BRUSH (manus) — the distal department of an upper extremity possessing difficult motive and touch functions.
- 1 The comparative anatomy
- 2 Embryology
- 3 Anatomy
- 4 Age features
- 5 Pathology
The comparative anatomy
Initial formation of a five-fingered extremity of land vertebrata in the course of phylogenetic development is the fin of fishes dismembered on separate beams. Distal department of a front extremity of land vertebrata — the pad - (autopodium) — has. the basis (basipodium) which received the name of a wrist (carpus) a distal part (acropodium) consisting of the joints forming a shank (metacarpus), and actually fingers each of which consists of several phalanxes. At the lowest land vertebrata in the basis To. the large number of the bone elements located in the form of beams contains. The highest forms have a reduction of number of bones owing to accretion of some of them. Along with it there is also a reduction of number of phalanxes of fingers.
In the course of evolution strong connection of elements of a skeleton of extremities is replaced with the mobile connections by means of joints forming difficult levers. The differentiation and isolation of a large number of muscles and reduction of length of K. Sokhraniv considerable looking alike is at the same time observed To. monkeys, To. the person from it considerable larger other thumb and thinner movements of fingers opposed to all is highly - differentiated. It funkts, perfection To. the person is result of release it from basic function upon transition to vertical position of a body and result of influence of work.
Only the person has a hand, and in particular To., fully becomes body of production activity. Being working body, the hand is improved in the course of work, i.e., by words F. Engels, «the hand is not only an instrument of labor, but also its product». Morfol, changes in a structure To., connected with adaptation to labor operations, are expressed in differentiation of the neuromuscular device along with reorganization of bones and joints that free opposition of a thumb to the rest results in ability to make the isolated movements by fingers, etc.
Kidneys of upper extremities appear at the end of the 4th — the beginning of the 5th week of development of a germ. Primary rudiments of upper extremities correspond to preferential distal department of future extremity, i.e. To. During the 6th week a terminal part of a kidney is flattened, and at its free edge expansion appears, on Krom four grooves are soon formed. Five thicker sites between them quickly grow and soon begin to support limits of ground mass, forming fingers. On the 8th week the thumb of a hand gradually departs from the others. In development the hand experiences considerable changes in the situation and a ratio of its segments (see. Extremities ). At embryos of the person at the age of 1,5 — 2 months. To. makes 30 — 34% of length of all hand. During 3 — 4 months of pre-natal development reduction of relative length is observed To. Proportions of a hand in general during this period of development are close to final, observed at the adult.
Border between a forearm and To. the line is radiocarpal joint (see), located 1 cm above the line between awl-shaped shoots of beam and elbow bones. To. makes 24 — 28% of length of all hand at the person, its length on average at men is equal to 18,4 cm, women have 17,4 cm. These figures vary depending on race, a floor, a profession, features of structure and physical. development of this person.
V K. distinguish three parts: wrist (carpus), shank (metacarpus) and fingers (digiti) and areas: area of a palm (regio palmae manus) and area of the back To. (regio dorsi manus).
Wrist form eight bones located in two ranks. The first (proximal) row of bones, considering from beam edge, make carinate (os scaphoideum), semi-lunar (os lunatum), trihedral (os triquetrum) and pea-shaped (os pisiforme) of a bone; second (distal) — a trapeze, or a big polygonal bone (os trapezium s. os multangulum majus), trapezoid, or small polygonal, bone (os trapezoideum s. os multangulum minus), capitate (os capitatum) and ankyroid (os hamatum) of a bone. A proximal number of bones of a wrist and the distal end of a beam bone form a radiocarpal joint. A distal number of bones of a wrist, being jointed with the bases of metacarpal bones, forms carpal and metacarpal joints. The joint between proximal and distal ranks of bones of a wrist is called a srednezapyastny joint, and joints between separate bones of a wrist — intercarpal. Cross section of a brush at the level of bones of a wrist is presented on tsvetn. fig. 1.
Shank form five metacarpal bones (ossa metacarpalia I — V) which bases participate in formation of carpal and metacarpal joints. The bases of the II—IV metacarpal bones are jointed among themselves by intermetacarpal joints (art. intermetacarpeae) strengthened by back, palmar and interosseous sheaves (ligg. metacarpea dorsalia, palmaria et interossea). Cross section of a brush at the level of metacarpal bones is given on tsvetn. fig. 2.
Allocation of various joints in a wrist and a shank is made from the anatomic point of view. Physiologically all these joints function as components of a uniform joint, and patol, processes, as a rule, extend to all this part K. Therefore joints of a wrist (srednezapyastny and intercarpal) and the next joints (distal radioulnar, radiocarpal, pyastnozapyastny and intermetacarpal joints) combine in one wrist joint.
Bones fingers (ossa digitorum manus) consist of the phalanxes connected by interphalangeal joints (articulationes interphalangeae manus). At each finger, except big, three phalanxes. Heads of metacarpal bones with proximal phalanxes of fingers form metacarpophalangeal joints (articulationes metacarpophalangeae) causing big mobility fingers (see).
Palm (palma manus) in the bent situation forms deepening in the form of a castle from where received the name (a castle — a palm). This concavity (deepening) limited on the one hand to an eminence of a thumb (thenar), and with another — an eminence of a little finger (hypothenar), increases at reduction of a thumb and bending of the others. Skin of a palm is plentifully supplied with nerves and vessels and thereof has more high temperature and sensitivity, than K. V back to it is a large number of sweat glands. On skin of a palm there are three constant lines (palmar folds). These lines almost never disappear at inflammatory processes of a palm, at hypostases and so forth.
Hypodermic cellulose of a palm is dense. The palmar aponeurosis (aponeurosis palmaris) in the middle of a palm is especially well developed and has the form of a triangle, the sinew of a long palmar muscle is interwoven into top to-rogo, and the basis is turned to fingers where the aponeurosis disperses on four flat tyazh, between to-rymi cross bunches are tense. In places of transition of an aponeurosis to the thin fascial plates covering muscles of eminences of a thumb and a little finger the partitions connecting to a fascia of interosseous muscles deep into depart from it. Thereof on a palm three fascial beds — two side and median are formed; side — for muscles of a thumb and a little finger, median — for sinews of sgibatel of fingers.
Muscles To. reach a high differentiation. Muscles of an eminence of a thumb are especially developed thanks to what its considerable opposition to a little finger is possible. Enter into this group: the short muscle which is taking away a thumb (m. abductor pollicis brevis), a short sgibatel of a thumb (m. flexor pollicis brevis), a muscle, opposing a thumb (m. opponens pollicis), the muscle giving a thumb (t. adductor pollicis). In an eminence of a little finger superficial position is held by a short palmar muscle (m. palmaris brevis) which is pulling together skin of elbow edge To. and forming on it folds. Three muscles of a little finger are located consistently, beginning from elbow edge of a palm: a muscle, taking-away little finger (m. abductor digiti minimi), a short sgibatel of a little finger (m. flexor digiti minimi) and the muscle opposing a little finger (m. opponens digiti minimi). The average group located in a palmar hollow is made by four worm-shaped muscles (mm. lumbricales), three palmar and four back interosseous muscles (mm. interossei palmares et dorsales).
Allocate two synovial vaginas of sinews of muscles for palms — the general synovial vagina of sinews of sgibatel of fingers and a vagina of a sinew of a long sgibatel of a thumb.
On the back To. (dorsum manus) skin is very mobile and is easily taken pleated. Unlike palmar, it is not so plentifully supplied with vessels and nerves. At strong assignment of a thumb on the back To. between contours of a sinew of a long razgibatel of a thumb and sinews of a short razgibatel and long abductor of a thumb deepening — a so-called anatomic snuffbox is formed, at the bottom to-rogo the pulsation of a beam artery is probed. Appear through the veins forming back venous network of a brush (rete venosum dorsalis manus), which are filled during the lowering of a brush skin of a back of the hand. Hypodermic cellulose friable. A back fascia To. (fascia dorsalis manus) is thin, consists of two leaves from which deep covers interosseous muscles. Between leaves of a fascia there pass sinews of razgibatel of a wrist (brush) and fingers. A fascia of a back surface of a forearm upon transition to a back fascia To. forms a thickening — a retinaculum of razgibatel (retinaculum extensorum). The last by means of spurs grows together with a dorsum of the distal ends of beam and elbow bones and forms six osteofibrous vaginas through which pass on To. sinews of razgibatel of fingers and To.
Blood supply. Arteries To. form the anastomosis having an appearance of arches from which smaller vessels, or vascular networks located in joints depart. The beam artery (a. radialis) passes to the back To. distalny attachments of a humeroradial muscle, but before gives the superficial palmar branch (ramus palmaris superficialis) going over muscles of a thumb under a fascia, connecting to the termination of a trunk of an elbow artery (a. ulnaris) and forming a superficial palmar arch (areus palmaris superficialis) and a palmar carpal branch. On the back To. the beam artery passes in an anatomic snuffbox, then passes to a palm in an interval between I and II metacarpal bones, being divided into a back carpal branch (ramus carpeus dorsalis), the first metacarpal back artery (a. metacarpea dorsalis I) and an artery of a thumb (a. princeps pollicis). On a palm continuation of a beam artery connects to a deep palmar branch of an elbow artery (of palmaris profundus) and forms a deep palmar arch (areus palmaris profundus). An elbow artery, passing on To., at beam edge of a pea-shaped bone gives a deep palmar branch for short circuit of a deep palmar arch, and itself proceeds in the form of a superficial arch. A convex part of a superficial palmar arch leaves the general palmar manual arteries (aa. digitales palmares communes). Each of them is divided into two own manual arteries going on palmar side of fingers. Palmar metacarpal arteries depart from a deep palmar arch (aa. metacarpeae palmares), which at interdigital folds merge from the ends of the general manual arteries. They give also pro-butting branches (rr. perforantes) to back metacarpal arteries. The back carpal network forms from back branches of elbow and beam arteries and final branchings of front and back interosseous arteries. The II—IV back metacarpal arteries depart from it (aa. metacarpeae dorsales II — IV) from which back manual arteries begin.
Veins To. begin from manual veniplexes. Veins of fingers in deepenings between heads of metacarpal bones connect to mezhgolovkovy veins (vv. intercapitales). The ground mass of veins follows on the back To., passing superficially between metacarpal bones. Veins a palmar surface connect to back veins. Superficial veins of the back To. form back venous network K. (rete venosum dorsalis manus). It is subject to considerable variations. From veins of back network at beam edge the lateral saphena of a hand (v. cephalica), at elbow edge — a medial saphena of a hand (v. basilica) forms. Deep veins of the back To. accompany, mostly in pairs, arteries also pass into deep veins of a forearm. Superficial veins of a palm are developed poorly, deep — accompany arteries and to respectively two arterial arches form two venous (areus venosus palmaris superficialis et arcus venosus palmaris profundus). The deep venous arch is the main venous collector of veins of a palm. Blood from it flows in beam and elbow veins and in venous network of the back To.
Absorbent vessels To. share on superficial and deep. The main superficial lymphatic collectors To. form at its elbow and beam edges and proceed on a forearm, deep — bear a lymph from bones of joints and muscles To., follow on the course of beam and elbow vessels on a forearm.
Innervation on To. it is carried out by final branchings of median, elbow and beam nerves. The median nerve (n. medianus) innervates muscles of an eminence of a thumb, except a deep head of a short sgibatel of a thumb, and the muscle giving a thumb, two lateral worm-shaped muscles, and also skin of I, II, III and beam surfaces of the IV finger including the back of a distal phalanx of these fingers. The elbow nerve (n. ulnaris) in the lower third of a forearm is divided into back and palmar branches (of dorsalis et of of palmaris). The first passes on the back To. under a sinew of an elbow sgibatel of a wrist, innervates skin of an elbow surface of the back and gives to V, IV and elbow side of the III finger back manual nerves (nn. digitales dorsales). The palmar branch is divided into superficial and deep branches. The superficial branch gives own manual a nerve to the elbow surface of a little finger and the general which is divided into two own — to the beam surface of a little finger and the elbow surface of the IV finger. The deep branch innervates all muscles of an eminence of the V finger, two medial worm-shaped, two interosseous — the muscle giving a thumb and a deep head of a short sgibatel of a thumb. A superficial branch of a beam nerve (of superficialis of the item radialis), passing to the back of Km gives back manual nerves (nn. digitales dorsales), the innervating backs of I and II fingers and the beam surface of the III finger to the level of a trailer phalanx.
Arteries, veins and nerves of a brush are presented on tsvetn. fig. 3 — 8.
For a research K. usually make pictures in three projections — in direct palmar, side and slanting. All bones To. — phalanxes, metacarpal, carpal and sesamoid — in their natural provisions and relationship clearly are visible on the direct palmar roentgenogram (fig. 1). Bones of a wrist are located in two ranks. On a shadow of a trihedral bone the shadow of pea-shaped is imposed. The trapeze is located at the basis of the I metacarpal bone, a trapezoid bone — at the basis of the II metacarpal; a navicular — between an awl-shaped shoot of a beam bone and a capitate bone. The semi-lunar bone is between carinate, capitate, trihedral bones and medial edge of an epiphysis of a beam bone and has an appearance of the wrong quadrangle. Only on the side roentgenogram it has the semi-lunar form. The capitate bone distal edge adjoins to the basis of the III metacarpal bone. In an uncinatum on the roentgenogram distinguish its ankyroid shoot; it is jointed with IV and V metacarpal bones. The trihedral bone is located between ankyroid, semi-lunar bones and an awl-shaped shoot of an ulna.
Metacarpal bones on the direct roentgenogram clearly are visible in all details. Sometimes in compact layers slanting lines of enlightenments — vascular channels are visible. At the basis of the III metacarpal bone the shadow of the bone education which is imposed partially on the basis of the II metacarpal and on a capitate bone (a so-called awl-shaped shoot) is defined.
Phalanxes of fingers — short tubular bones — clearly are visible on roentgenograms. In distal (nail) phalanxes distinguish tuberosity with rough edges — so-called nail shoots. On palmar side of proximal and average phalanxes small shoots and roughnesses — the places of attachments of tendinous vaginas which are especially boldly acting by an old age quite often come to light. At elderly people in phalanxes, mostly trailer, points of edges and regional growths are noted. Sesamoids are located usually at metacarpophalangeal joints.
In the area I of a metacarpophalangeal joint they are available constantly, in others (II—V) meet much less often.
To additional bones To. refer bone educations which sometimes are found on the roentgenogram over usual number of bones. Sometimes they are a consequence of injuries To. in the past. The true additional bones of a wrist (fig. 2) which are option of development should be considered only those which are noted by embryologists. Carry the following to true additional bones. The central bone (os centrale) is found in 96% of cases. It is the small bone element located between trapezoid, capitate and carinate bones. The second trapezoid bone (os trapezoides secundarium) is located between a trapeze both trapezoid with bones and the basis of the 11th metacarpal bone. The awl-shaped bone (os styloideum) is located at the basis of the III metacarpal bone, between II and the III metacarpal, trapezoid and capitate and tends to a synostosis with the next bones. Awl-shaped bone — the largest of all additional bones; it reaches to dia. 1 cm also meets in 3— of 4% of cases. The triangular bone (os triangulare) is found in the early embryonal period, usually grows together with an awl-shaped shoot of an ulna and to a thicket happens unilateral.
At newborns and children of the first years of life skin of a hand forms the folds caused by good development of hypodermic cellulose. By 5 — 7 years hypodermic cellulose decreases, and then again accrues by the period of puberty, remaining at one level on average within 20 years. By 40 years hypodermic cellulose K. considerably increases, and then by 65 — 70 years — decreases, skin forms folds which are not smoothed. The venous network located in hypodermic cellulose quite often well visible through skin in the field of the back To., at children it is widely developed and consists of the thin veins anastomosing among themselves. Palm at newborns and children till 1 year vaulted; with age its arch decreases.
At newborns and children of younger age the superficial palmar arterial arch is projected above the middle II and III metacarpal bones, then its projection is displaced in the distal direction, and at adults it is at the level of the middle of the III metacarpal bone. The deep palmar arterial arch with age, in connection with growth of bones of a brush, is also displaced in the distal direction. It is established that the caliber of arteries and veins of extremities considerably depends on development of muscles.
Future bones of a wrist at newborns cartilaginous, and in development in each of them appear kernels of ossification. Bones of a shank have the cartilaginous reasons, and bones of fingers — cartilaginous heads. Terms of emergence of kernels of ossification — see. Age bone .
Uniform classification of malformations To. is not present in view of their polymorphism. It is accepted to distinguish inborn malformations To. with increase or reduction of the sizes and numbers of its parts. The first call hyperplastic defects, the second — hypoplastic, in extreme expression — aplastic defects.
Hyperplastic defects: the most frequent form — syndactylia (see) — an union of fingers among themselves; a hyper dactylia and a hyperphalangy (giantism) — increase in the size of a finger or phalanx (fig. 3); a polydactylia and a polyphalangism — increase in number of fingers or their phalanxes.
Hypoplastic defects: a brachydactyly — reduction of the size of a finger, a brakhifalangiya — reduction of a phalanx of a finger; a hypodactylia — reduction of number of fingers, a gipofalangiya — reduction of number of phalanxes; an electrodactylia — the brush (fig. 4) split (rachya); a kamptodaktiliya — a flexion contracture of the V finger, a clinodactyly — a side deviation with a flexion contracture IV and V fingers.
Aplastic defects: an akheyriya — lack of a brush; an ektrodaktiliya — lack of a finger; an adaktiliya — lack of fingers of K. K to this type of defects is referred by amniotic banners of fingers and their otshnurovyvaniye.
Malformations To. are quite often combined among themselves (fig. 5) and with other malformations of a musculoskeletal system.
Special group of diseases To. make the deformations which arose in the period of fetation as a result of various patol, conditions of mother: «a frog brush» — at a tuberculosis infection; «a spoon-shaped brush» — at radiation exposure; «a brush of the Madonna» — at a hyperthyroidism of mother; «spidery fingers» (a hereditary syndrome of Marfan) — a malformation of not clear etiology; «bottle fingers» — at syphilis. Distinguish also deformations To. as a result of diseases of a fruit: «a krotoobrazny brush» — at cretinism; «brush paw» — at dysostoses and an acromegalia; nails in the form of clock glasses — at a generalized hyperostosis with a pachydermia.
Conservative treatment of inborn malformations To. begin from the first days of life of the child. It is directed to recovery of active function K. and reduction of cosmetic defects. Apply massage, to lay down. gymnastics, stage elastic bandaging and splintage, physical therapy — bathtubs, parafinoozokeritovy applications, electrostimulation of muscles. The operational treatment which is carried out with 5 — 7-year age, consists of various skin and bone plastic surgeries.
Damages of a brush
Damages of a brush make nearly 1/3 injuries of other parts of a body.
Fighting damages To. in days of the Great Patriotic War among all wounds of upper extremities made 12%, and left To. owing to more vulnerable position of the left hand in fight was surprised much more often than right.
Fire damages To. and fingers in most cases are followed by extensive damages of soft tissues and bones, and in more hard cases the full or incomplete separation of fingers and even destruction of a brush is noted.
The closed damages include bruises, stretchings of the sumochno-copular device, hypodermic injuries of sinews, dislocations to joints of fingers and a brush, fractures of bones of a wrist, metacarpal bones and phalanxes of fingers, and also the combined damages of soft tissues, bones and joints.
Most often bruises of all departments meet To. and fingers which need to be differentiated with a change, dislocation. Sharp pain, a swelling and hemorrhages is characteristic of a bruise. Bruises of interphalangeal joints often are complicated by circumarticular and intra joint hemorrhages. They are followed by hypostasis and pains that quite often leads to a contracture and rigidity in a joint. Bruises of the back To. and palms, owing to features of an anatomic structure of these departments, quite often are followed by extensive hematomas. The hematoma extends to palms in interface-tsialnye of space and imbibirut muscles To. This complication can lead to fibrosis and various disorders of motive function K. and fingers.
Sprain and joint bags is characterized by pain, a swelling of a joint, circumarticular hemorrhages and dysfunction of a joint. The sprains of metacarpophalangeal and carpometacarpal joints of the I finger resulting in looseness of a finger with incomplete dislocations and to disturbance of capture are most frequent.
Apply cold, punctures of a joint, a compressing bandage and splints for 7 — 10 days in a complex with physical to treatment of bruises, sprains and joint bags. factors of Treatment and enzymotherapy (see) to lay down. gymnastics, massage and hydrotherapy. Duration of treatment — 4 — 6 weeks.
At treatment of heavy bruises To. with the accruing ischemia make decompressive cuts for release of own muscles To. from an internal prelum. To. give sublime situation, periodically apply cold and fixing by a removable plaster splint with the early beginning of the dosed movements, futlyarny novocainic blockade, UVCh-therapy. In the subsequent recovery treatment sometimes is required.
From injuries of sinews hypodermic ruptures of a razgibatel, hl most often meet. obr. in the field of a distal interphalangeal joint, sometimes followed by a separation of a bone fragment from the basis of a nail phalanx. A characteristic sign of this damage is the otvisaniye of a nail phalanx and impossibility of its active extension. Treatment consists in fixing of a nail phalanx of a finger in the provision of the maximum extension by a thin spoke or by means of a plaster splint in the provision of «a writing feather» for a period of 5 — 6 weeks then conduct a course of recovery treatment.
From dislocations of bones To. and fingers on frequency dislocations in interphalangeal joints, on the second — dislocations in a metacarpophalangeal joint of the I finger (fig. 6, 1, 2) are on the first place. Quite often dislocations are followed by damage para-articular fabrics, a rupture of sheaves, a hemarthrosis, changes (dislocation-fractures). Back dislocations of fingers in proximal and distal interphalangeal joints meet more often. Clinically dislocation is shown by deformation of a joint, shortening of a finger, sharp restriction of movements and pain. The X-ray analysis specifies the diagnosis and the nature of dislocation.
Treatment of fresh dislocations consists in the closed their reposition (fig. 6, 3) under local anesthesia.
In case of failure apply open reposition. After the closed or open reposition apply a plaster bandage or the joint ends fix transartikulyarno a thin spoke at easy bending of a finger. At instability of the joint ends after reposition, and also at dislocation-fractures or damages of the copular device imposing pivotally-distraktsionnogo of Volkov's device — Oganesyan is shown (see. Distraktsionno-kompressionnye devices ). By means of the device reposition of dislocation with recovery of mobility in a joint (fig. 7) is reached.
Difficulties of treatment of dislocations of interphalangeal joints are caused by bystry development of contractures with proliferative changes in circumarticular fabrics, and also the fact that they quite often are followed by injury of side ligaments, a palmar plate and the extensive device of a finger. At dislocation of the I finger quite often there is an infringement of a sinew of a long sgibatel of a finger between a head of a metacarpal bone and the main phalanx. In that case the closed reposition is impossible and shown operational treatment.
At chronic dislocations, dislocation-fractures of interphalangeal joints prescription apprx. 1,5 months apply open reposition with fixing of fragment a thin spoke and the subsequent treatment in pivotally-distraktsionnom device. At chronic dislocation in a metacarpophalangeal joint of the I finger the artificial ankylosis is shown.
Among the closed fractures of bones To. fractures of phalanxes of fingers prevail. Intra joint changes which quite often are complicated by contractures, rigidity of a joint or an ankilozirovaniye that leads to dysfunction of a brush are the most difficult. At fractures of the main and average phalanxes there is a typical shift of fragments with the corner opened to the back combinations of shifts aside and on length are possible.
Fractures of metacarpal bones meet often and make apprx. 1/3 all fractures of tubular bones To. Fractures of the I metacarpal bone have the features (see. Bennett change ). Fractures of metacarpal bones are characterized by pain, deformation, a swelling, dysfunction, patol, mobility and crepitation of fragments. Diaphyseal fractures of metacarpal bones can be cross, slanting or spiral; in addition to shifts on width and length, shifts at an angle are possible. At fractures of metacarpal bones in their proximal departments shift, as a rule, does not come. The fracture of a neck of metacarpal bones is most typical for the V metacarpal bone. In diagnosis of these changes crucial importance belongs rentgenol, to a research, a cut specifies the nature of a fracture, shift of fragments etc.
By the main method of treatment of the closed fractures of bones To. and fingers reposition of fragments under local anesthesia with the subsequent immobilization a plaster bandage is. Quality of reposition is checked on a x-ray film in a plaster bandage. In some cases apply chreskostny fixing to prevention of repeated shift spokes: at fractures of metacarpal bones — two crossing thin spokes or with additional fixing to the next unimpaired metacarpal bones (fig. 8), at fractures of phalanxes of fingers — one or two spokes entered in the cross directions (fig. 9). Apply the special electric microdrills allowing to carry out precisely and atraumatic spokes in any direction to carrying out spokes. At failure of the closed reposition quite often apply open reposition and fixing of fragments. At the most difficult intra joint changes for treatment tactics depends on size and the shift of fragments. In these cases use pivotally-distraktsionnykh of the devices creating conditions for reposition and an union of fragments with simultaneous recovery of function of a joint is effective.
Open damages depending on extensiveness of damage of integuments divide into the damages which are demanding and not demanding skin plastic surgeries. Complications of wounds To. — bleeding, at severe open injuries — traumatic shock, development of purulent process in fabrics K.
Treatment of open damages of a brush has a number of specific features: radicalism of primary surgical treatment is combined with the greatest possible preservation of fabrics and educations To. and fingers necessary for function of capture; use of early closing of wounds by skin plastics for prevention of cicatricial deformations.
Crucial importance in treatment of open damages To. surgical treatment has. The question of its volume and the nature of surgery is solved depending on a condition of the patient, prescription, extensiveness and localization of damages, age and a profession of the patient.
There are two methods of primary surgical treatment of wounds To. 1. At limited damages To. and fingers, and also at extensive injuries, on without crush of soft tissues and extensive disturbance of their viability apply the single-step primary surgical treatment consisting in a toilet of a wound with plentiful washing by solutions of antibiotics and antiseptic agents, intra bone introduction of antibiotics, economical excision of impractical fabrics, a careful hemostasis and in the greatest possible recovery of the damaged structures To. At the same time according to indications apply osteosynthesis (see), tendinous seam (see), nervous seam (see), different types skin plastics (see), formation of amputating stumps or replantation of a finger (see. Replantation ), and also primary and reconstructive operations. 2. At open injuries To. with a big zone of damage of soft tissues and disturbance of their viability the two-stage primary delayed surgical treatment is shown. The first stage includes a complex of the minimum emergency actions (antishock therapy, anesthesia, power tool cleaning of a wound, a stop of bleeding, a plentiful bathing of the wound antiseptic agents with antibiotics, Intra bone introduction of antibiotics, excision of obviously impractical fabrics, closing of a wound with a bandage with solution of antiseptic agents and fixing To. a plaster splint in fiziol, situation).
The second phase is completed by specialists in 12 — 24 hours and later (in 3 — 7 days) according to strictly individual plan, usually under an endotracheal anesthesia also consists in a repeated careful bathing of the wound, excision of impractical fabrics, reposition of dislocations, recovery of an integrity of bones, sinews, nerves and integuments To. using different types of skin plastics. Impractical fingers will amputate at the level of a line of demarcation and process stumps. Perform the primary and reconstructive operations providing recovery of capture To. (during the loss of the I finger) — primary pollitsization (creation of a finger), change of fingers or any stages of skin and bone reconstruction of fingers. For the prevention of suppuration and treatment of the developing infection carry out purposeful antibacterial therapy with bacteriological control separated wounds.
Stage treatment. First aid in the battlefield and in the centers of mass defeat (including in the conditions of GO) consists in a temporary stop of bleeding, in imposing on a wound of a sterile bandage and immobilization of a brush and a forearm. Densely rolled bandage or a first-aid dressing kit invests in a brush. The forearm and a brush are suspended on a kerchief.
During the rendering the pre-medical help on the IFV it is necessary to carry out more perfect immobilization, the edge is reached by the otmodelirovanny wire tire. The immobilization is carried out in the provision of a dorsiflexion at an angle by 30 °C by assignment and opposition of the I finger and bending of the II—V fingers at an angle 60 °. The tire is imposed from finger-tips to an elbow bend. Fingers shall be moved apart for what between them wadded and gauze wedges are laid. At the proceeding bleeding before splinting apply a compressing bandage a wound. Antibiotics and anesthetics are entered.
The first medical assistance on PMP consists in control and according to indications correction of a bandage and the tire. In case of change of a bandage the circle of a wound is processed, gauze napkins between fingers are laid, the brush and a forearm is immobilized. Antitetanic serum, antibiotics and according to indications anesthetics are entered. Wounded are evacuated in MSB (or OMO).
In the conditions of GO the first medical assistance is carried out on OPM by the same rules. If conditions of a medical situation, and also presence of experienced surgeons allow, primary surgical treatment of open damages of a brush can be carried out to OPM. In the absence of the specified conditions wounded are evacuated in the relevant pro-thinned-out hospitals.
The qualified surgical help in MSB (OMO) is given only at arterial bleeding, and also at separations and crushes To. It consists in surgical treatment of a wound, a stop of bleeding and amputation according to indications.
Treatment of damages of a brush to hospitals for lightly wounded, all-surgical hospitals and in the pro-thinned-out GO hospitals shall be directed to achievement of the best functional results. These problems are solved by broad use of a complex method of the treatment including operational methods, an immobilization, LFK, physical therapy, work therapy.
The forecast at damages To. depends on extensiveness of damage of anatomical structures of body, on timeliness and rationality of operational or conservative treatment, on quality of rehabilitation therapy (to lay down. gymnastics, trudo-and mechanotherapy, a hydrotherapy, massage, parafinoozokeritovy applications, an electrophoresis and fonoforez with use of various resorptional drugs) and in no small measure from psikhol, features of the patient.
Prevention of damages of a brush has great social value and consists of a complex of the actions directed to performance of all norms of labor protection, further automation of labor processes, a complete recovery of function K. after the former injury, transfer into other work at insufficiently recovered function K.
Inflammatory purulent diseases
the Causative agent of a purulent infection To. preferential hemolitic white or golden staphylococcus in a monoculture or association with other pyogenic microbes is.
II, III and IV fingers, phlegmon of a beam or elbow synovial bag, their joint defeat — so-called Y-shaped phlegmon belong to inflammatory diseases of tendinous vaginas and bags the Tendovaginitis (thecal whitlow).
Basic groups of phlegmons To. — phlegmons of a palmar surface and phlegmon of the back To. Phlegmons of a palm can be superficial (nadaponevrotichesky) and deep.
Carry skin abscess, hypodermic and interdigital phlegmons to superficial phlegmons of a palm; to deep — phlegmon of median palmar space, phlegmon of space of an eminence of muscles of the I finger, phlegmon of space of an eminence of muscles of the V finger. Phlegmons of the back To. divide into hypodermic and it is given neurotic.
Skin, or corn, abscess («nominal») arises at persons physical more often. work in distal department of a palm over heads of metacarpal bones, usually on a site fresh watery or dry callosity. Under the exfoliated epidermis pus accumulates. Around there is a dermahemia, a swelling, morbidity and even hypostasis of the back To. Early excision of the exfoliated epidermis leads to recovery. If operation is made late, pus gets through thickness of skin into hypodermic cellulose that leads to development of hypodermic phlegmon of a palm with amotio of skin from a palmar aponeurosis on a big extent. Penetration of pus in interdigital an interval causes development of interdigital phlegmon.
Also other reasons can cause development of hypodermic and interdigital phlegmons: small damages To., a hypodermic felon of the main phalanx of a finger, a thecal whitlow (in case of break of pus from the proximal end of a tendinous vagina).
The wedge, picture of hypodermic phlegmon is characterized by existence of a swelling of a palm, a hyperemia, sharp morbidity over the center of purulent fusion. At interdigital phlegmon the swelling, a hyperemia and sharp morbidity are most expressed in the field of interdigital intervals both with palmar, and from a dorsum. Fingers at the same time are moved apart, are in halfbent situation, their extension is sharply painful. Function of a brush is broken. Treatment operational in perhaps earlier terms. A slit on the site of the greatest morbidity. The wound is drained from pus and carefully investigated for an exception of break of an abscess under an aponeurosis. At interdigital phlegmon the slit from an interdigital membrane to a distal palmar fold is done in each interdigital interval where there are inflammatory changes. The wound, as well as at other types of phlegmons, rykhlo is tamponed a narrow gauze tampon with hypertensive solution of sodium chloride and enter into it tubules for introduction of antibiotics and aspiration of pus. To. immobilize a plaster splint. The bandage is changed for 2 days. On 3 — the 4th day there begin the careful movements with fingers. Average terms of recovery — 10 — 15 days. Complications: distribution of pus on cellulose of oval openings in a palmar aponeurosis and on channels of worm-shaped muscles in median palmar space.
Phlegmons of median palmar space seldom happen primary and result more often from distribution of a purulent inflammation at a hypodermic, bone, thecal whitlow III, IV, V fingers, break of pus from intermuscular space of an eminence of the I finger, osteomyelitis III, IV, V metacarpal bones. Clinically phlegmon of median palmar space proceeds as a serious purulent illness, often is followed by high temperature, oznoba, tachycardia, sleeplessness, nonsense. Note protrusion on a palmar surface, sharply expressed hypostasis of the back To., a dermahemia of a palm and the back To., Ill, IV and V fingers are bent, their extension is almost impossible because of pains. Fluctuation is defined on palms only in the started cases at purulent fusion of an aponeurosis. Hand pain constant.
Superficial phlegmon of median palmar space proceeds not so sharply and a wedge, its manifestations are less expressed, than deep.
Treatment of phlegmons of median palmar space operational. A section on the centerline of a palm 5 — 6 cm long cut skin and an aponeurosis. At superficial phlegmon from under a dissect aponeurosis pus is emitted. If during the opening of an aponeurosis of pus it is not found, in the stupid way get between sinews of sgibately III and IV fingers into deep median space, from to-rogo in the presence of phlegmon pus is emitted. In the presence of zatek of pus make additional linear cuts with the subsequent drainage of purulent cavities. To. fix a back plaster splint in functionally advantageous position.
Complications of phlegmon of median palmar space are numerous and connected first of all with distribution of pus: on channels of worm-shaped muscles in interdigital intervals and hypodermic cellulose of the back To. and fingers with the subsequent formation of interdigital abscesses, diffuse hypodermic phlegmon of the back To. and main phalanxes; pus can spread to a forearm via the channel of an elbow artery, and also in space of an eminence of muscles of the I finger, in tendinous vaginas III, IV and V fingers with formation of a purulent tendovaginitis, in space of an eminence of muscles of the V finger with break of pus under skin of medial region of the back To., in an elbow synovial bag at purulent fusion of its wall, in a radiocarpal joint with formation of purulent arthritis, on the back To. through intermetacarpal intervals at purulent fusion of interosseous muscles, in a beam synovial bag, in Pirogov's space on a forearm. Besides, in the postoperative period there can be secondary arrosive bleeding. Development of contractures and K. Flegmon's deformations of space of an eminence of muscles of the I finger seldom is possible results from infection of small damages To. Most often develops as a complication of purulent diseases of fingers and To.: hypodermic, bone or thecal whitlow of I and II fingers, phlegmon of median palmar space, skin abscess. Clinically in uncomplicated cases in the field of an eminence of a thumb roundish, almost semi-spherical swelling limited by a skin fold of an eminence of a thumb is defined. All other part of a palm remains not changed. The thumb is slightly bent in an interphalangeal joint and taken away, also the II finger is a little bent; their movements are limited because of pains. A constant sign is puffiness and a hyperemia of a beam half of the back To. and especially I intermetacarpal interval. Palpatorno according to a swelling note a dense elastic consistence sharply painful infiltrate. In far come cases fluctuation is defined. The palpation is painful also in the I interdigital interval. Often the lymphangitis of a forearm takes place. Treatment operational: make two sections — on palmar and back surfaces K. Razrez skin on a palm do on an inner edge of an eminence of a thumb. Not to damage the branch of a median nerve innervating muscles of an eminence, a section do not carry out higher than the level of a navicular. Edges of a wound part, muscles of an eminence of a thumb raise a hook and get into a purulent cavity. On a dorsum To. on the outer edge of the II metacarpal bone several smaller sizes do the second section. Wounds drain and rykhlo tampon. To. and the forearm is immobilized in functionally advantageous position with the taken-away I finger. In the postoperative period daily bathtubs and the early movements of fingers are necessary and To.
Complications: hypodermic phlegmon of the back To., resulting from distribution of pus from an eminence of a thumb on the back To.; break of pus in median palmar space though the return is more often observed — distribution of a purulent inflammation from a palmar hollow in space of an eminence of a thumb (diagnosis of phlegmon of an eminence of a thumb easier and therefore operation is made usually timely); purulent fusion of a beam synovial bag with emergence of a beam tenobursitis, hypodermic phlegmon of a forearm.
Phlegmon of an eminence of a little finger results from infection of damages of this area, suppuration of callosities, and also at osteomyelitis of the V metacarpal bone. The swelling, morbidity, a dermahemia and often hypostasis of the back is clinically noted To. on its elbow edge. Borders of an inflammation usually correspond to limits of an eminence of muscles At a finger. The movements V of a finger are limited, painful. Treatment — a slit by the most acting part of a swelling and morbidity.
Phlegmons of the back To. result from infection of damages of the back To., however is more often as a complication of inflammatory processes of a palm and fingers (purulent flow). The reason of development of phlegmon of the back To. the furuncle or an anthrax can be.
Hypodermic phlegmon of the back To. it is characterized by existence of a diffuse swelling, dermahemia, morbidity at a palpation, and at purulent fusion of hypodermic cellulose — and fluctuations. Subgaleal (subfascial) phlegmon of the back To., a cut most often the infected microtraumas are the reason, develops also at osteomyelitis of metacarpal bones, and also at arthritis of metacarpophalangeal joints. Clinically note dense, sharply painful infiltrate in the depth of the back To. with the expressed hypostasis of hypodermic cellulose (tsvetn. fig. B.2). Due to the features of a lymphokinesis in the area K. these phenomena can be caused also by the purulent process which is localized on fingers and a palm as display of the so-called collateral or accompanying hypostasis of the back of K. Odnako at the accompanying hypostasis tension of fabrics, the dermahemia and morbidity are considerably less expressed, than at phlegmon. Errors of diagnosis in such cases lead to unjustified cuts on the back To., whereas the suppurative focus is localized in other place.
At hypodermic phlegmon of the back To. the movements of fingers are less painful, and at deep phlegmon of the back To. fingers (unlike phlegmons of a palm To., at which fingers in the bent situation, and their extension is sharply painful) are straightened and their bending is almost impossible because of pains.
Treatment of phlegmons of the back To. operational. At subgaleal phlegmon usually do two sections: on the outer edge of the back of the II metacarpal bone and on an inner edge of the V metacarpal bone. Open an aponeurosis, empty an abscess. The wound is drained, drained. To. with the straightened fingers and the forearm is fixed a palmar plaster splint. If phlegmon of the back To. arose as a complication of purulent process of other localization (phlegmon of median palmar space, etc.), operation is made with obligatory opening of primary suppurative focus.
The general principles of treatment of phlegmons To.: preferential use of an anesthesia at operation, is more rare than local anesthesia; desalination To. during operation by means of the plait imposed on a shoulder; early and full drainage of a suppurative focus with opening of zatek; an immobilization To. after operation, use of the irrigating sucking-away drainage, topical and general administration of antibiotics taking into account flora; use of means of an immunotherapy (staphylococcal anatoxin, anti-staphylococcal gamma-globulin, hyperimmune An-tistafilokokkovaya plasma). In the postoperative period correctly constructed scheme of rehabilitation with use of physiotherapeutic procedures is important, to lay down. physical cultures, massage.
The forecast at acute inflammatory diseases To. in each case depends on localization, terms of diagnosis, timeliness and rationality of treatment, on quality of rehabilitation and on a condition of protective forces of the patient.
Prevention is directed to an exception of microtraumas, protection of hands, to processing of wounds To. antiseptic solutions and various glues, personal hygiene.
Pathological changes of a brush at specific and other infections
At tuberculosis development of specific process in tendinous vaginas and synovial bags is possible To. — hron. Tendovaginitis. Tuberculosis of metacarpal bones and fingers arises at children more often, is characterized by spindle-shaped swelling of the affected bone (see. Spina ventosa ). At a disease of Yunglinga (see. Yunglinga disease ) multiple bone cysts of tubercular character are observed.
Primary defeat To. at syphilis (a syphilitic dactylitis) it is observed extremely seldom.
In sowing. latitude of the country, hl. obr. at fishermen, sometimes develops Ching (see) — monoarthritis of a joint of a finger.
At a malignant anthrax To. there are skin defeats, typical for this infection (see. Malignant anthrax ).
Erizipeloid (see) it is often observed on To., the skin changes reminding an erysipelatous inflammation, and joint pains are characteristic of it.
At pseudorheumatism (see) damages of joints both are typical To.
Diseases of a brush of dystrophic character
To dystrophic diseases To. carry the stenosing tendovaginites of various localization: ring-shaped ligaments of tendinous vaginas of fingers (Nott's disease), the I channel of a back ligament of wrist (de Querven's disease), a cross ligament of a wrist — a syndrome of a carpal tunnel. Dystrophic processes in sheaves are the cornerstone of diseases. The main reason of their emergence — professional hron, an injury. During a disease distinguish three stages: acute, subacute and chronic. Main symptoms: the pain localized on the palmar surface of a metacarpophalangeal joint of a finger or in a wrist according to a zone I of the back channel, a characteristic phenomenon of clicking with formation of a flexion or extensive contracture of a finger, and also numbness and parasthesias To. in a zone of an innervation of a median nerve. Quite often stenosing tendovaginitis develops against the background of a humeroscapular periarthritis, an epicondylitis, a spondylarthrosis and other diseases.
Conservative treatment is shown in acute and subacute stages of a disease; it consists in use of physical therapy and injections of a hydrocortisone to the area of the affected ligaments on 0,5 — 1 ml 2 times a week, 4 — 8 injections on a course. Operational treatment is radical, is shown in cases of failure conservative and consists in a section or partial excision of a reinforced sheaf and wall of the kostnofibrozny channel with release of sinews, vessels and nerves from a prelum.
Regeneration of fabric palmar «an aponeurosis brings note fingers (see. Dyupyuitrena contracture ).
The deforming arthrosis of interphalangeal joints results from aging of a joint cartilage (a senile osteoarthrosis) or injuries, acute and chronic (posttraumatic and professional osteoarthroses). Diseases are the cornerstone the dystrophic changes of a joint cartilage leading to deformation of joint surfaces. The disease differs hron, a current with gradual progressing of defeat of joint surfaces of an epiphysis of phalanxes of fingers and emergence, at sharply expressed changes, growths of neogenic fabric — so-called nodes of Geberden in distal and Bouchard's nodes — in proximal interphalangeal joints. At the same time there are changes in soft tissues of joints in the form of thickenings of a synovial membrane, the capsule of a joint, dystrophy of sheaves and para-articular fabric. The wedge, a picture is characterized by pains, a crunch at the movement, restriction of mobility, deformation of a joint (see. Arthroses ). Treatment conservative (different types of physical therapy, sedatives, iodide drugs). At the deforming arthrosis of the I carpal and metacarpal joint, in cases of failure of conservative treatment, it is shown artificial ankylosis (see).
Kinbek's disease — the isolated damage of a semi-lunar bone also concerns to the same group (see. Kinbeka disease ).
A peculiar change of bones and soft tissues To. — Zudek's syndrome — sometimes develops owing to injuries, including and nerves, frostbites (see. Zudeka atrophy ).
Pathological changes of a brush at general diseases of a skeleton
the Specification on changes To. at general diseases of a skeleton not the wedge, a picture, and rentgenol gives, a research.
V K. the centers are usually localized osteopoikiloses (see). At the same time in spongy substance of bones To. (is more rare also in other bones) on roentgenograms islands of a compact bone tissue are found multiple small and larger (1 cm). At other general disease — melocheostosis (see) in bones To. the characteristic sclerous, more often located asymmetrically, bone masses which tower over the surface of cortical substance are observed or narrow a marrowy cavity.
Initial manifestations rickets (see) in a bone skeleton can be found in pictures To. and radiocarpal joint. At myelosyringoses (see) changes can be expressed or arthropathies in joints To., or rassasyvaniye (ossifluence) of final departments of distal phalanxes. The similar picture can be observed at sclerodermas (see) and other neurotrophic processes (a leprosy, scaly deprive, a Raynaud's disease, etc.). Neurotrophic changes in a skeleton To. and a radiocarpal joint can be shown by uneven osteoporosis (see). Sometimes at a X-ray analysis To. find multiple periosteal imposings on phalanxes of fingers and on metacarpal bones (and at bigger area of a research — and on bones of a forearm), being a symptom of other diseases, e.g. Bambergera-Mari of a periostosis (see).
Rentgenol, a picture of soft tissues To. has special value at intersticial calcification (see); it is found in To. and in other sites or that is observed less often, only in To. Changes in To. are observed at various patol, conditions of the general character which are followed by growth disorder and differentiations of a skeleton such as acromegalia (see), dwarfism (see), a myxedema (see. Hypothyroidism ), etc.
Tumours and tumorous educations
Distinguish the following types of benign tumors and tumorous formations of soft tissues To.: skin — epithelial cysts, a piogenic granuloma (see. Granuloma piogenic ), dermoid cysts (see. Dermoid ), atheromas (see. Epidermoid cyst ); fatty tissue — lipoma (see), Xanthoma (see); connecting fabric — fibroma (see. Fibroma, fibromatosis ), giant-cell synoviomas (see), ganglion (see), tumors circulatory and limf, vessels — hemangiomas (see), glomal tumors (see); tumors of peripheral nerves — neuroma (see), neurinoma (see) and neurofibroma. From benign tumors of soft tissues To. fibromas meet more often.
A malignant synovioma (see. Synovial sarcoma ) proceeds usually from palmar tendinous vaginas, synovial bags and joint capsules. The tumor arises at children and persons of young age more often, is characterized by slow: growth and bent to a recurrence and innidiation. Represents knotty education, is located more often in a palm and fingers, it is frequent with germination deep into at vague limitation, at the same time dysfunction is noted To. and fingers. The diagnosis is made on [the basis a wedge, data and gistol, researches of biopsy material or fabrics during operation. Treatment operational: in an initial stage of a disease — radical, careful excision of a tumor, chemotherapy, a roentgenotherapy; in the started cases amputation is shown To. within healthy fabrics.
A carcinoma cutaneum (see. Skin ) can develop both in normal skin, and in damaged as a result of her long irritation. Among cancerogenic factors mechanical irritations of skin play a role To. and beam influence. The tumor is most often formed on the back To. from hems, ulcers, cracks, dermatitis and eczema also represents the firm, flat thickening on the surface of skin which is slowly ulcerating in the center with infiltration of surrounding fabric. The diagnosis is specified by a biopsy. Treatment operational also consists in broad excision of a tumor within healthy fabric, also radiation therapy is applied.
In emergence hyponychial melanomas (see) a large role the injury plays, it can be also formed of a pigmental birthmark. Drift. Usually the tumor is located under a nail of the I finger, at the beginning of development has the fungoid form, burgeons too much a nail, destroys it. The differential diagnosis is carried out with a hyponychial hematoma, fibroma and a hemangioma which do not burgeon through a nail. The hyponychial melanoma metastasizes on limf, to ways to axillary area. Treatment radical — amputation of a finger, removal axillary limf, nodes. Radiation therapy is ineffective and is applied only at impossibility of operational treatment.
The vast majority of tumors of a skeleton To. make cartilaginous tumors — enchondromas (see. Chondroma ). Clinically they differ in a long, asymptomatic current, cause deformation of the affected bones (fig. 10) without essential dysfunction To. The first manifestation of enchondromas are patol, changes or a thickening of a finger.
Other tumors of a cartilaginous and bone tissue To. — ecchondromas, osteoma (see), osteoid osteomas (see) and osteoblastoclastomas (see), and also tumorous educations — cartilaginous exostoses (see), multiple Chondromatosis of bones (see), solitary bone cysts (see. Bone ) — differ in the slow growth, the low-expressed symptoms and a high-quality current. More often tumors are localized in phalanxes of fingers less often in metacarpal bones and in bones of a wrist. The bone cyst usually leads to symmetric spindle-shaped swelling of a phalanx or metacarpal bone with the central enlightenment and with thinning of cortical substance on the roentgenogram. The picture of a giant-cell tumor differs from a picture of a bone cyst in existence of bone crossbeams against the background of depression (fig. 11). Local display of a bone cyst and giant-cell tumor can differ in nothing from a hyper parathyroid osteodystrophy in one of bones To.; crucial importance for the diagnosis in that case has a condition of other departments of a skeleton. In phalanxes of fingers and in metacarpal bones at a hyper parathyroid osteodystrophy longitudinal stratification of a bast layer is often observed that has differential and diagnostic value.
Treatment of tumors of bones To. operational. At the choice of a method of surgical treatment along with onkol. tasks the question of preservation funkts, abilities is of great importance To. (savings operations). Definition of nature of surgery depends on a type of a tumor, its localization and distribution to bones. At enchondromas, bone cysts apply an ekskokhleation of a tumor. At osteoarticular exostoses, an osteoid osteoma with localization on phalanxes and metacarpal bones, excentricly located small enchondromas and ecchondromas make a regional resection. At an osteomove and osteoarticular exostoses the partial resection is shown. At the widespread tumoral centers, enchondromas of metacarpal bones make a segmented resection of a tumor within a healthy bone that is a radical operative measure. After a resection apply different types to substitution of defect of a bone bone plastics (see). Amputation and an exarticulation make only in exceptional cases — at extensive damage of bones and destruction of joint surfaces, at germination of a tumor in soft tissues and at malignant tumors — paraossalny sarcoma, a chondrosarcoma, an osteosarcoma, Ewing's tumor which in bones To. meet seldom.
Anatomy, embryology — Zolotko Yu. L. Atlas of topographical anthropotomy, p. 3, M., 1976; Kovanova. And. and Anikina T. I. Surgical anatomy of fastion and kletchatochny spaces of the person, M., 1967; Petten B. M. Embryology of the person, the lane with English, M., 1959; From tannins of e to I. Embriologiya of the person, the lane with slovatsk., Bratislava, 1977; T about N to about in V. N. Textbook of normal anthropotomy, t. 1 — 2, L., 1953; With 1 and and M. of Das Nerven-system des Menschen, Lpz., 1959.
Pathology — Bogoyavlensky I. F. Fractures of bones of a wrist, L., 1972, bibliogr.; Fight che in B., etc. Surgery of a brush and fingers, the lane with bolg., Sofia, 1971; In and l of e with about in S. P., D m and t r and e-VAZ. E. and Kruglikov E. I. Primary and delayed skin plastics at damages of a brush and fingers, M., 1973, bibliogr.; Vishnevsky A. A. and Schreiber M. I. Field surgery, page 306, M., 1975; M. V Wolves. Diseases of bones at children, M., 1974; Grigoryan. Century, Gostishchev V. K. and Kostikov B. A. Purulent diseases of a brush, M., 1978; Dolnitsky O. V. and D r yu to N. F. Traumatic deformations of a brush at children, Kiev, 1977; Kosh R. Surgery of a brush, the lane with Wenger., Budapest, 1966, bibliogr.; Kurbangaleev S. M., Yelets O. I. and Zykov A. A. Topical issues of purulent surgery, L., 1977; Marx V. O. Orthopedic diagnosis, Minsk, 1978, bibliogr.; The multivolume guide to orthopedics and traumatology, under the editorship of N. P. Novachenko, t. 3, page 489, M., 1968; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 11, book 1, M., 1960; Experience of the Soviet medicine in the Great Patriotic War 1941^-1945, t. 18, page 13, M., 1950; Open heavy damage of a brush, Saturday. nauch. works Leningr, nauch. - issled. in-that travmat. and orthoitem, 1976; Petrovsky B. V. and Krylov of V. S. Mikrokhirurgiya, M., 1976; Popkirov S. It is purulent - septic surgery, the lane with bolg., Sofia, 1977; P e y flee r S. A. Radiodiagnosis of diseases of bones and joints, t. 2, M., 1964; The Reconstructive plastic surgery at an injury of a brush, Works of the 2nd Mosk. medical in-that, t. 45, century 10, M., 1975; Rozov V. I. Injuries of sinews of a brush and fingers and their treatment, L., 1952; Pods V. I., Grigoryan A. V. and Gostishchev V. K. Purulent wound, M., 1975, bibliogr.; V. I. pods, etc. Antibiotics in surgery, M., 1973, bibliogr.; Watson-D zhons River. Fractures of bones and injury of joints, the lane with English, M., 1972; Usoltceva E. V. imashkarak. I. Hirurgiya of diseases and damages of a brush, L., 1978, bibliogr.; Fishman L. G. Clinic and treatment of diseases of fingers and brush, M., 1963, bibliogr.; Chernyavsky V. A. Diagnosis and treatment of changes and dislocations, Tashkent, 1977; E l to and M. A N. Occupational surgical diseases of hands, L., 1971, bibliogr.; In i e of of A., Braun H. u. To ii m m e 1 1 H. Chirurgische Operationaslehre, Bd 6, Lpz., 1975; B o h-1 e r L. Technik der Knochenfruchbehand-lung, Wien, 1963; Bunnell S. Surgery of the hand, Montreal — Philadelphia, 1964; Chirurgische Operationslehre» hrsg. v. I. Littmann, Budapest, 1976, Bibliogr.; R e i 1 1 P. Infectionen der Hand, Ther. Umsch., Bd 32, S. 778, 1975; S with h i n k W. Pyogene Infektionen der Hand, Chirurg, S. 356, 1971, Bibliogr.
B. A. Chernavsky, And. H. Shinkarenko; E. A. Vorobyova (An.), B. V. Gusev (malformations), V. A. Dyachenko (rents.), E. V. Lutsevich (inflammatory diseases), D. E. Malakhovka (soldier.), S. A. Sviridov (rents.).