JOINTS

From Big Medical Encyclopedia

JOINTS [articulationes synoviales (PNA), articuli (JNA), articulationes (BNA); synonym: synovial connections, joints] — the mobile, preryvny connections of bones of a skeleton which are characterized by existence of the joint surfaces covered with a joint cartilage, a joint cavity and a joint bag, participating in movements of separate bone levers relatively each other in locomotion (movement) of a body and saving its provision.

This type of connections of bones differing from synarthroses (see), call a diarthrosis. An intermediate form of these groups of connection of bones is the semi-joint, or a symphysis (see. Pubic symphysis ).

HISTORY

S.'s Descriptions are available in Hippocrates's works, Ibn-Sina and A. Vezaliya's works. In 1710 H. L. Bidloo described S. in «Manual for studying surgery in dissecting room», and in 1742 in St. Petersburg the first domestic guide to I. Veytbrekht's syndesmologia was published. In 19 century N. I. Pirogov in detail described auxiliary elements C. and showed their complex topografo-anatomic relationship on cuts of bones of joints. The foundation biomechanics S. was laid by P.F. Lesgaft for the first time studying S.'s structure by results rentgenol. researches and shown the defining influence of nature of movements on a structure of Page. Function C. was studied by R. Fick, Fischer (O. of Fischer), N. A. Bernstein, P. N. Bashkirov, B. V. Sermeev, etc. Limf, S.'s vessels were carefully studied by D. A. Zhdanov with sotr. Fundamental works on studying of diseases of S. were created by clinical physicians. So, R. Lerish and And. Palikar (1930) scientifically proved treatment of diseases of joints, M. M. Diterikhs in the book «Introduction to Clinic of Diseases of Joints» (1937) emphasized interrelation of structure and function C., showed value of their innervation, blood supply and a lymph drainage. Age features of a structure of S. of the person were studied by I. P. Kallistov, M. G. Prives with sotr., F. I. Valker, L. K. Semenova with sotr., V. N. Pavlova with sotr., P. M. Mazhuga, Gardner, Polachek (R. Polacek), J. Kos, etc. S.'s radioanatomy in the ontogenetic plan was studied by D. G. Rokhlin.

The COMPARATIVE ANATOMY

S.'s Structure of various animals in the course of phylogenesis changed according to a way of life (transition from water to land) and with specifics of locomotion.

The type of a support, body weight, character and way of movement create a relief of joint surfaces of the jointed bones and a specific structure of each S. U stopo-, a finger - and falangokhodyashchy the type of a support regardless of further specialization defines structure not only S. of a brush and foot, but also all S. of extremities. Mobile intercarpal S. plantigrade in a form are close to spherical. At the identical number of bones of a wrist number of joints between them the greatest at a horse, a hare, a wolf (running) and the smallest — at an elephant and a hippopotamus. In a knee joint of elephants lack of meniscuses excludes rotary motions, and at primacies and the person of the movement in them reach the highest degree. At the paltsekhodyashchy, adapted for bystry run, dorsal flattening of bones interfere with front overextension, cylindrical interphalanx S. will be transformed to saddle. In blokovidny joints of one-hoofed animals polydactylism is lost and the form and S. U relief which are climbing and enough a thumb becomes complicated it is opposed for capture.

Only the saddle form of carpal and metacarpal S. providing opposition of a thumb of a brush and ability of a grasp is inherent to the person; the maximum pronation and supination of a forearm (together with a brush) at the expense of the difficult elbow and combined radioulnar S.; maximum bending and straightening of fingers.

EMBRYOLOGY

S.'s Formation in the antenatal period is connected with a bookmark and a differentiation of a skeleton. At a germ 9 mm long (the 5th week) in accumulations of a precartilaginous mesenchyma a vertebral complex, shovels, laying of extremities and a basin are excreted. At a germ 14 mm long the ends of cartilaginous models of bones in the field of large S. are created and outlined by the dense mass of the mezenkhimny cells oriented according to a relief of future epiphysis; depression of an interepiphyseal mesenchyma with the subsequent formations of primary joint cracks begins, formation to-rykh is influenced by tensile forces. At increase in vigorously growing mass of prekhondralny fabric in an epiphysis of a loop and bridges of a mezenkhimny reticulum are broken off, creating a set of inter-reticular cells. Mobility of a fruit also promotes modeling of joint surfaces and expansion of joint cracks with their gradual transformation to joint cavities. Joint cracks (prototypes of future joint cavities) arise in humeral and coxofemoral S. on the 6th week, in sacroiliac — on the 7th week, in elbow and knee — on the 8th week, in atlantozatylochny, costal and cross, grudinoklyuchichny, radiocarpal S. — on 8 — the 9th week of pre-natal development. The fabric differentiation of a joint cartilage and enchondral ossification of an epiphysis are predetermined by intensive implementation in cartilaginous models of bones of blood vessels from a nadkhryashchnitsa. Further vessels are obliterated, on their place there are sites of amorphous main substance and the young hyaline cartilage is differentiated. The centers of reorganization are characterized by the highest concentration of hyalrunates, Hondas-roitinsulfatov A and C, accumulation of enzymes, existence of ethylenic groups. In cytoplasm of chondrocytes the glycogen and lipids collect.

In nek-ry S. the centers of ossification appear in an epiphysis in the pre-natal period (in a distal epiphysis of a femur, in an astragalus). In such «prebone» cartilages almost all enzymes and metabolites of a tricarbonic acid cycle are found (see. Trikarbopovy acids cycle ).

ANATOMY

Basic elements of a joint are the joint surfaces of the connecting bones (facies articulares) covered with a joint cartilage (cartilago articularis), the joint capsule (capsula articularis) and a joint cavity (cavitas articularis). Except these elements, in S. auxiliary educations of various anatomic structure and functional value are had, one of to-rykh are more or less constant for many S., others meet only in nek-ry S., is frequent even in any one. Carry to number of such auxiliary educations sheaves (see), joint disks and meniscuses (see. Meniscuses joint ), joint lips and synovial bags (see).

Depending on number of joint surfaces allocate: simple S. (articulatio simplex) formed by two joint surfaces, napr, interphalanx S. intermetatarsal, humeral S.; the difficult S. (articulatio composita) formed by several bones and representing several simple S. having the general joint capsule, napr, an elbow joint; complex S., in a cavity to-rykh there is an intra joint cartilage; the combined S. — some of S. isolated from each other combined by a community of the carried-out function, napr, temporal and mandibular, atlantozatylochny, distal and proximal radioulnar Page.

Comparison of a form of the connecting joint surfaces to a form of solids allows to distinguish spherical (bowl-shaped) S. [articulatio spheroidea (cotylica)], ellipse S. (articulatio ellip-soidea), blokovidny (ginglymus), condylar (articulatio bicondyla-ris), cylindrical (articulatio trochoidea), saddle (articulatio sellaris), flat C. (articulatio plana). The name of the last is conditional as joint surfaces in many flat S., as a rule, possess the signs characteristic of ovoidny or saddle forms. Flat rigid S., napr, between bones of a tarsus, call amphiarthroses.

The form of joint surfaces and their compliance (congruence) each other define degree of mobility of bones, amplitude of their movement, and also quantity of axes, around to-rykh the movements are made.

Distinguish three axes (frontal, sagittal and vertical), around to-rykh bending and extension, reduction and assignment, rotation inside and outside are made. In the presence of movements in S. around two and more axes also roundabouts in it with transition from one axis of the movement to another are possible.

On number of the axes defining function of a joint distinguish uniaxial, biaxial and multiaxis S. K uniaxial brushes and feet and talocrural S. carry blokovidny interphalanx S., in to-rykh the movement it is possible only around a frontal axis (bending and extension). Blokovidny S.' kind are spiral S., napr, humero-ulnar. Carry also cylindrical S. to uniaxial, napr, median atlantoosevy S., providing the movements of the head around a vertical axis and combined by S. (proximal and distal radioulnar) during the combined work to-rykh pronation and supination of a brush is carried out. Biaxial S. are ellipse, napr, radiocarpal S., in Krom bending and extension around a frontal axis, assignment and reduction of a brush around a sagittal axis is possible; saddle S., napr, carpal and metacarpal S. of a thumb of a brush, in Krom, in addition to assignment and reduction, bending and extension, opposition (oppositio) of a thumb is possible; condylar, napr, as blokovidno-spherical S. K multiaxis S. can carry the knee S. (articulatio genus) differing in irregular shape of the distal end of a femur and which is often considered spherical, napr, humeral S. Raznovidnostyyu of spherical S. is, e.g., coxofemoral S. Naimeney flat S. — dugootrostchaty, intermetatarsal, sacroiliac, etc. are mobile.

Joint surfaces of most of S. are covered with a hyaline cartilage. The exception is made by temporal and mandibular and grudinoklyuchichny S., in to-rykh joint surfaces are covered with a fibrous cartilage. Thickness of a joint cartilage in various S. is not identical.

The joint capsule — the multilayer connective tissue layer which is hermetically delimiting S.'s cavity and consisting of the outer fibrous membrane and an inner synovial membrane formed by a synovial membrane (see). The fibrous membrane consists of collagenic and elastic fibers and friable connecting fabric, in a cut there pass nerves, circulatory and limf, vessels. Bunches of collagenic fibers are interwoven into a periosteum of the bones forming S. and also are closely connected with sinews of the muscles passing close and many Pages strengthening the capsule.

A joint cavity the space — closed, limited to a synovial membrane between the jointed joint surfaces of bones containing transparent viscous synovial fluid (see), carrying out locomotory, metabolic and barrier (protective) functions.

The innervation is carried out by branches of the nerves going to the periosteum, fastion, muscles surrounding a joint and nerves of vascular textures. In a fibrous membrane of the joint capsule nerves create the krupnopetlisty texture connected by numerous branches with deeper melkopetlisty texture reaching in separate zones of the joint capsule of a covering layer of a synovial membrane.

Distribution of nervous elements in different S. nonidentical. E.g., in atlantozatylochny S. they are located preferential in back departments of the joint capsule; in lateral atlantoosevy S. — in side departments; in humeral S. — in the lower medial and lateral quadrants, in front and back departments of the joint capsule and in a zone of a klyuvoplechevy sheaf; in elbow S. — in front department of the joint capsule and in sheaves.

Blood supply is carried out by joint arteries, and also branches from fascial, muscular, periosteal and intra bone arteries, to-rye, widely anastomosing among themselves, form the uniform network of blood vessels providing if necessary development of collateral circulation (see Collaterals vascular). The main arterial vessels of extremities and also ascending, descending and surrounding bones of an artery give branches to the largest S. V to a fibrous membrane of the joint capsule each artery is followed by two veins and, being divided into branches of various orders, creates krupnopetlisty network, anastomoses edges with dense melkopetlisty network of capillaries in a synovial membrane.

Lymph drainage. Limf, S.'s vessels begin lymphatic capillaries in the depth of a synovial membrane, to-rye vessels proceed in larger taking out limf. Deep limf, the network is connected with superficial network limf, the vessels of a fibrous membrane merging in larger vessels going to regional limf, nodes.

Age features. By the time of the birth the joint and copular device of the child is anatomically created, however growth, further modeling of a form of joint surfaces and a differentiation of all its fabric components proceed and come to the end in various terms.

Newborns have a structure of a joint cartilage heterogeneous. The superficial zone sharply of an oksifiln, contains a large number of cells and fibrous structures. In an intermediate zone of cellular elements and fibers it is less; in a deep zone cells of a young cartilage, the centers of reorganization and the main substance are found. Formation of a young coarse-fibered bone proceeds very intensively thanks to existence of a large number of osteoblasts. Intensive biosynthesis of the sulphated glycoproteins is characteristic of a zone of proliferation. In a zone of cellular columns phosphorylase, and in an osteogene layer — respiratory enzymes is revealed.

By the end of the first year of life osteogene zones of a joint cartilage considerably extend, the quantity of hypertrophied vacuolated chondrocytes increases. In places of an attachment of sheaves or the joint capsule proliferation of cartilaginous tissue is observed. By 3rd years in a joint cartilage of large S. the quantity of again formed centers of reorganization is found a nek-swarm. At the age of 4 — 5 years in a joint cartilage the number of cellular elements considerably decreases and the amount of the main substance in all its layers increases. The superficial zone is narrowed, in an intermediate zone there are a lot of single chondrocytes of rounded shape. The number of the centers of reorganization considerably decreases. By 7 years orientation of chondrocytes in a superficial zone quite corresponds to a relief of joint surfaces. In an intermediate zone a lot of the little isogenic groups surrounded with wide, sharply basphilic fields of the main substance form. Quantity of cells in isogenic groups and width of the territories occupied by them increase towards a zone of ossification. In 12 — 14 years the centers of reorganization in a joint cartilage are absent. Isogenic groups reach its surface layers, by 16 years — the most fringe regions. In cytoplasm of chondrocytes there are numerous inclusions. The amount of the main substance increases and vigorously there is its calcification.

Young chondrocytes are poor in cytoplasm, in a cut only a small amount of ribosomes and short mitochondrions is found. The double cellular membrane on certain sites does not come to light, and numerous cytoplasmatic shoots of a chondrocyte (their length averages 0,36 microns, and width of 0,06 microns) get into the main substance of a cartilage.

In the main substance of a young cartilage of fiber are located randomly, but with age their orientation is strictly arranged and they are located radially or parallel to a longitudinal axis of cells. At a mineralization of a cartilage density of collagenic fibers increases, and between their bunches adjournment of crystals of apatite begins. The intra joint surface of a synovial membrane of the newborn uneven, places forms superficial hillocks and not numerous thin fibers. Aged after 5 years the relief of a synovial membrane becomes complicated, the vorsina of the 2nd and 3rd order gaining complex structure and the considerable sizes by 16 — 18 years are formed. After 15 years in many vorsina fatty tissue appears.

Neuroplexes in S. of the newborn are created, terminal receptors are presented by free nerve terminations and the encapsulated nervous little bodies of various form and different levels of a differentiation. Within the first year of life grow and considerably free nerve terminations extend. Neuroplexes in friable connecting fabric have an appearance of melkopetlisty networks, and in narrow sites of an arrangement of collagenic fibers consist of the long extended loops. For the period from 1 year to 3 years the capsule is considerably thickened, in the encapsulated receptors the internal flask accurately is delimited, the course of nervous conductors becomes complicated. The high level of development is reached by touch, lamellar and bulbar corpuscles, the free terminations of nerves, the most numerous in friable connecting fabric, in sheaves and synovial torsions extend to considerable territories. During from 3 to 7 years the tendinous spindles located in a fibrous membrane get orientation by a longitudinal axis on a longitudinal axis of tendinous fibers.

Development by 9 — 10 years of mechanioreceptors, chemoceptors, touch corpuscles provides a differentiation of the direction of movements, speeds, accelerations, vibrations, and also chemical, pain and temperature stimulations. Complexity and a variety of shapes of receptors in S. are higher than extremities, than in S. of a thorax or a backbone. By 9 — 10 years instead of diffusion distribution of nervous elements their centers clearly revealed in all Villages are differentiated. At the age of 14 — 16 years the structure of the in-nervatsionny device C. corresponds to its structure at adults. Borders of innervatsionny territories of separate nerves are erased with age, there are zones of overlapping, the quantity of connecting branches increases. At the age of over 60 years local destruction of nerve fibrils in the form of varicose swellings, flows of a myelin cover, pycnosis of kernels of special cells in receptors, etc. come to light. The very tectonics of vascular network C. in process of change of a relief of a synovial membrane considerably becomes complicated, increases number of an anastomosis with vessels periartikul yarny fabrics.

Processes of aging in S. proceed very individually that depends on a way of life, a profession, the postponed diseases, etc. First of all S. and joints of a backbone are surprised to the mezhfalango-Vyya. Then knee, humeral and coxofemoral S. U of heads of average phalanxes of a brush, at the upper edge (basis) of a patella, medial edge beam and the rear edge of a carinate brush of bones, and also at an upper epiphysis of a tibial bone appear osteophytes. At the age of over 60 years changes in vessels of the joint capsule are found (deposits of salts of calcium, signs of an atrophy, an obliteration, a sclerosis). Ossification of soft tissues of S. and intra joint educations is sometimes noted. On certain sites the joint cartilage becomes thinner and uzurirutsya, its surface grows turbid. At the same time the fringe regions of joint cartilages adjoining on the joint capsule or on sheaves and subchondral zones of compact substance of bones are most vulnerable, in to-rykh sclerous changes come to light.

PATHOLOGICAL ANATOMY

Dystrophic defeats of S. are presented to hl. obr. arthrosis (see) various etiology. The most expressed changes arise in coxofemoral, knee, distal interphalanx and intervertebral (dugootrostchaty. T.) joints. Disturbance of metabolism of a joint cartilage is the cornerstone of arthroses (see. Cartilaginous tissue ), consisting in reduction of amount of proteoglycans in its matrix, change of function of chondrocytes. Microscopically it is expressed in change of tinktorialny properties of the main substance of a cartilage, death of separate chondrocytes and in proliferation of the remained cells. At arthrosis the joint cartilage loses elasticity, elasticity, becomes dry, rough, muddy. In the subsequent there is its razvo-lokneniye, cracking and an ulceration to an exposure of the subject bone, subchondral develops in a cut osteosclerosis (see).

In later stage in the field of an osteosclerosis there are sites of ischemia and a necrosis with formation of cysts. On the periphery of a joint surface where vascularization is better, there occurs compensatory growth of a joint cartilage with the subsequent formation of osteophytes. Along with it is thickened, shrivels and the joint capsule obyzvestvlyatsya sometimes, reactive develops synovitis (see).

Also changes in S. at syphilitic damage of a spinal cord, a myelosyringosis, polyneurites, a cross myelitis, the hemiplegia caused by hemorrhage in a brain have the dystrophic (neurodystrophic) nature. At the same time structural changes are localized also preferential in large Pages. At early stages patol. process in S. the phenomena of hypostasis which are replaced then sclerous changes in a synovial membrane and para-articular fabrics with development prevail osteoporosis (see) in the joint ends of bones.

At inflammatory diseases of S. the synovial membrane, the joint capsule, sheaves, sinews, the paraarticle yarny fabrics are involved in process, in to-rykh hypostasis, a hyperemia, cellular infiltration are noted. Process is followed by an exudate in a joint cavity of serous, serofibrinous, purulent exudate. Serofibrinous arthritis can accompany inf. diseases (pneumonia, measles, brucellosis, dysentery, iyersinioz). Macroscopically at the same time in acute and subacute stages the amount of liquid in a joint cavity increases, on an inner surface of a synovial membrane imposings of fibrin are possible. Microscopically in a synovial membrane along with a plethora and hypostasis ochazhka of mucoid and fibrinoid swelling, in synovial fluid — a large amount of polymorphonuclear leukocytes are found. Upon transition of arthritis in hron. a form as it, e.g., takes place at pseudorheumatism (see), destruction of a cartilage due to the granulations accruing on it in the form of a pannus is noted (see. Arthritises ).

The purulent arthritis developing at S.'s wounds, gonorrhea, sepsis is characterized by a tendency to bystry development of destruction of a joint cartilage (see Arthritises). In the outcome of purulent arthritis can develop fibrous or bone anchylosis (see).

Tubercular defeat of S. arises at hematogenous dissimination of process. Tubercular arthritis is characterized by defeat, first of all, of a synovial membrane. In it there are centers of leukocytic, then lymphocytic infiltration, serofibrinous exudate, sites of a caseous necrosis with formation of massive granulations (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints). Syphilitic defeat of S. meets extremely seldom now. Specific inflammatory process can develop in separate S. at inborn syphilis and at various stages of the acquired syphilis (see. Syphilis ).

METHODS of INSPECTION

At recognition of diseases of S. data of the anamnesis, results a wedge are of great importance., rentgenol. and lab. researches. Most often patients note joint pains. In the analysis of this symptom it is necessary to consider character and intensity of pains, time of their emergence, localization, dependence on movements, reception of pharmaceuticals.

Function C. can be broken in various degree — from difficulty to make a certain movement (it is characteristic of defeat of circumarticular fabrics) to their total absence (usually in the outcome of arthritis). Quite often in the presence in a joint cavity of free bodies (see. Joint mouse ), and also at injury of meniscuses there is «blockade» of a joint, i.e. sudden difficulty or the termination for some term of movements, as a rule, followed by severe pain. So-called morning constraint — difficulty of the beginning of movements during the first hours after awakening can be one of manifestations of passing disturbance of movements in S. This sign is characteristic, e.g., of a pseudorheumatism.

At the long course of a disease, napr, rhematoid and tubercular arthritis, arthrosis, the form S. Patol can change. process in a large joint of the lower extremity quite often causes lameness, change of a bearing, gait (see) etc.

Studying of the general condition of the patient shall precede inspection of a musculoskeletal system. It is necessary to pay attention to its constitutional type; e.g., dystrophic diseases of Page are more inherent to persons of a hypersthenic constitution. Symptoms of endocrine diseases can indicate a possibility of various endocrine arthropathies. Pay attention to a condition of an integument; napr, the peeling, a hyperpegmentation are characteristic of a pseudorheumatism, a plaque on extensor surfaces of elbow, knee joints, a pilar part of the head — of psoriasis defeat. In skin and hypodermic cellulose rheumatic, rhematoid small knots, gouty nodes, etc. can be revealed. At nek-ry options of a current of a pseudorheumatism and diseases of blood with involvement in patol. process of joints is noted increase peripheral limf, nodes and a spleen.

The research C. is conducted in position of the patient lying, sitting, standing also in the course of walking. At the same time it is necessary to watch attentively the movements of the patient upon transition from one situation to another. The struck S. is compared with healthy, and at symmetric defeat of S. define extent of change of everyone. Pages of upper extremities usually inspect in the centripetal direction, lower — in centrifugal.

Survey is begun with definition of position of an extremity in relation to a shoulder girdle or a basin, the segments distally located — to proximal. At the same time the patient shall be in the most convenient for it the situation which is not causing unpleasant feelings in S. Obrashchayut attention to length of an extremity and its segments in comparison with healthy, contractures, changes of a form C. Usually distinguish three types of change of a configuration of S.: a swelling — uniform increase in S. in volume and smoothing of its contours at the expense of hypostasis of circumarticular fabrics and accumulation of an exudate in his cavity; a defiguration — uneven change of a form C. due to exudative and proliferative changes in it, circumarticular fabrics, accumulations of an exudate in torsions of the joint capsule; deformation — gross violation of a form C. owing to changes in the bones forming it and the capsular and copular device.

Skin over S. depending on character patol. process can be hyperemic, intense, brilliant, pale, thinned (usually at inflammatory defeat) or dry and atrofichny (is more often at dystrophic diseases). It is necessary to pay attention to a condition of saphenas (e.g., at a pseudorheumatism they are most expressed around knee joints), existence of rashes (are observed at the arthritises caused inf. diseases), plaques (are characteristic of a psoriasis arthropathy), ulcerations, hems (at banal or specific suppurative processes), on disturbance of pigmentation (the hyperpegmentation meets at hron. current of a pseudorheumatism); existence of small knots and other educations.

At survey of muscles pay attention to its tone, signs of an atrophy and existence of a local spasm.

By means of a superficial palpation define change of temperature of skin over a joint, at easy stroking reveal hypodermic rhematoid and rheumatic small knots, tofusa. Deeper palpation reveals painful points, damage actually of a joint, an inflammation of circumarticular fabrics, pain in nervous trunks and lymphadenitis. Definition of balloting of a patella (see. Balloting ) allows to find an exudate, granulyatsionny fabric, growth of fibers of a synovial membrane in a joint cavity. Increase in a skin fold over a joint (Alexandrov's symptom) along with other signs helps with diagnosis of arthritises. During the imposing of a palm on area C. at the time of active or passive movements easy crepitation (is quite often felt at arthritises) or a rough crunch and a crash (at arthrosis and free bodies in a joint cavity). The similar technique helps to establish localization of a bursitis, a free body, the broken-off joint meniscus. Pressure upon a sacrum and upper front ileal awns in various provisions of the patient on a rigid bed allows to distinguish an inflammation in sacroiliac joints, characteristic of an initial stage of a disease of Bekhterev (see. Bekhtereva disease ).

The research of function C. consists in scoping of active and especially passive movements (see. Goniometriya ), what helps to exclude a variety of reasons of disturbance of the movement, the Page which are not connected with pathology. Absolute mobility in large S. makes: in humeral S. bending and assignment without participation of a shovel — 90 °, with participation of a shovel — 180 °, internal and outside rotation — on 90 °; in elbow S. bending — 150 °, pronation and supination at the expense of a radioulnar joint — on 90 °; in hand S. extension — 70 °, bending — 80 — 90 °, reduction — 50 — 60 °, assignment — 30 °; in coxofemoral S. bending — 120 °, overextension — 10 — 15 °, assignment 40 — 45 °, reduction — 20 — 30 °, internal rotation — 40 °, outside rotation — 45 °; in a knee joint bending — 150 °; in talocrural S. bending — 45 °, extension — 20 °; in subcollision S. supination — 30 °, pronation — 20 °. Comparison of the greatest possible passive movements in a joint with the similar movements in pair healthy S. reveals not only restriction of function C., but also existence in it patol. the mobility which is observed at individual diseases (a syphilitic, siringomiyelitichesky arthropathy) and damages (a rupture of crucial, collateral ligaments of knee S.).

S.'s auscultation has limited use. However in some cases, especially at defeat of circumarticular fabrics (a humeroscapular periarthritis, the «clicking» finger), it helps to characterize a disease more precisely. Auscultation is carried out by a phonendoscope during passive movements with registration by a goniometer of situation, in Krom there is a noise.

S.'s percussion after an artropnevmografiya (see. Artrografiya ) gives the chance to establish the sizes of joint torsions — reduced at a pigmental villeznom, rhematoid and other inflammatory defeats of a synovial membrane and increased — at hyperproduction of synovial fluid that can meet, e.g., at a highly active peripheral form of a disease of Bekhterev. Local pain at effleurage on bones of extremities helps to differentiate joint pains from pain in bones (ossalgiya).

ROE which is usually raised at inflammatory defeats of S. at dystrophic diseases practically does not differ from norm and seldom (at secondary synovites) reaches 30 mm an hour. To inflammatory diseases of S., especially purulent, svoystven the expressed leukocytosis. Moderate anemia of holes-mokhromnogo of type is characteristic of a pseudorheumatism, expressiveness a cut usually corresponds to activity of a disease.

Detection of rhematoid factors in blood serum by means of Voler's reactions — Rouza, positive latex test and dermato-lovy test more often happens at a pseudorheumatism (see), by test of rosetting (see Rosetting tests) it is possible to define a rhematoid factor when usual reactions happen negative.

For confirmation of the diagnosis of gonorrheal arthritis use Borde's reaction — Zhangu (see. Reaction of binding complement ). Wright and Haddlson's reactions (see Wright reaction., Haddlson reaction), Byurne's test is applied at diagnosis of brucellous arthritis (see the Brucellosis). At suspicion of tubercular and syphilitic arthritis it is necessary to carry out respectively Mantoux reaction (see. Tuberculinodiagnosis ) and Wassermann reaction (see Wasserman reaction).

Rentgenol. the research C. is conducted with tselyo identifications of a form and structure of the jointed bones, by thickness of joint cartilages and a condition of surrounding soft tissues, and also patol. processes and dynamics of their development. Shooting is made in the standard projections which are easily reproduced at repeated researches. The choice of a projection and laying of the patient at S.'s pathology quite often presents certain difficulties. The village needs to be explored in two projections (direct and side). In some cases carry out also a X-ray analysis in additional projections, apply functional rentgenol. a research, a tomography, an artrografiya with contrasting, a fistulografiya, etc. At any S.'s research in standard projections the image of the bones forming it, a joint crack giving the idea of a condition of joint cartilages, and surrounding S. of soft tissues allowing to judge the joint capsule, sheaves, sinews shall be received.

Humeral and coxofemoral S.'s X-ray analysis is usually made in one projection. At detection of aberrations, and especially at suspicion of pathology the research can be added with a X-ray analysis in special laying.

Fig. 1. It is normal of the roentgenogram of the right shoulder joint: and — in a direct projection; images of the bones forming a shoulder joint accumulate at each other, the joint crack is not traced; — at special laying with turn of the patient to the right on 30 — 45 °; clearly the bones forming a shoulder joint and a joint crack are visible (it is specified by shooters).

Obtaining the image of a joint crack does not represent serious difficulties at the unimpaired S.' research; at the same time use standard laying. However at diseases of S. which are followed by contractures for obtaining their optimum image it is necessary to stack that bone on the cartridge, edges forms a joint hollow, napr, at a X-ray analysis of a shoulder joint — a shovel. For this purpose the patient have lying or standing a back to a support with turn on 30 — 45 ° on the studied party so that the shovel laid down on a support. In this situation the joint hollow of a shovel is located perpendicular to a film that allows to receive the image of all joint crack (fig. 1).

Elbow S.'s X-ray analysis is at a loss at a flexion contracture of a forearm. In this case for obtaining the image of a joint crack it is necessary to stack a forearm so that it lay on a table with the supinated brush. At a flexion contracture in knee S. the shin shall adjoin to a table. For this purpose the patient is stacked on a stomach, and under it enclose special boxes and pillows. In situation on a stomach it is rational to make shooting and in the absence of a contracture since it allows to receive roentgenograms, easily comparable at dynamic observation. Anatomic features of an ankle joint (see), and also phalanxes and mezhfalan-govy S. feet (see) cause considerable difficulties at their research.

The objective information about weight of defeat of S., activity of an inflammation, prevalence of process and efficiency of treatment give thermovision (see Termografiya) and a radio isotope research (see).

S.'s puncture by means of a needle — frequent diagnostic reception. Research of a joint exudate (color test, transparency, viscosity of a joint exudate, its cellular and biochemical structure, if necessary bacterial. the research) allows to differentiate various inflammatory diseases of S. and dystrophic defeats.

Arthroscopy (synonym: endoscopy of joints, an artroendoskopiya) — a research of a cavity of a joint by means of the optical device of an artroskop. It is applied for the purpose of diagnosis and treatment at damages and S.'s diseases, sometimes to control of results of treatment. In clinic knee S.'s arthroscopy found application; there are single messages on an arthroscopy of other joints. For the first time knee S.'s arthroscopy on a corpse by means of the cystoscope was carried out in 1918 by Takagi (To. Takagi). In 1920 it made an arthroscopy by means of an artroskop of own design at patients with tubercular gahnite. This method gained recognition only in the 60th after in 1959 Watanabe (M. of Watanabe) and S. Takeda created technically convenient model of an artroskop (artroskop Watanabe No. 21). In the USSR knee S.'s arthroscopy was executed for the first time N. A. Pollyak (1962) and B. I. Kirsanov (1963). In sovr. art roskopakh the fiber optics is used. There are artroskopa with a small diameter of a tube for a research of various joints, including joints of fingers. The surgical tools allowing to carry out an arthrolysis, washing of a joint cavity, a partial meniscectomy, removal of free bodies enter a set of an artroskop. In the course of an arthroscopy the biopsy of a synovial membrane under control of sight and photography of intra joint structures is possible.

Artroskop and tools will sterilize during 24 hours in vapors of formalin. The research is carried out in the operating room under anesthetic or local anesthesia. C are most convenient for an arthroscopy knee. lower anteroexternal (main), lower anteromedial and upper outside accesses. Through a section of skin a trocar with a sharp-pointed stylet puncture with length apprx. 4 mm in the knee joint bent at right angle the joint capsule. After change of a sharp-pointed stylet with a stylet with the rounded-off end the joint is unbent, through a patellofemoralny joint (the knee S.'s part located between the patellar surface of a femur and the joint surface of a patella) get into a cavity of upper torsion, take a stylet and entered artroskop. S.'s cavity is filled with sterile isotonic solution of sodium chloride and study its various departments. Upper torsion and a patellofe-moral part of knee S. are examined at the unbent S.; function of a patellofemoralny joint (its congruence, an incomplete dislocation of a patella) is studied at gradual extraction of an artroskop and bending of an extremity in knee S. (within 50 — 60 °); for survey of internal department of knee S. the extremity is bent on 90 °, the shin is rotirut by knaruzh and take away, examine intercondyloid area (crucial ligaments, a back horn of a medial meniscus); the outside department of S. is inspected, bending an extremity in S. at an angle 120 °, the shin is rotirut by knutr and bring, artroskop have in the sagittal plane (from top to down).

Fig. 5 — 10. The arthroscopic picture of a knee joint is normal also at separate forms of pathology. Fig. 5. The arthroscopic picture is normal: 1 — an entocondyle of a femur; 2 — an internal meniscus; 3 — the joint surface of a tibial bone; joint surfaces smooth, brilliant. Fig. 6. The front crucial ligament is normal (it is specified by shooters). Fig. 7. The Patellyarny surface of condyles of a femur at an initial stage of a pseudorheumatism (the crawling pannus is specified by an arrow). Fig. 8. Razvolokneniye of a surface layer of a cartilage on a joint surface of a condyle of a femur at the I stage of the deforming arthrosis (it is specified by an arrow). Fig. 9. Destruction of a joint cartilage with the certain remained its whitish sites (are specified by shooters) on a condyle of a femur at the III stage of the deforming arthrosis. Fig. 10. Razvolokneniye of a surface layer of a joint cartilage at a chondromalacia of a nadkrlennik (it is specified by shooters).

The synovial membrane of a knee joint of reddish-pink color with a small amount translucent vorsin is normal of a various form; it has a wavy appearance at the expense of folds, accurate capillaries. A joint cartilage of a patella and condyles of a hip bright white, brilliant, a tibial bone — with a yellowish shade (tsvetn. fig. 5). Meniscuses of white color with a smooth brilliant surface and keen free edge. The front crucial ligament has tendinous structure and thin gyrose vessels on edge (tsvetn. fig. 6). The changes found by means of an arthroscopy at injuries of a joint cartilage, crucial and collateral ligaments, meniscuses at inflammatory and other diseases — see. Knee joint , table, and also tsvetn. fig. 7 — 10.

In diagnostically difficult cases during the carrying out an arthroscopy resort to a biopsy.

Superficial injuries of a joint cartilage, a hemarthrosis, a reactive synovitis as result of an arthroscopy usually do not demand special treatment.

PATHOLOGY

S.'s Pathology includes malformations, damages and diseases.

Malformations joints arise on 4 — 12 weeks of embryonic development under the influence of various teratogens (see Malformations). They are considered as a part of malformations of extremities, a backbone, thorax, face bones and a basin (see the Thorax, the Brush, the Backbone, Foot).

The diagnosis is based on data of survey, a palpation, results of anthropometry (see), an uglometriya and a X-ray analysis of joints of extremities, a backbone and a thorax.

Treatment complex. In surgical treatment all types of skin plastics (see), bone plastics found application (see), for stabilization of joints by means of repozitsionny, distraktsionno-compression devices (see). Recovery process most often is multi-stage.

The forecast depends on severity of a malformation, a condition of other bodies and systems. Patients with malformations of S. are disabled people and most of them needs special guardianship.

Injuries of joints arise owing to influence of various mechanical factors and can be open and closed. Wounds of area C. and open intra joint changes belong to open damages (see). Not getting open damages, at to-rykh are damaged one or two layers of the joint capsule, but the synovial membrane remains, and getting — with damage of all layers of the joint capsule — treat according to the general rules of treatment of wounds, including surgical treatment of a wound (see), an immobilization of a joint, antibacterial treatment, etc. (see Wounds, wounds).

The closed S.'s damages — bruises, stretchings and ruptures of the capsular and copular device, damage of intra joint educations, dislocations (see), incomplete dislocations, intra joint changes. They can be followed by cracks of an epiphysis, a rupture of meniscuses of a knee joint, hemorrhage in a joint cavity and the capsule (see. Hemarthrosis ). Blood clots and fibrin are postponed for the surfaces of joint cartilages and a synovial membrane therefore the aseptic productive inflammation develops. In a joint cartilage at a hemarthrosis there occur the dystrophic changes connected with an injury and an immobilization of Page. Along with a resorption of a cartilage in S.'s cavity proliferative changes, development of granulyatsionny fabric (see) and commissures (see), education are noted contractures (see) and ankiloz (see).

S.'s bruises usually are a consequence of direct impact on it the injuring factor (blow, falling on S., etc.), especially S. which are not covered with muscles or a little covered napr, knee, talocrural, elbow. For the diagnosis matter an injury of a joint in the anamnesis and existence of pains in it. The exception of heavier damages of S. (a rupture of sheaves, changes) with use of methods rentgenol is obligatory. researches. At a bruise in S. liquid (a symptom of tension of the joint capsule, the balloting patella, increase in volume of torsions of S.), puffiness and a swelling of circumarticular soft tissues can be defined.

First aid at bruises consists in creation of rest. At slight injuries (without the expressed hemarthrosis) it is enough to apply a soft compressing bandage area C. At heavy bruises with formation of a hemarthrosis (see) the early puncture of S., anesthesia of 2% by solution of novocaine and removal of the blood which streamed in S. are shown. Within the first days it is necessary to apply cold locally. S.'s fixing is carried out by the plaster tire during 1 — 3 week. With 3 — the 4th day after an injury appoint heat and physiotherapeutic procedures to area C. At the correct treatment of the movement in S. are recovered in full in 2 — 4 weeks.

Fig. 2. The diagrammatic representation of a part of a joint at a partial, full rupture of sheaves and at a separation of sheaves together with a plate of compact substance of a bone (in).

Stretchings and ruptures of the kapsulnosvyazochny device arise owing to violent ultraboundary movements in S. which are followed by a sharp tension of sheaves, and then and their gap most often at places of an attachment of sheaves to a bone (see. Distortion ). Depending on intensity of the injuring force the gap can be partial and full (fig. 2, and, b). It is conditionally accepted to call a partial rupture of fibers of a sheaf stretching of a sheaf. At a rupture of sheaves there is acute local pain, the swelling of fabrics and restriction of movements in S. owing to pains is observed. At a tension of a sheaf local pain sharply amplifies. Identification of this symptom demands care not to increase a rupture of a sheaf. The separation of a sheaf can occur at the place of its attachment together with a plate of compact substance of a bone (fig. 2, c). In old cases the diagnosis of a rupture of sheaves can be confirmed radiological. For this purpose during S.'s X-ray analysis create conditions of an excess tension of sheaves from damage. E.g., for the purpose of diagnosis of injury of a tibial collateral ligament of knee S. of a hip bandage to each other above knee S., and at the level of the lower third of a shin insert the strut creating assignment of shins. Both S. are removed on one film. Comparison on the roentgenogram of width of medial departments of joint cracks of both S. gives the chance to confirm or exclude the diagnosis of a rupture of sheaves since on the party of damage the joint crack is usually expanded. For diagnosis of damages of acromial and clavicular S., and also the capsular and copular device of humeral S. carry out a X-ray analysis in position of the patient standing after it held in hands within 5 — 8 min. any load. At suspicion on a rupture of teams of talocrural S. the so-called derzhany X-ray analysis (by means of a strap the back department of foot is given the provision of assignment or reduction) is shown.

Fig. 3. Imposing of a figure-of-eight bandage on an ankle joint at sprain: and — a medial (deltoid) sheaf — a calcaneal and fibular sheaf; shooters specified the direction, in Krom impose tours of a bandage.

At first-aid treatment by such patient the fixating bandage by soft bandage, a so-called figure-of-eight bandage, with observance of conditions of the maximum rapprochement of points of an attachment of sheaves (fig. 3) can be applied area C. At the complete separation of sheaves leading to disturbance of stability of S. make sewing together of sheaves. Treatment of stretchings and ruptures of sheaves includes creation of position of an extremity, at Krom of a point of an attachment of sheaves as much as possible approach. In such situation segments of extremities shall be recorded by a plaster bandage for a strong union of sheaves for the term of 5 — 6 weeks. In old cases of ruptures of sheaves (later more than 4 weeks after an injury) their plastics is shown. The plastics local fabrics (a sinew, an aponeurosis, a fascia) is most effective, in some cases lavsan can be used.

Injury of a joint cartilage can be caused by blow to Page. At the same time there is a gap and amotio of a cartilage, fragments to-rogo become free intra joint bodies (see. Joint mouse ). In fresh cases such damage is usually regarded as a bruise of Page. Over time, if in S. pains remain, there is its blocking, feeling of a crunch, and sometimes and sharp click at the movements, it is necessary to suspect injury of a joint cartilage. The artropnevmografiya of joints allows to specify the diagnosis (see. Artrografiya ). On the roentgenogram against the background of the gas entered into a joint cavity injury of a joint cartilage is defined. Treatment consists from a joint cavity in the operational way of sites of the exfoliated cartilage and free fragments at a distance. The forecast after operational treatment favorable.

Dislocations (see) in S. are always combined with a rupture of its capsule, a hemarthrosis.

Very often in S. disks and meniscuses (see Meniscuses joint), especially in knee and akromi-alno-clavicular, and also crucial ligaments of a knee joint are damaged (see). Injuries of joint cartilages and other fabrics can come owing to is long the operating injuring factors of small force (see. Microtrauma ).

Heavy damage with the bad functional forecast are intra joint changes (see).

Fighting damages, stage treatment. S.'s wounds classify by the form a hurting shell, to the nature of wound (getting and not getting), damage rates of soft tissues and a bone, and also by the damages of large vessels and nerves accompanying them. The getting S.'s wounds differ in heavier a wedge, a current and frequent development of complications.

By experience of the Great Patriotic War gunshot wounds of large S. were observed approximately in 5% of cases of all fire damages. At the same time missile wounds were noted in 55,2%, bullet — in 44,7% and wounds by secondary shells — in 0,1% of cases. Frequency of damages of separate large S. made: humeral — 24%, elbow — 22,9%, coxofemoral — 6,6%, knee — 31%, talocrural — 13,8%. Simultaneous injury of several joints was observed in 1,7%. The getting wounds made 57,3% which are not getting — 42,7%. 62% wounded in S. had injuries of a bone. At S.'s wounds of damage of large vessels of upper extremities took place in 2,7%, lower — 4,6%; nerves of upper extremities were injured in 11,9%, lower — in 6,2% of total number of wounds of Page. S.'s wounds of upper extremities in most cases proceeded more favorably, than S.'s wounds of the lower extremities. So, also flow phlegmons at humeral S.'s wound were available for 48% of wounded, knee — for 53,3%, coxofemoral — for 76%. Distinctions of a current and outcomes of wounds of joints are caused by their ana-tomo-physiological features.

At fighting damages of S. changes in a bone tissue have the conducting value. At gunshot wounds of S. as a result of direct and side blow of a shell in a bone tissue there are hemorrhages, bone crossbeams collapse, there comes the necrosis of marrow. At extensive destructions of S. and infection of a wound the purulent inflammation in spongy substance of a bone (see Osteomyelitis) and purulent arthritis develops. Heavy purulent arthritis quite often is complicated by phlegmon of the joint capsule, can be formed flow, the intermuscular phlegmons leading to exhaustion and sepsis (see).

Purulent arthritis at humeral S.'s wounds occurred at 28%, coxofemoral — at 83%, knee — at 89,6% of wounded.

Deterioration in the general condition of the wounded, high temperature, strengthening of pains in a joint, emergence of signs of an inflammation, allocation from a wound of muddy synovial fluid or pus testify to the developed infection. Unsharply expressed dermahemia, the considerable purulent exudate in a joint, pain at rest amplifying at the movements, a satisfactory general condition of the wounded despite high temperature of a body are characteristic of S.'s empyema (to 38 — 39 °). Phlegmon of the joint capsule is characterized by S.'s increase in volume due to infiltration of the joint capsule and circumarticular fabrics, an insignificant exudate in S., intolerable spontaneous pains, early emergence of the expressed intoxication, high temperature and a serious septic condition. The osteomyelitis developing in areas of an epiphysis of bones leads to strengthening of pains and an aggravation of symptoms of the wounded, and in the started cases is followed by formation of intermuscular zatek. A mephitic gangrene (see) it is more often observed at the getting wounds of Page. Before development of its signs the general condition of the wounded worsens, there is an apathy, slackness, the general weakness, pulse becomes frequent to 110 — 120 ud. in 1 min. In a wound sites of a necrosis of fabric, small vials of gas are visible; hypostasis of muscles is noted, to-rye get pale coloring.

At diagnosis of fire damages of S. consider localization of entrance and output openings of a wound, the direction of the wound channel, the expiration from a wound of synovial fluid, existence in it of the bone fragments covered with a cartilage, fragments of a joint cartilage, deformation of a joint and position of an extremity, existence in a joint cavity of blood, morbidity at S.'s palpation and the movements in it and also restriction of mobility of S. Inogd at preservation of an integrity of the joint capsule can be the intra joint changes caused by force of side blow of a hurting shell. At such wounds in a joint cavity blood streams, to-ruyu it is possible to find by means of a puncture. Results rentgenol. researches allow to specify the nature of damage of the joint ends of bones, rate of decay of a bone tissue and existence in S. of foreign bodys. At use sovr. types of firearms the damage rate of vessels, nerves and a bone tissue increases.

First aid (see) the wounded with S.'s damages includes a stop of bleeding by means of a plait (compressing bandage) and imposing of a protective bandage. The immobilization (see) extremities is carried out by hl. obr. by means of make-shifts, and also by a pribintovyvaniye of a wounded lower extremity to a healthy, and upper extremity to a trunk. At a stage of rendering the pre-medical help (see) enter analgetics, exercise control and correction of bandages, tires and styptic plaits. At weak outside bleeding the plait is replaced with a compressing bandage; enter anesthetics and antibiotics. The immobilization of the injured extremity is improved by means of transport tires (see. Splintage ). At a stage of rendering the first medical assistance (see), during the carrying out medical sorting (see Sorting medical) allocation of the following groups of wounded with damages S. is provided: the wounded needing according to urgent indications medical assistance in the conditions of a dressing room (wounded with the imposed plait and not stopped bleeding, in state of shock, and also with extensive damages when there is a threat of development of shock); the wounded needing medical assistance in a dressing room in the second turn (who arrived without immobilization or with an insufficient immobilization, needing introduction of antibiotics and change of a bandage); and, at last, the wounded who are subject to evacuation without rendering the first medical assistance. In the course of rendering the first medical assistance control, correct or replace bandages, tires and styptic plaits, check correctness of indications to use of a plait. The temporary stop of bleeding at nek-ry wounds is carried out by imposing of a compressing bandage, and sometimes a clip on the bleeding vessel in a wound; enter antibiotics, antitetanic serum and adsorbed tetanic by anatoksinony Carry out the antishock actions ensuring safety of further transportation.

At a stage of rendering the qualified medical care (see) at medical sorting allocate the following groups of wounded: needing the surgical help first of all (according to urgent indications); needing the surgical help in the second turn: the subject evacuations in GB; lightly wounded, to-rye can be left in MSB in team recovering at the term of treatment up to 10 days.

The indication to an urgent operative measure are the proceeding bleeding, the imposed styptic plait, the accruing hematoma, crush of an extremity, shock, a mephitic gangrene. In the second turn primary surgical treatment of wounds (see) carry out at wounded with the injuries of joints which are followed by extensive destruction of soft tissues. Wounded are brought out of state of shock, carry out a final stop of bleeding.

At dot wounds without considerable crush of fabrics, hypostasis, symptoms of suppuration are limited only to processing of skin around a wound and infiltration by its solution of antibiotics. During the carrying out surgical treatment of a wound define a damage rate of fabrics.

At the wounds caused by shells with high initial velocity fabrics on considerable removal from the wound channel can be damaged. The wound is cut all the way down that allows to conduct its research, and also to remove the foreign bodys which are freely lying in a wound small bone splinters and to economically excise impractical fabrics. The wound is plentifully washed out disinfecting solution, drained, if necessary resort to counteropenings (see), put a deaf stitch on the joint capsule. Surgical treatment is finished with an obkalyvaniye of edges of a wound solution of antibiotics. The wound is not sewn up, and closed the friable gauze bandage providing conditions for a good drainage. The improvised tires replace organic. Sheena Diterikhsa strengthen plaster rings. The wounded who is subject to evacuation enter antibiotics (better into fabrics around a wound) and anesthetics.

At stages of rendering specialized medical care (see) the wounded with fire injuries of joints according to indications carry out local anesthesia in the field of wounds, enter antitetanic serum and the adsorbed tetanic anatoxin (if they were not entered earlier), carry out a X-ray analysis of the damaged segment of an extremity in two projections before and after reposition, and also in the course of treatment; radical surgical treatment of a wound (primary and if necessary repeated), according to indications — a vascular seam (see) and a neurorrhaphy (see. Nervous seam) and reliable immobilization. Besides, make operative measures concerning various complications of wounds of Page. At dot wounds without considerable hematoma and inflammatory changes conservative treatment with introduction to the wound channel and S. of solution of antibiotics is shown. At a hemarthrosis (see) are shown S.'s puncture with removal of blood and introduction to his cavity, and also intramusculary antibiotics, an immobilization of an extremity. At more extensive damage of soft tissues with insignificant damage of the joint ends carry out primary hirurgich. processing of a wound with economical excision of fabrics, is opened by pockets and hematomas, on the joint capsule put a deaf stitch. If after surgical treatment the joint capsule cannot be sewn up, then its defect is closed surrounding soft tissues. Enter antibiotics into a joint cavity and circumarticular fabrics, immobilize an extremity a circular fenestrated plaster bandage (see. Plaster equipment ) or the device for an extra focal chreskostny osteosynthesis (see). At considerable destruction of the joint ends of bones, besides, carry out S.'s resection or artificial ankylosis (see) by means of devices for extra focal chreskostny fixing. At the coxofemoral S.'s damages complicated by heavy purulent destructive process the resection of a head of a femur is shown. If after primary surgical treatment the purulent inflammation progresses, then repeated surgical treatment with obligatory excision of impractical fabrics, opening of purulent zatek, creation of good outflow is necessary for wound contents by imposing of counteropenings; enter antibiotics, transfuse blood and carry out fortifying treatment. At arthritis with quickly occurring deterioration in the general condition of the patient make a resection of Page. The plaster immobilization of humeral, elbow S. is carried out with the help a Torah-kobrakhialnoy of a bandage, radiocarpal S. — by means of the plaster bandage applied from the middle of a forearm to heads of metacarpal bones, coxofemoral and knee — by means of a koksitny plaster bandage, talocrural — a plaster bandage to an upper third of a shin. Frailty of an extremity as a result of heavy damage of the joint ends of bones with extensive destruction of soft tissues and damage of vessels is the indication to primary amputation (see) or an exarticulation (see).

At S.'s empyema its daily puncture, introduction of antibiotics and constant irrigation of S. by them, an immobilization of an extremity are shown by a plaster bandage. In the absence of effect in the next 2 — 3 few days the arthrotomy (see) and audit of a cavity of Page is shown. At osteomyelitis of the joint ends of bones, the panarthritis which is followed by purulent zateka and sepsis make amputation of an extremity.

Diseases. Carry not only various forms of defeat of a musculoskeletal system (bones, joints, muscles, circumarticular soft tissues), but also the nek-ry general diseases and syndromes proceeding with damage of joints to S.'s diseases (rheumatism, a system lupus erythematosus, a disease of Reuters, Bekhchet's syndromes, Shegrena, etc.). The general for all this group of diseases are similar changes of connecting fabric, defeat of a musculoskeletal system with a pain syndrome and disturbance of its function.

In structure of diseases of S. relative increase hron is observed in the last decade. forms that is explained by decrease in incidence of rheumatism, effective antibacterial therapy at acute inf. arthritises and increase in life expectancy of people with inherent in the senior age groups hron. diseases of joints and backbone.

Numerous forms of defeats of S. can be subdivided into primary nosological forms and secondary joint syndromes which are observed at various diseases. Primary actually joint diseases have the greatest social value, to-rye often are followed by temporary or permanent disability.

Primary diseases of S. on the origin and a current divide into two basic groups: inflammatory diseases — arthritises (see) and dystrophic diseases — arthroses (see). Carry a pseudorheumatism to the most typical inflammatory diseases of S. (see), Bekhterev's disease (see Bekhterev a disease), inf. arthritises — tubercular, syphilitic, gonorrheal, etc., psoriasis arthritis (see Arthritises), a disease of Reuters (see Reuters a disease), metabolic arthritises (see Gout, Hondrokaljtsinoz).

The group of arthroses is made: the deforming osteoarthrosis (see Arthroses), the osteochondrosis (see) deforming a spondylosis (see), an osteochondropathy (see).

Secondary joint syndromes are one of manifestations of a number of diseases. Arthritises at allergic diseases, diffusion diseases of connecting fabric concern to them — a system lupus erythematosus (see), sclerodermas (see), etc., lungs (bronchogenic cancer, pneumonia, etc.), blood — leukoses, hemophilia (see), a lymphogranulomatosis (see), went. - kish. a path (nonspecific ulcer colitis, Whipple's disease, a disease Krone), a nervous system — a myelosyringosis (see), back to tabes (see), a sarcoidosis, endocrine diseases — a diabetes mellitus, an acromegalia (see), a hyperparathyreosis, etc., at malignant tumors and other diseases. The secondary joint syndrome can have various a wedge, manifestations — from an arthralgia \see) to hron. arthritis. Their general feature are often asymmetric defeats of S. without tendency to an ero-zirovaniye of joint surfaces and development of an anchylosis, parallelism of their current with development of a basic disease, efficiency of the special methods of treatment directed to suppression of the basic patol. process.

At the I All-Union congress of rheumatologists (1971) classification of diseases of joints and extraarticular soft tissues of the musculoskeletal device is accepted. In it allocate: the main forms of diseases of joints and a backbone — arthritises, arthroses and such special forms as inborn diseases and syndromes — an inborn dysplasia of a hip, anomaly of a backbone (see), an osteochondrodystrophy (see. Gargoilizm ), Marfan's syndrome (see. Marfana syndrome ), etc., tumors — synovioma (see), primary tumors of an epiphysis of bones, a chondromatosis of joints (see), a pigmental villonodulyarny synovitis; psychogenic arthropathies; the arthritises and arthroses connected with other diseases; damages of joints at the opened and closed injury; extraarticular diseases of soft tissues of a musculoskeletal system with defeat of synovial bags and vaginas — a bursitis (see), tendovaginitis (see), fibrous and fabric educations — a periarthritis (see) — humeroscapular, knee, an epicondylitis, a styloiditis, trochanteritisis (see), tendovaginites (the latched finger, a syndrome of a carpal tunnel), a fasciitis, aponevrozit — palmar fibromatoses (see. Dyupyuitrena contracture ) and to Lidderkhoza, muscular tissue — a miositis (see), the mialgiya (see), miofastsiit, miokaltsinoz, miopatoza, somatic and autonomic nerves — neuritis (see), neuralgia (see), sympathetic truncites (see), neuroreflex and l go dystrophy — a syndrome a shoulder — a brush, Zudek's syndrome (see. Zudeka atrophy ), hypodermic fatty tkanp — panniculites (see), etc.

The main differential diagnostic characters of a number of diseases of joints are given in the table.

Tumors. Allocate two groups of tumors of S.: the tumors of soft tissues developing in a synovial membrane, the joint capsule and circumarticular fabrics, and a tumor of bones.

Tumors of soft tissues. From benign tumors of soft tissues the high-quality synovioma most often meets (see). Also rare tumors — a lipoma are described (see) and hemangioma (see) synovial membranes, more often arising in circumarticular fabrics.

A wedge, displays of benign tumors of soft tissues depend on their localization. With a growth of a tumor the node of usually rounded shape, a plotnoelastichesky or soft, pasty consistence is ekstraartikulyarno palpated. The tumor grows slowly and, only reaching the big sizes, can cause pain or break function of an extremity.

At tumors of intra joint localization pains, embarrassment and a crunch in a joint at the movement can develop, hypostasis of fabrics over area of defeat, an exudate in a joint.

Treatment is operational, consists in excision of a tumor. Forecast favorable.

The most frequent malignant tumor of soft tissues of joints is synovial sarcoma (see the Synovioma), the liposarcoma meets less often (see). In the field of large S. can be observed a fibrosarcoma (see) and an angiosarcoma (see), but they are, as a rule, not connected with the joint capsule. About origins of malignant tumors of soft tissues of S., as well as all group of sarcomas, is known not much. More than a half of patients indicate the injury preceding emergence of a tumor. It is considered to be that sarcomas of soft tissues very seldom arise from the previous benign tumors or hems. The exception is made by a fibrosarcoma which quite often develops in cicatricial fabric.

Malignant tumors of soft tissues of joints have various consistence — pasty, dense, elastic or ligneous.

Synovial sarcoma and a fibrosarcoma belong to the category of dense tumors; the elastic consistence is more characteristic of an angiosarcoma and a liposarcoma. Despite the expressed infiltrative growth, considerable number of sarcomas of soft tissues has the rounded or ovoidny shape and rather accurate contours that gives them looking alike high-quality new growths.

The wedge, the course of sarcomas of soft tissues differs in an extreme variety. In one cases the tumor slowly increases in sizes and does not give the remote metastasises; in others — its rapid growth is noted, after excision of a recurrence does not occur, but multiple metastasises preferential in lungs come to light. Often painless tumor is a find at survey. Different pain and emergence of a painful tumor are less often noted; intensity of pains is, as a rule, small and only at germination in a bone they become painful and constant. One of constant symptoms (to 80% of cases) is restriction of mobility in S. that is connected with infiltration and germination by a tumor of surrounding fabrics. At germination in a bone the tumor becomes almost not movable. Idiosyncrasy of sarcomas of soft tissues — their shift in transverse direction and insignificant mobility in longitudinal.

The wedge, symptoms of malignant tumors of soft tissues of joints have no specific character for any one type of sarcoma. However they form the basis for the assumption of existence of a malignant tumor and use in the diagnostic purposes of additional methods of a research.

Diagnosis is based on comprehensive examination of the patient, a cut includes a wedge., rentgenol. and morfol. research. With the help rentgenol. researches in the field of an arrangement of a tumor approximately the shadow of a new growth is found in 90% of patients. Approximately at 15% of patients in fabric of a tumor reveal calcificats. Both of these symptoms can be observed almost at all types of sarcomas of soft tissues, a number of benign tumors (a lipoma, a hemangioma), and also at not tumoral defeats (an ossifying miositis, posttraumatic changes).

At X-ray inspection also secondary changes of bones in the form of a periostitis, an uzuration of a bone and its destruction come to light. These signs are late, reflect the invasive growth of a tumor, feature of its localization and prevalence of process. In the diagnostic relation contrast methods of a research are of great value — angiography (see) and an artrografiya (see). At an angiography it is found excessive patol. vascularization and diffusion treatment of a tumor a contrast agent that allows to distinguish high-quality new growths from malignant, and in nek-ry cases to specify gistogenetichesky accessory of a tumor, napr, angiosarcomas. Artropnevmografiya gives clear idea of depth of spread of a tumor, its ratio with a bone, allows to reveal shadows of not palpated satellites.

Morfol. diagnosis usually begins with tsitol. researches, a cut approximately in 90% of cases of malignant tumors of soft tissues allows to reveal them. The puncture biopsy has great opportunities in establishment of gisto-genetic accessory of a tumor. The Intsizionny biopsy is applied according to special indications as the final stage morfol. diagnoses of malignant tumors of soft tissues. An indispensable condition of its carrying out is respect for all principles of an ablastika (see Tumours, surgical treatment).

Characteristic biol. line of sarcomas of soft tissues is tendency to recuring after removal. Metastasises in regional limf, nodes occur at 15 — 20% of patients. An angiosarcoma (see), a rhabdomyosarcoma (see), a malignant synovioma and a fibrosarcoma are most inclined to lymphogenous innidiation (see). Sarcomas of soft tissues (see. Sarcoma ) have the expressed ability of selective innidiation in the hematogenous way that is noted at 15 — 60% of patients.

The main method of treatment of the majority of sarcomas is an operative measure — broad excision of a tumor or amputation (exarticulation) of an extremity. The last is shown at the big sizes of a tumor, its germination in a bone, unsuccessfulness of safe operations, the breaking-up bleeding tumor (see. Amputation , Exarticulation ). Radiation therapy (see) as the independent method is used seldom, usually with the palliative purpose when an operative measure cannot be executed. Often it is used in the preoperative period for reduction of the sizes of a tumor or in the postoperative period if there is no confidence in radicalism of an operative measure.

The forecast depends on gistogeneti-chesky accessory of a tumor, timeliness and radicalism of the carried-out treatment.

Tumors of bones. The most frequent benign tumors affecting bone structures of S. are a chondroma (see), an osteoblastoclastoma (see), a hondroblastoma (see). The last meets more often at teenagers and young men and the wedge, a current differs peculiar. Patients show complaints to the aching pains in the affected joint, lameness, fatigue of an extremity. At survey the atrophy of muscles of an extremity, restriction of mobility in S., sometimes a flexion contracture, the phenomena of a synovitis is noted (a smoothness of contours of a joint, an exudate in it, increase in local temperature). Progressing of process can lead to break of a tumor in a joint. Treatment operational. The forecast at timely treatment favorable.

From malignant tumors of bones of S. an osteosarcoma (see), parostaljny sarcoma (see), the malignant osteoblastoclastoma, Ewing's tumor are most frequent (see. Ewing tumor ), a reticulosarcoma (see. Reticulosarcoma of a bone primary ) and a chondrosarcoma (see). According to All-Union oncological scientific center of the USSR Academy of Medical Sciences of 65,4% of all bone sarcomas S. is localized in the field of large: 48,9% in the field of knee S., 8,9% — humeral, 5,9% — talocrural and 1,7% — in the field of elbow Page. Sarcomas of bones are more often observed at children's, teenage and youthful age; a chondrosarcoma and parostalny sarcoma — at mature age. At detection of a tumor of a bone at patients aged after 40 years it is necessary to exclude its secondary metastatic origin first of all. The vast majority of patients in the anamnesis has instructions on an injury.

The wedge, a picture of primary tumor of a bone depends on its structure, localization and extent of distribution to surrounding fabrics. The pains accruing on intensity amplifying at night not decreasing at rest and even at an immobilization of an extremity are characteristic of the majority of malignant tumors of bones. The sizes of a tumor can be various, the largest size is reached by a chondrosarcoma and parostalny sarcoma. In process of growth of a tumor there can be contractures in S., an atrophy of muscles of an extremity, at nek-ry forms of new growths (Ewing's sarcoma, primary reticulosarcoma of a bone) are quite often observed patol. changes.

Diagnosis is based on comparison of these clinical, X-ray and morphological trials.

Bone sarcomas metastasize in usually hematogenous way preferential to lungs. Lymphogenous innidiation and secondary defeat of other departments of a skeleton is observed usually at Ewing's tumor and primary reticulosarcoma of a bone. The osteosarcoma and Ewing's tumor at which metastasises come to light, as a rule, within the first year of a disease concern to the most malignant.

Treatment is complex, includes surgery, radiation therapy and use of antineoplastic means. The choice of a method of treatment depends on a form of a tumor and it biol. properties. So, at a chondrosarcoma, parostalny sarcoma and a fibrosarcoma method of the choice is an operative measure (amputation, an exarticulation, mezhlo-patochno-chest amputation and boundaries - ileal and belly exarticulation). According to indications (the high-differentiated forms of a chondrosarcoma, a fibrosarcoma and parostalny sarcoma) safe operations — a segmented osteoarthrotomy with substitution of defect an allokost or a metal endoprosthesis are possible. At Ewing's sarcoma and primary reticulosarcoma of a bone operational methods of treatment are practically not applied since these tumors have high radio-sensitivity in this connection use, as a rule, methods of radiation therapy in a combination with chemotherapy.

The forecast depends on a form of a tumor, degree of its differentiation, localization in this or that department of a skeleton. Five-year survival, according to H. H. The t of a rapezniko-v (1981), at an osteosarcoma makes 12%, at a chondrosarcoma — 35%, parostalny sarcoma — 69%, at Ewing's sarcoma — 5%, primary reticulosarcoma of a bone of 28,6%.

OPERATIONS

Operative measures on S. are shown at inflammatory, dystrophic and other their defeats and malformations of S., usually at inefficiency of conservative treatment.

The uniform, standard classification of operations on S. does not exist. By the anatomic principle they can be divided on inside - and brought authorized operations. Operations within a synovial membrane of S. and out of it, but directed to change of anatomy and function of a joint are intra joint. Extraarticular operations are performed on bones and circumarticular soft tissues.

The artropunktion and arthroscopy (see above), an arthrotomy (see), S.'s reposition, an arthrolysis (see), an arthrorisis (see), an arthroplasty belong to intra joint operations (see), the arthrectomy, a heylektomiya, an arthrectomy, endoprosthesis replacement (see) both a row

apply other Artropunktion and an arthroscopy with the diagnostic and medical purposes. Reposition — recovery of normal anatomic relationship of the joint ends of bones at dislocation (see Dislocations); quite often, especially at chronic dislocations, it is carried out by means of pivotally-di-straktsionnykh or distraktsionno-compression devices. The arthrotomy — opening of a cavity of S. — can be independent operation (diagnostic, draining, for correction of contractures etc.), but is more often used as access to S. at interventions on intra joint structures. Artroksezis (removal patol. fabrics from the surface of a joint cartilage) as independent operation is applied seldom. The arthrolysis — recovery of a joint crack and, respectively, S.'s mobility — quite often comes to the end with imposing pivotally-distraktsionnykh or distraktsionno-compression devices (see). An arthrorisis — restriction of mobility of S. by creation of artificial «brake» from a bone, myagkotkanny transplant or polymeric materials (e.g., lavsan). Arthroplasty — recovery of mobility of a joint by means of methods of plastic surgery (see. Plastic surgeries).

S.'s resection (removal of a joint cartilage) can be economical (with the minimum removal of podkhrya-shchevy bone tissues), expanded (atypical, reconstructive) with excision of considerable fragments of the joint ends. These operations are directed to S.'s sanitation and usually assume the subsequent achievement of an anchylosis or substitution of the joint end of a bone hallo - an autograft or an endoprosthesis. In some cases carry out the modeling S.'s resections — economical resections with the subsequent modeling of the joint ends for approach of their form to normal anatomic and the subsequent recovery of mobility in S. Hey-lektomiya — — make removal of osteoarticular growths at the edges of joint surfaces (usually at the deforming arthrosis) for the purpose of recovery of a form and function C. A synovectomy (see) — excision patholologically of the changed synovial membrane of S. — it is shown at inflammatory and tumoral processes. The arthrectomy — S.'s removal — is applied at S.'s tumors and as a stage at S.'s endoprosthesis replacement for the purpose of preparation of the perceiving bed for nek-ry models of endoprostheses, and also with the similar purpose at an alloplasty S. Artrodez (see) — the operation directed to receiving an anchylosis; on technology of carrying out quite often matches an economical and expanded resection of Page. Endoprosthesis replacement — S.'s replacement or its separate elements products from artificial materials (metals, polymers, ceramics, etc.). Operations at damage of intra joint structures — see the Osteosynthesis, Meniscuses joint, Sheaves. Amputation at the level of an epiphysis of bones — see Grit-ti — Szymanowski operation, Pirogova amputation.

Extraarticular operations, most often various osteotomies (see), are carried out for the purpose of change by biomechanics S., loads of them, normalization of microcirculation in the joint ends of bones, etc. Examples of such operations are an osteotomy of a basin at congenital dislocation of a hip and its effects, an epicondylic osteotomy of the distal end of a femur at treatment of effects of poliomyelitis, an osteotomy at the level of condyles of a tibial bone at knee S.'s arthrosis with valgus or varus deformation. In the latter case make a wedge-shaped or hinged corrective osteotomy of a tibial bone with fixing of bone fragments distraktsi-onno-compression devices or special plates for an osteosynthesis (see). At arthrosis of a pas-tellofemoralnoy of a part of knee S. apply a so-called ventraliza-tion of a patella — movement of its kpereda by cutting off of tuberosity of a tibial bone and implementation between it and its bed of bone allotransplant. Various movements of the place of an attachment of a ligament of patella apply also at incomplete dislocations and dislocations of a patella.

Operations on circumarticular soft tissues are quite often combined with intra joint or represent independent interventions. Operations of recovery of an integrity of muscles, sinews, sheaves, etc. concern to them at their damages, changes of places of an attachment of muscles, lengthening of muscles, sinews, napr, at paresis and paralyzes, effects of poliomyelitis, etc.

During operations on S. with the haemo-static purpose quite often apply plaits, to-rye before mending of an operational wound it is recommended to remove and carry out a careful hemostasis.

For prevention of intra joint hematomas and inf. complications reasonablly effective drainage of S. during 1 — 2 days after operation, and also removal of the remains of blood from S. by means of their punctures.

In the postoperative period quite often it is necessary to develop movements in S., including by means of hinged devices, against the background of use of physical therapy, massage, LFK.

See also Temporal and mandibular joint , Ankle joint , Knee joint , Elbow joint , Radiocarpal joint , Shoulder joint , Hip joint .


Table. MAIN DIFFERENTIAL DIAGNOSTIC CHARACTERS of a NUMBER of DISEASES of JOINTS

Bibliography: Abalmasova E. A. and Luzina E. V. Treatment of inborn and dysplastic deformations of the musculoskeletal device at children and teenagers, Tashkent, 1979; Astapenko M. G. and Pavlov V. P. Puncture of joints and intra joint administration of steroid hormones, M., 1973; Astapenko M. G. and P and x l and to E. G. Diseases of joints, M., 1966, bibliogr.; Astapenko M. G. and E r I am l and with P. S. Extraarticular diseases of soft tissues of a musculoskeletal system, M., 1975; Boychev B., Konforti B. and H ok and N about in To. Operational orthopedics and traumatology, the lane with bolg., Sofia, 1961; Vinogradova T. P. To biology of cartilaginous tissue, Arkh. patol., t. 34, No. 6, page 63, 1972; it, Tumours of joints, sinews, fastion, aponeuroses, M., 1976, bibliogr.; Vishnevsky A. A. and Schreiber M. I. Field surgery, page 296, M., 1975; In about l to about in M. V. and Dedov V. D. Children's orthopedics, M., 1980; Voronovich I. P. Damages of a knee joint, Minsk, 1971, bibliogr.; Gostev V. S. Gunshot wounds of joints of peace time, Vestn. hir., t. 116, No. 5, page 87, 1976; D e-dova V. D., Gorbunov R. L. and Gusev of B. V. Klinicheskiye проявле^-ния a dysplastic syndrome at children and teenagers, in book: Damages and diseases of bones and joints, under the editorship of M. V. Volkov, page 167, M., 1981; D about r m and-dontov E. N, Kites N. I. and Frizen B. N. Pseudorheumatism, M., 1981; Dyachenko of V. A. Rent-genoosteologiya, M., 1954; Zedgenid-z e G. A. and Zharkov of P. L. Metodik of a X-ray and radiological inspection of a backbone and large vessels, Tashkent, 1979; And m and m and l and-ev A. S. Homoplasty of the joint ends of bones, M., 1975, bibliogr.; Kaplan A. V. Injuries of bones and susta-bob, M., 1979; To wasps and not Kai N. S. Degenerative and dystrophic defeats of the bone and joint device, L., 1961, bibliogr.; it, Disturbances of development of the bone and joint device, L., 1966, bibliogr.; Maykova-Stroganov V. S. and Rokhlin D. G. Bones and joints in the x-ray image, the Extremity, L., 1957; Mironova 3. Page, A. S's Martens. and Inagamdzha-n about in T. I. Mistakes and complications in diagnosis and treatment of patients with intra joint damages and diseases of a knee joint, Tashkent, 1977; M and-telman Yu. N. A radiographic research of large joints at patients of ortopedotravmatologichesky clinic, Kiev, 1962; The Multivolume guide to orthopedics and traumatology, under the editorship of N. of the Item No-vachenko, t. 2 — 3, M., 1968; Multivolume Rukoyeodstvo on pathological anatomy, under the editorship of A. I. Strukov, t. 5, page 536, 1959, t. 6, page 289, M., 1962; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 11, book 1, page 74, M., 1960; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 17, page 191, M., 1953; Pavlova V. N. Synovial environment of joints, M., 1980; Podrushnyak E. P. Age changes of joints of the person, Kiev, 1972; Rheumatology, under the editorship of V. T. Tsonchev, the lane with bolg., Sofia, 1965; Sivash K. M. Alloplastika of a hip joint, M., 1967, bibliogr.; With to l I am p e N to about E. T. Hirurgiya of joints of extremities, Kiev, 1975, bibliogr.; Sorokin A. P. General patterns of a structure of the basic device of the person, M., 1973, bibliogr.; Strukov A. I. and Beglaryan A. G. Pathological anatomy and pathogeny of collagenic diseases, M., 1963; Trapeznikov H. N, etc. Malignant tumors of soft tissues of extremities and trunk, Kiev, 1981; Watson-Jones R. Fractures of bones and injury of joints, the lane with English, M., 1972; Ushakova O. A. A role of an arthroscopy in diagnosis and treatment of damages and diseases of joints, Ortop. and travmat., No. 10, page 74, 1978; Chaplin V. D. Fundamentals of operational orthopedics and traumatology, M., 1964; Davies D. V. The anatomy and physiology of joints, Physiotherapy, v. 49, p. 3, 1963; G e h a n E. A. a. o. Osteosarcoma, in book: Immunother. cancer, present status trials in man, ed. by W. D. Terry a. D. Windhorst, p. 271, N. Y., 1978; Kaiser G. Leitfaden fiir die Orthopadie, Jena, 1964; Lehrbuch der Orthopadie, hrsg. v. P. F. Matzen, B., 1967; L o e f f 1 e r F. Allgemeine Orthopadie, Lpz., 1964; McCarty D. J. Arthritis and allied conditions, Philadelphia, 1979; Rheumatology and immunology, ed. by A. S. Cohen, N. Y., 1979; Smillie I. S. Diseases of the knee, Edinburgh a. o., 1980; W a-tanabe M., Takeda S. Ike-uch i H. Atlas of arthroscopy, Tokyo, 1978; Zelander T. Ultrastructure of articular cartilage, Z. Zellforsch., Bd 49, S. 720, 1959.


M. G. Astapenko (disease), I. A. Bityugov (damages), B. V. Gusev (malformations), L. A. Eremina (PMC.), I. I. Zha-denov, V. A. Mitrofanov (methods of inspection), P. L. Zharkov (rents.), N. K. Permyakov, G. M. Mogilevsky (stalemate. An.), L. K. Semenova (ist., embr., An., age features), S. S. Tkachenko (soldier.), O. A. Ushakova (hir., arthroscopy), author of table E. R. Agababova.

Яндекс.Метрика