CHANGES

From Big Medical Encyclopedia

CHANGES (fractura, singular) — injuries of a bone with disturbance of its integrity. Distinguish P. traumatic and pathological. Traumatic P. usually result from sudden impact of significant mechanical force on a normal bone. Unlike them patol. Items happen in changed some preceding patol, process of a bone at rather insignificant injury or is even spontaneous. Patol. Items are observed less often than traumatic.

Items of bones of all localizations meet at men, except for P. of a neck and trochanterian area of a femur, P. of a neck of a humeral bone and bones of a forearm in the typical place more often. Among patients with P. apprx. 55% it is the share of age of 21 — 50 years.

The most often traumatic P. arise at the road accidents.

Traumatic changes

Classification. At P. both parts of the separated bone call fragments, smaller fragments of the bone injured in a zone P. — splinters. Traumatic P. depending on a condition of covers (skin, mucous membranes) divide on closed and opened. At the closed P. the integrity of covers is kept or there are grazes. At open P. in its area there is a wound, through to-ruyu the injured bone or a zone of surrounding soft tissues can be infected. Depending on the plane P. distinguish cross, longitudinal, slanting, spiral, T-shaped, Y-shaped, star-shaped and buttonhole fractures. Items can be with the shift of fragments or without shift, P. of bones with the escaped periosteum, is more often at children, designate as subperiostal. At the hammered together P. there is a coupling of gear surfaces of fragments. The driven P. is characterized by implementation of one fragment in another, at the same time the wedged fragment destroys and moves apart splinters of the last. In a spongy bone can take place so-called compression (from a prelum) P., at to-rykh occur structural destructions of a bone. On localization distinguish diaphyseal P., epiphyseal (intra joint) and metafizarny (circumarticular). Items can be followed by the mutual shift of joint surfaces — dislocations or incomplete dislocations (e.g., lodyzhechny P. with incomplete dislocations of foot). These P. concern to group of so-called dislocation-fractures. In the presence of two fragments — proximal and distal — say about simple P., in the presence of two and larger segmented fragments throughout a bone — P.'s polifokal-nomas (double, triple etc.). Nek-ry traumatologists call these P. multiple. The item with one or several splinters is considered to be splintered. If the bone on a considerable extent turns into the mass of small and large splinters, P. designate as shattered. Items within one anatomo-functional education call isolated, P. in two and more anatomo-funktsio-nalnykh educations in one or several segments of an extremity — multiple; e.g., P. of a diaphysis of two femurs or simultaneous P. of a femoral and humeral bone or bones of two shins, etc. can call P. with a simultaneous internal injury combined; e.g., P. of a basin with injury of a bladder, P. of a backbone with injury of a spinal cord. At children's and youthful age the special type of P. — a so-called epiphysiolysis — sliding (department) of an epiphysis of bones in the area of the neogrowing stiff rostkovy cartilage is noted.

For specification of local diagnosis of P. use the anatomic terms appropriated to this area; e.g., P. of a surgical neck of a shoulder, subcapital P. of a neck of a hip, nadlodyzhkovy Item. A row P., arising at the similar mechanism of damage, having same morfol, a picture, call typical or classical. Often the name of the author who for the first time described such P. is appropriated to them; e.g., P. of a beam bone in the typical place: an extensive change of Kollis (see. Kollis change ) and a flexion change of Smith (see. Forearm ), P. of Dyupyuitren's anklebones (see. Dyupyuitrena change ), P. of a basin Malgenya (see. Malgenya changes ), etc.

The origins of changes best of all speak a basis of provisions of science about resistance of hard materials. The live human bone represents a solid with rather low elastic limit. Under the influence of the external force which is not exceeding limits of its elasticity, the bone is quickly deformed and again takes the initial form. If the influencing external force exceeds this limit, the integrity of a bone is broken. Depending on character of the influencing force (compression, stretching, shift) there is the corresponding deformation: flattening, a gap and shift, however pure types of deformations are observed seldom. The form of destruction of a bone depends on two main moments: 1) sizes, durations and directions of influence of external force; 2) physical properties of the bone — its structure, hardness, elasticity. These properties of a bone are not identical at people of different age and in different bones of a skeleton. Depending on a point of application of force distinguish P. from a direct injury (P. directly in a zone of application of force; e.g., at direct stroke) and from an indirect injury (P. arises far from a place of application of force; e.g., P. of a backbone during the falling on legs from height). Taking into account the direction of the operating force distinguish P. from shift (or a cut), from a vklineniye, from a bend, from flattening, from torsion, from a separation and from smashing. Force operating in the direction, cross to an axis of a diaphysis of a bone, under the influence of shift of its parts causes cross or slanting Items. Under the influence of the push operating in lengthwise direction there is a vklineniye of fragments to formation of the mnogooskol-chaty Item. Under the influence of bending of a bone of P. arises at first on the convex party of a bend of a bone where its structure is exposed to stretching, and then on its concave party where the bone is exposed to compression; at the same time the wedge-shaped splinter which is located between the ends of fragments is often formed here. Pressure upon a spongy bone in lengthwise direction causes its flattening, at the same time the compression and driven Items are formed. Typical P. of this kind are compression P. of a backbone. At action of the twisting force there are spiral, or spiral, Items. Such P. of a shin are usually formed at skiers at the time of falling with simultaneous sharp turn of a trunk aside at strongly fixed foot. At immediate effect of especially big force on a bone quite often there is its smashing. Perforated and regional P. are observed at immediate effect of hurting weapon, usually at gunshot wounds. In some cases the exact mechanism P. does not manage to be installed because of difficult interaction of the injuring moments.

Shift of fragments and the accompanying damages of surrounding fabrics. From the clinical point of view the concept «change» joins not only disturbance of an integrity of a bone, but also the simultaneous damage of surrounding soft tissues caused by both an external injury, and influence of the displaced fragments. Degree and the nature of these damages can be very various. Most often small ruptures of muscles and small vessels take place, as a result to-rykh in a zone P. it is formed hematoma (see). The volume of the streamed blood in a zone P. and surrounding fabrics, even in the absence of damage of large vessels, fluctuates over a wide range. So, e.g., at P. of bones of a shin it reaches 500 ml, at trochanterian P. of a femur — from 100 to 500 ml and more, at P. of a diaphysis of a femur — from 700 ml to 1 l, P. of a basin — from a small amount to 2 l and more. Quite often the bodies which are located in the neighbourhood with the injured bone or being in bone cavities are damaged by fragments of a bone that can be more dangerous than P. (e.g., injury of a bladder and urethra at P. of a basin, a head or spinal cord at P. of a skull or a backbone, etc.). The displaced fragments can damage large vessels and nerves, and also skin or a mucous membrane, then the closed P. turns into open. It is observed most often at P. of bones of a shin and a mandible.

The direction and degree of shift of fragments at P. depend on character and P.'s localization; from the direction of action and size of force causing an injury; from a form and mechanics of joints, with to-rymi the central and peripheral fragments are connected; from weight of a peripheral part of an extremity; from reflex reduction (retraction) of muscles. The following types of shifts of fragments are observed: 1) longitudinal shift, or shift on length when fragments come one for another or put each other owing to what there is a shortening of an extremity; less often fragments disperse (e.g., at cross P. of a patella); 2) laterposition, or shift on width of fragments; 3) shift of fragments on an axis, at Krom they are located at an angle to each other; 4) rotation of fragments around a longitudinal axis of an extremity. Usually the shift of fragments occurs at the same time in several planes and the directions. At the shift of fragments infringement between them of muscles, vessels, nerves (interposition of fabrics) is possible. Their untimely release can be the cause of paralysis, disturbance of blood circulation of an extremity, failure of union of fragments.

Pathological anatomy

Microscopically soon after an injury in a zone of a change reactive changes, in the beginning in the form of a circulatory disturbance with paralytic vasodilatation of a microcirculator bed with stazy blood are noted. Already during the first hours appears and quickly hypostasis progresses. At a sufficient obezdvizhennost of fragments and lack of extensive damages of bone vascular networks in 1 — 2 days after P. staz and paresis of vessels are replaced by the active hyperemia proceeding during the entire period of a mozoleobrazo-vaniye. After development of a hyperemia in a zone P. appear leukocytic infiltration and a fibrinous exudate that is considered as manifestation of aseptic serous inflammations (see), inherent to each injury. Fibrin at P., by A. V. Rusakov's definition, is some kind of «primary glue» and substrate for future development of specific elements of a bone callosity (see). Cells soon get into it, and process of formation of cellular and fibrous fabric begins.

Against the background of early reactive changes in a zone P. dystrophic and necrobiotic changes appear: in soft tissues — since the end of the first days after an injury, in a bone tissue — with 3 — the 7th days. At the closed diaphyseal P. in the marrowy channel throughout 0,5 cm from edges of fragments the detritis impregnated with the breaking-up erythrocytes and threads of fibrin is visible fabric; kernels of osteocytes are not painted. In more remote sites of a diaphysis find a necrobiosis only of separate osteocytes. In the marrowy channel necrotic masses is exposed to a lysis that leads to formation of the multiple microcysts filled with plazmopodobny liquid. According to A. V. Rusakov, the necrosis of osteocytes is not an indicator of necrosis of all bone tissue yet, viability a cut can be shown in a reactive rassasyvaniye of bone substance. This reaction from bone fragments comes to light to 3 — to the 5th day after an injury in the form of small jags on the plane of a break, in expansion of vascular channels of this zone that can be treated as manifestation of an osteodystrophy.

At the usual closed epiphyseal P., at P. of spongy and flat bones find the same phenomena, as at diaphyseal, but hypostasis of fabrics of marrowy spaces, necrobiotic and dystrophic changes are expressed to a lesser extent.

Healing of changes

the Nature of recovery of an integrity of a bone depends on a number of the general and local factors. Among the first it should be noted age of the patient, his physical and psychological condition, the constitution, function of endocrine system, a metabolism, a condition of food, etc. At children the union occurs much rather, than at adults. So, the union of the uncomplicated closed P. of a femur at the baby comes within 1 month, the teenager has 15 years — in 1,5 — 2 months, at the 30-year-old man — in 2,5 — 3 months, at 50 — 60-year-old — in 3 — 4 months. The slowed-down P.'s union is observed at avitaminosis, diabetes, a radial illness, during pregnancy and a lactation, at persons with the expressed anemia and a hypoproteinemia and at nek-ry other diseases. Long introduction of a cortisone, hydrocortisone, Prednisolonum also worsens process of healing of P. Odnako process of an union of P. in much bigger degree is influenced by local factors. Under favorable local conditions and the correct treatment value of the general factors is shown only a nek-eye by prolongation of an union. Such local factors as localization, degree of shift and mobility of fragments, type P exert impact on the speed of an union. Slanting and spiral P. with the big, well adjoining surfaces of breaks grow together quicker, than cross. Much rather the driven P. Thus grow together, than more precisely are compared and the fragments are less mobile, rather they grow together. Process of formation of a callosity is broken at interposition of soft tissues or the large splinter which turned between the main fragments. Degree of vascularization and viability of bone fragments are of great importance for a mozoleobrazovaniye. The disturbance of blood circulation of fragments as a result of an injury or operation is more considerable, the process of recovery of a bone proceeds more slowly. So, double P. of a diaphysis grow together slowly in connection with bad blood supply of an average fragment. In formation of a callosity the mechanical factor is of great importance. The moderate pressure operating perpendicularly to the plane P. favors to process of a mozoleobrazovaniye, and the stretching, shifting and rotary forces — are adverse. The insufficient, not excluding the movement of fragments, short-term or often interrupted immobilization is the frequent reason of a delay of an union and a resorption of a weak callosity, P.'s failure of union and education nearthrosis (see).

Local conditions for P.'s union at treatment by various methods are not identical. So, at treatment additional damage of fabrics, including vessels, to a zone P. does not happen a plaster bandage or extension, unlike operational treatment, that is a factor, favorable for a mozoleobrazovaniye. Together with it reposition and immobilization of fragments at the same time are less perfect, than at steady osteosynthesis (see), carried out, e.g., by submersible fixers. Conditions for reparative regeneration at the closed nailing others, than at open. Process of healing of P. at extramedullary metalosteo-synthesis by screws and plates differs from P.'s healing at nailing. At the first Intra bone blood supply of well compared and withheld fragments usually remains or suffers a little. Certain features have recovery processes at the osteosynthesis closed or opened extra focal compression distraktsionnom. At the same time not only the full immovability of fragments is reached, but also there is no additional damage of intra bone and periosteal blood supply. At open P., especially when the infection develops, conditions for reparative processes are less favorable, than at the closed Items.

During the determination of terms of an union of fragments, recovery of the patient and recovery of working capacity it is necessary to consider rentgenol, and a wedge, given about funkts, endurance of the spliced bone and recovery of function of an extremity. Sometimes at P.'s union the repeated injury causes P. (refraktura) again; more often it takes place at a weak bone callosity owing to the premature termination of an immobilization or removal of the fixer.

Fig. 1. Microdrug of a zone of a bone union of extremely pulled together fragments of a spongy bone tissue of a metaphysis in 2 weeks after a change. Contours of accrete fragments are not defined: 1 — old bone plates; 2 — neogenic bone plates from not quite mature bone tissue, people around old; 3 — interframe spaces with osteoblastic fabric and vascular capillaries; coloring hematoxylin-eosine; x 20.
Fig. 2. Microdrug of the site of an union of fragments of a compact bone tissue (1) of a diaphysis in 3 months after a change: the mature intermediary bone callosity is visible (2); coloring hematoxylin-eosine; x 75.

By exact comparison of fragments perhaps direct bone union by means of an intermediary bone callosity that is called primary bone union. When the union of fragments comes after preliminary connection by their osteoarticular provisional callosity, on a basis the cut will gradually form a final intermediary bone callosity, speak about a secondary bone union. Primary bone union can occur only in strictly certain conditions: at sufficient blood supply of fragments, the accuracy of their comparison, sufficiency of their immobilization. Microphotos of a bone at primary union are submitted within different terms of consolidation in fig. 1 and 2.

Fig. 3. Microdrug of the site of a diaphysis of a bone in 2,5 months after a change: fixing of fragments (1) of compact substance of a bone insufficient, is visible an intermediary cartilaginous callosity (2) with the center of an endostosis (3); coloring hematoxylin-eosine; x 20.

In most cases because of difficulties of providing all necessary conditions the bone union happens secondary, at Krom in different terms (but not earlier than — 8th week and about many months) after P. the final bone callosity forms. Such option is manifestation of the adaptable mechanisms of an organism directed to recovery of an integrity of a bone in unfavorable conditions for healing of bone wounds. The impossibility of mobilization of such adaptive reactions leads to failure of union of fragments of the injured bone. P. of those departments of bones where there is a periosteum and the muscular array surrounding it, napr, diaphyseal P. of tubular bones are optimum for manifestation of adaptation opportunities of an organism. The item of the epiphysis of bones deprived of a periosteum in the absence of the conditions necessary for primary bone union, cannot grow together by an adaptive secondary bone union therefore without use of an osteosynthesis fragments often do not grow together, napr, at medial P. of a neck of a femur. The microphoto of a bone at a secondary union is presented in fig. 3.

Open P. quite often are complicated by development of inflammatory process that is shown by more expressed phenomena of disturbance of blood circulation and big accumulation of segmentoyaderny leukocytes in marrowy spaces, adjacent to a zone P., and soft tissues surrounding a bone. Further there is a granulyatsionny fabric (see) with considerable impurity of segmentoyaderny leukocytes. Zones of a necrosis and a rassasyvaniye of a bone tissue come to light. Manifestation in a zone P. of reparative processes at the same time is late, and the union comes only after elimination of acute inflammatory process, dragging on for months and even years.

Morfol, a picture of healing of P. in different bones of a skeleton has the features. So, in a backbone where there are compression P. of bodies of vertebrae with a vkolachivaniye of fragments and destruction of bone plates more often, reparative processes in a zone of damage are characterized by a new growth of the bone plates which are stratified on old bone plates of spongy substance. Further there is a maturing of a bone tissue and streamlining of structure of spongy substance. P.'s healing the edges having quite thick cortical substance and being in conditions of mobility happens by a secondary bone union to preliminary formation of a periosteal osteoarticular callosity. At P. of a body of the mandible at the wrong treatment the union can not come at all since owing to anatomo-physiological conditions (the chewing movements) it is not always possible to create conditions to a sufficient obezdvizhennost of fragments.

The clinical picture

the General condition of P. which were injured at the majority happens satisfactory, moderately severe, is more rare — heavy. However at multiple P., especially in the presence of open injuries, and also at the combined damages at patients, as a rule, heavy quickly develops and critical condition is frequent, is frequent with a symptom complex of traumatic shock (see). Weight of a condition of the patient at the combined damages is defined not so much by injury of a skeleton, how many a damage rate of internals.

In the area P. usually note a swelling and bruise. Function of an extremity in most cases is immediately broken. The active and passive movements are painful and limited. However sometimes, napr, at the driven P. of a neck of a femur, nek-ry patients continue even to move that can lead to the shift of fragments and transformation of the driven P. into not driven. Unconditional symptoms of P. are deformation of an extremity, abnormal mobility on site of P., crepitation of fragments and shortening of an extremity. Along with these other, less characteristic signs, napr, the irradiating pain far from P.'s place, disturbance of sound transmission of a bone, etc. are observed. At cracks, the subperiostal, driven, intra joint and circumarticular P. a part of symptoms can be absent. There is also a number of the symptoms characteristic of certain types of P., napr, the strengthened pulsation of femoral vessels and pain at a palpation under an inguinal (pupartovy) sheaf at medial, especially varus, P. of a neck of a hip (a symptom Girgolava); an arrangement of a big spit over the line to Roza-ra — Nelatona at P. of a neck and trochanterian P. of a hip with shift (see. Hip joint); education two unequal (acute and stupid) adjacent corners between the longitudinal axis of a shoulder and the line connecting both condyles of a humeral bone (instead of equal right angles is normal), at epicondylic P. of a humeral bone, etc. At intra joint P. is defined hemarthrosis (see), and also rotational, laterpositions and movements not inherent to this joint.

At inspection of the patient with P. it is necessary to check existence of pulse lower than the level P. At suspicion on damage of the main vessel it is shown angiography (see). The research of skin sensitivity, active movements and animal force allows to judge possible damage of elements peripheral or the central nervous system. Especially carefully it is necessary to investigate the patients who are in unconsciousness or a condition of heavy alcoholic intoxication. In the presence of P. can remain timely not diagnosed life-threatening damages, napr, ruptures of internals, a bladder and an urethra, a severe injury of a head and spinal cord, etc. with them.

The special attention is deserved opened their P. Harakter is defined by the mechanism of an injury, P.'s localization, extensiveness and a damage rate of soft tissues (skin, muscles, a fascia, sinews, vessels, nerves, etc.), an arrangement of a wound, its microbic pollution. Open P.' current depends considerably on features of an anatomic structure of the injured area, reactivity, extensiveness and severity of damage of soft tissues and a type of the Item. As a rule, microbic pollution of fabrics (and probability of development of an infection) at small wounds is less, than at extensive deep and heavy injuries of skin and subjects of soft tissues. Quite often the zone of damage of soft tissues is much more extensive, than the sizes of a skin wound. At the open P. resulting from a puncture of fabrics fragments from within soft tissues are damaged less, than at the open P. arising during the drawing wound from the outside. The broken bone can be naked on a bigger or smaller extent or is not visible at all. In nek-ry cases originally closed P. turns in opened several days (so-called secondary open P.) later. It is observed at a necrosis of skin as a result of the injury or under the influence of pressure from within the end of the displaced fragment. Most often the necrosis arises on a shin. Danger of infection of open P. is more on the lower extremities, than on upper. On the lower extremity there is a bigger array of muscles, skin is stronger contaminated also a high probability of pollution of a wound by the soil. Bakteriol, a research of wounds at fresh open P. shows that in the prevailing most cases (90% and more) wounds are bakterialno contaminated. Most often crops give growth of stafilokokk or various combinations of microbic flora (staphylococcal, colibacillus, Xing purulent, etc.). Than it is more extensive, deeper and heavier than injury of skin and subjects of soft tissues at open P., that a high probability of transition of microbic pollution to a heavy infection — purulent, anaerobic or putrefactive. At open P. it is considerable more often than at closed, damage of the main vessels takes place, a cut can lead to disturbance of blood supply of an extremity up to development of ischemic gangrene.

Open P. are diverse on the wedge, to forms and therefore the diagnosis «an open change» does not give complete idea of weight of an injury.

Several classifications open P. Naiboley are offered A. V. Kaplan and O. N. Markova's classification offered in 1967 (tab. 1) was widely adopted. It considers extensiveness and the nature of injury of skin and all subjects of fabrics, damage of the main vessels, localization and P.'s character, i.e. is based on the major factors defining weight and features of the open Item.

Classification allows not only to specify open P.'s diagnosis, but also it is more correct to establish indications to use of this or that method of treatment, to predict an outcome and to carry out the differential analysis of result of treatment depending on open P.'s weight

Features of traumatic changes at children

P. at children have the specifics caused by age anatomo-physiological features of a children's organism. The age of the child is less, the these differences are expressed more.

Injuries at children happen quite often, however in most cases it is bruises, grazes and if there is P., then it, as a rule, has the isolated character. At the same time the mechanism of an injury is more often indirect. Multiple and combined P. occur at children considerably less than at adults, and generally are result of the road accidents. Items at children quite often arise during the falling from trees, fences, during the sports occupations, at physical education classes at defects of control.

Items of upper extremities are observed considerably more often than lower — respectively 69 and 31% (adults have the return ratio).

Children have certain differences in frequency and localizations P. Tak, e.g., most often children have II. in an elbow joint (over - and transcondylar P., the detachable P. of a medial epicondyle which are combined with dislocation of bones of a forearm, P. of the block and a head of a condyle of a humeral bone, a neck of a beam bone and an elbow shoot, detachable P. of a coronal shoot). Are quite frequent at P. children of both bones of a forearm, generally cross in the lower third at one level. The isolated P. of a tibial bone are very widespread. At children at an injury of a shin the tibial bone, as a rule, breaks and does not break, and owing to the elasticity the fibular bone only caves in. In this regard fragments of a tibial bone are, as a rule, displaced slightly and only at an angle to each other. Items of anklebones at children and ruptures of an intertibial syndesmosis are observed extremely seldom, there are transepiphyseal P. of an inner edge of a tibial bone more often. Items of bones of a brush meet quite often, bones of foot break much less often.

Items at newborns can arise at the time of delivery. Diagnosis them does not present special difficulties. More often the clavicle and a femur breaks. Such P. usually in 7 — 10 days grow together, but sometimes for the rest of life there are angular deformations.

The children's bone grows at hl. obr. at the expense of cartilaginous regions of growth of an epiphysis and apophyses. Therefore only at children an epiphysiolysis (osteo-epifizeolizy) and apophyseolyses is observed. At similar damages damage of regions of growth and in this regard their premature short circuit is possible that can bring in the subsequent to shortening and angular deformation of an extremity. So, e.g., P. and an epiphysiolysis in the field of the proximal end of a humeral bone and the osteo-epifizeolizy distal end of a femur quite often come to an end with lag of growth of the corresponding segment of an extremity. An osteoepiphysis about Iza's l of the distal end of a beam bone at the correct conservative treatment seldom lead to lag of growth of a beam bone and beam talipomanus (see). At transepiphyseal P. of the distal end of a tibial bone the medial department of a rostkovy zone is damaged that quite often comes to an end with lag of growth of medial edge of a tibial bone with the subsequent varus deformation of an ankle joint. Osteoepi-fizeoliza of the distal end of a tibial bone, as a rule, do not leave effects.

At children dense and rather thick periosteum, bones contain a large amount of organic compounds. In this regard bones of the child in comparison with bones of adults more flexible. Therefore subperiostal P. as «bent» are frequent, at to-rykh the integrity of cortical substance is broken, and the integrity of a periosteum remains.

At complete fractures fragments are often displaced within the unimpaired periosteum and do not perforate skin. Same rather well developed hypodermic cellulose on extremities interferes. In this regard open P. are rather rare (by 4 times less than at adults).

Certain differences are available also in a wedge, a picture P. The injury of an extremity at children, especially upper, is always followed by considerable hypostasis of soft tissues. From here need of much more frequent use of splints-nykh of plaster bandages and a close check behind a condition of blood circulation of the injured extremity, especially, follows if it was necessary to apply a circular plaster bandage. It is necessary to pay attention to a condition of peripheral nerves, damage to-rykh at children it is very often observed in an elbow joint.

Features of traumatic changes at advanced and senile age

P. — a frequent injury at persons of advanced and senile age. Among victims women prevail. Frequent P. at elderly are promoted by involute processes in a musculoskeletal system, osteoporosis (see), fragility and fragility of bones, loss of elasticity of cartilages that reduces their shock-absorbing role at an injury. Pedestrians are the victims of accidents often 60 — 65 years are aged more senior that, obviously, is connected with deterioration at them in orientation and decrease in speed of reaction to danger. Nek-ry localizations of P. meet in old age more often, than at more young people. The item of a neck of a femur and trochanterian area, a surgical neck of a humeral bone, a backbone, a forearm in the typical place and nek-ry others are specific to people of old age not only because often meet, but also because arise at rather small injury against the background of senile osteoporosis. In this regard many old people throughout the short period (2 — 5 years) can have several P. of different localization.

Items at people of advanced and senile age usually well grow together if necessary conditions are for this purpose created. The main distinction of finally created callosity at the old and young man consists in what in the first case make callous as well as the bone, is less dense, more osteo-porozna, is brittle and has the lowered durability.

Complications

At patients with P., especially at the multiple and combined injuries, at open changes, P. of a basin and P. of a hip, can develop shock, a fatty embolism (see), traumatic toxicosis (see), anemia (see). At elderly people of P. quite often are complicated by pneumonia, at alcoholics — acute psychosis (see Delirium acutum). At open and fire P., especially at extensive damages of fabrics, superficial or deep suppuration quite often develops, osteomyelitis (see), is much more rare — mephitic gangrene (see), tetanus (see). At the closed P. the purulent infection arises seldom — a hematogenous way or from superficial grazes as a complication after an osteosynthesis submersible fixers. The most various complications can develop in connection with the accompanying damages, napr, blood vessels — gangrene of an extremity, fibrinferment, insufficiency of blood supply of an extremity, folkmannovsky contracture (see), at injury of nerves (paresis, paralyzes, neuritis, osteoporosis). Carry the slowed-down union and formation of a nearthrosis to late complications of P. (see), the wrong union of P., development of spotty posttraumatic osteoporosis of Zudek (see Zudek an atrophy), formation of heterotopic ossificates (see), traumatic arthroses (see), myogenetic and artrogenny contractures (see), posttraumatic hypostases, etc.

At children function of the injured extremity is recovered in rather short terms. But errors and mistakes made at diagnosis and treatment quite often involve serious consequences, treatment to-rykh presents great difficulties, often does not lead to recovery of the child, comes to an end with disability. Disturbance of blood circulation (folkmannovsky contracture), loss of function of peripheral nerves, failure of union of bones (nearthroses, defects of bones), restriction of function of a joint and deformation of bones and joints belong to such effects (complications).

The diagnosis

is of great importance For P.'s diagnosis well collected anamnesis directed to clarification of conditions and the mechanism of an injury. Circumstances and the mechanism of the arisen P. often are very typical. E.g., for compression P. of a backbone falling from height on buttocks, is characteristic of calcaneuses — on legs, of P. of a basin and edges — a prelum in the perednezadny or side direction; for P. of a neck of a hip and trochanterian P. of a femur, especially at elderly people — falling sideways also hurt in the field of a big spit; for P. of bones of foot — falling of weight on foot; for Dyupyuitren's change — podvertyvany feet of a knaruzha; for P. of a forearm in the typical place — falling arm-distance in the provision of back extension of a brush. Nek-ry types of P. are observed more often during certain periods of year; e.g., P. of cervical vertebrae quite often arise at divers during the bathing, spiral P. of bones of a shin — in the winter at skiers. Local diagnosis of P. is made on the basis of definition of the symptoms described above.

For differential diagnosis between fresh and old P., between traumatic and nek-ry forms patol. Items, diagnoses of nearthroses, posttraumatic aseptic necroses of a bone, etc., in addition to usual a X-ray research, use tracer and ultrasonic techniques of a research (see. Radio isotope diagnosis, Ultrasonic diagnosis), angiography, etc. It is necessary to remember a possibility of internal injuries in a zone P., in the neighbourhood with it or far from it (vessels, a head and spinal cord, bodies of a chest and abdominal cavity).

P.'s diagnosis has the age specifics. So, at newborns and at early children's age it is based generally on rentgenol, inspection. At elderly people the differential diagnosis between traumatic P. against the background of osteoporosis and patol is sometimes necessary. The item because of a possible metastasis of a malignant tumor or another patol, process. The differential diagnosis is especially difficult at P. of a backbone.

The method is of great importance for P.'s diagnosis rentgenol. The roentgenogram gives the chance to distinguish not only P. with the shift of fragments, but also the cracks driven and other P., at to-rykh a characteristic wedge, signs are absent. Rentgenol, a method allows to establish character of shift of fragments, is the watch facility behind development of a bone callosity, provides control of treatment and its anatomic result. Therefore treatment of each patient with P. shall begin and come to an end in a X-ray analysis.

At rentgenol, a research P. it is necessary to make pictures not less than in two mutually perpendicular projections. On roentgenograms shall receive display not only damaged, but also the next healthy departments of bones on a sufficient extent. If the sizes of films allow, pictures shall take both adjacent to P. of a joint.

An indispensable condition for the correct recognition of P. is the high quality of pictures determined first of all by existence of clearly visible bone drawing. The sharp and contrast image of the damaged departments of a bone on roentgenograms can be received at observance of the following conditions: exposure shall be, whenever possible, very short; in exposure time a dischargeable object for prevention of shift shall be densely fixed; the provision of a X-ray tube shall cause the perpendicular direction of beams to area P. and the cartridge.

Fig. 4. The direct roentgenogram of a hip with a cross fracture of a femur: shift of fragments on length, width and at an angle.
Fig. 5. Side roentgenogram of an elbow joint: a splintered change of an elbow shoot with discrepancy of fragments.
Fig. 6. Direct roentgenogram of a radiocarpal joint: change (1) of a distal metaepiphysis of a beam bone and separation of an awl-shaped shoot (2) ulnas.
Fig. 7. Side roentgenogram of the lower third of a shin: a slanting spiral-shaped splintered fracture of a tibial bone with small shift on length.
Fig. 8. Direct roentgenogram of the lower third of a shin: a slanting fracture of both tibial bones with the shift of fragments on length.
Fig. 9. Direct roentgenogram of the lower third of a shoulder and elbow joint: longitudinal intra joint fracture of a humeral bone.
Fig. 10. Direct roentgenogram of an upper third of a shin: a slanting crack of a proximal metaepiphysis of a tibial bone and a fracture of a fibular bone (are specified by shooters).
Fig. 11. Side roentgenogram of a skull: a fracture of a temporal bone (it is specified by an arrow).

The main rentgenol, a sign of disturbance of an integrity of a bone — the line P. Great diagnostic value has the shift of fragments, existence to-rogo so undoubtedly proves disturbance of an integrity of a bone that need for differential diagnosis disappears. As if in detail it was described rentgenol, the picture P., the fullest and correct idea of degree and character of shift of fragments the doctor can make only at direct viewing of pictures. Overriding of fragments of one behind another at longitudinal shift on the roentgenogram in one projection can be followed by stratification of shadows of the ends of fragments — so-called superposition of shadows. In this case exact determination of shift of fragment is possible on the basis of these pictures in the second projection. At P. of flat bones (a shovel, edges, a basin, etc.), at to-rykh for technical reasons production of a picture in the second projection it is complicated, superposition of fragments often is the only reliable sign of the Item. Recognition of longitudinal shifts with discrepancy of fragments usually does not represent any difficulties. Shifts of this sort are observed at P. of a patella with a rupture of the copular device, an elbow shoot, spits of a hip, separations of bone ledges, to the Crimea the muscles which are reduced at damages and leading to discrepancy are attached. Interposition of soft tissues between fragments of bones at rentgenol, a research is not distinguished. Different types of P. in the most informative projections are presented in fig. 4 — 11.

At disturbance of an integrity of a bone without the shift of fragments on the roentgenogram according to the plane P. (both in spongy, and in cortical substance of a bone) the very narrow strip of a break of bone structure is defined. Most clearly it is traced in cortical substance. The line P. usually has uneven edges, and the course and the direction it are various depending on a type of the Item.

If the line P. in a picture does not reach the opposite edge of a bone, P. call incomplete, or a crack. Having begun at one edge of a bone and being gradually narrowed, the crack disappears in structure of not changed bone substance. Most often cracks arise in flat and spongy bones, first of all in bones of a skull, calcaneuses; much less often they meet at injuries of tubular bones. Intra joint consider P., at Krom disturbance of an integrity of a bone extends to its joint end.

Cracks and P. without the shift of fragments are quite often so poorly expressed that clearly it is possible to see them on the roentgenogram only with the help of a magnifying glass. In these cases are of great importance for specification of the diagnosis tomography (see) and a X-ray analysis with direct blowup. If careful studying of roentgenograms does not allow to establish signs of disturbance of an integrity of a bone, and a wedge, the picture speaks well for it, the issue can be resolved repeated rentgenol. a research in 5 — 10 days. To this term owing to a rassasyvaniye of a part of nekrotizirovanny bone plates and trabeculas in the damaged area the line P. becomes wider and is clear seen on the roentgenogram. The great value rentgenol, a method of a research has technically executed roentgenograms in recognition of the driven P. Horosho allow to find in these cases not only the line P., but also small deformation of a bone with shortening of the relevant department (a neck of a femur, a humeral bone, etc.).

Existence of regions of growth and kernels of ossification at children results in certain difficulties rentgenol, P. Eto's diagnoses first of all treats an elbow joint, in Krom the joint ends of bones consist considerably of cartilaginous tissue and on roentgenograms are not visible, and existence of a large number of kernels of ossification and regions of growth quite often is the reason of appreciable diagnostic mistakes. Kernels of ossification and region of growth are accepted to P. and vice versa — the medial epicondyle displaced in a cavity of an elbow joint is regarded as a kernel of ossification and timely is not removed from a cavity of an elbow joint. At children, especially at newborns, at P.'s union formation of the extensive callosity, at a X-ray analysis which is quite often taken for sarcoma is observed. Rentgenol, recognition of an epiphysiolysis is possible only from age when kernels of ossification appear and if P. is followed by shift. At an epiphysiolysis the line P. often passes on border of a zone of preliminary calcification of an epiphyseal cartilage and a bone part of a metaphysis so that at the same time the wedge-shaped piece of a bone from a metaphysis is broken off. In pure form the epiphysiolysis is observed usually in a neck of a femur and often is complicated by an aseptic necrosis of its head.

In differential diagnosis of P. the shadow images found sometimes in pictures reminding the line P., a crack and even shifts of fragments are of particular importance. The strips, linear shadows and spots appearing on roentgenograms in connection with defects on x-ray films and X-ray intensifying screens (artifacts) can be a source of diagnostic mistakes. Folds of clothes or integuments, different bandages, the remains of ointment and plaster, as well as imposing of lumbar muscles and gas bubble of intestines, can give the shadows reminding the line P. of this or that bone. Differential diagnosis is based that such line goes beyond contours of a bone while at P. it comes to an end within a bone.

Most often take apofizarny and epiphyseal rostkovy cartilaginous zones, a pseudo-epiphysis (an additional epiphysis), vascular channels, additional stones and zones of reorganization of Loozer for P. (see. Loozera zone ). Recognition of rostkovy and cartilaginous zones unlike P. is based on knowledge of terms of ossification of various bones, the account anamnestic and a wedge, data and wide experience of the doctor making a research. More or less expressed shift of fragments, in particular kernels of ossification of the damaged party in comparison with healthy is the Differentsialnodiagnostichesky sign of P. in the field of rostkovy zones. Bases of differential diagnosis of P. of a pseudo-epiphysis are same. Often for the line P. or a crack take the vascular channels (especially for a. nutricia) which are available almost in each bone and places allocated against the background of cortical substance, and also in bones of a skull. That it is the vascular channel, but not P., tell a characteristic arrangement, equal contours and the rectilinear direction of rather wide slit-like enlightenment. the 3atrudne-niya in differential diagnosis of P. can cause existence of additional and double sesamoids of foot and brush. In these cases the research of symmetric area can turn out though options of this sort of a skeletogeny can be and unilateral useful. Additional stones have always equal accurate roundish contours while the jagged, uneven contours are characteristic of P., and contours which by comparison of edges of fragments are jagged shall match completely and teeth of one bone to fill dredging another. The line P. on the roentgenogram so-called zones of reorganization of Loozer have external looking alike. In the x-ray image such zone is presented in the form of a very narrow strip of an enlightenment very similar to lines P., especially in the presence of the small periosteal stratifications at appropriate level of a bone simulating a bone callosity. Differential diagnosis between true P. and a zone of reorganization on the basis of one rentgenol given is very difficult. Diagnosis help localization, characteristic of zones of reorganization (metatarsal, tibial to a bone, the distal end of a femur, etc.) and absence with the anamnesis of an injury, and also existence of dystrophic diseases and funkts, overloads of separate bones or a skeleton in general, to-rye can cause emergence of zones of reorganization of Loozer (rickets, Pedzhet's disease, etc.). Symmetric and multiple changes always speak well for zones of reorganization.

Radiodiagnosis at P.'s healing is based on observation of a number of the stages of this process replacing each other — see. Bone callosity.

Treatment

Treatment aims at preservation of life of the victim, the prevention of possible complications of P. and recovery in the shortest possible time of an anatomic integrity of a bone, function of an extremity and working ability of the patient. For achievement of the specified purposes P.'s treatment is based on certain principles.

1. Treatment shall begin on site incidents. The main objectives of the first medical aid at open P. are fight against shock, pain, bleeding, the prevention of secondary microbic pollution of a wound, an immobilization of the injured extremity by means of transport tires (see Tires, splintage) and training of the patient for evacuation, careful transportation of the victim in to lay down. establishment for rendering the qualified help. On site incidents close a wound a protective sterile bandage. If skin is injured and bones stick out outside, it is not necessary to set them. The pressing wadded gauze bandage applied a wound not only protects a wound from pollution, but also, as a rule, stops bleeding. Need for imposing of a styptic plait arises seldom. At an immobilization of the injured extremity two joints — above and below P. surely are immobilized (see the Immobilization). The first medical aid by the victim with closed by P. comes down generally to a temporary immobilization the transport tire. At diaphyseal P. of a hip, a shoulder, both bones of a shin or a forearm sharp deformation of an extremity at the expense of the angular shift of fragments is possible. It is desirable to eliminate a curvature so as far as it is required for splinting, at the same time extreme care is necessary. Antishock and other actions of the general character — according to indications. At first-aid treatment of ambulance by service the complex of events for fight against shock is held, including local anesthesia P. or futlyarny anesthesia is higher than P.'s place according to Vishnevsky (see. Anesthesia local ).

2. Treatment of victims in to lay down. institutions is under construction on the principles of an urgent surgery, and first of all, if necessary, resuscitation actions are carried out (see Resuscitation).

3. Rendering acute medical aid by the victim with P. at the combined and multiple injury is carried out by the principle of the dominating damage (see Politravm). First of all urgent actions shall be directed to correction life-threatening funkts, disturbances with simultaneous identification of the damages defining serious condition of the victim. The choice of a method of treatment of P. is defined by the general condition of the patient. The serious condition of the patient, the and simpler the way of treatment of the Item shall be less traumatic. After removal of the patient from shock carry out rentgenol. inspection. The priority at multiple P. is given to priorities of treatment to open Items. At the closed multiple P. the method of treatment is chosen depending on a condition of the patient and carried out at the same time or step by step.

Prevention of a wound fever (see) — the most important problem of treatment of open P. V complex treatment its main methods are careful primary surgical treatment of a wound (see. Surgical treatment of wounds) and immobilization of fragments. Along with it carry out antimicrobic therapy (antibiotics, etc.), apply the means increasing reactivity of an organism (anti-staphylococcal serum, gamma-globulin, hemotransfusion, etc.).

4. All to lay down. actions, including reposition of fragments, an immobilization, etc., shall be provided adequate anesthesia (see). Pain causes reflex reduction of muscles that holds fragments in the displaced state and interferes with their reposition. Anesthesia promotes removal of the patient from shock and, eliminating a muscle tension, facilitates reposition. Most often at fresh P. apply local (in a zone P.) introduction of 20 — 40 ml of 1 — 2% of solution of novocaine. Use futlyarny, intradermal, conduction anesthesia or one of types of an anesthesia less often.

5. The displaced fragments shall be precisely compared that provides anatomic recovery of length, axes and shapes of an extremity, and also creates optimal conditions for P.'s union and the fullest recovery of function of an extremity (see Reposition).

6. The compared fragments shall be in the immobilized state to a bone union. At an immovability of fragments pains decrease, the inflammatory phenomena abate, it is recovered krovo-and the lymphokinesis of an extremity, is limited inf. process, the biological, biochemical and physical conditions providing conditions for a wound repair and an union

of Item 7 are normalized. P.'s treatment shall be functional and include timely use of active movements with involvement of perhaps bigger number of joints, rhythmical reductions and relaxations of muscles of the immobilized segment of an extremity. Such method prevents' rigidity of joints, an atrophy of muscles, osteoporosis, hypostases, improves krovo-and the lymphokinesis of an extremity, promotes a bystry union of P., funkts, to recovery of an extremity and working ability of the patient.

8. In the course of treatment at the corresponding indications it is necessary to apply the means contributing to normalization of reparative regeneration (Nerobolum, retabolil, a calcitonin, vitamins, etc.), the corresponding food.

The main methods of treatment of P. of bones are skeletal traction (see), a plaster bandage (see. Plaster equipment), outside chreskost-ny compression distraktsionny: an osteosynthesis by means of various devices (see Distraktsionno-kompressionnye devices) and an operational osteosynthesis submersible (internal) fixers (see the Osteosynthesis). Each of these methods has the indications and contraindications. They supplement each other and shall not be opposed.

Skeletal traction is used most often at P. of a basin, trochanterian and diaphyseal, preferential spiral and splintered P. of bones of a shin or a femur. At P. of bones of the lower extremity extension is carried out on Beler, Shulutko, Thomas's tires, etc. (see Tires, splintage). In the course of extension carry out funkts, treatment to lay down. gymnastics. Usually bone union at adults at difficult P. of a basin and P. of a femur comes within 3 — 4 months. At P. of bones of a shin skeletal traction is often applied as the first stage of treatment. Later 3 — week would apply a plaster bandage to a proximal third of a hip. The bone union at P. of bones of a shin usually comes in 2 — 4 months. Skeletal traction is applied also in an initiation of treatment as a preparatory stage before operation at P. by necks femoral: a bone and trochanterian P. of a femur for reposition of fragments and also when at dru7-gy types of P. because of serious condition of the patient there are temporary contraindications to an osteosynthesis. Often it takes place at the multiple or combined injuries or in the presence of grazes in a zone of alleged operation, etc. Skeletal traction at fractures of a humeral bone is carried out on the taking-away tire for an elbow shoot within 1 — 2 month.

Advantage of skeletal traction is that at this method good reposition of fragments and an opportunity to carry out funkts, treatment is usually reached.

A lack of a method is that it does not provide strong immobilization of fragments after their reposition before formation of primary callosity, and also a forced long bed rest for the patient. Cutaneous (glue, adhesive, etc.) the extension per continuitatem is applied extremely seldom.

The plaster bandage (deaf and longetny) as an independent method of treatment of P. is applied often: almost at all P. without the shift of fragments, and also it is frequent for an immobilization after single-step manual or frame reduction (e.g., at P. of anklebones, bones of a forearm, a clavicle, intra joint and circumarticular P., changes of a diaphysis of bones of a shin, etc.). The plaster bandage is applied after initial treatment by skeletal traction, and also as an additional immobilization after operational treatment of the Item. It can be used as a temporary immobilization at P. when because of weight of a condition of the patient it is impossible to apply other methods of treatment, and also at P. of almost all localizations as a transport immobilization. The plaster bandage at P. is usually applied mentally sick and at crazy conditions of victims.

Duration of an immobilization depends on localization and P.'s type, and also on age of the patient. At P. of bones of a forearm in the typical place the plaster bandage the adult is applied 4 — 5 weeks, at diaphyseal P. of bones of a forearm — for 2 — 3 months and more, at P. of anklebones — 6 — 12 weeks, at P. of bones of a shin — for 2 — 4 months. At the driven P. of a surgical neck of a humeral bone duration of treatment by imposing of a plaster splint — 7 — 12 days, and then apply a functional method.

The positive side of a plaster bandage consists that it is well modelled, densely and evenly adjoins to a body, quickly hardens, easily is removed and can be applied in any conditions and at the majority closed and opened P. Pokoy reached by its use promotes reduction of pain, normalization of a wound process at the opened and infected Items. The plaster bandage has good hygroscopicity. In it the purulent discharge at the infected P. is well soaked up that gives the chance to exclude frequent bandagings. At the infected P. with plentiful purulent separated bridge-like and fenestrated plaster bandages give the chance to tie up wounds, without breaking immobilization about t of l omko century.

It is necessary to consider that after single-step reposition of fragments and imposing of a plaster bandage in connection with reduction of muscles and reduction of hypostasis perhaps repeated shift of fragments of a bone. Therefore in 7 — 8 days after imposing of a plaster bandage it is necessary to make the control roentgenogram. Besides, the bandage limits use funkts, treatments in full. The long plaster immobilization leads in most cases to a temporary restriction of movements in the immobilized joints, is more rare to resistant contractures.

The outside chreskostny compression osteosynthesis by Gudushauri's devices, Volkova — Oganesyan, Ilizarov, Kalnberz, Sivash, etc. is applied to P.'s treatment (see. Distraktsionno-kompressionnye devices ). By means of these devices it is possible to reponirovat fragments, to create dense contact between them and to provide their steady immovability. The osteosynthesis is carried out without immersion of the fixer in a zone P. In the course of treatment of the patient has an opportunity to go. Positive sides of this method are especially shown at treatment of patients with opened and infected with P., at multiple P., at the slowed-down P.'s union and at nearthroses.

The most frequent complications at P.'s treatment by means of distraktsionno-compression devices are pains, the inflammatory phenomena, suppuration, and sometimes and osteomyelitis in venues of spokes. Constant observation and care of the field of carrying out spokes are of great importance for prevention of these complications.

Urgent operative measure at P. is shown in the presence of symptoms of damage of vessels and disturbance of blood circulation of an extremity, at the sharp pains caused by a possible prelum fragments of nervous trunks; in cases when the closed reposition of fragments is accompanied by risk to damage a neurovascular bunch; when at the closed reposition there can be a break of skin or its necrosis, i.e. there is a danger of transformation of the closed P. into open. Operational treatment is shown at interposition between fragments of soft tissues, sometimes bone fragment that is observed at P. of a diaphysis of long tubular bones, at detachable P.' most with discrepancy of fragments — P. of a stifle joint, an elbow shoot, etc. All adduktsionny P. of a neck of a femur if the condition of the patient allows, it is necessary to treat quickly. Operation is shown at treatment of the not set or difficult set P. and also easy set, but trudnouderzhivaye-my (unstable) Items. In the absence of contraindications from the general state or local conditions such P. treat in the operational way without any preliminary attempt to apply the standard closed practices of reposition of fragments.

It is necessary to operate at P. in the next few days after an injury when it becomes clear that reposition of fragments in the single-step way or extension was not crowned with success and P.'s union can provide in the vicious provision to funkts, to disturbances. Equally it belongs to those cases when after reposition in a plaster bandage there was difficult removable repeated shift of fragments.

Operational treatment is contraindicated at a serious general condition of the patient, cardiovascular insufficiency and other heavy somatopathies. Any purulent process serves as a contraindication to operational treatment in an organism.

At children, considering their psychological features, at diaphyseal and metafizarny P. preference should be given to conservative methods of treatment and to eliminate first of all angular, rotational shifts and big shifts on length.

Indications to open reposition arise, as a rule, at intra joint P. Odnako unlike adults for P.'s treatment, at to-rykh use various metalwork, at children apply to intra joint P.' fixing generally Kirchner's spokes which are almost not injuring regions of growth. Items at children proceed favorably and grow together in shorter terms, but unreasonable extension of indications to open reposition of diaphyseal P. or, on the contrary, untimely fixing of intra joint P. quite often lead to their failure of union and development of a nearthrosis.

P.'s treatment at people of advanced and senile age quite often should be carried out against the background of age changes and diseases of the vital systems and bodies, osteoporosis, degenerative changes in joints and a backbone, an atrophy of muscles, disturbance of blood supply of the injured extremity. All this dictates need of special approach.

Fig. 12. Roentgenograms of a hip joint with a medial fracture of a neck of a hip: 1 — before operation (shift of fragments is visible), 2 — a straight line and 3 — side roentgenograms after an osteosynthesis a three-blade nail.
Fig. 13. Direct roentgenograms of a hip joint at a fracture of a neck of a hip: 1 — before operation; 2 — after endoprosthesis replacement of a head and a neck of a hip.

At the choice of a method of treatment of P. (especially operational) it is important to find out adaptation and compensatory opportunities and reserve forces of an organism. It is preferable to the elderly weakened patient to apply simple, easily transferable and rather safe methods of treatment. It is necessary to avoid methods of treatment, forcing it is long to lie in a bed and complicating movement. At this contingent of patients degree of operational risk considerably increases. Therefore an operative measure concerning P. at elderly people needs to be applied when conservative methods are not effective and also when the operational way can be easier transferred by the patient, than conservative. Operational treatment most often apply necks of a femur at adduk-tsionny (varus) medial P. In these cases the osteosynthesis by a three-blade nail or other fixer, and also Endoprosthesis replacement (fig. 12 and 13) is shown. At the corresponding indications trochanterian and diaphyseal P. hips also treat quickly.

Takes the important place in complex treatment of P. to lay down. physical culture. Its purpose is improvement of a course of reparative processes, recovery of musculoskeletal function, the prevention of disturbances of the general condition of the patient and development of trophic changes in the muscular and copular device, joints, bones. Contraindications to purpose of physical exercises with to lay down. the purpose — the general serious condition of the patient, danger of bleeding, disturbance of anatomic relationship of fragments, sharp pain reaction at LFK. Apply the following means of LFK: to lay down. gymnastics, physical exercises in water, a training of skill of walking and household skills, mechanotherapy, work therapy, massage (see. Physiotherapy exercises). The general principles of LFK at P.: 1) purpose of physical exercises in early terms after P. and is adequate to the course of processes of a reparation of a bone tissue; 2) performance of physical exercises against the background of relaxation of muscles and without pain reaction; 3) use of preferential active physical exercises; 4) a complex combination of various means to lay down. physical cultures; 5) the correct dosage of an exercise stress according to the general funkts, a state and a condition of the struck departments of a musculoskeletal system.

The technique of use of LFK is defined by P.'s localization, way and the period of its treatment, age of the patient. In the acute period use the fortifying and breathing exercises, the movements in peripheral departments of extremities directed to improvement of blood circulation, and also rhythmical muscular tension. In the period of consolidation of fragments apply the facilitated exercises which are strictly dosed active to lay down. gymnastics and physical exercises in warm water, and in the period of the residual phenomena — the exercises strengthening muscles of extremities and directed to stretching of periartikulyarny fabrics, a training in walking, mechanotherapy.

At diaphyseal P. in the period of an immobilization use in addition to fortifying exercises the isometric rhythmical muscular tension, the movements of joints, free from an immobilization, and after the termination of an immobilization — the careful active movements in joints of a zone of damage. At intra joint P. physical exercises use in earlier terms; they have active character, are carried out at relaxation of muscles repeatedly for day.

At an immobilization a plaster bandage apply fortifying and breathing exercises, rhythmic muscle tensions of the affected extremity, the movements in joints, free from an immobilization, and joints of not affected extremity.

During the use of skeletal traction in addition to the listed exercises appoint the careful active movements in the joints located near the place of defeat (e.g., the movements in knee and talocrural joints at P. of a femur), and also the massage of muscles of the affected extremity stimulating process of formation of a bone callosity. Use distraktsionno - compression go and quite often nailing also allows to carry out in early terms the movements in the joints located near the place of damage and earlier to start load of the affected lower extremity.

The technique of LFK at changes differs in certain features backbone (see) and basin (see).

LFK at patients of advanced and senile age is directed to improvement of function of respiratory and cardiovascular systems (the prevention of the hypostatic phenomena), earlier raising of patients. The exercise stress shall be strictly dosed. At children, depending on age, use game or imitating forms to lay down. ishnas-tics, exercises are repeated repeatedly for day (occupations shall be short).

In addition to LFK at P. widely use physiotherapeutic methods of treatment. Them appoint already with 2 — the 3rd day after reposition of fragments and an immobilization of an extremity at the closed P. for the purpose of anesthesia of the place of P., strengthening of blood circulation, elimination of hypostasis and a vasospasm and muscles of a sore extremity. For this purpose apply electric field of UVCh (cross on area P. in a slaboteplovy dose within 10 — 15 min.) daily, on a course 8 — 10 procedures; ultrasound on area P. (through a window in a plaster bandage) in the continuous mode, intensity of 0,6 — 1,0 W/cm2 within 10 min. labilno, daily, on a course 10 — 12 procedures; an inductothermy on area P. in a slaboteplovy dose daily, on a course 10 — 12 procedures; an electrophoresis of novocaine on area P., and in the presence of a plaster bandage — above and below it, within 30 min. daily, on a course from 3 to 6 — 8 procedures. At sharply expressed pain syndrome and an acrimony appoint an electrophoresis of bromine to a collar zone 15 min., to a course 12 — 15 procedures.

At P. of a diaphysis of femoral or humeral bones, bones of a shin or a forearm apply UF-radiations of area P., and at impossibility of radiation of this zone — segmented zones or a symmetric zone of a healthy extremity; begin with 2 — 3 biodoses, at reirradiations increase a dose by 1 biodose, each field is irradiated by 3 — 4 times.

After a cast removal for treatment of a muscular atrophy, in addition to massage and to lay down. physical cultures, appoint electrostimulation of muscles daily, to a course 15 — 25 procedures; the general coniferous and salty bathtubs of t ° 36 — 37 ° 12 — 15 min. every other day, on a course 12 — 15 procedures; chloride sodium and radonic bathtubs; ultrasound on area of the weakened muscles in pulsed operation (10 ms), intensity of 0,4 — 0,6 W/cm2, 10 — 15 min. daily or every other day, on a course 10 — 15 procedures.

At contractures it is preferable ultrafonoforez a hydrocortisone in the continuous mode on area of the affected joint by the above described technique.

At the slowed-down formation of a bone callosity apply on area P. ultrasound in the continuous mode, a mobile technique, intensity of 0,4 — 0,6 W/cm 2 , 5 — 8 min. every other day, on a course 8 — 10 procedures; paraffin applications of t ° 46 — 48 ° 30 — 40 min. daily, only 10 — 12 procedures; an electrophoresis of calcium by the above described technique, on a course 15 — 20 procedures; general bathtubs (coniferous and salty, radonic, chloride sodium). Electroprocedures and bathtubs appoint in one day with the general UF-radiations.

After a submersible osteosynthesis according to indications apply variation magnetic field of low frequency 10 — 20 min. daily, on a course 15 — 20 procedures; an inductothermy 15 — 20 min. daily or every other day, on a course 8 — 10 procedures; electric field of UVCh, longwise, 10 — 15 min. daily or every other day, on a course of 10 procedures; in the absence of gypsum apply mud applications on all blemished surface of t ° 40 — 42 ° 15 — 20 min. every other day, only 12 — 15 procedures.

After a cast removal the main task of physical therapy — improvement of a trophicity of fabrics, fight against hypostasis, a muscular atrophy, development of mobility of joints of a sore extremity, treatment of contractures. For this purpose at hypostasis of an extremity appoint local light bathtubs, radiation by a lamp sollyuks 30 — 40 min. daily, to a course 8 — 10 procedures; electric field of UVCh, is longitudinal on an extremity in a slaboteplovy dosage 10 — 15 min. daily, on a course 3 — 6 procedures; local salt baths with water temperature 38 — 39 °, 15 — 20 min. daily. During the development of movements in joints use fresh local bathtubs of t ° 38 °, 15 — 20 min. daily or 2 times a day, on a course 15 — 20 procedures; paraffin, ozokeritovy applications of t ° 48 — 50 ° 30 — 40 min. daily or every other day, only 10 — 12 procedures; mud applications of t ° 38 — 39 °, 15 min. every other day, on a course 12 — 15 procedures; ultrasound in the continuous mode, intensity of 0,4 — 0,6 W/cm2, a mobile technique 8 — 10 min. daily, on a course 6 — 10 procedures. At severe pains in the joints limiting the movements apply diadinamoforez novocaine on area of a joint duple continuous current 10 min. daily, on a course 4 — 8 procedures; the harmonic modulated currents on area of a joint in the first mode 3 — 5 min. (depth of modulations of 50 — 75%, the frequency of 80 — 100 Hz on 2 — 4 sec. in series) daily, on a course 4 — 8 procedures; variation magnetic field of low frequency on area of a joint, in the continuous sinusoidal mode, 10 — 20 min. daily, on a course prior to 20 procedures.

At an excess bone callosity appoint an electrophoresis of iodine (2% solution of potassium iodide) to the center of defeat, cross, 15 min. daily, to a course 15 — 20 procedures; paraffin, ozokeritovy or mud applications (temperature of dirt 44 — 48 °) 20 — 30 min. daily, on a course 15 — 20 procedures; ultrafonoforez by the above described technique, on a course 12 — 15 procedures.

At open P. a problem of physical therapy to prevent development of an infection in a wound and to promote healing by its first intention. For this purpose after primary surgical treatment of a wound appoint UF-radiations of a wound and a surrounding skin surface (10 — 12 cm from edges of a wound) since 3 — 4 and to 6 — 8 biodoses, every other day, to a course 4 — 5 radiations; from the 2nd day after an injury — electric field of UVCh on area P. and wounds in an oligotermi-chesky dosage, 8 — 10 min. daily, on a course 8 — 10 procedures. After a wound repair further treatment is carried out as at the closed

P. V children's age at P. the same methods of physical therapy, as at adults are applied, but in smaller doses: appoint electric field of UVCh (duration of the procedure of 10 min.), ultrasound in a dose to 0,6 W/cm 2 5 — 6 min., UF-radiation of area P., since 2 biodoses.

Pathological changes

Patol. Items (spontaneous) arise spontaneously under the influence of an insignificant injury (or even without any injury) the bone changed any preceding patol. process, most often destructive. They are at high-quality and malignant new growths of a bone (see), at osteodystrophies (see), fibrous osteodysplasia (see), at metastasises in a bone (e.g., carcinomas of a mammary gland, a hypernephroma, lung cancer, cancer of a thyroid gland). Quite often patol. Items at metastasises have multiple character, especially at damages of bodies of vertebrae. Fragility of bones is observed at a multiple myeloma. Patol. Items at adults arise at Pedzhet's disease (see. Pedzheta disease ) and a parathyroid osteodystrophy (see), at arthropathies (see) because of tabes (see. Back tabes) and myelosyringoses (see), repeated P. at imperfect bone formation (see. Bone formation imperfect ). Less often they are observed at inflammatory diseases of bones — osteomyelitis, tuberculosis and tertiary syphilis.

Frequency and localization patol. The item is defined by character of a basic disease. Considerably more often than in other bones, patol. Items arise in a backbone, on a femur, then on the decreasing frequency — on a tibial bone, a humeral bone, edges etc. Carefully collected anamnesis allows to suspect patol. The item arising at an insignificant injury at the movement of an extremity at small loading, etc. Such P. can be the first sign of existence of primary malignant tumor in any body. Quite often from the anamnesis it is possible to find out that in the past to P. patients were operated or treated apropos onkol, diseases. At primary tumors of bones patients to P. quite often feel pains in this zone, without attaching them significance. Shift of fragments at patol. The item is observed seldom or it happens small.

patol, process the research of a zone patol gives valuable information on the nature rentgenol. Item and other departments of bone and joint system. Lab., wedge., biochemical, isotope and other methods of a research allow to specify the diagnosis. In doubtful cases the diagnosis is specified on the basis gistol, by researches patholologically of the changed fabric received at a biopsy. The choice of a method of treatment depends on a basic disease, character patol, process in a bone in the area P., its loka-lizatspa, prevalence, operability, and also the forecast. Quite often at treatment patol. The item comes a bone union. Even at a metastatic malignant tumor the union in some cases is not excluded. Partial reparative regeneration can go only from residual, not struck with tumoral process, bones and periosteums. Again formed bone callosity usually is located around tumoral weight and extremely seldom burgeons on small depth in a cancer tumor. Such union patol. The item is temporary and unreliable since the growing primary or metastatic malignant tumor destroys the formed callosity. At benign tumors fragments can grow together with rather strong callosity giving the chance in limited degree to use an extremity.

The forecast at patol. The item depends on basic process.

At patol. The item as a result of metastasises and primary malignant tumors if there are no indications to operation, the extremity shall be immobilized in the usual way.

At patol. Items of long tubular bones of the lower extremity quite often apply nailing a long metal nail. At the same time do not pursue the aim of elimination of metastasises or creation of conditions for an union patol. P. Thus for some period fix fragments and create «an internal prosthesis» of a bone. The patient has an opportunity during nek-ry time to move by means of crutches, and it creates illusion of improvement. At primary malignant tumors and in some cases at a solitary metastasis after removal of primary tumor apropos patol. Items make amputation (see) or exarticulation (see) extremities. At patol. Items because of the nek-ry slowly developing malignant tumors, and also at benign tumors apply the savings operations directed to preservation of an extremity. Make a partial or full resection of the center of defeat without bone plastics or with a bone alloplasty, an osteosynthesis various designs, Endoprosthesis replacement (see).

Treatment patol. To the item on the soil hron, inflammatory processes it has to be directed to elimination of process in bones and creation of conditions for a bone union of P. (a plaster immobilization, an outside distraktsionno-compression osteosynthesis, etc.).

Changes of wartime

Changes in field conditions. In wartime fire P. of bones meet more often, to-rye classify by localization of wound, a type of a hurting shell (bullet, fragmental, etc.), to the nature of wound (through, blind, tangent), to P.'s type (perforated, regional, driven, large and splintered, melkooskolchaty, cross, slanting, longitudinal), and also by the accompanying damages of soft tissues, large vessels, nerves, joints. The wounds of extremities which are followed by changes on frequency prevail over wounds of other localizations. By data A. N. Maksimenkova, fire fractures of upper extremities are observed in 57%, lower — in 43% (tab. 2). The isolated, splintered and mnogooskol-chaty P. prevailed over regional and perforated.

Wounds of extremities modern types of firearms are characterized by plurality of damages, dot inlet and wide outlet openings, complex structure of the wound channel, considerable zones of primary and secondary necrosis, frequent damages of large vessels and nerves. Regional and perforated P. of bones meet seldom. Generally there are splintered P. which are followed by considerable destruction of a bone on an extent. During the Great Patriotic War most often fire P. of a femur (7,7%) were complicated by shock, is more rare than bones of a shin (5,3%) and a humeral bone (2,5%). Wounds of large arteries occurred at 10% of the bones which were injured with P. Injury of nerves is noted at fire P. of a humeral bone (35,6%), bones of a forearm (30,5%), bones of a shin (22,2%) and a femur (10,6%). The mephitic gangrene at fire P. is established to a femur at 12,3% of wounded, bones of a shin — at 10,0%, a humeral bone — at 5,0% and bones of a forearm — at 2,1%. Purulent complications are registered at 61,6% of wounded at P. of a femur, at 56,7% — at P. of bones of a shin, at 47,2% — at P. of a humeral bone.

Fig. 14. The diagrammatic representation of a bullet wound of a hip with a splintered fracture of a bone: 1 — the center of hemorrhage, 2 — the center of crush, 3 — bone splinters, 4 — a zone of a commotio of the distal end of a femur, 5 — a periosteum, 6 — the wound channel, 7 — a zone of a commotio of the proximal end of a femur.

Action of a fire shell on living tissues develops of force of the direct stroke influencing fabrics of the site where the bullet or a splinter directly adjoin to them, and forces of the side blow arising outside the wound channel in the fabrics located at various distance from the place of passing of a hurting shell (fig. 14). At multisplintered P. bone splinters play a role of secondary shells and cause considerable destructions of soft tissues. Existence of a large amount of necrotic fabrics on the course of the wound channel and in a surrounding zone creates a favorable environment for development of purulent complications.

First aid. In the battlefield (in the center of defeat) struck with fire P. of bones carry out a temporary stop of bleeding a compressing bandage or a styptic plait (see Bleeding), apply an aseptic bandage. The immobilization of an extremity is carried out by means of make-shifts, and in the absence of the last — by a pribintovyvaniye of the injured lower extremity to a healthy, and upper extremity — to a trunk (see the Immobilization). Enter analgetics.

The pre-medical help is carried out by the paramedic of the IFV, to-ry carries out control and correction of bandages, tires and styptic plaits. Only at considerable arterial bleeding the plait is imposed, in other cases for the purpose of a stop of bleeding the compressing bandage is applied. According to indications anesthetics, cardiovascular means and antibiotics of a broad spectrum of activity are entered. At struck, having an immobilization make-shifts, it is replaced with organic standard tires (see. Sheena, splintage ).

First medical assistance. During the carrying out medical sorting on regimental medical aid station (see) allocate: 1) the extremities affected with damages needing the first medical assistance according to urgent indications in a dressing room (struck with the imposed plait not stopped by bleeding in state of shock); 2) needing assistance in a reception and classifying section as preparation for evacuation in MSB; 3) struck, the Crimea the help can be postponed until MSB. In a dressing room control correctness of indications to an applying a tourniquet, a temporary stop of bleeding reach imposing of a compressing bandage, and sometimes a clip on the bleeding vessel in a wound; carry out antishock actions; anesthetize area P., enter analgetics; improve a transport immobilization; carry out transfusion therapy by antishock and blood-substituting solutions. Enter antibiotics, antitetanic serum and tetanic anatoksinony In a reception and classifying section control and if necessary correct or replace bandages, tires, and also enter antibiotics, antitetanic serum and tetanic anatoksinony

the Qualified medical care. At the stages which are carrying out the qualified medical aid during medical sorting allocate the following groups of struck: 1) needing the qualified surgical help first of all (according to urgent indications), including being in state of shock; 2) needing the qualified surgical help in the second turn; 3) struck, the Crimea the qualified medical care can be postponed until hospital base.

Depending on a fighting and medical situation in MSB it is possible to carry out the full or reduced volume of the help. Regardless of a situation everything struck with fire P. according to indications apply antibiotics, anesthetics, improve a transport immobilization.

At the reduced volume of the qualified medical care carry out a final stop of bleeding by bandaging of a vessel in a wound. At frailty of an extremity and explicit threat of emergence of complications perform its amputation within healthy fabrics (see Amputation). Carry out complex treatment of shock. At massive blood loss, except administration of antishock and blood-substituting solutions, transfuse blood. If the current of a wound process is complicated by a mephitic gangrene, carry urgently out surgical treatment of a wound (see) with its wide section. Leave to Rahn open and irrigate with solutions of antibacterial drugs. Appoint intramusculary high doses of antibiotics of a broad spectrum of activity; kapelno intravenously — mix of antigangrenous anti-toxic serums (to lay down. a dose of 150 000 ME) and isotonic liquid not less than 2 — 4 l a day. At quickly extending form of a mephitic gangrene with deep distribution of the infectious center resort to amputation.

At the full volume of the qualified help in MSB carry out surgical treatment of damages and at struck, needing the help in the second turn. Carry to them the bones affected with P. and extensive destructions of soft tissues, and also with pollution of wounds products of nuclear explosion and resistant toxic agents. During surgical treatment of wounds of intervention on bones do not carry out, are limited to removal of the bone splinters which are freely lying in a wound.

Specialized medical care by the victim with P. is performed in medical institutions of hospital base. Struck with P. of ossicles of a brush, foot which are followed by insignificant damage of soft tissues send from MSB for treatment to hospital for lightly wounded, other struck with P. — to the relevant hospital of hospital base. Hospitals carry out rentgenol, the inspection of victims and the surgical treatment of wounds at the persons needing it opened or closed reposition (see) and fixing of fragments to lay down. an immobilization, vessels sew (see. Vascular seam ) and nerves (see. Nervous seam ); perform surgeries concerning complications (suppurative processes, a necrosis of an extremity and integuments, a contracture, etc.). At the final stages of evacuation the full complex of medical actions, including rehabilitation is carried out.

Rendering the first medical aid at P. in the conditions of MSGO is made by forces of staff sandruzhin, and also as most and mutual assistance. It develops of a temporary stop of outside bleeding, imposing of an aseptic bandage at open P., administrations of anesthetics, implementation of a transport immobilization by means of the standard or improvised tires. Special attention is paid on administration of anesthetics and an effective transport immobilization as the most efficient prophylactics of traumatic shock.

Victims with P. from the center of defeat are sent to group of first aid (see) — OPM. First of all evacuate victims with the imposed styptic plaits and in a serious condition.

In OPM carry out correction of bandages and a transport immobilization, anesthetics and cardiovascular means are entered. Preventively antibiotics, antitetanic serum are applied, tetanic the anatoksinony Person in need carry out cleansing and deactivation. Struck in state of shock go to antishock department for implementation of complex therapy. On OPM it is carried out final or, at an adversity, a temporary stop of bleeding by imposing of a styptic clip on the bleeding vessel, amputation of an impractical extremity and other urgent actions, to-rye are in total directed to rescue of life and creation of the conditions for the subsequent evacuation struck with P. in hospital base (see). At the same time in BB institutions first of all evacuations victims are subject, at to-rykh the temporary stop of bleeding, after removal from shock, and also with signs of the developing mephitic gangrene is made.

The specialized help in B B at P. is carried out in pro-thinned out-tsakh. At receipt carry out medical sorting of victims for the purpose of identification of persons in need in complex therapy of traumatic shock, syndrome of long crush, and also in primary surgical treatment. The special group is made by victims, at to-rykh P. were complicated by a mephitic gangrene. They are immediately isolated and placed for treatment in anaerobic department.

In the pro-thinned-out hospital use of various methods of treatment of P. is possible, however preference shall be given to the least labor-consuming, easy ways. Treatment is most widely performed by a plaster bandage and skeletal traction. Treatment a lump - pressionno-distraktsionnymi is shown by devices at splintered opened (including fire) and the long tubular bones closed by P., preferential bones of a shin and a shoulder, multiple P., and also the changes which are combined with burns.

Victims with P. are in BV which are pro-thinned out-tsakh on treatment up to recovery in this connection use of various methods of rehabilitation is provided.

Changes in the medicolegal relation

In court. - the medical relation the fact of presence of P. testifies not only to the former injury, but also to significant force, about a cut damage was caused. On P.'s features it is possible to judge a type of the hurting tool (subject), its form, the direction and force of blow, and also other details of the mechanism of an injury.

Fig. 15. Depressed fracture of a calvaria.
Fig. 16. Splintered change of the arch and base of skull.

In court. - medical practice the big place is occupied by researches P. of bones of a skull, to-rye divide on direct and indirect. Direct P. of a calvaria arise in a place of application of force. The pressed, perforated, splintered P. (fig. 15 and 16) concern to them. The pressed and perforated P. sometimes repeat a surface and a form of the striking subject that is used for identification of the tool. At blows (e.g., the hammer) not perpendicularly, and at an acute angle uneven distribution of the operating force to the field of damage happens tools to sides. In places of bigger action of force breakdown, in places with smaller pressure — only cracking is formed that gives to P. a type of the ladder consisting of 2 — 3 steps. Such P. are called terrasovidny.

The pressed P. often are followed by fracturing. On an arrangement of cracks it is possible to judge the direction of blow to a certain extent. If the blow is struck perpendicularly, then cracks evenly disperse from the place of impression on radiuses and if at an angle in some direction, then in this direction the majority of the formed cracks departs. Similar pattern is observed also at P.'s emergence on a base of skull. Cross P. bases of skull are more often noted at side-winders, especially if the head was on some firm support. Longitudinal P. of a base of skull are observed at strong blows in front or behind. If the big firm subject uses the force with big, then splintered P. of the arch and a base of skull are formed. Indirect P. the skulls which are formed not in the place of blow arise or at a prelum of the head between two blunt firm objects, or as a result of an injury a firm blunt object with the big striking surface.

Fig. 17. Macrodrug of a femur about «bumper change».

In court. - the medical relation also so-called bumper changes of bones of a shin and femur, direct and indirect P. of edges, P. of pelvic bones matter. The bumper change comes from blow by a bumper of the car moving with high speed. At the same time the wedge-shaped splinter of a bone is formed, the basis to-rogo corresponds to the party of arrival (fig. 17).

Direct P. of edges are formed in the place of blow. At the same time on an internal bone plate of an edge the flat line P. with a gaping is noted, on outside — P.'s edges are split, the gaping is absent. Indirect P. of edges arise not in a place of application of force, and in a point of their greatest bending. At such P. on an outside bone plate the line P. direct with a gaping, on internal — P.'s edges are split, indistinct, without gaping.

Extensive P. of a basin with damage to front and back departments are characteristic of blow or a prelum of big force. At blow by parts of the car moving with a small speed P. of pelvic bones are limited more often to the isolated injury of separate bones (an upper branch of a pubic bone, a wing of an ileal bone).

Changes of separate parts of a skeleton — see the relevant articles (e.g., Hip , Shin , Thorax , Shoulder , Backbone , Taz etc.).


Tables

Table 1. CLASSIFICATION OPEN (NEOGNESTRELNYH) of DIAPHYSEAL, CIRCUMARTICULAR (METAFIZARNYH) And VNUTRISUSTAVNYH (EPIPHYSEAL) FRACTURES of LONG TUBULAR BONES (A. V. Kaplan and O. N. Markova)


&Table 2nbsp; FREQUENCY of FIRE FRACTURES of EXTREMITIES DEPENDING ON LOCALIZATION (as a percentage) (according to A. N. Maksimenkov)




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And. B. Kaplan; H. A. Vladimirova (physio-rubbed.), A. P. Gromov (court.), G. A. Zedgenidze (rents.), A. F. Kaptelin (to lay down. physical.), G. I. Lavrishcheva (pat.an.), G. M. Ter-Egiazarov (it is put. hir.), S. S. Tkachenko, A. B. Rusakov (soldier.).

Яндекс.Метрика