From Big Medical Encyclopedia

EXTENSION (extensio) — one of the main orthopedic methods of treatment of damages and diseases of a musculoskeletal system and their effects — deformations, contractures, cicatricial styazheniye.

V.'s essence is that by means of short-term or long draft muscular retraction is overcome, the shift of fragments at a change is eliminated or the gradual stretching effect is had on this or that area of a human body for the purpose of elimination of a contracture, deformation. By means of constant V. lengthening of an extremity and deduction of this or that segment in the necessary situation is reached.

Fig. 1. Extension by means of two stakes (according to Hippocrates).
Fig. 2. Doug Kirchner: 1 — an arch; 2 — the spitsenatyagivatel (straining a key); 3 — a spoke; 4 — the fixing key. Fig. 3. The spoke is carried out through an elbow shoot and fixed by Kirchner's arch.
Fig. 4. Brackets (terminal) for skeletal traction: 1 and 2 — Shmerts's brackets; 3 — 6 — brackets of a design of the Kharkiv scientific research institute of prosthetics, orthopedics and traumatology of the prof. M. I. Sitenko; 7 and 8 — brackets Sverdlovsk in-that traumatology and orthopedics; 9 — a bracket of the Cake layer — Altukhova.

Treatment of changes, dislocations in way was known to V. (fig. 1) in an extreme antiquity. Hippocrates (4 century to and. aa.) describes devices for treatment of changes by violent stretching. Later we find similar designs at K. Galen (2 century), Ibn-Sina (Avicenna, 11 century), Gui de Choliaca (Guy de Chauliac, 14 century) etc. However all these devices and devices based on operation of levers, collars, belts were calculated on single-step Century.

Practical application a method B. as is long and gradually operating force found only in 19 century.

In 1839 in America James suggested to use a rubber adhesive plaster for constant V. The German scientist B. Bardengeyer (1889) formulated original positions of this method. He offered the side setting drafts, the modern, not irritating skin adhesive plaster, a number of designs of the special equipment.

Big contribution to improvement of a method, to it fiziol. and the biomechanical direction was brought by G. Zuppinger who proved value srednefiziologichesky, halfbent, provisions of an extremity, at Krom there is a uniform relaxation of all groups of muscles and V. is reached by smaller loads.

In 1907 Mr. F. Steinmann applied at treatment of fractures of hip intra bone V. by means of offered them nailing. The nail was carried out cross over condyles of a hip. This offer served as the beginning of use of the brand new principle of transfer of draft directly on a bone — constant skeletal V.; the method quickly won the leading place among all kinds of constant

V. V of Russia treatment of changes by skeletal V. for the first time was applied, and then improved in Kharkiv, in medico-mechanical in-those (nowadays by scientific research institute of prosthetics, orthopedics and traumatology of the prof. M. I. Sitenko). Here in 1910 K. F. Vegner applied F. Steinmann's nail at a fracture of a hip.

Over time the technique and constant V.'s equipment were improved and were implemented into practice more and more. Instead of rough nailing F. Steinmann, 3 — 4 mm thick, in the twenties our century Kirchner's (fig. 2 and 3) arch, a wire across Gelinsky, across Klapp were offered, a number of brackets (or terminals) — Shmerts, Pavlovich, Marx — Pavlovich, Voeller, the Cake layer — Altukhova, etc. appeared (fig. 4).

Fig. 5. Standard position of an extremity on Bogdanov's tire at a fracture of a hip.
Fig. 6. Skeletal traction at a fracture of a hip in the lower third on Beler's tire: 1 — peripheral fragment is displaced kzad; 2 — the rigid pillow enclosed under the lower third of a hip promotes elimination of shift of fragment.

At V. began to use various tires and devices to creation of the necessary position of an extremity — Brown, Beler, Ozerov, Sitenko, Chaklin, Bogdanov, etc. (fig. 5 and 6), abroad widely use the tires suspended to overbed frames (Thomas's tire and her modifications). For the same purpose in a number of clinics use rigid figured orthopedic pillows. On width on the periphery apply the setting, fixing and rotiruyushchy loops to elimination of shift of fragments.

Depending on indications and the purpose of use of V. distinguish two of its look — short-term (single-step) and long (constant). Quickly V. is carried out by hands of the surgeon or special devices for Sokolovsky, Edelstein, Chizhin's reposition, etc. Usually single-step V. is applied when only reposition of fragments is necessary at changes (see) or the joint ends of bones at dislocations (see). Short-term V. in transport is of great importance immobilization (see) as the stage treatment at fractures of a hip providing deduction of fragments in the fixed situation.

Long (constant) V. is carried out by means of special materials, tools, the equipment and loads. Constant V.'s purpose is reposition of fragments (reposition), their deduction (retention) in the reached situation before consolidation and early recovery of function.

Fig. 7. Glue extension across Sheda at a fracture of the right hip. Fixing of a counterlateral extremity and a pelvic girdle promotes forced saving the necessary provision of the child.

Apply two methods of constant V. — glue and skeletal. Glue V. does not allow to develop the sufficient force of traction and as the independent method of treatment is applied generally at children. At children up to 3 years glue V. in vertical position (across Sheda) is shown at a fracture of a hip (fig. 7). Glue V. is applied also when it is necessary to create rest of an extremity after a bruise, nek-ry operative measures.

Gained distribution in 60 — the 70th years of the 20th century distraktsionny devices of Sivash, Gudushauri, Ilizarova, etc. in fact are devices for constant V., or stretching (distractio) since force of draft is applied to distal and proximal bone fragments or segments (see. Distraktsionno-kompressionnye devices ).

Technique and technology of use of skeletal traction. For creation forces of draft at constant V. are used by loads, to-rye suspend by means of various frames and blocks, screw mechanisms, turning, springs.

It is significantly important to carry out constant V. in so-called srednefiziologichesky position of an extremity, at Krom there is a uniform relaxation of all groups of muscles, including and antagonists (Tsuppinger's principle). In srednefiziol. position B. of an extremity demands considerably smaller loads, does not cause convulsive reductions of separate hyperinflate groups of muscles.

By whatever way skeletal draft was carried out, it does not provide all conditions of Century. Skeletal draft is only a fundamental unit in the general complex of actions, to-rye are summed up in wider concept «system of constant skeletal Century». Here enters: the correct laying of the patient and the injured extremity, the exact direction of drafts, size of a load, countertraction, a combination of skeletal draft to glue draft on other segments, use of the additional setting, rotiruyushchy and fixing loops and some other details. Only use of all system of constant V. can provide detection of high qualities, this functional and highly effective method of treatment of traumatologic and orthopedic patients. The combination of sufficient force of draft to its gradualness, dosage and continuity makes the philosophy of a method. Constant V. is carried out on a rigid metal bed. Through system of blocks loads from a spoke or a bracket, and also from loops by means of overbed frames and bars remove out of limits of the bed (fig. 6). Countertraction is carried out lifting of the foot end of a bed, brassieres, loops and so forth. In the beginning loads on the main skeletal draft it is dosed, but quickly increase before full elimination of shift of fragments on length or before reposition of dislocation that is determined by a research of the patient (measurement, a palpation, rentgenol, control). The load less maximum approximately on 1/3 is sufficient for deduction of fragments. The size of a load is individual and depends on degree of shift of fragments, age of the patient, prescription of a change and its localization.

At dislocation-fractures and dislocations in cervical department of a backbone skeletal draft for a skull (parietal hillocks or zygomas) is carried out by means of special brackets. Extension for the head can be carried out by Gleason's loop also.

Fig. 8. Typical places of use of skeletal traction on the lower extremity (the bracket is imposed on a big spit, through other bones spokes are carried out).

Imposing of any skeletal drafts needs to be considered as the pure surgery demanding strict observance of all rules of an asepsis. Venues of a spoke or introduction by a branch of a bracket anesthetize to a periosteum 1% solution of novocaine. During the carrying out a spoke it is necessary to pay attention to that it was located perpendicularly to a longitudinal axis of a segment and passed through the center of a bone. After introduction the spoke is pulled in a special arch with the screw mechanism and strongly fixed in a condition of a tension. The load is connected to a bracket or an arch. Skeletal V. can almost be carried out at any level of all segments of an extremity, for a wing of a basin, but both spokes, and brackets for avoidance of damage of large vessels and nervous trunks impose preferential in typical safe places: over condyles of a hip, through tuberosity of a tibial bone, for a big spit, an elbow shoot over epicondyles of a humeral bone, for a metaphysis of a tibial bone, for anklebones and a calcaneus (fig. 8).

From 60th 20 century widely apply a dempferirovaniye to creation of constancy of force of V. The spring inserted between a bracket and the block dempferirut (extinguishes) fluctuations of force of V. and by that provides rest in a zone of a change and prevents reflex reductions of muscles.

As a contraindication to skeletal V. contamination of integuments can serve in typical places of imposing of a spoke, bracket — then they should be imposed distalny — and also frustration of mentality of the patient, moronity, epilepsy. Carefully it is necessary to apply this method at senile age when the long bed rest in situation on spin can lead to development of tromboembolic episodes, hypostatic pneumonia, decubituses etc.

Complications: a change of a spoke (from substandard steel), eruption of a spoke in an osteoporotichny bone, infection of fabrics in the field of introduction of a spoke or a bracket. In all cases extraction of a spoke, bracket and introduction of a new spoke or bracket in other place is necessary.

Underwater extension — the medical method combining physical. influence of water (fresh, mineral) on an organism with receptions of Century. Effect of water at t ° 36 — 37 ° on proprioceptors promotes decrease in a tone of cross-striped muscles owing to what the distance between vertebrae increases and intervertebral foramens extend, through to-rye there pass spinal roots. Besides, decrease in a muscle tone at underwater V., providing elimination of muscular contractures, promotes elimination of a vascular spasm and improvement of blood circulation in the damaged area. Underwater V. is widely used in orthopedic and neurologic practice for the purpose of reduction of a protrusion of a disk at the discogenic pain syndromes, lumbosacral and cervicobrachial radiculitises caused by osteochondrosis of a backbone; at the shift of an intervertebral disk, a rachiocampsis, and also at contractures of coxofemoral, knee and elbow joints and at nek-ry reflex frustration. Underwater V.'s methods are ineffective in the presence of cicatricial and commissural infectious process, a reactive epidurit, sharply expressed deforming spondylosis, the pain syndrome caused by dysplastic changes in a backbone at vascular disorders of a spinal cord (myelipathies), and also after operational removal of hernia of a disk. Underwater V. is rather contraindicated at associated diseases cordial sosudisoty systems, kidneys, a liver, a gall bladder.

Vertical V.'s technique with a load in the pool was for the first time applied by the Hungarian doctor Moll of ohms (To. Moll) in 1953 at diskopathies. In the Soviet Union underwater vertical and horizontal V.'s method is developed in Central in-those traumatology and orthopedics; the essential contribution to development of this problem was made by employees of the 1st MMI, and also row to lay down. institutions of Sochi, Pyatigorsk, Nalchik, Pärnu.

Fig. 9. Underwater vertical extension by means of a headholder.

Vertical underwater extension is carried out by means of various simple devices (a circle from polyfoam, wooden parallel hand-rail) and more difficult designs in the special pool 2 — 3 m long, 1,5 — 2 m wide and 2 — 2,2 m in depth at water temperature 36 — 37 °. At cervical osteochondrosis originally underwater V. is begun with 5 — 7-minute water immersion, usually without load, using a headholder (fig. 9); the subsequent procedures supplement with use of a load 1 — 3 kg on lumbar department within 8 — 15 min. At good tolerance the load is increased further to 8 — 10 kg. In case of pains, dizzinesses lose the weight of a load. At chest and lumbar osteochondrosis plechederzhatel use. After initial adaptation at chest osteochondrosis the load by lumbar department is gradually increased from 2 — 5 to 8 — 15 kg, and duration of the procedure up to 10 — 15 min.; at lumbar osteochondrosis apply a load from 2 — 8 to 15 — 30 kg whereas underwater V.'s duration increases from 10 to 30 min. After the procedure rest in a prone position on a hard bed within 30 — 40 min., then — fixing of a waist is recommended by a special belt or a corset. Total number of such procedures makes 15 — 20 on a course. Except passive V. with a load, apply installations, with the help to-rykh force of draft it is dosed by means of the device. At arthroses of a hip joint, after operational reposition of dislocation of a hip the load is suspended on the cuffs strengthened above an ankle joint.

Fig. 10. Underwater extension on a traction board.

Horizontal underwater extension at localization of process in lumbar department of a backbone is made by longitudinal traction of a backbone or sagging of a trunk in a usual or big bathtub (length of 2 — 2,5 m, width of 0,9 — 1 m and depth of 0,7 m), on a traction board (fig. 10). The patient is fixed by means of a bodice, straps to-rogo are attached to brackets at the head end of a board. On a lumbar part of the patient impose a semi-corset with straps, to the Crimea by means of the metal ropes thrown through system of blocks, behind a board suspend a load. At the first three procedures the load is not applied, and use the weight of the patient for sagging of a trunk. Further use a load within 4 — 5 min., gradually increasing it to 5 kg; at the end of the procedure also gradually reduce the weight of a load. With each subsequent procedure the load is increased by 5 kg so to 4 — the 5th procedure it reaches 20 — 30 kg. Optimum load for women — 35 — 40 kg, for men — 40 — 50 kg, duration of procedures in sweet water of 20 — 40 min., in mineral — 15 — 20 min. At defeats of cervical department of a backbone use Gleason's loop, reduce a load to 4 — 8 kg (up to 12 — 15 kg more rare), and V. carry out duration of the procedure up to 8 — 10 min. in the provision of small bending of the head. Procedures are carried out daily or every other day, by only 10 — 16 procedures.

At slightly expressed kyphosis underwater V. of a backbone is reached by sagging of a trunk in sweet or mineral water under the influence of the weight of the patient. The shoulder girdle is fixed by means of the brackets strengthened at the head end of a bathtub, legs in ankle joints fix by means of elastic rollers, and the body of the patient in water sags in a pose of a hammock. The procedure is carried out daily, by only 12 — 20 times. All types of underwater V. can be combined with other methods physical. therapies (LFK, massage, ultrasound, dirt, etc.) - Sometimes at an acute pain syndrome apply previously fonoforez a hydrocortisone or analginum (see. Ultrasonic therapy ), UF — erythema doses, diadynamic currents.

Bibliography: Wolves M. V. Metod of vertical underwater extension with a load in orthopedic practice, Ortop, and travmat., JVb 4, page 87, 1965; Gavrilenko B. S. Use of underwater extension in complex treatment a lumbar cross - tsovykh radiculitises, in book: Physical and resort, factors and them lechebn. use, under the editorship of G. A. Gorchakov, etc., century 4, page 73, Kiev, 1970; Kaplan A. V. The closed injuries of bones and joints, M., 1967, bibliogr.; Kaptelin A. F. Methods of extension of a backbone at patients with a discogenic pain syndrome, Ortop, and travmat., 3, page 13, 1972; To about r A. A., Brackets of a lean A. P. and Elyashberg F. E. To history of skeletal traction, in the same place, No. 3, page 81, 1971; Treatment by extension in water at diseases of a backbone, sost. M. V. Volkov and A. F. Kaptelin, M., 1966; M and t yu N and N N. K. and Klyuchevsky V. V. Dempferirovan-noye skeletal traction, Yaroslavl, 1974, bibliogr.; Novachenko N. P. and Elyashberg F. E. Extension per continuitatem. M, 19 72, bibliogr.; Rutsky A. V. An extension per continuitatem in traumatology and orthopedics, Minsk, 1970, bi bliogr.; Watson - Jones of R. Pere of a loma of bones and injury of joints, the lane with English, M., 1972; In h I e of L. Die Technik der Knochenbruchbehandlimj?, Bd 1 — 2, Wien — Dtisseldorf, 1953 — 1957.

A. A. Korzh; H. I. Strelkova (fizioter.).