TRAVMATYZM (Greek trauma, trau-matos a wound, damage) — set of the injuries which arose in a certain group of the population for a limited span.
T. accompanied the person always, being a consequence of its interaction with the environment. Especially large number of injuries arose during wars. Apogee of T. reached with development of capitalism.
In Russia the first law on obligatory registration of accidents where also injuries entered, is entered in 1903, however T., especially at the industrial enterprises, after that did not decrease. Emergency medical service before revolution existed on private charitable means and in 1917 was available only in 7 cities. Specialized traumatologic BCs and outpatient appointments were not. The Russian physicians always gave T. great attention. S. A. Alexandrov, P. I. Kurkin, N. I. Tezyakov, F. F. Erisman, etc. dealt with this problem. Questions T. were discussed at Pirogovsky congresses. At the VIII congress (1902) the independent section concerning factory and mining medicine was for the first time created. In the decision of a congress need of the device of defensors by machines and mechanisms, restrictions of work of juveniles, strengthenings of responsibility of owners for industrial accidents, etc. was noted. At the XII congress (1913) it was offered to open specialized «traumatic» hospitals, and at medical faculties of high fur boots — departments of traumatology.
Fight against T. in the state scale began only after the victory of Great October socialist revolution. In 1921 in Moscow the Medical and prosthetic institute was organized (since 1940 —
Central in-t of traumatology and orthopedics). At the first meeting on fight against traumatism and its effects in Narkomzdrava of RSFSR (1926) under the chairmanship of II. A. Semashko made
the decision on creation in the country uniform travmatol. the help, including the organization of first-aid stations at the enterprises. In 1927. The board Narkomzdrava of RSFSR obliged to lay down. institutions to be engaged in studying industrial in T. and development of measures of its prevention. In a crust, time 20 institutes of traumatology and orthopedics (see Na-uchno-issledovateljskiye institutes) and 97 departments of traumatology in medical gsh-ta, universities and in-ta of improvement of doctors work in the country. An important role travmatologo-ortho-pedicheskoy services played the orders M3 of the USSR (1946, 1957 and 1970) directed to prevention of T in creation., improvement and improvement of the traumatologic and orthopedic help to the population. In these documents the main directions of development of traumatology and orthopedics were defined, evidence-based standards of need for medical staff and bed fund for rendering highly skilled travmatol are given. help. Questions of improvement of the help to patients with damages and diseases of a musculoskeletal system and the victim at the road accidents found reflection in the joint orders M3 of the USSR and the Ministry of Internal Affairs of the USSR.
Fight against T. is one of the most important medico-social problems of the present. According to Art. 42 of the Constitution of the USSR, our state undertakes care about health of workers, improvement of working conditions, development and improvement of the accident prevention (see) and production sanitation (see), holding broad preventive actions. In the Program of the CPSU it is written down: «On all before
priyatiya modern means of the accident prevention will be implemented and provided sanitary gigiyeniche-skiye the conditions eliminating operational injuries and occupational diseases» (The program of the Communist Party of the Soviet Union, M., 1976, Art. 95).
In modern traumatology there is no uniform universal classification of T., what is connected with difficulties of systematization of injuries. Various classifications were at different times created, the principles to-rykh were defined by the purposes and problems of specific researches. V. V. Gorinevskaya allocated 9 types of T., to-rye combined in three groups: military, professional (craft and handicraft, industrial, agricultural, sports), household (street, connected with conditions of life, criminal, suicides). H. N. Priorov subdivided T. on industrial, agricultural, street, household, sport willows
ny, elektrotravmatpzm. In 1952. The board of M3 of the USSR made the decision to allocate three basic groups of traumatism: production, non-productive and intentional. Further the first two groups were detailed therefore there was a classification, long time applied in our country: industrial,
agricultural, transport, street (at the pedestrian movement), sports, military traumatism. Since 1970 in the USSR the International
statistical classification of diseases, injuries and causes of death is used, the XVII class a cut includes injuries, and for classification of an initial (external) cause of death from injuries it is necessary to use additional headings of a code E.
In economically developed countries of an injury and accidents take the second place among the reasons of primary disability and the third — among the reasons there is mortality of the population. In the USA in the 70th years the number of production injuries exceeded 2 million cases a year, including more than 15 thousand injuries from the death are registered, and more than 30 thousand ended with mutilations or full disability. Children's T. Tak grows in many countries, in Germany in 1972 3 330 children and teenagers died. From them 64% became the victims of road and transport incidents. In the socialist countries in general the tendency to continuous decrease in T. S of 1930 for 1965 the general is noted by T. in the USSR decreased almost three times, including production on average by 5 times, only for years of the 10th five-years period (1976 — 1980) operational injuries decreased by 11%. Essentially the same dynamics is noted in other socialist countries. In Hungary from 1954 to 1970 production T. decreased by 49%, in Czechoslovakia for the same period — for 20%.
On the frequency of injuries separate types of T. in our country are distributed in such sequence: household, production, road and transport, street, agricultural, sports, other types. On the frequency of various localization of damages the following sequence is noted: injuries of upper extremities, lower extremities, heads, basin and backbone.
Reasons of T. are various and in many cases are connected with growth of technical equipment of industrial ii of the agricultural enterprises and life, the complication of the production technology, increase in number, power and speed of vehicles accelerated and an intense rhythm of life — inevitable satellites of an urbanization (see) and scientific and technological revolution. For the organization of rational prevention of T. it is necessary to systematize its reasons in each case. So, production T. has a set of the reasons, to-rye can be united in several groups. Shortcomings of the organization of labor processes, including outdated ways of production, failure of the technical equipment, a clutter of jobs and their bad illumination, non-compliance with safety regulationss and production sanitation, etc. concern to one of them. In various industries and agriculture these organizational reasons cause more than a half of all injuries. E.g., in agriculture there are not enough safety specialists, quite often these positions are held by people without vocational education and necessary experience. In the conditions of quickly growing technical equipment of agriculture these factors inevitably lead to injuries. Other group of the reasons of production injuries includes the factors characterizing generally psychophysiological state and nek-ry personal qualities of participants of incidents. Dependence of T is established. from age, qualification, discipline of workers, observance of safety regulationss by them and a gigabyte. norms of loading, and also from influence of nek-ry social, biological, geomagnetic and other factors. E.g., among the beginning young working T. is on average slightly higher, than at the workers of middle age having higher qualification. Often developing of injuries is connected with alcoholic intoxication (see Alcoholism). At many enterprises T. reaches a maximum on Monday (a consequence of insufficient moral and psychological reorganization after the days off or unreasonable rest) and at the end of the week — result of exhaustion (see) and decrease in attention. It is characteristic that the frequency of T. raises by the end of a shift.
In household T. among all types non-productive T. makes more than a half of cases. Among its main reasons — shortcomings of improvement of inhabited districts and apartments, non-compliance with rules of the handling of household appliances or its failure, an alcohol abuse. Danger of home accidents increases with growth of the technical equipment of life which is quite often advancing growth of technical literacy of the population. In this regard one of tasks of the relevant departments is drawing up maintenance instructions of devices and an explanation of instructions for use them.
The reasons children's T are specific. Among them a special role is played by discomfort of domestic territories, streets, shortcomings of the organization of physical education classes and work, leisure of children, etc. However insufficient educational work among children is the main reason that leads to absence at them strong skills of behavior on the street, at home, at school.
The special attention is deserved road and transport by T., the tendency to decrease to-rogo still is absent. Road and transport T. it is characterized by the heaviest damages and effects. According to WHO data, on roads of the world annually perishes apprx. 250 thousand people, and more than 10 million people sustain injuries. Level road and transport T. substantially depends on weather conditions and visibility on roads. But to the main reasons road and transport T. belong: bad organization of traffic, failure or constructive shortcomings of vehicles, traffic offense by drivers and pedestrians, alcoholic intoxication of that and others, difficult road conditions, inexperience of drivers, etc.
Effects of T. include temporary or permanent disability (see Disability, Disability) and injuries mortality (see Mortality). These effects cause to society extensive moral and material damage. Dynamics of mortality from injuries in general is parallel the loudspeaker T. Injuries mortality rate is defined by their frequency and severity of a so-called average injury. In recent years weighting of injuries is noted, i.e. even more often at an injury not only the musculoskeletal system, but also internals of the person is damaged. Death on site of incident is most often caused by weight of damage and its next complications — kr about - vopotery (see), shock (see), injury of the central nervous system (see. Vertebral and spinal injury, Craniocereberal injury), etc. According to M. V. Volkov et al. (1976), at the road accidents apprx. 30% of deaths it is the share of a pre-hospital stage. At the same time most of them (96,8%) make the died on the spot incidents.
In the general injuries mortality distinguish a so-called intrahospital lethality (i.e. mortality from the hospitalized victims of injuries). Not only weight of damages, but also inopportuneness or poor quality of the first medical aid, and also diagnostic is the cornerstone of it and to lay down. mistakes. It is noted, e.g., that surgeons and traumatologists underestimate weight of craniocereberal injuries more often, and neurosurgeons — weight of injuries of a skeleton and internal; bodies. Effective fight against mortality from injuries demands improvement of the help to victims at all stages — from the scene before medical establishment inclusive. According to CYTO, the number of days of disability only from road and transport injuries grows annually for 7 — 8%. The average duration of temporary disability at these injuries reaches 45 days. By data K. K. Etc. (1976), workers of agriculture have Mageramova the average duration of temporary disability caused by an injury makes 25 days. • Duration of disability considerably is defined by localization and weight of damage. Resistant disability has considerable economic effects. According to different researchers, in structure of the reasons of disability 7,7 — 14,6% are the share of a share of injuries and accidents. The most often resistant disability — a consequence of craniocereberal injuries, changes of a basin with internal injuries, the complicated spinal fractures. At injuries of a backbone more than a half of victims become disabled people. At fractures of bones of a shin disability, according to V. E. Odnora-lova (1975), is received by 17,1% of victims, and at open changes, by data A. A. Nikolayenkova (1974) — 43,7%. On average becomes disabled people owing to injuries apprx. 15% of victims with damages of a musculoskeletal system. The percent of failures is higher at advanced and senile age. Duration of disability depends on timeliness and quality of medical aid by the victim. A bad immobilization (see) at fractures of bones at a pre-hospital stage or its absence promote more frequent emergence of such complications as a nearthrosis, posttraumatic osteomyelitis, etc.
Improvement of the organization of medical aid travmatol. the patient provides its increasing specialization and approach to the scene. The system of the help includes three interconnected stages: first aid (see) on site incidents, the help during transportation of the patient in to lay down. establishment and the medical care provided to the victim in to lay down. establishment.
The volume of the help on each of these stages is defined by the nature of an injury and opportunities of this stage. So, at the majority of superficial damages of soft tissues at the first stage the help is limited to roughing-out of grazes, bruises, small wounds (see. Surgical treatment of wounds) and bandagings (see). At the same time the second stage is most often excluded since patients, as a rule, independently arrive in to lay down. establishment where they are given the main help. At heavy, especially multiple and combined, damages (see Changes, Politravm) value of the first and second stages increases. First aid depends on the scene and can be various: from the elementary types most and mutual assistance (see the Self-care and mutual assistance) before medical manipulations, sometimes before the specialized help. On average first aid less than a half of victims, from them only receives 3 — 5%, according to M. V. Volkov and N. A. Liu-boshitsa (1979), from medics. In this regard mass training of the population in methods of first-aid treatment, especially employees of militia, GAI, drivers of motor transport, machine operators of agriculture, etc. is of particular importance. At the enterprises creation a dignity is necessary. the posts staffed by the persons who had special training. The sanitary post (see) shall have the equipment and equipment for first aid (styptic plaits, tires, a dressing material, etc.).
The second stage — the help to the victim during the transportation in medical establishment. It is known that in the cities apprx. 50% of the victims needing the qualified help are delivered in to lay down. establishment by ambulance cars (see Emergency medical service). In other cases transportation is carried out by passing means, cars of militia, GAI, etc. Their impracticality for transportation of patients with damages and absence of the prepared accompanying persons are fraught with aggravation of damage and an aggravation of symptoms of the patient. At linear crews of emergency medical service the percent of diagnostic and medical mistakes is rather high. Therefore combination of transportation with the specialized resuscitation and traumatologic help became the main tendency of improvement of the second stage of medical aid. Correctness of the diagnosis, timeliness of resuscitation actions (see Resuscitation),-chshgayemykh on on site incidents, and also competent tactics of the doctor in the traumatologic relation allow to improve considerably a condition of victims by the time of receipt in a hospital and if necessary immediately to start to an operative measure. During the transportation of victims by specialized crews of emergency medical service the number of the patients coming to a hospital in state of shock of all degrees is cut by half. The organization of such crews is reasonable in the large cities. The importance for the correct organization of the second stage of medical aid and for an outcome of many injuries has creation of an accurate communication system between settlements, posts of GAI, medical institutions, etc. It provides the most bystry arrival to the scene of medics, adoption of the optimal solution on a way of transportation of the victim and the volume of the help in a way. If necessary call a specialized ambulance crew. For increase in efficiency of medical aid at a stage of transportation of victims development of territorial schemes of interaction of stations of emergency medical service, BC, ambul atorno-on a face of l inichesk their institutions with their arrangement at the minimum distance from each other is reasonable (in the country — no more than 80 — 100 km). In the cities continuous watches of ambulance cars in places of the largest frequency of injuries or the organization in these places of independent substations of ambulance are necessary.
The third stage — the help in out-patient and polyclinic institutions and hospitals the injury-tologo-orthopedist of an ichesky profile. To 95% of patients with damages of a musculoskeletal system receive in them the help in full. On an extract from a hospital most of patients continue treatment in out-patient and polyclinic institutions. More than a half of all days of disability from injuries is the share of ambulatories. According to M. A. Rogovy
(1976), in structure of injuries, treated it is out-patient, bruises and stretchings make 53,8%, wounds of soft tissues — 19,5%, fractures of bones — 13,1%, dislocations — 0,5%, burns — 5,9%, other injuries — 7,2%. The ambulatory care at injuries is given in medical and obstetrical centers (see), medical assistant's and medical health centers (see), out-patient clinics (see), traumatologic offices of policlinics (see) or in specially created emergency stations (see). On medical and obstetrical centers carry out the first and pre-medical help (see) the victim, and at small damages carry out their full treatment. To 70% of patients after rendering first aid to them on medical and obstetrical centers further do not address for treatment anywhere. The same work is performed by medical assistant's and medical health centers of the industrial enterprises and educational institutions. The maximum approach of medical aid to the scene increases its timeliness and efficiency. The volume of the help on medical and medical assistant's health centers is approximately identical: according to M. A. Rogovy (1976), bandages make 81,7%, drug treatment — 15,9%, an immobilization of extremities — 2,2%, a stop of bleeding — 0,2%. Except medical, health centers perform big scheduled maintenance, especially at the industrial enterprises. Together with administration workers of health centers make plans of prevention of T. monitor their implementation, control observance of safety regulationss and labor protection, carry out a dignity. - a gleam, work (lectures, conversations, a dignity. bulletins, etc.).
Traumatologic offices and points take extremely important place in system of medical aid travmatol. patient. Recently for the purpose of more rational use of hospitals the volume of the help on emergency stations is expanded.
Hospitalization travmatol. patients it is carried out in most cases by traumatologic and surgical departments of regional, city and regional BCs that allows to render to victims specialized medical aid. Planning of power and structure specialized surgical and travmatol. departments of hospitals is based on evidence-based standards of need of the population for the beds a travmatologo-shouting-toped of an ichesky profile accepted by M3 of the USSR for the perspective period, with their differentiation in relation to features of the serviced contingents of the population and levels T.
At the organization travmatol. departments in hospitals their optimum power it is considered to be 60 beds. Such departments provide rational use of bed fund and arrangement of medical shots, and also high quality of medical aid. In the republican and regional centers, in the nek-ry cities allied' values the organization of large traumatologic departments in the hospitals of emergency medical service (see Emergency medical service hospital) providing the specialized help to patients with any damages is most justified. Such tendency is validated by experience of hospitals of emergency medical service in Moscow, Leningrad, Prokopyevsk, Kharkiv, Tula and other cities.
Duration and the nature of disability at injuries depends not only on quality of medical aid, but also considerably on quality of medical labor examination (see Examination) during the definition of an outcome of injuries. Work of specialized travmatologo-orthopedic VTEK is especially effective in this respect. They are created at regional departments of social security and promote improvement of quality of treatment travmatologo-ortopediche-skikh patients, and also develop expert questions. Specialized VTEK pay special attention to the organization of rehabilitation of disabled people and temporarily disabled.
Efficiently reductions of terms of disability and the number of disabled people correctly organized rehabilitation travmatol is. patients, especially at spinal fractures, a basin, intra joint fractures of bones, etc. Importance of rehabilitation (see) it is caused also by the fact that the most part incapacitated is made by persons of young and middle age. The reversible functional disturbances which are effectively giving most in to treatment take place almost at a third of patients with changes. The main ways of medical rehabilitation of patients with effects of damages of a musculoskeletal system — recovery of the broken functions and development of compensatory adaptations. Prevention of disability begins from the first days of treatment of patients with injuries. The combined and rational use of physiotherapy exercises, massage, work therapy, medicinal therapy, prosthetics, etc. increases efficiency of the main treatment. Early rehabilitation of disabled people even with rough defects of upper extremities (up to amputation) allows to return on condition of training of possession of a prosthesis them to active work. The respective state of specialists is necessary for the correct organization of rehabilitation: massage therapists, methodologists of LFK, work therapy specialists, physiotherapists, etc., and also special equipment. These issues are easier resolved in large specialized institutions, in the so-called centers of rehabilitation and departments of large municipal and regional hospitals. In a crust, time there is a clear tendency to merging of small departments and offices of physical therapy and physiotherapy exercises at policlinics in interdistrict and city physiotherapeutic policlinics or departments of rehabilitation, the full complex of recovery treatment of patients, including traumatologic enters functions to-rykh. Experience of the rehabilitation centers of stationary type in Moscow, Leningrad, Vladimir, Riga and other cities showed prospects of a wide spread occurance of such centers. Success of rehabilitation work is promoted also correctly organized by a dignity. - hens. treatment of patients with damages of a musculoskeletal system.
Prevention generally comes down to timely elimination of the reasons causing T. Prevention production T. includes first of all increase in culture of production, replacement of outdated cars and mechanisms, implementation of modern technology, improvement of the organization of work, increase in discipline and strict control of observance of safety regulationss, etc. Prevention road and transport T. provides a complex of the actions directed to improvement of quality of roads, pavings, the organizations of traffic, control of observance of rules street and traffic and behind a condition of vehicles, increase in discipline of drivers and pedestrians, etc.
Prevention of T. represents the complex problem demanding joint efforts of many departments and institutions. So, fight with children's T. it is conducted under the direction of the interdepartmental commissions including representatives of national education, militia, health care and other administrative and economic organizations. The representative of Executive committee of Council of People's Deputies heads them usually. The provision on these commissions is drafted by M3 of the USSR. In prevention household and children's T. broad educational work among the population, first of all among children has special value. Its indispensable condition — constancy, lack of formalistic approach to business.
Medical aspects of prevention of T. include the scientific analysis of different types of T., development of measures of its prevention, studying of features of private types of injuries and circumstances of their emergence, recommendation about their warning, improvement of medical aid to gyust-radavshy. The leading role belongs to the physicians who are carrying out training of the population in methods of first-aid treatment by the victim. Ying-you and departments of traumatology and orthopedics give methodical help in the organization of periodic routine maintenances of the nek-ry contingents of the population, napr, pretrip and complex surveys of drivers of transport, participate in drawing up comprehensive programs of fight against
T. V to system of prevention of T. the big place is allocated a dignity. - a gleam, the work which is carried out under the direction of All-Union society «Znaniye» and the Union of societies of the Red Cross and Red Crescent. In prevention of T. along with traumatologists social hygienists and organizers of health care, workers a dignity participate. - epid. services, in-t of sanitary education, etc. At the enterprises control of actions for prevention of T. it is carried out jointly with service of the accident prevention and the trade-union organizations. Each case of an injury at the enterprise or in child care facility is a subject of consideration of the special commission. Plans of work on decrease in T. on the scale of the cities, areas, etc. are approved by the relevant Councils of People's Deputies. Household and children's T. are least studied. However does not raise doubts that competently organized broad educational work among the population shall be a basis of their prevention.
Prevention of T. it is impossible without its correct account. There are special forms of the account approved by TsSU of the USSR, M3 of the USSR, the Ministry of Internal Affairs of the USSR, the All-Union Central Council of Trade Unions, etc. In ambu-latorno-polyclinic institutions M3 of the USSR at each case of an injury the statistical coupon is filled in (F. No. 25-B), in Krom contains the final diagnosis allowing to analyze injuries on localizations and a nek-eye to features of damages. In statistical reports of the out-patient and polyclinic institutions giving traumatologic help data on number of injuries for the reporting period at adults, teenagers and children in various nosological forms and types of T are entered. A little bigger volume of information on the nature of an injury contains in the medical record of an ambulatory or the medical record of the inpatient if the patient was hospitalized. At the address in connection with an injury on medical assistant's health centers, medical and obstetrical centers, in receptions of BC information is entered in books of record of ambulatories. The information about victims, to the Crimea the crew of emergency medical service was called, records of calls and in the coupon to an accompanying leaf are made in books at hospitalization of patients. In preschool institutions and orphanages individual maps of the child are filled in. Statistical accounting of T., except institutions of the USSR M3 system, conduct TsSU USSR and All-Union Central Council of Trade Unions.
Scientific research on various aspects of T. are carried out in all research in-ta of traumatology and orthopedics and at many departments of traumatology and orthopedics. The scope of researches is defined by M3 of the USSR and traumatism, scientific bases of the organization a travmatologo-shouting-topedicheskoy of the help» Scientific council on problems of traumatology and orthopedics of the USSR Academy of Medical Sciences is coordinated by the allied problem commission «. Plans of scientific research and reports on their performance are submitted in Scientific council where are exposed to reviewing and combine in consolidating plans and reports on researches on a problem.
Training of traumatologists-ortho-pedov is carried out first of all at the departments of traumatology, orthopedics and field surgery created in all medical in-ta. Primary specialization and improvement in traumatology are carried out in in-ta of improvement of the doctors having the relevant departments. The important place in professional development of traumatologists is taken by a training in clinics of in-t of traumatology and orthopedics, in regional, republican and large city-tsakh under the leadership of highly qualified specialists. Training of specialists of high qualification is carried out in a clinical internship and a postgraduate study at all scientific research institutes of traumatology and orthopedics and most departments of traumatology. An important role is played by training of adjacent specialists — physiotherapists, radiologists, etc. for work in travmatol. institutions. Average medics for work upon termination of medical schools, medical assistant's and obstetric schools, etc. pass a training in institutions (departments) of a herbs-matologo-orthopedic profile in corresponding to lay down. - the prof. institutions (e.g., on massage, work of the instrument nurse, etc.).
See also Damages, Traumatology.
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M. V. Volkov, AA. P. Mathis.