone formation occurs in the area of the diaphysis of long tubular bones, arthralgia and symmetrical arthritis-like changes occur in the shoulder, knee, ankle, wrist and elbow joints. Diagnosis by radiography and bone scintigraphy.

The symptom of drumsticks is characteristic of all chronic lung infections.

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Phalanges of fingers

The phalanges of the human fingers have three parts: proximal, main (middle) and terminal (distal). On the distal part of the nail phalanx there is a clearly visible nail tuberosity. All fingers are formed by three phalanges, called the main, middle and nail. The only exception is the thumbs - they consist of two phalanges. The thickest phalanges of the fingers form the thumbs, and the longest ones form the middle fingers.

Structure

The phalanges of the fingers belong to the short tubular bones and have the appearance of a small elongated bone, in the shape of a semi-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 have a block-like shape. They can perform extensions and flexions. The joints are well strengthened by collateral ligaments.

Appearance of the phalanges of the fingers and diagnosis of diseases

In some chronic diseases of the internal organs, the phalanges of the fingers are modified and take on the appearance 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 most often occur as a result of a direct blow. A fracture of the nail plate of the phalanges is usually always comminuted.

Clinical picture: the phalanx of the fingers hurts, swells, function injured finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. In case of fractures of the phalanges of the fingers without displacement, sprain or displacement is sometimes mistakenly diagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with injury, then an X-ray examination (fluoroscopy or radiography in two projections) is required, which allows making 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 this, physiotherapeutic treatment, massage and exercise therapy are prescribed. Full mobility of the damaged finger is usually restored within a month.

In case of a displaced fracture of the phalanges of the fingers, comparison of bone fragments (reposition) is performed under local anesthesia. Then a metal splint or plaster cast is applied for a month.

If the nail phalanx is fractured, 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, gout, psoriatic) and deforming osteoarthritis. If these diseases are not treated, then over time they lead to the development of severe deformation of the damaged joints, 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 the phalanges of your fingers hurt, you should not self-medicate. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and accordingly prescribe the necessary therapy.

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I only had the very tip of the bone removed, about 4 mm. and now the nail phalanx is 4 mm shorter, this is of course nothing, but it still catches the eye, and even the nail cannot really grow. With the help of what modern biotechnologies can this be cured? please give me the link.

My index finger in front of the nail plate has become thinner (decreased in diameter). One gets the impression that there is just bone left in this place. The finger began to look like an irregularly shaped hourglass. The finger jerks periodically. The skin in this area is smooth and soft.

Possible causes are listed in the article, and the exact cause can only be determined after an examination.

The article lists those conditions that may be a sign of enlarged phalanges, and to find out for sure, you need a face-to-face consultation with a specialist (an orthopedist or surgeon to start with).

Hello. I'm afraid not.

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How to treat arthrosis of the fingers using traditional and folk medicine

Typically, joint diseases occur in most cases in people of mature age.

But today, due to hormonal changes in the body, you can find many young girls suffering from arthrosis of the fingers, an inflammatory process that is localized on the joints of the hands.

Such manifestations cause discomfort to the fair sex not only due to the cosmetic effect, but also due to the loss of functions. Treatment should be started immediately, even at the stage of initial symptoms.

Concept and characteristics of the disease

The disease arthrosis – inflammation of a joint or joints – has not yet been fully studied.

Scientists cannot identify the exact causes of this disease, although they provide several hypotheses. The main hypothesis is that the cause of the disease is a hereditary factor.

That is, a person has a gene from birth that can lead to an inflammatory process as soon as there are grounds for this - the reasons for the disease.

Osteoarthritis of the fingers is no exception. In this form, all inflammatory processes in the joints occur on the phalanges of the fingers.

In rare cases, the joints of the hands are affected - in this case, the disease polyarthrosis is diagnosed. The presented disease is dangerous for humans due to its irreversible manifestations. So, in advanced cases, deformation of the joint itself and the bone to which it is adjacent is diagnosed.

Such features of the disease can no longer be eliminated, and to improve the standard of living, experts suggest performing surgery.

A sick person has a characteristic thickening in the joints between the phalanges.

Causes and risk factors of the disease

The disease has the following causes:

old age of the patient - due to the characteristic depletion and thinning of the articular cartilage;
during the period of hormonal imbalance (menopause in women and other diseases), a metabolic disorder of cartilage tissue occurs;
weakened immunity affects the exacerbation of existing arthrosis, and also provokes its initial occurrence;
injuries and bruises of fingers;
genetic characteristics that caused deformation and other defects in the development of joints;
excessive physical labor, where the basis was work with the hands;
excessive hypothermia;
the presence of any disease, both articular and distinctive character, for example, rheumatoid arthritis, gout, diabetes mellitus and others;
metabolic disorders of the whole body;
past infectious diseases - chlamydia and others.

Stages of the disease and characteristic signs

Symptoms of arthrosis of the fingers differ significantly depending on the stage of development of the disease.

So, there are three stages, each of which manifests itself in its own way:

The first stage is characterized by initial symptoms: pain in the joints occurs every time under heavy loads; there is a characteristic crunch in the fingers; swelling of the joints appears; diagnose joint compactions between the phalanges of the fingers; constant tension in the periarticular muscle tissue, which manifests itself as difficulty in self-care.
In the second stage, the person is bothered constant pain in the joints, as inflammation of the joints occurs. It is difficult for a person not only to serve himself, but also to simply move his fingers. Inflammation of the joints is always accompanied

In the photo there is stage 3 arthrosis of the fingers

an increase in local temperature (when palpated, you can notice an increase in the temperature of the skin in the joints).

The third stage is the beginning of an irreversible process. A person suffers from constant pain in his fingers, and there is deformation of the phalanges. Bone deformation also leads to a lack of mobility in the fingers or all hands. Treatment of the third stage is extremely difficult and does not return a person to their previous life.

A person should contact a specialist at the first manifestations of the disease. At the first stage, treatment of arthrosis of the fingers can completely restore cartilage tissue and return the patient to his previous standard of living.

Rhizarthrosis of the thumb

Arthrosis of the thumb has a second name - rhizarthrosis. It appears quite rarely - in approximately 5% of all cases diagnosed with joint diseases.

In this case, the metacarpal joint is affected at the junction with the wrist bone. At the site of the lesion, deformation of the joint is observed with its protrusion outward.

Diagnostics in a medical institution

Pathology is diagnosed by visual examination by a doctor and subsequent X-ray examination.

In the picture you can see characteristic damage to the joints, as well as determine the stage of development of the disease presented.

Treatment methods

Treatment of the disease involves restoring the previous mobility of the joints by restoring cartilage tissue by any suitable method.

Traditional medicine and effective folk methods are used here.

Traditional medicine

Treatment methods using traditional medicine directly depend on the stage of manifestation of the disease.

Drug therapy - first of all, the specialist prescribes non-steroidal anti-inflammatory drugs to eliminate inflammation and pain. After some relief, the patient begins to take chondroprotectors - drugs for restoring cartilage tissue.
Physiotherapy – laser therapy, magnetic therapy, paraffin baths, ozokerite baths are used. The sessions are excellent for relieving pain.
Exercise therapy – the patient must do simple exercises to regain your previous mobility. Tapping your fingers on the table uses all your finger joints.
Massage - light stroking and rubbing - a gentle massage regimen performed by an experienced specialist.
Diet – throughout the entire treatment, the patient must adhere to a low-salt diet so that fluid does not remain in the body, and therefore does not provoke swelling and inflammatory processes.
Surgical intervention - the patient undergoes removal of growths in the joint parts, and in case of arthrosis of the thumb, the joint is immobilized by installing a fixator - arthrodesis.

Traditional medicine is used in a comprehensive manner in most cases. The patient must follow all the doctor’s instructions in order to quickly eliminate the pain syndrome and return to the previous level of life.

ethnoscience

Treatment of arthrosis of the fingers with folk remedies is used only to relieve pain, eliminate swelling and inflammation, since they do not stop the process of destruction of cartilage tissue that has begun and do not help restore the balance of microelements.

In particular, the following recipes are used:

Mix honey and salt in equal proportions. Mix the mixture thoroughly and apply it to sore joints. Cover your hands with plastic and put on wool mittens. Leave the compress on overnight.
It is recommended to make a compress for the night from crushed burdock leaves. They are pre-washed and passed through a meat grinder.

In addition to compresses for the treatment of arthrosis, you can use infusions and other formulations for oral administration. Extract the juice from fresh celery and take 2 teaspoons three times a day.

Be careful, complications are possible!

Pathology with untimely intervention is fraught with serious consequences.

Surgical intervention is the result of complications of the onset of the disease, since the surgical method is used in case of deformation of the joint and adjacent bone.

Therefore, at the first manifestations of aching fingers, you should contact specialists for help.

Prevention methods

As preventive measures, experts recommend eating right - eating more vegetables and fruits, and not overusing salt.

Distribute physical activity correctly so that your fingers do not bear all the weight. If you have relatives in your family with similar problems, carry out preventive actions diligently.

Hand health directly depends on a person’s attitude towards himself. In a busy world, you often don’t find time to visit a doctor in the initial stages of a serious illness.

This kind of negligence can lead to significant problems that will take a long time to resolve.

Phalanges of fingers

Phalanges of fingers upper limbs humans consist of three parts - proximal, middle (main) and distal (final). The distal part of the phalanx has a clearly visible nail tuberosity. All fingers of the human hand are formed by three phalanges - nail, middle and main. If we talk about the thumb, it consists of two phalanges. The longest phalanges form the middle fingers, and the thickest ones form the thumbs.

The structure of the phalanges of the fingers

According to anatomists, the phalanges of the fingers of the upper extremities are short tubular bones, which have the shape of a small elongated bone, in the form of a cylinder, with its convex part facing the back of the palms. Almost each end of the phalanges has articular surfaces that take part in the formation of interphalangeal joints. These joints have a block-like shape. They perform two functions - flexion and extension of the fingers. The interphalangeal joints are strengthened by collateral ligaments.

What diseases cause changes in the appearance of the phalanges of the fingers?

Very often, with chronic ailments of the internal organs, the phalanges of the fingers of the upper extremities are modified. They, as a rule, take on the appearance of “drum sticks” (a spherical thickening is observed on the terminal phalanges). As for the nails, they resemble “hour hands”. Similar modifications of the phalanges are observed in the following diseases:

heart defects;
cystic fibrosis;
lung diseases;
infective endocarditis;
diffuse goiter;
Crohn's disease;
lymphoma;
cirrhosis of the liver;
esophagitis;
myeloid leukemia.

The phalanges of the fingers hurt: the main causes

Interphalangeal joints (smallest joints) human body) can be affected by diseases that impair their mobility. These diseases are in most cases accompanied by excruciating pain. The main causes of impaired mobility of the interphalangeal joints are:

deforming osteoarthritis;
gouty arthritis;
rheumatoid arthritis;
psoriatic arthritis.

If these ailments are not treated, then after some time they will lead to severe deformation of the diseased joints, complete disruption of their motor function, as well as atrophy of the hands and muscles of the fingers. The clinical picture of the above ailments is very similar, but their treatment is different. Therefore, medical specialists advise people who have pain in the phalanges of their fingers not to self-medicate, but to contact experienced doctors.

Fracture of the phalanx of the finger

Judging by the reviews of medical specialists, fractures of the phalanges of the fingers, as a rule, occur as a result of a direct blow. If we talk about a fracture of the nail plate of the phalanx, then it is almost always fragmented. Such fractures are accompanied by severe pain in the area of damage to the phalanx, swelling and limited function of the broken finger.

Treatment of fractures of the phalanges of the fingers of the upper extremities without displacement is conservative. In this case, traumatologists apply a plaster cast or an aluminum splint for three weeks, after which they prescribe therapeutic massage, physical education and physiotherapeutic procedures. In case of a displaced fracture, reposition (comparison of bone fragments) is performed under local anesthesia. A plaster cast or metal splint is applied for a month.

What diseases are accompanied by bumps on the phalanges of the fingers?

Bumps on the phalanges of the fingers are manifestations of many diseases, the main ones of which are:

Bumps that appear on the fingers of the upper extremities are accompanied by unbearable pain, which intensifies at night. In addition, there is a characteristic compaction, leading to immobility of the joints, as well as limitation of their flexibility.

As for the treatment of these bumps, it consists of: drug therapy, therapeutic and preventive gymnastics, massage, physiotherapeutic procedures and applications.

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The information presented on our website should not be used for self-diagnosis and treatment and cannot serve as a substitute for consultation with a doctor. We warn you about the presence of contraindications. Specialist consultation is required.

Thickening of the terminal phalanges of the fingers or toes

Thickening of the terminal phalanges of the fingers or toes are changes in the area under and around the nails. Thickening of the terminal phalanges of the fingers does not in itself pose any health hazard. However, it is often a symptom of lung disease; however, many other diseases can be the cause. Thickening of the terminal phalanges of the fingers, not associated with any diseases, is inherited in some families.

Symptoms

Softening nails. The nails may seem to “float” - that is, not be firmly attached;

The angle between the nails and the cuticle increases;

The last part of the finger may appear large or protruding. It can also be warm and red;

Curve nails downward, similar to the shape of the round part of an inverted spoon.

Thickenings can develop quickly, often within a few weeks. They can also be easily eliminated once the cause is clear.

Causes of thickening of the terminal phalanges of the fingers or toes

Lung cancer is the most common cause of this disease. Thickenings often develop due to diseases of the heart and lungs, which reduce the amount of oxygen in the blood, such as:

Heart defects that are present at birth (congenital);

Chronic pulmonary infections in humans: bronchiectasis, cystic fibrosis (a systemic hereditary disease caused by a mutation in the gene for the transmembrane regulator of cystic fibrosis and characterized by damage to the exocrine glands, severe dysfunction of the respiratory and gastrointestinal tract; the most common autosomal recessive potentially lethal hereditary disease in white people race), lung abscess;

Infection of the lining of the heart chambers and heart valves (infectious endocarditis), which may be caused by bacteria, fungi, or other infectious agents;

Lung diseases in which the deep tissues of the lungs swell and then form a scar (interstitial lung disease).

Other causes of thickening of the phalanges of the fingers:

Celiac disease (or celiac enteropathy is a multifactorial disease, a digestive disorder caused by damage to the villi small intestine some food products containing proteins - gluten and related cereal proteins);

Liver cirrhosis and other liver diseases;

Graves' disease (diffuse toxic goiter, Graves' disease - a life-threatening disease of the thyroid gland);

Overactive thyroid gland;

Other types of cancer, including liver and gastrointestinal tract, Hodgkin's lymphoma.

Diagnosis and treatment of thickening of the terminal phalanges of the fingers or toes

The patient should contact his doctor if he notices thickening of the terminal phalanges of the fingers or toes.

Diagnosis is usually based on:

Examination of the lungs and chest.

The doctor's questions to the patient may include the following:

Does he have difficulty breathing;

Do the bulges affect the mobility of his fingers and toes;

When did this thickening first become noticeable;

Is the skin bluish in color at the site of thickening;

What other symptoms accompany this disease?

The following tests can be done:

Arterial blood gas analysis;

CT scan of the chest;

Pulmonary function test.

There is no specific treatment for such thickenings of the terminal phalanges, but treatment concomitant diseases almost always leads to the elimination of these thickenings.

Thickening of the terminal phalanges of the fingers like “drumsticks”

CLINICAL CASE

A 31-year-old man with congenital heart disease has thickened terminal phalanges fingers like “drumsticks” since childhood (Fig.). Upon closer examination, thickening of the distal phalanges is visible in the “drumstick” type. He has become accustomed to living with the limitations caused by his congenital heart defect, and his fingers do not bother him at all.

EPIDEMIOLOGY

Prevalence in the general population is unknown:

2% of adult patients seeking care in Wales.
38% of patients with Crohn's disease and 15% of patients with ulcerative colitis.
33% of patients with lung cancer and 11% with COPD.

DRAWING. Thickening of the phalanges like “drumsticks” in a 31-year-old man with congenital heart disease. Noteworthy is the thickening around the proximal edge of the nail.

ETIOLOGY AND PATHOPHYSIOLOGY

The etiology is poorly understood.

Megakaryocytes and platelet accumulations penetrate the histemic bloodstream; from platelets release platelet-derived growth factor, which can cause thickening of the nail bed.

DIAGNOSIS and CLINICAL SIGNS

Usually painless.
Changed angle of the nail (Fig.).
Angle to profile (ABC) > 180°.
Hyponychial angle (ABD) > 192°.
Phalanx depth ratio (BE:GF) > I

TYPICAL LOCATION

Bilateral, all fingers and sometimes toes are involved.
Rarely unilateral or involving one or more fingers.

DIFFERENTIAL DIAGNOSIS

PRIMARY THICKENING OF THE END PHALANGES ACCORDING TO THE TYPE OF “DRUM STICKS”

Pachydermoperiostosis.
Familial thickening of the terminal phalanges of the “drumstick” type.
Hypertrophic osteoarthropathy.

SECONDARY THICKENING OF THE TERMINAL PHALANGES ACCORDING TO THE TYPE OF “DRUMP STICKS”

Secondary thickening of the terminal phalanges in the form of “drumsticks” can be caused by many diseases, including the following:

Gastrointestinal diseases: inflammatory bowel disease, liver cirrhosis and celiac disease.
Lung diseases: malignant neoplasms, asbestosis, ischemic obstructive pulmonary diseases, cystic fibrosis.
Heart disease: congenital heart defects, endocarditis, atrioventricular malformations or fistulas.

TREATMENT

DRAWING. Thickening of the phalanges like “drumsticks” close-up.

DRAWING. Thickening of the phalanges in the form of “drumsticks” in a 55-year-old man suffering from COPD. Changed angle in profile (ABC); the depth of the distal phalanx (BE) is greater than the interphalangeal depth (GF)

Drumstick symptom

The symptom of drumsticks (Hippocratic fingers or drum fingers) is a painless, flask-shaped thickening of the terminal phalanges of the fingers and toes that does not affect the bone tissue, which is observed in chronic diseases of the heart, liver or lungs. Changes in the thickness of the soft tissues are accompanied by an increase in the angle between the posterior nail fold and the nail plate to 180° or more, and the nail plates are deformed, resembling watch glasses.

General information

The first mention of fingers resembling drumsticks is found in Hippocrates in the description of empyema (an accumulation of pus in a body cavity or hollow organ), therefore such deformation of the fingers is often called Hippocratic fingers.

In the 19th century The German doctor Eugene Bamberger and the Frenchman Pierre Marie described hypertrophic osteoarthropathy (secondary damage to the long bones), in which “drumstick” fingers are often observed. These pathological conditions already by 1918, doctors considered it a sign of chronic infections.

Forms

In most cases, drumstick fingers are observed on the hands and feet simultaneously, but isolated changes also occur (only the fingers or only the toes are affected). Selective changes are characteristic of cyanotic forms birth defects hearts, in which only the upper or lower half of the body is supplied with oxygenated blood.

Based on the nature of the pathological changes, fingers are classified as “drumsticks”:

Resembling a parrot's beak. The deformity is associated primarily with the growth of the proximal part of the distal phalanx.
Reminiscent of watch glasses. The deformity is associated with tissue growing at the base of the nail.
True drumsticks. Tissue growth occurs along the entire circumference of the phalanx.

Reasons for development

The causes of the drumstick symptom may be:

Lung diseases. The symptom manifests itself in bronchogenic lung cancer, chronic suppurative lung diseases, bronchiectasis (irreversible local dilation of the bronchi), lung abscess, pleural empyema, cystic fibrosis and fibrous alveolitis.
Cardiovascular diseases, which include infective endocarditis (heart valves and endothelium are affected by various pathogens) and congenital heart defects. The symptom is accompanied by the blue type of congenital heart defects, in which a bluish tint to the patient’s skin is observed (includes tetralogy of Fallot, transposition of the great vessels and pulmonary atresia).
Gastrointestinal diseases. The symptom of drumsticks is observed in cirrhosis, ulcerative colitis, Crohn's disease, enteropathy (celiac disease).

Drumstick fingers can be a symptom of other types of diseases. This group includes:

cystic fibrosis is an autosomal recessive disease that is caused by a CFTR mutation and manifests itself with severe respiratory impairment;
Graves' disease (diffuse toxic goiter, Graves' disease), which is an autoimmune disease;
trichocephalosis is a helminthiasis that develops when the gastrointestinal tract is affected by whipworms.

Fingers resembling drumsticks are considered the main manifestation of Marie–Bamberger syndrome (hypertrophic osteoarthropathy), which is systemic damage tubular bones and in 90% of all cases is caused by bronchogenic cancer.

The cause of unilateral damage to the fingers may be:

Pancoast tumor (occurs when cancer cells damage the first (apical) segment of the lung);
lymphangitis (inflammation of the lymphatic vessels);
application of an arteriovenous fistula to purify the blood using hemodialysis (used for renal failure).

There are other, little-studied and rare causes of the development of the symptom - taking losartan and other angiotensin II receptor blockers, etc.

Pathogenesis

The mechanisms of development of drumstick syndrome have not yet been fully established, but it is known that deformation of the fingers occurs as a result of impaired blood microcirculation and the local tissue hypoxia that develops as a result.

Chronic hypoxia causes dilation of blood vessels located in the distal phalanges of the fingers. There is also increased blood flow to these areas of the body. It is believed that blood flow is increased by the opening of arteriovenous anastomoses (blood vessels that connect arteries to veins), which occurs as a result of the action of an unidentified endogenous (internal) vasodilator.

The result of impaired humoral regulation is the proliferation of connective tissue lying between the bone and the nail plate. Moreover, the more significant the hypoxemia and endogenous intoxication, the more severe the modifications of the terminal phalanges of the fingers and toes will be.

However, hypoxemia is not typical for chronic inflammatory bowel diseases. At the same time, changes in the fingers like “drum sticks” are not only observed in Crohn’s disease, but also often precede intestinal manifestations of the disease.

Symptoms

The symptom of drumsticks does not cause pain, so initially it develops almost unnoticed by the patient.

Signs of the symptom are:

Thickening of the soft tissues at the terminal phalanges of the fingers, in which the normal angle between the digital fold and the base of the finger disappears (Lovibond angle). Usually the changes are more noticeable on the fingers.
Disappearance of the gap that normally forms between the nails if the nails of the right and left hands are placed together (Shamroth’s symptom).
Increasing curvature of the nail bed in all directions.
Increased looseness of tissue at the base of the nail.
Special elasticity of the nail plate during palpation (balling the nail).

When the tissue at the base of the nail grows, the nails become like watch glasses.

Front view Side view

Signs of the underlying disease are also observed.

In many cases (bronchiectasis, cystic fibrosis, lung abscess, chronic empyema), the symptom of drumsticks is accompanied by hypertrophic osteoarthropathy, which is characterized by:

aching pain in the bones (in some cases severe) and painful sensations on palpation;
the presence of shiny and often thickened skin that is warm to the touch in the pretibial area;
symmetrical arthritis-like changes in the wrist, elbow, ankle and knee joints (one or more joints may be affected);
coarsening of the subcutaneous tissues in the area of the distal arms, legs, and sometimes the face;
neurovascular disorders in the hands and feet (paresthesia, chronic erythema, increased sweating).

The time for symptom development depends on the type of disease that provoked the symptom. Thus, a lung abscess leads to the disappearance of the Lovibond angle and the balloting of the nail 10 days after aspiration (foreign substances entering the lungs).

Diagnostics

If the symptom of drumsticks occurs in isolation from Marie–Bamberger syndrome, the diagnosis is made based on the following criteria:

There is no Lovibond angle, which can be easily established by applying a regular pencil to the nail (along the finger). The absence of a gap between the nail and the pencil indicates the presence of the drumstick symptom. The disappearance of the Lovibond angle can also be determined thanks to the Shamroth symptom.
Elasticity of the nail upon palpation. To check for a runaway nail, press on the skin just above the nail and then release it. If the nail sinks into the soft tissue when pressed, and springs back after the skin is released, suggest the presence of a drumstick symptom (a similar effect is observed in older people and in the absence of this symptom).
Increased ratio between the thickness of the distal phalanx at the cuticle and the thickness of the interphalangeal joint. Normally, this ratio averages 0.895. In the presence of the drumstick symptom, this ratio is equal to or greater than 1.0. This ratio is considered a highly specific indicator of this symptom (in 85% of children with cystic fibrosis, this ratio exceeds 1.0, and in children suffering from chronic bronchial asthma, this ratio is exceeded in only 5% of cases).

If a combination of the drumstick symptom with hypertrophic osteoarthropathy is suspected, bone radiography or scintigraphy is performed.

Diagnosis also includes studies to identify the cause of the symptom. For this:

study anamnesis;
do an ultrasound of the lungs, liver and heart;
a chest x-ray is performed;
CT and ECG are prescribed;
examine the functions of external respiration;
determine the gas composition of the blood;
do general analysis blood and urine.

Treatment

Treatment for drumstick-type finger deformities involves treating the underlying disease. The patient may be prescribed antibiotic therapy, anti-inflammatory therapy, diet, immunomodulatory drugs, etc.

Forecast

The prognosis depends on the cause of the symptom - if the cause is eliminated (cure or stable remission), symptoms may regress and the fingers will return to normal.

All fingers are formed by three phalanges, called the main, middle and nail. The only exception is the thumbs - they consist of two phalanges. The thickest phalanges of the fingers form the thumbs, and the longest ones form the middle fingers.

Structure

Appearance of the phalanges of the fingers and diagnosis of diseases

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers most often occur as a result of a direct blow. A fracture of the nail plate of the phalanges is usually always comminuted.

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. In case of fractures of the phalanges of the fingers without displacement, sprain or displacement is sometimes mistakenly diagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with injury, then an X-ray examination (fluoroscopy or radiography in two projections) is required, which allows making the correct diagnosis.

If the nail phalanx is fractured, it is immobilized with a circular plaster cast or adhesive plaster.

The phalanges of the fingers hurt: causes

Finger bones (phalanx)

The bones of the fingers (phalanx), ossa digitorum (phalanges) (see Fig. 127, 149, 150, 151, 163), are represented by phalanges, phalanges, related in shape to long bones. The first, thumb, finger has two phalanges: proximal, phalanx proximalis, and distal, phalanx distalis. The remaining fingers also have a middle phalanx, phalanx media. Each phalanx has a body and two epiphyses - proximal and distal.

The upper, proximal end of the phalanx, or base, basis phalangis, is thickened and has articular surfaces. The proximal phalanges articulate with the bones of the metacarpus, and the middle and distal phalanges are connected to each other.

The lower, distal end of the 1st and 2nd phalanges has a head of the phalanx, caput phalangis.

In the area of the metacarpophalangeal joints of the 1st, 2nd and 4th fingers and the interphalangeal joint of the 1st finger on the palmar surface, in the thickness of the muscle tendons, there are sesamoid bones, ossa sesamoidea.

Features of anatomy and structure of the phalanges of the fingers in humans

The phalanx of the human finger has 3 parts: proximal, main (middle) and terminal (distal). On the distal part of the nail phalanx there is a clearly visible nail tuberosity. All fingers are formed by 3 phalanges, called the main, middle and nail. The only exception is the thumbs; they consist of 2 phalanges. The thickest phalanges of the fingers form the thumbs, and the longest ones form the middle fingers.

The human hand and foot as a result of evolution

Our distant ancestors were vegetarians. Meat was not part of their diet. The food was low in calories, so they spent all their 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 stayed on branches and deftly climbed trunks. However, the fingers remained inactive in the horizontal projection. The palms and feet were difficult to open into a flat plane with the toes spread wide apart. The opening angle did not exceed 10-12°.

At a certain stage, one of the primates tried meat and found that this food was much more nutritious. He suddenly had time to take in the world around him. He shared his discovery with his brothers. Our ancestors became carnivores and descended from the trees to the ground and rose to their feet.

However, the meat had to be cut. Then a man invented a chopper. People still actively use modified versions of the chopper today. In the process of making this instrument and working with it, people's fingers began to change. On the arms they became mobile, active and strong, but on the legs they became shortened and lost mobility.

By prehistoric times, human fingers and toes acquired an almost modern appearance. The opening angle of the fingers at the palm and foot reached 90°. People learned to perform complex manipulations, play musical instruments, draw, draw, engage in circus arts and sports. All these activities were reflected in the formation of the skeletal basis of the fingers.

The development was made possible thanks to the special structure of the human hand and foot. It is, in technical terms, all “hinged”. Small bones are connected by joints into a single and harmonious shape.

The feet and palms have become mobile, they do not break when performing turning and turning movements, arching and torsion. Fingers and toes modern man can press, open, tear, cut and perform other complex manipulations.

Anatomy and structure of the finger

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 people.

In humans, the fingers and toes, despite noticeable external differences, have the same phalanx structure. At the base of each finger 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 trochlea or distal end.

Each finger (except the thumb) consists of 3 phalanges:

proximal (main);
average;
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 ridges. The body has a nutrient opening that passes into a canal directed from the proximal end to the distal end. The proximal end is thickened. It contains 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 side. The articulation with the bones of the metacarpus and foot is formed by the proximal phalanges. The remaining phalanges of the fingers provide a reliable connection between the bones of the finger.

Deformations of the phalanges and their causes

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 of the internal organs, which may include:

heart defects;
pulmonary dysfunction;
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 an advanced state, these diseases can become a serious threat to your health and even life. It happens that deformation of the phalanges of the fingers and toes is accompanied by excruciating, nagging pain and a feeling of stiffness in the hand and foot. These symptoms indicate that the interphalangeal joints are affected.

Diseases that affect 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 your quality of life. The doctor will prescribe examinations that will identify the causes of the disease.

Determining the causes will allow you to make an accurate diagnosis and prescribe a treatment regimen. If all medical recommendations are strictly followed, the prognosis for such diseases will be positive.

If painful bumps appear on the phalanges of your fingers, then you are actively developing gout, arthritis, arthrosis, or deposited salts have accumulated. A characteristic sign of these diseases is compaction in the area of the cones. A very alarming symptom, because this is a compaction that leads to immobilization of the fingers. With such a clinic, you should go to a doctor so that he can prescribe a therapy regimen, draw up a set of gymnastic exercises, prescribe massage, applications and other physiotherapeutic procedures.

Injuries to joints and bone structures

Who among us has not pressed our fingers against doors, hit our nails with a hammer, or dropped some heavy object on our feet? Often such incidents result 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 a fracture can be chronic illness, which 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 treating such fractures of the phalanges is a troublesome and expensive undertaking.

Traumatic fractures, according to the nature of the damage, can be closed or open (with traumatic ruptures and tissue damage). After a detailed examination and x-ray, the traumatologist determines whether the fragments have shifted. Based on the results obtained, the attending physician decides how to 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 people often try to endure closed fractures of the phalanges. You have a closed fracture if after the injury:

pain on palpation (touch);
finger swelling;
restriction of movements;
subcutaneous hemorrhage;
finger deformation.

Immediately go to a traumatologist and get treatment! WITH closed fractures fingers may be accompanied by dislocations of the phalanges, damage to tendons and ligaments, so you will not be able to cope without the help of a specialist.

Rules for providing first aid

If the phalanx is damaged, even if it is just a bruise, you should immediately apply a splint or a tight polymer bandage. Any dense plate (wooden or plastic) can be used as a tire. Pharmacies today sell latex splints that do a good job of fixing broken bones. You can use the adjacent healthy finger together with the splint. To do this, bandage them tightly together or glue them with a band-aid. This will immobilize the injured phalanx and allow you to calmly work with your hand. This will also help prevent bone fragments from dislodging.

Conservative treatment (wearing tight bandages and plaster) for fractures lasts about 3-4 weeks. During this time, the traumatologist conducts x-ray examinations twice (on 10 and 21 days). After removing the plaster, active development of the fingers and joints is carried out for six months.

The beauty of hands and feet is determined by the correct shape of the phalanges of the fingers. You need to take care of your hands and feet regularly.

Damage to the extensor tendons in the area of the distal and middle phalanges of the finger

Rice. 27.2.40. The most common types of rupture of the extensor tendons are at the level of the distal interphalangeal joint of the finger.

a - outside the joint capsule; b - within the joint capsule; c - separation from the place of attachment to the distal phalanx; d - avulsion with a fragment of the distal phalanx.

Conservative treatment is very effective for closed injuries. The main problem of treatment is to keep the finger joints in a position that ensures maximum approximation of the end of the tendon and the distal phalanx (Fig. 27.2.41, d). To do this, the finger must be bent at the proximal interphalangeal joint and fully extended (hyperextended) at the distal joint.

Rice. 27.2.41. Using the tire when conservative treatment closed ruptures of the extensor tendon in the area of the distal interphalangeal joint.

a, b - options for applying a splint; V - appearance finger with a simple splint; d - position of the finger at which the lateral bundles of tendon stretching are maximally relaxed (explanation in the text).

The task of the patient (and the surgeon) is greatly simplified with additional transarticular fixation of the distal interphalangeal joint with a wire for the entire period of immobilization. The technique for performing this technique is that after passing the pin through the joint, the distal phalanx is hyperextended, thereby achieving bending of the pin (Fig. 27.2.42). In this case, hyperextension in the joint should not be excessive, as this can lead to severe pain due to tissue tension.

Rice. 27.2.42. Stages of fixation of the distal phalanx of the finger in the hyperextension position using a transarticularly inserted wire.

a - drawing a perforation hole on the fingertip; b - biting the inserted needle; c - hyperextension of the phalanx on the knitting needle.

Surgical treatment. Surgical treatment for primary indications is advisable when a significant bone fragment is torn off along with the extensor tendon. In this case, either a transosseous CP suture is performed with fixation of the bone fragment, or (if the bone fragment is large enough) osteosynthesis with a wire is added to this.

Rice. 27.2.43. Transosseous fixation of the extensor tendon to the distal phalanx of the finger in chronic injury.

A skin-tendon suture can also be applied (Fig. 27.2.44). It is removed after 2 weeks. In all cases, finger immobilization is continued for up to 6-8 weeks.

Rice. 27.2.44. Use of skin-tendon sutures for open injuries of the extensor tendon in the area of the distal interphalangeal joint (a).

b - 8-shaped seam; c - continuous continuous seam.

1) access is carried out so as not to damage the growth zone of the nail;

2) the scar tissue between the ends of the tendon is excised;

3) the tendon suture is applied with the nail phalanx fully extended (overextended).

1) performing arthrodesis of the distal interphalangeal joint;

2) tendon plasty according to Iselin (Fig. 27.2.45).

Rice. 27.2.45. Scheme of tendoplasty for chronic damage to the extensor tendon in the area of the distal interphalangeal joint (according to Iselin)

Injuries to the extensor tendons at the level of the middle phalanx of the finger are only open and involve injury to one or both lateral legs of the extensor tendon stretch. If only one leg is damaged, the extension function of the distal phalanx may be preserved. The generally accepted treatment tactic is suturing the damaged elements of the tendon stretch, followed by immobilization of the finger for 6-8 weeks in the position of flexion in the proximal and extension in the distal interphalangeal joints.

Distal phalanx

Bones of the foot (ossa pcdis).

5-tuberosity of the fifth metatarsal bone;

8-lateral malleolar surface;

10-lateral process of the buffalo calcaneus;

11-tubercle of the calcaneus;

12th posterior process of the talus;

13-block of the talus;

14-support of the talus,

15-neck of the talus;

17-latsral sphenoid bone;

18-intermediate sphenoid bone;

19-medial sphenoid bone;

4-tuberosity of the first metatarsal bone;

5-lateral sphenoid bone;

6-intermediate sphenoid bone;

7-medial sphenoid bone;

8-tuberosity of the fifth metatarsal bone;

9-groove of the peroneus longus tendon;

12-head of the talus;

13-support of the talus;

15-tubercle of the calcaneus.

Atlas of human anatomy. Akademik.ru. 2011.

See what “Distal phalanx” is in other dictionaries:

Phalanx (anatomy) - This term has other meanings, see Phalanx. Bones of the human left hand, dorsal (dorsal) surface ... Wikipedia

Phalanx of the fingers - Phalanges of the fingers of the right hand of a person Phalanges of the fingers of the left foot of a person Phalanges (Greek φάλαγξ) short tubular bones that form the skeleton of the fingers of the limbs poses ... Wikipedia

The skeleton of the free part of the upper limb - (pars libera membri superioris) consists of the humerus (humerus), radius (radius) and ulna (ulna) bones of the forearm and bones of the hand (wrist bones, metacarpal bones and phalanges of the fingers). The humerus (Fig. 25) is a long tubular bone; her... ...Atlas of Human Anatomy

Foot - I Foot (pes) is the distal section of the lower limb, the boundary of which is a line drawn through the tops of the ankles. The basis of S. is its skeleton, consisting of 26 bones (Fig. 1 3). There are posterior, middle and anterior sections of the S., as well as... ... Medical encyclopedia

List of bones of the human skeleton - The adult human skeleton consists of 206 bones. The Latin names are given in brackets, the number in brackets indicates the number of identical bones... Wikipedia

Human Bones - The adult human skeleton consists of 206 bones. The Latin names are given in brackets; the number in brackets indicates the number of identical bones. Contents 1 Bones of the head 2 Bones of the body ... Wikipedia

Skeleton - I Skeleton (skeleton) is a system of bone and cartilaginous formations in the body of animals and humans that perform supporting, protective and a number of biological functions related to metabolism. Bone is capable of quickly releasing the compounds that make up its composition into the blood ... Medical encyclopedia

Leg - This term has other meanings, see Leg (meanings). The request for "Legs" is redirected here; see also other meanings. Leg (lower free limb, lat. mémbrum inférius liberum) a paired organ of support and movement of a person ... Wikipedia

Lower limb - Leg (lower free limb, lat. mémbrum inférius liberum) is a paired organ of support and movement of a person. The part of the lower limb located distal to the hip joint. Phylogenetically, the human leg comes from the hind limbs... Wikipedia

Human leg - This term has other meanings, see Leg (meanings). The request for "Legs" is redirected here; see also other meanings. This article may contain original research. Add... Wikipedia

Distal phalanges of fingers

Fractures of the distal phalanges are divided into extra-articular (longitudinal, transverse and comminuted) and intra-articular. Knowledge of the anatomy of the distal phalanx is important for the diagnosis and treatment of these types of injuries. As shown in the figure, fibrous bridges are stretched between the bone and skin to help stabilize the distal phalanx fracture.

A traumatic hematoma can form in the space between these bridges, causing severe pain due to increased pressure inside this enclosed space.

Two tendons are attached to the distal phalanges of the II-V fingers. As shown in the figure, the deep flexor tendon is attached to the palmar surface, and the terminal portion of the extensor tendon is attached to the dorsal surface. If too much force is applied, these tendons can tear off. Clinically, there is a loss of function, and radiologically, minor avulsion fractures at the base of the phalanx can be detected. These fractures are considered intra-articular.

The mechanism of injury in all cases is a direct blow to the distal phalanx. The force of the impact determines the severity of the fracture. The most typical fracture is a comminuted fracture.

Examination usually reveals tenderness and swelling of the distal phalanx of the finger. Subungual hematomas are often observed, indicating a rupture of the nail bed.

In diagnosing a fracture and possible displacement, images in both direct and lateral projections are equally informative.

As mentioned earlier, subungual hematomas and lacerations of the nail bed are common. Often, in combination with a transverse fracture of the distal phalanx, incomplete separation of the nail is observed.

Hairpin type splint used for distal phalanx fractures

Treatment of extra-articular fractures of the distal phalanges of the fingers

Class A: Type I (longitudinal), Type II (transverse), Type III (comminuted). These fractures are treated with a protective splint, elevating the limb to reduce swelling, and analgesics. A simple palmar splint or a hairpin splint is recommended. Both allow for some degree of tissue expansion due to edema.

Subungual hematomas should be drained by reaming the nail plate using a hot paper clip. These fractures require protective splinting for 3-4 weeks. Comminuted fractures may remain painful for several months.

Draining a subungual hematoma with a paper clip

Class A: Type IV (with displacement). Transverse fractures with angular deformation or width displacement may be difficult to reduce because soft tissue interposition between the fragments is likely. If left uncorrected, this fracture may be complicated by nonunion.

Reduction is often performed by dorsal traction on the distal fragment, followed by immobilization with a volar splint and control radiography to confirm correct reduction. If this fails, the patient is referred to an orthopedist for surgical treatment.

Class A (open fractures with nail bed rupture). Fractures of the distal phalanges in combination with tears of the nail plate should be considered as open fractures and treated in the operating room. The treatment for these fractures is described below.

1. For anesthesia, a regional block of the wrist or intermetacarpal spaces should be used. Then the brush is processed and covered with sterile material.

2. The nail plate is bluntly separated from the bed (using a spoon or probe) and the matrix.

3. Once the nail plate is removed, the nail bed can be raised and repositioned. The nail bed is then closed with a No. 5-0 Dexon ligature using a minimal number of sutures.

4. Xeroform gauze is placed under the roof of the matrix, separating it from the root. This prevents the development of synechiae, which can lead to deformation of the nail plate.

5. The entire finger is bandaged and splinted for protection. The outer bandage is changed as needed, but the adaptation layer separating the root from the matrix roof must remain in place for 10 days.

6. To confirm the correctness of the reposition, control radiographs are shown. If the bone fragments remain unmatched, osteosynthesis can be performed with a wire.

A. Treatment technique for an open fracture of the distal phalanx.

B. The nail is removed and the nail bed is sutured with an absorbable suture.

B. Simple suturing of the nail bed results in good alignment of the bony fragments of the phalanx.

D. The nail bed is covered with a small strip of xeroform-soaked gauze, which is placed over the nail bed and under the eponychium fold.

Complications of extra-articular fractures of the distal phalanges of the fingers

Fractures of the distal phalanges can be associated with several serious complications.

1. Open fractures are often complicated by osteomyelitis. Open fractures include fractures associated with a nail bed rupture and fractures with a drained subungual hematoma.

2. Nonunion usually results from interposition of the nail bed between the fragments.

3. With comminuted fractures, as a rule, delayed healing is observed.

Bones of the fingers (phalanx).

The bones of the fingers (phalanges), ossa digitorum (phalanges), are represented by phalanges, phalanges, related in shape to long bones. The first, thumb, finger has two phalanges: the proximal one, phalanx proximalis. and distal, phalanx distalis. The remaining fingers also have a middle phalanx, phalanx media. Each phalanx has a body and two epiphyses - proximal and distal.

The body, corpus, of each phalanx is flattened on the anterior (palm) side. The surface of the body of the phalanx is limited on the sides by small scallops. There is a nutrient opening on it, which continues into the distally directed nutrient canal.

The upper, proximal end of the phalanx, or base, basin phalangis, is thickened and has articular surfaces. The proximal phalanges articulate with the bones of the metacarpus, and the middle and distal phalanges are connected to each other.

The lower, distal end of the 1st and 2nd phalanges has the head of the phalanx, caput phalangis.

At the lower end of the distal phalanx, on the back side, there is a slight roughness - the tuberosity of the distal phalanx, tuberositas phalangis distalis.

In the area of the metacarpophalangeal joints of the 1st, 2nd and 5th fingers and the interphalangeal joint of the 1st finger on the palmar surface, in the thickness of the muscle tendons, there are sesamoid bones, ossa sesamoidea.

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Panteleeva A.S.: Diseases and injuries of the hand (Monograph 2008)

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 often damaged than other parts of the body.

The structure of injuries is dominated by industrial (63.2%), household (35%) and street (1.8%) types of injuries. Industrial injuries are usually open and account for 78% of all open injuries of the upper extremities. Damage to the right hand and fingers is 49%, and to the left – 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 disruption of their function, temporary loss of ability to work, and often to disability of the victim. The consequences of injuries to the hand and fingers account for more than 30% of the disability structure due to damage to the musculoskeletal system. The loss of one or more fingers leads to professional and psychological difficulties. The 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 treatment of patients with injuries and diseases of the hand.

The main condition for performing fine intervention on the hand is adequate pain relief. Local infiltration anesthesia can only be used for superficial defects; its use is limited on the palmar surface of the hand due to low skin mobility.

In most cases, during hand surgeries, conduction anesthesia is performed. Blocking the main nerve trunks of the hand can be carried out at the level of the wrist, elbow joint, axillary and cervical region. For finger surgery, anesthesia according to Oberst-Lukashevich or a block at the level of the intermetacarpal spaces is sufficient (see Fig. 1)

Fig. 1 Points of injection of anesthetic during conduction anesthesia of the 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, necrosis of the finger, may occur. For severe hand injuries, anesthesia should be used.

Bleeding of the surgical field.

Among blood-soaked tissues, it is impossible to differentiate the vessels, nerves and tendons of the hand, and the use of tampons to remove blood from the surgical field causes harm to the gliding apparatus. Therefore, bleeding is mandatory not only for major interventions on the hand, but also when treating minor injuries. To bleed the hand, an elastic rubber bandage or a pneumatic cuff is applied to the upper third of the forearm or the lower third of the shoulder, in which pressure is injected at dom.Hg, which is more preferable, as it reduces the risk of nerve paralysis. Before using them, it is advisable to apply an elastic rubber bandage to a previously raised arm, which helps to force out a significant part of the blood from the arm. To operate on a finger, it is enough to apply a rubber tourniquet at its base. If the surgical intervention lasts more than 1 hour, then it is necessary to release the air from the cuff for a few minutes with the limb elevated, and then fill it again.

The epidermis on the hand forms a complex network of lines, the direction of which is determined by various movements of the fingers. On the palmar surface of the skin of the hand there are many furrows, wrinkles and folds, the number of which is not constant. Some of them, having a specific function and being landmarks of deeper 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 carpal grooves, 5-interdigital folds, 6-interphalangeal folds

From the base of the main grooves, connective tissue bundles extend vertically 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, moving away - extension. Wrinkles and folds are reservoirs of movement and contribute to an increase in skin surface.

A rational skin incision should be subject to minimal stretching during movement. Due to 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, dermatogenous contracture. Incisions perpendicular to the grooves undergo the greatest change with movement, while incisions parallel to the grooves heal with minimal scarring. There are areas of the hand skin that are neutral in terms of stretching. Such an area is the midlateral line (Fig. 3), along which stretching in opposite directions is neutralized.

Fig. 3 Medial lateral line of the finger.

Thus, the optimal incisions on the hand are those parallel to the primary skin formations. If it is impossible to provide such access to damaged structures, it is necessary to select the most correct permissible type of incision (Fig. 4):

1. the incision parallel to the furrows is complemented by a straight or arcuate one of the wrong direction,

2. the incision is made along the neutral line,

3. an incision perpendicular to the grooves is complemented by a Z-shaped plastic,

4. The incision crossing the primary skin formations should be arcuate or Z-shaped to redistribute tensile forces.

For optimal primary surgical treatment of hand injuries, it is necessary to widen the wounds through additional and lengthening incisions in the correct direction. (Fig. 5)

Fig. 5 Additional and lengthening incisions on the hand.

Atraumatic surgical technique.

Hand surgery is surgery of sliding surfaces. The surgeon must be aware of two dangers: infection and trauma, 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, use only sharp instruments and thin suture material, constant tissue hydration. Traumatization of tissues with tweezers and clamps should be avoided, since micronecrosis forms at the site of compression, leading to scarring, as well as leaving tissue in the wound. foreign bodies in the form of long ends of ligatures, large knots. It is important to avoid the use of dry swabs to stop bleeding and tissue preparation, and also to avoid unnecessary wound drainage. The skin edges should be joined with minimal tension and without interfering with the blood supply to the flap. The so-called “time factor” plays a huge role in the development of infectious complications, since too long operations lead to “fatigue” of tissues and a decrease in their resistance to infection.

After atraumatic intervention, the tissues retain their characteristic luster and structure, and during the healing process only a minimal tissue reaction occurs

Immobilization of the hand and fingers.

The human hand is in constant motion. A stationary state is unnatural for the hand and leads to serious consequences. The idle hand assumes a resting position: slight extension at the wrist joint and flexion at the finger joints, abduction of the thumb. The hand takes a resting position lying on a horizontal surface and hanging (Fig. 6)

Fig.6 Hand in rest position

In the functional position (position of action), extension in the wrist joint is 20, ulnar 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 a state of opposition, and the great The finger forms an incomplete letter “O” with the index and middle fingers, and the forearm occupies a position midway 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 at the wrist joint causes extension of the fingers, and extension causes flexion (Fig. 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 straight position is an irreparable mistake and leads to stiffness in the finger joints in a short time. This fact is explained by the special structure of the collateral ligaments. They extend distally and palmarly from the rotation points. Thus, in a straightened position of the finger, the ligaments relax, and in a bent position they become tense (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.

Connective tissue septa, stretching from the bone to the skin, form a cellular structure and participate in stabilizing the fracture and minimizing the displacement of fragments. (Fig. 9)

Fig. 9 Anatomical structure of the nail phalanx: 1-attachment of collateral ligaments, 2-connective tissue septa, 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 of the finger, attached to the base of the distal phalanx, do not play a role in the displacement of the fragments.

There are three main types of fractures (according to Kaplan L.): longitudinal, transverse and comminuted (eggshell type) (Fig. 10).

Rice. 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.

Non-displaced and comminuted fractures are treated conservatively. For immobilization, palmar or dorsal splints are used for a period of 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 either conservatively or operative method– 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 phalangeal fragments is primarily determined by muscle traction. With unstable fractures of the main phalanx, the fragments are displaced at an angle towards 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 point for the tendons and its hyperextension occurs due to the traction of the central portion of the extensor tendon of the finger, which is attached to the base of the middle phalanx (Fig. 13).

Fig. 13 The mechanism of displacement of fragments in fractures of the main phalanx

In case of fractures of the middle phalanx, it is necessary to take into account two main structures that influence the displacement of fragments: the middle portion of the extensor tendon, attached to the base of the phalanx from the rear, and the superficial flexor tendon, 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 should be paid to fractures with rotational displacement, which must be eliminated especially carefully. In a bent position, the fingers are not parallel to each other. The longitudinal axes of the fingers are directed towards the scaphoid bone (Fig. 15)

When the phalanges are fractured with displacement, the fingers intersect, which makes functioning difficult. In patients with phalangeal fractures, flexion of the fingers is often impossible due to pain, so rotational displacement can be determined by the location of the nail plates in a semi-flexed position of the fingers (Fig. 16)

Fig.16 direction determination longitudinal axis fingers with phalangeal fractures

It is extremely important that the fracture heals without permanent deformation. The sheaths of the flexor tendons pass in the palmar groove of the phalanges of the fingers and any irregularity prevents the tendons from sliding.

Non-displaced or impacted fractures can be treated using so-called dynamic splinting. The damaged finger is fixed to the neighboring 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 use of a plaster splint for fractures of the phalanges of the fingers

If after reposition the fracture is not stable, the fragments cannot be held using a splint, then percutaneous fixation with thin Kirschner wires is necessary (Fig. 18)

Fig. 18 Osteosynthesis of the phalanges of the fingers using Kirschner wires

If closed reduction is impossible, open reduction is indicated, followed by osteosynthesis of the phalanx with knitting needles, screws, and plates. (Fig. 19)

Fig. 19 Stages of osteosynthesis of the phalanges of the fingers with screws and a plate

For intra-articular fractures, as well as comminuted fractures, the best treatment result is provided by the use of external fixation devices.

The metacarpal bones are not located in the same plane, but form the arch of the hand. The arch of the wrist meets the arch of the hand, forming a semicircle, which is completed to a full circle by the first finger. This way the fingertips touch at one point. If the arch of the hand flattens due to damage to bones or muscles, a traumatic flat hand is formed.

Depending on the anatomical location of the damage, there are: fractures of the head, neck, diaphysis and base of the metacarpal bone.

Fractures of the metacarpal head 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. The fracture of the neck of the fifth metacarpal bone, as the most common, is called the “boxer’s fracture” or “fighter’s fracture.” Such fractures are characterized by displacement at an angle open to the palm and are unstable due to destruction of the palmar cortical layer (Fig. 20)

Fig. 20 Fracture of the metacarpal neck with destruction of the palmar cortical plate

With conservative treatment by immobilization with a plaster splint, it is usually not possible to eliminate the displacement. The bone deformation does not have a significant effect on the function of the hand; only a small cosmetic defect remains. To effectively eliminate displacement of fragments, closed reduction and osteosynthesis with two intersecting 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 wires 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 direct force, transverse fractures usually occur, and with indirect force, oblique fractures occur. Displacement of fragments leads to the following deformations: formation of an angle open to the palm (Fig. 21)

Fig. 21 The mechanism of displacement of fragments during 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 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 splint does not always eliminate displacement of fragments. For transverse fractures, transfixation with pins to the adjacent metacarpal bone or intramedullary seosynthesis with a pin is most effective (Fig. 22)

Fig. 22 Types of osteosynthesis of the metacarpal bone: 1- with knitting needles, 2- with plate and screws

For oblique fractures, osteosynthesis is performed using AO miniplates. These methods of osteosynthesis do not require additional immobilization. Active movements of the fingers are possible from the first days after surgery after swelling subsides and pain decreases.

Fractures of the base of the metacarpal bones are stable and do not pose difficulties for treatment. Immobilization with a dorsal splint reaching the level of the heads of the metacarpal bones for three weeks is quite sufficient for healing of the fracture.

Fractures of the first metacarpal bone.

The unique function of the first finger explains its special position. Most fractures of the first metacarpal 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)

Rice. 23 Classification of fractures of the base of the first metacarpal bone: 1- Bennett’s fracture, 2- Rolando’s fracture, 3,4 – extra-articular fractures 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 a saddle joint formed by the base of the first metacarpal bone and the trapezium bone. Four main ligaments are involved in stabilizing the joint: anterior oblique, posterior oblique, intermetacarpal and dorsal radial. (Fig. 24)

Fig. 24 Anatomy of the first metacarpophalangeal joint

The volar portion of the base of the first metacarpal is somewhat elongated and is the site of attachment of the anterior oblique ligament, which is key to the stability of the joint.

For the best visualization of the joint, radiography is required in the so-called “true” anterior-posterior projection (Robert projection), when the hand is in the position of maximum pronation (Fig. 25)

Fig.25 Robert's projection

Bennett's fracture-dislocation results from direct trauma to the subflexed metacarpal. At the same time it happens

dislocation, and a small triangular-shaped volar bone fragment remains in place due to the force of the anterior oblique ligament. The metacarpal bone is displaced to the radial side and to the rear due to the traction of the abductor longus 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 bone or trapezium bone (Fig. 27)

Fig. 27 Osteosynthesis using Kirschner wires.

For reposition, 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 reposition. In this position, the needles are inserted. After the operation, immobilization is performed in a plaster splint for a period of 4 weeks, after which the splint and wires are removed and rehabilitation begins. If closed reduction is not possible, they resort to open reduction, after which osteosynthesis is possible using both Kirschn wires and thin 2 mm AO screws.

Rolando's fracture is a T- or Y-shaped intra-articular fracture and can be classified as a comminuted fracture. The prognosis for restoration of function with this type of injury is usually unfavorable. In the presence of large fragments, open reduction and osteosynthesis with screws or wires are indicated. To preserve the length of the metacarpal bone, external fixation devices or transfixation to the second metacarpal bone are used in combination with internal fixation. In case of compression of the base of the metacarpal bone, primary bone grafting is necessary. If it is impossible to surgically restore 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 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 splint in a hyperextension position in the metacarpophalangeal joint for 4 weeks. Oblique fractures with a long fracture line may be unstable and require percutaneous osteosynthesis with wires. Opening reduction for these fractures is used extremely rarely.

Scaphoid fractures

Scaphoid fractures account for up to 70% of all wrist fractures. They occur when falling on an outstretched hand due to hyperextension. According to Russe, horizontal, transverse and oblique fractures of the scaphoid are distinguished. (fig28)

Recognizing these fractures can be quite difficult. Local pain when pressing on the area of the anatomical snuffbox, pain when dorsiflexing the hand, as well as radiography in a direct projection with some supination and ulnar abduction of the hand are important.

Indicated for fractures without displacement of fragments. Plaster immobilization in a bandage covering the thumb for 3-6 months. The 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

Open reduction and screw fixation.

The scaphoid bone is exposed through access along the palmar surface. Then a guide pin is passed through it through which a 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 bone with a screw

Nonunion of the scaphoid bone.

For nonunions of the scaphoid bone, bone grafting according to Matti-Russe is used. Using this technique, a groove is formed in the fragments into which cancellous bone taken from the iliac crest or from the distal radius is placed (D.P. Green) (Fig. 31). Plaster immobilization 4-6 months.

Fig. 31 Bone grafting for nonunion of the scaphoid.

Screw fixation with or without bone grafting can also be used.

Damage to small joints of the hand.

Damage to the distal interphalangeal joint.

Dislocations of the nail phalanx are quite rare and usually occur on the dorsal side. More often, dislocations of the nail phalanx are accompanied by avulsion fractures of the attachment sites of the tendons of the deep flexor or extensor of the finger. In fresh cases, open reduction is performed. After reduction, lateral stability and the nail phalanx hyperextension test are checked. If there is no stability, transarticular fixation of the nail phalanx is performed with a pin for a period of 3 weeks, after which the pin is removed. Otherwise, immobilization of the distal interphalangeal joint in a plaster splint or a special splint for a day is indicated. In cases where more than three weeks have passed since the injury, it is necessary to resort to open reduction, followed by transarticular fixation with a wire.

Injuries to the proximal interphalangeal joint.

The proximal interphalangeal joint occupies a special place among the small joints of the hand. Even if there is no movement in the other joints of the finger, with preserved movements in the proximal interphalangeal joint, hand function remains satisfactory. When treating patients, it is necessary to take into account that the proximal interphalangeal joint is prone to stiffness not only with injuries, but also with prolonged immobilization of even a healthy joint.

The proximal interphalangeal joints are block-shaped in shape and are strengthened by collateral ligaments and the palmar ligament.

Damage to collateral ligaments.

Injury to the collateral ligaments occurs as a result of the application of lateral force to a straightened toe, most commonly seen during sports. The radial radial ligament is injured more often than the ulnar ligament. Collateral ligament injuries diagnosed 6 weeks after injury should be considered old. It is important to check lateral stability and perform stress radiography to make a diagnosis. When assessing the results of these tests, it is necessary to focus on the amount of lateral movement of healthy fingers. To treat this type of injury, the method of elastic splinting is used: the injured finger is fixed to the adjacent one for a period of 3 weeks with partial rupture ligaments and for 4-6 weeks if complete, then for another 3 weeks it is recommended to spare the finger (for example, excluding sports activities). (Fig. 32)

Fig. 32 Elastic splinting for injuries of collateral ligaments

During the period of immobilization, active movements in the joints of the injured finger are not only not contraindicated, but are absolutely necessary. In the treatment of this group of patients, it is necessary to take into account the following facts: full range of motion is restored in the vast majority of cases, while pain persists for many months, and the increase in joint volume in some patients lasts a lifetime.

Dislocations of the middle phalanx.

There are three main types of dislocations of the middle phalanx: dorsal, palmar and rotational (rotatory). For diagnosis, it is important to take x-rays of each damaged finger separately in direct and strictly lateral projections, since oblique projections are less informative (Figure 33)

Fig. 33 X-ray for 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. Elastic splinting for 3-6 weeks is sufficient for treatment.

With a 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 finger deformity

To prevent this complication, a dorsal splint is used that 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-type deformation

Rotational subluxation is easily confused with palmar subluxation. On a strictly lateral radiograph of the finger, you can see the lateral projection of only one of the phalanges and the 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 a loop formed by the central and lateral portions of the extensor tendon, which is intact (Fig. 37).

Fig. 37 rotational dislocation mechanism

Reduction is carried out according to the Eaton method: after anesthesia, the finger is flexed at the metacarpophalangeal and proximal interphalangeal joint, and then carefully rotated the main phalanx (Fig. 38)

Fig. 38 Reduction of rotatory dislocation according to Eaton

In most cases, closed reduction is not effective and it is necessary to resort to open reduction. After reduction, elastic splinting and early active movements are performed.

Fractures and dislocations of the middle phalanx.

As a rule, a fracture of the palmar fragment of the articular surface occurs. This joint-destructive injury can be successfully treated if diagnosed early. The simplest, non-invasive and effective method of treatment is the use of a dorsal extension locking splint (Fig. 39), applied after reduction of the dislocation and allowing active flexion of the finger. Full reduction requires flexion of the finger at the proximal interphalangeal joint. Reduction is assessed using a lateral radiograph: the adequacy of reduction is assessed by the congruence of the intact dorsal part 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 extension blocking splint.

Fig.40 V-sign for assessing the congruence of the articular surface.

The splint is applied for 4 weeks, and its extension is performed weekly.

Damage to the metacarpophalangeal joints.

Metacarpophalangeal joints are condylar joints that allow, along with flexion and extension, adduction, abduction and circular movements. The stability of the joint is provided by the collateral ligaments and the palmar plate, which together form a box shape (Fig. 41)

Fig. 41 Ligamentous apparatus of the metacarpophalangeal joints

Collateral ligaments consist of two bundles - proper and accessory. The collateral ligaments are more tense during flexion than during extension. The palmar plates of fingers 2-5 are connected to each other by a deep transverse metacarpal ligament

There are two types of finger dislocation: simple and complex (irreducible). For the differential diagnosis of dislocations, it is necessary to remember the following signs of a complex dislocation: on the radiograph, the axis of the main phalanx and metacarpal bone are parallel, the sesamoid bones may be located in the joint, and there is a depression of the skin on the palmar surface of the hand at the base of the finger. A simple dislocation can be easily corrected by applying gentle pressure to the main phalanx without requiring traction. Elimination of a complex dislocation is possible only surgically.

Damage to the nail bed.

The nail gives the distal phalanx hardness when gripping, 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. Injuries to the nail bed are among the most common injuries of the hand and accompany open fractures of the distal phalanx and injuries to the soft tissues of the fingers.

The nail bed is the layer of dermis that lies beneath the nail plate.

Rice. 42 Anatomical structure of the nail bed

There are three main zones of tissue located around the nail plate. The nail fold (roof of the matrix), covered with an epithelial lining - eponychium, prevents uncontrolled growth of the nail upwards and to the sides, directing it distally. In the proximal third of the nail bed there is the so-called germinal matrix, which ensures nail growth. The growing part of the nail is delimited by a white crescent - a hole. If this area is damaged, the growth and shape of the nail plate are significantly disrupted. Distal to the socket is a sterile matrix that fits tightly to the periosteum of the distal phalanx, allowing the advancement of the nail plate as it grows and thus playing 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, distal advancement of the nail stops for 3 weeks, and then nail growth continues at the same rate. As a result of the delay, a thickening forms proximal to the injury site, persisting for 2 months and gradually becoming thinner. It takes about 4 months before a normal nail plate forms after an injury.

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 of a pulsating nature. The treatment method is to perforate the nail plate at the site of the hematoma with a sharp instrument or the end of a paper clip heated over a fire. This manipulation is painless and instantly relieves tension 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, secured with a suture. (Fig. 43)

Fig. 43 Refixation of the nail plate

The nail plate is a natural splint for the distal phalanx, a conductor for the growth of new nails and ensures healing of the nail bed with the formation of a smooth surface. If the nail plate is lost, it can be replaced with an artificial nail made from 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 tissue, precise comparison of fragments of the nail bed and suture with thin (7\0, 8\0) suture material. The removed nail plate is refixed after treatment. In the postoperative period, immobilization of the phalanx is required for 3-4 weeks to prevent its injury.

The choice of tendon reconstruction method is made taking into account the time that has passed since the injury, the prevalence of scar changes along the tendons, and the condition of the skin at the operation site. A tendon suture is indicated when it is possible to connect the damaged tendon end to end and the soft tissue in the area of surgery is in normal condition. There is a primary tendon suture, performed within a day after the injury in the absence of signs of infection in the wound area and its incised nature, and a delayed suture, which is applied from 12 days to 6 weeks after the injury under less favorable conditions (lacerations and contusions). 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 immersed (Fig. 44).

Fig. 44 Types of tendon sutures (a - Bunnell, b - Verdun, c - Cuneo) d - application of an intra-trunk suture, e, f - application of adapting sutures. Stages of suturing in the critical zone.

Removable sutures, proposed in 1944 by Bunnell S., are used to fix the tendon to the bone and in areas where early movements are not so necessary. The suture is removed after the tendon has fused sufficiently firmly with the tissue at the point of fixation. Immersion seams remain in the tissues, bearing a mechanical load. In some cases, additional sutures are used to ensure 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 tendon autograft is tendons, the removal of which does not cause significant functional and cosmetic disturbances, for example, the tendon of the palmaris longus muscle, the superficial flexor of the fingers, the long extensor of the toes, and the plantaris muscle.

Damage to the finger flexor tendons.

Flexion of 2-5 fingers is carried out due to two long tendons - superficial, attached to the base of the middle phalanx and deep, attached to the base of the distal phalanx. Flexion of the 1st finger is carried out by the tendon of the long flexor of the 1st finger. The flexor tendons are located in narrow, complex-shaped osteo-fibrous canals that change their shape depending on the position of the finger (Fig. 45)

Fig. 45 Change in the shape of the osteo-fibrous canals of the 2-5 fingers of the hand when they are bent

In places of greatest friction between the palmar wall of the canals and the surface of the tendons, the latter are surrounded by a synovial membrane that forms the sheath. The deep digital flexor tendons are connected through the lumbrical muscles to the extensor tendon apparatus.

If the deep digital flexor tendon is damaged and the middle phalanx is fixed, flexion of the nail is impossible; with combined damage to both tendons, flexion of the middle phalanx is also impossible.

Rice. 46 Diagnosis of flexor tendon injuries (1, 3 – deep, 2, 4 – both)

Flexion of the main phalanx is possible due to contraction of the interosseous and lumbrical muscles.

There are five zones of the hand, within which anatomical features influence the technique and results of the primary tendon suture.

In zone 1, only the deep flexor tendon passes through the osteofibrous canal, so its damage is always isolated. The tendon has a small range of motion, the central end is often retained by the mesotenon and can be easily removed without significant expansion of the damaged area. All these factors determine good results from applying a primary tendon suture. The most commonly used transosseous tendon suture is removed. It is possible to use immersed seams.

Throughout zone 2, the tendons of the superficial and deep flexor fingers intersect; the tendons are tightly adjacent to each other and have a large range of motion. The results of tendon suture are often unsatisfactory due to scar adhesions between the sliding surfaces. This zone is called critical or “no man’s land”.

Due to the narrowness of the osteofibrous canals, it is not always possible to suture both tendons; in some cases, it is necessary to excise the superficial flexor tendon of the finger and apply a suture only to the deep flexor tendon. In most cases, this avoids finger contractures and does not significantly affect flexion function.

In zone 3, the flexor tendons of adjacent fingers are separated by neurovascular bundles and lumbrical muscles. Therefore, tendon injuries in this area are often accompanied by damage to these structures. After suture of the tendon, suture of the digital nerves is necessary.

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 combined with damage to the median nerve. The operation involves dissecting the transverse carpal ligament, suturing the deep digital flexor tendons, and excising the superficial flexor tendons.

Throughout zone 5, the synovial sheaths end, the tendons of adjacent fingers pass close to each other and, when the hand is clenched into a fist, they move together. Therefore, cicatricial fusion of the tendons with each other has virtually no effect on the amount of finger flexion. The results of tendon suture in this area are usually good.

The finger is immobilized using a dorsal plaster splint for a period of 3 weeks. From the second week, after the swelling subsides and the pain in the wound decreases, passive flexion of the finger is performed. After removing the plaster splint, active movements begin.

Damage to the extensor tendons of the fingers.

The formation of the extensor apparatus involves the tendon of the common extensor finger and the tendon of the interosseous and lumbrical muscles, connected by many lateral ligaments, forming a tendon-aponeurotic stretch (Fig. 48, 49)

Fig. 48 Structure of the extensor apparatus of the hand: 1 - Triangular ligament, 2 - attachment point of the extensor tendon, 3 - lateral connection of the collateral ligament, 4 - disc above the middle joint, 5 - spiral fibers, 5 - middle bundle of the long extensor tendon, 7 - lateral bundle of the long extensor tendon, 8 - attachment of the long extensor tendon on the main phalanx, 9 - disc above the main joint, 10 and 12 - long extensor tendon, 11 - lumbrical muscles, 13 - interosseous muscles.

Rice. 49 Extensors of the fingers and hand.

It must be remembered that the index finger and little finger, in addition to the common one, also have an extensor tendon. The middle bundles of the extensor tendon of the fingers are attached to the base of the middle phalanx, extending it, and the lateral bundles are connected to the tendons of the small muscles of the hand, 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 finger. When the main phalanx is bent, they act as flexors, and when extended, together with the extensor fingers, they become extensors of the distal and middle phalanges.

Thus, we can speak of perfect extension-flexion function of the finger only if all anatomical structures are intact. The presence of such a complex interconnection of elements to some extent favors the spontaneous healing of partial damage to the extensor apparatus. In addition, the presence of lateral ligaments of the extensor surface of the finger prevents the tendon from contracting when damaged.

The characteristic position that the finger takes depending on the level of damage allows you to quickly make a diagnosis (Fig. 50).

Fig. 50 Diagnosis of damage to the extensor tendons

extensors at the level of the distal phalanx, the finger assumes a flexion position at the distal interphalangeal joint. This deformity is called a “mallet finger.” In most cases of fresh injuries, conservative treatment is effective. To do this, the finger must be fixed in a hyperextended position at the distal interphalangeal joint using a special splint. The amount of hyperextension depends on the patient’s level of joint mobility 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 condition of the elements of the splint, as well as the patient’s understanding of the task facing him, therefore, in some cases, transarticular fixation of the nail phalanx with a knitting needle is possible for the same period. Surgical treatment is indicated when the tendon is torn from its attachment site with a significant bone fragment. In this case, a transosseous suture of the extensor tendon is performed 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 bundles of the tendon diverge in the palmar direction. Thus, they do not straighten, but bend the middle phalanx. In this case, the head of the main phalanx moves forward through a gap in the extensor apparatus, like a button passing into a loop. The finger assumes a position bent at the proximal interphalangeal joint and hyperextended at the distal interphalangeal joint. This deformation is called a “boutonniere”. With this type of injury, surgical treatment is necessary - suturing the damaged elements, followed by immobilization for 6-8 weeks.

Treatment of injuries at the level of the main phalanx, metacarpophalangeal joints, metacarpus and wrist is only surgical - 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 with subsequent development of movements.

The hand is innervated 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 nerve, innervating the muscles of the eminence of the little finger, interosseous, 3 and 4 lumbrical muscles and the adductor pollicis muscle. Of important clinical significance is the motor branch of the median nerve, which arises from its lateral cutaneous branch immediately after exiting the carpal tunnel. This branch innervates the short flexor of the 1st finger, as well as the short abductor and opponor muscles of the Many. the muscles of the hand have double innervation, which preserves to one degree or another the function of these muscles if one of the nerve trunks is damaged. The superficial branch of the radial nerve is the least significant, providing sensation to the dorsum of the hand. If both digital nerves are damaged due to loss of sensitivity, the patient cannot use the fingers and their atrophy occurs.

The diagnosis of nerve damage should be made before surgery, since this is not possible after anesthesia.

Suturing the nerves of the hand requires the use of microsurgical techniques and adequate suture material (6\0-8\0 thread). In case of fresh injuries, soft and bone tissues are first processed, after which the nerve suture is started (Fig. 51)

Fig. 51 Epineural suture of the nerve

The limb is fixed in a position that provides the least tension on the suture line for 3-4 weeks.

Defects of soft tissues of the hand.

Normal hand function is possible only if the skin is intact. Each scar creates an obstacle to its implementation. The skin in the scar area has 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 placing a primary suture on the skin. If, due to a skin defect, it is impossible to apply a primary suture, then plastic replacement is necessary.

In case of superficial defects, the bottom of the wound is represented by well-supplied tissues - subcutaneous fatty tissue, muscle or fascia. In these cases, transplantation of non-vascularized skin grafts gives good results. Depending on the size and location of the defect, split or full-thickness flaps are used. Necessary conditions for successful graft engraftment 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 applying a pressure bandage (Fig. 52)

Fig52 Stages of applying a pressure bandage

The bandage is removed on the 10th day.

Unlike superficial defects, with deep wounds the bottom of the wound is tissue with a relatively low level of blood supply - tendons, bones, joint capsule. For this reason, the use of non-vascularized flaps is ineffective in these cases.

The most common damage is tissue defects of the nail phalanx. There are many methods for covering them with blood-supplied flaps. When detaching the distal half of the nail phalanx, plastic surgery with triangular sliding flaps, which are formed on the palmar or lateral surfaces of the finger, is effective (Fig. 53)

Fig. 53 Plastic surgery with a triangular sliding flap for a skin defect of the nail phalanx

Fig. 54 Plastic surgery using a palmar digital sliding flap

Triangular areas of skin are connected to the finger by a stalk consisting of fatty tissue. If the soft tissue defect is more extensive, then a palmar digital sliding flap is used (Fig. 54)

For defects in the flesh 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-fat flap from the palmar surface of the hand.

The most severe type of hand tissue defect occurs when the skin is removed from the fingers like a glove. In this case, the skeleton and tendon apparatus can be completely preserved. For the damaged finger, a tubular flap on a pedicel is formed (Filatov’s sharp stem); when skeletonizing the entire hand, plastic surgery is performed using skin-fat flaps from the anterior abdominal wall (Fig. 56).

Fig. 56 Plastic surgery of a scalped wound of the middle phalanx using Filatov’s “sharp” stem

Tendon canal stenosis.

The pathogenesis of degenerative-inflammatory diseases of the tendon canals has not been fully studied. Women are more likely to get sick. The predisposing factor is static and dynamic overload of the hand.

De Quervain's disease

1 osteofibrous canal and the tendons of the long abductor pollicis muscle and its short extensor muscle passing through it are affected.

The disease is characterized by pain in the area of the styloid process, the presence of a painful lump on it, a positive Finkelstein symptom: acute pain in the area of the styloid process of the radius, occurring when the hand is abducted ulnarly, 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 identify local osteoporosis of the apex of the styloid process and hardening of the soft tissues above it.

Conservative therapy involves local administration of steroid drugs and immobilization.

Surgical treatment is aimed at decompressing 1 canal by dissecting its roof.

After anesthesia, a skin incision is made over the painful lump. Just under the skin is the dorsal branch of the radial nerve; it must be carefully retracted to the rear. By making passive movements with the thumb, 1 canal and the site of stenosis are examined. Next, the dorsal ligament and its partial excision are carefully dissected using the probe. After this, the tendons are exposed and inspected, making sure that nothing interferes with their sliding. The operation ends with careful hemostasis and suturing of the wound.

Stenosing ligamentitis of the annular ligaments.

The annular ligaments of the tendon sheaths of the flexor fingers are formed by thickening of the fibrous sheath 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 primarily affected - 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 leads to “snapping” of the finger.

Diagnosis is not difficult. Patients themselves show a “snapping finger”; a painful lump is palpated at the level of pinching.

Surgical treatment gives a quick and good effect.

The incision is made according to the rules described in the “access to the hand” section. The thickened annular ligament is exposed. The latter is dissected along a grooved probe, and its thickened part is excised. The freedom of tendon gliding is assessed by flexion and extension of the finger. In case of old processes, additional opening of the tendon sheath may be required.

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) suffer.

Diagnosis usually does not cause difficulties. The disease usually develops over several years. Strands 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 of 4 fingers of the right hand.

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 oxygen content, which leads to the activation of fibroplastic processes.

Often combined with Ledderhose disease (scarring of the plantar aponeurosis) and fibroplastic induration of the penis (Peyronie's disease).

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, and the tendon of the palmaris longus muscle is woven into it. The base of the triangle breaks up into bundles going to each finger, which intersect with the transverse bundles. The palmar aponeurosis is closely connected with the skeleton of the hand and is separated from the skin by a thin layer of subcutaneous fatty tissue.

Depending on the severity clinical manifestations There are 4 degrees of Dupuytren's contracture:

1st degree – characterized by the presence of a compaction under the skin that does not limit the extension of the fingers. At this degree, patients usually mistake this lump for “namin” and rarely consult a doctor.

2nd degree. At this degree, finger extension is limited to 30 0

3rd degree. Limitation of extension from 30 0 to 90 0.

4th degree. Extension deficit exceeds 90 0 .

Conservative therapy is ineffective and can be recommended only in the first degree and as a stage of preoperative preparation.

The main method of treating Dupuytren's contracture is surgery.

A large number of operations have been proposed for this disease. The following are of primary importance:

Aponeurectomy – excision of the scarred palmar aponeurosis. Made from several cross sections, which are made according to the rules described in the “cuts on the hand” section. Strands of the altered palmar aponeurosis are isolated and excised subcutaneously. This can damage the common digital nerves, so this step 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 the formation of a hematoma. A few days after the operation, they begin to move the fingers to the extension position using dynamic splints.

Aponeurotomy is the intersection of the strands of the palmar aponeurosis. Palliative operation. The cords are crossed without excision.

Dermoaponeurectomy. With severe degrees of Dupuytren's contracture, the palmar aponeurosis is tightly fused with thinned skin, which also undergoes scarring. In such cases, after excision of the aponeurosis and areas of changed skin above it, the operation is completed using skin grafting methods.

8146 0

Closed fresh CP tears are the most common of the extensor tendon apparatus injuries and occur at various levels (Fig. 27.2.40). The more distal the rupture occurs, the more the preserved elements of the capsule of the distal interphalangeal joint prevent the occurrence of diastasis between the end of the tendon and its insertion.

Rice. 27.2.40. The most common types of rupture of the extensor tendons are at the level of the distal interphalangeal joint of the finger.
a - outside the joint capsule; b - within the joint capsule; c — separation from the place of attachment to the distal phalanx; d — avulsion with a fragment of the distal phalanx.

The latter can be easily achieved using a simple aluminum bus (Fig. 27.2.41, a-c). However, keeping the finger in flexion at the proximal interphalangeal joint is a more difficult task. Using even the simplest splints requires patients to understand the task at hand, constantly monitor the position of the finger and the condition of the splint elements, and make the necessary adjustments. If all this succeeds, then a good treatment result is natural, provided that the period of immobilization is at least 6-8 weeks.

Rice. 27.2.41. Use of a splint in the conservative treatment of closed extensor tendon ruptures in the area of the distal interphalangeal joint.
a, b - options for applying a splint; c — appearance of a finger with a simple splint; d - position of the finger at which the lateral bundles of tendon stretching are maximally relaxed (explanation in the text).

Rice. 27.2.42. Stages of fixation of the distal phalanx of the finger in the hyperextension position using a transarticularly inserted wire.
a — drawing a perforation hole on the fingertip; b - biting the inserted needle; c — hyperextension of the phalanx on the knitting needle.

Open injuries to the extensor tendons. For open injuries of the extensor tendons in the area of the distal interphalangeal joint, any type of tendon suture can be used, and in particular, an immersed or removable suture (Fig. 27.2.43).

Rice. 27.2.43. Transosseous fixation of the extensor tendon to the distal phalanx of the finger in chronic injury.

A skin-tendon suture can also be applied (Fig. 27.2.44). It is removed after 2 weeks. In all cases, finger immobilization is continued for up to 6-8 weeks.

Rice. 27.2.44. Use of skin-tendon sutures for open injuries of the extensor tendon in the area of the distal interphalangeal joint (a).
b - 8-shaped seam; c - continuous continuous seam.

Old damage. 2 weeks after closed CP injury, conservative treatment is no longer effective. In these cases, a transosseous or submersible suture is applied to the tendon. In this case, pay attention to the following technical details of the operation:
1) access is carried out so as not to damage the growth zone of the nail;
2) the scar tissue between the ends of the tendon is excised;
3) the tendon suture is applied with the nail phalanx fully extended (overextended).

It should be noted that almost any type of tendon suture is not able to resist the pull of the deep digital flexor tendon. Therefore, strict additional immobilization with a splint is mandatory (as with conservative treatment). That is why it is advisable to additionally temporarily transfix the distal interphalangeal joint with a wire, which immediately simplifies the postoperative treatment of the patient and makes the prognosis more optimistic.

If the outcome of surgical treatment is unsatisfactory, there are two main options for subsequent actions:
1) performing arthrodesis of the distal interphalangeal joint;
2) tendon plasty according to Iselin (Fig. 27.2.45).

Rice. 27.2.45. Scheme of tendoplasty for chronic damage to the extensor tendon in the area of the distal interphalangeal joint (according to Iselin)

IN AND. Arkhangelsky, V.F. Kirillov

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