Fracture of the nail phalanx of the big toe: how long it heals and whether gypsum is needed. By the presence of displacement

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fracture thumb legs - a common injury to the lower extremities, which changes the structure of the bone in the specified area and causes not only a number of pathological symptoms but also various complications.

How to determine a fracture of the big toe, what to do and how long to treat it, and what are the features of rehabilitation after the therapy? You will learn about this and much more below.

Common causes of a broken toe

Mankind invented shoes in ancient times - the main protection of the toes and feet from possible damage. However, despite the fact that this element of the wardrobe is constantly being modified and improved, injuries in the above area are not decreasing. The main causes of thumb fractures are usually:

• Strong and sharp blows to the fingers;
• stumbling when walking or running;
• Fall on the lower limb of gravity, moving it with a car wheel;
• Accelerated, uneven and sharp bending of the foot;
• Occupational, sports or domestic injury associated with compression of the above area (squeezing from 2 sides);
• Strong twisting of the foot.

Provoking factors in the formation of a fracture are considered to be problems with the musculoskeletal system, the presence of previous injuries of the ankle, flat feet, osteomyelitis, osteoporosis, bone tuberculosis, hyperparathyroidism, certain types oncological diseases. The above risk factors reduce strength and elasticity bone tissue making her more prone to injury.

Fracture classification

Fractures of the big toe are classified according to a number of criteria. In traumatology, the following types of injuries are usually distinguished.

According to bone fragments:

• Open. It is formed with the formation of skin defects, bone elements are in contact with the external environment;
• Closed fracture of the big toe. The wreckage does not break the outer coverings.

By location:

• No offset. Normal position bone structures does not change;
• With offset. Bone structures deviate from their normal position.

By the nature of the destruction:

• No shards. Ordinary cracks or breaks;
• Single and double sided. At a fracture, 1 or several fragments are formed;
• Multifragmented. The most severe type of injury, the bones are severely crushed.

By localization:

• Fracture of the main phalanx of the big toe. Fracture closer to the foot;
• Fracture of the nail phalanx of the big toe. Fracture closer to the nail plate.

According to the mechanism of education:

• Direct. Fractures and defects of bone structures coincide with the place of application of the traumatic force;
• Indirect. The localization of traumatic force and bone tissue defects do not coincide.

Symptoms of a broken toe

Symptoms of a fracture of the big toe can be absolute and relative. In the first case, we can talk about a reliably confirmed injury, while the second option is conditionally attributed to a number of pathological acute conditions of the musculoskeletal system.

Reliable symptoms and signs of a fractured big toe:

• Abnormal mobility of the thumb;
• Visible unnatural curvature of the phalanges;
• The formation of open fragmental bone wounds in the affected area;
• An audible crunch of bone fragments when moving the thumb.

In most cases, the above symptoms refer to complicated, open and comminuted types of fractures, which is quite rare in patients. That is why additional relative signs acute pathology considered to be:

• Pain in the area of ​​the thumb, aggravated by movement of the phalanges;
• Swelling of the area of ​​injury and the area around it, which subsequently spreads to the entire foot;
• Local redness of the skin;
• Formation of subcutaneous and nail hematomas;
• Decline or disappearance motor activity feet.

The above manifestations can also be diagnosed with dislocations, bruises and other injuries, therefore, if a fracture is suspected, it is necessary to undergo a comprehensive diagnosis.

The difference between a fracture and a bruise and the diagnosis of injury

Fracture can form open wounds with visible fragmented phalanges. When you try to move your thumb, a distinct crunch is heard. In the case of a bruise, there is no unnatural curvature of the phalanges of the thumb, its mobility is reduced.

In the absence of clear symptoms of a fracture or the presence of signs similar to a bruise, it is necessary to contact the hospital for additional diagnostics.

The complex of diagnostic measures includes an initial examination by a traumatologist and instrumental research methods.

At the first appointment in the hospital, the doctor will listen to the patient's complaints, examine the injured thumb, palpate it for the presence of curvature of the phalanges and other signs of a fracture. After making the primary diagnosis, the victim is sent for X-rays - the image obtained in 2 projections will allow you to evaluate general character damage and complexity of injury with the degree of displacement of bone structures.

If necessary, as additional instrumental methods MRI and CT can be used- they are designed to detect soft tissue injuries, as well as to diagnose intra-articular injuries, mainly in complicated forms of fracture.

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First aid for a fracture

If you suspect a fracture of the big toe, it is advisable to call an ambulance, and then proceed to the basic measures:

Thumb fracture treatment

After admission to the hospital and determining the diagnosis, the victim is transferred to the trauma department.

Conservative therapy:

• Appointment of painkillers and anti-inflammatory drugs by injection: ketorolac, analgin, nimesulide. In rare cases, narcotic analgesics.
• In the case of a closed fracture without displacement - applying cold to the foot, regularly, in sessions of 10-15 minutes.
• Immobilization of the big toe with a splint and bandages. It is made only after the reduction of the finger.
• Moderate bed rest. Movement - only on crutches, without relying on a leg with an injured toe.
• Closed reposition. The local area of ​​injury is treated with local anesthetics, after which a single finger extension is performed with the return of the phalanges to physiological state. Applicable only for closed fractures without fragments with displacement. If necessary, the procedure is repeated several more times until the physiological movement of the finger joints is normalized. After the control radiography, a splint is applied to the damaged area.
• Skeletal traction. It is carried out with the ineffectiveness of a closed reposition. The scheme consists in long-term retention of a bone fragment in a retracted position.

The traumatologist treats the toe with a local anesthetic, threads a nylon thread through the skin or nail, makes a “ring” that is attached to the plaster with a wire hook. In this position, the damaged phalanx is 2 weeks.

Every day, the attachment area is treated with local antiseptics to prevent suppuration. After the specified period, the system is disassembled, a control radiography is performed, and the finger is fixed with a classic splint with props or plaster until the fracture is completely healed.

The operation is usually prescribed in case of open fractures of the finger, as well as fragmentation of the phalanges. and accompanying elements into several or more fragments. The surgeon's job is to restore the physiological anatomy of the finger. Bone fragments are fixed inside with plates, pins, screws and wire using complex osteosynthesis.

After the procedure and cleaning of the wound in the damaged area, a drainage channel is formed, after which a splint is applied, and on top of it - a plaster "boot" on the entire foot.

The area of ​​injury is regularly disinfected to prevent secondary bacterial infection.

After the fusion of all structures and the formation of a sufficient amount callus the plaster is removed, leaving only a supporting bandage - the patient is transferred to the rehabilitation stage.

Rehabilitation after a fracture of the big toe

On average, the rehabilitation of a victim with a fracture of the big toe takes 4-8 weeks. The main activities include:

• Massage legs, feet with a damaged toe and areas adjacent to the injury zone;
• exercise therapy. The general strengthening complex of exercises of physiotherapy exercises is aimed at maintaining the general tone of the body, restoring blood circulation and mobility of the lower extremities;
• Physiotherapy. The patient is prescribed courses of electrophoresis with novocaine, calcium salts and nicotinic acid, UHF, UVI, magnetotherapy, amplipulse, myostimulation, paraffin-ozocerite applications;
• Proper nutrition. Introduction to the diet of more protein foods, sour-milk and dairy products, fruits and vegetables. Exclusion of fried foods, soda, coffee, alcohol and products rich in simple carbohydrates;
• Limitation of physical activity. Temporary refusal to engage in active sports, where the predominant load is distributed on the lower limbs;
• Wearing the right orthopedic, comfortable shoes to fit, medium hardness and with good adhesion to surfaces.

Proper rehabilitation is very important to avoid serious complications after an injury.

Now you know how to develop a big toe after a fracture.

Complications and consequences

Improper treatment or lack of qualified therapy for fractures of the big toe can lead to:

• Visible curvature of the finger with limited mobility and functionality;
• The formation of false joints, ankylosis;
• osteomyelitis;
• Gangrene due to secondary bacterial infections.

In most cases, untimely treatment even with an ordinary mild fracture leads to improper fusion and healing of the bone, which is quite difficult to correct even with surgical methods. In this situation, problems with the musculoskeletal system will remain with you forever.

Legs are common. The phalanges of the limbs are vulnerable to many external influences, and are also subjected to constant pressure from the weight of a person. From the materials of this article, you will learn what symptoms this pathology accompanies and how long it takes to treat it.

The structure of the finger joint and its main functions

Toes are an integral part of the locomotor system in the human body. Together with the foot, they hold the weight of the body, make it possible to move around, while helping to maintain balance.

Each toe consists of several small bones, which are otherwise called phalanges. They are interconnected by movable joints, which makes it possible to bend and unbend the fingers.

The limbs are the vulnerable part human body which is most frequently fractured. In most cases, the big toe is affected. It differs from the rest in that it has only two phalanxes instead of the prescribed three. While walking, the thumb experiences the main load. The probability of getting a fracture increases several times. When traumatized, blueing and swelling usually spread to the entire foot.

The leg quickly swells and acquires a bluish tint. The painful discomfort that accompanies this pathology usually does not allow the victim to fully lean on the limb. Often an open fracture of the big toe is complicated due to injury skin and penetration of infection. In this case, the person has clear signs body intoxication.

The difference between a fracture and a bruise

With a strong bruise, the clinical picture may be the same as with a fracture. It is possible to distinguish one pathology from another by absolute signs:

• unnatural position of the foot;
• there is abnormal mobility in the area of ​​the fracture;
• characteristic sound when pressed, similar to a crunch.

These signs indicate a fracture of the big toe. Symptoms of injury should alert and become a reason for going to the hospital.

Which meet?

To determine the most efficient scheme Treatment is important to determine the type of injury. When the skin is damaged, when the wound and the bone itself are visible, we are talking about an open fracture. In this case, the threat of infection of the affected area increases, so the help of a doctor is required immediately. Having applied an aseptic bandage, the victim must be immediately delivered to a traumatologist.

The closed version of the injury needs bone reposition, that is, the return of fragments to their anatomical place. A fracture with a displaced big toe requires the fragment to be placed in place and properly fixed. Otherwise, fusion may not occur correctly.

When surgical intervention is required. During the operation, the doctor makes an open reposition of the debris and performs intra-articular fixation using special needles. The mobility of the affected joint is restored by about the eighth week. Throughout the entire period of treatment, the body is recommended to be supported with vitamin therapy.

Big toe fracture: do I need a cast?

Even in ancient times, people believed that a diseased organ needed complete rest to recover. The bone is no exception. Its main function is to create support for the muscles. With fractures, complete immobilization of the bone can be considered a kind of equivalent of rest. Immobilization allows you to accelerate and direct the process of regeneration of the damaged area in the right direction.

The patient is imposed bandage bandages, which are pre-wetted in a gypsum solution. When applied to a limb, they take on its shape and remain until complete recovery. A plaster bandage is usually applied not only to the injured finger, but also to the foot and part of the lower leg. High immobilization is not entirely justified, as it seriously limits the mobility of the leg. On the other hand, in order to provide peace to the finger, it is necessary to immobilize the entire foot, and this is possible only with the help of a “boot” plaster bandage.

Sometimes immobilization is not required for patients diagnosed with a fracture of the big toe. Without gypsum, they do with bone cracks that heal on their own. Also, the category of exceptions includes the first few days after surgical procedures on a limb with a broken finger, when the injury is a secondary pathology. In this case, there is a need for regular monitoring of the wound healing process. When signs of a successful recovery begin to appear, a cast is immediately applied to the leg.

Rehabilitation after a fracture

Within six weeks after the injury, it is necessary to protect the injured finger from stress and try not to overexert it. Long walks, sports are contraindicated.

The rehabilitation period includes physiotherapy, special gymnastics and therapeutic massage. The diet is recommended to diversify foods rich in protein and calcium.

Some patients complain about discomfort with prolonged wearing of gypsum. This condition must simply be endured so that the bones grow together correctly. Gypsum with a fracture of the big toe should not be wetted or attempted to be removed on its own.

Prevention

In order to avoid fractures of the toes, doctors advise wearing comfortable shoes with stable soles. You should also exclude from the diet foods that “wash out” calcium from the body. These include sweet soda, coffee, and alcoholic beverages. Nutrition should be as balanced as possible. Special attention it is recommended to give foods containing calcium (beans, cabbage, carrots, Rye bread). In case of pathologies of bone tissue, it is recommended to undergo regular examinations. Such simple preventive measures can prevent fractures, significantly improve the quality of life and stay healthy at the same time.

Nail plate. It is a tissue derivative arising from the three zones of the nail bed. Fully grows in length in 70-160 days.

nail bed. It consists of three parts: the back cover, the germinal matrix (also known as the ventral floor), and the sterile matrix (also known as the ventral nail bed). The proximal end of the nail plate originates between the dorsum and the U-shaped germinal matrix of the nail bed.

Nail fold (eponychial fold). The proximal part of the nail plate is located under the nail fold. The skin on the back of the nail fold is the nail fold (it is located on top of the back cover of the nail bed). The thin plate extending from the nail fold to the rear of the nail plate is called the eponychium. The lunula is a curved, opaque strip on the nail distal to the eponychium at the junction of the germinal and sterile matrix.

hyponychium. This is an accumulation of keratin between the distal part of the nail plate and the nail bed. Due to its strong adhesion, it is resistant to infection.

blood supply. Dorsal branch of the terminal trifurcation of the digital artery.

Function

• Soft tissue support of the fingertip (hyponychium)
• Used as a tool (scratching, plucking, scraping, grabbing and lifting, etc.).

Damage to the nail bed

• Usually occurs due to hard hit, which leads to compression and damage to the (soft tissue) nail bed between the (hard) nail phalanx and the nail plate.
• It is necessary to perform radiographs in frontal and lateral projections.

Subungual hematoma

The nail bed is well supplied with blood. A closed injury to the nail causes bleeding under the nail plate with the formation of a tense hematoma, with a characteristic throbbing pain.

Treatment of subungual hematoma

Closed lesions (usually hematoma, less than 25% of the visible nail bed) can be evacuated by perforating the nail plate with a hot needle or paper clip. If a rupture of the nail bed is suspected, revision is necessary.

Rupture of the nail bed

May be simple, stellate (due to blast-type trauma), or crushed (causing fragmentation of the nail bed). The nail plate can move out from under the nail fold.

Rejection of the audit acute period after injury with these injuries leads to the development late complications, such as deformation of the nail plate or its detachment from the nail bed.

Treatment of nail bed ruptures

• Ring block with local anesthetics
• Peel off the nail plate (saving for use as a splint)
• Tip: use a small mucosal elevator or anatomical blunt scissors to get them between the nail plate and the nail bed, then peel off the nail plate with a thin vascular clamp.
• Wash off the sterile matrix.
• Carefully restore the sterile matrix (absorbable suture 6/0-7/0) using a magnifying glass.
• A defect in the sterile matrix can be replaced with a split skin flap or a split nail bed graft (from the adjacent injured toe or from the first toe).
• If the nail bed is torn out from under the nail crease, it should be set and sutured (if possible) or fixed in place with a splint.
• Use the nail plate to splint the nail fold.
• In young children, the replanted nail plate can take root and begin to grow.
• If the nail plate is missing or severely damaged, the silicone plate or foil from the suture package can be used to splint the nail fold.

Tearing of the nail bed with a fracture of the nail phalanx

In almost 50% of cases, damage to the nail bed is combined with a fracture of the nail phalanx. The presence of a tear in the nail bed makes the fracture open.

Treatment of ruptures of the nail bed with a fracture of the nail phalanx

The following are the principles for treating nail bed ruptures. Additionally:

• Intraoperative administration of intravenous antibiotics and oral administration in the postoperative period.
• Abundant irrigation until the fracture is repositioned.
• Non-displaced fractures can be treated conservatively after flushing and restoring the nail bed. They are splinted with soft tissues.
• In case of displaced fractures, thin (0.8-1 mm) pins are used for fixation, except in cases with many small fragments, then it is better to splint the bone fragments with soft tissues without pin fixation.
• Tip: Pass the Kirschner wire 2-3 mm below the hyponychium to achieve precise placement in the nail phalanx.
• Check the position of the pin on the radiograph in the lateral projection - it is easy to miss and not get into the nail phalanx!
• Seymour fracture - epiphyseolysis of the nail phalanx with a displacement of its distal part to the rear in combination with a rupture of the nail bed. The nail also moves out from under the eponychial fold (see Chapter 5).

Violation of the growth of the nail after injury

Within 21 days after the injury, the nail stops growing in length, and its thickening appears proximal to the injury site. This causes the nail to bulge as it continues to grow. After that, the growth of the nail accelerates compared to the norm for 50 days, and then slows down for 30 days, and only after that the growth becomes normal. Reconstruction of the nail complex

Reconstruction of the nail complex is difficult and often imperfect, even in the most experienced hands. Below are possible options reconstruction. Problems often overlap, and the choice of treatment should be approached individually.

Detachment of the nail plate from the nail bed

• Scarring of the underlying part of the nail bed due to lack of fusion with the nail plate.
• Keratin builds up under the nail and this can be mistaken for a fungal infection.
• Treatment:
• Excise scars.
• Suture if possible.
• Replace the defect with a split nail bed graft, usually taken from the first toe.

splitting of the nail

• The cause is scarring in the backcoat/germenal matrix/sterile matrix complex.
• Treatment:
• Excise scars and restore the sterile matrix.
• Excise part of the germinal matrix and replace with a full-thickness complex germinal matrix graft from the 2nd toe with an acceptable but not perfect result.
• Removal of the germinal matrix in severe cases.

Nail spicule (thorn)

• Usually the remnant of the germinal matrix complex after distal amputation.
• Treatment:
• Raise the eponychium flap
• Excise the spicule and the remainder of the germinal matrix.

Hooknail (deformity in the fork of a parrot's beak)

• Occurs as a result of tension suturing of the fingertip during distal amputation or loss of bony support for the nail bed.
• Treatment:
• Excise scars on the fingertip
• Raise the nail bed
• Replace the bone defect with a bone graft (may dissolve)
• Replace the soft tissue defect with a local movable flap
• Microsurgical grafting of a part of the toe (difficult decision)

Absence

• Congenital or post-traumatic.
• Treatment:
• Excise skin or nail-like scars and replace with a full-thickness skin graft
• Microsurgical transplantation of the nail bed.

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

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

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

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

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

A fracture of the phalanx of the finger occurs from a direct blow or injury and is more often open. It can also be diaphyseal, periarticular or intraarticular. Fracture of the nail phalanx is usually fragmental.

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

Treatment of a fracture of the phalanx of the fingers without displacement is carried out with plaster or an aluminum splint, which is applied when the nail phalanx is bent up to 150, the middle one - up to 600, the main one - up to 500. They wear a bandage or splint for 3 weeks. After removing the material, therapeutic gymnastics with physical therapy. A month later, the working capacity of the phalanx is fully restored.

In case of displaced phalanx fractures, the fragments are compared under local anesthesia. After that, a plaster or metal splint is applied for 3-4 weeks. In case of fractures of the nail phalanges, the finger is immobilized with an adhesive plaster or a circular plaster bandage.

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

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

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

Closed dislocations are reduced after local anesthesia. If it is difficult to set it in the usual way, then use the introduction of a spoke through the distal phalanx or the use of a pin. The procedure is simple and safe. Then they carry out traction for the injured finger along the length and counter-traction (which is carried out by the assistant) for the ankle joint. By pressing on the base of the phalanx displaced to the side, the dislocation is reduced.

For chronic dislocations, surgical intervention is needed.

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Fracture - dangerous injury which always brings a lot of physical and psychological inconvenience. Excessive stress on the bones musculoskeletal system can easily damage most of them. Indeed, of the more than two hundred bones of the body, only less than half have a "special" strength. Also, one should not forget about the joints in which the main load is taken by connective tissue. Therefore, a fracture of the big toe is a threat from which no one is absolutely protected. Everyone needs to know the types of this damage and the methods of treatment.

Anatomical features

Fragment of the main phalanx on the radiograph

The foot is the most complex and most distant element of the musculoskeletal system. A feature of its structure is the presence of a large number of joints and small bones, each of which is quite vulnerable to mechanical injury. This vulnerability is most relevant for the extreme toes due to their location - the thumb and little finger. It is they who most often undergo dislocation, fracture and, according to statistics, are considered the most traumatic part of the leg.

The foot includes twenty-four separate bones that make up its three divisions. Together they form a complex vaulted support system that helps support vertical position body. The third section is considered the most traumatic, which includes fourteen tubular hollow bones connected by joints and muscles. They form five fingers, but their length and structural features do not allow us to talk about the special strength of each of them.

Diagnosis of a fracture of the bones and joints of the thumb is the easiest thing in comparison with other fingers. The main symptoms are sharp pain, the inability to step on the foot, the appearance of swelling. The intensity of symptoms depends on the type of fracture. With other fingers, the manifestation of symptoms occurs in an increasing manner over time. This often misleads the patient about the true severity of the injury to the finger.

The thumb is the most susceptible to injury. It protrudes forward in relation to others, and is one of the anchor points that support the weight. standing man. It is on the finger under consideration that a significant part of the loads is accounted for.

Fracture classification

Structure of the foot and toes

There are two categories of fractures. The first medicine refers to a traumatic fracture - the "classic" version of mechanical damage. Its severity, complexity of treatment and danger to the body depend on the magnitude of the destructive force acting on the thumb. The second category is pathological fracture, the danger and treatment of which is often significantly higher than in the first case.

Pathological fractures also form as a result of mechanical damage, but this often requires much less impact. The reason lies in the pathology, which causes a violation of the strength of the bones locally or throughout the body. It can be any acute or chronic disease that directly or indirectly affects bone tissue.

Tuberculosis, malignant tumors, systemic diseases leading to circulatory and balance disorders nutrients in blood plasma - the list is very wide. These and similar ailments can provoke conditions when an intra-articular fracture becomes a chronic condition of the thumb.

The specific classification of fractures according to the general state of damage distinguishes between:

Closed fracture - there is no damage to the skin, the bone is not visible. This case usually does not require surgical intervention and is fairly easy to treat. An open fracture is the most dangerous type of injury, in which fragments of the damaged bone destroy soft tissues. Often accompanied heavy bleeding, displacement of bones, rupture of muscle tissue, blood vessels. Requires immediate medical attention. Displaced fracture - the damaged bone moves to the side, infringing on the tissues, vessels, and nerves located in it. May be open. A non-displaced fracture is a simple form of injury accompanied by tissue edema and painful sensations. Complete or incomplete fracture - the damaged bone is completely divided into two or more separate sections or a crack forms in it. Fracture enough long bones may be accompanied by the appearance of damage of each type. A comminuted fracture is a dangerous destruction of a bone, in which it is crushed into several fragments. Recovery often requires surgery.

Each of the injuries can happen to any of the bones of the foot, but it is the big toe that most often suffers.

The classification of the fracture is the first thing you should pay attention to. To select the most effective course of treatment, it is necessary to determine the category to which the resulting limb injury belongs.

Diagnostic methods

Swelling of tissue at the fracture site

The psychology of modern man is such that everyone is sure that bad things happen to anyone except us. After a thumb injury, when examining the symptoms, many people unconsciously try to put them under those that correspond to the bruise. This is especially true after a less dangerous, but accompanied by severe pain, dislocation of the phalanx of the fingers. A fracture after this, especially simple, and without displacement, it is simply impossible to diagnose on your own. It will not hurt as much as the previously received dislocation. Or, if we are talking about other fingers, the victim will be misled by the “slow” development of negative sensations. It is not uncommon for the pain in a broken finger to get worse as the day progresses. But a few hours after the injury, the sensations in the finger resemble an ordinary bruise or dislocation.

There are probable and absolute signs of a fracture. Probable signs only suggest the presence of such damage in the thumb. Therefore, they require diagnostic confirmation and include:

pain during palpation of the injury; swelling of tissues at the site of injury, significantly increasing the volume of the affected area; the appearance of a hematoma in the damaged area; sharp pain when moving a finger.

Only an X-ray of the finger will allow, in the presence of the mentioned symptoms, to answer the question: "the patient has a fracture or a simple bruise." Also, the answer can be obtained without an X-ray over time, but a broken bone can heal incorrectly, and this is a very difficult pathology to treat.

A fracture of any of the toes is guaranteed to confirm that the patient has symptoms such as:

change appearance fingers and their adoption of an unnatural position; complete inability to control the mobility of the injured finger; crunch of bone fragments during palpation of the damaged area; the case of an open fracture, allowing to observe the displacement and destruction of bone tissue; severe swelling of tissues, accompanied by sharp pain even with the slightest pressure.

An x-ray of the damaged area is also necessary in this case, because it will allow you to see the degree of damage and establish its danger.

For displaced fractures, x-rays are needed to correctly set the displaced area. Do not try to do it yourself - without the necessary knowledge, you can only aggravate the situation by provoking tissue rupture and internal bleeding.

First aid

Thumb fixation

If you are not going to see a doctor, you must first immobilize your finger. It is worth taking off your shoes, conducting a visual inspection of the damaged area, choosing a solid object that will become an analogue of a medical splint. Fixing the finger will help avoid tissue damage from bone fragments and reduce pain. Seeing a doctor if a fracture is suspected is the best treatment option. Especially if the edema continues to increase or maintain an abnormally large volume, and the intensity of the pain only intensifies.

The choice of treatment option depends on the location and preliminary diagnosis of the fracture. For the thumb, there are three main varieties of it:

Damage to the distal nail phalanx. The site should be anesthetized, then the bone is immobilized. The treatment consists in fixing the broken fragments with a plaster, if necessary, the nail plate is completely removed. Fracture of the middle and main phalanx. The vast majority of cases allow outpatient treatment, which consists in immobilizing the damaged bone. The average recovery time is two weeks. Complex multiple fractures. For treatment, it is required to wear a “gypsum shoe” for the time set by the attending physician.

A multiple fracture resulting in the formation of two or more bone fragments requires manual reposition of the broken sections. This task can only be performed by an experienced doctor, since any careless movement can damage nearby tissues. For cases that require repositioning of bone sections, the recovery time is from two weeks to a month.

The choice of treatment for a fracture of the thumb depends on the degree and severity of its damage. The degree of danger of the injury depends on the force that affected and the vector of its application.

Self-treatment and prevention

Cold compress to relieve swelling

The home treatment option includes several recommendations that are similar to healing a bruise. The only difference is the need to immobilize the injured finger, so as not to provoke a further aggravation of the situation. To relieve swelling, it is recommended to apply cold compress for ten to fifteen minutes. To achieve the effect, the procedure should be repeated every hour for several days. You can also hold the injured leg above heart level to reduce swelling.

Prevention of fracture of the thumb is:

in the use of comfortable shoes that reliably protect all fingers; in refusing to use foods that leach calcium from the body - this increases bone fragility; in compliance with safety regulations.

To get rid of pain, you can take painkillers that the doctor will approve. To strengthen bones, it is recommended to eat foods containing calcium. These include dairy products, peas, beans, eggs, rye bread, apples, grapes and many others.

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Valgus deformity

Inflammation

Joint treatment

Edema and tumors

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

Structure

The phalanges of the fingers are short tubular bones and look like a small elongated bone, in the form of a semi-cylinder, with a convex part facing the back of the hand. At the ends of the phalanges are the articular surfaces that take part in the formation of interphalangeal joints. These joints are block-shaped. They can perform extensions and flexions. The joints are well reinforced with collateral ligaments.

The appearance of the phalanges of the fingers and the diagnosis of diseases

In some chronic diseases of the internal organs, the phalanges of the fingers are modified and take on the appearance of "drumsticks" (a spherical thickening of the terminal phalanges), and the nails begin to resemble "watch glasses". Such modifications are observed in chronic lung diseases, cystic fibrosis, heart defects, infective endocarditis, myeloid leukemia, lymphoma, esophagitis, Crohn's disease, liver cirrhosis, diffuse goiter.

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers most often occur as a result of a direct blow. Fracture of the nail plate of the phalanges is usually always shrapnel.

Clinical picture: the phalanx of the fingers hurts, swells, the function of the damaged finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. With fractures of the phalanges of the fingers without displacement, stretching or displacement is sometimes misdiagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with an injury, then an x-ray examination (fluoroscopy or radiography in two projections) should be required, which allows you to put correct diagnosis.

Treatment of a fracture of the phalanx of the fingers without displacement is conservative. An aluminum splint or plaster cast is applied for three weeks. After that, physiotherapy treatment, massage and physiotherapy exercises are prescribed. Full mobility of the injured finger is usually restored within a month.

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

In case of a fracture of the nail phalanx, it is immobilized with a circular plaster bandage or adhesive plaster.

Phalanges of fingers hurt: causes

Even the smallest joints in the human body - interphalangeal joints can be affected by diseases that impair their mobility and are accompanied by excruciating pain. Such diseases include arthritis (rheumatoid, gouty, psoriatic) and deforming osteoarthritis. If these diseases are not treated, then over time they lead to the development of a pronounced deformity of the damaged joints, a complete violation of their motor function and atrophy of the muscles of the fingers and hands. Despite the fact that the clinical picture of these diseases is similar, their treatment is different. Therefore, if you have pain in the phalanges of the fingers, then you should not self-medicate.. Only a doctor, after conducting the necessary examination, can make the correct diagnosis and, accordingly, prescribe the necessary therapy.

Dislocations of the phalanges of the fingers range from 0.5 to 2% of all hand injuries. Most often, dislocations occur in the proximal interphalangeal joint - about 60%. Approximately with the same frequency, dislocations occur in the metacarpophalangeal and distal interphalangeal joints. Dislocations in the joints of the fingers are more often observed on the right hand in people of working age due to domestic trauma.

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

1) rear, anterior, lateral dislocation;

2) fracture-dislocation.

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

Lateral dislocations are the result of abductor or adductor forces acting on the finger when the finger is extended. The radial collateral ligament is damaged much more often than the ulnar ligament. As a rule, spontaneous reduction occurs with this damage. The reduction of fresh lateral and posterior dislocations is often not difficult and is performed in a closed way.

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

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

Radiographically, with a rupture of the collateral ligament or with severe swelling, a small fragment of bone is detected at the base of the middle phalanx.

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

Dislocations in the distal interphalangeal joints.

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

Dislocations in the metacarpophalangeal joints.

The metacarpophalangeal joints are condylar joints, which, in addition to flexion and extension, have a lateral movement of at least 30 ° when the joint is extended. Because of its shape, this joint is more stable in flexion, when the collateral ligaments are taut, than in extension, which allows lateral movement of the joint. The first finger suffers more often.

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

Treatment of metacarpal fractures

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

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

The terms of immobilization with plaster bandages for fractures and dislocations of the phalanges of the fingers and metacarpal bones of the hand are 4-5 weeks.

When carrying out open reposition or reduction of fragments of the phalanges and metacarpal bones of the hand for osteosynthesis, various extraosseous and intraosseous fixators of various sizes are widely used - rods, pins, spokes, screws made of various materials.

Especially great difficulties arise in the treatment of complex intra-articular fractures - both the head and base of the bones in the same joint, with multiple comminuted fractures, accompanied by ruptures of the capsule and ligamentous apparatus joint and resulting in dislocation or subluxation. Often these injuries are accompanied by interposition of bone fragments with blockade of the joint. The authors also offer various methods of treatment: the imposition of external fixation devices, primary arthrodesis of the damaged joint. Most Effective surgical treatment, which consists in open reposition and connection of fragments with various fixators.

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

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

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

To eliminate the contracture of the fingers in both interphalangeal joints, an external device of the I.G. type can be used. Korshunov, equipped with an additional trapezoidal frame made of Kirchner spokes, and a screw pair on the side of the top of the frame. The external device consists of two arcs with a diameter of 3-3.5 cm, in the region of the ends of the arc there are holes: with a diameter of 0.7-0.8 mm - for conducting knitting needles and with a diameter of 2.5 mm - for threaded rods connecting the arcs to each other. One arc is fixed with a needle to the proximal phalanx, the other to the middle phalanx. A needle is passed through the distal phalanx at the level of the base of the nail, the ends of the needle are bent towards the end of the phalanx and fastened together. The resulting frame is attached to the screw pair of the outer trapezoidal frame. At the same time, a spring can be placed between the screw pair and the frame that fixes the end phalanx for a more gentle and efficient traction.

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

When using surgical treatment and osteosynthesis according to the AO method, an early start of movements in the operated hand is recommended. But in the future, it is necessary to carry out repeated surgical intervention to remove metal structures. At the same time, when fixing fragments with knitting needles, their removal is not technically difficult.

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

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

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

Since the 1940s, metal and plastic structures have been widely used to restore joint mobility, which were used to replace various parts of the joints, articular ends and entire joints. The solution to the problem of endoprosthesis replacement of the joints of the fingers went in two main directions:

development of articulated endoprostheses;

creation of endoprostheses from elastic materials.

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

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

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

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

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

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

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

plastic with local tissues:

plastic with displaced flaps;

cross plastic;

plasty with flaps on a vascular pedicle:

plastic according to Kholevich;

plastic according to Littler;

radial rotated flap;

2) remote plasty:

on a temporary feeding leg:

sharp Filatov stem;

plastic according to Blokhin-Conyers;

free transplantation of tissue complexes with microsurgical technique:

flap of the first interdigital space of the foot;

other blood-supplying tissue complexes.

Methods restoring segment length:

heterotopic replantation;

pollicization;

2nd toe transplant:

transplantation of segment I toe.

Methods that do not increase segment length:

phalangization.

Methods that increase the segment length:

1) methods using tissues of the injured hand:

distraction lengthening of the segment;

pollicization;

skin and bone reconstruction with a radially rotated skin and bone flap;

2) distant plasty with the help of free transplantation of tissue complexes using microsurgical techniques:

transplantation of the finger of the opposite hand;

transplantation of the second toe;

transplantation of segment III toe;

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

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

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

sufficient length;

stable skin;

sensitivity;

mobility;

acceptable appearance;

growth ability in children.

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

The length of the 1st ray stump is a determining factor in choosing the method of surgical treatment.

In 1966, in the USA, N. Buncke for the first time performed a successful simultaneous transplantation of the first toe to the hand in a monkey with the imposition of microvascular anastomoses, and Cobben in 1967 was the first to perform such an operation in the clinic. Over the next two decades, the technique of performing this operation, indications, contraindications, functional results and consequences of borrowing the first toe from the foot were studied in detail by many authors, including those in our country. Studies have shown that in functional and cosmetic terms, the 1st toe almost completely corresponds to the 1st toe. As for the function of the donor foot, here the opinions of surgeons differ. N. Buncke et al. and T. Mau, having performed biomechanical studies of the feet, came to the conclusion that the loss of the first toe does not lead to significant gait limitations. However, they noted that prolonged healing of the donor wound is possible due to poor engraftment of a free skin graft, and the formation of rough hypertrophic scars on the back of the foot is also possible. These problems, according to the authors, can be minimized by following the rules of precision technique when isolating the toe and closing the donor defect, as well as with proper postoperative management.

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

Buncke toe transplant I

preoperative planning.

The preoperative examination should include a clinical assessment of the blood supply to the foot: determination of arterial pulsation, dopplerography and arteriography in two projections. Angiography helps to document the adequate blood supply to the foot from the posterior tibial artery. In addition, hand arteriography should be performed if there is any doubt about the condition of potential recipient vessels.

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

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

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

According to a group of studies, the dorsal artery of the foot is absent in 18.5% of cases. Nutrition from the system of the anterior tibial artery is carried out in 81.5% of cases. Of these, 29.6% have a predominantly dorsal type of blood supply, 22.2% have a predominantly plantar type, and 29.6% have a mixed type. Thus, in 40.7% of cases there was a plantar type of blood supply to the I and II toes.

Venous outflow is carried out through the veins of the rear of the foot, which flow into the dorsal venous arch, which forms the large and small saphenous systems. Additional outflow occurs through the veins that accompany the dorsal artery of the foot.

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

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

Isolation on the foot

Before surgery, the course of the great saphenous vein and dorsal artery on the foot is marked. A tourniquet is applied to the shin. On the back of the foot, a straight, curved or zigzag incision is made along the dorsal artery of the foot, preserving saphenous veins, the dorsal artery of the foot and its continuation - the first dorsal metatarsal artery. If the first dorsal metatarsal artery is present and located superficially, then it is traced in the distal direction and all lateral branches are tied up. If the dominant artery is the plantar metatarsal artery, then the exposure is started from the first interdigital space in the proximal direction, by making a longitudinal incision on the sole for a wider view of the metatarsal head. Isolation in the proximal direction is continued until an artery of sufficient length is obtained. Sometimes it is necessary to cut the transverse intertarsal ligament to mobilize the plantar metatarsal artery. If it is impossible to determine which of the vessels is dominant, then the extraction is started in the first intermetatarsal space and performed in the proximal direction. In the first interdigital space, the artery is ligated to the second finger and the first intermetatarsal artery is traced until it becomes clear how to isolate it - from the dorsal or plantar access. The vascular bundle is not crossed until the possibility of blood supply to the finger through it is verified and the preparation of the hand for transplantation is completed.

The dorsal artery of the foot is traced to the short extensor of the first finger, crossed, raised and the deep peroneal nerve located lateral to the dorsal artery of the foot is opened. The deep peroneal nerve is isolated to restore it with the recipient nerve on the hand. The first metatarsal artery is traced to the interdigital space, keeping all the branches going to the first finger, and bandaging the rest. Allocate and mobilize superficial veins so as to obtain a long venous stalk. In the first interdigital space, the plantar digital nerve is isolated along the lateral surface of the finger and separated from the digital nerve leading to the second finger by carefully dividing the common digital nerve. In the same way, the plantar nerve is isolated on the medial surface of the first finger and mobilized as much as possible. The length of the exposed nerves depends on the requirements of the recipient area. Sometimes a nerve graft may be required. Determine the approximate required length of the tendons on the hand. The tendon of the long extensor of the first finger is crossed at the level of the suspensory ligament or proximal if necessary. To highlight the tendon of the long flexor of sufficient length, an additional incision is made on the sole. At the level of the sole, between the tendon of the long flexor of the first finger and the flexor tendons of other fingers, there are jumpers that prevent it from being isolated from the incision behind the ankle. The finger is isolated from the metatarsophalangeal joint. If it is necessary to restore the metacarpophalangeal joint on the hand, then you can take the joint capsule together with your finger.

The plantar surface of the head of the first metatarsal bone should be preserved, but the back of it can be taken with a finger if an oblique osteotomy of the head is made. After removing the tourniquet, hemostasis is carefully performed on the foot. After tying the graft vessels and crossing them, the finger is transferred to the hand. The wound on the foot is drained and sutured.

Brush preparation.

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

Allocate the stump of the first finger. From the palmar incision, the digital nerves to the 1st finger, the tendon of the long flexor, the adductor 1st finger muscle and the short abductor muscle are mobilized, if possible, as well as the palmar digital arteries, if they are suitable for anastomosis. Now remove the tourniquet and perform a thorough hemostasis.

Actually transplantation of the toe to the hand.

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

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

The inflow through the recipient radial artery is checked, and anastomosis is made between the dorsal artery of the foot and the radial artery.

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

Transplantation of a fragment of the first toe

In 1980, W. Morrison described a free vascularized complex tissue complex from the 1st toe, "wrapping" a traditional non-vascularized bone graft from the iliac crest for the reconstruction of the lost 1st toe.

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

The advantages of this method are:

restoration of the length, full size, sensitivity, movement and appearance of the lost finger;

only one operation is required;

preservation of the toe skeleton;

minimal gait disturbance and minor damage to the donor foot.

The disadvantages are:

the need for the participation of two teams;

potential loss of the entire flap due to thrombosis;

the possibility of bone resorption;

the absence of the interphalangeal joint of the reconstructed finger;

the possibility of prolonged healing of the donor wound due to rejection of a free skin graft;

inability to use it in children due to lack of growth ability.

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

Operation technique

A skin-fat flap is isolated so that the entire first toe is skeletonized, with the exception of a strip of skin on the medial side and distal tip of the toe. The distal end of this strip should extend almost to the lateral edge of the nail plate. The width of this band is determined by the amount of skin required to fit the size of a normal I finger. A 1 cm wide strip is usually left. The flap should not extend too proximally to the base of the first toe. Leave enough skin in the interdigital space to be able to sew up the wound. The direction of the first dorsal metatarsal artery is marked. Lowering the foot and using a venous tourniquet, mark suitable dorsal veins of the foot.

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

The dorsal veins leading to the flap are isolated. Lateral branches are coagulated to obtain a vascular pedicle of the required length. If the plantar metatarsal artery is used, it may be necessary to plasty it with a venous graft to obtain a vascular pedicle of the required length.

Once the neurovascular pedicle has been exposed, a transverse incision is made at the base of the toe, avoiding damage to the vein draining the flap. The toe flap is raised, unfolded, and the lateral plantar neurovascular bundle is identified. The medial neurovascular bundle is isolated and mobilized, maintaining its connection with the medial skin flap.

Separate the toe flap under the nail plate by careful subperiosteal exposure, avoiding damage to the matrix of the nail plate. Remove with a flap about 1 cm tuberosity of the nail phalanx under the nail plate. The parathenon is kept on the tendon of the long extensor of the first finger in order to make it possible to perform the plastic surgery with a free split skin graft. Raise the plantar part of the flap, leaving the subcutaneous tissue on the plantar surface of the finger. The lateral plantar digital nerve is cut off from the common digital nerve at the appropriate level. If the lateral plantar digital artery is not the main feeding artery of the flap, then se coagulate and cross.

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

Brush preparation.

The hand preparation team should also take the iliac crest cancellous-cortical graft and process it to fit a healthy finger. Normally, the tip of the first finger of the hand in adduction to the second finger is 1 cm proximal to the proximal interphalangeal joint of the second finger. On the brush, two zones require preparation. This is the dorsal-radial surface slightly distal to the anatomical snuffbox and directly the amputation stump. A longitudinal incision is made under the tourniquet in the first interdigital space. Two or more dorsal hand veins are isolated and mobilized. A. is mobilized between the first dorsal interosseous muscle and the adductor muscle of the first finger. radialis. Identify the superficial radial nerve. The arterial pedicle is mobilized, dissecting it proximally to the level of the proposed anastomosis at the level of the metacarpal or metacarpophalangeal joint.

The skin on the stump of the first finger is dissected with a straight incision across its tip from the mid-medial to mid-lateral line, highlighting the dorsal and palmar subperiosteal flap about 1 cm in size. The neuroma of the ulnar digital nerve is isolated and excised. Refresh the end of the stump for osteosynthesis with a graft. A recess is created in the stump of the proximal phalanx of the first finger or in the metacarpal bone in order to place it in a bone graft and then fix it with Kirschner wires, a screw or a miniplate with screws. The flap is wrapped around the bone so that its lateral side lies on the ulnar side of the bone graft. If the bone graft is too large, then it must be reduced to the required size. The flap is fixed with interrupted sutures in place so as to position the nail plate dorsally and the neurovascular bundle in the first intermetacarpal space. Using optical magnification, an epineural suture is applied to the ulnar digital nerve of the 1st finger of the hand and the lateral plantar nerve of the toe with a 9/0 or 10/0 thread. The own digital artery of the finger is sutured to the first dorsal metatarsal artery of the flap. The arterial inflow is restored, and the dorsal veins are sutured. The deep peroneal nerve is sutured to a branch of the superficial radial nerve. The wound is sutured without tension, and the space under the flap is drained, avoiding placing the drain near the anastomoses. Then apply a loose bandage and plaster so as not to squeeze the finger, and leave the end of it to monitor the blood supply.

Postoperative management is carried out according to the usual technique developed for all microsurgical operations. Active finger movements begin after 3 weeks. As soon as the wound on the foot heals, the patient is allowed to walk with support on the foot. Special footwear is not required.

Osteoplastic reconstruction of the finger

Complex insular radial forearm flap.

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

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

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

The operation is performed under a tourniquet. The flap is lifted from the palmar and dorsal-radial surface of the forearm, its base is placed a few centimeters proximal to the styloid process radius. The flap should be 7-8 cm long and 6-7 cm wide. After preparing the distal part of the stump of the first finger, the flap is raised based on the radial artery and its comitant veins. Special care must be taken not to damage the cutaneous branches of the radial nerve or disrupt the blood supply to the radius just proximal to the styloid process. Small branches of the radial artery leading to the pronator quadratus muscle and further to the periosteum of the radius are identified. These vessels are carefully mobilized and protected, followed by an osteotomy of the radius and elevation of the radius fragment using bone instruments. The length of the graft may vary depending on the length of the stump of the first finger and the planned lengthening. The bone graft must include a corto-cancellous fragment of the lateral surface of the radius at least 1.5 cm wide, and it must be raised so that vascular connections to the flap are preserved. The radial vessels are ligated proximally, and the entire flap is mobilized as a complex complex to the level of an anatomical snuffbox. The tendon of the long abductor muscle of the first finger and the short extensor of the first finger is released proximally by dissecting the distal part of the first dorsal supporting ligament. A complex skin and bone graft is then carried out under these tendons to the rear to the distal wound of the stump of the first finger. The bone graft is fixed with the spongy part of the I metacarpal bone in the position of opposition to the II finger. Fixation is carried out longitudinally or obliquely with knitting needles, or a mini-plate is used. The distal end of the graft is processed to give it a smooth shape. The skin portion of the flap is then wrapped around the graft and the rest of the metacarpal or proximal phalanx.

At this stage, from the ulnar side of the III or IV fingers are raised islet flap on the vascular pedicle and placed on the palmar surface of the bone graft to provide sensitivity. A full-thickness skin graft is used to cover the donor finger defect. A split or full-thickness skin graft is taken from the anterior thigh to cover the donor area of ​​the forearm after covering the radius defect with muscles. After removing the tourniquet, it is necessary to control the blood supply to both flaps and, in the presence of any problems, perform revision of the vascular pedicle.

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

Second toe transplant.

The first successful transplantation of the 2nd toe into the position of the 2nd toe was performed by the Chinese surgeons Yang Dong-Yue and Chen Zhang-Wei in 1966. The 2nd toe is supplied by both the first and second dorsal metatarsal arteries, which originate from the dorsal artery of the foot, and the first and the second plantar metatarsal arteries, extending from the deep plantar arch. The first dorsal metatarsal artery passes through the first intermetatarsal space. Here it is divided into the dorsal digital arteries, going to the I and II fingers. The deep branch of the dorsal artery of the foot runs between the I and II metatarsal bones, connecting with the lateral plantar artery, and forms a deep plantar arch. The first and second plantar metatarsal arteries arise from the deep plantar arch. At the plantar surface of each interdigital space, the plantar artery bifurcates and forms the plantar digital arteries to adjacent fingers. In the first interdigital space there are digital vessels of the I and II fingers. Transplantation of the second toe is carried out either on the first dorsal metatarsal artery, extending from the dorsal artery of the foot, as a feeding artery, or on the first plantar metatarsal artery, extending from the deep plantar arch. There are variants of the anatomy of the vessels of the toes, in which the second toe is supplied with blood mainly from the system of the dorsal artery of the foot and the plantar arch. Depending on the anatomical features highlighting the toe on the foot can be simple or complex. Based on the technique proposed by S.Poncber in 1988, a method was developed for isolating the second toe on the foot, which allows all the vessels supplying the second toe to be isolated from the back access.

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

On the back of the foot, a curved incision is made in the projection of the dorsal artery of the foot and the first intermetatarsal space. At the base of the second finger, a fringing incision is made with cutting out triangular flaps along the rear and plantar surface of the foot. The size of the cut patches can be different. After separating the skin and providing wide access to the dorsal structures of the foot, the veins are carefully isolated - from the great saphenous vein at the level of the ankle joint to the base of the triangular flap at the second finger. The tendon of the short extensor of the first finger is crossed and retracted, after which the dorsal artery of the foot is isolated along the required length proximally and distally to the base of the first metatarsal bone. At this level I define! the presence of the first dorsal metatarsal artery and its diameter. If the first dorsal metatarsal artery is more than 1 mm in diameter, then it must be traced to the base of the second finger. After isolation and intersection of the extensor tendons of the second finger, a subperiosteal osteotomy of the second metatarsal bone is performed in the region of its base, the interosseous muscles are peeled off, and the second metatarsal bone is raised by flexion at the metatarsophalangeal joint. This allows you to open wide access to the plantar vessels and trace the deep branch connecting the dorsal artery of the foot with the plantar arch. From the plantar arch, the plantar metatarsal arteries leading to the II finger are traced and evaluated. Usually the medial plantar digital artery of the second finger is of large diameter and departs from the first plantar metatarsal artery in the first interdigital space perpendicular to the axis of the finger. With this variant of anatomy, the first plantar metatarsal artery, departing from the plantar arch, goes in the first intermetatarsal space and goes under the head of the first metatarsal bone, where, giving off lateral branches, it goes to the plantar surface of the first finger. It can be isolated only after the intersection of the intertarsal ligament and muscles attached to the lateral side of the head of the first metatarsal bone. The selection is facilitated by the tension of the vessel, taken on a rubber holder. After mobilization of the artery, the branches leading to the first finger are coagulated and crossed. If necessary, the second plantar metatarsal artery can be isolated, running in the second intermetatarsal space. Then, the common toe plantar nerves are isolated, the bundles leading to the adjacent fingers are separated, and the digital nerves of the second finger are crossed. The tendons of the flexors of the II finger are isolated, and they are crossed. After crossing the vessels leading to the III finger, the II finger remains connected to the foot only by an artery and a vein. Take off the tourniquet. It is necessary to wait for the complete restoration of blood flow in the finger.

Selection on the brush. A tourniquet is applied to the forearm. An incision is made through the end of the stump of the 1st ray with a continuation to the rear and palmar surface of the hand. Select all structures that need to be restored:

dorsal saphenous veins;

extensors of the first finger;

tendon of the long flexor of the first finger;

palmar digital nerves;

recipient artery;

remove scars and the endplate of the stump of the 1st beam.

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

Transplantation of the graft to the hand. The graft is prepared for osteosynthesis. This moment of the operation depends on the level of the defect of the first finger. When the I metacarpophalangeal joint is preserved, the II metatarsal bone is removed and the cartilage and cortical plate of the base of the main phalanx of the II finger are removed. In the presence of a stump at the level of the metacarpophalangeal joint, 2 options are possible - joint restoration and arthrodesis. When performing arthrodesis, the preparation of the graft is performed as described above. When restoring the joint, an oblique osteotomy of the metatarsal bone is performed under the head at the level of attachment of the metatarsophalangeal joint capsule at an angle of 130°, open to the plantar side. This eliminates the tendency to hyperextension in the joint after finger-to-hand transplantation, since the metatarsophalangeal joint is anatomically an extensor joint. In addition, this osteotomy allows you to increase the amount of flexion in the joint.

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

If in the area of ​​the stump of the 1st ray on the hand there is cicatricial deformity or a metatarsal toe graft is planned, then additional skin grafting may be required, which can be performed either before the toe graft or at the time of the operation. Immobilization is carried out with a plaster splint bandage.

Sewing up a donor wound on the foot. After careful hemostasis, the intertarsal ligament is restored and the crossed muscles are sutured to the first finger. The metatarsal bones are brought together and fixed with Kirschner wires. After that, the wound is easily sutured without tension. Drain the space between the I and II metatarsal bones. Immobilization is carried out with a plaster splint bandage along the back surface of the lower leg and foot.

Postoperative management is carried out, as in any microsurgical operation.

The immobilization of the hand is kept until the onset of consolidation, on average 6 weeks. From the 5th-7th day after the operation, you can start careful active movements of the transplanted finger in a bandage under the supervision of a doctor. After 3 weeks, the pin fixing the distal interphalangeal joint is removed. The immobilization of the foot is carried out for 3 weeks, after which the needles are removed, the plaster cast is removed. Within 3 months after surgery, the patient is not recommended to fully load the leg. Within 6 months after surgery, it is recommended to bandage the foot to prevent flattening of the forefoot.

pollicization

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

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

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

pollicization of the 2nd finger. Under the tourniquet, flaps are planned around the base of the second finger and over the second metacarpal bone. A racket-shaped incision is made around the base of the second finger, starting from the palm at the level of the proximal digital crease and continuing around the finger, connecting to a V-shaped incision above the middle part of the metacarpal bone with a bend extending to the base of the metacarpal bone, where it deviates laterally to the area of ​​the stump I metacarpal bone.

Skin flaps are carefully isolated, and the remnants of the II metacarpal bone are removed. On the palm, neurovascular bundles are isolated to the second finger and flexor tendons. The digital artery to the radial side of the third finger is identified and transected behind the bifurcation of the common digital artery. Perform a thorough separation of the bundles of the common finger nerve to the II and III fingers.

On the back, several dorsal veins are isolated to the second finger, mobilized by tying up all the side branches that interfere with its movement. Cross the transverse intermetacarpal ligament, and separate the interosseous muscles. The extensor tendons of the II finger are mobilized. Further, the course of the operation varies depending on the length of the stump of the first beam. If the saddle joint is preserved, then the II finger is isolated in the metacarpophalangeal joint and the base of the main phalanx is resected, so the main phalanx of the II finger will perform the function of the I metacarpal bone. If the saddle joint is absent, only the polygonal bone is preserved, then the metacarpal bone is resected under the head, so the II metacarpophalangeal joint will perform the function of the saddle joint. The second finger now remains on the neurovascular bundles and tendons and is ready for transplantation.

Prepare the I metacarpal bone or, if it is small or absent, a polygonal bone for osteosynthesis. The medullary canal of the stump of the 1st metacarpal or trapezius bone is expanded, and a small bone pin, taken from the removed part of the 2nd metacarpal bone, is inserted into the base of the proximal phalanx of the 2nd finger, as soon as it is transferred to a new position, and fixed with Kirschner wires. It is important to position the finger to be moved in sufficient abduction, opposition, and pronation. If possible, the extensor tendons of the second finger are sutured to the mobilized stump of the long extensor of the first finger. Since the II finger is noticeably shortened, it may sometimes be necessary to shorten the flexor tendons to the II finger. The tourniquet is removed, the viability of the displaced finger is assessed. The skin wound is sutured after moving the lateral flap of the interdigital space into a new split between the moved finger and the third finger.

The immobilization of the 1st beam is kept for 6-8 weeks, until the onset of fusion. Additional surgical interventions are possible, including shortening of the flexor tendons, extensor tenolysis, opponenoplasty, if the thenar muscle function is lost and satisfactory rotational movements in the saddle joint are preserved.

pollicization of the 4th finger.

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

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

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

The first metacarpal bone is prepared for transplantation of the fourth finger, and if it is short or absent, then the articular surface of the polygonal bone is removed to the spongy substance. It is possible to make a channel in the I metacarpal or in the trapezoid bone for the introduction of a bone pin when fixing the transplanted finger. An incision is made along the rear of the first metacarpal bone in the proximal direction to identify and mobilize the tendon stump of the long extensor of the first finger. Remove scars in the area of ​​the stump of the first finger, leaving a well-perfused skin to cover the brine after finger transplantation.

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

The operation is completed by suturing the extensor tendon of the fourth finger with the distal stump of the long extensor of the first finger. The tendon suture is performed with sufficient tension until full extension of the fourth finger in the proximal and distal interphalangeal joints is obtained. The rest of the tendon of the short muscle abducting finger I is connected to the rest of the tendons of the interosseous muscles of the fourth finger from the radial side. Sometimes it is possible to sew the remnant of the tendon of the adductor muscle to the tendon stumps of the short muscles on the ulnar side of the transplanted finger. Since the outflow of blood is carried out mainly through the dorsal veins, and when the finger is removed and passed through the tunnel, they must be crossed, it is often necessary to restore venous outflow by suturing the veins of the transplanted finger with the veins of the dorsal hand in a new position. Then the tourniquet is removed to control blood supply and hemostasis.

The suturing of the donor wound is carried out after the restoration of the transverse intermetacarpal ligament of the III and V fingers.

In the first interdigital space, the wound is sutured so that there is no splitting of the hand. When suturing the wound at the base of the transplanted finger, several Z-plasty may be required to prevent the formation of a circular pressure scar that disrupts the blood supply to the transplanted finger.

Immobilization is maintained until bone union, approximately 6-8 weeks. The movements of the IV finger begin after 3-4 weeks, although with fixation with a plate, movements can be started earlier.

Method of two-stage pollicization.

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

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

Operation technique. The first stage is the formation of the vascular pedicle of the selected donor finger. Brush preparation. Excised scars on the palm. An incision is made along the palmar surface of the main phalanx of the donor finger, which is connected to the incision in the palm. Then a small longitudinal incision is made along the rear of the main phalanx of the donor finger. Carefully exfoliate the skin along the lateral surfaces of the main phalanx of the finger to form a bed for the fascia of the flap. Next, an incision is made in the projection of the future recipient vessels in the area of ​​the "anatomical snuffbox". The recipient vessels are mobilized and prepared for anastomosis.

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

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

Second phase. Actually pollicization of the finger-donor in the position of the first finger. Stump preparation. Excised scars on the end of the stump, refresh it to prepare for osteosynthesis, mobilize the skin. Allocate the extensor tendons of the first finger, dorsal veins.

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

Isolation of the donor finger on the vascular pedicle. Initially, on the palmar surface, before the tourniquet is applied, the course of the vascular pedicle is noted along the pulsation. A skin incision is made at the base of the donor finger with triangular flaps cut out on the back and palmar surface. Subcutaneous veins are isolated on the back surface of the finger, and after marking they are crossed. Cross the extensor tendon of the finger. An incision is made along the palmar surface from the top of the triangular flap along the marked vascular pedicle. Carefully allocate actually digital nerves. The disarticulation of the finger in the metacarpophalangeal joint is performed by dissecting the joint capsule and crossing the tendons of the short muscles. The finger is lifted on a new vascular pedicle by carefully separating it in the direction of the stump of the first finger.

Isolation of the vascular pedicle is continued until sufficient length of it is allocated for rotation without tension. At this stage, the tourniquet is removed and the blood supply to the finger is controlled. An incision along the palmar surface of the stump of the 1st ray is connected to an incision in the palm in the region of the isolated vascular pedicle.

The vascular pedicle is unfolded and placed in the incision.

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

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

On the back surface of the stump, a skin incision is made to lay a triangular flap in order to avoid a circular compressive scar.

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

| Hand | Fingers of the hand | Bumps on the palm | hand lines | Dictionary | Articles

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

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

The second, or middle, finger. Saturn is considered the father of Jupiter and corresponds to the ancient Greek god Kronos, the god of time. The finger of Saturn is associated with wisdom, a sense of responsibility, and a general attitude in life, such as whether a person is happy or not.

The third or ring finger. Apollo, god of the Sun and youth in ancient Roman mythology; in Ancient Greece it was matched by a deity of the same name. Since the god Apollo is associated with music and poetry, Apollo's finger reflects Creative skills person and their sense of well-being.

The fourth finger, or little finger. Mercury, the Greek god Hermes, the messenger of the gods, and this finger is the finger of sexual intercourse; it expresses how clear a person is, that is, whether he is really as honest as he says about it.

Definition of phalanges

Length. In order to determine the phalanx, the palmist considers factors such as its length compared to other phalanges and overall length. In general, the length of the phalanx reflects how self-expressive a person is in a particular area. Lack of length indicates a lack of intelligence.

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

marks

These are vertical lines. As a rule, these are good signs, as they channel the energy of the phalanx, but an excessive number of grooves can mean stress.

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