Amputation is one of the oldest surgical operations, which was performed by the ancient Egyptians. This is a truncation of the peripheral part of a limb along an organ or bone. The disarticulation operation is an analogue of amputation, during which the peripheral part of the limb limited by the joint is isolated.
Surgical intervention of this kind is quite radical, and in most cases can turn a physically functional patient into a disabled person. It is also necessary to take into account the psychological consequences of amputation, after which complex and lengthy social and intrafamily rehabilitation is required.
Both amputations and disarticulations are done only in exceptional cases, when the possibilities of conservative medicine have been exhausted and there is an immediate threat to the patient’s life. Disarticulation of the toe involves its complete removal along with the head of the metatarsal bone.
When a decision is made to remove part of a limb, the patient should actively participate in discussions about this.
Disarticulation of the toes is necessary in the following cases:
With diabetic gangrene in combination with atherosclerosis and infection, small distal arteries are affected, so bypass surgery or prosthetics is not possible
Extensive venous thrombosis, embolism, endarteritis and peripheral aneurysms are also indications for disarticulation. If a part of a limb has been torn off, it is necessary to use all available possibilities to restore integrity and try to reattach (replant) the separated part.
It is worth noting that even with complete avulsion, replantation is possible if it is performed by a qualified surgeon experienced in microsurgery. The time factor is also extremely important, and if the journey to the hospital is short and you have ice on hand, then there is every chance of saving part of the limb.
In cases with congenital anomalies, the patient's written consent will be required - he must have a clear understanding of the degree of risk and possible complications. It is noteworthy that disarticulation is done relatively rarely, despite its simplicity and low traumatic nature. During such operations, fibrous soft tissues are cut, but the bones are not damaged. In addition, the threat of infection and acute osteomyelitis is minimal.
Disarticulations are performed primarily on the hands and feet, where prosthetics are not required and limb function is not affected. And when it comes to preserving every millimeter of tissue (as in the case of fingers), disarticulation at the joint is the best option.
Both amputations and disarticulations in the foot area are carried out with strict adherence to certain rules, namely:
The most common indication for surgery is gangrene of the foot and distal phalanx of the finger, provided there is satisfactory blood flow in the tissues. It is necessary to first cut out an external and plantar fasciocutaneous flap. The joint capsule and ligaments located on the sides of the joint are dissected. Then the main phalanx is turned upward.
It is very important not to damage the articular surface of the head of the metatarsal bone. Once all bone structures have been removed, the wound is sutured and drained as necessary.
The French surgeon Garangeau proposed this method in the second half of the 17th century, demonstrating the anatomical possibility of covering the heads of the metatarsal bones with a skin flap taken from the plantar region.
Such operations are performed for severe frostbite of the legs or after serious injuries when the bones are crushed. The operation begins with an incision in the skin and subcutaneous tissue along the plantar-digit fold. The beginning of the incision is the medial edge of the thumb, the end is the lateral edge of the little finger.
To cover the volumetric head of the first metatarsal bone, a skin flap is cut out on the plantar part of the 1st toe, but slightly above the plantar-digit fold.
On the outside of the foot, an incision is made along the line of the interdigital folds. The beginning of the incision is the outer edge on the side of the little finger, the end is the medial edge of the thumb. It should also be taken into account that the incision is made slightly above the plantar-digit fold.
Polydactyly is one of the indications for surgery to remove extra fingers.
Next, a longitudinal incision is made, which starts from the junction points of the external and plantar incisions, and ends at the level of the first and fifth metatarsal bones. The incision is made along the medial and lateral edges of the foot.
After making a longitudinal incision, fasciocutaneous flaps of the outer and plantar parts are separated up to the heads of the metatarsal bones. Then the opening of the joints begins: all the fingers are bent down towards the sole, and a precise incision is made from left to right. In this case, the flexor tendons and ligaments, which are located on the sides, intersect.
The joint capsule is incised from the side of the sole, and each toe is individually peeled. At this stage, it is necessary to ensure that the fingers do not completely separate from the interdigital fold. Only when all the fingers are in the doctor’s left hand can they be separated.
It is important to remember that the cartilage tissue on the heads of the metatarsal bones must be left. After the fingers are removed, work is carried out on the digital arteries, which need to be ligated. The skin flap of the sole is sutured to the outer one, and the operation is considered complete.
Operations using the Garangeau method allow you to ultimately obtain the longest stump of the foot. The greatest difficulty is cutting out skin flaps, and the disadvantage is that postoperative scars leave little opportunity for prosthetics, since they are too thin and hard.
First, anesthesia is performed using the Brown-Usoltseva method: conduction anesthesia is performed in the area of the middle of the finger or wrist. A needle with one percent novocaine is inserted into the base of the finger from the outside of the hand, directed towards the nerve and vascular bundles. Typically 10-15 ml of anesthetic is required. After insertion, a rubber band is placed at the base of the finger.
A skin-subcutaneous incision affecting the tendons and joint capsule begins on the outer side and is carried out according to the projection of the interphalangeal joint. This projection is determined along a straight line passing from the middle of the lateral surface of the second phalanx to the lower part of the phalanx to be removed. The finger should be bent to the maximum.
Then surgical scissors are inserted into the joint cavity and the lateral ligaments are cut, revealing the joint cavity. Using a scalpel, a skin flap is selected on the palmar surface of the removed phalanx, which corresponds in size to the circumference of the finger at the point of isolation. The result is a multi-layered and solid flap at the base, and thinner and more elastic towards the end of the phalanx. Thus, at the site of suturing, the skin consists only of the epidermis, and it is easy to adapt it to the skin where the external incision is made.
In case of slight bleeding that occurs towards the end of the operation, silk sutures are placed on the edges of the incisions. Next, the hand and finger are slightly bent, and a splint is applied to the arm.
The course of the operation is similar to the previous one, but there is also a difference. After isolating the phalanx in the dorsal edge and the palmar skin flap, it is necessary to find the vascular and nerve bundles of the fingers. The arteries are grasped above the level of the bones with surgical clamps to mark the nearby nerves. The paired dorsal and palmar nerves are cut off, after which the blood vessels are ligated and sutures are applied.
If it is necessary to isolate the fingers of the hand, then, if possible, the cuts are made on the non-working side. The ideal option is scars on the back side, but for the thumb and index finger they can be placed on the radial, and for the little finger, on the ulnar surface of the hand.
A skin-subcutaneous incision is made from the back of the base of the index finger to the middle of the radial edge of the middle phalanx, and then along the palmar surface to the ulnar edge of the metacarpophalangeal joint and to the point where the incision begins on the back.
The same incision is made near the base of the little finger from above, and it is led to the middle of the ulnar edge of the middle phalanx. The incision ends on the side of the palm near the radial edge of the metacarpophalangeal joint.
Now it is necessary to separate and unscrew the skin flaps and cut the extensor tendon slightly above the head of the metacarpal bone. After this, using surgical scissors, open the metacarpophalangeal joint and cut the lateral ligaments. When the joint capsule is opened, the flexor tendons are cut from the side of the palm and a little closer to the metacarpus.
Having determined the projections of the palmar and external bundles of nerves and vessels, they grasp the latter with clamps, remove and remove the nerves. Two pairs of palmar and external nerve endings must be cut off above the heads of the metacarpal bones. Next, the tendons are sutured and sutures are placed on the wound. Care must be taken to ensure that the skin flaps cover the head of the metacarpal bone.
It is worth noting that the shape of the incision may vary depending on the indications for the operation. A cosmetic defect can be removed with plastic surgery. By preserving the head of the metacarpal bone and the integrity of the ligaments of the intermetacarpal joints, bone function is quickly restored.
The incision starts from the back of the metacarpal bone and is carried out along an oblique line along the lateral edge of the middle phalanx to the surface of the palm. Then the incision moves along the palmar-digital fold, passes along the other side of the phalanx, and ends at the starting point of the incision on the back.
The resulting skin flaps are separated and raised upward using surgical hooks. The extensor tendon is cut slightly above the head of the metacarpal bone, the finger to be removed is pulled back, and the joint capsule is cut with scissors on all sides. The flexor tendons and other tissues that support the finger are also cut. When the finger is isolated, the nerves and vessels are manipulated in the same way as during Farabeuf dissection - the arteries are clamped, the nerves are cut off, the vessels are ligated, and the tendons are sutured. The wound is sutured in layers, after which the half-bent hand is placed on a splint.
During this operation, the incision is made in the shape of an elongated circle, and is carried out from the metacarpophalangeal joint on the outside of the hand to the interphalangeal fold on the surface of the palm, and then to the starting point of the incision.
The finger to be isolated is pulled back, the edge of the skin flap on the back is pushed back with a hook, and the metacarpophalangeal joint is opened. The articular capsule is incised with a scalpel from the side of the palm, pointing the instrument at an angle of 45° to the metacarpal bone, with the tip directed distally. This point is most important because it preserves the attachment of the muscles to the sesamoid bones, which are located in front of the joint capsule.
After the operation, the tendons are sutured and the wound is sutured in layers. It should be noted that without the first finger, the function of the hand suffers quite severely, its performance drops by almost 50%. Therefore, phalangization of the first metacarpal bone is used for correction.
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As automation and safety advances, finger avulsions are becoming less common. According to our data, they amount to 2.6%. Severations of phalanges and fingers in most cases occur at work when the hand gets caught in moving parts of mechanisms, less often - from transport or household injuries. Avulsions most often affect the distal phalanges of the fingers; The more proximal the part of the hand is located, the less common is its primary loss.
The primary loss of fingers and parts of the hand refers to avulsions, when damage causes one or another part to be separated from the hand (Fig. 126).
Plumber M., 44 years old, while drunk, got his hand under the drive belt. At the trauma center, primary treatment was performed: cross-sectional anesthesia in the middle third of the forearm with 0.25% novocaine 100 ml, hemostatic bandage at the level of anesthesia.
Rice. 126. Detachment of fingers II-III-IV-V at the level of the base of the proximal phalanges.
a - view of the hand after injury - severed fingers are brought in a bandage (drawing from life); b - diagram of the radiograph.
Cleaning of the skin, primary treatment of wounds of the stumps of II-III-IV and V fingers, removal of bone fragments, alignment of bone stumps and closure of circular wounds with grafts according to Krasovitov and Yanovich-Chainsky. Wound healing with complete engraftment of grafts and good stump formation. Six months later, the victim was offered reconstructive intervention, which he refused, citing the fact that he could cope with the work of a plumber. The short stumps and proximal phalanges are mobile and painless.
Sometimes victims bring to the surgeon the torn parts in a bandage, but more often they present with an open wound and a tissue flaw.
Recognizing separations, of course, is not difficult. Wounds with incomplete cutting, when there is a connection between the damaged part and the proximal part of the hand, are not avulsions, but complicated wounds or open fractures.
The principles and methods of treating the stump are the same as those discussed in the wounds section, but the rules for preserving every centimeter of tissue must be strictly observed. The surgeon faces the following questions: is it advisable to reattach the torn phalanges, is it possible to use soft tissue from the torn parts, how to treat the stump in case of avulsions with limited and extensive tissue damage, destruction of the arm, what are the features of subsequent treatment?
Almost every surgeon working in a trauma center tries to reattach a torn part or finger, but so far in the case of a true avulsion this is only possible in the hands of specialists. More often, there are reports of cases of complete or partial success of reimplantation of fingers and hands, which retained the connection with the limb in the form of a narrow skin-vascular bridge (subtotal avulsions).
P. D. Topalov (1967), who developed a special surgical technique and a microclimate chamber, reports the reimplantation of 42 severed fingers in 32 victims. In 30 patients, complete engraftment was achieved, in 9 - partial (with necrosis of the distal phalanges), complete necrosis - in 3.
Reimplantation of a hand amputated at the level of the wrist with modern advances in microsurgery is considered natural. Cobbett (1967) considers reimplantation of fingers severed proximally to the diaphysis of the middle phalanx to be indicated in all cases where the finger is not crushed. At present, the indications, necessary conditions and instruments, the duration of microsurgical reconstructive operations on the fingers (4-6 hours) have already been clarified, a technique for suture of the digital arteries, veins and nerves and details of the postoperative period have been developed. In specialized departments of hand surgery in the coming years, reimplantation of the hand and fingers will be the final stage of primary wound treatment (B.V. Petrovsky, V.S. Krylov, 1976).
Therefore, if the rejected part of the hand is preserved, then the victim should be sent for reimplantation to a medical institution where there are conditions and a specialist involved in hand microsurgery. This approach is especially important for thumb avulsions and multiple traumatic finger amputations. All viable tissues are used here, various methods of transplantation, and movement of adjacent fingers are used, taking into account their significance for the function of the hand. The success of primary restorative treatment of wounds with avulsions of parts, entire fingers and sections of the hand depends on the atraumaticity, asepsis of the operation, the thoroughness of restoration of anatomical relationships: osteosynthesis, vascular suture of arteries, veins and nerves of the finger, skillful use of anticoagulants and antibiotics. The further process of rehabilitation of the victim is very important.
Torn skin is successfully used in processing using the Krasovitov method. Hanging, exfoliated skin is cut off, tubular flaps are dissected and turned into flat ones. The flap is cleaned of contamination, washed with a hypertonic solution, and lubricated with iodine tincture both from the wound and from the outer epidermal side. Having placed the flap with the wound surface up on a hard table covered with a smooth sterile napkin or sheet, or on a dermatome, the surgeon and assistant stretch it and use a sharp abdominal scalpel to remove fat from it to the dermis. It takes on the appearance of a “full-thickness flap.” Then it is washed again in a warm saline solution and wiped with a napkin soaked in a saline solution mixed with alcohol. A scalpel is used to puncture several holes for lymph drainage, and then the reimplant is sewn to the defect with frequent nylon sutures. The rejected skin flaps are used after 24-48 hours.
In case of extensive injuries, when there are simultaneous avulsions of several fingers or parts of the hand and there are insufficient local resources to cover the stump wound, it is necessary to close the skin defects by transplanting full-thickness grafts or other methods, observing the principles of sparing treatment.
The advantage of replacing defects in the stump with a graft and other types of transplantation before primary amputation along the length is that thanks to the transplantation, the distal parts are preserved from truncation, which are subsequently well mastered by patients or are suitable for reconstructive operations and prosthetics. In this case, the wound heals almost in the same time as after truncation (V.K. Kalnberz, 1975).
Damage to the nail and fingertip. The increased interest in modern literature in injuries accompanied by damage to the nail, loss of the tip of the fingers, indicates the recognition of the importance of the nail and the “tip of the finger” in differentiated types of labor.
In this regard, the tactics for the initial treatment of a wound complicated by damage to the nail are being revised. The torn nail plates are not thrown away, but after treatment they are placed in a bed and sewn on (Masse, 1967). In their absence, specially prepared homografts of nail plates are used. For 3 weeks they perform a protective and fixing role, and with the beginning of the growth of a new nail, they disappear. When treating open fractures, fragments of the phalanx associated with the nail bed are preserved, the nail bed is restored, the edges of its wound are compared and an atraumatic suture is applied to ensure the growth of the nail plate (Fig. 127).
Many methods are proposed for “full” replacement of a defect in the loss of a fingertip. The method of choice for guillotine amputation is considered to be moving the flap from the palm side of the finger. In this case, the pedicle of the flap must contain the palmar digital nerve to preserve sensitivity and stereognosis. This method is preferred to grafting from adjacent fingers and layer-by-layer grafting. The Tranguilli-Leali method has become more widespread (P. A. Gubanova, 1972). Now there is a unanimous opinion among surgeons that in case of traumatic avulsions at the level of the distal phalanx, when reimplantation is impossible, reliable coverage of the defect is necessary in one way or another (Fig. 128). When taking flaps from the palm and adjacent fingers, it must be taken into account that this will create a new defect and sometimes require long-term adaptation of the patient to the additional scar.
In the last decade, the issue of complete restoration of the fingertip has grown into a problem discussed in periodicals, at symposia and congresses of surgeons. As a result of the discussion, a classification of the types of primary losses of the fingertip is recommended (R. A. Gubanova, 1972; S. Ya. Doletsky et al., 1976). Michon et al. (1970) and others, the basis for the classification and recommendations for replacing a defect is the level of amputation, taking into account damage to the bone, nail matrix and tendon attachments (Fig. 129).
Now special attention is being paid to the conservative method of treating the stump using a long-term bandage, under which spontaneous healing occurs at levels I-II. Levels III and IV amputation require radical excision of the nail matrix and closure of the stump by plastic surgery (E. V. Usoltseva, 1961; S. Ya. Doletsky et al., 1976).
Postoperative complex treatment for finger avulsions is early, systematic rehabilitation training of the victim in self-care and work processes. It is carried out in various techniques, but all of them are aimed at developing and strengthening functional skills so that the victim masters the stumps and reimplants of the fingers. This is facilitated by: painlessness of the operation, bed rest, elevated position of the arm, painkillers and sleeping pills, contact of the patient with the surgeon and the methodologist of therapeutic exercises, familiarization of the victim with the prognosis and his role in the rehabilitation process.
Rice. 127. Scheme of fixation of the nail plate.
Rice. 128. Various types of plastic surgery for avulsions and guillotine amputations of the fingertips.
a - movement of the skin on the finger; b - Tranquili-Leali method; c - flap on the feeding pedicle from the adjacent finger; g - from the palm; E - microstem according to Khitrov.
Rice. 129. Four levels of traumatic amputation of the distal phalanx.
Defect: 1 - crumb; 2 - at the level of the tuberosity of the distal phalanx; 3 - at the level of the diaphysis of the distal phalanx; 4 - at the level of the base of the distal phalanx with damage to the nail matrix and tendons.
The course and outcomes after primary loss of fingers and hands are similar to open fractures, but the duration of treatment is longer. Multiple losses of the phalanges have a particularly difficult impact on hand function; the victims find it difficult to adapt to work until their stumps are strong and painful, and this must be taken into account.
Amputation and disarticulation of phalanges, fingers, hands. The need to amputate the phalanges, fingers, parts and the entire hand may arise during the treatment of wounds and open fractures, in the process of treating not only injuries, but also diseases of the hand, and sometimes in the period long after injury or illness, when the hand becomes a hindrance and threatens health . Depending on the time, the purpose, indications and technique of amputation are different.
Amputation and disarticulation along the finger during the primary treatment of wounds in peacetime are indicated only when the finger is crushed, i.e., with complete disruption of blood circulation, innervation, damage to the tendons and skeleton - this is amputation for primary indications.
Secondary indications for amputation of the phalanges of the fingers and hand are dictated by complications that arise during the wound process, threatening the life of the victim or the preservation of the organ, as well as consequences that reduce the functional suitability of the hand.
The question of the level of amputation of phalanges, fingers and hands currently does not have the same importance as at the end of the last century and in the thirties of our century. This is explained by the fact that reconstructive operations now use those parts of the phalanges that were previously considered to have no functional significance. Currently, surgeons amputate the phalanges, fingers and hand “as low as possible” (N.I. Pirogov).
The question of the advantage of amputation over disarticulation is decided by surgeons in accordance with the level and severity of tissue damage. Of particular importance is the preservation of the attachment sites of the flexor and extensor tendons of the fingers, the bases of the proximal phalanges, as they support the surviving fingers and prevent them from deviating to the sides, ensuring stability and the exact direction of their movements.
When disarticulation of the II and V fingers, some surgeons recommend immediately removing the head of the metacarpal bone, creating a narrow hand. However, the question of the advantage of a “narrow” brush must be approached with caution, since cosmetic considerations are not always acceptable. They are not a reason to truncate the metacarpal bone if it is possible to amputate more distally. When filing the head of the metacarpal bone, the strength of the hand is significantly reduced and subsequent reconstructive operations are difficult. Therefore, amputation of fingers at the level of the diaphysis of the metacarpal bones during primary treatment of the wound is permissible only if not only the fingers, but also the metacarpophalangeal joints are crushed. A special approach in this matter requires the thumb, which provides 40% of the functionality of the hand. Even a short stump of the thumb is useful if the rest of the toe can reach it and a grip is possible. The scalped thumb is covered with a Filatov stem, and the short stump is lengthened using the distraction method (N.M. Vodyanov, 1974; V.V. Azolov, 1976, etc.).
With multiple wounds, as already indicated, every millimeter of tissue should be preserved, since at the first moment it is difficult to predict which fingers and parts of the hand will be viable and functionally suitable.
19 year old vocational school student E. I hit my hand in a stone crusher. An ambulance was taken to the hospital, where an open fracture of the distal and middle phalanges of the II and V fingers, a fracture of the distal phalanx of the III and middle phalanx of the IV finger was established. Under general anesthesia, primary treatment was performed with the separation of the II and V fingers in the proximal interphalangeal joint and the application of blind sutures to the stumps. The wound of the fourth finger is treated, the fragments are compared and a blind suture is applied and traction is applied to the soft tissue of the distal phalanx using a Beler splint. The patient was sent to the clinic for further treatment. There were no acute pains, but on the seventh day an infection developed, the sutures on the stumps of the II and V fingers separated, the sawdust of the phalanges was exposed, and necrosis of the IV finger became apparent (Fig. 130, a, see inset). Further treatment was lengthy: the second finger was reamputated twice, the fourth and fifth fingers were reamputated once, and the phlegmon of the midpalmar space was opened. The victim was disabled for 97 days and recognized as a group II disabled person.
U machine operator Ts., 44 years old, the surgeon preserved the partially severed crushed phalanges of the I-I fingers of the right hand. The outcome is favorable (Fig. 130, b, c).
Finger amputation technique
Finger and hand truncation operations do not present any particular difficulties, but they are often atypical and individual for each victim. However, the basic rules for finger amputation must be followed in any setting. Briefly, they boil down to the following provisions.
Thorough disinfection of the skin of the hand and forearm. Complete anesthesia and bleeding. Skin flaps with subcutaneous tissue are cut out longer than the diameter of the finger on any side of it - palmar, dorsal or lateral, where there is healthy skin. The soft tissues are cut down to the bone with a cutting motion at a selected level, retracted proximally with a hand retractor, and carefully protected while sawing through the bone.
The bone is sawed perpendicular to the axis of the finger with a diamond disc included in a drill, or with an electric drill (this is the most atraumatic method that produces an even sawdust), if there is no disc, with a Gigli saw or a thin hacksaw. The sawdust is smoothed with a fissure and cleaned with a rasp or file. Ligatures are applied to the palmar digital arteries. The finger flexor and extensor tendons are inspected; if they are crushed or torn, they are cut off at the level of the healthy part and sewn to the soft tissue or periosteum. The nerves of the fingers are examined; if they are visible on the surface, they stand out slightly and are cut off with a safety razor blade 1.5-2 mm proximal to the bone sawdust. When the soft tissues are cut correctly, the nerves in the wound are not visible. Bone chips from the bone sawdust are carefully removed with a stream of hot saline solution or rivanol or with a damp ball. Stump drainage is necessary in cases where the surgeon is not confident in hemostasis and aseptic healing. Drainage is carried out with threads of fishing line, silk or thin rubber strips and is brought to the rear through a special incision. It is not recommended to place it on the palm or side of the finger. Before suturing, excess tissue is cut off, the flaps are carefully adjusted and strengthened with rare sutures or pinned with thin short needles (if there are no contraindications to closing the wound). Stumps can be covered in a variety of ways depending on the condition of the tissue.
For example, in patient B., when fingers I-II and III were torn off at the level of the proximal phalanges, the more even stump of the first finger was covered with a graft using the Larin method after treatment. On the stump of the second finger, the palmar and dorsal flaps turned out to be sufficient and were freely brought together over the sawdust and stitched. On the third finger, there was not enough soft tissue to cover the defect, and the sawdust was covered with skin grafts taken from the severed finger.
After the operation, the stump is covered with a tiled-like applied pressure bandage. For extensive damage, a plaster splint with pad or splint is applied. After a day, without completely removing the bandage, the drainage is removed. Sutures after amputation are removed later than usual - on the 10-12th day. Therapeutic exercises begin when the pain subsides and the danger of infection has passed.
Exarticulation of the fingers is carried out on the basis of the same provisions. Experience has shown that its success largely depends on how carefully the articular capsule and ligaments are excised; the cartilaginous surface, if not damaged, is preserved. When amputating a finger at the level of the diaphysis of the metacarpal bones, a longitudinal incision parallel to the axis of the finger is most often used, less often - rocket-shaped and wedge-shaped, depending on where there is healthy skin on the finger; The surgical technique is not standard.
When amputation is performed at the level of the metacarpal bone, the metacarpal joint, or at the base of the finger, especially the first, when there is no flap to cover the stump, tissue is moved, a free skin graft or a flaw is replaced with a Filatov stem.
Amputation or disarticulation of fingers during the period of purulent tissue melting is inappropriate, as it leads to a high percentage of complications, reamputation, prolongs the treatment period and aggravates the outcome.
The gentle tactics adopted by surgeons of the Soviet Union both in peacetime and in wartime are fully justified, since with timely surgical treatment of the wound, antibiotic therapy, osteosynthesis and skin plastic surgery, those fingers for which there are relative indications for truncation are preserved. Subsequent complex treatment, reconstructive interventions and labor training for victims contribute to the restoration of lost functions and adaptation of preserved functions. Saved fingers turn out to be active.
In modern literature, much attention is paid to the issue of postoperative pain in the stump. Linking the origin of these pains with the development of neuroma on the nerve stump, to prevent it, surgeons used various methods of treating the end of the truncated nerve - from alcoholization, freezing with chlorethyl to cauterization.
However, the cause of postoperative pain is not always the presence of a neuroma developing at the end of the truncated nerve, as was the general opinion. Pain is often caused by irritation of axons by inflammatory infiltrate or compression by scar tissue and concomitant vasomotor disorders. Consequently, the most effective measure aimed at preventing these complications is to prevent the development of inflammatory phenomena in the wound. Therefore, most modern surgeons refuse any chemical or physical effects on the nerve stump during amputation. The average number of days of disability for primary losses and amputation of the phalanges ranges from 28.5 to 64.5.
E.V.Usoltseva, K.I.Mashkara
Surgery for diseases and injuries of the hand
Traumatic amputation refers to accidental conditions characterized by the complete or partial separation of a body part as a result of an accident. In a complete amputation, the limb or other protruding parts are completely separated, while in a partial amputation, some soft tissue, such as skin, muscles and tendons, remain attached to the area. Traumatic amputation most often occurs in the areas of the extremities, ears, fingers and nose.
Traumatic amputation requires immediate surgical intervention, since the blood in the separated part of the body quickly clots, clogs the vessels, and necrosis begins in the tissues. Such conditions make it impossible for the body part to be successfully reattached to its place.
Unlike surgical amputation, which is carried out for medical reasons, traumatic amputation, as the name suggests, is the result of an injury, that is, an accident that occurred due to the fault of the patient himself or as a result of force majeure.
Traumatic amputation is a fairly rare occurrence. The loss of a limb usually occurs directly during an accident, but in some cases, body parts are surgically separated after a few days due to medical complications. Statistically, the most common causes of traumatic amputations are:
In some cases, amputated body parts can be successfully restored to their original location. The success of the operation depends on the following factors:
Witnesses to a traumatic amputation should follow the following instructions in the order listed.
Call emergency services and try to stop the bleeding yourself. Complete amputation is caused by rupture of large blood vessels. Blood under high pressure is released into the external environment very quickly. Depending on the diameter of the vessel, a vital volume of blood can leave the body within 5-10 minutes, after which death is possible. Therefore, it is necessary to stop the bleeding as soon as possible.
To stop bleeding it is necessary
An injury of such force that it can separate a limb will cause a state of severe shock in the victim and significant pain. There is simply nothing to help a witness without medications, except to be prepared for a situation accompanied by a state of shock. Signs of physiological shock include:
Restoration of the amputated body part, if possible, is carried out strictly in an operating room. The severed limb or other body part is usually transported to the hospital with the victim. If a part of the body cannot be found immediately, transportation of the victim to a medical facility is under no circumstances delayed. The amputated part can be delivered no later than 24 hours after the accident.
If a separated part is detected, before the ambulance arrives, you must:
The ideal option for this would be a refrigerator or a simple container with ice. If you don’t have this on hand, you can use cold water. But it should be remembered that placing a part of the body that is not protected from water directly into water is strictly prohibited.
After delivering the victim to the operating room, all measures will be taken to maintain the patient’s life, provide pain relief, stop bleeding and relieve stress. In the second stage, surgery begins to restore the separated body part.
First of all, both sides of the wound surfaces are treated antiseptically, then large blood vessels, nerves, and then muscles and bones are connected in sequence.
As already stated, a person may experience psychological trauma and severe emotional discomfort as a result of what happened to them for a very long time. This especially happens in cases where reverse restoration of the limb is not possible. Many experience severe affective disorders to the point that they require the support of a psychologist or psychotherapist. This is especially true for military veterans, who develop post-traumatic stress disorder against the backdrop of shocks they have experienced. Limb loss can present significant or even drastic practical limitations, which certainly affects quality of life.
A large proportion of amputees (50-80%) experience the phenomenon of phantom limbs - they "feel" parts of the body that are no longer there. These extremities may show itching, pain, burning, tightness, dryness, or wetness. Patients often feel as if the amputated limb or body part is in motion.
Scientists attribute phantom limbs to features of certain areas of the human brain, which send information to the rest of the central and peripheral nervous system about the limbs, regardless of their existence. Sensations and phantom pains can also occur after removal of other parts of the body, not just limbs, such as breast amputation, tooth extraction, or eye removal.
In many cases, phantom manifestations help in adaptation to the prosthesis, as they allow the person to better feel the prosthetic limb. To support improved resistance or convenience, comfort or healing, some types of artificial extension of the body may well be perceived as their own anatomical part.
Another side effect is heterotopic ossification, especially when bone injuries are combined with traumatic brain injury. The brain signals bone growth, and scar tissue can interfere with prosthetics. Such cases sometimes require further operations. This type of injury is especially common among soldiers injured by explosive devices.
Due to technological advances in prosthetics, many people with disabilities are living active lives with little limitation. Organizations such as the Paralympics challenge the many hardships of life for a disabled person. People have the opportunity to participate in sports competitions, adaptive sports, drive a car, play musical instruments, draw and do their favorite activities that were available to them before the accident.
Limb amputation is considered one of the oldest operations in the history of medicine. The first descriptions date back to the 4th century BC. e. However, the inability to stop severe bleeding, as well as the lack of knowledge about vascular ligation, usually led to death. Doctors were recommended to truncate the limb within the affected tissue; this eliminated fatal bleeding, but did not stop the spread of gangrene.
In the first century AD, Celsus Aulus Cornelius proposed a revolutionary approach to such operations for that time, which included recommendations:
Carry out truncation at the level of viable tissue;
Isolated ligation of stump vessels to prevent bleeding;
Cutting out a reserve flap of tissue to cover the stump without pathological tension.
An important role in improving the methods of amputation of limbs was played by the introduction of the method of bloodless surgery, when Esmarch created the rubber tourniquet that is still used today.
In the modern world, diabetes mellitus and cardiovascular pathologies occupy leading positions among the indications for amputation.
Amputation is the truncation of a limb, or rather its distal part, along the bone, but it would be a terrible mistake to consider it as a simple removal of the affected segment. This term implies plastic and reconstructive surgeries aimed at further rapid and effective rehabilitation of the patient.
There are certain indications for this type of surgery. Let's consider these indications in more detail.
Gangrene.
The presence of a source of severe infection that threatens the patient’s life (anaerobic infection).
Irreversible ischemia with muscle contracture.
Traumatic crushing of a limb with damage to the main vessels and nerves, so-called traumatic amputation is performed.
Obliterating vascular diseases leading to gangrene.
Reamputation to correct a failing stump.
There are circular, elliptical and patch amputations. Let's look at these types below.
The main indications for amputation, namely guillotine (single-stage circular) amputation, are resection of limbs hanging on a musculocutaneous flap. This intervention is carried out exclusively for emergency reasons. A significant disadvantage of this technique is the creation of a non-functional stump and mandatory subsequent reamputation in order to adapt the limb to the further installation of a prosthesis.
The advantage of this amputation is the absence of necrotic changes in the flap even with reduced blood supply.
In guillotine amputation, the bone is sawed off at the same level as the soft tissue.
How is the operation performed? Amputation at the first stage consists of cutting the skin, subcutaneous fat and fascia. The edge of the displaced skin is a further guide along this edge. At the second stage, the muscles are dissected to the bone and the bone tissue is further cut. The bone end is covered by the skin and fascia.
The first two stages of the operation are similar to a two-stage amputation. Next, after moving the muscles and superficial tissues proximally, the muscles are re-dissected along the edge of the retracted skin. Thanks to this, the deep muscle layers are dissected, which contributes to the further formation of a cone-shaped stump.
Flap methods are divided into:
When forming a stump, it is necessary to take into account that the scar should not be on the working surface. The flaps must be formed taking into account the ability to withstand loads.
How is lower limb amputation performed? A distinctive feature is the presence of a bone fragment covered with periosteum as part of the flap.
The method of osteoplastic amputation of the leg according to Pirogov has received worldwide recognition in connection with the highly successful anatomical rehabilitation of the end support of the operated leg.
Advantages of the method:
Less severe pain in the stump.
The presence of an end support of the stump.
Preservation of proprioceptive sensitivity of muscles and tendons.
When removing the tibia according to Pirogov, two incisions are made. An amputation knife is used for this. First, a transverse dissection of the soft tissue is made, exposing the ankle joint, then an arcuate incision is made along the dorsum of the foot. After crossing the lateral ligaments, the talus is isolated and the shin bones are sawed off. The cross section is covered with a flap. A stump is formed.
There is another method by which amputation of the lower extremities is performed.
When removing the foot, soft tissue dissection is carried out several centimeters distal to the first phalanges of the metatarsal bones. After preparing the periosteum, the ends of the cut are sawed off and smoothed with pliers. The cut is covered with a plantar flap.
Let's look at the main reasons for amputation.
The surgeon's actions depend on the extent of the damage. According to the prevalence of purulent-necrotic lesions, five stages are distinguished:
Superficial focus of necrosis without tendon involvement.
Gangrene of the finger involving the first phalanx and tendons.
Widespread gangrene of the fingers, combined with gangrene of the foot.
Gangrenous lesion of the entire foot.
Involvement of the lower leg in the process.
Upon admission of a patient with purulent-necrotic ischemia, emergency sanitation of the lesion is carried out, which consists of opening abscesses, draining phlegmons, minimal resection of the affected part of the bone and removal of dead tissue. After excision of non-viable tissue, operations are recommended to restore adequate blood flow to the damaged limb.
For ischemia:
First degree only sanitation of the lesion is performed;
The second degree involves amputation of the affected finger with excision of the tendons involved in the process;
In the third degree, amputation according to Sharp is performed, a special amputation knife is used;
Treatment of the fourth degree consists of resection at the level of the tibia;
In the fifth degree, amputation is performed at the level of the hip.
There are:
There are four degrees:
The first degree is accompanied by reversible changes in the skin: hyperemia, swelling, itching, pain and an unexpressed decrease in sensitivity. After a few days, the affected areas peel off.
The second degree is characterized by the appearance of blisters with light contents, a pronounced decrease in sensitivity, and possible infection due to trophic disorders.
The third degree is manifested by necrotic changes in soft tissues as a result of their death, a line of demarcation is formed (demarcation of dead tissues from healthy ones by a strip of granulations), damaged areas of the limb are mummified, and with the addition of microbial flora, the development of wet gangrene is possible.
In the fourth degree, tissue necrosis spreads to the bone, the liquid in the blisters on the skin becomes cloudy black, the skin is bluish, pain sensitivity completely disappears, the affected limb turns black and mummifies.
is a consequence of a slowly progressive disruption of the blood supply to tissues, typical for patients with atherosclerosis and
It is distinguished by the absence of general intoxication of the body and the presence of a clear demarcation shaft. During treatment, it is possible to use wait-and-see tactics.
Used: drugs that improve tissue trophism, systemic antibacterial therapy. The operation is carried out after the formation of a clear demarcation line.
Wet gangrene occurs as a consequence of acute cessation of blood circulation (frostbite of the fingers, thrombosis, compression of blood vessels). It is characterized by severe intoxication, absence of a demarcation line and severe edema. Amputation in case of gangrene is carried out urgently; wait-and-see tactics are unacceptable. After detoxification therapy, surgery is performed. The amputation line should be significantly higher than gangrene (if the foot is affected, amputation is recommended to be carried out at the level of the hip).
Gas gangrene is an absolute indication for guillotine amputation. Characteristic manifestations: pronounced, rapidly progressing edema, the presence of gas in tissues and muscles, necrosis and phlegmon with melting of soft tissues. Visually, the muscles are grayish, dull, and wrinkle easily upon palpation. The skin is purplish-bluish, and when pressed, a crunching and squeaking sound is heard. The patient complains of unbearable, bursting pain.
For the prosthesis to function fully, the length from the stump to the joint must be greater than its diameter. Its physiological shape (slightly tapering downwards) and painlessness are also important. The mobility of the preserved joints and the skin scar (its mobility and lack of adhesion to the bone base) are assessed.
The scar spreads to the work surface.
Excess soft tissue.
Absence of a cone-shaped narrowing of the stump.
Fusion of the scar with the tissues, its immobility.
The muscles are too high.
Excessive tension of the skin with bone filings.
Deviation of bone segments during amputation of paired bones.
Excessively conical stump shape.
Amputation of a limb is an anatomical defect, as a result of which a disability group is assigned indefinitely. If a leg amputation occurs, a disability group is assigned immediately.
The assessment of the degree of loss of functional activity, disability and limited ability to live, as well as further assignment of disability, is carried out by a medical rehabilitation expert commission.
When establishing a disability group, the following is assessed:
Self-care ability.
Possibility of independent movement.
Adequacy of orientation in space and time, provided there is no pathology of mental activity (hearing and vision are assessed).
Communication functions, ability to gesture, write, read, etc.
Level of control of one’s own behavior (compliance with legal, moral and ethical standards of society).
Learning ability, the opportunity to acquire new skills, master other professions.
Ability to engage in work activities.
The ability to continue to work within the framework of one’s professional activities after rehabilitation and when special conditions are created.
Functionality and degree of mastery of the prosthesis.
Indications for assignment to the first group:
Amputation of both legs at the hip level.
Absence of four fingers (including the first phalanges) on both hands.
Amputation of the hands.
Amputation of three fingers (with the first phalanges) of both hands.
Removal of 1st and 2nd fingers.
Absence of 4 fingers with preservation of the first phalanges.
Amputation of fingers on one hand with a high stump of the other hand.
Operation according to Chopart and Pirogov.
High resections of one leg, combined with the absence of fingers of one hand or eye.
Amputation of one arm and eye.
Disarticulation of the hip or shoulder.
Unilateral finger amputations without removal of the first phalanx.
Bilateral finger amputation.
High amputation of one leg or arm.
Removal of both feet according to Sharpe.
The difference in leg lengths is more than 10 cm.
In addition to the anatomical defect, amputation of a limb leads to severe psychological trauma to the patient. The patient becomes isolated in thoughts about his own inferiority in the eyes of society and believes that his life is over.
The success of further prosthetics is determined not only by the timeliness of the operation, the level of amputation and further proper care of the stump.
On the 3-4th day after amputation, prevention of flexion contractures and movements of the stumps begin. After removal of the sutures, active training of the muscles of the stump is recommended. A month later they begin to try on the first prosthesis.
The most important goal of rehabilitation measures is to stabilize the patient’s psychological state and develop an adequate attitude towards prosthetics.
Further activities include:
Training in the use of a prosthesis;
A set of trainings to activate the prosthesis and include it in the general motor pattern;
Normalization of movement coordination, use of therapeutic and training prostheses.
Social rehabilitation measures, patient adaptation to life with a prosthesis;
Development of an individual rehabilitation program, retraining and further employment (for groups 2 and 3).
If phantom pain occurs in an amputated limb, novocaine blockade, hypnosis sessions and psychotherapy are recommended. If there is no improvement, surgical intervention with resection of the affected nerve is possible.
Truncation of the fingers of the upper limb. Indications: trauma, gangrene, tumors. Approaches and incision: two-flap. Complications The basic rule is to maintain maximum economy while preserving every millimeter of stump length.
When amputating the nail phalanx, it can be done under local anesthesia using a one- or two-flap method. Principle: the flap is cut out from the palmar side, and the scar is located on the back. The palmar flap is formed of such length as to cover the stump.
When disarticulating the phalanges of the fingers, a single-flap method is used with the formation of a palmar flap so that the scar is located, if possible, on a non-working surface.
Hip amputation.Indications: trauma, gangrene, tumors. Approaches and incision: circular incision, three-stage, osteoplastic, two-flap. Complications
Three-stage cone-circular amputation of the hip according to N. I. Pirogov.
Amputation of the thigh in the lower and middle third is usually performed using the three-stage cone-circular Pirogov method.
Technique. A circular, or even better, elliptical skin incision is made 1/3 of the length of the thigh circumference below the level of the intended bone section, taking into account skin contractility (3 cm on the posteroexternal side, 5 cm on the anterior internal side). The muscles are cut along the edge of the contracted skin right down to the bone. The assistant pulls the skin and muscles with both hands, and along their edges a secondary section of the muscles is made to the bone. To avoid double transection of the sciatic nerve, it is recommended that the first section of the muscles from behind should not be taken to the bone. The soft tissue is pulled back with a retractor, the periosteum is cut 0.2 cm above the level of the bone section and it is moved distally with a retractor. They saw through the bone. At this moment, the assistant holds the limb in a strictly horizontal position in order to avoid bone fracture. The femoral artery and vein are ligated, as well as visible small arteries. Nerves cross. Layer-by-layer sutures are applied to the fascia and skin and drainage is introduced.
Amputation of the lower leg.Indications: trauma, gangrene, tumors. Approaches and incision: osteoplastic, two-flap. Complications: bleeding, causalgia and phantom pain, trophic ulcers, neuromas, osteomyelitis.
Osteoplastic amputation according to Pirogov indicated for crushed feet and destruction of the ankle joint without damage to the Achilles tendon and heel bone.
Technique. First, a transverse soft tissue incision is made on the dorsum of the foot, opening the ankle joint, from the lower end of one ankle to the lower end of the other. The second incision (in the form of a stirrup) is made from the end of the first incision through the sole, perpendicular to its surface, deep into the heel bone. The latter is sawed down, removing the entire forefoot along with the talus bone and part of the heel bone. The cut of the preserved part of the calcaneus is applied to the stump of the tibia after sawing off the lower epimetaphyses of the tibia.
The advantage of the operation: the formation of a good stump supported by the calcaneal tubercle without noticeable shortening of the limb length, i.e. no need for prosthetics.
Disadvantage of the operation: the possibility of necrotization of the heel tubercle with the soft tissues covering it as a result of transection of the heel vessels.
Kinematization of the forearm stump- a method of limb amputation in which muscles and tendons are grouped in the stump in such a way that they can perform independent movements and give mobility to the prosthesis.
Replantation. Replantation (lat. replantare to replant, replant) is the surgical engraftment of a limb or its segment separated from the body.
Indication for replantation are: amputation of the thumb, multiple amputations of fingers in children, amputation of the wrist, amputation of the forearm, amputation of both upper limbs, both legs or feet.
Contraindications to replantation are severe general condition, old age, and the critical period from the moment of amputation to admission to the hospital. Extensive crushing of the tissues of the severed segment. In replantation surgery, the following principles are important: 1) one-stage operation. Thanks to this, restoration of blood circulation and functional structures occurs simultaneously; 2) extensive primary treatment and sanitation of the wound to stitch only healthy tissue; 3) prevention and elimination of tension in the area of vascular anastomosis; 4) use of venous autografts; 5) the period of anoxemia should be as short as possible; 6) amputated parts must be cooled to 4 °C during transportation and maintained in this condition until replantation.
Fingers of the hand. The indication for amputation of the phalanges or finger may be an inflammatory process (rarely) or, more often, injury. The indication for amputation of a finger in case of injury is usually failure of peripheral circulation. The most complete information can be obtained using arteriography through the brachial artery at the level of the cubital fossa. If there are difficulties in immediately determining the viability of damaged tissue, a wait-and-see approach followed by amputation at the level of healthy tissue is acceptable.
Sitz baths: 100 g of horsetail are left overnight in cold water, the next day the maceration is boiled to a boil and added to bathing water. Do not wipe after bath, but rinse in a robe, sweat for 1 hour in bed. Bathing water should cover the kidneys. Compost with porridge: Fresh horseradish is washed well and crushed on a wooden bottom to form porridge.
Change the patch when it is saturated with absorption of ulcer exudate or leakage. If he has a local infection, the patches should contain silver. Placing the patches The spotting mechanism prevents secondary infections. These two factors are nerve damage and low blood flow. Combinations of these two symptoms can lead to countless cases that require further diabetic ulcers. This causes it to worsen and develop ulcers. This is due to low blood flow in the legs. When the body is injured, blood provides oxygen, proteins and nutrients to heal the wound.
Level of amputation or disarticulation on the II-IV finger determined by the ability to form a sufficient flap to cover the bone fragment. In the area of the first finger, if there is a lack of soft tissue, plastic surgery is used to preserve the maximum possible area of the finger. When amputating the fifth finger, the phalanx is removed at a level that ensures the formation of a reliable flap.
If blood flow is low, treatment is stopped. Reducing acidity in the diet also benefits the environment greatly in overall health. Applying an extremely alkaline solution with more than 8.0 helps reverse skin acidity, accelerating the restoration of healthy cells and improving appearance. In diabetic patients, leg ulcers are a serious problem that requires special attention and for which prevention is key. Wounds that may be created on a diabetic foot can easily become infected.
Anesthesia according to Oberst-Lukashevich. Two flaps are cut out from soft tissues (the larger one is from the palmar surface). The phalanx is sawed with a Gigli saw at a level that ensures free approximation of the skin flaps. The end of the tendon is shortened as much as possible, the vessels are ligated, and the nerves are stretched and cut off with a razor. The skin is brought together with 1-2 sutures. A bandage and plaster splint are applied.
An infected leg ulcer is difficult to rehabilitate and causes many problems for the patient. In some patients, this is the first stage of a painful condition that leads to amputation. Why do foot ulcers occur in diabetic patients? In diabetic patients, prolonged high blood glucose levels cause damage to their small blood vessels and nerves. If the patient follows the instructions of his doctors, he/she receives regular treatment and follows a healthy lifestyle and diet, minimizing the likelihood of chronic hyperglycemia and the risk of diabetic neuropathy and angiopathy.
Disarticulation of the middle and distal phalanges of the fingers. Anesthesia according to Oberst-Lukashevich. In the position of maximum flexion on the dorsal side, a circular incision is made to the middle of the diameter above the projection of the joint (a continuation of the palmar side of the proximal phalanx) and then, turning the knife in the frontal plane, a flap is cut out from the palmar surface of the removed phalanx. Treatment and subsequent care - as in the previous case.
In diabetic feet, nerve damage causes loss of sensation as well as deformity. Calves and deformed toes are causes of high tread pressure. Diabetic patients can hurt their feet even with minor relapses, such as those that occur after a long walk. Foot injuries can also be caused by significant trauma such as abrasion, ugly cutting of nails, wearing shoes that do not fit well in the foot, contact of the feet with very hot water, or pressing on sharp objects.
In these cases, due to peripheral neuropathy, the diabetic patient does not feel pain and this can lead to diabetic foot ulcer. Also, due to diabetic vasculopathy, blood circulation to the patient's foot is not good, which aggravates the condition, slows down the healing mechanisms and increases the risk of infection and injury. Among patients with diabetes, it is estimated that 4% to 10% have foot ulcerations. Each year, the percentage of new cases of leg ulcers in patients with diabetes ranges from 1% to 4.1%. It is also estimated that up to 25% of patients with diabetes will experience an ulcer at some point in their lives.
Disarticulation of the second or fifth fingers of the hand(Farabeuf operation). Conduction or diamond anesthesia. A racket-shaped cut with a descending part on the back of the hand.
To remove the second finger, the palmar flap is made longer on the radial side, and for V - on the ulnar side. The incision begins 1 cm distal to the interdigital fold, runs along the lateral surface of the finger and ends on the dorsal surface distal to the head of the metacarpal hand. The extensor and flexor tendons are divided, then the lateral ligaments are dissected. This is followed by ligation of the digital arteries and suturing of skin flaps. Immobilization with a plaster splint is required.
These data show the great importance of preventing foot ulcers in diabetic patients. Proper management of diabetes and careful foot care are measures that can prevent diabetic foot ulcers and all the complications that may arise. What are the preventive measures against leg ulcers in diabetic patients? Patients with diabetes should monitor and monitor their feet daily to see if there are cuts, sores, or areas of irritation, especially in the areas between the toes.
If they find that there is any problem, they should immediately seek advice from their doctor. Patients who for some reason cannot look at their feet should use either a floor mirror or a long-handled mirror to see them. The temperature of the water to which the legs are to be placed must be carefully controlled. With their own hands they can get used to it and understand how hot the water is. After washing your feet, dry them very well, especially in the areas between the toes.
Disarticulation of the third or fourth fingers of the hand(Luppi operation). Intraosseous or conduction anesthesia according to Brown at the base of the finger. A circular incision along the palmar-digital fold with maximum extension of the injured finger and maximum flexion of the rest. A small longitudinal cut on the back of the hand, giving it a T-shape. The flexor tendons are also crossed after changing the position of the extensor finger. After dissecting the ligaments, the finger is removed, the arteries of the finger are ligated and the articular cartilage is excised sharply. Several stitches on the skin.
The toes must be cut carefully, straight, not deep and without risk of irritation or injury to the flesh. Also, the nails need to be rubbed with a special file so that they are not sharp. Patients suffering from diabetic neuropathy should not trim their nails alone. A podiat can provide regular advice and care for your feet. Diabetics should also be very careful when choosing shoes. Their application on the feet must be flawless to avoid friction and pressure. Diabetic patients with peripheral neuropathy should be checked for foreign bodies before wearing shoes.
The cosmetic result of the operation gains slightly, but the mechanics of the hand loses when the heads of the metacarpal bones are removed together with the II and V fingers.
For amputations of the fingers, plastic techniques are widely used to obtain longer stumps with better functionality.
Disarticulation of the toes. Strict indications are required for the intervention, since after the removal of the toes, changes may occur in the position of the remaining toes and the kinematics of the foot as a whole. Removal of the fingers is carried out after a racket-shaped dissection of the skin and maximum flexion of the fingers. After crossing the extensor muscle and the joint capsule, the flexor tendon is made visible by forced flexion, which is divided along with the remaining tissue. Hemostasis. Applying sutures to the flap. Immobilization with a plaster splint.
In addition, they should never go barefoot. In cases where there is an inflammatory outbreak or wound in the leg of a diabetic patient, immediate medical attention is required. When we talk about chronic venous insufficiency, we are talking about a sequence of lesions that can occur in the lower limb when its veins do not function properly. The veins of the lower extremities act as conduits that carry blood from the legs to the heart. This is achieved through a series of valves present in their inner walls, which, like dams, are open to allow blood flow to the heart and closed to prevent blood flow in the opposite direction.
More significant amputations or disarticulations, although purely technical ones, can be performed in the clinic, however, in terms of both ensuring the operation and monitoring in the postoperative period, the feasibility of this is questionable.
It is advisable (in the absence of contraindications) to perform all amputations and disarticulations on the upper and, less commonly, on the lower extremities under a tourniquet.
Thus, the blood flow is naturally always directed towards the heart. In some situations, these valves do not close properly, leaving a gap between them, and therefore they cannot prevent blood from flowing back away from the heart. In this way, the blood pulsates and flows into the veins at the bottom of the penis and into the tissues of the members. - When valvular insufficiency concerns the superficial veins, venous varices may develop. - When it comes to the deep veins, swelling of the limb may occur.
When damage to the valves in the deep veins occurs due to venous thrombosis, the condition is called post-thrombotic syndrome. - When there are factors that interfere with the normal functioning of the gastrointestinal muscle pump, a sequence of changes in chronic venous insufficiency can also be caused. When the veins of the lower limb do not work properly and the blood flow in them has a double direction, the blood begins to lick the tissues of the limbs. This venous congestion can have consequences.
Clinic surgeon's directory. Kutushev F.Kh., Libov A.S. Michurin N.V., 1982
Emergency medical care for injury
Traumatic amputation of the distal phalanx (tip) of the finger- the most common type of traumatic amputation of the upper limb. A characteristic feature of the structure of the distal phalanx of the finger is that, despite its small volume, it is formed by different tissues. The nail covers the nail bed. It includes the matrix of the nail, which ensures its growth, and the hyponychium - the spinous and basal layers of the epidermis, due to which the nail grows in thickness. The place where the nail matrix transitions to the hyponychium forms the nail lunula. The nail is normally fixed to the nail bed and becomes detached from it due to injury or scarring. The top of the nail is covered with a supra-nail skin, which gives it shine. Proximally and laterally, the nail bed is limited by the posterior and lateral nail folds. Between the free edge of the nail and the nail bed is the subungual skin. The support for the nail is the distal phalanx. If it is too short, the nail curls around the tip of the finger. Neurovascular bundles run along the sides of the finger on both sides.
It causes lipoprophylaxis and fibrosis, or sclerosis of the skin and subcutaneous tissues of the leg. The skin becomes reddish or dark brown in color, like rust, due to the deposition of hemosiderin from damaged red blood cells. In addition, the skin may become distracted locally, becoming whitish in color. If this condition is not corrected, venomous ulcers often appear, which cause a lot of disability and discomfort. How is the diagnosis made? In a swollen lower extremity, even if skin hyperpigmentation or dermoculsion has occurred, chronic venous insufficiency is suspected, especially if the person has varicose veins, a history of more advanced deep vein thrombosis, or other factors contributing to gastropodemal muscle pump deficiency.
The classification of traumatic amputations of the distal phalanges of the fingers was proposed by E. A. Rossenthal. He identified four types of transverse amputations of the distal phalanges of the fingers. Type I injuries include injuries to the soft tissues of the distal phalanx, type II injuries include amputation at the level of the proximal third of the nail, type III injuries include amputation at the level of the posterior nail fold, and type IV injuries include amputation at the distal interphalangeal joint. Oblique amputations are divided into palmar, lateral and dorsal.
Differential diagnosis often includes triplex ultrasound examination of the penile vein. The best diagnoses are made by doctors specially trained in such exams. What Causes Ulcers? Venous ulcers. They make up more than 70% of all ulcers. Whenever your calf muscles move to help you pump blood to your heart, a series of valves stop the blood from flowing backwards. If these valves collapse, blood flows back and increases pressure in the veins. After some time, the veins will become congested and fluid will leak from them at the level of the venous capillaries, which will lead to swelling of the legs and thickening and deterioration of the skin.
There are several factors to consider when choosing a treatment method. To ensure grip and retention, it is very important to maintain sensitivity of the thumb, the lateral sides of the index and middle fingers, and to ensure safety - the medial side of the little finger. Treatment tactics are also determined by the direction of action of the damaging force, the localization of viable tissues and a number of other factors. The selected method of plastic closure of the defect must meet the following requirements: ensure preservation of the length of the finger, sensitivity and protective function of the skin, as well as sufficient support for the nail.
In the category of postural ulcers we can classify the relatively rare lymphoid ulcers or cardiogenic edema because their treatment is important. Venous ulcers are usually located on the inside of the leg just above the ankle, where venous pressure is greatest and the large phrenic veins are located. The head may swell and be tender to the touch. The skin may have reddish or brownish-black hyperpigmentation and areas of white atrophy, while the skin and subcutaneous fat are induced by lipodermal sclerosis due to chronic venous stasis.
For transverse amputations of types I-II and oblique amputations, different treatment methods are used. Conservative treatment is effective. It consists of daily dressings. Healing occurs by secondary intention. The disadvantage of this method is that it takes several weeks to heal. This method of treatment is recommended for wounds less than 1 cm in size. If shortening the distal phalanx does not impair the function of the finger and the support for the nail, the bone is shortened, retreating 2 mm from the edge of the wound, and sutures are applied. In other cases, the defect is covered with a free or non-free skin flap or a flap on a vascular pedicle. When suturing the wound, the digital nerves are excised, retreating a few millimeters from the edge of the wound to avoid the formation of a traumatic neuroma. In case of non-free skin grafting, a flap is cut out from an adjacent finger or from the eminence of the thumb. In type III transverse amputations, the support for the nail is lost, so disarticulation is performed at the distal interphalangeal joint. An exception is injuries to the thumb, since
Itchy and dry skin is enough. Some venous ulcers are painful, especially if the infection develops around the tissue. Treatment of venous ulcers is primarily aimed at reducing high pressure in the veins of the extremities and the ulcer itself. - Penis lift. Put your feet up high whenever you can. Raise the bottom of your bed so that your feet are slightly above heart level when you are in bed. - Squeezing the dress or sock. To maintain low venous pressure at ankle level when standing, we compress the leg and leg with appropriate bandages.
When the ulcer heals, it is usually necessary to use special compression socks to avoid recurrence. - Gaskets. With each wound change, we place appropriate patches based on the healing phase your ulcer is in. These patches may change from time to time. - Operation. Vein surgery may sometimes be necessary if the ulcer is caused by superficial venous disease or a skin graft is placed on the ulcer. This usually occurs several years before underlying chronic venous insufficiency causes an ulcer, so it is not surprising that ulcers can take quite a long time to heal.
Amputation of limbs is often a major and very traumatic surgical intervention, so the struggle for the life of the victim continues in the postoperative period.
After limb amputation, almost all victims have persistent and severe anemia. Blood transfusion in the first days after injury is the most effective treatment for anemia and serves as a prevention of wound suppuration. For this purpose, in the first and next days after surgery, it is necessary to transfuse 250-400 ml of whole blood or red blood cells every one to two days, depending on the patient’s condition and the degree of tissue destruction. In case of severe and putrefactive complications, it is better to transfuse fresh blood. The volume of transfused solutions should reach 2-3 liters per day when combined with the use of diuretics (Lasix, mannitol).
To compensate for metabolic acidosis, which, as a rule, occurs with crushed limbs accompanied by shock, the use of alkaline solutions under the control of acid-base balance is indicated. Sodium bicarbonate is injected into a vein in the amount of 200-400 ml of a 4% solution. In order to correct metabolic disorders and improve metabolism, it is advisable to administer concentrated 40% glucose in an amount of 60-100 ml with insulin, vitamin C (5% solution - 10 ml) and vitamin C (6% solution - 2 ml). Systematic monitoring of the state of the blood coagulation system is necessary. For prophylactic purposes, the administration of indirect anticoagulants is indicated.
All victims with avulsions and crushed limbs are required to be administered 3000 units of anti-tetanus serum according to Bezredko and 0.5 tetanus toxoid subcutaneously. To prevent anaerobic infection, 30,000 units of anti-gangrenous serum are used, administered intramuscularly, according to the instructions included with the drug.
With open wound management, the first dressing, unless there are special indications, is performed after 4-6 days. If in the postoperative period there is no improvement in the victim’s well-being, then the condition of the wounds must be checked earlier. A dry wound with dirty gray tissue indicates a septic condition of the patient or severe anemia, hypoproteinemia and requires, in addition to massive blood transfusions and blood substitutes, wide opening of the wound and additional incisions and fasciotomies. If there is a suspicion of bleeding, it is necessary to open the wound, ligate the bleeding vessel and introduce drainage.
To evacuate discharge from a wound, it is convenient to use glass or synthetic drains. If purulent contents are released through the drainage tube, inspect the wound.
Ointment dressings on the stump have limited use. Draining and drying dressings moistened with hypertonic or antiseptic solutions (iodinol, chlorhexidine, boric acid, etc.) are indicated.
Immobilization after truncation of the leg and foot, forearm and hand continues until the elimination of acute postoperative phenomena (swelling, tissue necrosis, presence of discharge) or until the sutures are removed. After hip amputation, the patient should be placed on a bed with a wooden board under the mattress. The hip joint on the side of the amputation should be extended as much as possible.
After amputation of the shoulder, the patient is placed on the bed with the shoulder girdles elevated, without additional immobilization; the stump of the shoulder is in a position of moderate abduction.
The wound should be closed as soon as the stump is cleared of necrotic and purulent tissue. When the skin is mobile, secondary sutures are placed in the area of the wound edges. If the wound could not be closed immediately, then after two or three days the sutures are tightened again until the edges of the wound are completely closed. When a cavity forms under the closed edges of the wound, a drainage with holes for the outflow of contents is placed at its bottom.
If plastic surgery cannot be performed with local tissues, free plastic surgery with a thick flap is indicated. Dermatomal plasty with stamps can be performed even on an insufficiently cleaned wound. Such an operation not only reduces the wound surface, but also helps to cleanse the wound, stimulates the development of healthy granulations and significantly improves the general condition of the patient.
Therapeutic prosthetics promotes faster formation of the stump, allows the patient to be raised earlier and significantly improves his general condition. When treating a victim with multiple and combined injuries, concomitant injuries to the upper extremities make it difficult to use crutches, and damage to both lower extremities deprives the victim of the only means of support.
