SINEWS

From Big Medical Encyclopedia

SINEWS [tendo (PNA, JNA, BNA)] — a connective tissue part of muscles, by means of a cut they are attached to bones and provide a paredacha of muscular efforts.

Anatomy

the Sizes and a form C. widely vary depending on a way of an attachment of muscle fibers to S. and muscles to bones. Distinguish short and long S., wide, narrow, roundish, shnurovidny and tape-like S., and also lamellar — aponeuroses (see). S. in the form of crossing points (intersectio tendinea) meet, to-rye dismember a muscle on several departments, tendinous arches (arcus tendineus) tense between two bone points. The special form is represented it is central the located S. in dome-shaped muscles (e.g., centrum tendineum of a diaphragm, galea aponeurotica of a nadcherepny muscle). Also the intermediate S. connecting separate parts of a muscle are observed (e.g., S. of biventral muscles).

C. can extend on a side surface of a muscle from one or two parties, get in a muscle, at the same time muscle fibers can go parallel to a long axis C. or form a corner with this axis. Spindle-shaped muscles, being gradually narrowed on both ends, pass one into S. V - and a two-per isty muscles muscle fibers are attached to a side surface of S. that considerably increases force of draft of a muscle (see. Muscles ).

Pages of muscles of distal segments of extremities differ in considerable extent and, passing about joints, usually lie, in osteofibrous channels. For simplification of sliding in osteofibrous channels C. are concluded in synovial vaginas (see). In places of the greatest mobility and S.'s friction about bone ledges can be synovial bags (see), promoting friction reduction.

In nek-ry S. (e.g., the four-head of a muscle of a hip) are available sesamoids (see). They change a corner of an attachment of a muscle and increase the lever of action of muscular draft.

During the post-natal period S.'s development is characterized by intensive building of a tendinous component of muscles. In newborn S.'s muscles are developed poorly; only by 12 — 14 years the muscular and tendinous relations characteristic of muscles of the adult are established. By data A. I. Vunch (1949), children aged up to 15 years have an increase in length of a muscle belly and S. on an upper extremity happens to identical intensity; from 15 to 23 — 25 years a tendinous part of a muscle grows quicker. At advanced age the involute changes of cellular and fibrous structures of S. connected with homogenization and disorganization of tendinous bunches, and also with reduction of amount of elastic fibers in endotendineums take place.

Fig. 1. Microdrug of a sinew is normal: 1 — nerve fibrils; 2 — neurosukhoshilnye spindles; 3 — bunches of collagenic fibers; impregnation by silver; x 16.

The nervous device C. is presented by various receptors. On border of muscular and tendinous parts of a muscle there are neurotendinous spindles sensitive to a tension (fig. 1). Along with it in S. lamellar little bodies, similar to Fater's little bodies — to Pacinija Golgi — Mazzoni and free nerve terminations are described; the last, probably, transfer painful impulses at hyperdystension of Page.

Fig. 2. Microdrug of a sinew is normal: the network of blood vessels in endotendineums is visible; injection of aqueous solution of ink; x 16.

Arteries get into S. from a muscle or a periosteum. In S. blood vessels extend on a peritendiniya and to an endotendineum, forming rather uniform networks (fig. 2). Veins follow on the course of arteries and fall into veins of a muscle or a periosteum.

An initial link limf, beds is the network limf, capillaries, lying in the depth of S. Limf, capillaries and vessels pass together with circulatory capillaries and vessels between bunches of tendinous fibers as a part of an endotendineum. Outflow of a lymph is carried out in larger limf, vessels of a muscle or periosteum.

Histology

All S. consist of dense connecting fabric (see), rich with collagenic fibers (see. Collagen ). The last lie parallel bunches, between to-rymi a chain the fibrocytes called by tendinous cells are located. A part of more fine collagenic fibers is located at an angle to longitudinal axis C. Tendinous cells are capable to mitotic division. Layers of the friable fibrous connecting fabric dividing bunches of collagenic fibers of different orders call an endotendineum, and the connecting fabric covering S. — peritendiniy. The structure and thickness of tendinous bunches is defined by forces of longitudinal tension of S., and a structure of an endotendineum — forces of radial tension.

Connection C. with muscle fibers is carried out by means of collagenic fibers. Surrounding the ends of muscle fibers, they form a number of spiral or circular layers and strongly grow together with a sarcolemma. On the end of muscle fibers the sarcolemma forms deep finger-shaped outgrowths, between to-rymi collagenic fibers C lie. In addition, there is a direct transition of collagenic fibers an endomiziya in tendinous bunches.

Connection C. with bones happens by growing of its collagenic fibers or into a periosteum or a nadkhryashchnitsa, or directly in a bone or a cartilage.

Pathological anatomy

Patol. processes in S. conditionally divide on dystrophic, inflammatory, reparative and tumorous (see. Fibromatoses ).

Fig. 3. Microdrug of a ganglion of a sinew: 1 — a cavity of a cyst; 2 — fibers of the inner layer; 3 — surrounding fabrics; coloring hematoxylin-eosine; x 60

Carry mucous dystrophy to dystrophic processes, edges it is shown by formation of a ganglion (see) — cystous education of S. (more often than razgibatel of fingers of a brush) containing muciform substance. The wall of a cyst consists of dense or friable connecting fabric without signs of an inflammation (fig. 3). The inner layer of a cyst has outgrowths, the cellular vystilka often is absent.

Calcification (see) it is shown in the form of adjournment of salts of calcium in vaginas of sinews and mucous bags as a result hron. a bursitis or at the general disturbances of exchange of calcium. Universal, focal and tumorous calcification of soft tissues is characterized by formation of nodes in sinews, and also in skin, hypodermic cellulose and muscles. Around deposits of salts of calcium the necrosis can be observed, inflammatory infiltration and granulyatsionny fabric with so-called cells of foreign bodys develop, sometimes there is suppuration.

Inflammatory processes arise not in S. more often, and in his vaginas and in a peritenoniya. Acute serous and crepitant tendovaginitis (see) are connected with repeated microtraumas (more often at athletes and workers), at to-rykh there are small anguishes and hemorrhages in S.'s vaginas with hypostasis of their fibers, exudation of serous liquid with small impurity of leukocytes and erythrocytes (see. Microtrauma, sinews ).

S.'s pathology can be caused by an injury (microtrauma) and a number of diseases. Malformations usually have no independent value since are only an element of anomalies of a musculoskeletal system.

Damages sinews happen closed (hypodermic) and open.

The closed (hypodermic) damages of S. meet in the form of dislocations (seldom) and gaps. S.'s dislocation can result from an injury at a rupture of the sheaves holding it. At the same time hemorrhage, a swelling, local morbidity, dysfunction S. Vozmozhen S.'s dislocation of a long fibular muscle is observed at an underdevelopment of a superficial flat groove where S. Byvayut S.'s dislocations of razgibatel of fingers of a brush lies at damage of tendinous plates as a result of sharp cultivation of fingers. Treatment of dislocation of S. consists in its reposition and an immobilization a plaster splint during 3 — 4 weeks. At chronic dislocations an operative measure is shown. Forecast, as a rule, favorable. However a recurrence is possible.

The closed S.'s ruptures occur owing to a direct injury or at sharp reduction of a muscle. Usually the sinew comes off the place of an attachment to a bone, sometimes together with a bone fragment, or is broken off in the place of transition to a muscle, is more rare — on an extent. At S.'s rupture the crash is heard, there is an acute pain, function of the corresponding muscle is broken. More often than others S.'s rupture of a biceps of a shoulder, by the four-head of a muscle of a hip, sgibatel and razgibatel of fingers of a brush is observed. Calcaneal (akhillov) S.'s rupture comes at sharp reduction of a gastrocnemius muscle or at direct stroke to it (see the Achilles tendon). The hypodermic rupture of S. can be a consequence of frequent microtraumas at athletes (athletes, gymnasts, skiers) or working nek-ry professions (grinders, cutters); besides, it meets at changes, inf. diseases (tuberculosis, typhoid, syphilis). S.'s rupture is possible at any age, but a thicket in elderly when elasticity of fabrics decreases. At gistol. a research of fresh ruptures of S. along with effects of an acute injury (hemorrhage, hypostasis, leukocytic infiltration, destruction of tendinous bunches) dystrophic and necrobiotic changes of tendinous fibers, the cicatrizing granulations and growths of fatty tissue indicating the previous microtraumas are found, as a rule. Also the hypertrophy of an internal cover of tendinous arteries and narrowing of their gleam comes to light.

For emergence of spontaneous ruptures of S. without the expressed functional loads, in addition to the previous microtraumas, exchange and toxic and infectious and toxic factors can matter (diabetes, obesity, arthritis, inf. diseases, etc.), leading to dystrophic and inflammatory changes in Page.

Fig. 4. Ways of an immobilization at conservative treatment of hypodermic ruptures of sinews of razgibatel of fingers: and — an immobilization of a finger in the writing situation a plaster bandage; — an immobilization Rozov's tire; in — an immobilization Vinterstein's tire.
Fig. 5. The scheme of temporary chrezsustavny fixing of a distal phalanx in the provision of hyperextension Kirchner's spoke on Pratt's way at a hypodermic rupture of sinews of razgibatel of fingers of a brush.

Treatment can be conservative or operational depending on localization and prescription of damage. E.g., treatment of a rupture of S. by the two-head of a muscle of a shoulder, four-head of a muscle of a hip, calcaneal (akhillov) S., sinews of sgibatel of fingers and long razgibatel of a thumb of a brush, as a rule, operational. In the latter case operation of movement of S. of a razgibatel of the II finger of the I finger was repaid. At S.'s rupture of razgibatel of other fingers of brushes, a cut occurs usually at the level of a distal phalanx, favorable results are yielded by an immobilization of a finger in the writing situation during 5 — 6 weeks a plaster bandage, special tires (fig. 4) or fixing of a distal phalanx in the provision of hyperextension Kirchner's spoke according to Pratt (fig. 5). Further physiotherapeutic treatment is shown.

Forecast, as a rule, favorable. Idea that S.'s damages always begin to live a hem owing to inability of the high-differentiated tendinous cells to proliferation is disproved by G. N. Voronin's works (1954), H. R. Amosova (1958), N. F. Braytsev (1958), Prichard (J. Pritchard, 1971), etc., to-rye showed that not only cells endo-and a peritenoniya, but also tendinous cells proliferate. According to gistoavtoradiografiche-sky data of V. I. Gusikhina (1970, 1972), not less than 50% of the last participate in regeneration that testifies to productive capacity of the tendinous cells which are at the different levels of a differentiation. Between the ends of the damaged S. the regenerate forms, to-ry at first has character of granulyatsionny fabric, and through 1V2 — 2 month in a form and an arrangement of cells and fibers, and also on gistokhy. to features differs from intact a little S. Polnota of S.'s regeneration after operation depends on the size of defect, a look and quality of a tendinous seam, character of a suture material. Special value has tightness of a seam. At the raised tension growth of granulations amplifies and commissures are formed. Under favorable conditions (preservation a peritenoniya, small traumatization of the sewed ends, small hemorrhage) S.'s regenerate anatomically is also functionally most perfect. At damage the peritenoniya and surrounding fabrics, and also bleeding is observed intensive formation of granulations, formation of commissures. Cicatricial fabric with a chaotic arrangement of cells and fibers is formed. Despite nek-ry subsequent reorganization the hem remains anatomically imperfect that leads to S.'s stretching and its functional insolvency.

Open damages of S. arise at wound a sharp object (glass, a knife, etc.) or, more rare, at hit of an extremity in moving parts of cars. S.'s damages muscles of an upper extremity at the level of a brush in forearms are generally observed, and is more often than sgibatel of fingers. The isolated S.'s damages meet, but more often they are combined with wound of nerves and vessels, especially at localization of wound on a front surface of a forearm. Hit of an extremity in moving mechanisms causes the fragmentary smashed wounds with a separation or a razvolokneniye of a sinew. At the same time S.'s ends considerably disperse owing to reduction of a muscle. Quite often insignificant injury of skin by an edge of a knife is followed by a full section of Page. Therefore any damage demands a careful research of function C.

Diagnosis of open damages of S. of muscles of sgibatel of fingers of a brush does not present difficulty. The gap breaks them balance between sgibatel and razgibatel and the corresponding finger deviates a typical fiziol. provisions. It is possible to specify the diagnosis, defining a possibility of active bending or extension of a finger. S.'s damage a deep sgibatel of fingers is distinguished during the fixing of an average phalanx, at the same time active bending of a distal phalanx is impossible. In cases of damage of superficial and deep sgibatel of fingers at the fixed proximal phalanx active bending of average and distal phalanxes is absent. The close anatomic neighbourhood of S. of flexor muscles and nerves does necessary a research of sensitivity of the corresponding zones for diagnosis of injury of this or that nerve.

Fig. 6. The diagrammatic representation of characteristic provisions of fingers at damage of an extensor tendon of a brush at the level of a forearm and a brush (a), at the level of a proximal phalanx (b), at the level of an average and distal phalanx (in); level of injury of a sinew is specified by shooters.
Fig. 7. The diagrammatic representation of a double contracture of an index finger of the right brush (bending in a proximal interphalangeal joint and extension — in distal) at damage of an extensor tendon of a finger with preservation side tyazhy.

Diagnosis of damage of S. of extensor muscles of fingers of a brush is also simple. The relevant provision of a finger (fig. 6) is characteristic of each level of damage, in addition to dysfunction of extension. At damage of a razgibatel of fingers on a forearm or a brush the proximal phalanx is slightly bent, the finger is in halfbent situation. At wound of a dorsum of a proximal phalanx sukhozhilnoaponevrotichesky stretching with its side bunches is damaged, at the same time bending of average and distal phalanxes is noted. S.'s damage a razgibatel at the level of average and distal phalanxes leads to bending of a distal phalanx. S.'s wound of a proximal interphalangeal joint with preservation of side bunches leads to formation of a double contracture of a finger (fig. 7), i.e. to bending of an average phalanx and extension of distal. At wound of a back and beam surface of a forearm or area of a wrist both razgibatel of the I finger of a brush and S. of the long muscle which is taking away a thumb of a brush can be damaged. The finger adopts the provision of reduction and bending, active extension and assignment are absent. Wound at the level of phalanxes leads a long razgibatel of a finger to S.'s damage, the distal phalanx is bent, its extension is impossible.

The integrity of both the sgibatel, and razgibatel damaged by S., is recovered by means of imposing of a tendinous seam (see). Contraindications to it at open damages are existence of the fragmentary smashed wounds, fractures of bones and injury of joints.

At old damages of S., hl. obr. sgibatel of fingers of a brush, their plastics is shown. The last provides substitution of defect of S. a free transplant from an autosukhozhiliya of a superficial sgibatel of fingers or a long palmar muscle, and also from allosukhozhiliya of razgibatel of fingers of foot. The distal end of a tendinous transplant is hemmed to a distal phalanx a removable seam on Bannella (see. Tendinous seam). The proximal end of a transplant is hemmed to the central end of S. of a deep sgibatel of fingers at the level of a forearm or at the level of worm-shaped muscles. The main condition for plastics C. is free passive bending in joints of a finger before operation.

Auto-and S.'s alloplasty are always followed by a rassasyvaniye of a transplant. In the subsequent it burgeons granulyatsionny fabric and is gradually replaced with fabric, edges differs from fabric C. only in the increased number of cells both nek-ry histochemical and ultrastructural features. Speed and completeness of regeneration is slowed down during the use of fresh transplants, and also at increase in length of the last. Synthetics are less suitable for plastics since they lose elasticity, burgeon connecting fabric and form commissures.

The forecast at open damages of S. more often favorable also depends on the nature of damage, and also timely rendering the specialized help.

Prevention of injuries of sinews is a part of prevention of traumatism, especially production and household (see. Traumatism ).

Features of fighting injuries of sinews, stage treatment — see. Wounds, wounds ; Brush , Foot , Joints .

Diseases. Acute inflammatory processes of vaginas of S. are most often a consequence of a microtrauma — pricks, scratches, small cuts of fingers of a brush (see. Felon ). They are observed quite often and demand operational treatment (see. Tendovaginitis ).

Cicatricial changes around S. develop as a result of its damage (later 1 1/2 — 2 months), a purulent inflammation, disturbance of the equipment of primary seam of S., long immobilization of the corresponding joint. The contractures arising at the same time (see) often demand an operative measure.

In cases of development of a flexion tenogenny contracture of fingers and the brush connected with S.'s damage or patol. process on a forearm, showed S.'s lengthening sgibatel according to Bayer (a Z-shaped section of S. on length with the subsequent suture on the displaced ends) or according to Epstein and Rozov (S.'s crossing a deep sgibatel of fingers proksimalno, and superficial — distally and their sewing together among themselves a side sideways). At contractures as a result of formation of cicatricial commissures on a palmar surface of a brush and fingers it is shown tenolysis (see) or tenotomy (see).

Quite often dystrophic changes in aponeurotic ring-shaped sheaves meet (a ring part of a fibrous vagina, T.), causing narrowing of their gleam. Pages of sgibatel at the same time hardly pass under a sheaf and for the second time are thickened with development of a syndrome the clicking finger (see).

Tumors, proceeding directly from S., are not observed. Benign tumors (a ganglion, cysts), coming from tendinous vaginas meet. They are located, as a rule, on the palmar surface of fingers. Treatment their operational. Forecast favorable.

Operations — see. Tendinous seam , Tenotomy .



Bibliography: Amosova H. P. Regeneration of sinews under various experimental conditions, Arkh. annate., gistol. and embriol., t. 35, No. 6, page 90, 1958, bibliogr.; Vinogradova T. P. Tumors of joints, sinews, fastion, aponeuroses, M., 1976. bibliogr.; Gusikhina V. I. About cambial elements of sinews, Arkh. annate., gistol. and embriol., t. 59, No. 7, page 77, 1970, bibliogr.; Ya. G oak groves. Injuries of sinews of a brush and their treatment, Ortop. and travmat., No. 12, page 3, 1962; To about sh R. Hirurgiya of a brush, the lane with Wenger., page 147, Budapest, 1966; Treatment of damages and diseases of a brush, under the editorship of T. P. Rozovskaya, page 83, L., 1981; The Multivolume guide to pathological anatomy, under the editorship of A. I. Str\tkov, t. 6, page 423, M., 1962; Nelzina 3. T. Urgent surgery of open damages of a brush and fingers, page 122, M., 1980; Omelyanen-k about N. of the Item, X about r about sh to about in Yu. A. and e-r.ebtsov L. D. Features of the space organization of collagenic fibers of an Achilles tendon of the person, Arkh. annate., gistol. and embriol., t. 81, No. 8, page 77, 1981; With about r about to and A. P N. General patterns of a structure of the basic device of the person, M., 1973; At with about l c e in and E. V. and M and sh to and r and K. I. Hirurgiya of diseases and damages of a brush, page 166, 190, L., 1978; Fuchs B. B. and F at to with B. I. Sketches of morphology and histochemistry of connecting fabric, L., 1968; Kharitonov R. D. Treatment of hypodermic ruptures of the distal end of sinews of razgibatel of fingers of a brush, Ortop. and travmat., No. 7, page 32, 1965; Bunnell S. Bunnell’s surgery of the hand, p. 393, Philadelphia — Toronto, 1970; Crosby E. B. a. Lin-s with h e i d R. L. Rupture of the flexor profundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate, J. Bone Jt Surg., v. 56-A, p. 1076, 1974; Flynn J. E. Hand surgery, p. 184, Baltimore, 1966; Mackenzie D. H. The differential diagnosis, of fibroblastic disorders, Oxford — Edinburgh, 1970; M fise n e d e r H., Fink D. u. Grab-herr H. Der subcutane Riss der langen Daumenstrecksehne, Arch. Orthop., Bd 81, S. 267, 1975; Petersen H. u. Meyer W. Strecksehnenrupturen des Daumens nach Radiusfrakturen, Act. Chir., Bd 9, S. 209 1974.


L. H. Bryantseva; V. I. Kozlov (An., gist.), A. B. Shetkher (stalemate. An.).

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