Surgical treatment of the wound. Primary surgical treatment of wounds

40. Technique for suturing and removing sutures.Primary debridement(PHO) wounds - is the main component of surgical treatment for them. Its goal is to create conditions for rapid wound healing and prevent the development of wound infection.

Distinguish between early PST, carried out in the first 24 hours after injury, delayed - during the second day and late - after 48 hours.

The task during PHO ran s is to remove non-viable tissues and the microflora in them from the wound. PHO, depending on the type and nature of the wound, consists either in the complete excision of the wound, or in its dissection with excision.

Complete excision is possible provided that no more than 24 hours have passed since the moment of injury and if the wound has a simple configuration with a small area of ​​damage. In this case, PST of the wound consists in excision of the edges, walls and bottom of the wound within healthy tissues, with the restoration of anatomical relationships (Fig. 3).

Rice. 3. Primary surgical treatment of the wound (scheme):

a - excision of the edges, walls and bottom of the wound;

b - the imposition of the primary seam.

Dissection with excision is performed for wounds of complex configuration with a large area of ​​damage. In these cases, the primary treatment of the wound consists of the following points:

1) wide dissection of the wound;

2) excision of deprived and contaminated soft tissues in the wound;

3) stop bleeding;

4) removal of free-lying foreign bodies and bone fragments devoid of periosteum;

5) wound drainage;

6) immobilization of the injured limb.

PST of the wound begins with the treatment of the surgical field and its delimitation with sterile linen. If the wound is on the hairy part of the body, then the hair is first shaved 4-5 cm in circumference, trying to shave from the wound to the periphery. For small wounds, local anesthesia is usually used.

The treatment begins with the fact that in one corner of the wound with tweezers or a Kocher clamp, they capture the skin, slightly lift it, and from here a gradual excision of the skin is made around the entire circumference of the wound. After excision of the crushed edges of the skin and subcutaneous tissue, the wound is expanded with hooks, its cavity is examined and non-viable areas of the aponeurosis and muscles are removed. Existing pockets in soft tissues are opened with additional incisions. During the primary surgical treatment of the wound, it is necessary to periodically change scalpels, tweezers and scissors during the operation. PHO is performed in the following order: first, the damaged edges of the wound are excised, then its walls and, finally, the bottom of the wound. If there are small bone fragments in the wound, it is necessary to remove those that have lost contact with the periosteum. In case of PXO of open bone fractures, sharp ends of fragments protruding into the wound, which can cause secondary injury to soft tissues, vessels and nerves, should be removed with bone forceps.

Depending on the timing of the PST, they are divided into early, delayed and late. early processing produced within a day after injury. Prophylactic use of antibiotics often allows you to increase the period up to 2 days. In this case, processing is called delayed primary. Despite more late dates intervention, delayed primary processing is designed to solve the same problem as early processing, i.e. ensure the prevention of wound infection. Late debridement It is aimed not at prevention, but at the treatment of wound infection. It is performed after 2 days (48 hours) in those who received antibiotics or on the 2nd day (after 24 hours) in those who did not receive them. It is quite obvious that the possibilities of closing the wound with sutures after late surgical treatment are sharply limited.

Primary surgical treatment should not be performed when:

1 - small superficial wounds and abrasions;

2 - small stab wounds, including blind ones, without damage to blood vessels and nerves;

3 - with multiple blind wounds, when there is a large number of small metal fragments (shot, fragments of grenades);

4 - penetrating bullet wounds with even inlet and outlet holes in the absence of significant damage to tissues, blood vessels and nerves.

Along with the primary distinguish secondary surgical treatment wound, which is carried out according to secondary indications, due to complications and insufficient radicalness of the primary treatment in order to treat wound infection.

Depending on the period from the moment of injury and the nature of the surgical treatment, a primary suture is distinguished, which is applied immediately to a fresh wound, and a suture is applied after treatment or after 24-48 hours, i.e. until granulation appears. In this case, it is called a delayed primary suture (Fig. 4).

Rice. 4. Imposition of primary delayed sutures.

When using a delayed primary suture, many surgeons suture the wound immediately after surgical debridement, leave it untied, and if there is no suppuration within a few days, they are tied, connecting the edges of the wound. In addition to the primary, in surgical practice, a secondary suture is used, which is early and late. An early secondary suture is applied on the 2nd week (8-14 days) after treatment on a granulating wound that has cleared of necrotic tissues and does not have obvious signs of inflammation in its edges. A late secondary suture is applied at 3-4 weeks (20-30 days) after careful excision of granulations and scars.

For purulent wounds, conservative and surgical treatment is used, which is aimed at the fastest recovery of the patient and the full restoration of anatomical and functional relationships. However, in the vast majority of cases, only surgical intervention can provide the necessary conditions for optimal wound healing due to the removal of non-viable purulent tissues, the creation of an adequate outflow from the wound, and the reduction of intoxication. Complete surgical treatment creates the best conditions for the success of conservative therapy.

Surgical treatment of a purulent wound is carried out in accordance with the principles that are used in the primary surgical treatment. It is advisable to perform the operation under general anesthesia. This allows you to painlessly expand the wound if necessary, remove damaged and dead tissues, perform effective hemostasis, and establish adequate drainage (Fig. 5).

Rice. 5. Vacuum drainage according to Redon: a significant vacuum is created in the bottle (a), due to which not only blood and wound fluid are removed, but also the edges of the wound are actively pressed against each other (b).

The volume of tissue excision depends on the extent of necrosis, the spread of the purulent process, and the presence of vital anatomical formations in this area that limit the actions of the surgeon. Intraoperative wound debridement is of great importance. For this, multiple washing of the wound with an antiseptic solution, treatment of the wound cavity with a pulsating jet of an antiseptic solution or ultrasound, evacuation of the wound, photocoagulation of the cavity of a purulent wound using a high-energy laser can be effectively used. Thanks to these measures, it is possible to reduce the bacterial contamination of the wound below the critical level, which in some cases makes it possible to suture the wound using through drainage for constant flowing washing (Fig. 6).

Rice. 6. Scheme of flow drainage.

With conservative treatment, the phase of the course of the wound process should be taken into account. AT Iphase- hydration phase - first of all, it is necessary to ensure the rest of the wounded area, the appointment of antibiotics and antiseptics, the manifestation of detoxification and the activation of the body's defenses, topical application dehydration drugs, hypertonic solutions, detoxification tampons, proteolytic enzymes with careful and gentle handling of tissues.

In II phase - phase of regeneration and epithelialization - to reduce the duration of treatment and obtain better functional results, one should more widely resort to the imposition of an early and late secondary suture, plasty with local tissues, autodermoplasty, and in the case of conservative treatment, use biostimulating ointments.

Technique for removing sutures from a postoperative wound.

All manipulations in the wound should be performed using a sterile instrument. Remove the bandage from the wound first. If the dressing material dries to it, it is necessary to moisten the dressing with a sterile antiseptic solution. The skin around the wound and the sutures themselves must be treated with an antiseptic solution (1% iodonate, 0.5% chlorhexidine solution, etc.). The suture is held with tweezers, closer to the knot, grabbing the ends of the ligature, which, when the suture is applied, are not cut short, but left about 1 cm long. The ligature is pulled up to show the area that was in the tissues. It is most often unpainted if the wound was treated with iodine solutions and is clearly visible. For decreasing pain you can hold the skin in the seam area using scissors for this. As soon as the seam has shifted, you need to stop its tension, because. this is accompanied by a pain reaction. With pointed scissors, the ligature in the intersection zone (uncolored zone) is cut and pulled out with tweezers. At the same time, the section of the seam that was on the skin does not pass through the wound, and thereby the infection is prevented from entering the wound.

Wounds. Primary surgical treatment. Wound drainage.

Wounds. Classification of wounds.

Wound

The main signs of a wound

Bleeding;

Violation of functions.

Elements of any wound are:

The bottom of the wound.

Wounds are classified on various grounds.

stab wounds

cut wounds

Chopped wounds

scalped wounds patchwork.

Bite wounds

poisoned wounds

gunshot wounds -

- wound channel area

- injury zone

Zone of secondary necrosis;

3. By infection

The course of the wound process

During wound healing, dead cells, blood, and lymph are resorbed, and as a result of the inflammatory reaction, the process of wound cleansing is carried out. The walls of the wound close to each other are glued together (primary gluing). Along with these processes, connective tissue cells multiply in the wound, which undergo a series of transformations and turn into fibrous connective tissue - a scar. On both sides of the wound, there are counter processes of new formation of vessels that grow into a fibrin clot that glues the walls of the wound. Simultaneously with the formation of the scar and blood vessels, the epithelium multiplies, the cells of which grow on both sides of the wound and gradually cover the scar with a thin layer of the epidermis; in the future, the entire layer of the epithelium is completely restored.

Signs of festering wounds correspond to the classical signs of inflammation, as a biological reaction of the body to a foreign agent: dolor (pain);

calor (temperature);

tumor (tumor, edema);

rubor (redness);

functio lesae (functional dysfunction);

INFLAMMATION

The stage is characterized by the presence of all signs of a purulent wound process. In a purulent wound there are remnants of non-viable and dead tissue, foreign objects, pollution, accumulation of pus in cavities and folds. Viable tissues are edematous. There is an active absorption of all this and microbial toxins from the wound, which causes the phenomena of general intoxication: fever, weakness, headache, lack of appetite, etc.

Stage Treatment Tasks: wound drainage to remove pus, necrotic tissue and toxins; fight infection. Wound drainage can be active (using aspiration devices) and passive (drainage tubes, rubber strips, gauze wipes and turundas moistened with water-salt solutions of antiseptics. Therapeutic (drugs) for treatment:

Hypertonic solutions:

The most commonly used by surgeons is a 10% sodium chloride solution (the so-called hypertonic solution). In addition to it, there are other hypertonic solutions: 3-5% solution of boric acid, 20% sugar solution, 30% urea solution, etc. Hypertonic solutions are designed to ensure the outflow of wound discharge. However, it has been established that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretion, and the outflow stops. Therefore, in recent years, surgeons refuse hypertonic saline.

In surgery, various ointments are used on a fatty and vaseline-lanolin basis; Vishnevsky ointment, synthomycin emulsion, ointments with a / b - tetracycline, neomycin, etc. But such ointments are hydrophobic, that is, they do not absorb moisture. As a result, tampons with these ointments do not provide an outflow of wound secretions, they become only a cork. At the same time, antibiotics contained in ointments are not released from ointment compositions and do not have sufficient antimicrobial activity.

Pathogenetically justified the use of new hydrophilic water-soluble ointments - Levosin, levomikol, mafenide-acetate, oflokain. Such ointments contain antibiotics that easily pass from the composition of ointments into the wound. The osmotic activity of these ointments exceeds the effect of hypertonic solution by 10-15 times, and lasts for 20-24 hours, so one dressing per day is enough for effective action to the wound.

Enzyme therapy (enzyme therapy):

For the speedy removal of dead tissue, necrolytic preparations are used. Widely used proteolytic enzymes - trypsin, chymopsin, chymotrypsin, terrilitin. These drugs cause lysis of necrotic tissue and accelerate wound healing. However, these enzymes also have disadvantages: in the wound, the enzymes retain their activity for no more than 4-6 hours. Therefore, for effective treatment festering wounds dressings should be changed 4-5 times a day, which is almost impossible. It is possible to eliminate such a lack of enzymes by including them in ointments. So, the ointment "Iruksol" (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of action of enzymes can be increased by immobilizing them in dressings. So, trypsin immobilized on napkins acts within 24-48 hours. Therefore, one dressing per day fully provides a therapeutic effect.

Use of antiseptic solutions.

Solutions of furacillin, hydrogen peroxide, boric acid, etc. are widely used. It has been established that these antiseptics do not have sufficient antibacterial activity against the most common pathogens of surgical infection.

Of the new antiseptics, it should be noted: iodopyrone, a preparation containing iodine, is used to treat the hands of surgeons (0.1%) and treat wounds (0.5-1%); dioxidine 0.1-1%, sodium hypochlorite solution.

Physical methods of treatment.

In the first phase of the wound process, wound quartzing, ultrasonic cavitation of purulent cavities, UHF, hyperbaric oxygenation are used.

Application of the laser.

In the phase of inflammation of the wound process, high-energy, or surgical lasers are used. With a moderately defocused beam of a surgical laser, pus and necrotic tissues are evaporated, thus it is possible to achieve complete sterility of wounds, which in some cases makes it possible to apply a primary suture to the wound.

GRANULATION

The stage is characterized by complete cleansing of the wound and the filling of the wound cavity with granulations (tissue of bright pink color with a granular structure). She first fills the bottom of the wound, and then fills the entire cavity of the wound. At this stage, its growth should be stopped.

Stage tasks: anti-inflammatory treatment, protection of granulations from damage, stimulation of regeneration

These tasks are:

a) ointments: methyluracil, troxevasin - to stimulate regeneration; fat-based ointments - to protect granulations from damage; water-soluble ointments - anti-inflammatory effect and protection of wounds from secondary infection.

b) drugs plant origin- aloe juice, sea buckthorn and rosehip oil, Kalanchoe.

c) the use of a laser - in this phase of the wound process, low-energy (therapeutic) lasers are used, which have a stimulating effect.

EPITHELIZATION

The stage begins after the execution of the bottom of the wound and its cavity with granulation tissue. Tasks of the stage: to accelerate the process of epithelialization and scarring of wounds. For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin-jelly, low-energy laser irradiation are used. At this stage, the use of ointments that stimulate the growth of granulations is not recommended. On the contrary, it is recommended to switch back to water-salt antiseptics. It is useful to achieve drying of the dressing to the surface of the wound. In the future, it should not be torn off, but only cut off along the edges, as it detaches due to the epithelialization of the wound. From above, such a bandage is recommended to be moistened with iodonate or other antiseptic. In this way, healing of a small wound under the scab is achieved with a very good cosmetic effect. The scar is not formed.

With extensive defects of the skin, long-term non-healing wounds and ulcers in the 2nd and 3rd phases of the wound process, i.e. after cleansing the wounds from pus and the appearance of granulations, dermoplasty can be performed:

a) faux leather

b) split displaced flap

c) walking stem according to Filatov

d) autodermoplasty with a full thickness flap

e) free autodermoplasty with a thin-layer flap according to Thiersch

At all stages of the treatment of purulent wounds, one should remember the state of immunity and the need to stimulate it in patients of this category.

The first and main step in the treatment of wounds in medical institution is the primary surgical treatment.

Primary surgical treatment of wounds (PHO). The main thing in the treatment of wounds is their primary surgical treatment. Its goal is to remove non-viable tissues, the microflora in them, and thereby prevent the development of a wound infection.

Primary surgical treatment of wounds:

It is usually carried out under local anesthesia. Stages:

1. Inspection of the wound, toilet of the skin edges, their treatment with an aetiseptic (tincture of iodine 5%, avoid getting into the wound);

2. Revision of the wound, excision of all non-viable tissues, removal of foreign bodies, small bone fragments, dissection of the wound, if necessary, to eliminate pockets;

3. Final stop of bleeding;

3. Drainage of the wound, according to indications;

4. Primary suture of the wound (according to indications);

Distinguish between early primary surgical treatment, carried out on the first day after injury, delayed - during the second day and late - 48 hours after injury. The earlier the primary surgical treatment is performed, the more likely it is to prevent the development of infectious complications in the wound.

During the Great Patriotic War, 30% of wounds were not subjected to surgical treatment: small superficial wounds, penetrating wounds with small inlet and outlet holes without signs of damage to vital organs, blood vessels, multiple blind wounds.

Primary surgical treatment must be simultaneous and radical, i.e. it must be performed in one stage and in the process of it non-viable tissues must be completely removed. First of all, the wounded are operated on with a hemostatic tourniquet and extensive shrapnel wounds, with soil contamination of the wounds, in which there is a significant risk of anaerobic infection.

Primary surgical treatment of the wound consists in excision of its edges, walls and bottom within healthy tissues with the restoration of anatomical relationships.

Primary surgical treatment begins with the dissection of the wound. The skin and subcutaneous tissue around the wound are excised with a fringing incision 0.5–1 cm wide, and the skin incision is extended along the axis of the limb along the neurovascular bundle for a length sufficient to inspect all blind pockets of the wound and excise non-viable tissues. Next, the fascia and aponeurosis are dissected along the skin incision. This provides a good view of the wound and reduces muscle compression due to swelling, which is especially important for gunshot wounds.

After dissection of the wound, scraps of clothing, blood clots, freely lying foreign bodies are removed and the excision of crushed and contaminated tissues is started.

Muscles are excised within healthy tissues. Non-viable muscles are dark red, dull, do not bleed on incision, and do not contract when touched with tweezers.

Intact large vessels, nerves, tendons during the treatment of the wound should be preserved, contaminated tissues are carefully removed from their surface. (small bone fragments freely lying in the wound are removed, sharp, devoid of periosteum, protruding into the wound, the ends of the bone fragments are bitten off with wire cutters. If damage to the vessels, nerves, tendons is detected, their integrity is restored. non-viable tissues and foreign bodies are completely removed, the wound is sutured (primary suture).

Late debridement performed according to the same rules as the early one, but with signs of purulent inflammation, it comes down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissues, opening streaks, pockets, hematomas, abscesses to provide good conditions for the outflow of wound discharge.

Excision of tissues, as a rule, is not performed due to the risk of generalization of infection.

The final stage of the primary surgical treatment of wounds is the primary suture, which restores the anatomical continuity of tissues. Its purpose is to prevent secondary infection of the wound and create conditions for wound healing by primary intention.

The primary suture is applied to the wound within a day after the injury. The primary suture, as a rule, also ends with surgical interventions during aseptic operations. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmon and excision of necrotic tissues, providing postoperative period good conditions for drainage and prolonged washing of wounds with solutions of antiseptics and proteolytic enzymes.

A primary delayed suture is applied up to 5–7 days after the primary surgical treatment of wounds until granulations appear, provided that the wound has not suppurated. Delayed sutures can be applied in the form of provisional sutures: the operation is completed by suturing the edges of the wound and tightening them after a few days, if the wound has not suppurated.

In wounds sutured with primary suture, inflammatory process weakly expressed and healing occurs by primary intention.

To the Great Patriotic War due to the risk of infection, primary surgical treatment of wounds was not performed in full - without the imposition of a primary suture; primary delayed, provisional sutures were used. When acute inflammation subsided and granulations appeared, a secondary suture was applied. The widespread use of the primary suture in peacetime, even when treating wounds at a later time (12–24 hours), is possible due to targeted antibiotic therapy and systematic monitoring of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the sutures. The experience of the Second World War and subsequent local wars showed the inexpediency of using a primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of the possibility of systematic monitoring of the wounded in military field conditions and at the stages of medical evacuation.

The final stage of the primary surgical treatment of wounds, delayed for some time, is the secondary suture. It is applied to a granulating wound in conditions where the danger of wound suppuration has passed. Terms of application of the secondary suture from several days to several months. It is used to speed up wound healing.

An early secondary suture is applied to granulating wounds within 8 to 15 days. The edges of the wound are usually mobile, they are not excised.

A late secondary suture is applied at a later time (after 2 weeks) when cicatricial changes have occurred in the edges and walls of the wound. The convergence of the edges, walls and bottom of the wound in such cases is impossible, therefore, the edges are mobilized and the scar tissue is excised. In cases where there is a large defect in the skin, a skin graft is performed.

Indications for the use of a secondary suture are: normalization of body temperature, blood composition, satisfactory general condition of the patient, and on the part of the wound, the disappearance of edema and hyperemia of the skin around it, complete cleansing of pus and necrotic tissues, the presence of healthy, bright, juicy granulations.

Apply different kinds sutures, but regardless of the type of suture, it is necessary to follow the basic principles: there should be no closed cavities, pockets in the wound, the adaptation of the edges and walls of the wound should be maximum. The sutures should be removable, and ligatures should not remain in the sutured wound, not only from non-absorbable material, but also from absorbable, since the presence of foreign bodies in the future can create conditions for suppuration of the wound. With early secondary sutures, granulation tissue must be preserved, which simplifies the surgical technique and saves barrier function granulation tissue preventing the spread of infection to surrounding tissues.

The healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by the type of primary intention, in contrast to true primary intention, since, although the wound heals with a linear scar, processes of scar tissue formation occur in it through the maturation of granulations.

Wound drainage

Wound drainage plays an important role in creating favorable conditions for the course of the wound process. It is not always carried out, and the indications for this procedure are determined by the surgeon. By modern ideas wound drainage, depending on its type, should provide:

Removal of excess blood from the wound (wound contents) and thus prevention of wound infection (any kind of training);

Tight contact of wound surfaces, which helps to stop bleeding from small vessels (vacuum drainage of spaces located under the flaps);

Active cleansing of the wound (during its drainage with constant postoperative irrigation).

There are two main type of drainage: active and passive (Fig. 1).

Types of wound drainage and their characteristics

Rice. left. Types of wound drainage and their characteristics

Passive drainage

It involves the removal of wound contents directly through the line of skin sutures and is able to provide drainage of only the superficial sections of the wound. This provides for the imposition, first of all, of an interrupted skin suture with relatively wide and leaky intersutural spaces. It is through them that drains are installed, which can be used parts of drainage pipes and other available material. By spreading the edges of the wound, drains improve the outflow of wound contents. It is quite clear that such drainage is most effective when installing drains, taking into account the action of gravity.

In general, passive wound drainage is simple, reverse side which is its low efficiency. Drainage with a piece of glove rubber in the photo on the left. It is obvious that passive drainages are not able to provide drainage of wounds with a complex shape, and therefore can be used, first of all, for superficial wounds located in those areas where the requirements for the quality of the skin suture can be reduced.

Active drainage

It is the main type of drainage of complex wounds and involves, on the one hand, sealing the skin wound, and on the other hand, the presence of special drainage devices and tools for conducting drainage tubes (Fig. 2).

Standard devices for active wound drainage with a set of conductors for conducting drainage tubes through tissues.

Figure 2. Standard devices for active wound drainage with a set of conductors for passing drainage tubes through tissues.

An important difference of the active wound drainage method is its high efficiency, as well as the possibility of wound drainage by floor. In this case, the surgeon can use the most precise skin suture, the quality of which is fully preserved when the drainage tubes are removed away from the wound. It is advisable to choose the places where the drainage tubes exit in “hidden” areas, where additional pinpoint scars do not impair aesthetic characteristics ( hairy part head, armpit, pubic area, etc.).

Active drains are usually removed 1-2 days after surgery, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.

The greatest drainage effect is provided by tubes made of a non-wettable material (eg silicone rubber). The lumen of the PVC tubing can quickly become blocked by blood clotting. The reliability of such a tube can be increased by its preliminary (before installation in the wound) washing with a solution containing heparin.

Drainage panaritium: a) drainage tube; b) introduction of the tube into the wound; c) washing; d) removing the tube.

Failure to drain or its lack of effectiveness can lead to the accumulation of a significant amount of wound contents in the wound. The further course of the wound process depends on many factors and can lead to the development of suppuration. However, even without the development of purulent complications, the wound process in the presence of a hematoma changes significantly: all phases of scar formation are lengthened due to a longer process of intrawound hematoma organization. A very unfavorable circumstance is a long-term (several weeks or even months) increase in the volume of tissues in the area of ​​the hematoma. The scale of tissue scarring increases, the quality of the skin scar may worsen.

Factors contributing to wound healing:

General state organism;

The state of nutrition of the body;

Age;

Hormonal background;

Development of a wound infection;

Condition of oxygen supply;

Dehydration;

immune status.

Types of wound healing:

Healing by primary tension- fusion of the edges of the wound without visible cicatricial changes;

Healing secondary tension- healing through suppuration;

- healing under the scab - under the formed crust, which should not be removed prematurely, additionally injuring the wound.

Stages of wound dressing:

1. Removing the old bandage;

2. Inspection of the wound and the surrounding area;

3. Toilet skin surrounding the wound;

4. Wound toilet;

5. Manipulations in the wound and preparing it for the application of a new dressing;

6. Applying a new bandage;

7. Bandage fixation (see Desmurgy section)

Wounds. Classification of wounds.

Wound(vulnus) - mechanical damage to tissues or organs, accompanied by a violation of the integrity of their integuments or mucous membranes. It is the violation of the integrity of the integumentary tissues (skin, mucosa) that distinguishes wounds from other types of damage (bruise, rupture, sprain). For example, rupture of lung tissue caused by blunt trauma chest, is considered a rupture, and in case of damage when struck with a knife - a lung wound, because there is a violation of the integrity of the skin.

It is necessary to distinguish between the concept of "wound" and "wound". In essence, a wound is the end result of tissue damage. The concept of injury (vulneratio) is understood to mean the process of damage itself, the entire complex and multifaceted totality pathological changes, which inevitably arise during the interaction of tissues and a wounding projectile both in the area of ​​​​damage and throughout the body. However, in daily practice the terms wound and injury are often used interchangeably and are often used interchangeably.

The main signs of a wound

The main classical signs of wounds are:

Bleeding;

Violation of tissue integrity;

Violation of functions.

The severity of each symptom is determined by the nature of the injury, the volume of damaged tissues, the characteristics of the innervation and blood supply of the wound canal zone, the possibility of injuring vital organs

Elements of any wound are:

Wound cavity (wound channel);

The bottom of the wound.

The wound cavity (cavum vulnerale) is a space bounded by the walls and bottom of the wound. If the depth of the wound cavity significantly exceeds its transverse dimensions, then it is called the wound channel (canalis vulneralis).

Wounds are classified on various grounds.

1. By the nature of tissue damage:

stab wounds applied with a stabbing weapon (bayonet, needle, etc.). Anatomical feature their is a significant depth with little damage to the integument. With these wounds, there is always a danger of damage to vital structures located deep in tissues, in cavities (vessels, nerves, hollow and parenchymal organs). Appearance and discharge from puncture wounds Does not always provide sufficient evidence for a diagnosis. So, with a stab wound of the abdomen, it is possible to injure the intestine or liver, but the discharge of intestinal contents or blood from the wound usually cannot be detected. With a stab wound, in an area with a large array of muscles, a large artery may be damaged, but there may be no external bleeding associated with muscle contraction and displacement of the wound channel. An interstitial hematoma is formed, followed by the development of a false aneurysm.

Puncture wounds are dangerous because, due to the small number of symptoms, damage to deep-lying tissues and organs can be seen, therefore, a particularly thorough examination of a sick wound is necessary, also because microorganisms are introduced into the depths of the tissues with a wounding weapon, and wound discharge, not finding a way out , serves as a good nutrient medium for them, which creates a special favorable conditions for the development of purulent complications.

cut wounds applied with a sharp object. They are characterized by a small number of destroyed cells; surrounding Pishi are not damaged. The gaping of the wound allows you to examine the damaged tissues and creates good conditions for the outflow of the discharge. With an incised wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they tend to turn them into incised wounds.

Chopped wounds applied with a heavy sharp object (checker, ax, etc.). Such wounds are characterized by deep tissue damage, wide gaping, bruising and concussion of surrounding tissues, which reduces their resistance and regenerative abilities.

Bruised and lacerated wounds (crushed) are the result of the impact of a blunt object. They are characterized by a large number of mashed, bruised, blood-soaked tissues with a violation of their viability. Bruised blood vessels are often rhombic. In bruised wounds, favorable conditions are created for the development of infection.

scalped wounds wounds tangent to the surface of the body, caused by a sharp cutting object. If at the same time the flap remains on the leg, then such a wound is called patchwork.

Bite wounds are characterized not so much by extensive and deep damage as by severe infection with the virulent flora of the mouth of a person or animal. The course of these wounds more often than others is complicated by the development acute infection. Bite wounds can be infected with the rabies virus.

poisoned wounds- these are wounds into which poison enters (when bitten by a snake, scorpion, penetration of toxic substances), etc.

gunshot wounds - special among the wounds. They differ from all others in the nature of the injuring weapon (bullet, fragment); the complexity of the anatomical characteristics; a feature of tissue damage with zones of complete destruction, necrosis and molecular shaking; high degree of infection; a variety of characteristics (through, blind, tangent, etc.).

I distinguish the following elements of a gunshot wound:

- wound channel area- zone of direct impact of the traumatic projectile;

- injury zone- zone of primary traumatic necrosis;

- molecular jar zone- zone of secondary necrosis;

A special approach in the treatment of such wounds, moreover, is very different in peacetime and in wartime, at the stages of medical evacuation.

2. Due to damage to the wound divided into operational (deliberate) and accidental.

3. By infection allocate wounds aseptic, freshly infected and purulent.

Purulent wound (burn) with areas of necrosis

4. In relation to body cavities(cavities of the skull, chest, abdomen, joints, etc.) distinguish between penetrating and non-penetrating wounds. Penetrating wounds are of great danger due to the possibility of damage or involvement in the inflammatory process of the membranes, cavities and organs located in them.

5. Distinguish between simple and complicated wounds in which there is any additional tissue damage (poisoning, burns) or a combination of soft tissue injuries with damage to bones, hollow organs, etc.

The course of the wound process

The development of changes in the wound is determined by the processes occurring in it and the general reaction of the body. In any wound there are dying tissues, hemorrhages and lymphorrhages. In addition, one or another amount of microbes gets into wounds, even clean ones, operating ones.

From all variety of surgical operations, to-rymi in us, the current time has operational surgery, two operations have the expressed and great state and social value. These are the operations:

Primary surgical treatment of the wound;

Amputation operation

The state and social significance of the noted operations is based on two principles:

Reducing the terms of treatment and disability;

Prevention of deep disability of the wounded.

Primary surgical treatment of the wound called a complex surgical operation performed in the first 24-48 hours from the moment of injury (before the development of infection) in order to prevent infectious complications in the wound and prevent severe complications associated with damage to vital organs and tissues. The operation solves the following tasks :

Remove non-viable tissues from the wound, representing a good nutrient medium for microflora;

Remove foreign bodies;

Stop the bleeding;

Find damage to vital organs, large vessels and, if possible, eliminate these damage.

Classification of the operation of primary surgical treatment of the wound :

Early - up to 24 hours; --- delayed - up to 48 hours; --- late - over 48 hours.

On the basis of the tasks set, the operation consists of strictly defined stages developed over several centuries of wars, and which are currently mandatory. Neglect of these rules leads to severe complications of the course of the wound process and disability of the victim.

When it comes to wounds, first of all always referring to gunshot wounds, since the complexity of their structure, expressed in morphological and functional changes, to-rye extend far beyond the wound channel, make their treatment very difficult.

The stages of the operation of surgical treatment are associated with the features of the morphology of gunshot wounds. It is necessary to pay attention to the fact that in case of gunshot wounds, a wounding projectile-bullet, fragment, flying at high speed, have high kinetic energy. This is their distinguishing feature from edged weapons, which do not have such destructive power.

At the moment of contact with the body, the kinetic energy of the injuring projectile is transferred to the tissues. Parts of clothing are torn out, then skin, subcutaneous tissue, fascia, muscles, and bones are destroyed. Part of the kinetic energy is transferred to these particles, and they begin to behave like a wounding projectile. A stream of particles of destroyed tissues is formed around the bullet. This flow rushes through the tissues at the speed of a bullet, but the direction of its movement is both parallel to the trajectory of the bullet and in the radial direction. At the same time, air enters the wound channel, which is affected by the kinetic energy of the bullet, and gas bubbles are formed from the destruction of tissues. In the process of injury, a temporary pulsating cavity is formed, which subsides as the projectile passes. Then it is formed again in a smaller volume. The described both factors acting at the moment of injury (the flow of particles, destroyed tissues and a temporary pulsating cavity) contribute to extensive destruction of tissues, deep penetration of foreign bodies and the development of infection in the tissues.

As a result of a gunshot wound, a wound channel is formed, filled with blood clots, wound detritus, foreign bodies, to Krom the zone of primary necrosis is directly located. These are dead tissues destroyed at the moment of injury (direct impact zone). Tissues adjoin them, changes in to-rykh are less pronounced (zone of side impact and zone of molecular concussion and vasomotor disorders). Changes in this zone are reversible, but if surgery is not performed, this extensive zone of lateral impact becomes a zone of secondary necrosis due to compression in the fascial cases of edematous muscles and disruption of their blood supply due to prolonged arterial spasm (up to 24 hours), which contributes to the development of anaerobic infection . In this way, features of gunshot wounds is a combination of the following:

Formation of a tissue defect along the wound channel;

The presence of a zone of dead tissue around the wound channel;

Development of circulatory and nutritional disorders in tissues bordering the wound area;

Contamination of the wound with various microorganisms and foreign bodies.

All of the above determines the course of the operation of the primary surgical treatment of the wound.

Stages of primary surgical treatment of the wound:

Dissection of the wound. Begin with a dissection of the skin, subcutaneous adipose tissue. Then dissect the fascia and muscles. On the limbs, the dissection is performed along the axis of the limb, i.e., along the course of the neurovascular bundles. For the correct execution of the dissection of the wound, it is necessary to know the projections of the neurovascular bundles. At the first stage, the surgeon solves the problem of creating an optimal wide operative access in order to qualitatively solve the main tasks of the operation, i.e., to perform a high-quality operative reception. During primary surgical treatment (PST) of wounds on the face, this stage of the operation is usually not done, or if it is done, then in the presence of deep local wounds and large pockets, usually in the submandibular region.

Excision of non-viable tissues. The excision starts from the skin. The edges of the wound are sparingly excised within a few millimeters (2-3 mm). Exfoliated but viable skin remains. The skin is protected to close the wound as much as possible at the end of the operation. The subcutaneous tissue is excised more widely. adipose tissue. Fatty tissue can be removed more - all subcutaneous fatty tissue, contaminated and saturated with blood, is excised, since this is a good environment for pyogenic and putrefactive infection. Own fascia rarely has to be excised widely, only scraps are excised in the fascia. It should be noted that the wounds of the fascia, as a rule, are perforated in nature, and the destruction of the muscles is significant (large side impact zone). Developing traumatic edema leads to compression of the damaged muscles in the fascial cases and a sharp deterioration in the blood supply to the tissues in the lateral impact zone - secondary necrosis quickly sets in. Therefore, when treating wounds of the limbs, the own fascia is dissected with a wide longitudinal incision and supplemented with transverse notches in the form of the letter Z. Such an operative technique is called decompressive fasciotomy.

Next, the muscles are widely excised. At the same time, they strive to excise all non-viable muscles. Damaged and non-viable muscles have a dark crimson color, are saturated with blood, and do not contract. Crushed muscles are an excellent environment for anaerobic microflora, which develops especially well in closed fascial cases on the limbs. The stage of muscle excision is especially important in gunshot wounds of the extremities, which is associated with the morphological features of the gunshot wound listed above and the sheath structure of the fascial system on the extremities.

Next, the muscles are carefully excised. Thus, at the second stage, the surgeon must excise all non-viable tissues and partially tissues of the lateral impact zone, preferably within healthy tissues. Excision is performed to the entire depth of the wound channel. Summing up, it should be noted that excision and dissection create favorable conditions for healing.

In parallel with excision, the surgeon conducts an audit of the wound, determines the depth of penetration of the injuring projectile, the nature of the injury (blind, penetrating), the direction of the wound channel, the severity of damage to organs and tissues. If large vessels are damaged, then the bleeding is stopped. When the main vessels are injured, the issue of a vascular suture, prosthetics of the vessels or ligation of the vessel is decided. The stage of wound revision is especially important for wounds localized in the projection of the head, chest, and abdomen. In these areas, injuries can be of a penetrating nature with damage to internal organs and the development of life-threatening complications. With head injuries, complications can be associated with hemorrhages in the cranial cavity and the formation of hematomas, damage to the substance of the brain. With penetrating wounds of the chest, pneumothorax, hemothorax, damage to internal organs, lungs, and heart develop. With penetrating wounds of the abdomen, damage to the hollow organs of the abdomen causes peritonitis; with injuries of the liver, spleen, hemoperitoneum is formed. If the penetrating nature of the wound is revealed during PST, a wide operational access is made, the damaged organ is found and its suture or resection is performed, the recovery stage of the operation.

The final stage of the operation. The closure of the surgical wound in PHO is carried out strictly individually. When deciding whether to close a wound, one should take into account the nature of the wound, its location, the duration and quality of PST. Consideration of the conditions in which further treatment will take place after PST. With incised and chopped wounds, under conditions of constant monitoring of the patient, a primary suture can be applied to the wound.

With gunshot wounds, the wound remains open. Swabs moistened with antiseptic liquids, wound irrigation tubes and drains are introduced into the wound. In the absence of purulent-inflammatory complications between 4 and 7 days after treatment, a primary delayed suture is applied.

Classification of seams after PST:

Primary seam;

Primary delayed suture (imposition period 5-7th day);

Secondary early seam (overlay period 8-15th day);

Secondary late seam (overlay period 20-30th day).

Lecture 15 TOPOGRAPHIC ANATOMY OF LARGE JOINTS OF THE LIMB, PRINCIPLES OF OPERATIONS ON THE JOINTS.

Lecture plan:

The general design of the joints, the value in pathology;

The structure of large joints upper limb(shoulder, elbow);

Joint Features lower limb, the structure of the knee and hip joints;

Principles and types of operations on the joints (puncture, arthrotomy, arthrodesis, arthrosis, joint resection, joint plasty).

Diseases and injuries of large joints of the extremities are very common. Therefore, knowledge of the topographic anatomy of large joints is of great interest to doctors of various specialties. First of all, of course, for traumatologists-orthopedists, therapists-specialists in diseases of the joints, as well as pediatricians, infectious disease specialists, dermatovenereologists. Knowledge of the topographic anatomy of the joints makes it possible to make a correct diagnosis, to make a differential diagnosis of articular and periarticular lesions, and for an orthopedist it makes it possible to perform corrective operations on the joints. In the lecture, we will touch on the topographic anatomy of large joints: shoulder, elbow, hip, knee. This is due to the fact that they are most often affected by injuries and various diseases, sometimes leading to a deep disability of the patient.

General design of limb joints includes the following elements:

The articular surfaces of the bones that determine the shape of the joint and are covered with articular cartilage;

Joint capsule, consisting of a fibrous layer and a synovial membrane;

Ligamentous apparatus that strengthens the joint capsule;

torsion of the synovial membrane;

Silly bags;

Intra-articular formations.

SHOULDER JOINT

The shoulder joint refers to joints with a large range of motion, formed by the head and articular surface of the scapula. The joint belongs to weakly congruent joints, since the head of the shoulder is immersed in the gentle articular surface of the scapula only by 1/3. Thus, the articular surface of the scapula is 3 times smaller than the articular surface of the head of the shoulder. The joint has the largest joint cavity. To some extent, this discrepancy between the articular surfaces is compensated by a cartilaginous lip along the edge of the articular surface of the scapula. From above, in front and partially behind the joint is protected by bony protrusions of the scapula, shoulder (acromion) and coracoid processes (processus coracoideus) and the coracobrachial ligament (lig. coracoacromiale) connecting them, forming the arch of the shoulder. The arch of the shoulder protects the joint from above and inhibits the abduction of the shoulder and raising the arm above shoulder level. The joint capsule is the largest, spacious. It is stretched weakly, which helps to carry out a large range of movements in the statute. Greater mobility leads to loss of joint stability. Stability depends mainly on the muscles and ligaments of the rotator cuff. The capsule is almost devoid of reinforcing ligaments.

Shoulder ligaments:

Lig. glenohumerale superior, medius (front), inferior;

Lig. coracohumerale;

Lig. coracoacromeale.

The last ligament and processes of the scapula form the arch of the joint, which inhibits raising the arm up and abducting the shoulder above shoulder level. Movements above are due to the entire shoulder girdle.

The joint capsule is well strengthened by the tendons of the muscles that form the rotator cuff of the shoulder and ensure the stability of the shoulder joint. The rotator cuff is made up of the supraspinatus, infraspinatus, and teres minor muscles attached to the greater tubercle of the humerus. The subscapularis attaches to the lesser tubercle of the humerus. The lower part of the capsule of the shoulder joint from the axillary fossa is not strengthened by muscles. It is a weak point - capsule ruptures easily occur here.

The inner surface of the joint is lined with a synovial membrane, which extends beyond the attachment of the fibrous joint capsule, forming inversions or eversion of the synovial membrane. These are peculiar pockets that provide redistribution of intra-articular fluid during movements in the joint in various directions. With arthritis, the infection breaks through to neighboring areas.

Torsion of the synovial membrane of the shoulder joint:

Intertubercular volvulus (recessus intertubercularis or vagina sinovialis caput longum m. biceps);

Subscapular torsion (recessus subscapularis);

Axillary torsion (recessus axillaries).

The direction of streaks in purulent arthritis of the shoulder joint is determined by the position of the torsions.

The presence of a wide capsule at the shoulder joint with the formation of a large axillary torsion causes a high frequency of traumatic dislocations in the area of ​​the shoulder joint (41.6% of traumatic dislocations, according to Sinillo MI, 1979). This is also facilitated by the weak congruence of the articular surfaces, a thin capsule devoid of strong ligaments, and a large amount of motion in the joint. In traumatic dislocations, the displaced head of the shoulder quite easily breaks the capsule in the lower part and slips out of the articular surface of the scapula.

Projection relationships in the area of ​​the shoulder joint. The head of the humerus is projected from the front 1-1.5 cm outward from the inner edge of the deltoid muscle; behind - a line drawn from the acromial end of the clavicle down; from below - by 6-7 cm of the acromioclavicular joint.

In accordance with this, operative access to the joint cavity - arthrotomy, happens: anterior, external and posterior. When puncturing the joint, the puncture sites are similarly chosen: in front, outside or behind.

Dislocation of the shoulder may be accompanied by damage to the elements of the neurovascular bundle lying in the axillary fossa. More often than others, between the displaced articular surfaces, the axillary nerve (n. axillaries) is infringed, which threatens with paralysis and atrophy of the deltoid muscle, since the nerve goes around the surgical neck of the shoulder and innervates the deltoid region. Less commonly, the radial nerve (n. radialis) and other nerves of the brachial plexus are infringed. Therefore, after reposition, it is necessary to check the sensitivity of the skin in the areas of innervation of the main nerves.

ELBOW JOINT

Another large joint of the upper limb, which ranks second in the frequency of traumatic dislocations, is the elbow joint (traumatic dislocations of the forearm account for 13.4%). The elbow joint is an example of a complex joint. Unlike the shoulder joint, this joint is more complex, since it consists of 3 joints in one fibrous capsule and has a common joint cavity.

It is made up of:

Shoulder joint; --- shoulder joint; --- radioulnar joint

Recall that the articular surface of the distal epiphysis of the shoulder has a complex configuration and is represented by a block for articulation with the ulna and a capitate eminence for the beam, i.e., the articular surfaces are highly congruent. Thanks to the articular surfaces, the shape of the joint looks like a block, which includes the humeroulnar and humeroradial (spherical) joints. The radioulnar joint is cylindrical in shape. The fibrous capsule of the joint is thin and rather weakly stretched. The anterior and posterior sections of the capsule are devoid of ligaments. On the lateral surfaces of the capsule there are strong ligaments - lateral ligaments, around the head radius- annular ligament ((lig. annulare radii). Due to the presence of strong lateral ligaments, high congruence of articular surfaces, the main movement in the joint is flexion, and lateral movements are completely absent. The anatomical complexity of the elbow joint explains the variety of dislocations in the elbow joint area. More often there are anterior dislocations of the forearm, less often posterior and isolated dislocations of the head of the radius in children.

Orientation anatomy helps diagnose dislocations and fractures. Bone protrusions in the area of ​​the elbow joint, the epicondyle of the humerus and the olecranon form a regular equilateral triangle with the apex down (Gunther's triangle). If the forearm is extended, then the epicondyles and the olecranon will be located on the same line - Tilho's line.

With dislocations of the forearm, there is a danger of infringement of the nerves, since the radial nerve enveloping the head of the beam and the ulnar nerve in the region of the ulnar groove lie on the joint capsule. This determines the puncture points of the elbow joint and operational approaches. The joint is punctured from two points. First, from the outside, between the external epicondyle and the head of the radius. Secondly, from the rear point above the tip of the olecranon.

LOWER LIMB JOINTS

The joints of the lower limb have their own anatomical features, which are associated with the functional features of the lower limb - supporting and depreciation. The legs of a person support the entire weight of the body. Therefore, the joints of the lower limb experience a greater physical load along the axis. Because of this, the joints of the lower limb are more massive and have a number of common adaptive mechanisms that provide a high physical load on the legs.

These include:

A powerful ligamentous apparatus that strengthens the fibrous capsule of the joints;

High congruence of articular surfaces and special auxiliary devices - intra-articular cartilage;

Intra-articular ligamentous apparatus;

Intra-articular fat bodies (shock absorbers);

Due to this, the joints of the lower limb are characterized by high stability.

HIP JOINT

This is one of the largest joints human body. In shape, it represents a kind of spherical joint - walnut. The joint is formed by the articular surface of the femoral head and the acetabulum. There is no cartilage on the lower inner surface of the acetabulum, here lies a fatty body - a pillow.

The hip joint is enclosed on all sides in a very dense fibrous capsule. The fibrous capsule starts from the edge of the acetabulum and attaches to the distal end of the neck. femur, which is very important. In front, the capsule is attached to the intertrochanteric line. And thus, the entire neck of the femur is in the cavity of the joint. The articular cavity is divided into cervical and acetabular. Therefore, fractures of the femoral neck, quite common in clinical practice in the elderly and senile age, refer to intra-articular fractures. The fibrous capsule tightly covers the neck and, in addition, the high congruence of the articular surfaces determines the low capacity of the joint, only 15-20 cubic meters. see and explains severe arching pains even with a slight hemorrhage in the joint cavity or the formation of exudate during inflammation. The density of the fibrous capsule is supplemented by ligaments:

Lig. Iliofemorale (Y-shaped) - Bertini's ligament; 1 cm can withstand stretching up to 350 kg;

Lig. Pubofemorale;

Lig. Ishiofemorale;

Lig. Transverse;

Zona orbicularis Weberi;

Lig. Capitis femoris, an intra-articular ligament 2 to 4 cm long, up to 5 mm thick, can withstand rupture up to 14 kg. It has great retention value.

However, the fibrous capsule of the hip joint has weaknesses due to the nature of the course of the ligament fibers. Weak spots are located between the ligaments in:

Anterior-internal part of the capsule, between the ligament of Bertini and the pubofemoral ligament;

The lower part of the capsule, between the pubofemoral and ischio-femoral ligaments;

Posteriorly between the iliofemoral ligament and ischiofemoral ligament.

In these places, the fibrous capsule is torn during traumatic hip dislocations, which are less common than dislocations in the upper limb, but compared to dislocations of other segments of the lower limb, quite often (from 5 to 20% according to different authors). Hip dislocations can be depending on the direction of displacement of the femoral head: posterior, anterior and iliac. Since the hip joint is surrounded on all sides by powerful muscles, it is well protected from traumatic effects, therefore, significant forces are required to dislocate the femoral head. Usually this is a serious injury, road or motorcycle, falling out of a train car on the move and in other situations.

However, the hip joint is characterized by a large range of motion with pronounced stability. Joint stability is provided by:

Strong muscles;

Strong fibrous capsule, well reinforced with ligaments;

The deep position of the femoral head in the articular cavity, deepened by the cartilaginous lip.

Between m.iliopsoas and eminentis iliopectinea of ​​the ilium there is a mucous bag (bursa iliopectinea). In addition, there is a trochanteric pouch and an ischio-buttock pouch.

Close to the anterior surface of the hip joint femoral artery. Therefore, one of the symptoms in case of damage to the hip joint is a symptom of increased pulsation of the femoral artery (Girgolav's symptom), for example, with anterior dislocations and fractures of the femoral neck. Conversely, with posterior dislocations of the hip, the pulsation disappears. It should be noted that the head of the femur is projected approximately 1 cm outward from the pulsation point of the artery.

On the posterior surface of the capsule of the hip joint lies sciatic nerve. Dislocations of the joint are sometimes accompanied by trauma to the sciatic nerve.

The correctness of the anatomical relationships in the area of ​​the hip joint during the examination of patients is confirmed by a number of reference lines:

--- Roser-Nelaton line - this is a straight line connecting three points: the anterior iliac spine (spina iliaca anterior superior), greater trochanter and ischial tuberosity; when bending the hip in the hip joint at 35 degrees;

--- Shemaker line - this is a straight line connecting three points: the greater trochanter, the anterior iliac spine and the navel;

--- Briand's triangle , the parties to-rogo are: the axis of the thigh, going through the greater trochanter, and the line drawn from the anterior upper spine backwards; connecting, they form a right triangle, the legs of which are approximately equal.

With dislocations of the hip, fractures and other pathologies in the area of ​​the hip joint, these anatomical landmarks are violated.

The joint space is projected outward from the point of pulsation of the femoral artery. Joint puncture made from two points. First, from the anterior point, the edge is located in the middle of the line between the middle of the inguinal ligament and the greater trochanter. Secondly, from a lateral point above the greater trochanter.

KNEE-JOINT

The knee joint is the largest human joint. Functionally and in form, this joint belongs to the rotational block type.

It is formed by the articular surfaces of the thigh, the condyles of the femur, the patella and the condyles of the tibia.

The congruence of the articular surfaces of the tibia is enhanced by interarticular cartilages - menisci, which are located on the condyles of the tibia with their anterior and posterior ends attached to the intercondylar eminence. Anteriorly, the menisci are connected by a transverse ligament. The outer edge of the menisci is fused with the articular capsule. With sharp flexion in the joint with simultaneous rotation of the lower leg, ruptures of the menisci can occur, more often the inner one, since it has a free edge and a posterior horn. In this case, the menisci are between the two condyles, as in millstones.

The knee joint has a thick fibrous capsule, reinforced with numerous ligaments. Allocate lateral ligaments, own patellar ligament, patella retinaculum, transverse ligament, in addition, on the back surface of the joint - oblique and arcuate.

Lateral ligaments impede lateral movements, therefore, when these ligaments are damaged, rocking movements occur; the joint space on radiographs becomes uneven.

A distinctive feature of the joint is the presence of intraarticular cruciate ligaments, anterior and posterior (lig.cruciatumanteriusetposterius). The main role of the cruciate ligaments: to limit the displacement of the lower leg back and forth. Damage to the cruciate ligaments leads to gross instability of the joint. When damaged, the lower leg moves relative to the thigh back and forth, the so-called drawer symptom.

The synovial membrane in front of the joint protrudes into the cavity in the form of two pterygoid folds, which contain a layer of fat, these are the so-called plicaalarae or fat bodies.

Cruciate ligaments, menisci, fatty bodies form a kind of depreciation system of the knee joint, a buffer-brake system, which is of great importance in the functioning of the joint.

The volume of the joint cavity is increased due to torsion of the synovial membrane. There are 9 of them in total. The largest inversion is the anterior upper one, which is formed due to the transition of the synovial membrane from the femur to the patellar tendon's own ligament. The rest are located around the cartilage of the condyles of the femur and tibia. They serve as a place of accumulation of exudate and blood. Joint puncture is made from the side points, stepping back from the patella and the upper pole.

There are mucous bags in the joint area. Highest value have bags in front of the patella (prepatellar). Prepatellar bursitis may form here.

JOINT SURGERY

Principles of operations on the joints:

Anatomical access to the joint cavity, i.e. go into the joint cavity through the places where the articular membranes are closest to the skin surface; make incisions away from important ligaments or parallel to their fibers and away from the neurovascular bundles;

Physiological approach; do not damage the ligaments and muscles at the site of attachment without special need;

Atraumatic; spare the synovial membrane and articular cartilage, do not leave coarse drainage in the cavity; restore the joint capsule strictly in layers;

Careful hemostasis; residual blood in the joint cavity causes arthrosis, the occurrence of ossification;

Technical equipment; the presence of an orthopedic table, special orthopedic instruments, a mobile x-ray machine, a plaster room with special equipment, the skill of operations on the joints.

Types of operations on the joints:

Joint puncture is a surgical procedure used for diagnostic or therapeutic purpose, at a cut make a puncture of a capsule of a joint;

Arthrotomy is a surgical operation of opening the joint and exposing the articular surfaces for the purpose of prompt access to the joint cavity;

Joint resection - surgical removal of articular surfaces and joint closure;

Joint plasty, arthrolysis - an operation to restore mobility in a joint by restoring congruent articular surfaces (arthroplasty);

Arthrodesis - an operation to create an artificial ankylosis of the joint;

Arthrosis - an operation that creates a bone brake to limit the range of motion in the joint;

Endoscopic operations on the joints.

Arthrotomy, opening surgery or exposure of the joint, is carried out according to the following indications:

Access to the joint cavity in order to remove foreign bodies in case of injuries, to remove menisci, to reduce chronic dislocations, in case of injuries and wounds, etc., in case of tumors of the articular surfaces;

In the treatment of purulent arthritis for the evacuation of pus.

Types of arthrotomy.

For arthrotomy, a place is chosen where the joint capsule is closer to the skin in order to less disrupt the ligamentous apparatus, and taking into account the position of large vessels and nerves located near the joint. At the same time, the access should be wide enough to allow a thorough examination of the joint cavity.

On the shoulder joint often do arthrotomy according to Langenbeck. Skin incision from the scapular process down or along the inner edge of the deltoid muscle. The muscle fibers are stratified and the capsule is opened. Access can also be rear and external. The posterior method of arthrotomy is less convenient, because there is a risk of damage to the axillary nerve.

For arthrotomy of the elbow joint, vertical incisions are used along the lateral surface of the joint, parallel to the ligaments, but it must be taken into account that the ulnar nerve runs along the inner surface of the joint, and the branches of the radial nerve go along the outer surface.

The hip joint can be approached by an anterolateral approach or a lateral approach with muscle dissection.

For access to the knee joint, for example, for resection of a torn meniscus, lateral and posterior approaches are used: parapatellar, transverse, oblique. But in order to make a major operation in the cavity of the knee joint, the joint is opened wide along the Textor with an arcuate incision under the patella. In this case, the ligaments have to be restored.

Joint resection– operation, at a cut removal of articulate surfaces is made. It can be economical when only cartilage and part of the epiphysis are removed, complete resection with removal of the epimetaphysis with the joint capsule. Indications are joint damage in tuberculosis, osteomyelitis with the transition to the joint. Joint resection, as a rule, ends with artificial ankylosis of the joint, joint closure, arthrodesis.

Indications for arthrodesis(operation of artificial ankylosis of the joint) serve as paralytic looseness of the joint with dysfunction of the limb. The operation is performed for tuberculosis, osteomyelitis. The joint is fixed in a functionally advantageous position and intra-articular or extra-articular arthrodesis is performed.

Arthrosis– surgery to limit the range of motion in the joint (bone brake). Produced with paralytic looseness of the joint with cerebral palsy, poliomyelitis, nerve injury in order to increase the support ability of the limb. Arthrosis is done more often on the knee or ankle joint.

Arthroplasty- restoration of mobility in the joint by recreating congruent articular surfaces. It is used for ankylosis of inflammatory or other etiology, after resection of the joint. Types of arthroplasty:

With the use of autoplastic materials; refreshing the articular surfaces and covering them with their own tissues, for example, the wide fascia of the thigh; The disadvantage of this method is the formation of adhesions and the occurrence of contractures;

With the use of alloplastic materials (ceramics, metal prostheses); for example, the use of acrylic prostheses, endoprostheses according to Zivyan, metal coatings from vitalium, ceramics.

Joint transplantation;

Full prosthetics with replacement with artificial joints.

The principle of atraumatic operations on the joints made it necessary to develop a completely new technology of operations on the joints using endoscopic techniques, in which an orthopedic traumatologist penetrates into the joint cavity by puncturing the capsule with a special surgical endoscope and performing an operative procedure through the endoscope, for example, removing a torn meniscus , intra-articular foreign bodies, etc.

Lecture 16. OPERATIONS ON VESSELS. TOPOGRAPHANATOMICAL SUBSTANTIATION OF OPERATIONS ON VESSELS. PRINCIPLES OF VASCULAR SEAM. TYPES OF OPERATIONS ON VESSELS.

Lecture plan:

Anatomical foundations of vascular surgery; --- kinds vascular operations;

Principles and types of vascular suture; --- types of operations using a vascular suture;

Vascular plastics; --- Modern trends in the development of vascular surgery.

Diseases of the cardiovascular system are one of the leading problems of modern medicine. Prevention and treatment of diseases of the blood vessels is the focus of attention of doctors of various profiles: therapists, surgeons. In the last 20-30 years, vascular surgery has been rapidly developing due to the introduction of new methods of diagnostics and surgical treatment into clinical practice. However, it should be recalled that operative vascular surgery is based on knowledge of the topographic anatomy of the vascular system. Perhaps, it is precisely in vascular pathology and in vascular surgery that the fundamental importance of anatomy for the general practitioner and surgeon is more acutely manifested! Of great importance to the practitioner are three fundamental questions of the topographic anatomy of the vascular system:

The doctrine of the patterns of construction of fascial sheaths of neurovascular bundles, or, in other words, the doctrine of paravasal connective tissue structures;

The doctrine of individual constitutional variability in the structure of the vascular system;

The doctrine of collateral circulation.

One of the important prerequisites for the development of surgery of blood vessels was the teaching of NI Pirogov about the regularities of the location of the vessels of the extremities in relation to the surrounding tissues, which is set out in the clinical work "Surgical Anatomy of Arterial Trunks and Fascia", published in 1837. The greatest merit of Pirogov lies in the fact that he was the first to formulate the most important laws for the construction of vascular sheaths. These laws remain a guide to action during operations on the main vessels of the extremities.

To date, the complex of connective tissue formations around the vessel is united by a common name - paravasal structures. They include:

Common fibrous sheath of the neurovascular bundle;

Own fibrous sheaths of the artery, vein and nerve;

Paravasal fissure filled with loose fiber;

Connective tissue spurs;

Paravasal nerves and vascular tracts.

All of these elements are of great importance for the normal functioning of the vessels, and their violation in pathology is accompanied by a violation of the function of the vessels.

The second fundamental question of topographic anatomy is the doctrine of individual variability of the vascular-nervous system, the main position of which is the dependence of the structure of the vascular-nervous system on body type. There are two extreme types - dolichomorphic and brachymorphic body type. They correspond to two types of structure of the vascular-nervous system - loose and main. This is of particular importance in pathology and should be taken into account during operations.

The third fundamental issue of topographic anatomy - the doctrine of collateral circulation allows us to understand the compensatory capabilities of the vascular system in violation of blood flow through the main vessels (with thrombosis, embolism, compression). In addition, taking into account the collateral circulation, forced ligation of blood vessels is performed in case of injuries, plastic surgeries. So, we already know that it is better to ligate the axillary artery below the origin of the subscapular artery in order to maintain roundabout blood flow through the scapular arterial circle, and to prevent gangrene of the lower limb, ligation of the femoral artery is done below the origin of the deep artery of the thigh. Let us pay attention to the fact that collaterals can be intrasystemic - these are branches of the same artery and the paravasal vascular bed, and intersystemic - anastomoses between vessels of different areas. In case of insufficiency of natural collaterals, they can be formed artificially. To do this, you can use an oil seal. It is also possible to stimulate the opening of collaterals by dissecting the sympathetic nerves running in the paravasal tissue - periarterial sympathectomy.

Thus, operations on vessels are performed taking into account the noted fundamental provisions.

All surgical techniques used in operations on the vessels can be divided into the following types:

Ligation of vessels; --- operations on the sympathetic nervous system;

Operations with the use of a vascular suture.

The most historically ancient type of operations on vessels - ligation was considered in practical classes.

Consider operations on vessels using a vascular suture. The modern principles and technique of the vascular suture were laid down by Alexis Carrel. He was born in France in 1873. This is an outstanding experimental surgeon, who worked in the USA and dealt with the issues of kidney transplantation. For the development of the technique of vascular suture and work on kidney transplantation in animals, he was awarded the Nobel Prize in 1912. The technique of the seam, which he used, is as follows. After temporary clamping of the vessel with clamps, the ends of the vessel are brought together by three sutures-holders applied along the perimeter of the vessel at the same distance from each other through all layers of the vessel wall. The vessel is stretched by these holders, after which the lumen of the vessel takes the form of an equilateral triangle. After that, all three sides of the vessel are sewn with a continuous twist stitch. To date, there are many modifications of the vascular suture.

They can be divided into two groups:

Twisted seams - Carrel, Morozova; --- turning seams.

The second group of vascular sutures makes it possible to compare the inner surfaces of the vessels more carefully. The most widespread are Gorsley's suture, Polyantsev's suture (1945), Braitsev's suture.

Regardless of the type of vascular suture, it must meet the following principles:

The sutured ends of the vessel must touch along the seam line with their inner shell - intima to intima;

Atraumatic - careful handling of intimacy;

The suture material should not protrude into the lumen of the vessel to avoid thrombosis;

tightness;

The seam should not narrow the lumen of the vessel;

Types of operations with the use of a vascular suture:

Vessel suture in case of injury;

Reconstructive and plastic surgery on vessels in vascular diseases;

Reconstructive operations on vessels in diseases of organs (heart, liver, lungs5);

Organ transplantation.

With the improvement of the technique of the vascular suture, it became possible to restore traumatic damage to the vessels, which made it possible in a number of cases to avoid amputation of limbs, and in last years the technique of attaching a completely severed limb has been developed.

But most operations using a vascular suture are performed not for injuries, but for diseases with impaired patency of the vessel due to narrowing or occlusion of its lumen by a pathological process (for example, atherosclerosis, nonspecific aortoarteritis). Such diseases are singled out in a special group - occlusive vascular diseases.

Reconstructive and plastic surgery on vessels using a vascular suture:

Embolectomy; --- intimendarterectomy; --- bypass shunting; - replacement of a section of the vessel.

One of the terrible complications of cardiovascular diseases is thromboembolism of the main vessels, when a large vagus embolus wedged into one or another part of the vessel and disrupts its patency. In this case, an operation is used - embolectomy using a Fogarty balloon probe (indirect embolectomy). In easily accessible anatomical areas, direct embolectomy is used.

Often, with atherosclerosis, an overgrown atherosclerotic plaque narrows the lumen of the blood vessel and disrupts blood flow, as in nonspecific aortoarteritis. Then the operation of thrombointimectomy and endarterectomy is used. The muscular layer and adventitia remain during these operations.

If the vessel is affected for a significant extent, then prosthetics (replacement of the vessel) or bypass shunting with a prosthesis is used. As a prosthesis, the patient's own vessels (for example, an autovein) or synthetic prostheses can be used.

Types of vascular prostheses:

1.Biological:

Autovena;

Homoprostheses - lyophilized cadaveric vessels, umbilical cord;

Heteroprostheses (xeno-) - processed animal vessels [ aortograft (USA, sleepy

arteries of cattle), Solcograft (1986, Switzerland, carotid arteries calves)]

2.Synthetic:

Materials from lavsan, nylon, teflon, fluorolone, etc. are used.

Dentures with a velor inner surface;

Prostheses with a silver frame;

Antithrombogenic prostheses.

Materials for vascular plastics:

Autovena (Carrel) – v. saphena magna; --- homotransplants (left);

Heterografts (left); --- synthetic fabric prostheses - dacron, lavsan, ftorlon.

The possibilities of creating prostheses with an antithrombogenic surface, the introduction of anticoagulants are being studied. Giving an electronegative potential to the prosthesis - to prevent thrombosis. Created prostheses with a silver frame. Created antimicrobial prostheses.

Requirements for prostheses:

Should not be pathogenic; ---should not be allergenic;

Should not destroy tissue; --- must not be thrombogenic;

Should not be carcinogenic; --- strength;

Flexibility elasticity; --- ease of sterilization;

Durability (modern prostheses lose up to 60-80% of their strength after 5 years).

Unfortunately, prostheses that fully meet all these criteria have not yet been created.

EXAMPLES OF OPERATIONS USING PROSTHETICS

Along with operations for vascular diseases, with the development of the vascular suture technique, it became possible to treat a number of diseases. internal organs using vascular surgery. For example, with complex congenital heart defects, when a one-stage radical operation is dangerous. In patients with tetralogy of Fallot, an anastomosis can be made between the pulmonary artery and branches of the aortic arch, or the connection of the aorta with the pulmonary artery using a vascular prosthesis.

With cirrhosis of the liver, a syndrome of portal hypertension develops (increased pressure in the portal vein), which is dangerous for bleeding from varicose veins of the esophagus. To reduce pressure in the portal vein and prevent bleeding, operations are used to create porto-caval anastomoses using a vascular suture - the portal vein is sutured into the vena cava.

The progress of vascular surgery does not stop today. A new direction in vascular surgery has appeared - X-ray endovascular methods for the treatment of vascular diseases. A number of promising operations have already been developed and introduced into clinical practice, the main principle of which is a more gentle operation mode with minimal trauma to the patient and blood vessels.

Here are some of them:

X-ray endovascular sealing of cerebral aneurysms. If earlier, with aneurysms of cerebral vessels, trepanation of the skull was performed with the vessel with the aneurysm turned off or its plasty, then at present, probing of the cerebral vessels through the common carotid artery or femoral artery and sealing the aneurysmal sac with plastic is performed.

X-ray endovascular dilatation of blood vessels. An example would be coronary arteries, iliac arteries. The methodology looks like this. Under local anesthesia, the femoral artery is probed according to Seldinger. A probe with a balloon is inserted into the desired segment of the vascular system and a contrast agent is injected into the balloon under pressure until the vessel expands to the desired diameter. After the procedure is completed, the balloon is emptied. The procedure is carried out several times until the dilation effect is achieved.

X-ray endovascular prosthetics of vessels. After a simple balloon expansion of the vessel, a relapse may occur. Therefore, to prevent it, a folded helix or stent made of a special alloy, nitinol (nickel-titanium alloy) - an alloy with "memory" is inserted into the expanded area (after dilatation). In the vessel, under the influence of body temperature, the spiral of this alloy expands to the planned width and this section of the vessel is maintained in a dilated state, which improves blood flow in this segment of the vessel.

Use of a laser. This is the cutting edge of vascular surgery. In the All-Russian Scientific Center of Surgery (Moscow), a laser was successfully used in the experiment to evaporate atherosclerotic plaques in the coronary, renal and other arteries. In this case, a light guide is inserted into the lumen of the vessel, which is brought to the plaque, and a laser pulse is applied to evaporate the plaque.

Summing up what has been said, it should be noted that vascular surgery is the most rapidly developing area of ​​modern surgery - the surgery of the future.

Lecture 17 THE DOCTRINE ABOUT AMPUTATIONS. LIMB REPLANTATION.

Lecture plan:

Definition and indications for surgery;

Types of amputation by timing and technique;

The main stages of the operation;

Features of amputations in children;

Limb replantation.

Amputation is an operation in which the peripheral part of the limb is removed along the length of the bone. A variation of amputation is exarticulation - removal at the level of the joint.

Information about amputation dates back to ancient times. Probably, the indications for amputation then were mainly injuries during hunting or military operations. Despite a long history, the operation retains its practical significance to the present, and its technique continues to improve.

The operation is of great national and social importance. First, because of its crippling nature, as a rule, it leads to a deep disability of the patient. Therefore, according to the decision of the 27th All-Union Congress of Surgeons (1965), the decision on amputation is made by a council of three doctors, and the patient is informed about the nature of the operation. Secondly, the operation has a restorative character, its purpose is to return the patient to an active life. Therefore, the quality of the operation contributes to early prosthetics and the return of the patient, at least partially, to work.

Modern indications for amputation can be divided into 5 groups:

The first group of indications is traumatic lesions of the limbs (42% in peacetime):

Traumatic avulsion of a limb;

Extensive crushing of limb tissues with rupture of the main neurovascular bundles and loss of soft tissues by more than 2/3 of the volume;

Damage to the neurovascular bundles, if it is impossible to apply a vascular suture;

Thermal burns of the 4th degree (charring);

electrical injury;

Frostbite of extremities, but not earlier than the 12-14th day from the moment of frostbite - after the formation of a demarcation line.

The first group of indications for amputation can be called primary. Amputations with them are performed in the first hours after the injury, before the development of clinical signs of infection in the wound, and is, as a rule, in the nature of the primary surgical treatment of the wound. This group increases markedly during hostilities. According to the experience of the Second World War, amputation was performed in 26% of the wounded.

The second group of indications is severe purulent-septic complications of wounds of the extremities and infectious diseases of the tissues of the extremities.

Progressive gas anaerobic infection, not amenable to intensive antibiotic therapy, the so-called, fulminant form; according to the experience of the Second World War, amputation for gas infection was 14.4% of the total number of amputations, and was performed in 43.2% of patients with gas gangrene;

Progressive purulent infection of wounds, not amenable to intensive antibiotic therapy and threatening sepsis;

(These two indications can be attributed to secondary indications; the operation is preceded by conservative therapy, and surgical treatment is performed to save the limb and life of the patient)

Purulent osteomyelitis, threatening amyloidosis of internal organs;

Osteoarticular tuberculosis with the threat of generalization of infection and amyloidosis of internal organs;

(The last two indications can be called late, because the disease can be chronic

for a long time).

The third group of indications is vascular diseases of the extremities with deep trophic disorders in the tissues (47.6% in peacetime):

Thrombosis and embolism of the main arteries with tissue necrosis, usually 5-6 hours after the embolism;

Obliterating atherosclerosis of vessels;

Obliterating endarteritis;

diabetic gangrene;

Long-existing trophic ulcers with degeneration into cancer.

The fourth group - malignant tumors limb tissues.

Fifth group - orthopedic amputations and reamputations:

Congenital deformities of the limbs;

Large bone defects due to injuries with the impossibility of plastic surgery and prosthetics;

Reoperations for vicious stumps.

According to the indications for amputation and the time of the operation from the moment of the disease NN Burdenko divided amputations into:

Early: a) primary, b) secondary.

Late;

Repeated.

According to the technical method of performing amputations, they are divided into:

Circular; --- patchwork; --- osteoplastic.

Circular amputation methods are among the oldest methods of amputation and therefore, for the most part, are no longer used due to imperfection. With circular methods of amputation, the truncation of the tissues of the limb is performed strictly perpendicular to the axis of the limb. Depending on the level of tissue truncation, circular methods are divided into guillotine method, one-, two-, three-moment methods. The guillotine method retains its practical significance, with Krom the tissues are truncated at the same level, as they are chopped off with a guillotine (Guillotin - a French doctor became famous for inventing the guillotine, 18th century). The only indication for this method is anaerobic gas infection at the stages of evacuation, where there is no specialized surgical care and continuous monitoring of the wounded. The purpose of the method is to stop the progression of the infection.

Great distribution received patchwork methods of amputation, allowing to close the wound with primary sutures, and proceed with early prosthetics of the amputee. Patchwork methods are divided into one- and two-patch. According to the composition of the tissues included in the flaps, the fascioplastic method and the myoplastic method are distinguished.

Osteoplastic methods of amputations originate from the osteoplastic amputation of the lower leg, developed by NI Pirogov in 1852. In osteoplastic amputations, to increase the support ability of the stump, the sawdust of the bone is closed with a bone graft. For the first time, this kind of bone grafting during the operation was performed by NI Pirogov. He proposed to close the stump of the tibia with sawdust of the calcaneus when amputating the lower leg. Thus, after the operation, the tissues of the heel region, intended by nature for support, were preserved. In addition, the length of the limb decreased slightly, which allowed the amputee to do without a prosthesis. Later, Pirogov's idea was further developed with amputations in other areas. Methods for amputation of the thigh were developed with the closure of the femoral stump with sawdust of the patella (the Gritti-Szymanovsky method - 1857-1863, amputation of the lower leg according to Bir - 1892). closed with a ring from the removed segment of the thigh.

Regardless of the method of amputation, the operation consists of three stages:

Cutting out the skin-fascial flap; --- dissection periosteum and bone sawing;

Toilet wound stump.

Technique of individual stages of the operation:

After introducing the patient into anesthesia, a hemostatic tourniquet or elastic bandage is applied to the root of the limb. The surgeon plans 1-2 flaps, to-rye should close the stump. At the same time, the supply of skin for contractility is added - on the thigh it is 3-4 cm. Next, the flaps are separated and pulled to the root of the limb and the muscles are truncated with an amputation knife. The latter are pulled with a retractor. The periosteum is truncated in a circular motion with a scalpel, shifted with a raspator to the distal side. The bone is cut with a frame saw.

The third stage of amputation is the most responsible - the toilet of the wound of the stump. It consists of three points:

Stop bleeding; we begin with the capture of hemostatic clamps and ligation of large arteries and veins in the wound of the stump, which are visible on the transverse section of the limb; small vessels that have contracted in the tissue are stitched with Z-shaped seams; then we remove the tourniquet and additionally stitch the bleeding places;

The second point is the truncation of the nerve; we perform anesthesia of the nerve by introducing perineurally 1% novocaine solution, pull the nerve into the wound by 3-4 cm and truncate with a safety razor blade (Albrecht's method); truncation of the nerve prevents the ingrowth of its stump into the soft tissue scar and the development of causalgia;

The final stage of the operation is suturing the fasciocutaneous flap with the installation of rubber drains under the flap to drain residual blood and serous transudate from the wound. After suturing the wound to prevent flexion contractures, the stump is immobilized with a plaster longet bandage.

FEATURES OF AMPUTATION IN CHILDREN

(for the pediatric faculty)

Strict economy of the length of the removed segment;

The use of skin plastics in amputations for injuries;

Sparing of epiphyseal growth zones, preservation of joints;

With vicious stumps, the use of plastic surgery, not reamputations;

When amputating the lower leg to prevent the formation of a conical stump, a shorter truncation of the fibula due to its advanced growth.

REPLANTATION OF FAILURE

No matter how economically the amputation is performed, and no matter how comfortable the prosthesis is, the operation leads to disability, and therefore surgeons developed ways to restore the severed limb. With the development of anesthesiology and the technique of vascular suture, it became possible to restore the lost limb, and since the late 70s, the operation has become widely used in clinical practice.

Replantation of a limb is an operation to anatomically restore a limb with its complete or incomplete separation.

The success of the operation depends on the quality and timeliness at the prehospital stage, effective anti-shock measures at the site of injury, proper transportation of the severed limb to an institution where there are conditions for replantation. During transportation, the limb is preserved by external cooling using ice packs. Small segments are transported in a double ice pack. It is believed that if the limb was immediately cooled, it can be replanted in the following terms: fingers - within 18-24 hours; hand and foot - 10-12 hours; larger segments - 5-6 hours.

The success of replantation depends on:

General condition of the patient (shock, blood loss);

The local state of the tissues of the severed segment; a crushed, crushed limb with severe contamination is not suitable for replantation;

Technical support of the operation (the presence of an anesthetic team, two specially trained teams of surgeons, instrumentation and suture material, the possibility of qualified postoperative management).

The replantation operation consists of the following stages, provided that two teams of surgeons work simultaneously:

Primary surgical treatment of the wound of the stump and the wound of the severed segment with marking of anatomical formations;

Restoration of the bone skeleton of the limb with the help of osteometallosynthesis;

Restoration of the main blood circulation in the limb, restoration of veins and arteries, as a rule, using microsurgical techniques;

Recovery of muscles and tendons;

Nerve repair is usually a secondary nerve suture;

Restoration of the skin with the use of skin plastics.

According to statistics, about 30% of replanted limbs do not take root, since it is difficult to fulfill all the conditions that ensure the engraftment of a severed limb segment. Therefore, in these conditions, an operation is required to remove the non-living segment.

Lecture 18 PLASTIC AND RECOVERY SURGERY.

Lecture plan:

Definition; classification and types of plastic;

Skin plastic; morphological bases and principles;

Types, indications and technique of plastic;

Restorative and plastic surgery on bones (osteosynthesis, bone grafting).

Plastic and reconstructive operations are called surgical operations aimed at restoring the normal form and function of various parts and organs of the human body, completely or partially lost due to injuries, diseases, surgical removal, or absent due to congenital deformities.

The whole variety of plastic and reconstructive operations on various tissues and organs constitutes a separate branch of surgery - plastic surgery. A number of plastic surgeries on individual systems that require a highly specialized approach are included in the relevant branches of surgery: vascular surgery, urology, gynecology, endocrine surgery, dentistry, etc.

Depending on the indications for plastic surgery plastic surgery solvesfollowing tasks:

Cosmetic operations aimed at restoring and changing external forms: plastic surgery of the nose, lips, auricles, mammary glands, elimination of wrinkles on the face, neck, removal of skin and fat folds, liposuction;

Operations aimed at restoring lost functions, plastic surgery on internal organs (plastic surgery of the esophagus, plastic surgery of heart valves), the endocrine system, bone marrow transplantation;

Operations that restore the shape and function of lost organs (skin grafting, bone grafting, keratoplasty);

It should be especially noted that one of the tasks that plastic and reconstructive surgery solves is the restoration of the psychological balance of the individual and the return to the person of a full-fledged social position.

Plastic surgery solves the presented problems by using various plastic materials and plastic methods.

Depending on the plastic material used, the following types of plastic are distinguished:

--- autoplasty; in autoplasty, a person's own tissues are used, to which it is performed Plastic surgery; these tissues either move completely, separating from the maternal or donor surface - free plasticity, or the connection with the donor surface is maintained through the feeding leg; in autoplasty, depending on the indications, all tissues of the body can be used: skin, fatty tissue, muscles, tendons, bones, cartilage, blood vessels, nerves;

--- homoplasty; in homoplasty, tissues taken from another human donor serve as plastic material. They are commonly referred to as transplants. Donors can be living people or corpses, in the first 6 hours after death. Due to tissue incompatibility, such tissues sometimes do not take root, but their transplantation allows you to get a temporary improvement in the patient's condition and prepare for another type of plastic surgery. If engraftment is required, then immunosuppression methods are used, i.e. suppression of immunity, both of the host and of the plastic material – homograft. Homoplasty is widely used in clinical practice. The skin, cornea of ​​the eye (keratoplasty), bones, joints, blood vessels, heart valves, cell material of individual organs (for example, bone marrow) are used;

--- heteroplasty; in heteroplasty, tissues taken from animals serve as plastic material; such tissues have complete biological incompatibility with the human body, and therefore require special treatment; as a rule, heterotissues transplanted into the human body gradually dissolve and are replaced by the connective tissue of the recipient; nevertheless, heteroplasty is useful in that by filling in tissue defects, it serves as a stimulator for the regeneration of a person's own tissues; in heteroplasty, specially treated skin, bones, blood vessels, heart valves (more often a porcine aortic valve) can be used;

--- alloplasty (xenoplasty); in alloplasty, the implantation of artificial materials is used; as materials are plastics (AKP, polystyrene, nylon, lavsan), silicone rubber, metals (titanium, tantalum, their alloys - vitalium), ceramics; plastics make it possible to correct the external forms of the surface of the human body if they are lost, or, if the patient wishes, to improve their external data, for example, breast plastic surgery; plastics and metals replace parts of the bone skeleton after injuries and surgical removal, for example, plastic surgery of a skull defect after resection trepanation, restoration of the upper jaw after resection for a tumor; artificial materials are used to make the lens of the eye, heart valves, blood vessels (woven synthetic prostheses), ligaments and joints.

When it comes to plastic surgery, the first thing we think of is skin plastic surgery. This is probably due to the fact that the covers of the human body give it a certain appearance, and its defects are noticeable and attract attention. And, probably, for the same reason, skin plastic surgery is the most ancient type of plastic surgery. In addition, skin plastic surgery is one of the most common types of plastic surgery.

To understand why it is necessary to do skin grafting and the technical differences between the various plasty methods, it is necessary to briefly recall the anatomy of the skin and its function.

The skin is a complex organ that covers the outside of the body and consists of the epidermis, dermis and subcutaneous tissue (hypoderm). In addition to protection human body from external harmful influences, the skin performs the functions of touch, metabolism, in particular, water-electrolyte metabolism, skin respiration, thermoregulation, etc. According to the histological structure, the skin has an outer layer represented by the epidermis, which belongs to the stratified squamous epithelium. The lowest layer of the epidermis is the basal layer, also called the germ layer. Cell division occurs in this layer. Above it lie successively: prickly layer, granular, vitreous. The outer layer of the epidermis is the stratum corneum. The thickness of the epidermis ranges from 0.07 to 1.5 mm (on the palms and soles). The dermis consists of dense connective tissue, its thickness is from 0.5 to 4 mm. Vessels and nerves of the skin pass through the dermis. The dermis contains sebaceous and sweat glands. The average thickness of the skin on most of the surface of the human body is 1mm.

Operations for skin plastic surgery:

Skin grafting (or skin grafting, skin transplantation) is a surgical operation undertaken to close skin defects after injuries, burns, frostbite, extensive operations for oncological diseases, trophic ulcers, and congenital malformations.

The classification of skin plastic surgery methods corresponds to the general principle of plastic surgery, depending on the choice of a donor and a plastic material. There are autoplasty (the skin is taken from the patient himself), homoplasty (from another person), heteroplasty (the use of animal skin preparations).

Autoplastic methods of skin grafting are divided into free skin grafting and non-free skin grafting. With free skin grafting, the transplanted area of ​​the skin - the graft - is completely separated from the maternal or donor surface. The main indications for free skin grafting are extensive thermal burns of the 3rd and 4th degree, as well as large granulating wounds. For free skin grafting, any healthy areas of the human skin are used, but the skin of the thigh, buttocks, chest and abdomen is most often used (Ariev TY, 1971). It is now generally accepted that a prerequisite for engraftment is the inclusion in the flap, in addition to the epidermis, of the surface layers of the dermis.

The most widespread are the following methods of free skin plastics:

Reverden's method (1869) - transplantation of pieces of the epidermis 0.3-0.4 mm thick and 0.4 sq. cm in area. The method was improved in 1869 by the Russian surgeon S. Yanovich-Chainsky, and later, 44 years later, by the American D. Davis. They recommended taking thicker pieces, capturing the superficial layers of the dermis (epidermal-dermal plasty). The skin of the donor site is lifted with a needle or tweezers and cut with a razor or a sharp scalpel and these pieces are placed on the granulating surface.

Thiersch method (1874) - transplantation of large skin flaps (20-25 x 5-6 cm).

The Krause method is a full-thickness skin graft without subcutaneous tissue. When closing a large surface, the flap is perforated. VK Krasovitov suggested using skin flaps torn off during trauma for autoplasty.

Dermatome skin plasty with a split flap became possible after the invention by Paget and Hood in 1939 of a mechanical dermatome, a tool for taking skin grafts. In 1946, M. Kolokoltsev developed an adhesive dermatome in Russia. Later, electrodermatomes were constructed. A dermatome is a complex surgical instrument that allows cutting skin flaps of a given thickness from 0.3 to 0.6 mm. In addition, the dermatome allows cutting flaps up to 20-25 cm wide and up to 50-60 cm long, depending on the donor surface. The collection of epidermal-dermal flaps with partial preservation of the sprout layer promotes spontaneous, rapid epithelization of the donor site, which makes it possible to re-take skin grafts from the used donor site after about 2-3 weeks.

To solve the problem of tissue deficiency have also been proposed accommodation methodsskin grafts on the wound and burn surface:

The method of "postage stamps" (Gabarro P., 1943). Using this method, it is possible to restore the skin on an area that is much larger than the size of the skin graft. The idea of ​​the method is that epithelialization occurs from the edges of the graft, so quite significant gaps (1:1.5 to 1:5) can be left between individual pieces of skin. The "postage stamp" method is one of the most effective methods for restoring the skin over large areas.

--- "interleaved band method", "zebra" method (Moulem and Jackson, 1952). In this method, skin grafts are arranged in the form of ribbons. Alternation of auto- and homografts of the skin is possible.

Transplantation of a widely perforated skin autologous flap. To increase the area of ​​the closed surface, the dermatome flap is perforated in a special device in a checkerboard pattern. At the same time the rag takes a form of a grid, a cut close a burn surface.

Method of using cell cultures. Closure of the burn surface with cultured human skin cells and grafts from cultured human fibroblasts. The latter method is used in combination with perforated flaps, since fibroblasts are regeneration stimulators.

Skin homoplasty it is used for extensive thermal burns to close the burn surface in order to combat burn shock and disturbances in water and electrolyte metabolism in burn patients, since water, proteins, electrolytes (plasmorrhoea) are lost through the burn surface. After 2-3 weeks, less often up to 2 months, the homograft resolves or is rejected, and the patients undergo skin autoplasty.

Skin heteroplasty used to treat burns for the same indications as homoplasty. Xenoskin is widely used - this is a specially processed (lyophilized) skin of pigs.

Non-free skin grafting. With this method, the donor flap remains connected to the maternal surface. This type of plasty is subdivided into plasty with local tissues and plasty with leg flaps. Plasty with local tissues is used to close small tissue defects. The method is carried out by shifting the skin areas closest to the defect. At the same time, the edges of the skin are cut off and laxative incisions are made.

To close large skin defects on the face with the restoration of the shape of individual areas of the face, it is necessary to move skin flaps of full thickness and with subcutaneous tissue. Such movements are possible only if the feeding pedicle is preserved at the skin flap. The most ancient method of plastic surgery is the Indian method. With this method, the skin flap is moved from the forehead to the nose. In Italy, at the beginning of the 16th century, a method was developed for rhinoplasty from the skin of the shoulder. Gaspar Tagliacozzi, a professor at the University of Bologna, became especially famous for these operations. The method was called Italian plastics and was extended to plastics of skin defects in other areas of the human body. The method allows you to transfer a full-thickness skin flap from areas that are distant from each other. Both methods retain their value to this day and are used in clinical practice.

The development of technology, including military technology, has led to the appearance of traumatic injuries of a significant volume, with a complete loss of organs and deep maxillofacial injuries, requiring multi-stage plastics with the use of large-volume full-thickness flaps in the restoration. This method was developed in 1916 by the famous Russian ophthalmologist VP Filatov. The method has established itself in world surgery under the name - plastic with a round migrating stem according to Filatov.

It should be recalled that another plastic operation is associated with the name of Filatov, which has also received worldwide recognition - this is the operation of keratoplasty - transplantation of the cornea of ​​\u200b\u200bthe eye from a corpse. This is one of the methods of restoring vision in patients with thorns.

The operation of plastics with a round migrating stem according to Filatov is carried out in several stages.

First stage. Two parallel cuts cut out the skin tape and separate it from the fascia. The tape can be cut anywhere where the skin gathers in a fold. The dimensions of the flap vary depending on the needs, but to ensure its viability, it is necessary that the length of the flap does not exceed its width by more than three times. The edges of the tape are sewn together so that a round stem is formed. The wound of the donor site is sewn tightly. After removing the sutures, they begin to train the stem, achieving the development of a good blood supply from one end of the stem. To do this, the stem is pulled with a rubber band from one end, which is planned to be crossed in the future. The clamping time is at first 5 minutes, then the stem overlap time is increased by 5-10 minutes daily. Ultimately, the flap is kept warm and of normal color for 1 hour. After that, proceed to the second stage.

Second phase. The flap is cut off and sutured into the defect, if it is located nearby. If the stem is located far from the defect, then the flap is transferred to an intermediate site, for example, on the hand or forearm, and the stem training is repeated. After training, the stem is cut off again and already transferred to the defect. Depending on the needs, the training is repeated and after 10-15 days the flap is cut off and the plastic use of the stem is started. On the face of the stem, you can model the nose, lips, cheek. The plasticity of the flap allows you to restore many organs, such as the breast, penis, close large defects in any part of the body. However, the multi-stage plasty with a migratory stem makes it lengthy, the operation can stretch for several months.

In recent years, in connection with the development of microsurgical techniques, free transplantation of a full-thickness skin flap with subcutaneous tissue has been used with the isolation and intersection of the supplying neurovascular bundle. Such a flap can be cut in the inguinal region. The flap is transferred to the area of ​​the defect, and its vascular pedicle is connected to the nearby neurovascular bundle. If the plastic is performed on the face, then with the facial artery or carotid. Plastic surgery using microsurgical techniques significantly reduces the time of plastic surgery.

BONE SURGERY (osteosynthesis, bone grafting)

Restorative and plastic surgery of the human skeleton is usually performed by a traumatologist-orthopedist. These operations are extremely common, because. in the 20th century, man-made injuries increased significantly, to-ry took on a mass character. All this required the development and widespread use of surgical methods for the treatment of bone fractures.

A surgical operation performed for bone fractures with the aim of open reposition and fixation of bone fragments is called osteosynthesis.

Osteosynthesis allows you to get a good result only with the maximum observance of all principles of fracture treatment:

Careful reposition of the fracture with elimination of tissue interposition;

Tight contact of fragments with compression;

Careful handling and preservation of the periosteum;

Preservation of blood supply to bone fragments.

Diverse ways of fixing bone fragments today can be divided into several groups:

--- percutaneous fixation fragments with the help of a bone suture, knitting needles, screws; this method of fixation is used to fix small bone fragments, for example, fractures of the olecranon, patella, fractures of the ankles, condyles of the femur and tibia, collarbone, etc.

--- extramedullary osteosynthesis is the oldest method of fixing bone fragments and is the binding of fragments with wire or metal bands; another extramedullary fixation is plate fixation; extramedullary osteosynthesis with the help of extramedullary plates is widely used in clinical practice for fractures of long tubular bones.

--- intramedullary osteosynthesis- fixation with intraosseous rods, pins; intramedullary osteosynthesis using rods inserted into the bone marrow canal was widely developed on the eve of the 2nd World War and is associated with the name of the German surgeon Küntscher (1940); at present, there are a large number of various designs of metal pins for osteosynthesis;

--- extrafocal compression osteosynthesis using Ilizarov apparatus, Gudushauri and others; in the mid-1950s, the Kurgan traumatologist GA Ilizarov developed an original device for extrafocal compression fixation of fractures; fixation of fragments outside the fracture zone and the creation of their compression allows accelerating the process of bone tissue regeneration; The device proved to be especially useful in the treatment of false joints and for bone grafting.

However, the treatment of fractures by conservative methods or surgical methods often ends in unsatisfactory outcomes. In these cases, bone deformities with dysfunction of the support and cosmetic defects may occur. Sometimes, due to extensive injuries, defects in the skeletal skeleton can occur. Violation of the process of bone regeneration can lead to the appearance of a false joint, when only a fragile connective tissue fusion is formed at the fracture site without restoring the full structure of the bone tissue. Unsatisfactory outcomes require a second operation, which is already called bone grafting.

bone grafting called a surgical operation to transplant bone tissue for the anatomical restoration of bone structures, as well as to stimulate regenerative processes and bone formation.

As in skin plastic surgery, there are the following types of bone grafting:

Autoplasty; --- homoplasty; ---heteroplasty; ---alloplasty.

With autoplasty the bone tissue of the patient is used. In this case, bone grafting can be free, when the bone graft loses its connections with the donor site. Bone grafting may also be non-free when the pedicle is preserved. An example of non-free bone grafting is the operation of osteoplastic amputation of the lower leg according to Pirogov, with a cut of the sawdust of the tibia is closed with sawdust calcaneus, which rests on a flap of soft tissues of the heel region (1852). Another example of non-free bone grafting is the closure of a skull defect during osteoplastic trepanation according to Olivekron, which was described in the last lecture. With resection trepanation of the skull, as a rule, they use alloplastic plastic AKP.

Usually bone grafting is combined with osteosynthesis, with the help of which both a bone graft and bone fragments are fixed.

In bone autoplasty, bone grafts are taken from the iliac wing. The fibula, ribs, cortical plate of the tibia can also serve as plastic material.

In the treatment of false joints by the method of laying a bone graft bone platemay be:

Bony parietal plasty;

Sliding graft according to Olbi-Khakhutov;

Combined bone grafting with intraosseous fixation with a rod;

Combined intra-extramedullary plasty according to Chaklin.

At large defects bones, such as the tibia, benefit from the movement of the fibula to the position of the tibia. In recent years, methods of plastic surgery using microsurgical techniques have been developed. In this case, the bone-periosteal flap is transferred to a new bed and its vascular pedicle is connected to a nearby large artery. Thus, the blood supply to the bone tissue is restored and regeneration processes are improved.

In the treatment of false joints and congenital or traumatic shortening of the limbs, good results were obtained using compression-distraction osteosynthesis using the apparatus of Ilizirov et al.

Bone homoplasty with material obtained from human cadavers is used to stimulate the process of osteogenesis during delayed consolidation or surgical treatment of false joints. The homograft is subjected to lyophilization (drying in a vacuum), or it is frozen, or preserved in formalin. The homograft is used for extraosseous parietal plasty. The graft is fixed to the own bone, as a rule, with catgut. The transplanted homograft gradually dissolves, stimulating the growth of its own bone.

The use of heterobones from animals has not yet become widespread in clinical practice due to high immune activity.

As for the use of plastics for bone grafting, they are widely used to restore the articular surfaces of bones damaged due to trauma or after economical resection of the joint.

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Operative surgery with topographic anatomy of childhood. (Edited by Isakov YuF et al. - Moscow, 1989

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Primary surgical debridement, or PST, of a wound is an obligatory measure in the treatment of open wounds of various nature. How this procedure will be carried out often depends on the health, and sometimes the life of the injured person. Correctly drawn up algorithm of the doctor's actions is the key to successful treatment.

Damage to the human body can be varied look and the nature of the occurrence, but the basic principle of PST of the wound remains unchanged - to provide safe conditions for eliminating the consequences of the wound through minor surgical manipulations and decontamination of the affected area. Preparations and instruments may change, but the essence of conducting PST does not change from this.

In the general case, wounds are called mechanical damage to body tissues with a violation of the integrity of the skin, in which gaping occurs and which are accompanied by bleeding and pain. According to the degree of damage, only soft tissue damage is distinguished; tissue damage, accompanied by damage to the bones, blood vessels, joints, ligaments, nerve fibers; penetrating injuries - with damage to internal organs. In terms of extent, pathologies with a small and large affected area differ.

You can find out about cut wounds at.

The principle of primary treatment

The first stage of treatment of an open wound is to stop bleeding, eliminate pain, decontaminate and prepare for suturing. The most important is the issue of sterilizing the affected area and removing non-viable cells. If the injuries are not extensive and penetrating, and measures are taken in a timely manner, then decontamination can be carried out by providing a wound toilet. Otherwise, primary methods are used. surgical training(PHO wound).

What is a wound toilet?

The principles of the wound toilet are based on the treatment of the affected area with an antiseptic preparation with increased hygiene requirements. Small and fresh wounds do not have dead tissue around the injury, so it will be sufficient to sterilize the site and the surrounding area. Purulent wound toilet algorithm:

1. Consumables are being prepared: wipes, sterile cotton balls, medical gloves, antiseptic compounds (3% hydrogen peroxide solution, 0.5% potassium permanganate solution, ethyl alcohol), necrolytic ointments (“Levomekol” or “Levosin”), 10% sodium chloride solution.
2. The previously applied bandage is removed.
3. The area around the lesion is treated with a solution of hydrogen peroxide.
4. The state of the pathology and possible complicating factors are being studied.
5. The toilet of the skin around the damage is carried out with the help of sterile balls, moving from the edge of the damage to the side, treatment with an antiseptic.
6. The wound is cleaned - removal of the purulent composition, wiping with an antiseptic.
7. The wound is drained.
8. A bandage with a necrolytic preparation (ointment) is applied and fixed.

Essence of PST wound

Primary surgical treatment is a surgical procedure that includes dissection of the marginal tissue in the area of ​​damage, removal of dead tissue by excision, removal of all foreign bodies, installation of cavity drainage (if necessary).

Thus, along with drug treatment, a mechanical antiseptic is used, and the removal of dead cells accelerates the process of regeneration of new tissues.

The procedure begins with a dissection of the injury. The skin and tissues around the destruction are dissected with a cut up to 10 mm wide in the longitudinal direction (along the vessels and nerve fibers) to a length that allows you to visually examine the presence of dead tissues and stagnant zones (pockets). Then, by making an arcuate incision, the fascia and aponeurosis are dissected.

Remnants of clothing, foreign bodies, blood clots are removed from the expanded wound; by excision, crushed, contaminated and blood-soaked non-viable tissue areas are removed. Lifeless areas of muscles (dark red), blood vessels and tendons are also eliminated. Healthy vessels and fibers are sewn together. With the help of nippers, the sharp spike-like edges of the bone are bitten out (in case of fractures). After complete cleaning, the primary suture is applied. In the treatment of penetrating gunshot wounds, PST is carried out separately, both from the side of the inlet and from the side of the outlet.

Youtube.com/watch?v=WWFZCNFD6Dw

PHO wounds of the face. Jaw injuries are the most common of facial wounds. PHO of such wounds has a certain algorithm of actions. First, a medical antiseptic treatment of the skin on the face and oral cavity is performed.

A solution of hydrogen peroxide, a solution of ammonia, iodine-gasoline is applied around the damage. Next, an abundant washing of the wound cavity with an antiseptic is performed. Skin covering the face is carefully shaved and disinfected again. The patient is given an analgesic.

After the preliminary procedures, PST of facial wounds is performed directly according to an individual plan, but with the following sequence of manipulations: treatment of the bone area; processing of soft adjacent tissues; fixation of splinters and fragments of the jaw; suturing in the sublingual zone, oral vestibule and in the region of the tongue; wound drainage; the imposition of a primary suture on the soft tissues of the wound. The procedure is carried out under general anesthesia or under local anesthesia depending on the severity of the injury.

Algorithm for PST of bitten wounds. A fairly common occurrence, especially among children, are wounds resulting from the bites of domestic animals. The PHO algorithm in this case is as follows:

1. Providing first aid.
2. Washing the damaged area with water laundry soap in copious amounts to completely remove the saliva of the animal.
3. Chipping around the wound with a solution of lincomycin with novocaine; injection of drugs for rabies and tetanus.
4. Processing of damage boundaries with iodine solution.
5. Carrying out PST by excising damaged tissues and cleaning the wound; the primary suture is applied only in the case of a bite by a vaccinated animal, if this fact is actually established; if in doubt, a temporary bandage with mandatory drainage is applied.

Youtube.com/watch?v=l9iukhThJbk

Primary surgical treatment of wounds is effective way treatment of open injuries of any complexity.

Human skin has an enormous reserve of self-healing capacity, and additional excision to thoroughly clean the wound will not harm the healing process, and the removal of non-viable tissues will accelerate the process of regeneration of new skin tissue.

According to the deadlines, they distinguish early, delayed and late PHO. Early PST and delayed PST are performed in the wound when there are no signs of inflammation (there is still no swelling of the wound edges, sanious discharge), and it is designed for wound healing without complications; late PST is performed in the wound when there are general and local signs of inflammation (edema, sanious discharge), and it is designed to prevent severe infectious complications.

According to the canons of military field surgeons, early PST is performed in the first 24 hours after injury; delayed - up to 48 hours, if measures were taken to prevent infectious complications; late - after 24 hours if antibiotics were not administered, and after 48 hours if antibiotics were administered to prevent infectious complications.
At present, due to the introduction of wound preservatives into surgery, these terms are extended to 3-4 days.

The operation of primary debridement is not performed in shock (but if it does not include stopping external or internal bleeding). With extensive destruction of the limbs, the primary surgical treatment with the formation of a stump is performed simultaneously with the removal from shock. Primary surgical treatment can be omitted with penetrating wounds of the limbs, if there is no large destruction of tissues (a bullet with a low flight speed), damage to blood vessels, nerves, bones; with penetrating and blind wounds of the chest, if there is no internal bleeding,
open and growing pneumothorax. This assumption is especially rational when a large number of victims are admitted simultaneously. In a favorable environment, the primary surgical treatment should be done if it is not more traumatic than the injury itself. But if the treatment is not performed, then intensive antibiotic therapy is carried out, and the surgeon closely observes the wounded. At the slightest sign of infection of the wound (temperature, increase in edema, pain in the wound), late primary surgical treatment is immediately performed.

In conditions district hospital it is advisable to perform the primary surgical treatment of the wound either in an emergency operating room (open fracture, extensive wounds, gunshot wounds, crush injuries and avulsions of the limbs), or in a clean dressing room (soft tissue wounds without damage to large vessels, nerves and internal organs). When planning the work of the functional premises of the department, the surgeon must provide, in addition to the emergency operating room, where operations are performed for acute diseases abdominal organs, the possibility of operating in a clean dressing room. Therefore, this room should be large so that an operating table, tables for sterile material, and sets of instruments in paraformalin oxicators can be placed there. In this dressing operating room, it is also possible to provide for the removal of victims from shock, the performance of diagnostic and minor therapeutic manipulations (thoracocentesis, puncture of the pleural cavity, laparocentesis, diagnostic laparotomy, skeletal traction, lumbar puncture, wound dressing, transport immobilization before evacuating the victim to the stage of specialized care, reposition of fractures of the radius in a typical location and fracture-dislocation of the ankle joint, application of a plaster cast). It is impractical to do all this in an emergency operating room because of its possible contamination by victims from the street and its possible contamination during emergency abdominal operations.

Of course, the primary surgical treatment of wounds of the chest and abdomen, the head should be carried out in the operating room.

Conditions for performing the operation of primary surgical treatment (PSD).

Indispensable conditions for primary surgical treatment should be complete anesthesia and thorough washing of the wound itself from dirt before primary surgical treatment.
The second without the first is simply impossible to perform properly. Local infiltration anesthesia also does not provide muscle relaxation and the breadth of operative access for the thorough implementation of all elements of the primary surgical treatment.

Under local anesthesia with a 0.25% -0.5% novocaine solution, it is possible to perform the primary surgical treatment of wounds that are not subject to hospital treatment (wounds that do not penetrate deeper than their own fascia).
An analysis of the clinical material showed that when treating wounds under local anesthesia, primary suppuration occurred 5 times more often than when treating under anesthesia.

What types of anesthesia should be preferred in the district hospital?

It all depends on the experience of the anesthesiologist working there. Of course, the best anesthesia is anesthesia. But due to the impossible, sometimes even minimal, examination of an urgently admitted patient in the conditions of the Central District Hospital, the possibilities of the inhalation period with intubation and muscle relaxation are limited. And this is one of the obstacles to performing a complete and exhaustive primary surgical treatment for open fractures in the CRH.

We do not recommend using intraosseous anesthesia for primary surgical treatment of wounds of the limbs, injuries of the hand, foot, open fractures and dislocations, since this requires the application of a tourniquet, which, on the one hand, limits the time of the operation, and on the other hand, increases tissue ischemia, and therefore, increases the possibility of infectious complications.

In the conditions of the Central District Hospital, it is advisable to give preference conduction anesthesia. It, with the addition of other non-dangerous methods of anesthesia for an emergency patient, provides complete anesthesia during operations on the collarbone, the entire upper limb, on the foot, lower leg and knee joint. The supraclavicular method of conduction anesthesia is indicated for operations on the shoulder joint and shoulder, elbow joint, forearm and hand.

"Injury Surgery"
V.V. Klyuchevsky