ANKLE JOINT

From Big Medical Encyclopedia

ANKLE JOINT (articulatio talocruralis) — a mobile joint of tibial (tibia) and a fibular (fibula) bone with an astragalus (talus).

Anatomy

Tsvetn. Fig. 1. Cut of foot (in front): 1 — tibia; 2 — articulatio talocrural is; 3 — pars tibiotalaris ant. lig. medialis (deltoidis); 4 — pars tibionavicularis lig. medialis (deltoidis); 5 — articulatio talonavicularis; 6 — os naviculare; 7 — articulatio cuneonavicularis; 8 — lig. intercuneiforine interosseum; 9 — os cunei forme med.; 10 — os cuneiforme intermedium; 11 — os cuneiforme lat.; 12 — os cuboideuni; 13 — lig. bifurcatuni; 14 — lig. talocalcaneum interosseum; 15 — lig. talofibulare post.; 16 — fibula.
Fig. 1. Diagrammatic representation of an ankle joint (back view): 1 — fibula; 2 — lig. tibiofibulare post.; 3 — facies sup. tali; 4 — lig. talofibulare post.; 5 — articulatio subtalaris; 6 — lig. calcaneofibulare; 7 — tuber calcanei; 8 — lig. talocalcaneum post. (BNA); 9 — tendo m. flexoris hallucis longi; 10 — sustentaculum tali; 11 — lig. talocalcaneum med.; 12 — tuberculum mediale processus post, tali; 13 — pars tibiocalcanea lig. medialis (deltoidis); 14 — pars tibiotalaris post. lig. medialis (deltoidis); 15 — tibia.

Of page is formed by the lower joint surface of a tibial bone (facies articularis inf.), joint surfaces of anklebones of tibial and fibular bones (facies articularis malleoli). Its two flat side, medial and lateral lodyzhkovy surfaces participate in its formation also an upper body of an astragalus, shaped the block (trochlea tali), and (facies malleolaris med. et lat.). Tibial and fibular bones cover the block of an astragalus like a fork thus that its upper surface (facies sup.) it is jointed with the lower joint surface of a tibial bone, and side surfaces — with the joint surfaces of anklebones. The joint bag (capsula articularis) is generally attached on edge of a joint cartilage, receding from it a little kpered where it is fixed on a neck of an astragalus. Front and back sites of a joint bag are tense poorly while its side surfaces are strengthened at the expense of sheaves. From the medial party the medial (deltoid) sheaf konturirutsya well [lig. mediale (deltoideum)], edges is subdivided into 4 parts (tsvetn. fig. 1): more bertsovo-carinate (pars tibionavicularis), tibial and calcaneal (pars tibiocalcanea), front tibial and collision (pars tibiotalaris ant.) and back tibial and collision (pars tibiotalaris post.). The lateral surface of a joint bag is strengthened by three sheaves (fig. 1): lobby collision and fibular (lig. talofibulare ant.), back collision and fibular (lig. talofibulare post.) and calcaneal and fibular (lig. calcaneofibulare). Of page in a form blokovidny. The frontal axis, around a cut occur the movements in a joint, passes through the center of a medial anklebone and the point located ahead of a lateral anklebone and forms with «the mezhlodyzhechny line» a corner 30 °. Around this axis when foot falls from top to bottom, there is a bending (so-called bottom bending), at Krom small lateral motions (in this situation narrower tail of the block of an astragalus not so strongly as at extension, it is covered by «fork» of bones of a shin), and also extension when foot rises the sock up (a so-called dorsiflexion) are at the same time possible. The vertical of the general center of gravity of a body on foot passes several kpereda from a lateral anklebone perpendicular to a frontal axis, around the cut in G. of page occurs the movement.

The distal ends of bones of a shin connect among themselves with the help of either a syndesmosis, or a slow-moving intertibial joint [syndesmosis (articulatio) tibiofibularis]. In front and behind this connection is supported with short front and back intertibial sheaves (ligg. tibiofibularia ant. et post.), tense from fibular cutting of a tibial bone to a lateral anklebone. Small mobility of bones of a shin in intertibial connections in general provides basic function of the lower extremity as if bearing on itself weight of overlying department of a body.

Fig. 2. Sagittal cut of foot: 1 — tibia; 2 — talus; 3 — lig. talocalcaneum interosseum; 4 — os naviculare; 5 — os cuneiforme intermedium; 6 — os metatarsi II; 7 — calcaneus; 8 — tendo calcaneus.

In most cases the movements in G. of page happen in a combination to the movements in two joints — subcollision (articulatio subtalaris) and collision and calcaneonavicular (articulatio talocalcaneonavicularis), located under an astragalus (tsvetn. fig. 2). According to the modern International nomenclature these two joints carry to number of intertarsal joints (articulationes intertarseae). The collision and calcaneonavicular joint in a form of the surfaces making it can be carried to spherical, however the movements in it happen not around three mutually perpendicular axes but only around the axis coming to sagittal; this axis passes slantwise — from the center of a head of an astragalus to an outer surface of a body of a calcaneus. The movements around this axis are combined with the movements in an ankle joint: during the bending of foot at the same time there is its supination (a pripodnimaniye of medial edge of foot) and reduction, and at extension — pronation (lifting of lateral edge of foot) and assignment.

Stability and G.'s fortress of page to a certain extent are promoted by a large number of sinews, the muscles surrounding a joint almost from all directions. In front G. page is covered with sinews of the following muscles: medially — a sinew of a front tibial muscle, lateralny — a sinew of a long razgibatel of a thumb and a sinew of a long razgibatel of fingers. These sinews are densely pressed in front by a top and bottom retinaculum of sinews-razgibateley (retinacula mm. extensorum sup. et inf.). From the lateral party to a joint the sinew of a long fibular muscle and the short fibular muscle which is located under it prilezhit. Sinews of the called muscles bend around a lateral anklebone behind and on an outer surface of a calcaneus pass to foot: passing behind a lateral anklebone, they are pressed to a joint and to foot top and bottom by retinaculums of fibular muscles [retinacula mm. peroneorum (fibularium) sup. et inf.]. Behind a medial anklebone pass to foot of a sinew of a back tibial muscle, a sinew of a long sgibatel of fingers, and between a medial anklebone and a calcaneal (Achilles) sinew [tendo calcaneus (Achillis)] the sinew of a long sgibatel of a thumb is located. Sinews of these muscles are strengthened by a retinaculum of sgibatel (retinaculum mm. flexorum). Any sinew is not attached directly to an astragalus; it matters from the point of view of both the mechanism of movements, and quick accesses to a joint.

Fig. 3. Arteries and nerves groans: 1 — a. malleolaris ant. med.; 2 — aa. tarseae med.; 3 — n. peroneus prof.; 4 — a. dorsalis pedis; 5 — rainus muscularis n. peronei prof.; 6 — a. arcuata; 7 — a. tarsea lat.; 8 — a. malleolaris ant. lat.; 9 — r. perforans a. peroneae.

Blood supply Of page (tsvetn. fig. 3) comes from rete malleolare med. et lat., formed by medial and lateral front lodyzhkovy arteries from a. tibialis ant. and lodyzhkovy branches [rr. malleolares a. tibialis post, et a. fibularis (peronea)]. A venous blood flows from area of a joint in deep veins of a shin: vv. tibiales ant., vv. tibiales post, et v. fibularis (peronea). The lymph drainage comes from a joint on deep collector limf, to vessels in nodi lymphatici poplitei. The capsule of a joint is innervated from n. tibialis and the item peroneus profundus.

Intertarsal joints krovosnabzhatsya from branches of areus plantaris and of plantaris profundus from a. dorsalis pedis.

Venous outflow and outflow of a lymph happens in the same veins and in the same limf, nodes in which a venous blood and a lymph from G. flows page.

Innervation joints of foot carry out nn. plantares med. et lat., nn. peronei (fibulares) superficialis et profundus.

Radioanatomy

Fig. 2. The roentgenogram of an ankle joint in a direct projection with turn of foot inside on 20 °: clearly the joint crack in all departments of a joint is visible.
Fig. 3. The roentgenogram of an ankle joint in a direct projection: the independent ossification center of an internal anklebone is visible (it is specified by an arrow).

Of page has features: 1) both in a straight line, and in side projections at adults the joint crack throughout has the identical width (fig. 2); 2) the synostosis of a distal epiphysis of bones of a shin comes at the age of 15 — 18 years; 3) the lateral anklebone has an independent ossification center, medial gradually forms from an epiphysis of a tibial bone; 4) sometimes at the age of 7 — 12 years the top of a medial anklebone has an independent ossification center (fig. 3), in rare instances it remains isolated for the rest of life.

Pathology

Diseases

Diseases are connected preferential with acute and hron, inflammations in this area. Most often the infection of skin of fingers and foot extending on the course limf, vessels which are grouped in larger vessels passing to a shin together with v. saphena magna in the field of the medial party of G. of page and to the back side of a shin — together with v. saphena parva behind a lateral anklebone is the reason of acute inflammations. Both superficial, and deep purulent inflammations are observed. Superficial inflammations take soft tissues of G. of page and do not get under a deep fascia in a joint and into a cavity of a joint; deep are located in a cavity of a joint and under a deep fascia of area of a joint. Often purulent process of almonds or other suppurative focus from where the metastatic purulent infection gets into a joint is the reason.

Nonspecific and specific processes in some cases are the reason hron, inflammatory diseases of G. of page. Syphilitic defeat of G. of page makes 12% among gummous arthritises. The disease during the late period is shown. Tuberculosis of an ankle joint takes the third place after coxites and gahnites and makes 5 — 7% of bone and joint tuberculosis.

To hron, to G.'s defeats by the village typhus and paratyphoid inflammations also belong. A certain place is taken by gonorrheal inflammations (monoarthritis or in combination with an inflammation of a knee joint) G. of page Besides, G.'s arthritises of page of a rhematoid and allergic origin meet.

A clinical picture

Inflammatory diseases of G. of page are followed by pains and disturbance (full or partial) functions of a joint. At acute superficial inflammations infiltration of skin and accumulation of exudate on the course limf, ways — on a back surface of a shin, behind a lateral anklebone and in medial area G. of page is found. Formation of abscesses is possible.

At deep purulent inflammations and hron, specific defeats of G. of page the wedge, a picture of arthritis is observed typical (see. Arthritises ).

Diagnosis of diseases of G. of page is based on the analysis of the described symptoms and radiological data.

Fig. 4. Roentgenogram of an ankle joint (initial phase of acute purulent arthritis): regional osteoporosis (it is specified by an arrow), an illegibility of contours of joint surfaces of bones.
Fig. 5. Roentgenogram of an ankle joint (tubercular arthritis): regional osteoporosis, contact destruction of joint surfaces of bones, in a medial anklebone — primary tuberculous focus with the sequester (it is specified by an arrow).

The acute purulent inflammation radiological is characterized by quickly developing spotty, and then diffusion osteoporosis, disappearance of contours of joint surfaces of bones, narrowing of a joint crack owing to bystry (during 1 — 3 week) destructions of joint cartilages (fig. 4). Rather there comes bone soon anchylosis (see). If as a result to lay down. influences acute process passes in hron., the specified phenomena last for several months, cartilages collapse only partially; deformation of an epiphysis and narrowing of a joint crack remains. Such picture is observed after any hron, an inflammation of a joint. Gummous defeat of G. of page is shown by sharply expressed fungozny arthritis that sometimes results in difficulties in differential diagnosis with tubercular defeat of G. of page. At G.'s tuberculosis of page usually is surprised for the second time. Initially the center is more often localized in an astragalus, is more rare in an epimetafiza of a tibial bone and anklebones. The Preartritichesky stage is characterized by pains, lameness. At the same time on the roentgenogram it is possible to find the centers of defeat. The arthritic phase in an initial stage is characterized by pains, functional frustration, a swelling, a joint, especially on each side an Achilles tendon. Further during the progressing of process fistulas are formed, there are deformations of foot and area G. of page.

Radiological the destruction of the bones forming a joint, which is most expressed in a zone of primary center is defined.

Tubercular damage of a joint, except regional osteoporosis, narrowing of a joint crack, destruction of joint surfaces of bones, it is characterized by the circumarticular tuberculous bone focus which is localized in the block collision, the epiphyseal end of a tibial or fibular bone or considerable contact destruction of the bones forming a joint, primary bone tuberculous focus (fig. 5) also is put into a cut.

Treatment depends on the nature of damage of a joint. At superficial nonspecific inflammations at early stages carry out antibioticotherapias) a broad spectrum of activity (a local obkalyvaniye of infiltrates), imposing of an oily-balsamic bandage, bandage with antibiotics or antiseptic agents, an immobilization of an extremity. At formation of abscesses they are opened. After emptying of purulent accumulations of a cavity are drained. Further treatment is carried out also with use of antibiotics wide, and after definition of sensitivity of the sowed microflora — the directed action. It is necessary to create rest of an extremity in a plaster longetny bandage or on the tire.

Treatment of deep purulent inflammations, as a rule, operational. Widely purulent open all flow into areas of a joint, both in front, and in its back department. Operation is performed from front and side cuts. After drainage of a joint of his cavity wash out antiseptic agents. Reasonablly constant irrigation of a cavity of a joint antiseptic agents with their constant removal by means of a vacuum suction, an antibioticotherapia, especially directed action.

In case of distribution of purulent process of G. of page on a bone or its transition in chronic when damage of a joint cartilage and destruction of an astragalus is observed, make its removal — an astragalektomiya or an arthrectomy. Further carry out drainage of a joint with broad use during the bandagings of antiseptic agents and antibiotics.

Treatment of tubercular defeat of G. of page complex, including fortifying treatment with antibacterial therapy and an immobilization of an extremity. Surgical treatment is made in the form of a necretomy at the isolated damages of bones of a joint (see. Necretomies ), arthrectomies — at hron, widespread process.

At gonococcal and gummous arthritis carry out specific therapy (see. Gonorrhoea , Syphilis ); in case of typhus and paratyphoid arthritis treatment can be conservative or operational depending on the nature of process.

Damages

Open provision G. of page and the fact that it takes out all loading of a body, explain rather frequent injuries of this joint — stretchings and ruptures of sheaves, dislocations and incomplete dislocations, fractures of anklebones. At damage of the copular device G. of page lateral sheaves suffer more often; stronger medial (deltoid) sheaf is broken off exclusively seldom (see. Distortion ). Considerably changes meet more often. Depending on the mechanism of an injury one lodyzhechny, bimalleolar and chrezlodyzhechny changes are possible (see. Dyupyuitrena change , Malgenya change , Potta change ). The majority of lodyzhechny changes carry to number of intra joint.

All damages of G. of page are subdivided on closed and opened. At open damages there is a disturbance of an integrity of the joint capsule and the cavity of a joint opens in a wound of soft tissues. Among the closed damages depending on time which passed from the moment of an injury distinguish fresh and old.

Fig. 6. Scheme abduction eversionnogo change of the I degree: and — a cross fracture of a medial anklebone of a tibial bone; — the slanting fracture of a fibular bone is higher than the level of an intertibial syndesmosis. There are no signs of an incomplete dislocation of foot.
Fig. 7. Scheme of an adduktsionno-inversion change of the I degree: and — the isolated slanting fracture of a medial anklebone of a tibial bone; — the isolated cross fracture of a lateral anklebone of a fibular bone is lower than the level of intertibial syndesmosis. There are no signs of an incomplete dislocation of foot.
Fig. 8. Scheme abduction eversionnogo change of the II degree: separation of a medial anklebone of a tibial bone; a fracture of a fibular bone with discrepancy of tibial bones and an incomplete dislocation of foot of a knaruzha.
Fig. 9. Scheme of an adduktsionno-inversion change of the II degree: a fracture of both anklebones with an incomplete dislocation of foot of a knutra.
Fig. 10. Scheme abduction eversionnogo change of the III degree: and — a fracture of both anklebones with discrepancy of an intertibial syndesmosis and an incomplete dislocation of foot of a knaruzha (anterior aspect); — a change of the rear edge of a tibial bone with an incomplete dislocation of foot of a kzada (lateral view).
Fig. 11. Scheme of an adduktsionno-inversion change of the III degree: and — a fracture of both anklebones with an incomplete dislocation of foot of a knutra (anterior aspect); — a change of the rear edge of a tibial bone with an incomplete dislocation of foot of a kzada (lateral view).

Immediate effect on a joint (blow, a compression a heavy subject, falling from height on the straightened legs, etc.) or, what is much more often, indirect (rychagovy) application of the injuring force can be the cause of damage. In the latter case character and features of damage of G. of page are considerably connected with situation, a cut the injuring force violently gives to foot. On this sign allocate abduction eversionnye (foot in the provision of assignment and turn of a knaruzha at the time of an injury) and adduktsionno-inversion (foot in the provision of reduction and turn of a knutra) damages. Depending on the size of the injuring force mark out three severity of damage of G. of page. The first is observed at insignificant influence of the injuring force that leads to the isolated change of one of anklebones or to a rupture of sheaves: medial at an abduction eversionnykh or lateral at adduktsionno-inversion damages (fig. 6 and 7). At the second degree the injuring force is so considerable that at an abduction eversionnykh damages there comes the fracture of two anklebones, a rupture of linking of an intertibial syndesmosis, sometimes a medial sheaf and an incomplete dislocation of foot of a knaruzha; at adduktsionno-inversion — a fracture of two anklebones (is more rare than one medial), a rupture of lateral ligaments of joint and an incomplete dislocation of foot of a knutra (fig. 8 and 9). At the third damage rate of G. of page when the size of the injuring force is especially big, along with the damages typical for the second stage, takes place and a separation of the rear edge of the lower epiphysis of a tibial bone (fig. 10 and 11). This type of damage often is followed by an incomplete dislocation of foot of a knaruzha and a kzada (abduction eversionnye damages) or knutr and kzad (adduktsionno-inversion damages).

The clinical picture and diagnosis

Pains in a joint, restriction of mobility or utter impossibility to use an extremity — the most constant complaints at G.'s damage by page. At the fresh closed damages depending on size and the nature of action of the injuring force note a swelling and quite often deformation in a joint (valgus, varus, sometimes with retrodisplacement). The hematoma in a joint can be so considerable that epidermis of skin exfoliates in the form of bubbles. The palpation is always painful, especially in the place of damage of bone and copular elements of a joint. At open damages of G. of page there is a wound of integuments and soft tissues, through to-ruyu bone elements of a joint can be looked through or stand and be allocated intra joint liquid. At old damages, as a rule, there are deformations (valgus, varus etc.); restriction of amplitude of movements in G. page and puffiness of foot is frequent.


The variety of damages of G. of page and lack of the signs typical for a certain type of damages, in some cases complicate diagnosis, however in most cases X-ray inspection allows to specify character and a type of damage.

Ruptures of lateral teams of G. of page without fractures of bones can be followed by incomplete dislocations of foot. At the same time the upper (horizontal) site of a joint crack on the roentgenogram takes the form of the wedge turned by the basis towards a gap.

Fractures of anklebones are diagnosed for adults according to roentgenograms in two standard projections. In the presence a wedge, and absence rentgenol, symptoms of a fracture the X-ray analysis in additional projections with turn of foot inside and knaruzh on 45 ° is necessary. Diagnosis of a fracture of anklebones at children is difficult; it is necessary to consider age features. Damage of distal department of a tibial bone in the form of an epiphysiolysis (see Changes) with angular shift or on width is more often observed. Epifizeoliz is often combined with the fracture of a tibial bone going slantwise from a cartilage and proksimalno or with a marginal change of back department of a metaphysis of a tibial bone; the line of a change sometimes passes near and along metaepiphyseal region of growth; there is no considerable shift of fragments. In that case special value has the analysis of width of a metaepiphyseal zone in comparison with a symmetric joint, and at a fracture of a lateral anklebone — width of a joint crack, becomes wider than edge at a lateral anklebone if there is no incomplete dislocation of an astragalus, or at medial if there was an incomplete dislocation of an astragalus of a knaruzha.

The incomplete dislocation of foot can accompany odnolodyzhechny, bimalleolar changes are more often. Expansion of a joint crack at one or both anklebones is observed also at a rupture of a distal intertibial syndesmosis without fracture of bones. Changes of back or front department of an epiphysis of a tibial bone often are followed by incomplete dislocations of foot of a kzada or a kpereda. They are distinguished on the roentgenogram in a side projection on wedge-shaped expansion of a joint crack in front department of a joint (at a back incomplete dislocation) or in its back department (at a front incomplete dislocation).

Treatment of damages both conservative, and operational is defined by a type of an injury. At interventions on G. villages use different types local (infiltration, intra bone, peridural) and the general anesthesia.

Treatment of the fresh closed damages preferential conservative. First of all provide reposition (see). At an abduction eversionnykh changes of the I degree the immobilization in a plaster bandage like «boot» is required (see. Plaster equipment ), and at adduktsionno-inversion changes of the I degree — in a longetny bandage (4 — 5 weeks). At changes of II and III degrees the immobilization a plaster bandage during 8 — 10 and 10 — 12 weeks respectively is necessary. After removal of gypsum carry out recovery treatment (LFK, massage, physical therapy).

In some cases at an abduction eversionnykh damages of the II—III degree at discrepancy of a fork of an intertibial syndesmosis for the purpose of its prelum use Sverdlov's device. At failure of the closed reposition or bent of elements G. of page to secondary shift resort to skeletal traction or chreskostny fixing by spokes.

Operational treatment of the fresh closed G.'s damages by page is made rather seldom. The indication are cases when by the closed reposition or skeletal traction it is not possible to compare and hold the damaged elements G. of page anatomically precisely. Operations carry out either from one, or from several quick accesses depending on a type of damage of elements of a joint. From vnutrennebokovy access carry out an osteosynthesis of a medial anklebone the screw or spokes; from naruzhnobokovy arc-shaped access for Kokher (the arc-shaped section from the lower third of a lateral anklebone, surrounding se a top and passing to the back of foot) — an osteosynthesis of a lateral anklebone and an intertibial syndesmosis by means of spokes or a special bolt with a lock-nut. At a separation of the rear edge of the lower epiphysis of a tibial bone operation of an osteosynthesis can be also carried out from a naruzhnobokovy section or from an additional back section. The bone fragment of the rear edge is strengthened by means of spokes or the screw. Front access is applied at an osteosynthesis of fragment of a first line of the lower epiphysis of a tibial bone, and also at a change of the block of an astragalus and G.'s artificial ankylosis of page. At an arthrotomy often use access of Keniga which is provided from two parallel slits. The first section passes on a first line of a tibial bone to a navicular; the second — to a first line of a lateral anklebone.

After operation carry out an immobilization in a plaster bandage on 8 — 12 weeks with the subsequent recovery treatment.

Fig. 12. The flow diagram of recovery of a medial (deltoid) sheaf at an old gap: a tendinous part of a back tibial muscle is split and its found rag is fixed to a medial anklebone.
Fig. 13. The flow diagram of recovery of lateral sheaves at an old gap: the sinew (dotted line) of a short fibular muscle is dissected away and carried out via the cross channel at the basis of a lateral anklebone, vertical — in a neck of an astragalus and a braid — through a top of a lateral anklebone.
Fig. 14. Scheme of an osteosynthesis of not accrete fracture of medial anklebone of a tibial bone: two crossing spokes fix fragment of a medial anklebone to its basis; the plastics of a deltoid sheaf is made.
Fig. 15. The flow diagram of recovery of an intertibial syndesmosis at its old gap and an osteosynthesis of not accrete fracture of medial anklebone of a tibial bone: fixing of a medial anklebone two spokes, plastics of a medial (deltoid) sheaf and an osteosynthesis (in the field of a rupture of an intertibial syndesmosis) a metal bolt.
Fig. 16. Scheme of an osteosynthesis of the rear edge of a tibial bone metal screw.
Fig. 17. The scheme of a wedge-shaped osteotomy at varus deformation: for calculation of the resected bone wedge it (is shaded) axial lines through the center of an astragalus (line 1) and a tibial bone are conditionally drawn (line 2); perpendicular to axial lines from a point 3 on the medial surface of a tibial bone there pass lateral faces of the resected bone triangle.

Old damages of G. of page, unlike fresh, in 95% of cases eliminate in the operational way: quick accesses are similar to the N applied at fresh damages are defined by the nature of damage. In the absence of the deforming arthrosis make recovery operations, and at the expressed deforming arthrosis — artificial ankylosis (see). Old ruptures of a medial (deltoid) sheaf recover at the expense of a front portion of a sinew of m. tibialis post, (fig. 12), and lateral sheaves — at the expense of a sinew of m. peroneus brevis (fig. 13) or a mylar tape. Not accrete fractures of a medial anklebone, except an osteosynthesis of bone fragments, also demand additional plastics from a front portion of a sinew of m. tibialis post, (fig. 14). Old ruptures of an intertibial syndesmosis eliminate by an osteosynthesis by means of a bolt with a lock-nut (fig. 15). Incorrectly accrete change of the rear edge of the lower epiphysis of a tibial bone after its department and bringing down is fixed the screw (fig. 16). The varus deformation at a proper correlation of a fork of G. of page with the block of an astragalus which is found at old adduktsionno-inversion damages is eliminated by a wedge-shaped osteotomy (fig. 17).

After operation the plaster immobilization for term 4g-12 depending on the volume of an operative measure with the subsequent recovery treatment is made week.

The existing ways of an artificial ankylosis divide into two big groups: using compression devices (see. Distraktsionno-kompressionnye devices ) and without their use. The artificial ankylosis using compression devices allows to reach in shorter terms of an anchylosis of a fork of G. of page and the block of an astragalus often without use of a plaster bandage, in one step or gradually to eliminate the vicious provision of foot. The greatest distribution was gained by Grishin's device (see. Artificial ankylosis ). The essence of a compression artificial ankylosis consists that the spokes or cores which are carried out through calcaneal collision and tibial bones, regulating degree of their tension the device, rigidly fix the jointed bones of a joint in the correct situation. By means of the compression device it is possible to hold strongly anatomic elements of a joint to their union without use of a plaster bandage.

The artificial ankylosis without use of compression devices has various operational techniques and often is followed by use auto-and gomotransplantat which, as the bridge, block the adjacent bone elements which are subject to an union.

At the deforming arthrosis caused by incorrectly accrete fracture of anklebones, collision and calcaneal bones carry out an artificial ankylosis by Yu. B. Dzhanelidze's technique: after an exposure with Kokher's access to an astragalus it is deleted and then divided into small bone fragments which densely stack in space between G.'s fork of page and a calcaneus.

In the presence of incorrectly accrete changes which are combined with considerable deformation of an astragalus and the deforming arthrosis of talocrural, subcollision, collision and carinate joints operation on Oppel — to Lortiuar is made. Technique of operation: after a wide exposure of a joint delete with Kokher's section a joint cartilage from area of a fork of G. of page, the block of an astragalus, a collision and calcaneonavicular joint. Broad application in the presence of deformation of foot in a subcollision joint is found by operation of Davis — a subcollision artificial ankylosis. Operation is made from two — naruzhnobokovy and vnutrennebokovy cuts from which the subcollision joint is bared; then delete joint surfaces from it, the joint is given functionally correct situation and for 3 months apply a plaster bandage.

Treatment of open damages is begun with careful roughing-out of a wound of soft tissues with removal (at indications) freely lying bone fragments and elements of a joint. Further make recovery of an anatomic integrity of bone and copular elements G. of page and layer-by-layer mending of a wound tightly or with the graduate.

The immobilization of bone and copular elements of a joint is usually carried out a plaster bandage, add fixing of bone fragments to it the elementary metal designs (spokes) less often. Asters aha Ektomiya's l, i.e. removal of an astragalus, is produced at its extensive destructions from outside access on Kokhera. After allocation of sinews of fibular muscles and a section of lateral teams of G. of page foot is rotirut by knutr and bring; bare an astragalus and delete it. Then strongly take in lateral sheaves.

G.'s resection of page and its primary artificial ankylosis are shown at considerable destruction of a cartilage and subchondral bone tissue of a fork of G. of page and the block of an astragalus. Operation is also made from access on Kokhera. After a wide exposure of G. of page delete the destroyed joint cartilage and a subchondral bone from a fork of a joint and the block of an astragalus. Foot is given the provision of bottom bending at an angle 95 — 100 °. Bone fragments hold by means of a plaster bandage, spokes which are carried out chreskostno or compression devices like Grishin's device or other designs. Use of compression devices allows to try to obtain in shorter terms a good bone anchylosis between G.'s fork of page and the block of an astragalus.

At treatment of open damages of G. of page antibiotics widely use both during operation, and in the postoperative period.

Tumors

G. the page is localization, more rare in comparison with a knee joint, of both benign, and malignant tumors which can affect bones and the soft tissues creating a joint.

Tumors of soft tissues happen high-quality (myomas, fibromas) and malignant (synoviomas).

Tumors of bone elements G. of page are also divided on high-quality and malignant. Treat high-quality osteoblastoclastoma (see), bone cyst (see), osteoid osteoma (see), chondroma (see); to malignant — polymorphocellular sarcoma (see), chondrosarcoma (see), a malignant osteoblastoclastoma, Ewing's tumor (see. Ewing tumor ), angiosarcoma, osteosarcoma (see). Exostoses (see), the pages which are also found in the area G., are not true bone tumors, but in a row, cases their malignant regeneration is possible.

Diagnosis of tumors of an ankle joint is carried out on the basis kliniko-rentgenol. inspections of patients.

Benign tumors and tumorous educations near a joint differ characteristic rentgenol. signs. The osteoarticular exostosis represents the bone outgrowth directed by a top to a diaphysis. In an exostosis the cortical layer and structure of the main bone are kept. Hondroblastoma has an appearance of the destructive center of more or less rounded shape, quite often is located on both sides of a metaepiphyseal cartilage that complicates differential diagnosis with a tubercular osteitis.

Malignant tumors can meet in the distal ends of bones of a shin. The joint at the same time is usually not affected as the joint cartilage is an obstacle for spread of a tumor. As a rule, the switching plate of an epiphysis is kept.

Synovial sarcoma, a chondrosarcoma can be suspected on the basis of destruction of the site of a joint surface and emergence of deposits of lime and okosteneniye of a circumarticular part of a tumor. Final diagnosis is carried out on set a wedge., laboratory and morfol, data.

For morfol, confirmations of the clinicoradiological diagnosis make a puncture or open biopsy of tissues of joint with the subsequent gistol, studying of the received material.

The main method of treatment of tumors is surgical. At a high-quality osteoblastoclastoma, a bone cyst, a chondroma the resection patol, the center and auto-or homoplastic substitution of defect is made; at malignant tumors — amputation at the level of a hip or an upper third of a shin. At Ewing's tumor the chemotherapy and beam treatment are shown. Treatment of exostoses operational.

Fighting damages

Gunshot wounds of G. of page during the Great Patriotic War made 13,8% and took the fourth place among wounds of large joints.

Fig. 18. The roentgenogram of an ankle joint with multiple metal splinters as a result of a gunshot wound without injury of a bone.
Fig. 19. The roentgenogram of an ankle joint with extensive injury of bones as a result of a gunshot wound.
Fig. 20. The roentgenogram of an ankle joint with a large metal splinter as a result of a gunshot wound.

G.'s wounds of page are subdivided on getting and not getting. Depending on the size of damage allocate the wounds having a small wound opening and insignificant damages of fabrics and not demanding surgical treatment, wound with considerable damage of soft tissues, wounds with extensive defect of soft tissues. The last two types of damages demand surgical treatment. Distinguish wounds without damage (fig. 18), with insignificant and considerable injury of bones (fig. 19). In the Great Patriotic War missile wounds of G. of page prevailed over bullet. Injuries of bones at getting G.'s wounds of page were observed in 89,9% and at the cases which are not getting into 22,6%. In a bone tissue and a joint often found metal splinters, bullets and other foreign bodys (fig. 20). Weight of wound is defined by extensiveness of injury of bones and soft tissues. The intra joint nature of wound is determined by existence in a wound of synovial fluid and the bone fragments covered with a joint cartilage. At through wounds it is correct to make the diagnosis studying of the direction of the wound channel helps. The final diagnosis is established after rentgenol, a research and surgical treatment of a wound. Injuries of nerves (6,3%), blood vessels (6,6%), shock (3,5%) and blood loss (1,4%) were the most frequent complications of wounds of G. of page.

Gunshot wounds of G. of page in 55% of cases were complicated by an infection. Among purulent complications were observed arthritis (see), osteomyelitis (see) and mephitic gangrene (see) which met by 3 times more often at the getting wounds, than at not getting.

Stage treatment. First aid at G.'s wounds of page includes a temporary stop of bleeding, imposing of an aseptic bandage and an immobilization of an extremity. If necessary replace a bandage with PMP (OPM), carry out an immobilization of an extremity transport tires, enter antibiotics, soothing. In MSB or OMO widely apply antibiotics, soothing, improve an immobilization, at an opportunity by imposing of plaster splints; surgical help is given according to vital indications. In hospital (or in GO hospital) at dot wounds make a puncture of a joint, wash out a cavity of a joint solution of novocaine with antibiotics, enter antibiotics and apply a plaster bandage. At extensive wounds of soft tissues with insignificant damage of the joint ends make surgical treatment, close defect of the capsule a deaf seam. At extensive wounds of soft tissues and destruction of the joint ends of bones during surgical treatment delete foreign bodys and freely lying bone splinters; the capsule is sewn up. At extensive intra joint damages make an arthrectomy. For completion of covers the plastics of skin is quite often shown (see. Skin plastics ). Surgical treatment in all cases is finished with introduction of antibiotics to surrounding fabrics and to a cavity of a joint and an immobilization of an extremity a plaster bandage. At strong indications of frailty of fabrics amputation is shown.


Bibliography Gratsiansky B. P. and Khokhlov D. K. Diagnosis of initial forms of bone and joint tuberculosis, page 121, L., 1966, bibliogr.; Guryev V. N. Conservative and operational treatment of injuries of an ankle joint, M., 1971, bibliogr.; 3 e d of e of N and-dze G. A., Gratsiansky V. P. and Sivenko F. F. Radiodiagnosis of bone and joint tuberculosis, L., 1958, bibliogr.; Kaplan A. V. Technology of treatment of fractures of bones, page 276, M., 1948; To about r N of e in P. G. Klinik and treatment kost - but - from authorized tuberculosis, M., 1959, bibliogr.; Kosinskaya N. S. Degenerative and dystrophic defeats of the bone and joint device, L., 1961, bibliogr.; Maykova-Stroganov V. S. and Rokhlin D. G. Bones and joints in the x-ray image, the Extremity, page 432, L., 1957, bibliogr.; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 12, page 435, M., 1960; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 17, M., 1953; M. G. Additional weight, L of bice of N to about in N. K. and Bushkovich V. I. Anthropotomy, page 154, L., 1974; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1 — 2, M., 1964; Sklyarenko E. T. Hirurgiya of joints of extremities, page 179, Kiev, 1975, bibliogr.; Watson-Jones R. Fractures of bones and injury of joints, the lane with English, page 536, M., 1972.

V. D. Chaklin, V. N. Guryev; P. L. Zharkov (rents.), G. S. Satyukova (An.), S. S. Tkachenko (soldier.).

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