FOOT

From Big Medical Encyclopedia

FOOT [pes (PNA, JNA, BNA)] — the distal department of the lower extremity performing basic and spring functions at the person. Conditional border of S. separating it from shins (see), the line drawn through tops of anklebones is.

Comparative anatomy — see. Extremities .

The embryology

for the 2nd month of the embryonal period a rudiment of a nishny extremity is extended and dismembered on departments (a hip, a shin and foot), and S. is slightly supinated. During this period the roundish plate, originative S., is extended, there are an area corresponding to future heel and a cross svodchatost on the bottom party, skeletal elements C begin to be differentiated. On the 3rd month of pre-natal development separate parts C. are well-marked, her joints form. Over the next months of pre-natal development there is a further formation of elements of foot.

Anatomy

In S. allocate the back of foot (dorsum pedis), a sole of foot (planta pedis) separated medial and lateral by S.'s edges and fingers (digiti). The tail of S. is made by calcaneal area, or a heel (calx). The right S. is usually slightly longer than left.

Kperedi from the widest part C. — tarsi (tarsus) lie a metatarsus (metatarsus) and fingers (see). Are a part of a tarsus: an astragalus (talus), to-ruyu P. F. Les-gaft considered as the biggest in a human body the bone meniscus located between bones of a shin and S., which is the lock of the arches of S.; the calcaneus (calcaneus), a hillock a cut forms a basis of a heel; navicular (os naviculare); cubical bone (os cuboi-deum); three wedge-shaped bones — medial, intermediate and lateral (ossa cuneiformia med., intermed. et lat.). The metatarsus is formed by five short tubular bones (ossa metatarsi I — V). The skeleton of each finger, except big, formed by two phalanxes, consists of proximal, average and distal phalanxes. At a bottom surface of S. in a metatarsophalangeal joint of a thumb constantly there are sesamoids (see). They can also meet in the field of interphalangeal joints.

S.'s bones are connected among themselves by joints, among to-rykh distinguish an ankle joint (see), joints between bones of a tarsus, a tarsus-plusnevye, intermetatarsal, metatarsophalangeal and interphalangeal joints. Treat joints of a tarsus: collision and calcaneonavicular (art. talocalcaneonavicula-ris), subcollision, or collision and calcaneal (art. subtalaris), pyatochnokubovidny (art. calcaneocuboidea) and klinoladyevidny (art. cuneona-vicularis) joints. Collision and carinate and calcaneocuboid joints combine a cross joint of a tarsus under the name (art. tarsi transversa), or «shopar joint». Predplusne-plusnevye joints (articulationes tarsometatarseae) are presented by three joints which combine under the name «Lisfrank's joint». Intermetatarsal joints (articulationes to an intermetatar-Zeaa) between the bases II and III, and also IV and V plusnevy bones are quite often tied with a cavity of a joint of Lisfrank. Heads of plusnevy bones are jointed with the bases of proximal phalanxes, forming metatarsophalangeal joints (articulationes metatarsophalangeae). Interphalangeal joints of foot (articulationes interphalangeae pedis) are similar to similar joints of a brush (see). Degree of a smeshchayemost of separate bones of S. relatively is each other minimum. Nek-roye the exception makes a joint of collision and calcaneal bones. In a subcollision joint pronation and S.'s supination, reduction and its assignment within 13 ° are possible, and back and bottom bending does not exceed 6 °. These insignificant movements receive on the ends of fingers, on to-rye they are transferred, considerable scope.

A large number of sheaves — interosseous, back and bottom takes part in strengthening of joints. Among them have special value an interosseous collision and calcaneal sheaf (lig. talocalcaneum interos-seum) which is carrying out a tarsal sinus, the doubled sheaf (lig. bifurcatum), strengthening a cross joint of a tarsus. On a sole the long bottom team of S. is well-marked (lig. plantare longum), being one of fixers of the longitudinal arches of Page.

In addition to bone and copular elements C., according to P. F. Lesgafta, it is necessary to consider also a role of active muscular tightenings — fixers. The muscles passing from a shin to S., and muscles actually of S. K to the last group take part in S.'s strengthening and its movements the muscles which are beginning on S. and attached to it belong. The main function of these muscles consists in bending (a muscle of a sole) and extension (a muscle of the back) of fingers. Muscles of a sole hold also S.'s arches and considerably provide its spring properties. Muscles of the back of S. slightly unbend fingers during the walking and run. They are presented by a short razgibatel of fingers (m. extensor digitorum brevis), a short razgibatel of a thumb (m. extensor hallucis brevis) and a non-constant third fibular muscle (m. peroneus tertius). Muscles of a sole are divided into three groups: internal (medial), outside (lateral) and average. The muscle, taking-away thumb (m. abductor hallucis), a short sgibatel of a thumb (m. flexor hallucis brevis) and the muscle giving a thumb belong to internal (t. adductor hallucis). Belong to outside the muscle which is taking away a little finger (m. abductor digiti minimi), and a short sgibatel of a little finger (m. flexor digiti minimi brevis). The average group of muscles is made: short sgibatel of fingers (m. flexor digitorum brevis), square muscle of a sole (m. quadratus plantae), and also four worm-shaped (mm. lumbricales), three bottom and four back interosseous (mm. interossei dorsales et plantares) muscles.

S.'s fascia are continuation of fastion of a shin. The back fascia of S. (fascia dorsalis pedis) thin, covers sinews of long razgibatel of fingers and is attached to bone ledges. Its deep leaf grows together with bones of a metatarsus and separates interosseous muscles from razgibatel of fingers. The bottom aponeurosis (aponeurosis plantaris) lasts from a calcaneal hillock of a kpereda, being divided into bunches according to fingers. The medial and lateral bottom partitions departing from it separate an average fascial bed from medial and lateral. I. D. Kirpatovsky suggests to allocate also interosseous fascial bed and a fascial bed of the back of foot. Under medial and average fascial beds of a sole in the depth of a tarsus there passes the bottom channel which is final department of the lodyzhkovy channel. Each muscular layer on a sole is separated by a fascial leaf. Sinews of long muscles in the area C. are shrouded synovial vaginas (see).

Skin of a sole unlike skin of the back of S. is rough, thick and has no hair. From a bottom aponeurosis to it there are short dense tyazh, between to-rymi the cells containing fatty segments are formed. The arrangement of folds of skin of a sole is very different.

Bones of a metatarsus and a tarsus are connected by means of ligaments and muscles in a row of the springing arches, to-rye give elasticity to gait and standing. The page has five longwise the put arches corresponding to five plusnevy bones, to-rye, besides, are connected among themselves in the form of the cross arch. All these five arches converge Kzadi through a tarsus to one basic calcaneus, in front the arches lean on heads of plusnevy bones. The highest point of the arch (raising of foot) is located between carinate and collision bones. S.'s arches are kept by passive and active tightenings, to the Crimea the copular device C., muscles and their sinews belong. Functionally three medial arches define as spring, and two lateral — as basic.

Fig. 1 — 4. Vessels and nerves of foot. Fig. 1. Back area of foot. Fig. 2. Bottom area. Skin and hypodermic cellulose are removed. Fig. 3. Cross section through distal ogdet tarsi. Fig. 4. Cross section through a metatarsus. 1 — the hypodermic nerve (is dissected away); 2 — big hypodermic ven (ogsechena); 3 — deep a fibular nerve; 4 — a sinew of a front bolshebertsoay muscle; 5 — a sinew of a long razgibatel of a thumb; 6 — a back artery and a vein of foot; 7 — (medial tarsal arteries; 8 — a short razgibatel of a thumb; 9 — the arc-shaped artery; 10 — back interosseous muscles; 11 — a venous arch of the back of foot; 12 — back manual arteries; 13 — back plusnevy arteries; 14 — a short razgibatel of fingers; 15 — the third fibular muscle; 16 — a lateral plusnevy artery; 17 — sinews of a long razgibatel of fingers; 18 — the lower retinaculum of sinews-razgibateley; 19 — lobbies a tibial artery and veins; 20 — the superficial fibular nerve (is dissected away); 21 — the bottom aponeurosis and a short sgibatel of fingers (is dissected away); 22 — a lateral bottom artery and veins; 23 — a lateral bottom nerve; 24 — the square muscle of a sole (is dissected away); 25 — a slanting head of the muscle giving a thumb of foot; 26 — a superficial branch of a lateral bottom nerve; 27 — a deep branch of a lateral bottom nerve; 28 — a bottom arch; 29 — an angle head of the muscle giving a thumb of foot; 30 — the general bottom manual arteries; 31 — own bottom manual arteries; 32 — own bottom manual nerves; 33 — the general bottom manual nerves; 34 — the Short sgibatel of a thumb of foot; 35 — the muscle which is taking away a thumb of foot; 36 — a medial bottom artery and veins; 37 — a medial bottom nerve; 38 — plusnevy bones; 39 — the muscle which is taking away a little finger and a short sgibatel of a little finger; 40 — a sinew of a long fibular muscle; 41 — a sinew of a long sgibatel of a thumb of foot; 42 — a worm-shaped muscle; 43 — sinews of long and short sgibatel of fingers; 44 — the first plusnevy bone; 45 — medial, intermediate and lateral wedge-shaped bones.

S.'s blood supply is carried out at the expense of a back artery of foot (a. dorsalis pedis) which is continuation of a front tibial artery, and hmedialny and lateral bottom arteries (aa. plantares med. et lat.), being continuation of a back tibial artery (tsvetn. fig. 1 — 4). Veins of fingers of the back of S. fall into a back venous arch of S. (arcus venosus dorsalis pedis) connected with back venous network C. (rete venosum dorsale pedis). The ends of an arch proceed in big and small saphenas of a leg. On a sole under skin the bottom venous network connected with deep veins and a bottom venous arch lies, edges connects with back through the pro-butting veins (vv. perforantes) passing in interosseous intervals.

Deep limf, vessels accompany the corresponding blood vessels, superficial — follow on the course of big and small saphenas of a leg to subnodal and inguinal limf, to nodes.

Skin of the back of S. final branches of a hypodermic nerve (item saphenus), medial, intermediate back cutaneous nerves of S. (subitem of cutanei dorsales medialis et intermedius), coming from a superficial fibular nerve, a lateral back cutaneous nerve of S. innervate (n. cutaneus dorsalis lat.), being continuation of a sural nerve, and a deep fibular nerve (n. peroneus profundus), to-ry innervates skin of the I interdigital interval and a muscle of the back of S. Kozhu and a muscle of a sole branches of a tibial nerve — medial and lateral bottom nerves innervate (n. plantaris med. et of the item plantaris lat.).

Radioanatomy

Fig. 1. It is normal of the roentgenogram of foot of the adult in a straight line(s), side and semi-side projections: 1 — a navicular; 2 — a cubical bone; 3 — a medial wedge-shaped bone; 4 — an intermediate wedge-shaped bone; 5 — a lateral wedge-shaped bone; 6 — plusnevy bones; 7 — phalanxes of fingers; 8 — a calcaneus; 9 — an astragalus; 10 — a sesamoid of the I metatarsophalangeal joint.

Radiological S. investigate in three main projections: direct, side and semi-side (braid). In a direct projection (fig. 1, a) the X-ray analysis can be made in bottom and back provisions C. depending on a research objective. The X-ray analysis in bottom situation is most convenient for obtaining the image of a distal half of a tarsus, a metatarsus, metatarsophalangeal joints and proximal phalanxes. Villages put on the cartridge, create the maximum bottom bending at the expense of a deviation of a shin back, send the central beam perpendicularly to a film if investigate metatarsophalangeal joints, or perpendicular to a dorsum of S. if they study a tarsus. For a research of fingers of S., to-rye are quite often bent, make shooting in back situation C. For this purpose the patient is stacked on a stomach, under S. place the cartridge with the raised proximal edge, fingers straighten and fix by made of cloth or other fixer. The central beam is directed to fingers perpendicular to the plane of the cartridge.

On roentgenograms in side (outside or internal) and semi-side (internal) projections all bones of S., including collision and calcaneal are visible (fig. 1, c). The navicular is well visible in all projections, cubical — in a semi-side projection. For studying of collision and calcaneal bones of side and semi-side projections sometimes it appears insufficiently. It is possible to see the block of an astragalus on the roentgenogram of an ankle joint in a direct projection (see. Ankle joint). For a calcaneus the second projection is axial, to-ruyu receive in two ways. In the first case shooting is made in position of the patient standing. Pages put on the cartridge, bend a shin as much as possible forward. The central beam is directed behind to a calcaneus at an angle 25 — 30 ° to a vertical. In the second case shooting is made in position of the patient on spin. Pages give the provision of the maximum dorsiflexion. The central beam is directed from the bottom party at an angle 25 — 30 ° to a vertical axis. Wedge-shaped bones owing to projective imposings are not visible on roentgenograms neither in a straight line, nor in side projections, slightly better they are looked through in a semi-side projection. Therefore at suspicion of their pathology it is necessary to resort to tomographies (see).

At interpretation of the roentgenogram of S. it is necessary to consider quite often found options of anatomic norm. So, in the V finger less often in IV at the correct shooting (with the straightened fingers) sometimes it is possible to find two phalanxes instead of three owing to merge average and distal phalanxes. Often in S. sesamoids come to light. They almost always are in both feet, have the equal rounded-off contours and homogeneous bone structure. Also those sites of the main bones have the same surface and structure, near to-rymi sesamoids are located. The shoot which is located behind an astragalus { processus tali post.), sometimes forms from the separate ossification center who is not merging with the ground mass of a bone. On a rentgenograkhmma at the same time behind an astragalus the separate stone carrying the name of triangular (os trigonum) is visible. At S.'s injuries this option of norm can be mistakenly accepted for otly a back shoot of an astragalus. Sometimes at vnutreynezadne-go edges of a navicular on the roentgenogram in a direct projection the additional bone called outside tibial is defined (os tibiale ext.).

Plusnevy bones develop from primary ossification centers appearing on 3 — the 4th month of an antenatal life, and additional, to-rye arise in heads of bones aged apprx. 3 years. In the I plusnevy bone the additional ossification center appears not in a head, and in the basis. Sometimes in each epiphysis there is not one, and several ossification centers. The V plusnevy bone always has the ossification center in tuberosity the reasons appearing at the age of 12 — 13 years.

Fig. 2. The roentgenogram of a calcaneus of the boy of 14 years is normal (a side projection): the apophysis of a calcaneus (it is specified by an arrow) is separated by a crack from its ground mass.

Due to the features of development of bones of S. there can be difficulties in interpretation rentgenol. pictures at children. So, at the age of 6 — 8 years the rear edge of a calcaneus normal has an uneven gear contour that sometimes take for destructive changes. In an apophysis of a calcaneus appears several ossification centers who are gradually merging in one oblong conglomerate with uneven contours which is located along a back surface of a calcaneus in the beginning. It quite often causes wrong treatment rentgenol. picture as change of a calcaneus or aseptic necrosis (fig. 2). The synostosis of an apophysis of a calcaneus comes at the age of 16 — 17 years.

Pathology

malformations, damages, inflammatory and dystrophic diseases, secondary deformations owing to other diseases, tumors belong To S.'s pathology.

Malformations

Malformations include disturbance of number of its separate elements or their form and the sizes. Lack of foot (ectropodia) can be isolated (hemimelia) or accompanies an underdevelopment of all lower extremity (ectrome-lia). Treatment consists in prosthetics (see).

Lack of a part of a finger (aphalangia) or all finger (adactylia), shortening of one or several fingers (hypodactylia, brachydactylia) at the expense of an underdevelopment, reduction of number of phalanxes (brachyphalangia) or shortening of a plusnevy bone (brachymetatarsia) occur among disturbances of number of separate elements C. As a rule, it significantly does not break function C., but sometimes promotes development of static deformations of its front department. Treatment conservative by means of porolonovy laying, orthopedic insoles or footwear (see).

Increase in number of fingers (polydactylia) — the bilateral, often descended deformation. Most often S.'s shestipalost meets, however the number of fingers can reach ten. Additional fingers can have all components, including also an additional plusnevy bone, or only a part of these elements. Treatment operational — removal of extreme additional fingers.

Increase in number of phalanxes of fingers (polyphalangism) more often happens on a thumb of S. — a three-phalanx thumb of Page. If at the same time the finger is excessively increased and breaks function C., amputation of a nail phalanx is shown.

Carry her true giantism, S.'s splitting and a spider finger to disturbances of a form and the sizes C.

Fig. 3. A distal part of the left foot at giantism of the II finger.

True giantism — the overgrowth of fabrics C. — can be combined with a hypertrophy of all extremity. At partial giantism the overgrowth of separate fingers and corresponding plusnevy bones (fig. 3) is noted. Excess proliferation of cells of various fabrics is the cornerstone of deformation. At the same time function C. is broken, selection of footwear is complicated. Treatment can be limited to purpose of orthopedic footwear. At heavier deformations excision of hypertrophied fabrics, an exarticulation of fingers or plusnevy bones are shown (see. Exarticulation ), amputation (see).

Fig. 4. Inborn splitting of both feet in combination with absence II and III fingers on both sides.

Cleft foot — S.'s deformation, at a cut its look reminds claws of cancer (fig. 4). It is often combined with an underdevelopment of bones of a tarsus and a metatarsus, lack of fingers, plusnevy bones, bone synostoses (see), a syndactylia (see). Depending on a form of defect apply plastic surgeries for the purpose of improvement of a form and function C.

A spider finger — lengthening and S.'s thinning and fingers (see the Spider finger).

Damages

Damages include dislocations in S.'s joints, fractures of her bones and the closed crush of Page.

Dislocations in S.'s joints occur under the influence of the big damaging force and meet seldom.

Subcollision dislocation of S. is observed more often during the falling on its outer edge. The page at the same time is displaced inside and supinated in such a way that the bottom surface is turned towards a healthy leg. Other types of subcollision dislocations (a knaruzha, a kzada and a kpereda) meet extremely seldom.

Fig. 5. The roentgenogram of the lower third of a shin and proximal department of foot at dislocation of foot in a collision and calcaneonavicular joint (a direct projection): 1 — an astragalus; 2 — other part of foot displaced knutr.

Dislocations (see) in subcollision or, more precisely, in a collision and calcaneonavicular joint on roentgenograms it is possible to distinguish on the shift of all foot, except for an astragalus, edges remains in an ankle joint (fig. 5). At the same time it is necessary to make as soon as possible the closed reposition of dislocation since symptoms of disturbance of blood circulation of Page are quite often observed. For reposition under anesthesia (see) or intra bone anesthesia (see. Anesthesia local ) make the movements, the return that, to-rye led to dislocation. After reposition would impose on week a demon - a covering plaster bandage from finger-tips to the middle of a hip with modeling of the arches (see. Plaster equipment ). If the closed reposition did not work well, urgent operational reposition is necessary.

Dislocations in Lisfrank's joint — full (all plusnevy bones) and isolated (it is preferential the I plusnevy bone) — are often combined with fractures of plusnevy bones (dislocation-fractures). Dislocations of plusnevy bones up, from top to bottom, of a knaruzha, knutr and in different directions are observed (the diverging dislocation).

The closed reposition of dislocation is undertaken immediately since circulatory disturbances of Page often join. Under anesthetic make an extension per contiguitatem (see) for distal department of S. and pressure upon the acting bases of plusnevy bones. Fixing by two-three spokes is necessary for deduction of the reached reposition. Then apply a plaster bandage S. and a shin on 6 — 8 weeks. If the closed reposition did not work well, make operational reposition, a cut in difficult cases demands a resection of the basis nevp-ravlyayushcheysya a plusnevy bone, and sometimes comes to an end with an artificial ankylosis to a tarsus-plusnevykh of joints.

Dislocations of fingers are possible in metatarsophalangeal and interphalanx joints at excessive extension or bending of fingers of S. Vozmozhna back or bottom dislocations. Dislocation in all metatarsophalangeal joints can be diagnosed according to the roentgenogram in a direct projection, on a cut of the image of the bases of phalanxes accumulate on images of heads of plusnevy bones. The direction of shift of phalanxes (a kpereda or a kzada) is established according to roentgenograms in side or semi-side projections.

At dislocation of fingers the closed reposition is shown; at its impossibility or in the started cases make open reposition with fixing by a spoke.

Fractures of bones of S. meet considerably more often dislocations.

Changes of an astragalus occur at action of indirect force. Distinguish the isolated changes of a back shoot of an astragalus at sharp bottom bending of S.; fractures of a neck of an astragalus at a sharp dorsiflexion of S. when the nizhneperedny edge of a tibial bone, resting against a neck, splits an astragalus into two fragments (at the same time there can be an incomplete dislocation of a body of an astragalus of a kzada); compression fractures of a body of an astragalus during the falling from height on feet when the body of an astragalus is as if crushed between tibial and calcaneal bones.

Changes of an astragalus are fullestly diagnosed according to S.'s roentgenograms in direct and side projections and the roentgenogram of an ankle joint in a perednezadny projection.

Treatment of changes without shift consists in imposing of a plaster bandage to a knee with modeling of the arches on 3 — 4 weeks at changes of a back shoot and of 6 weeks up to 3 — 4 months at fractures of a neck or body of an astragalus. After a cast removal appoint long (up to 4 — 5 months) unloading (walking on crutches), heat baths to lay down. gymnastics, massage, carrying orthopedic insoles. At changes with shift (see Changes) under local anesthesia or under anesthetic make the closed manual reposition; at impossibility of the closed reposition perform open reposition with the subsequent osteosynthesis of fragments the screw or spokes (see. Osteosynthesis ). At changes with dislocation of a body of an astragalus of a kzada or at compression changes the aseptic necrosis of a body of an astragalus, and in the subsequent — the deforming arthrosis of talocrural and subcollision joints with persistent pains often develops.

Fig. 6. The roentgenogram of proximal department of foot (a side projection) it is normal (a) and at a change of a calcaneus:

Changes of a calcaneus are most frequent and arise during the falling from height on heels. Distinguish the regional and isolated changes, with shift and without shift, and also compression changes with damage or without damage of joint surfaces. The calcaneal area at the same time is expanded, S.'s arch is flattened, a prelum of a calcaneus from sides, on an axis and from below is painful, load of a heel or rise of socks are impossible. At the regional and isolated changes symptoms are less expressed, load of legs and walking is often possible. If the change of a calcaneus is suspected, carry surely out rentgenol. a research at least in two projections — side and axial by the techniques described above. Diagnosis of a change according to roentgenograms of high quality is simple. However it is sometimes difficult to estimate the provision of fragments and a condition of the arch of S. In such cases the X-ray analysis of the second foot, and also definition of a collision and calcaneal corner are reasonable. It is formed * by crossing of two straight lines, one of to-rykh will be out on tops of a calcaneus, and another — along a subcollision joint. The size of a collision and calcaneal corner is normal equal 40 ° (fig. 6, a). At changes of a calcaneus the corner decreases (fig. 6, b).

Treatment of changes without shift is carried out by an immobilization a bespodkladochny plaster bandage to a knee. The term of an immobilization depends on a type of a change and makes from 3 to 8 weeks. At changes with shift under local anesthesia make the closed manual reposition of fragments (pressing of the departed fragment, tightening of an expanded calcaneus from sides etc.), and at its impossibility — open fixing of fragments by means of the screw.

Compression changes of a calcaneus with flattening, expansion and its shortening and with damage of joint surfaces treat by means of skeletal traction. Then apply a plaster bandage with modeling of the arches and a stirrup for 1,5 — 2 months, S.'s unloading up to 3 — 4 months. Further carry out LFK, massage, appoint warm trays and wearing orthopedic footwear. Forecast favorable.

Fractures of bones of a tarsus arise during the falling of weight on S. the collision and calcaneal corner formed by the straight line 1 passing along a subcollision joint and the straight line 2 passing through tops of a calcaneus is normal equal 40 °, and at a change of a calcaneus decreases to 20 ° (shooters specified lines of a change of a calcaneus).

At the same time one or several bones can be injured. Regional changes meet with shift or without it more often. At changes without shift imposing of a plaster bandage with modeling of the arches and with a stirrup on 3 — 4 Nol is shown. At changes with shift the separation of tuberosity of a navicular, to a cut is attached a sinew of a back tibial muscle, or a change of a navicular with dislocation of back fragment) if the closed reposition was not successful, apply open reposition and fixing of fragments spokes. After an immobilization during — 10 weeks carry out by a plaster bandage functional treatment and appoint long carrying orthopedic insoles.

Fractures of plusnevy bones (one or several, and also the isolated separations of tuberosity of the V plusnevy bone) and phalanxes of fingers usually arise owing to falling of weight on S.'s back or as a result of its overextension. Radiological they are diagnosed in pictures in direct and iolubokovy projections on available always at least a nezna chitet to the ny shift of fragments.

At fractures of one plusnevy bone without shift the immobilization by a plaster bandage to a knee with modeling of the arches on 2 — 3 weeks is shown, at fractures of several bones — to 5 — 6 weeks. At changes with shift the closed or open reposition with fixing of fragments spokes with the subsequent immobilization is necessary. At fractures of phalanxes of fingers without the shift of fragments apply a circular bandage from an adhesive plaster in several layers for 10 — 14 days, at changes with the shift of fragments carry out skeletal traction for a distal phalanx.

At open fractures of bones of S. make primary surgical treatment of wounds (see), after reposition of fragments impose a plaster splint on 4 — 6 weeks.

The closed crush of foot — a rare, but dangerous injury, napr, at its long prelum a heavy load. The integrity of skin at the same time is broken not always, however considerable damage of soft tissues takes place, injury of bones is sometimes noted. For the purpose of treatment do the deep decompressive cuts opening fascial muscular spaces and exempting muscles from an internal prelum. Pages fix a removable plaster splint, the extremity is given sublime situation. Apply cold, futlyarny novocainic blockade (see), UVCh-therapy (see). Appoint early recovery treatment. The forecast for function adverse.

Features of fighting damages, stage treatment

Gunshot wounds of S. it is accepted to divide into the following groups: limited damages of soft tissues without injury of bones of S.; limited damages of soft tissues with the isolated fractures of bones; limited damages of soft tissues with multiple fractures of bones; extensive damages of soft tissues without injury of bones; extensive damages of soft tissues and bones. By experience of the Great Patriotic War, among S.'s damages bullet wounds made 45,2%, fragmental — 51,3%, wounds caused by antipersonnel mines — 2,7%. Gunshot wounds of S. without injury of bones made at bullet wounds 35,6%, at fragmental — 35,4%, as a result of explosions of antipersonnel mines — 9,6%. More often (60%) heavy damages of S. were observed at the wounds caused by antipersonnel mines: separations of part C. or extensive wounds with a major defect of skin and multiple fractures.

Gunshot wounds of S. differ in big variety and various weight, often are followed by considerable bleeding (see) owing to wound of large vessels (a back tibial and back artery of foot) and traumatic shock (see).

First aid consists in imposing of a sterile bandage, introduction of analgetics, S.'s immobilization by means of make-shifts.

Pre-medical help (see) and first medical assistance (see) include correction of bandages, introduction of antibiotics and analgetics, and at fractures of bones or extensive damages of soft tissues — correction of a transport immobilization (see) using the ladder tires imposed on a bottom surface of S. to an upper third of a shin and is U is-shaped.

The qualified medical care (see) first of all is provided at S.'s separations, bleeding and a complication a wound fever (see. Wound fevers). At the same time primary surgical treatment includes rather wide section of fabrics, emptying of hematomas, a hemostasis, excision of impractical soft tissues (skin, especially on a bottom surface, exsect economically), removal of freely lying bone splinters, foreign bodys and a skusyvaniye of the acute ends of bones. The wound is washed out solution of antibiotics, to-rye appointed also in the postoperative period. Imposing of primary and delayed seams on S.'s wound is not allowed. At S.'s separations, extensive injuries of bones and soft tissues, damage of a neurovascular bunch when it is impossible to keep S., perform amputation according to primary indications. At through bullet wounds of the soft tissues which are not followed by considerable bleeding and multiple splintered superficial wounds primary surgical treatment of wounds is usually not carried out. Wounded with limited damage of soft tissues of S. are directed in hospital for lightly wounded (see), the others — in all-surgical hospital (see. Surgical field mobile hospital).

During the rendering specialized medical care (see) the wounded with through bullet wounds without considerable injury of bones and soft tissues and in the absence of purulent complications are limited to a toilet of a wound, introduction to a circle of a wound of antibiotics and an immobilization plaster splints from finger-tips to an upper third of a shin. At considerable damages of fabrics carry out surgical treatment of a wound: cut entrance and output wound openings, widely open an aponeurosis and cut the destroyed and impractical muscles, delete foreign bodys (see) and the small freely lying bone splinters. The wound is carefully infiltrirut solution of antibiotics. Primary stitches on a wound are not put. The immobilization is carried out by the plaster bandage cut a subtench. When there is no opportunity to hold fragments in the correct situation or the condition of fabrics does not allow to apply a plaster bandage, fixing of fragments is carried out by means of the device for extra focal chreskostny fixing. At severe forms of a local mephitic gangrene (see), development of sepsis (see) and S.'s necrosis (see Gangrene) resort to its amputation. In a complex to lay down. actions at open damages of S. apply physical therapy and LFK.

By experience of the Great Patriotic War of 1941 — 1945 osteomyelitis of bones of S. after its wounds was noted in 19,4% of cases and made 11,2% of fire osteomyelitis (see) all localizations. At gunshot wounds of S. the expressed disturbances of blood circulation quite often develop that can be the cause of a necrosis of distal departments of S. and first of all skin of the back of Page. The extremity needs to give sublime situation, and at threat of a necrosis cuts on S.

Diseases

In a growth period of bones of a skeleton are shown apophysites (see), an osteochondropathy meet (see Köhler of a disease). At a long overload of S. can arise patol. reorganization of plusnevy bones, so-called mid-flight changes — Deychlender's disease (see. Mid-flight foot). From inflammatory processes on foot, to-rykh the injury or a microtrauma can be the cause (see), a bursitis is most frequent (see).

An achillobursitis — an inflammation of a synovial bag between a calcaneal hillock and an Achilles sinew (see). The swelling at the place of an attachment of an Achilles tendon, pain during the walking is defined, with a pressure by a back of footwear. Treatment of an acute achillobursitis: rest, UVCh-therapy (see), paraffin-ozokeritovye of application (see the Ozoceritotherapy, the Paraffin therapy). At a frequent recurrence excision of a synovial bag is shown.

A subcalcaneal bursitis — an inflammation of a neogenic synovial bag under a spur of a calcaneus (see Spurs bone). Thermalgias in this area (feeling nailing in a heel) carry the name «kalkaneo-diniya». During the involvement in inflammatory process of nervous branches of tibial or sural nerves neuralgic pains extend on all calcaneal area (a so-called talalgia). Treatment: rest, microwave, ultrasonic therapy, an electrophoresis using novocaine, radiation by an out-of-focus laser beam, carrying orthopedic insoles with deepening under a heel and the calculation of the arches, soft laying (a ring under a heel). At persistent pains — excision of a synovial bag.

From other inflammatory processes of S. a tendovaginitis (see) and arthritises meets (see).

From purulent diseases on S. it is possible felon (see), paronychia (see), most often meeting at the grown nail (see. grown ), phlegmon (see) S., osteomyelitis (see) bones

S. S. is subject to fungus diseases. Most often epidermophitias meet (see). A rare fungus disease is so-called Madura foot (see).

Tuberculosis rather seldom affects S.'s bones (more often than others calcaneal, then an astragalus). Joints are surprised for the second time (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints). At the isolated centers make inside - and an extraarticular necretomy (see). At the expressed destructive forms — a resection of joints, sometimes — an astragalektomiya — removal of an astragalus (see. Ankle joint, operations).

Arthroses of joints of S. — hron. disease of dystrophic character. Arises more often as display of the general disease, is more rare — after an injury. The deforming arthrosis of the I metatarsophalangeal joint is one of the reasons of rigidity of a thumb (hallux rigidus), causes pains and breaks a normal rift of S. during the walking. At initial stages warm trays, LFK, massage, fizio-and a balneoterapiya are shown (see Arthroses). During the progressing of rigidity and strengthening of pains — an arthroplasty (see).

At the persistent, amplifying during the walking pains in front department of S. it is possible to think of mortonovsky metatarsal neuralgia (see).

From deformations of foot flat-footedness (see), hallux valgus (see), a clubfoot (see), horse foot (see), etc. are most often observed (see below).

Fig. 7. Feet at paralytic flat and valgus deformation: front departments of feet are taken away, secondary valgus deformation of the I finger of the right foot and varus deformation of the V finger of the left foot.

The strephexopodia is characterized by assignment of front department of S., pronation of a heel, a raising of the outer edge of Page. It is more often combined with longitudinal flat-footedness — so-called ploskovalgu-sny foot (pes planovalgus). Valgus deformation of feet can be inborn, paralytic (fig. 7), napr, because of poliomyelitis, spastic cerebral palsy, etc., develops owing to an injury or has static character. The disease is inclined to progressing and sharply breaks function of feet, causing pains during the walking, fatigue. Conservative treatment comes down to fizio-and to balneoprotsedura to lay down. to gymnastics, massage and purpose of orthopedic footwear (see Footwear, orthopedic). The nature of operational treatment depends on age of the patient, the reason of deformation, degree of its expressiveness. In case of gross violations of a form and function C. the artificial ankylosis of subcollision and even talocrural joints is shown.

Hollow foot is characterized by excessively high longitudinal arch, at Krom the calcaneus and heads of plusnevy bones become reference points of S., the head of the I plusnevy bone is sharply lowered to a sole, the bottom aponeurosis is shortened and intense. On a plantogramma (see Plantografiya) subsummary part C. completely is not painted over. Hollow S. of an inborn origin meets seldom. Its combinations to the horse and given foot at paralytic deformations because of poliomyelitis are more often observed, a myelodisplasia, Fridreykh's diseases (see the Ataxy), Sharko — Mari (see Amyotrophy), spastic paralyzes, etc. Treatment depends on an etiology and extent of deformation. At initial extents of deformation conservative treatment is shown: purpose of orthopedic insoles or footwear, physical therapy, massage. At the expressed forms operational treatment is shown: children have a change of a long razgibatel of a thumb on the I plusnevy bone; at adults the wedge-shaped or crescent resection on Kuslika is supplemented with a section of a bottom aponeurosis and an ugloobrazny osteotomy of the basis of the I plusnevy bone on the Turnip (see the Osteotomy).

Fig. 8. The diagrammatic representation of deformations of fingers at hollow foot: and — molotkoobrazny deformation at a contracture in a proximal interphalangeal joint; — molotkoobrazny deformation at a contracture in a distal interphalangeal joint; in — kogteobrazny deformation at a combination of a contracture in a distal interphalangeal joint with an incomplete dislocation or dislocation in a metatarsophalangeal joint; sites of callosity are designated by black color.

Hollow foot often is followed by an extensive flexion contracture of fingers — so-called molotkoobrazny fingers (fig. 8, and, b). The contracture of fingers in combination with an incomplete dislocation or dislocation in a metatarsophalangeal joint when the finger-tip does not touch a bearing area, is called kogteobrazny deformation of a finger (fig. 8, c). Sinews of razgibatel of fingers at the same time are tense under skin. Because of constant attritions callosity of skin arises footwear (see. Omozolelost ). The combination of kogteobrazny deformation of fingers from hollow S. makes a typical picture of so-called kogteobrazny foot. At initial unstable deformation of fingers carrying P-shaped porolonovy laying is shown, at sharply expressed deformation in some cases the resection of a distal part of a proximal (main) phalanx with the subsequent extension for a distal (nail) phalanx is shown.

Calcaneal foot — installation C. in the provision of the sharp fixed extension; the support occurs on a hillock of a calcaneus, active bending is absent. Deformation most often develops because of poliomyelitis at paralysis of back group of muscles. Conservative treatment — wearing orthopedic footwear, fizio-and a balneoterapiya, massage, LFK. The nature of operational treatment depends on age of the patient and extent of deformation. At children's age shortening of an Achilles tendon and change of the remained muscles on a calcaneus is possible, to-ruyu it is possible to combine with a subcollision artificial ankylosis or excision of a wedge the basis of a kzada from a calcaneus. At the fixed bone forms the wedge-shaped resection and three-joint is shown artificial ankylosis (see).

The given foot — reduction of front department of S. (plusnevy bones and fingers), is more often than inborn character. Treatment is begun with the birth with stage plaster bandages, then appoint orthopedic footwear. At the started form — an osteotomy of plusnevy bones, a wedge-shaped resection and an artificial ankylosis in Lisfrank's joint.

From the general diseases striking fabrics C. it should be noted the dyschondroplasia (a disease Ol league) deforming a joint chondrodysplasia and an ekzostozny chondrodysplasia (see). Solitary cysts of bones of S. meet, pednogtevy exostoses are frequent (see), to-rye it is necessary to differentiate with a glomal tumor (see).

The forecast of diseases of S., as a rule, is defined by disease severity, timeliness and adequacy of treatment.

Tumors of foot meet seldom. On S.'s skin the melanoma develops (see). From myagkotkanny tumors are observed fibroma (see), synovioma (see), an angioma (see), hygroma (see), a neuroma (see). In S.'s bones tumoral processes are also various on character, but tumors of the cartilaginous nature — a chondroma meet more often (see), hondroblastoma (see), the osteochondroma, is more rare an osteoma (see), osteoblastoclastoma (see). From malignant tumors are noted a chondrosarcoma (see), an angiosarcoma (see), Ewing's tumor (see. Ewing tumor ). Most often tumors arise on plusnevy bones, then on phalanxes of fingers, collision, a calcaneus.

Operations

carry out Operations on S. by means of front, side, back and bottom aim cuts depending on the purposes of intervention or localization patol. process. From typical accesses to S. Kokher's access which is bending around behind and from below an outside anklebone and allowing to bare areas talocrural, subcollision and a shoparova of joints is most widely known.

Operations on S. include various interventions, including radical — directed to sanitation of pathological and destructive focuses at osteomyelitis, tuberculosis, tumors, etc. These interventions consist in a necretomy, a resection, quite often include an artificial ankylosis (see) talocrural, subcollision and other joints of Page. Resections of bones and joints and an artificial ankylosis apply also to elimination of nek-ry deformations of S., including a dystrophic and neurogenic etiology. Besides, apply to correction of deformations of S. changes of places of an attachment of sinews, a tenotomy (see), an osteotomy (see), telodez (see).

Fig. 9. The diagrammatic representation of bones of foot with the indication of levels of different types of its amputation: 1 — on Shopara; 2 — across Eger; 3 — on Lisfranka; 4 — across Garanzho.

Feature of amputations at the level C. is the section of fabrics C. on lines of joints (fig. 9).

At exarticulation on Shopara it is important to cross the doubled sheaf then S. is easily isolated.

After this amputation the stump, unprofitable for function forms (see. Stump of an extremity ). Draft of gastrocnemius muscles promotes ekvi-nusny installation of a calcaneus in this connection the astragalus is displaced kpered and loading at a support occurs on its head. Therefore ulcerations of such stump are frequent. Amputation on Shopara is made seldom. Osteoplastic amputation according to N. I. Pirogov is more preferable (see. Pirogova amputation ).

When there is an opportunity to keep carinate and cubical bones, amputation across Eger is shown. At the same time oporo-ability of a stump and functionality ny result is better, than after amputation on Shopara. Exarticulation on Lisfranka is made rather seldom. Difficulties are presented by crossing of a key of a joint — an interosseous klinoplusnevy sheaf. Amputation across Garanzho represents exarticulation of fingers in metatarsophalangeal joints. Exarticulation of fingers in interphalangeal joints is inexpedient since the rest of a finger is deformed and is easily injured by footwear.

Vladimirov's operation — Mikulich (see. Vladimirova — Mikulich operation ) it is applied seldom because results in functional inferiority of an extremity.

Prosthetics of patients with S.'s stumps is performed by means of orthopedic footwear (see. Footwear, orthopedic ).



Bibliography: Vishnevsky A. A. and Sh r and y e p M. I. Field surgery, page 311, M., 1975; M. V Wolves. Bone pathology of children's age (Tumoral and dysplastic diseases of bones), M., 19G8; M. V. and Dedov V. D Wolves. Children's orthopedics, M., 1980; Dyachenko of V. A. Rentgenoosteo-logiya, M., 1954; And in and N about in G. F. Fundamentals of normal anthropotomy, t. 1 — 2, M., 1949; Kaplan A. V. Injuries of bones and joints, M., 1979; To about in and - N about in V. V. and T r and in and A. A N. Surgical anatomy of the lower extremities, M., 1963; To the Log of N about in and I. G. Rentgeno-anatomiya of a skeleton, page 335, M., 1981; L at - e and N and 3. P. Prevention and treatment of deformations of feet after poliomyelitis, M., 1963, bibliogr.; M and y to about in and - With t r au g and N about in and V. of Page and P about x l and D. G. N of Kostya and joints in the x-ray image, the Extremity, L., 195 7; The multivolume guide to orthopedics and traumatology, under the editorship of N. P. Novachenko, t. 2, page 681, etc., t. 3, page 729, M., 1968; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 12, M., 1961; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 18, page 238, M., 1950; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1 — 2, M., 1964; F r and d l and N d M. O. Ortopediya, M., 1954; H and to l and V. D's N. Orthopedics, book 1 — 2, M., 1957; it, Fundamentals of operational orthopedics and traumatology, M., 1964; Elkishek G. L. Indications and technology of removal of foreign bodys at nonperforating gunshot wounds of foot, Works Voyen. - the medical academician, t. 51, page 89, L., 1952; Du Vries H. L. Surgery of the foot, St Louis, 1965; Grey’s anatomy, ed. by D. V. Davies a. R. E. Coupland, p. 121 a. o., L., 1967; L o e f f 1 e r F. a. In 1 e n with k e B. Allgemeine Orthopadie, Lpz., 1964; Sigg K. Beinleiden, Ent-schung und Behandlung, B., 1976.


I. S. Istomina; E. A. Vorobyova (An., embr.), P. L. Zharkov (rents.), S. S. Tkachenko (soldier.).

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