Home Smell from the mouth Metacarpophalangeal joints and their pathologies. Treatment of closed fractures of the phalanges of the fingers Proximal phalanx of the toe

Smell from the mouth

Metacarpophalangeal joints and their pathologies. Treatment of closed fractures of the phalanges of the fingers Proximal phalanx of the toe

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.

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 handaxe 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 had almost modern look. 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 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.

Distal end The 1st and 2nd phalanges have 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 reliable connection finger bones together.

Sometimes a deformed phalanx of the finger becomes the result 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 a disease internal organs, which may include:

heart defects;
pulmonary dysfunction;
infective endocarditis;
diffuse goiter, Crohn's disease ( serious disease 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 feature These diseases are considered to be 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 a chronic disease that destroys the bone structure of the phalanx. Such diseases include osteoporosis, osteomyelitis and other severe tissue damage. If you have a high risk of getting such a fracture, then you should take care of your arms and legs, because 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! Closed fractures of the fingers can 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 twice X-ray examination(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.

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.

Introduction.

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 individual plan and in accordance with the principles set out below.

Features of treatment of patients with injuries and diseases of the hand.

Anesthesia.

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 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 may occur and the occurrence of tunnel syndromes, and in some cases, necrosis of the finger. 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 lower third of the shoulder, in which pressure is injected to 280-300 mm 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.

Skin incisions on the hand.

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, which have a specific function and are 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 occurs connective tissue, 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.

Rice. 4A-Optimal cuts on the hand,B-Z-plastic

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, and constantly moisturize the tissue. Trauma to tissues with tweezers and clamps should be avoided, since micronecrosis forms at the site of compression, leading to scarring, as well as leaving foreign bodies in the wound in the form of long ends of ligatures and large nodes. 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. Huge role in development infectious complications The so-called “time factor” plays a role, since too long operations lead to tissue “fatigue” 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 distal phalanx.

Anatomy.

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)

R is.9 Anatomical structure 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.

Classification.

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.

Treatment.

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.

Treatment.

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.

Fractures of the metacarpal bones.

Anatomy.

The metacarpal bones are not located in the same plane, but form the arch of the hand. The arch of the wrist 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.

Classification.

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

Treatment.

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 fracture, 2 - Rolando fracture, 3,4 - extra-articular fractures of the base of the first metacarpal bone.

To understand the mechanism of injury, it is necessary to consider the anatomy of the first carpometacarpal joint. The first carpometacarpal joint is 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

Treatment.

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.

Conservative treatment.

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

Surgical treatment.

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 10-12 days 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 pin.

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.

Anatomy.

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

Treatment.

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 the 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 3 weeks in case of partial ligament rupture and for 4-6 weeks in case of complete rupture, then sparing of the finger is recommended for another 3 weeks (for example, avoiding sports activities). (Fig. 32)

Fig. 32 Elastic splinting for injuries of collateral ligaments

During the period of immobilization, active movements in the joints injured finger Not only are they not contraindicated, but they 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 with early diagnosis. 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 is extended weekly by 10-15 degrees.

Damage to the metacarpophalangeal joints.

Anatomy.

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

Treatment.

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.

Anatomy.

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.

Treatment.

The most common injury is a subungual hematoma, which is clinically manifested by the accumulation of blood under the nail plate and is often accompanied by severe pain 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 postoperative period immobilization of the phalanx is required for 3-4 weeks to prevent its injury.

Tendon damage.

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 10-12 days 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 within 12 days to 6 weeks after the injury under less favorable conditions (lacerations and bruises). wounds). In many cases, more late 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.

Anatomy.

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.

Diagnostics.

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.

Treatment.

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

Fig.47 Brush zones

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.

Postoperative management.

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.

Anatomy.

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 talk about perfect extensor-flexion function of the finger only if all anatomical structures. 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.

Diagnostics.

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.

Damage to the nerves of the hand.

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. Important clinical significance has a motor branch of the median nerve that 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 tissue, after which they begin to suture the nerve (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 most important tasks hand surgery is to prevent scarring. 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

Stenosis tendon canals.

The pathogenesis of degenerative-inflammatory diseases of the tendon canals has not been fully studied. Women aged 30-50 years are most often affected. 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 seal on it, positive symptom Finkelstein: sharp pain in the area of the styloid process of the radius, occurring with ulnar abduction of the hand, with 1 finger pre-bent and fixed. (Fig. 57)

Fig. 57 Finkelstein's symptom

X-ray examination makes it possible to exclude other diseases of the wrist joint, as well as to identify local osteoporosis of the apex of the styloid process and hardening of the soft tissues above it.

Treatment.

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.

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.

Etiology and pathogenesis.

Not exactly known. The main theories are traumatic, hereditary. There is a connection with the proliferation of endothelial cells of the vessels of the palmar aponeurosis and a decrease in 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).

Anatomy of the palmar aponeurosis.

1. m. palmaris brevis.2. m. palmaris longus.3. volar carpal ligament communis.4. volar carpal ligament proprius.5. Palmar aponeurosis.6. Tendon of palmar aponeurosis.7. Transverse palmar ligament.8. vaginae and ligaments of mm. flexor muscles.9. tendon of m. flexor carpi ulnaris.10. tendon of m. flexor carpi radialis.

The palmar aponeurosis has the shape of a triangle, the apex of which is directed proximally, 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.

Classification.

Depending on the severity of 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 .

Treatment.

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. It is made from several transverse incisions, which are made according to the rules described in the “incisions 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 applied pressure bandage, which will 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.

Upper limb injuries

The most common injuries to the upper limb are fractures of the radius in the lower third...

The most common injuries to the upper extremity are fractures of the radius in the lower third (radius in a typical location) and fractures in the upper third of the humerus (surgical neck)

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 are 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, 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 you should definitely X-ray examination(fluoroscopy or radiography in two projections), which allows you to make the correct diagnosis.

Treatment of a fracture of the phalanx of the fingers without displacement is conservative. An aluminum splint or plaster cast is applied for three weeks. After 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 most small 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. Although clinical picture These diseases are 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.

The phalanges of the human fingers have three parts: proximal, main (middle) and final (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

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers most often occur due to 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

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 you have pain in the phalanges of your fingers, you should not self-medicate. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and accordingly prescribe the necessary therapy.

Dislocations of the phalanges of the fingers account for 0.5 to 2% of all hand injuries. The most common dislocations occur in the proximal interphalangeal joint - about 60%. Dislocations occur in the metacarpophalangeal and distal interphalangeal joints with approximately the same frequency. Dislocations in the joints of the fingers are more often observed on the right hand in people of working age due to domestic trauma.

Dislocations in the proximal interphalangeal joints. The proximal interphalangeal joint is characterized by two types of injuries:

1) dislocation posterior, anterior, lateral;

2) fracture dislocation.

Posterior dislocations occur when the proximal interphalangeal joint is hyperextended. This injury is characterized by rupture of the volar plate or collateral ligaments.

Lateral dislocations are a consequence of the action of abductor or adductor forces on the finger when the finger is extended. The radial collateral ligament is damaged much more often than the ulnar ligament. As a rule, spontaneous reduction occurs with this injury. Reduction of fresh lateral and posterior dislocations is often not difficult and is done in a closed manner.

Anterior dislocation occurs as a result of combined forces—adductor or abduction—and an anterior force that displaces the base of the middle phalanx forward. In this case, the central bundle of the extensor tendon is separated from its attachment to the middle phalanx. Palmar dislocations occur much less frequently than others, since the anterior wall of the capsule contains a dense fibrous plate that prevents the occurrence of this damage.

Clinically, with this type of injury in the acute period, swelling and pain can mask the existing deformity or dislocation. In patients with lateral dislocations, upon examination, pain is noted during the rocking test and tenderness on palpation on the lateral side of the joint. Lateral instability indicating a complete rupture.

Radiographically, when the collateral ligament is torn or when there is severe swelling, a small fragment of bone is revealed at the base of the middle phalanx.

In fracture-dislocations, there is a dorsal subluxation of the middle phalanx with a fracture of the palmar lip of the middle phalanx, which can involve up to 1/3 of the articular surface.

Dislocations in the distal interphalangeal joints.

The distal interphalangeal joints are stable in all positions because the supporting apparatus consists of dense accessory collateral ligaments connected to a fibrous plate on the outer palmar side. Dislocations are also possible here, both in the dorsal and palmar sides. Reduction of fresh dislocations does not present any significant difficulty. The only inconvenience is the short lever for reduction, represented by the nail phalanx. Reduction of old dislocations in the interphalangeal joints is much more difficult, since contracture quickly develops with scar changes in the surrounding tissues and the organization of hemorrhage in the joint. Therefore, it is necessary to resort to various methods of surgical treatment.

Dislocations in the metacarpophalangeal joints.

The metacarpophalangeal joints are condylar joints that, in addition to flexion and extension, are characterized by lateral movement of at least 30° when the joint is extended. Because of its shape, this joint is more stable in flexion, where the collateral ligaments are tight, than in extension, which allows lateral movement of the joint. The first finger is most often affected.

For chronic dislocations of the phalanges of the fingers, the main method of treatment is the application of compression-distraction devices. Often this method is combined with open reduction. In other cases, if reduction is impossible and the articular surfaces are destroyed, arthrodesis of the joint is performed in a functionally advantageous position. Arthroplasty using biological and synthetic pads is also used.

Treatment of metacarpal fractures

The main methods of restoring the function of the joints of the fingers are open and closed reposition of fragments in as soon as possible after injury, arthroplasty using various auto-, homo- and alloplastic materials, treatment using external fixation devices of various designs. Recently, with the development of microsurgical technology, many authors propose the use of vascularized grafts, such as blood-supplied joint transplantation, for total and subtotal destruction of articular surfaces. However, these operations are lengthy, which is unfavorable for the patient, have a high percentage of vascular complications, and subsequent rehabilitation treatment is difficult due to prolonged immobilization.

In the non-operative treatment of fractures and fracture-dislocations, the most common method is the use of plaster casts, twists and splint-sleeve devices. In clinical practice, immobilization with splints and circular plaster casts is used. Recently, various types of plastic dressings have been increasingly used.

The period of immobilization with plaster casts for fractures and dislocations of the phalanges of the fingers and metacarpal bones of the hand is 4-5 weeks.

When performing open reduction or realignment of fragments of the phalanges and metacarpal bones of the hand, various extraosseous and intraosseous fixators of various sizes are widely used for osteosynthesis - rods, pins, knitting needles, screws made of various materials.

Particularly great difficulties arise in the treatment of complex intra-articular fractures - both the head and base of bones in the same joint, with multiple comminuted fractures, accompanied by ruptures of the capsule and ligamentous apparatus of the joint and resulting in dislocation or subluxation. Often these injuries are accompanied by interposition of bone fragments with joint blockade. The authors also offer various treatment methods: application of external fixation devices, primary arthrodesis of the damaged joint. The most effective surgical treatment consists of open reduction and joining of fragments with various fixatives.

There is an opinion that in case of severe injuries to the joints of the fingers of the hand, the integrity of the articular surfaces should not be restored, but the joint should be closed by primary arthrodesis, since the creation of a weight-bearing finger while fixing the injured joint in a functionally advantageous position contributes to a faster and more complete rehabilitation of the patient, whose profession is not associated with subtle differentiated movements of the hand. Arthrodesis is widely used for injuries to the distal interphalangeal joints. This operation is also given priority for chronic joint injuries with significant damage to the articular surfaces.

In the last decade, many technical solutions have been described related to the modernization of existing and the creation of new models of compression-distraction and hinge-distraction devices.

M.A. Boyarshinov developed a method for fixing fragments of the phalanx of a finger with a structure made of knitting needles, which is mounted like this. A Kirschner wire is passed transversely through the proximal fragment of the phalanx closer to the base, a thin wire is passed through the same fragment, but closer to the fracture line, and a pair of thin wires is also passed through the distal fragment. The protruding ends of the Kirschner wire, passed through the proximal fragment at the base of the phalanx, 3-5 mm away from the skin, are bent in the distal direction at an angle of 90° and placed along the finger. At a distance of 1 cm from the distal end of the damaged phalanx, the ends of the needle are again bent towards each other at an angle of 90° and twisted together. As a result, a single-plane rigid frame is formed. Thin knitting needles are fixed to it with the effect of compression or distraction of the reduced phalanx fragments. Depending on the location and nature of the fracture, the technique for inserting the wires may be different. For transverse and similar fractures, we use fixation of fragments at the junction in the form of a lock using L-shaped curved knitting needles according to E.G. Gryaznukhin.

To eliminate finger contracture in both interphalangeal joints, an external device of the I.G. type can be used. Korshunov, equipped with an additional trapezoidal frame made of Kirschner knitting needles, and a screw pair from the top of the frame. The external apparatus consists of two arcs with a diameter of 3-3.5 cm; in the area of the ends of the arc there are holes: with a diameter of 0.7-0.8 mm - for holding the knitting needles and with a diameter of 2.5 mm - for threaded rods connecting the arcs to each other. One arch is fixed with a knitting needle to the proximal phalanx, the other to the middle phalanx. A needle is passed through the distal phalanx at the level of the base of the nail, the ends of the needle are bent towards the end of the phalanx and fastened together. The resulting frame is attached to the screw pair of the outer trapezoidal frame. In this case, a spring can be placed between the screw pair and the frame fixing the end phalanx for more gentle and effective traction.

Using screw pairs, distraction and extension of the phalanges is performed at a rate of 1 mm/day in the first 4-5 days, then up to 2 mm/day until complete extension and creation of diastasis in the interphalangeal joints up to 5 mm. Finger straightening is achieved within 1-1/2 weeks. Distraction of the interphalangeal joints is maintained for 2-4 weeks. and longer depending on the severity and duration of contractures. First, the distal phalanx is released and the distal interphalangeal joint is developed. After restoration of active movements of the distal phalanx, the proximal interphalangeal joint is released. Conduct final rehabilitation measures.

When using surgical treatment and osteosynthesis using the AO technique, early onset of movements in the operated hand is recommended. But in the future, it is necessary to perform repeated surgery to remove the metal structures. At the same time, when fixing fragments with knitting needles, their removal does not present any technical difficulties.

In otropedotraumatological practice, only a few of the devices that have originality and fundamentally significant differences are widely used: the Ilizarov, Gudushauri, articulated and repositioned Volkov-Oganesyan devices, the “stress” and “rigid” Kalnberz devices, the Tkachenko “frame” device. Many designs were used only by the authors and have not found wide application in hand surgery.

The main advantage of the Ilizarov apparatus is the variety of layout options, as well as the simple technology for manufacturing the apparatus elements. The disadvantages of this device include the multi-item nature of the kit; the complexity and duration of the processes of assembly, application and replacement of elements on the patient; possibility of fixed displacements in the device; difficulties in eliminating rotational displacements; limited possibilities for precisely controlled and strictly dosed hardware reposition.

When using distraction devices, one should take into account the rather long duration of treatment and the impossibility of complete restoration of the articular surfaces. As a result, the range of their use for various types of damage to the joints of the fingers is limited.

To restore joint mobility, since the 40s of the last century, metal and plastic structures have been widely used to replace various parts of joints, articular ends and entire joints. The solution to the problem of endoprosthetics of finger joints went in two main directions:

development of articulated endoprostheses;

creating endoprostheses from elastic materials.

An obligatory component in the complex of reconstructive treatment of patients with injuries of the bones of the hand is postoperative rehabilitation, which includes exercise therapy and a set of physiotherapeutic measures. Restorative treatment uses a set of measures; recently phototherapy has been actively used. These procedures help improve trophism, reduce swelling and pain.

The loss of the first finger leads to a decrease in hand function by 40-50%. The problem of its restoration continues to be relevant today, despite the fact that surgeons have been doing this for more than a hundred years.

The first steps in this direction belonged to French surgeons. In 1852, P. Huguier first performed plastic surgery on the hand, later called phalangization. The meaning of this operation is to deepen the first inter-board gap without increasing the length of 1 beam. Only the key grip was restored in this way. In 1886, Ouernionprez developed and performed an operation based on a completely new principle - the transformation of the second finger into the first. This operation was called pollicization. In 1898, the Austrian surgeon S. Nicoladom first performed a two-stage transplant of the second toe. In 1906, F. Krause used the first toe for transplantation, considering it more suitable in shape and size, and in 1918, I. Joyce replanted the toe of the opposite hand to replace the lost toe. Methods based on the principle of two-stage transplantation on a temporary feeding pedicle are not widely used due to technical complexity, low functional results and long-term immobilization in a forced position.

The method of skin-bone reconstruction of the first finger of the hand is also due to the emergence of C. Nicoladoni, who developed and described the surgical technique in detail, but for the first time in 1909, the Nicoladoni method was used by K. Noesske. In our country V.G. Shchipachev in 1922 performed phalangization of the metacarpal bones.

B.V. Pariah, in his monograph published in 1944, systematized all reconstruction methods known at that time and proposed a classification based on the source of the plastic material. In 1980 V.V. Azolov supplemented this classification with new, more modern methods of reconstruction of the first finger: distraction lengthening of the first ray using external fixation devices and microsurgical methods of free transplantation of tissue complexes.

With the development of microsurgery, it became possible to replant completely severed fingers. It is obvious that replantation provides the most complete restoration of function compared to any reconstruction operation, even with shortening and possible loss of movement in the finger joints.

All modern methods of restoring the first finger of the hand can be divided as follows.

plastic with local tissues:

plastic with displaced flaps;

cross plastic;

plastic flaps on a vascular pedicle:

plastic surgery according to Kholevich;

plastic surgery according to Littler;

radial rotated flap;

2) distant plastic surgery:

on a temporary feeding leg:

sharp Filatov stem;

plastic surgery according to Blokhin-Conyers;

free transplantation of tissue complexes with microsurgical technique:

flap of the first interdigital space of the foot;

other blood-supplied tissue complexes.

Methods that restore segment length:

heterotopic replantation;

pollicization;

Second toe transplant:

transplantation of the segment of the first toe.

Methods that do not increase segment length:

phalangization.

Methods that increase segment length:

1) methods using tissues of the injured hand:

distraction segment lengthening;

pollicization;

skin-bone reconstruction with a radial rotated skin-bone flap;

2) distant plastic surgery using free transplantation of tissue complexes using microsurgical techniques:

transplantation of a finger of the opposite hand;

transplantation of the second toe;

transplantation of segment III of the toe;

one-stage skin-bone reconstruction using a free skin-bone flap.

The criteria for primary and secondary recovery are the time elapsed since the injury. The acceptable periods in this case are the maximum periods during which replantation is possible, i.e. 24 hours.

The basic requirements for the restored first finger are as follows:

sufficient length;

stable skin;

sensitivity;

mobility;

acceptable appearance;

ability to grow in children.

The choice of method for its restoration depends on the level of loss; in addition, they take into account gender, age, profession, the presence of damage to other fingers, the patient’s health status, as well as his desire and capabilities of the surgeon. It is traditionally believed that the absence of the nail phalanx of the 5th finger is a compensated injury and surgical treatment is not indicated. However, the loss of the nail phalanx of the first finger is a loss of 3 cm in its length, and, consequently, a decrease in the functional ability of the finger and hand as a whole, namely, the inability to grasp small objects with the fingertips. In addition, nowadays more and more patients want to have a full-fledged hand in aesthetic terms. The only acceptable method of reconstruction in this case is transplantation of part of the first finger.

The length of the stump of the first ray is the determining factor in the choice of surgical treatment method.

In 1966 in the USA, N. Buncke was the first to perform a successful simultaneous transplant of the first toe to the hand in a monkey with microvascular anastomoses, and Cobben in 1967 was the first to carry out a similar operation in the clinic. Over the next two decades, the technique of performing this operation, indications, contraindications, functional results and consequences of borrowing the first toe from the foot were studied in detail by many authors, including in our country. Studies have shown that, in functional and cosmetic terms, the first toe almost completely corresponds to the first finger of the hand. As for the function of the donor foot, the opinions of surgeons differ. N. Buncke et al. and T. Mau, having performed biomechanical studies of the feet, came to the conclusion that the loss of the first toe does not lead to significant limitations in gait. However, they noted that prolonged healing of the donor wound is possible due to poor engraftment of the free skin graft, and the formation of gross hypertrophic scars on the dorsum of the foot is also possible. These problems, according to the authors, can be minimized by following the rules of precision technique when isolating the toe and closing the donor defect, as well as by proper postoperative management.

Special studies conducted by other authors have shown that in the final stage of the step on the first finger, up to 45% of body weight falls. After amputation, lateral instability of the medial part of the foot may occur due to dysfunction of the plantar aponeurosis. Thus, when the main phalanx of the first finger is shifted to the position of dorsiflexion, the body weight moves to the head of the first metatarsal bone. In this case, the plantar aponeurosis is stretched, and the interosseous muscles through the sesamoid bones stabilize the metatarsophalangeal joint and raise the longitudinal arch of the foot. After the loss of the first toe, and especially the base of its proximal phalanx, the effectiveness of this mechanism decreases. The axis of the load is shifted laterally to the heads of the II and III metatarsal bones, which in many patients leads to the development of metatarsalgia. Therefore, when taking the first finger, it is advisable to either leave the base of its proximal phalanx, or firmly suture the tendons of the short muscles and aponeurosis to the head of the first metatarsal bone.

Transplantation of the first finger according to Buncke

Preoperative planning.

Preoperative examination should include a clinical assessment of the blood supply to the foot: determination of arterial pulsation, Dopplerography and arteriography in two projections. Angiography helps document the adequacy of blood supply to the foot through the posterior tibial artery. In addition, hand arteriography should be performed if there is any doubt about the status of potential recipient vessels.

The dorsalis pedis artery is a continuation of the anterior tibial artery, which passes deep under the suspensory ligament at the level of the ankle joint. The dorsal artery of the foot is located between the tendons of m. extensor hallucis longus medially and extensor digitorum longus laterally. The artery is accompanied by committed veins. Deep peroneal nerve located lateral to the artery. Passing over the bones of the tarsus, the dorsal artery of the foot gives off the medial and lateral tarsal arteries and forms an arterial arch at the base of the metatarsal bones, which runs in the lateral direction. The second, third and fourth dorsal metatarsal arteries are branches of the arterial arch and pass along the dorsal surface of the corresponding dorsal interosseous muscles.

The first dorsal metatarsal artery is a continuation of the dorsal artery of the foot. It is usually located on the dorsal surface of the first dorsal interosseous muscle and supplies the skin of the dorsum of the foot, the first and second metatarsal bones and the interosseous muscles. In the region of the first interdigital space, the first dorsal metatarsal artery is divided into at least two branches, one of which passes deep to the tendon of the long extensor of the first toe, supplying the medial surface of the first toe, and the other branch supplies adjacent sides I and II toes.

The deep plantar branch arises from the dorsal artery of the foot at the level of the base of the first metatarsal bone and goes to the plantar surface of the foot between the heads of the first dorsal interosseous muscle. It connects with the medial plantar artery and forms the plantar arterial arch. The deep plantar artery also gives branches to the medial side of the first toe. The first plantar metatarsal artery is a continuation of the deep plantar artery, which is located in the first intermetatarsal space and supplies the adjacent sides of the first and second toes from the plantar side.

According to a group of studies, the dorsalis pedis artery is absent in 18.5% of cases. Nutrition from the anterior tibial artery system is provided in 81.5% of cases. Of these, in 29.6% there is a predominantly dorsal type of blood supply, in 22.2% – predominantly plantar and in 29.6% – mixed. Thus, in 40.7% of cases there was a plantar type of blood supply to the first and second toes.

Venous outflow is carried out through the veins of the dorsum of the foot, which flow into the dorsal venous arch, forming the greater and lesser saphenous systems. Additional outflow occurs through the veins accompanying the dorsal artery of the foot.

The dorsum of the toes is innervated by the superficial branches of the peroneal nerve, and the first interdigital space is innervated by the branch of the deep peroneal nerve and the plantar surface of the I-II fingers by the digital branches of the medial plantar nerve. All these nerves can be used to reinnervate the transplanted complexes.

Usually the toe is used on the side of the same name, especially if additional skin grafting is needed to cover the toe on the hand, which can be taken from the foot along with the toe being transplanted. The problem of soft tissue deficiency in the recipient area can be solved by traditional plastic methods, such as free skin grafting, pedicled flap grafting, and free tissue complex grafting before or during finger reconstruction.

Discharge on the foot

Before surgery, the course of the great saphenous vein and dorsal artery on the foot is marked. Apply a tourniquet to the lower leg. On the dorsum of the foot, a straight, curved or zigzag incision is made along the dorsal artery of the foot, preserving the saphenous veins, the dorsal artery of the foot and its continuation - the first dorsal metatarsal artery. If the first dorsal metatarsal artery is present and located superficially, then it is traced in the distal direction and all lateral branches are ligated. If the dominant artery is the plantar metatarsal artery, then dissection begins from the first interdigital space in a proximal direction, making a longitudinal incision on the plantar for a wider view of the metatarsal head. Isolation in the proximal direction is continued until the artery is of sufficient length. Sometimes it is necessary to divide the transverse intermetatarsal ligament to mobilize the plantar metatarsal artery. If it is impossible to determine which vessel is dominant, then the extraction begins in the first intermetatarsal space and is carried out in the proximal direction. In the first interdigital space, the artery to the second finger is ligated and the first intermetatarsal artery is traced until it becomes clear how to isolate it - from the dorsal or plantar approach. The vascular bundle is not crossed until the possibility of blood supply to the finger through it is ensured and until the preparation of the hand for transplantation is completed.

The dorsal artery of the foot is traced to the short extensor of the first toe, it is crossed, the deep peroneal nerve, located lateral to the dorsal artery of the foot, is elevated and exposed. The deep peroneal nerve is isolated to restore it with the recipient nerve of the hand. The first metatarsal artery is traced to the interdigital space, preserving all the branches going to the first toe and ligating the others. The superficial veins are isolated and mobilized to obtain a long venous pedicle. In the first interdigital space, the plantar digital nerve is isolated along the lateral surface of the finger and separated from the digital nerve going to the second finger by carefully dividing the common digital nerve. In the same way, the plantar nerve is isolated on the medial surface of the first finger and mobilized as much as possible. The length of the nerves released depends on the requirements of the recipient area. Sometimes nerve grafting may be required. Determine the approximately required length of the tendons on the hand. The extensor digitorum longus tendon is divided at the level of the suspensory ligament or more proximally, if necessary. To isolate the long flexor tendon of sufficient length, an additional incision is made on the sole. At the level of the sole, between the tendon of the long flexor of the first finger and the flexor tendons of the other fingers, there are jumpers that prevent it from being isolated from the cut behind the ankle. The finger is isolated from the metatarsophalangeal joint. If it is necessary to restore the metacarpophalangeal joint on the hand, then you can take the joint capsule along with the finger.

The plantar surface of the head of the first metatarsal bone should be preserved, but its dorsal part can be taken with a finger if an oblique osteotomy of the head is made. After removing the tourniquet, hemostasis is carefully performed on the foot. After ligation of the graft vessels and their intersection, the finger is transferred to the hand. The wound on the foot is drained and sutured.

Preparing the brush.

The operation begins with the application of a tourniquet to the forearm. Usually two incisions are required to prepare the recipient site. A curved incision is made from the dorsoradial surface of the stump of the first finger through the palm along the thenar fold, and, if necessary, extended to the distal part of the forearm, opening the carpal tunnel. An incision is made along the back of the hand in the projection of the anatomical snuffbox, continuing it to the end of the finger stump. The tendons of the long and short extensors of the first finger, the long abductor muscle of the first finger, the cephalic vein and its branches, the radial artery and its terminal branch, the superficial radial nerve and its branches are isolated and mobilized.

The stump of the first finger is isolated. From the palmar incision, the digital nerves to the first finger, the tendon of the long flexor, the adductor of the first finger and the short abductor muscle, if possible, are mobilized, as well as the palmar digital arteries, if they are suitable for anastomosis. Now the tourniquet is removed and careful hemostasis is performed.

The actual transplantation of the toe onto the hand.

The base of the main phalanx of the toe and the stump of the main phalanx of the toe are adapted, and osteosynthesis is performed with Kirschner wires.

The flexor and extensor tendons are repaired in such a way as to balance the forces on the transplanted finger to the greatest extent possible. T. Mau et al. proposed a tendon reconstruction scheme.

The inflow through the recipient radial artery is checked, and an anastomosis is performed between the dorsalis pedis artery and the radial artery.

An anastomosis is performed between the cephalic vein and the great saphenous vein of the foot. Usually one arterial and one venous anastomosis is sufficient. The lateral plantar nerve of the toe and the ulnar digital nerve of the toe are sutured epineurally, as well as the medial plantar nerve of the toe with the radial nerve of the toe. If possible, the superficial branches of the radial nerve can be sutured to the branch of the deep peroneal nerve. The wound is sutured without tension and drained with rubber graduates. If necessary, plastic surgery with a free skin graft is used. Immobilization is performed with a plaster cast in order to avoid compression of the transplanted finger in the bandage and to ensure control over the state of its blood supply.

Transplantation of a fragment of the first toe

In 1980, W. Morrison described a free vascularized complex complex of tissues from the first toe, “wrapping” a traditional non-vascularized bone graft from the iliac crest for reconstruction of the lost first toe.

This flap includes the nail plate, dorsal, lateral and plantar skin of the first toe and is considered indicated for reconstruction of the first toe when lost at or distal to the metacarpophalangeal joint.

The advantages of this method are:

restoring the length, full size, sensation, movement and appearance of the lost finger;

only one operation is required;

preservation of the toe skeleton;

minimal gait disturbance and minor damage to the donor foot.

The disadvantages are:

the need for the participation of two teams;

potential loss of the entire flap due to thrombosis;

bone resorption capabilities;

absence of the interphalangeal joint of the reconstructed finger;

the possibility of long-term healing of the donor wound due to rejection of the free skin graft;

impossibility of using it in children due to lack of growth capacity.

As with all microvascular foot surgeries, the adequacy of the first dorsal metatarsal artery must be assessed preoperatively. In those feet where it is absent, a plantar approach may be required to isolate the first plantar metatarsal artery. Before surgery, it is necessary to measure the length and circumference of the first finger of a healthy hand. The toe is used on the same side to ensure suturing of the lateral plantar nerve to the ulnar digital nerve of the hand. Two surgical teams are involved to speed up the operation. One team isolates the complex on the foot, while the other prepares the hand, takes a bone graft from the iliac crest and fixes it.

Operation technique

A skin-fat flap is isolated so that the entire first toe is skeletonized, with the exception of a strip of skin on the medial side and the distal tip of the toe. The distal end of this strip should extend almost to the lateral edge of the nail plate. The width of this strip is determined by the amount of skin required to correspond to the size of a normal first finger. A 1 cm wide strip is usually left. The flap should not extend too proximally to the base of the first toe. Leave enough skin between the fingers to allow the wound to be sutured. The direction of the first dorsal metatarsal artery is noted. By lowering the foot and using a venous tourniquet, the appropriate dorsal veins of the foot are marked.

A longitudinal incision is made between the I and II metatarsal bones. The dorsal artery of the foot is identified. Then it is isolated distally to the first dorsal metatarsal artery. If the first dorsal metatarsal artery is located deep in the interdigital space, or if the plantar digital artery is dominant for the first toe, make a plantar incision in the first interdigital space. The lateral digital artery is isolated in the first interdigital space, and its isolation is continued proximally through a linear incision. The vascular branches to the second toe are ligated, preserving all branches to the flap. The branch of the deep peroneal nerve is traced next to the lateral digital artery to the first toe, and the nerve is divided proximally so that its length meets the requirements of the recipient zone.

The dorsal veins leading to the flap are isolated. The side branches are coagulated to obtain a vascular pedicle of the required length. If the plantar metatarsal artery is used, it may require plastic surgery with a venous graft to obtain a vascular pedicle of the required length.

Once the neurovascular pedicle is isolated, cross section at the base of the toe, avoiding damage to the vein draining the flap. The toe flap is elevated, unfolded, and the lateral plantar nerve is identified. vascular bundle. The medial neurovascular bundle is isolated and mobilized, maintaining its connection with the medial skin flap.

The toe flap is separated under the nail plate by careful subperiosteal dissection, avoiding damage to the nail plate matrix. Approximately 1 cm of the tuberosity of the nail phalanx under the nail plate is removed with a flap. The paratenon on the tendon of the long extensor of the first finger is preserved to ensure the possibility of performing plastic surgery with a free split skin graft. The plantar part of the flap is lifted, leaving subcutaneous tissue along the plantar surface of the finger. The lateral plantar digital nerve is cut off from the common digital nerve at the appropriate level. If the lateral plantar digital artery is not the main feeding artery of the flap, then it is coagulated and divided.

At this stage, the flap retains its connection with the foot only due to the vascular bundle, consisting of the dorsal digital artery, which is a branch of the first dorsal metatarsal artery, and veins flowing into the system of the great saphenous vein of the leg. Remove the tourniquet and make sure that the flap is supplied with blood. It may take 30 to 60 minutes to restore blood flow to the flap. Wrapping with a napkin soaked in warm isotonic sodium chloride solution or lidocaine solution can help relieve persistent vasospasm. When the flap turns pink and the preparation of the brush is completed, microclips are applied to the vessels, ligated and divided. Plastic surgery of the first toe is carefully performed using a split skin graft. Removal of 1 cm of the distal phalanx allows a medial flap of skin to be wrapped around the top of the finger. A free split skin graft covers the plantar, dorsal and lateral surfaces of the finger. W. Morrison suggested using cross-plasty to cover the donor defect on the first toe, but it is usually not required.

Preparing the brush.

The hand preparation team should also take a cancellous cortical graft from the iliac crest and trim it to the size of a healthy finger. Normally, the tip of the first finger of the hand is adducted to the second finger 1 cm proximal to the proximal interphalangeal joint of the second finger. There are two zones on the hand that require preparation. This is the dorsoradial surface just distal to the anatomical snuffbox and directly the amputation stump. A longitudinal incision is made under the tourniquet in the first interdigital space. Two or more dorsal veins of the hand are identified and mobilized. Between the first dorsal interosseous muscle and the adductor digit I muscle, a. radialis. The superficial radial nerve is identified. The arterial pedicle is mobilized, isolating it proximally to the level of the intended anastomosis at the level of the metacarpal or metacarpophalangeal joint.

The skin on the stump of the first finger is incised with a straight incision across its tip from the mediomedial to mediolateral line, isolating a dorsal and palmar subperiosteal flap about 1 cm in size. A neuroma of the ulnar digital nerve is isolated and excised. The end of the stump is refreshed for osteosynthesis with a graft. A depression is created in the stump of the main phalanx of the first finger or in the metacarpal bone in order to place a bone graft into it and then fix it with Kirschner wires, a screw or a miniplate with screws. The flap is wrapped around the bone so that its lateral side lies on the ulnar side of the bone graft. If the bone graft is too large, it must be reduced to the required size. The flap is fixed in place with interrupted sutures so as to position the nail plate along the rear and the neurovascular bundle in the first intermetacarpal space. Using optical magnification, an epineural suture is placed on the ulnar digital nerve of the first finger and the lateral plantar nerve of the toe using a 9/0 or 10/0 thread. The proper digital artery of the finger is sutured to the first dorsal metatarsal artery of the flap. Restore arterial inflow, and the dorsal veins are sutured. The deep peroneal nerve is sutured to the branch of the superficial radial nerve. The wound is sutured without tension, and the space under the flap is drained, avoiding placing drainage near the anastomoses. Then a loose bandage and cast are applied so as not to compress the finger, and the end is left to observe the blood supply.

Postoperative management is carried out according to the usual technique developed for all microsurgical operations. Active finger movements begin after 3 weeks. As soon as the wound on the foot heals, the patient is allowed to walk with the support of his foot. No special shoes required.

Osteoplastic reconstruction of the finger

Complex island radial forearm flap.

This operation has the following advantages: good blood supply to the skin and bone graft; the working surface of the finger is innervated by transplanting an island flap on a neurovascular pedicle; one-stage method; there is no resorption of the bone part of the graft.

The disadvantages of the operation include a significant cosmetic defect after taking a flap from the forearm and the possibility of a fracture of the radius in the distal third.

Before the operation, angiography is performed to determine the viability of the ulnar artery and the superficial palmar arch, which provides blood supply to all fingers of the injured hand. The identification of predominant blood supply through the radial artery or the absence of the ulnar artery excludes the possibility of performing this operation in the author’s version, but a free transplantation of a complex of tissues from a healthy limb is possible.

The operation is performed under a tourniquet. The flap is raised from the palmar and dorsal radial surfaces of the forearm, its base is placed a few centimeters proximal to the styloid process of the radius. The flap should be 7-8 cm long and 6-7 cm wide. After preparing the distal part of the stump of the first finger, a flap based on the radial artery and its comitant veins is raised. Particular care must be taken not to injure the cutaneous branches of the radial nerve or disrupt the blood supply to the radius just proximal to the styloid process. The small branches of the radial artery are identified, going to the pronator quadratus muscle and further to the periosteum of the radius. These vessels are carefully mobilized and protected, after which a radial osteotomy is performed and the radial fragment is elevated using bone instruments. The length of the graft can vary depending on the length of the stump of the first finger and the planned lengthening. The bone graft should include a corticocancellous fragment of the lateral aspect of the radius that is at least 1.5 cm wide and should be elevated to maintain vascular connections to the graft. The radial vessels are ligated proximally, and the entire flap is mobilized as a complex complex to the level of the anatomical snuffbox. The abductor digitorum longus and extensor digitorum brevis tendons are released proximally by cutting the distal portion of the first dorsal suspensory ligament. A complex skin-bone graft is then passed under these tendons to the rear to the distal wound of the stump of the first finger. The bone graft is fixed to the first metacarpal bone with the spongy part in the position opposite the second finger. Fixation is carried out using longitudinal or oblique knitting needles, or using a mini-plate. The distal end of the graft is processed to give it a smooth shape. The skin portion of the flap is then wrapped around the graft and the remaining portion of the metacarpal bone or main phalanx.

At this stage, an island flap on a vascular pedicle is raised from the ulnar side of the third or fourth finger and placed on the palmar surface of the bone graft to provide sensitivity. A full-thickness skin graft is used to cover the donor finger defect. A split-thickness or full-thickness skin graft is taken from the anterior thigh to cover the donor area of the forearm after muscle coverage of the radius defect is completed. After removing the tourniquet, it is necessary to monitor the blood supply to both flaps and, if there are any problems, perform a revision of the vascular pedicle.

A plaster cast is applied, and sufficient areas of the flaps are left open to ensure constant monitoring of their blood supply. Immobilization is maintained for 6 weeks or more until signs of consolidation appear.

Transplantation of the second toe.

First successful transplant The second toe in the position of the second toe was performed by Chinese surgeons Yang Dong-Yue and Chen Zhang-Wei in 1966. The second toe is supplied with blood by both the first and second dorsal metatarsal arteries, which arise from the dorsal artery of the foot, and the first and second plantar metatarsal arteries arising from the deep plantar arch. The first dorsal metatarsal artery passes through the first intermetatarsal space. Here it divides into the dorsal digital arteries, going to the first and second fingers. The deep branch of the dorsal artery of the foot runs between the first and second metatarsal bones, connecting with the lateral plantar artery, and forms a deep plantar arch. The first and second plantar metatarsal arteries arise from the deep plantar arch. On the plantar surface of each interdigital space, the plantar artery bifurcates and forms the plantar digital arteries to adjacent toes. The first interdigital space contains the digital vessels of the first and second fingers. The second toe is transplanted either on the first dorsal metatarsal artery, which arises from the dorsal artery of the foot, as a feeding artery, or on the first plantar metatarsal artery, which arises from the deep plantar arch. There are variants of the anatomy of the vessels of the toes, in which the second toe is supplied with blood primarily from the system of the dorsal artery of the foot and the plantar arch. Depending on the anatomical features, the identification of the toe can be simple or complex. Based on the technique proposed by S. Poncber in 1988, a method for isolating the second toe was developed, which allows isolating all the vessels supplying the second toe from the dorsal approach.

Isolation of a graft on the foot. For transplantation, a finger from the same side is preferable, since normally the toes on the foot have a deviation to the lateral side, and therefore it is easier to orient the transplanted finger to the long toes. Before the operation, the pulsation of the dorsal artery of the foot is determined and the course of the artery and the great saphenous vein is marked. Then a tourniquet is applied to the limb.

On the dorsum of the foot, a curved incision is made in the projection of the dorsal artery of the foot and the first intermetatarsal space. At the base of the second toe, a bordering incision is made to cut out triangular flaps along the back and plantar surface of the foot. The size of the cut out flaps may vary. After separating the skin and providing wide access to the dorsal structures of the foot, the veins are carefully isolated - from the great saphenous vein at the level of the ankle joint to the base of the triangular flap at the second toe. The tendon of the short extensor of the first finger is crossed and retracted, after which the dorsal artery of the foot is isolated along the required length proximally and distally to the base of the first metatarsal bone. At this level I define! the presence of the first dorsal metatarsal artery and its diameter. If the first dorsal metatarsal artery is more than 1 mm in diameter, then it must be traced to the base of the second toe. After isolating and transecting the extensor tendons of the second finger, a subperiosteal osteotomy of the second metatarsal bone is performed in the area of its base, the interosseous muscles are peeled off, and the second metatarsal bone is raised by flexion at the metatarsophalangeal joint. This allows wide access to the plantar vessels and tracing of the deep branch connecting the dorsal artery of the foot with the plantar arch. From the plantar arch, the plantar metatarsal arteries going to the second toe are traced and assessed. Typically, the medial plantar digital artery of the second finger is large in diameter and arises from the first plantar metatarsal artery in the first interdigital space perpendicular to the axis of the finger. With this variant of anatomy, the first plantar metatarsal artery, departing from the plantar arch, goes in the first intermetatarsal space and goes under the head of the first metatarsal bone, where, giving off lateral branches, it goes to the plantar surface of the first finger. It can be isolated only after crossing the intermetatarsal ligament and the muscles attached to the lateral side of the head of the first metatarsal bone. Isolation is facilitated by the tension of the vessel, taken on a rubber holder. After mobilization of the artery, the branches going to the first finger are coagulated and crossed. If necessary, the second plantar metatarsal artery running in the second intermetatarsal space can be isolated. Then the common digital plantar nerves are isolated, the bundles going to the adjacent fingers are separated, and the digital nerves of the second finger are crossed. The flexor tendons of the second finger are isolated and crossed. After crossing the vessels leading to the third toe, the second toe remains connected to the foot only by an artery and a vein. Remove the tourniquet. Need to wait full recovery blood flow in the finger.

Brush selection. Apply a tourniquet to the forearm. An incision is made through the end of the stump of the first ray with continuation to the back and palmar surface of the hand. All structures that need to be restored are identified:

dorsal saphenous veins;

extensors of the first finger;

tendon of the long flexor of the first finger;

palmar digital nerves;

recipient artery;

remove scars and the endplate of the stump of the first ray.

After removing the tourniquet, the presence of inflow through the recipient artery is checked.

Transplantation of a graft to the hand. The graft is prepared for osteosynthesis. This moment of the operation depends on the level of the defect of the first finger of the hand. If the first metacarpophalangeal joint is intact, the second metatarsal bone is removed and the cartilage and cortical plate of the base of the main phalanx of the second finger are removed. If there is a stump at the level of the metacarpophalangeal joint, 2 options are possible - joint restoration and arthrodesis. When performing arthrodesis, the graft is prepared as described above. When restoring the joint, an oblique osteotomy of the metatarsal bone is performed under the head at the level of attachment of the capsule of the metatarsophalangeal joint at an angle of 130°, open to the plantar side. This makes it possible to eliminate the tendency to hyperextension in the joint after transplanting the finger onto the hand, since the metatarsophalangeal joint is anatomically an extensor joint. In addition, such an osteotomy allows you to increase the range of flexion in the joint.

If there is a stump of the first finger at the level of the metacarpal bone, the required length of the metatarsal bone is left as part of the graft. After preparing the graft, osteosynthesis is performed using Kirschner wires. Additionally, we fix the distal interphalangeal joint of the second finger with a knitting needle in a state of extension to exclude the possibility of developing a flexion contracture of the finger. When performing osteosynthesis, it is necessary to orient the transplanted finger to the existing long fingers of the hand to be able to perform a pinch grip. Next, the extensor tendons are sutured, the necessary condition being that the finger is in full extension. The flexor tendons are then sutured. The suture is placed with slight tension on the central end of the long flexor tendon to avoid the development of flexion contracture of the finger. Then anastomoses of the artery and vein are performed and the nerves are sutured epineurally. When suturing a wound, it is necessary to avoid tension of the skin to avoid the possibility of compression of blood vessels. When transplanting a finger with a metatarsophalangeal joint, it is most often not possible to cover the lateral surfaces in the joint area. In such a situation, plastic surgery with a free full-thickness skin graft is most often used. Rollers are not attached to these grafts.

If there is a scar deformity in the area of the stump of the first ray on the hand or a finger transplant with a metatarsal bone is planned, then additional skin grafting may be required, which can be performed either before finger transplantation or at the time of surgery. Immobilization is carried out with a plaster cast.

Suturing a donor wound on the foot. After careful hemostasis, the intermetatarsal ligament is restored and the transected muscles are sutured to the first finger. The metatarsal bones are brought together and fixed with Kirschner wires. After this, the wound is easily sutured without tension. The space between the I and II metatarsal bones is drained. Immobilization is carried out with a plaster cast on the back of the leg and foot.

Postoperative management is carried out as for any microsurgical operation.

Immobilization of the hand is maintained until consolidation occurs, an average of 6 weeks. From the 5-7th day after surgery, you can begin careful active movements of the transplanted finger in a bandage under the supervision of a doctor. After 3 weeks, the pin fixing the distal interphalangeal joint is removed. Immobilization of the foot is carried out for 3 weeks, after which the knitting needles are removed and the plaster cast is removed. Within 3 months. After surgery, the patient is not recommended to put full weight on the leg. Within 6 months. After surgery, foot bandaging is recommended to prevent forefoot flatness.

Pollicization

The operation of tissue transposition, which turns one of the fingers of the damaged hand into the first finger, has a history of more than a century.

The first report of true pollicization of the second finger with isolation of the neurovascular bundle and a description of the transplantation technique belongs to Gosset. A necessary condition for successful pollicization is the departure of the corresponding common palmar digital arteries from the superficial arterial arch.

Anatomical studies have established that in 4.5% of cases some or all common digital arteries arise from the deep arterial arch. In this case, the surgeon must choose a donor finger to which the common palmar digital arteries arise from the superficial arterial arch. If all common palmar digital arteries arise from the deep arterial arch, then the surgeon can perform transposition of the second finger, which, unlike other fingers, can be moved in this case.

Pollicization of the second finger. Under the tourniquet, flaps are planned around the base of the second finger and above the second metacarpal bone. A racket-shaped incision is made around the base of the second finger, starting from the palm at the level of the proximal digital crease and continuing around the finger, connecting with a V-shaped incision over the middle part of the metacarpal bone with a bend extending to the base of the metacarpal bone, where it deviates laterally to the stump area of I metacarpal bone.

Skin flaps are carefully isolated and the remains of the second metacarpal bone are removed. The palm contains neurovascular bundles to the second finger and flexor tendons. The digital artery to the radial side of the third finger is identified and divided beyond the bifurcation of the common digital artery. Carefully separate the bundles of the common digital nerve to the II and III fingers.

On the back, several dorsal veins are isolated to the second finger, mobilized, ligating all the lateral branches that interfere with its movement. The transverse intermetacarpal ligament is transected and the interosseous muscles are divided. The extensor tendons of the second finger are mobilized. Further, the course of the operation changes depending on the length of the stump of the first ray. If the saddle joint is preserved, then the second finger is isolated in the metacarpophalangeal joint and the base of the main phalanx is resected, thus the main phalanx of the second finger will perform the function of the first metacarpal bone. If the saddle joint is absent, only the polygonal bone is preserved, then the metacarpal bone under the head is resected, thus the second metacarpophalangeal joint will serve as the saddle joint. The second finger now remains on the neurovascular bundles and tendons and is ready for transplantation.

The first metacarpal bone or, if it is small or absent, the polygonal bone is prepared for osteosynthesis. The medullary canal of the stump of the first metacarpal or trapezoid bone is widened, and a small bone pin taken from the removed part of the second metacarpal bone is introduced into the base of the proximal phalanx of the second finger, as soon as it is transferred to a new position, and fixed with Kirschner wires. It is important to position the finger being moved in a position of sufficient abduction, opposition and pronation. If possible, the extensor tendons of the second finger are sutured to the mobilized stump of the long extensor of the first finger. So, since the second finger is noticeably shortened, sometimes it may be necessary to shorten the flexor tendons to the second finger. The tourniquet is removed and the viability of the displaced finger is assessed. The skin wound is sutured after moving the lateral flap of the interdigital space into a new cleft between the displaced finger and the third finger.

Immobilization of the first ray is maintained for 6-8 weeks until fusion occurs. Additional surgical interventions are possible, including shortening of the flexor tendons, tenolysis of the extensors, and opponenoplasty, if the function of the thenar muscles is lost and satisfactory rotational movements in the saddle joint are preserved.

Pollicization of the fourth finger.

Under the tourniquet, a palmar incision begins at the level of the distal palmar fold, continues on each side of the fourth finger through the interdigital spaces and connects distally above the fourth metacarpal bone approximately at the level of its middle. The incision is then continued to the base of the IV metacarpal bone.

The flaps are separated and elevated, and through the palmar incision the neurovascular bundles are identified and mobilized. Ligation of the ulnar digital arterial branch to the third finger and the radial digital arterial branch to the fifth finger is performed just distal to the bifurcation of the common digital artery in the third and fourth interdigital spaces, respectively. Under a microscope, the common digital nerves to the III and IV fingers and to the IV and V fingers are carefully split, which is required to move the finger through the palm without tension on the digital nerves or damage to the nerves to the III and V fingers.

The transverse intermetacarpal ligaments are dissected on each side, leaving sufficient length to allow the two ligaments to be connected after transplantation of the fourth finger. The extensor tendon of the fourth finger is divided at the level of the base of the fourth metacarpal bone and mobilized distally to the base of the proximal phalanx. The metacarpal bone is freed from the interosseous muscles attached to it, and the tendons of the short muscles to the fourth finger are crossed distally. Then an osteotomy of the IV metacarpal bone is performed at the base level and removed. The flexor tendons are mobilized to the middle of the palm, and all remaining soft tissue attached to the fourth finger is divided in preparation for passing it through the subcutaneous tunnel in the palm.

The first metacarpal bone is prepared for transplantation of the fourth finger, and if it is short or absent, then the articular surface of the polygonal bone is removed to the spongy substance. A canal can be made in the first metacarpal or trapezoid bone to introduce a bone pin when fixing the transplanted finger. An incision is made in the proximal direction along the back of the first metacarpal bone to identify and mobilize the stump of the tendon of the long extensor of the first finger. The scars in the area of the stump of the first finger are removed, leaving well-supplied skin to cover the wound after finger transplantation.

A tunnel is formed under the skin of the palmar surface of the hand to guide the fourth finger to the stump of the first ray. The finger is carefully guided through the tunnel. In its new position, the finger is rotated 100° along the longitudinal axis to achieve a satisfactory position with minimal tension on the neurovascular bundles. The articular surface of the proximal phalanx of the fourth finger is removed, and the bone is modeled to obtain the required length of the finger. Fixation is carried out using Kirschner wires. The use of a bone intramedullary pin through the bone contact site is not necessary.

The operation is completed by suturing the extensor tendon of the fourth finger with the distal stump of the long extensor of the first finger. The tendon suture is performed with sufficient tension until full extension of the fourth finger is achieved in the proximal and distal interphalangeal joints. The remnant of the tendon of the short abductor muscle of the first finger is connected to the remnant of the tendons of the interosseous muscles of the fourth finger on the radial side. Sometimes it is possible to suture the remainder of the adductor tendon with the stumps of the short muscle tendons along the ulnar side of the transplanted finger. Since the outflow of blood is carried out mainly through the dorsal veins, and when isolating a finger and passing it through the tunnel it is necessary to cross them, it is often necessary to restore venous outflow by suturing the veins of the transplanted finger with the veins of the dorsum of the hand in a new position. The tourniquet is then removed to control blood supply and hemostasis.

The donor wound is sutured after restoration of the transverse intermetacarpal ligament of the third and fifth fingers.

In the first interdigital space, the wound is sutured so that there is no splitting of the hand. When suturing a wound at the base of a transplanted finger, it may be necessary to perform several Z-plasties to prevent the formation of a circular compressive scar that impairs the blood supply to the transplanted finger.

Immobilization is maintained until bone union, approximately 6-8 weeks. Movements of the fourth finger begin after 3-4 weeks, although when fixed with a plate, movements can begin earlier.

Two-stage pollicization method.

It is based on the “prefabrication” method, which consists of a staged microsurgical transplantation of a blood-supplied tissue complex, including a vascular bundle with the surrounding fascia, into the intended donor area to create new vascular connections between this vascular bundle and the future tissue complex. The fascia surrounding the vascular bundle contains a large number of small vessels, which by the 5-6th day after transplantation grow into the surrounding tissues and form connections with the vascular network of the recipient area. The “prefabrication” method allows you to create a new vascular bundle of the required diameter and length.

Two-stage pollicization may be indicated in the presence of injuries to the hand that exclude the possibility of classical pollicization due to damage to the superficial arterial arch or common digital arteries.

Operation technique. The first stage is the formation of the vascular pedicle of the selected donor finger. Preparing the brush. Scars are excised on the palm. An incision is made along the palmar surface of the main phalanx of the donor finger, which is connected to the incision in the palm. Then a small longitudinal incision is made along the back of the main phalanx of the donor finger. The skin is carefully peeled off along the lateral surfaces of the main phalanx of the finger to form a bed for the fascia flap. Next, an incision is made in the projection of future recipient vessels in the area of the “anatomical snuffbox”. The recipient vessels are mobilized and prepared for anastomosis.

Formation of a fascial flap. A radial fasciocutaneous flap from the other limb is used in order, in addition to forming a vascular pedicle of the donor finger, to replace a defect in the palmar surface of the hand. Any fascial flap with an axial blood supply can be used. The details of the operation are known. The length of the vascular pedicle of the flap is determined in each specific case by measuring from the edge of the defect or the base of the donor finger, if there is no defect, then to the recipient vessels.

Formation of the vascular pedicle of the donor finger. The flap is placed on the palm of the injured hand so that the distal fascial part of the flap is passed under the skin of the main phalanx of the donor finger in a previously formed tunnel, wrapped around the main phalanx and sutured to itself in the palmar incision. If there is a skin defect on the hand, then the skin part of the flap replaces it. The vascular pedicle of the flap is brought to the site of the recipient vessels through an additional incision connecting the anastomotic area and the palmar wound. Then anastomoses are performed on the artery and veins of the flap and recipient vessels. The wound is sutured and drained. Immobilization is carried out with a plaster cast for 3 weeks.

Second phase. Actually pollicization of the donor finger into the position of the first finger. Preparation of the stump. The scars at the end of the stump are excised, it is refreshed to prepare for osteosynthesis, and the skin is mobilized. The extensor tendons of the first finger and the dorsal veins are distinguished.

On the palmar surface, the digital nerves and the tendon of the long flexor of the first finger are mobilized.

Isolation of a donor finger on a vascular pedicle. Initially, on the palmar surface, before applying a tourniquet, the course of the vascular pedicle is noted by pulsation. A skin incision is made at the base of the donor finger with triangular flaps cut out on the back and palmar surface. The saphenous veins are isolated on the dorsal surface of the finger, and after marking they are crossed. The extensor tendon of the finger is divided. An incision is made along the palmar surface from the tip of the triangular flap along the marked vascular pedicle. The digital nerves themselves are carefully isolated. Disarticulation of the finger in the metacarpophalangeal joint is performed by dissecting the joint capsule and cutting the tendons of the short muscles. The finger is raised on the new vascular pedicle by carefully isolating it in the direction of the stump of the first finger.

Isolation of the vascular pedicle is continued until sufficient length has been isolated for rotation without tension. At this stage, the tourniquet is removed and the blood supply to the finger is controlled. An incision along the palmar surface of the stump of the first ray is connected to an incision on the palm in the area of the identified vascular pedicle.

The vascular pedicle is unfolded and placed into the incision.

Fixing the donor finger in positionIfinger. Resection of the articular surface of the base of the main phalanx of the donor finger is performed. The finger is rotated 100-110° in the palmar direction in order to position the palmar surface of the donor finger in opposition to the remaining long fingers.

Osteosynthesis is performed using Kirschner wires, trying not to limit movements in the interphalangeal joints of the transplanted finger. The extensor and flexor tendons are restored and the digital nerves themselves are sutured epineurally. If there are signs of venous insufficiency, under a microscope, anastomoses are applied to 1-2 veins of the donor finger and the veins of the dorsal surface of the stump of the first finger.

A skin incision is made on the dorsal surface of the stump to place a triangular flap to avoid a circular compressive scar.

The wound is sutured and drained. Immobilization is carried out with a plaster cast until consolidation occurs.

This section examines each finger in turn, analyzing factors such as the length, width, signs and phalanges of each finger individually. Each finger is associated with a specific planet, each of which, in turn, is associated with classical mythology. Each finger is seen as an expression of different aspects of human character. The phalanges are the length of the fingers between the joints. Each finger has three phalanges: main, middle and initial. Each phalanx is associated with a special astrological symbol and reveals certain personality traits.

The first or index finger. In the ancient Roman pantheon, Jupiter was the supreme deity and ruler of the world - the equivalent of the ancient Greek god Zeus. Fully in line with this, the finger bearing the name of this god is associated with ego, leadership abilities, ambition and status in the world.

Second, or middle, finger. Saturn is considered the father of Jupiter and corresponds to the ancient Greek god Kronos, the god of time. The finger of Saturn is associated with wisdom, a sense of responsibility and general life position, for example, whether a person is happy or not.

Third, or ring finger. Apollo, god of the Sun and youth in ancient Roman mythology; V Ancient Greece it had a corresponding deity with the same name. Since the god Apollo is associated with music and poetry, the Apollo finger reflects a person's creativity and sense of well-being.

The fourth finger, or little finger. Mercury, among the Greeks the god Hermes, the messenger of the gods, and this finger is the finger of sexual communication; it expresses how clear a person is, that is, whether he is actually as honest as he says he is.

Definition of phalanges

Length. To determine the phalanges, the palmist considers factors such as its length in comparison to other phalanges and the overall length. In general, the length of the phalanx reflects how expressive a person is in a certain area. Insufficient length indicates a lack of intelligence.

Width. Width is also important. The width of the phalanx indicates how experienced and practical a person is in a given field. The wider the finger, the more actively a person uses the special features guided by this phalanx.

Marks

These are vertical lines. Typically this is good signs, as they channel the energy of the phalanx, but too many grooves can indicate stress.

Stripes are horizontal lines across the phalanx that have the opposite effect of the grooves: they are thought to block the energy released by the phalanx.

Fractures of the middle and proximal phalanges have much in common both in the mechanisms of damage and treatment, which allows us to consider them together, but taking into account their differences.
TO proximal phalanx tendons are not attached. However, some tendons that run close to it can complicate the treatment of fractures. Fractures of the proximal phalanges tend to be angularly deformed towards the palm due to the predominance of traction of the interosseous muscles over the extensor tendons.

Fractures of the middle phalanges are less common than proximal ones due to the fact that most of the damaging force acting along the axis of the finger is absorbed by the proximal phalanx. It leads to frequent fractures and dislocations of the proximal, but not the middle phalanges. Most fractures of the middle phalanx occur in its weakest part - the diaphysis. It is important to note that the superficial flexor tendon is attached to almost the entire palmar surface of the phalanx, while the insertion of the extensor tendon is limited to the proximal portion of the dorsal surface.
Tendon flexor superficialis bifurcated and attached to the lateral and medial edges of the bone.

Interosseous muscles and their relationship with extensor tendon extension

Having a wide area attachments, the superficial flexor develops significant force, leading to deformation when the middle phalanx is fractured. For example, a fracture of the base of the middle phalanx usually results in displacement of the distal fragment towards the palm, while a fracture of the diaphysis is usually accompanied by displacement of the fragments at an angle open to the dorsal side.

Last anatomical feature , which should be taken into account is the presence of a cartilaginous plate on the palmar side of the base of the middle phalanx. Intra-articular fractures can be complicated by displacement of this cartilaginous plate.

Classification of fractures of the proximal and middle phalanges of the fingers

Fractures of the proximal and middle phalanges divided into three types. Type I fractures are stable without displacement and can be treated by a doctor emergency care. Type II fractures may be displaced; after reduction they may remain either stable or unstable. Patients with type II fractures should be referred to an orthopedist for treatment. Type III fractures are unstable and often complicated by rotational displacement. They are reduced surgically.

These patients require careful examinations with fixation of nerve function distal to the fracture site. When treating fractures of this type, rotational displacement must be identified and corrected. A rotational deformity may be suspected when not all fingers of a clenched fist point toward the scaphoid. Another diagnostic method is to compare the direction of the nail plate lines on each hand. Normally, the line of the nail plate of the extended third finger of the right hand will run in the same plane as the line of the third finger of the left hand. With rotational displacement, these lines will not be parallel.
Rotational displacement can be identified by comparing the diameter bone fragments phalanx. It should be suspected in case of asymmetry of these fragments.

With rotational displacement, the lines of the nail plates are not parallel compared to the nail plates of the fingers of the uninjured hand

Treatment of fractures of the middle and proximal phalanges of the fingers

In the treatment of fractures of the middle and proximal phalanges There are two basic principles:
1. The finger should never be immobilized in full extension. The finger should be immobilized in a functionally advantageous position: 50° flexion at the metacarpophalangeal joint and 15-20° flexion at the interphalangeal joints to prevent rigidity and contractures. If stable fixation of fragments is possible only with full extension, then internal fixation is required for immobilization in the flexion position. In the flexion position, the collateral ligaments that facilitate reposition are stretched.
2. The cast should never be placed proximal to the distal palmar crease. If wider immobilization is required, you need to use a grooved splint that captures the adjacent healthy finger along with the injured finger, or a plaster cast with a traction device.

There are three known treatment methods fractures of the middle and proximal phalanges. The choice depends on the type of fracture, its stability and the experience of the doctor.

Dynamic splinting. This treatment method involves fixing the damaged finger together with the adjacent healthy one. This allows maximum use of the hand with early movement and prevents stiffness. The method is indicated only for stable non-displaced fractures, as well as stable transverse or impacted fractures. It should not be used for fractures with angular or rotational displacement. Application of plaster casts, splints and traction devices.

These methods mainly used only by orthopedists or surgeons (with the exception of grooved splints). A grooved splint is used for stable fractures that do not require traction and are not complicated by rotational or angular displacement. The grooved splint provides immobilization more reliable than dynamic splinting. Traction devices are used for complicated fractures and are applied, as a rule, only after consultation with an orthopedic surgeon.

Internal fixation. Typically, internal fixation with a Kirschner wire is performed for unstable or intra-articular avulsion fractures when precise reduction is required.