Absolute shortening of the limb. Methods for diagnosing the magnitude of the functional difference in the length of the lower limbs

Arms from the acromion of the scapula to the styloid process of the radius or to the end of the third finger	On right	Left
Shoulder a) from the acromial process to the external epicondyle of the shoulder b) b) from the acromial process to the internal epicondyle of the shoulder
Forearms a) from the ulna to the styloid process of the ulna
b) from the head of the ray to the styloid process
Legs from the anterior superior iliac spine to the lower edge of the inner malleolus
Femurs from the greater trochanter to the joint space of the knee joint
Shin from the joint space of the knee joint to the lower edge of the outer ankle

Measuring limb circumference

Joints: configuration, swelling, skin coloring in the joint area (hyperemia, hemorrhage), mobility (active, passive, forced), impaired mobility in the joint (ankylosis, contracture, rigidity, pathological mobility). Pain, its nature, localization, crunching, fluctuation.

Measuring movements in limb joints

	Outgoing Position	On right	Left
Shoulder joint 1. Flexion (raising the arm forward): without the participation of the scapula with the participation of the scapula 2. Extension (abduction of the arm back) 3. Abduction: a) without the participation of the scapula b) with the participation of the scapula 4. Rotation (rotation of the arm around the longitudinal axis): a) outward b) inward	0 0 0 0
Elbow joint: 1. Flexion 2. Extension 3 Supination (inward rotation) 4. Pronation (outward rotation)	180 0 0 0
Wrist joint: 1. Flexion (to the palmar side) 2. Extension (to the dorsal side) 3. Abduction: radial Ulnar
Hip joint: 1. Flexion 2. Extension 3. Abduction 4. Adduction 5. Rotation (rotation of the leg around the longitudinal axis): a) outward b) inward	180 0 0 0
Knee joint: 1. Flexion 2. Extension	180 0
Ankle joint: 1. Flexion: dorsal plantar 2. Supination (adduction) 3. Pronation (abduction)	115 0 0 0

The circumference of the joints is measured in three projections (above the joint, through the center of the joint and below the joint).

Types of joint mobility disorders:

1. Ankylosis- complete immobility in the joint (bone, fibrous, extra-articular).

2. Rigidity- the preservation of minor, rocking movements in the joint occurs as a result of the development of extensive scar tissue, against the background of altered articular surfaces.

3. Contracture– limitation of mobility in the joint resulting from arthrogenic, myogenic, desmogenic and dermatogenic changes, and can also be psychogenic (hysterical), neurogenic (cerebral, spinal, reflex, paretic). They differ in nature: flexion, extension, adduction, abduction and combined.

4. Excessive mobility- expansion of boundaries physiologically

possible movements.

5. Pathological mobility- mobility in atypical planes that do not correspond to the shape of the articular surfaces of a given joint.

RESPIRATORY SYSTEM

Cough(tussis): its character (dry or with sputum production, nasal, “barking”, etc.); time of appearance (day, night, morning); duration (constant, periodic, paroxysmal); conditions for the appearance and relief of cough.

Sputum(sputum)-, character, color and consistency (serous, mucous, mucopurulent, purulent, putrefactive), the amount of sputum at one time and per day, blood impurities. A position that facilitates the best removal of sputum (drainage position).

Hemoptysis(haemoptoe): amount of blood (streaks, clots or pure blood), color of blood (scarlet, dark, “rusty” or crimson), conditions for the appearance of hemoptysis.

Pain(dolor) in the chest: localization, nature of pain (sharp, dull, stabbing), intensity (weak, moderate, strong), duration (constant, paroxysmal), connection with respiratory movements, cough and body position, irradiation of pain.

Dyspnea(dispnoe): conditions of occurrence (at rest, during physical activity, when coughing, changing body position, etc.), the nature of shortness of breath (inspiratory, expiratory, mixed).

Suffocation(asthma) -, time and conditions of occurrence, nature, duration of attacks, their relief. Does the patient use a microflow meter?

Nose: breathing through the nose (free, difficult), charm, nosebleeds, feeling of dryness in the nose, discharge from the nose (character, quantity, odor, odorless).

Rib cage: normosthenic, hypersthenic, asthenic, pathological forms (emphysematous, paralytic, scaphoid, rachitic, funnel-shaped). Expressiveness of the supra and subclavian fossae (full, sunken, retracted). The width of the intercostal spaces (moderate, wide, narrow), the size of the epigastric angle (straight, acute, obtuse), the position of the shoulder blades and clavicles (not protruding, protruding moderately, clearly, wing-shaped shoulder blades), the ratio of the anteroposterior and lateral dimensions of the chest, the symmetry of the chest , (increase or decrease in one of the halves, local protrusions or recesses).

Circumference of the chest, excursion of the chest during inhalation and exhalation, at the level of the IV rib.

Spinal curvatures: kyphosis, lordosis, scoliosis, kyphoscoliosis.

Breathing type: thoracic, abdominal, mixed. Symmetrical breathing movements (lag in breathing of one half). Participation in breathing of auxiliary muscles. The number of respiratory movements per minute. Depth of breathing (shallow, deep, extended inhalation, extended exhalation).

Breathing rhythm: rhythmic (correct) arrhythmic, respiration of Cussmatius, Cheyne-Stokes and Biot.

The ratio of inhalation and exhalation.

Dyspnea: Inspiratory, expiratory and mixed.

Palpation: resistance, comparative definition of vocal tremor, pain. Measurement of chest circumference at nipple level with determination of maximum respiratory excursion.

Percussion: Comparative percussion of the lungs: the sound is pulmonary, box, tympanic, dull-tympanic, dull with precise definition of the boundaries of each sound.

Topographic percussion (normal):

	on right	left
Upper border of the lungs (height of the apexes): front, back: Krenig's fields:		3-4 cm. VII (sh.p.) of the cervical vertebra 3-8 cm.
Lower border of the lungs: along the parasternal line along the midclavicular line along the anterior axillary line along the middle axillary line along the posterior axillary line along the scapular line along the paravertebral line
V	-
VI rib	-
VII rib	VII rib
	VIII rib IX rib X rib Spinous process of the XI thoracic vertebra
Respiratory excursion of the lower edge of the lungs: along the midclavicular line along the midaxillary line along the scapular line	4-6 cm. 6-8 cm. 4-6 cm.	- 6-8 cm. 4-6 cm.

Auscultation: Breathing is vesicular, bronchial, hard, mixed, aphoric, weakened, vague, absence of respiratory noise. Precisely define the boundaries within which each type of breathing is determined.

Bronchophony(normal, enhanced, weakened).

Wheezing: dry (low, high pitch), wet (fine, medium, and large bubbles, ringing, not ringing), wheezing with a metallic tint. Localization of wheezing, appearance or disappearance during the cough reflex. Crepitus. Pleural friction noise.

THE CARDIOVASCULAR SYSTEM

(circulatory system)

Pain in the heart area: localization (behind the sternum, in the area of ​​the apex of the heart, to the left of the sternum at the level of II-VI ribs, etc.), irradiation, nature (compressive, stabbing, pressing, aching, etc.), intensity, constant or paroxysmal , duration of pain, conditions of occurrence (during physical activity, emotional stress, at rest), what is used to relieve it (validol, nitroglycerin, sedatives, drugs), what accompanies the pain.

Feeling of discomfort in the chest.

Dyspnea(dispnoe): conditions of occurrence (during physical activity, at rest), nature and duration of shortness of breath, how it is relieved.

Suffocation(asthma): time and conditions of occurrence (day, night, at rest or during physical activity), duration of attacks, their relief.

Heartbeat(palpitatiocordis): interruptions in the heart: the nature of the arrhythmia (constant, paroxysmal, periodic), duration of attacks, their frequency, conditions of occurrence, how they are stopped.

Edema(oedema): their localization (limbs, lower back, face, abdomen), prevalence (local or anasarca), their severity (pasty, moderate or pronounced), time and conditions of occurrence (at the end of the working day, after physical activity, constant ).

History of intermittent claudication, calf cramps, varicose veins and thrombophlebitis.

Examination of arterial palpations: Heads, necks, limbs, smooth walls. Vessels are tortuous, not tortuous, soft, hard, knotty. Corotid dance. Pulse (temporal, carotid, axillary, brachial, radial, femoral, subliminal, as well as on the arteries of the leg and foot). Determination of pulses simultaneously in symmetrical arteries. Pulse rate per minute. Pulse tension (normal, hard, soft). The rhythm is both correct and incorrect (type of arrhythmia). Filling (full, empty). Size (large, small, thread-like). The speed and nature of the pulse (fast and high, normal, slow and small, dicrotic). Condition of the arterial wall (soft, dense, elastic, nodular).

Inspection and palpation of veins: Venous pulse (positive, negative), venous pulsation with precise indication of the location of pulsation. Dilation of veins (extremities, abdominal wall, chest), indicating the location and wall of the expansion. Induration and soreness of the veins, indicating the vein and the extent of the induration and soreness.

Swelling, redness along the veins. For varicose veins of the lower extremities, describe the Troyanov-Trendelenburg symptom, the Delbe-Perthes gauze test, and the symptoms of Heckenbruch's cough impulse.

Functional tests: Barbell, orthostatic test for weakened patients, Martinet-Kushelevsky (20 squats in 30 seconds) for recovering and physically fit patients.

Inspection of the heart area:

Stretching of the heart region (Vibbuscordis) - apical impulse - cardiac impulse - pulsation in the second intercostal space near the sternum - pathological precordial pulsation.

Their characteristics, localization, strength, prevalence, relationship to the phases of cardiac activity.

Epigastric pulsation: its nature (connection with pulsation of the trouser aorta, heart, liver), prevalence (limited, diffuse)

varicose veins in the sternum area.

Palpation:

Apical push, its localization (indicate the intercostal space and relation to the left midclavicular line), strength (weakened, strengthened, elevating). Area (limited, diffuse), height (high, low), resistance (moderate, increased).

Heart beat: its location, area.

Trembling in the region of the heart (fremitus): its localization, relation to the phases of cardiac activity (systolic or diastolic).

Heart percussion:

Limits of relative dullness of the heart (normal):

Right - 1 cm outward from the right edge of the sternum.

Left - 1 cm inside from the left mid-clavicular line.

Upper - at the level of the third rib on the left.

The diameter of the relative dullness of the heart (11 – 13 cm).

The width of the cardiac bundle in the 1st – 2nd intercostal spaces (8-9cm).

Heart configuration (normal, mitral, aortic).

Limit of absolute dullness of the heart (normal):

Right - along the left edge of the sternum.

Left - 1-2 cm medially from the left border of absolute dullness of the heart, i.e. 2-3 cm medially from the left midclavicular line;

Upper – at the level of the IV rib.

Width of absolute dullness of the heart (5-6 cm).

Auscultation of the heart

Tones(clear, deaf, accented, weakened, split, forked). Rhythm of cardiac activity (correct, incorrect, indicating the type of arrhythmia, pendular, holop rhythm, embryocardia).

Noises, their relationship to the phases of cardiac activity (systolic, diastolic, presystolic, protodiastolic, mesodiastolic, etc.).

Force(sharp, weak).

Character of noise ( soft, blowing, scraping, rough, etc.) its timbre (high, low) duration (short, long, increasing, decreasing, etc.).

Duration(short, long, increasing, decreasing, etc.).

This is a chapter from a completely new textbook “Traumatology and Orthopedics”. Editors: Corresponding Member of the Russian Academy of Medical Sciences, Honored. activities Science of the Russian Federation Professor N.V. Kornilov and Professor E.G. Gryaznukhin, St. Petersburg, ed. “Hippocrates”, 2006. That is, new and fresh.

I have already posted the chapter about scoliosis from the same book:

Volume 1.
Chapter 4

RESEARCH METHODS IN TRAUMATOLOGY AND ORTHOPEDICS

Clinical examination of adults. Authors: E.G. Gryaznukhin, V.I. Ostashko, G.G. Epstein
Assessment of the degree of impairment of static-dynamic function and its compensation according to clinical examination data
Diagnostics in pediatric orthopedics. Authors: M.G. Dudin, S.F. Lesnova, D.Yu. Pinchuk
Clinical diagnosis of the musculoskeletal system in children ,
Instrumental diagnostics of the musculoskeletal system in children ,
Radiological research methods
X-ray methods(A.P. Medvedev)
Basic principles of skeletal X-ray image analysis
Computed and magnetic resonance imaging(A.F. Panfilenko)
Radionuclide research(M.G. Dudin)
Laboratory research methods(G.E. Afinogenov, A.G. Afinogenova)
Blood
General clinical blood test ,
Bone marrow puncture
Urine,
Fluids of serous cavities and cysts
Cerebrospinal fluid
Kal,
Biochemical studies
Protein and protein fractions
Nitrogen metabolism indicators
Glucose and metabolites of carbohydrate metabolism ,
Lipids
Pigment metabolism indicators
Enzymes and isoenzymes
Water-electrolyte metabolism
Iron metabolism indicators
Hemostasis system
Methods used to assess immune status
Preparations for immune-oriented therapy

Two and a half pages are missing because... are devoted to acute injuries and are not of interest to me.

Systematic examination of victims is carried out in a certain order: head, neck, chest, abdomen, pelvis, spine, limbs.

The main examination techniques are inspection, palpation, percussion, auscultation, determination of the range of motion in joints, survey and local radiography. (Percussion (from Latin percussio, literally - striking, here - tapping; Auscultation - listening to sounds formed in the parenchymal and hollow organs of a person (heart, lungs, intestines, pleural cavity) - H.B.) The main tools of an orthopedic traumatologist when examining patients are a centimeter tape and a protractor. Comparative measurements of limb length (relative, absolute), axial lines, circles, amplitude of active and passive movements in joints must be made in all patients.

28. Scheme of comparative measurements on bone protrusions.

Unlike injuries, orthopedic diseases do not have a clear boundary for the occurrence of pathological changes. Pain syndrome, forcing the patient to see a doctor, is, as a rule, a late manifestation of the pathological condition. When collecting anamnesis, it is necessary to clarify
- hereditary factors,
- possible birth injuries,
- past infectious diseases,
- traumas received in childhood, but forgotten.

The examination scheme also includes the determination of morphofunctional changes under dosed loads, analysis of laboratory test results, and surgical interventions (puncture, biopsy).

When studying the patient's complaints, it is necessary to clarify
- timing and nature of the onset of the disease,
- provoking factors,
- characteristics of pain,
- pay attention to the patient’s position when walking, sitting, lying down,
- on his state of mind and behavior. When collecting anamnesis, it is important to find out previous diseases, injuries, allergic reactions, living and working conditions. A skillfully collected anamnesis correctly guides the doctor in resolving issues of diagnosis, treatment tactics, and the scope of interventions.

A thorough and systematic examination helps to avoid many diagnostic errors. By the general appearance and position of the patient, his facial expression, and skin color, one can assess the severity of the patient’s general condition and the predominant localization of the pathological focus. Based on the typical posture and characteristic position of the limb, an experienced doctor can make a diagnosis “at first sight.” But this does not exclude the need for a full examination. The passive position of a limb can be the result of a bruise, fracture, paresis, or paralysis. A forced position is observed in cases of severe pain (gentle placement) in the spine or limbs, in cases of impaired mobility in joints (dislocation, contracture), as a result of compensation for shortening of the limb (pelvic distortion, scoliosis).

29. Axis of the lower limb, a - normal, b, c - varus and valgus curvature.

Upon examination, disturbances in the shapes and outlines of the limbs and body parts are revealed. Violation of the axis of a limb segment, angular and rotational deformation indicate a fracture; violation of the axis of the entire limb is more often associated with orthopedic diseases.

Many orthopedic diseases are named after typical skeletal deformities - clubfoot, clubhand, torticollis, flatfoot, scoliosis, kyphosis, etc.

For comparative measurements, bone protrusions on the limbs and torso are used. On the hand, identification points are the acromion, olecranon, styloid processes of the ulna and radius. On the lower limb - the superior anterior iliac spine, the greater trochanter of the femur, the distal ends of the femoral condyles, the head of the fibula, the lateral and medial ankles (Fig. 28). On the body there is the xiphoid process, the angles of the scapulae, the spinous processes of the vertebrae.

Axis of the lower limb a straight line connecting the superior anterior iliac spine and the first toe is considered. With a straight leg, the medial edge of the patella is located on this axis; with valgus curvature, the patella is displaced to the medial side of the axis, and with varus curvature, to the lateral side (Fig. 29).

The axis of the upper limb A straight line is considered connecting the head of the humerus, the head of the condyle of the humerus, the head of the radius and the head of the ulna. With valgus deformity, the head of the ulna is located lateral to the axis, and with varus deformity, it is more medial (Fig. 30).

30. Axis of the upper limb. a - normal: b, c - valgus and varus curvatures

Lower limb length measured by the distance from the superior anterior iliac spine to the medial malleolus.

The length of the femur is determined from the top of the greater trochanter to the joint space of the knee joint, the length of the tibia is determined from the joint space to the lateral malleolus.

The length of the upper limb is measured from the acromion to the styloid process of the radius or the end of the third finger, the length of the shoulder - from the acromion to the olecranon, the length of the forearm - from the olecranon to the styloid process of the ulna (Fig. 31).

Limb shortening can be:
- true (anatomical - when the bone of one of the segments is shortened directly),
- relative (for dislocations),
- projection (with flexion contracture, ankylosis),
- total (functional - when walking, standing, when all available types of shortening are added up).

(http://www.ncbi.nlm.nih.gov/pubmed/3403498?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements.

Friberg O, Nurminen M, Korhonen K, Soininen E, Mänttäri T.

Research Institute of Military Medicine, Central Military Hospital, Helsinki, Finland.

The results of 196 clinical determinations of leg length inequality and postural pelvic tilt scoliosis in 21 patients were analyzed and compared with reliable radiological measurements. Clinical methods have proven to be inaccurate and highly imprecise, the observer error being +/- 8.6 mm for direct and +/- 7.5 mm for indirect measurement of leg length inequality, and +/- 6.4 degrees for the estimation of postural lumbar scoliosis. More than half (53%) of the observations were erroneous when the criterion of leg length inequality was 5 mm. Failure to determine the presence or absence of length inequality of more than 5 mm occurred in 54 measurements (27% of the total). In 12% of the direct and in 13% of the indirect measurements, the observers erred in deciding which leg was longer; discrepancies occurred even when radiological reading gave a leg length inequality of as much as 25 mm.

Briefly and in Russian: it is impossible to reliably determine the difference in the length of the limbs by measuring the protruding parts - H.B.)

Circumference measurement segments of limbs and joints are performed strictly in symmetrical areas. Repeated measurements must be performed at the same level; bony protrusions serve as landmarks.

Range of motion in joints determined by a protractor. The vertical position of the torso and limbs is taken as the starting position. The branches of the protractor are installed along the axis of the articulating segments, and the axis is aligned with the axis of the joint (Fig. 32). Flexion and extension are carried out in the sagittal plane, abduction and adduction - in the frontal plane, rotational movements - around the longitudinal axis.

Depending on the nature of the mobility impairment in the joint, there are:
1) ankylosis (complete immobility);
2) rigidity (swinging movements are possible);
3) contracture - limitation of mobility
- when bending (extension contracture),
- during extension (flexion contracture),
- during abduction (adduction contracture).

31. Measuring the length of the lower and upper limbs.

a - relative length of the lower limb; b - thigh length; c - length of the lower leg;

d - relative length of the upper limb; d - shoulder length; a is the length of the forearm.

Ankylosis there are
- true (bone) and
- false (fibrous), which is determined by x-ray.

According to etiology, there are also various types of contractures:
- dermatogenic,
- desmogenic,
- tendogenic,
- myogenic,
- arthrogenic,
- neurogenic,
- psychogenic,
- mixed.

32. Measuring the range of motion in joints.

a - shoulder abduction; b - flexion at the shoulder joint; c - flexion at the elbow joint; d - flexion-extension in the wrist joint; d - adduction-abduction of the hand: f - hip abduction; g - flexion at the hip and knee joints; h - flexion-extension at the ankle joint.

When examining an orthopedic patient, important information is obtained using methods of contour drawing, prints, plaster casts, photographic recording, and optical topography (Fig. 33). (There is NO scientific evidence of any value to this information. See - H.B.)

Determination of excessive mobility, unusual (“abnormal”) movement in the joint area, along a bony segment of the limb, can be critical to diagnosis.

The patient's complaints about pain, limitation or dysfunction, and deformations that are leading to injuries and diseases of the musculoskeletal system are clarified based on information obtained from the anamnesis.

Anamnesis of life allows you to get an idea of ​​the patient’s personality and determine the level of communication with him to obtain information about living and working conditions. For congenital diseases, family history provides information about possible hereditary transmission (congenital dislocation of the hip joints, clubfoot, scoliosis, arthrogryposis, hemophilia) (Neither clubfoot nor scoliosis by itself is inherited. These maxims are simply a hymn to illiteracy, completely unforgivable for medicine, which has the audacity to call itself “scientific” - H.B.) . Living and working conditions make it possible to judge possible environmental (geochemical, toxic and radiation) effects that can have a primary genetic or secondary effect on the body and the musculoskeletal system and contribute to the occurrence of systemic osteoporosis, urinary disease, vibration disease, toxic arthrosis and other pathological changes.

From the anamnesis, the age at which the complaints appeared, their severity and dynamics over time is determined. The diagnosis established during the initial consultation with doctors, the treatment performed and its effectiveness should, if possible, be supported by documentation (certificates, extracts from the medical history, radiographs, data from laboratory and instrumental studies). (Especially considering that these statements are often impossible to obtain - H.B.)

Purposeful questioning of the patient allows you to clarify
- localization of pain,
- its prevalence,
— zone of possible irradiation,
- determine whether it is sharp or dull,
- constant or paroxysmal (stabbing, shooting, drilling, gnawing),
— arising spontaneously or provoked by load, posture or other influence.

It should be clarified
- what methods were used to reduce or eliminate pain (independently or on the recommendation of doctors),
- their effectiveness,
- frequency and duration of relapses,
— the circumstances of their occurrence and connection with the degree of dysfunction.

In case of dysfunction, it is also necessary to find out the age and duration of its onset, what the initial manifestations were and to what extent they limited the patient in everyday life and professionally. Determine whether the dysfunction preceded the onset of the deformity or developed later. To clarify their dynamics, the treatment performed and its effectiveness.

Assumptions about orthopedic diseases or injuries to the musculoskeletal system and their consequences are clarified during examination, comparing its results with examination data of symmetrical parts of the body or with indicators corresponding to ideas about the norm.

The position of the body and the relationship of its parts are clarified using the simplest geometric constructions, which make it possible to determine the axial lines of the body parts and the relative position of the bony protrusions.

34. Approximate planes that determine the deviation of the body from the neutral position (frontal, sagittal, horizontal) (according to V.O. Marx, 1978)

In an adult, normally developed healthy person standing in a free vertical position, the rear axis of the body runs along the line connecting the occipital protuberance with the intergluteal fold. In front, it is defined by a line connecting the jugular recess, the apex of the xiphoid process, the umbilical fossa and the pubic symphysis, running perpendicular to the line connecting the anterior superior iliac spines through its middle.

The right and left halves of the body are symmetrical, the shoulder girdles are the same length, the waist triangles formed by the lateral surfaces of the torso, the lumbar region and the inner surface of the upper limbs are symmetrical and have equal heights. The angles of the scapulae, crests and iliac spines are at the same level. Symmetrical limbs have the same length, and the ratio of the curvatures of the spine in the sagittal plane is such that the back is visually perceived as “straight or level” (normal posture).

Normal or loose posture- a reflexively accepted ratio of body parts with minimal energy consumption to maintain it. With normal posture, the lines connecting the scapular spines and the posterior superior iliac spines are parallel and located in the same plane (Fig. 34). (Actually, this reference does not correspond to the picture - H.B.)

The total length of the body (height), the length of individual parts and segments of the limbs can be assessed visually, and for the comparability of the results obtained they are measured according to certain rules using bone protrusions.

The average height of an adult man is 170-175 cm, women - 165-170 cm. Height from 175 to 185 cm for men and from 170 to 180 cm for women is high, and exceeding these figures is very high. (1) Height depends on a person's ethnicity; 2) These data refer to the middle, if not the beginning of the twentieth century. Since then, people have grown on average by 10 cm. With such cute marks you can easily see how old shit has been dragged from textbook to textbook for centuries without any processing or even weak attempts to rethink the material - H.B.)

Length front torso measured from the jugular notch to the upper edge of the pubic symphysis, and posteriorly determined by the distance between the line connecting the acromions and the line connecting the posterior superior iliac spines. Length front spine determined by the distance from the tip of the nose to the upper edge of the pubic symphysis, and from the back - from the occipital protuberance to the top of the coccyx.

About proportionality physique can also be judged by the relationship of certain parts of the body. For example, the length of the foot is approximately equal to the length of the neck and the length of the forearm from the elbow to the styloid process of the ulna. The length of the clavicle is equal to the length of the sternum without the xiphoid process, the length of the vertebral edge of the scapula, the distance between the shoulder blades and the length of the hand.

The degree of development of soft tissues is judged based on measuring the circumference of body parts or limb segments at several levels symmetrical relative to the bony protrusions.

During a clinical examination, the muscular system is assessed by the severity of muscle relief, tone and strength of contractions. (Muscle relief actually depends on the amount of fat - H.B.) The strength of contractions is determined using a 5-point system or measured using dynamometers (Table 6).

Table 6. Muscle function score

Normal mobility is visually determined by actively tilting the head forward until the chin touches the sternum. (What is mobility determined? - H.B.) , posteriorly - to the horizontal position of the occipital protuberance, to the side - until it touches the shoulder girdle, and when turning, touch the acromion area with the chin.

Tilt of the torso forward with straightened legs allows you to reach with your fingers to the supporting surface, and to the side - to the lower third of the outer surface of the lower leg.

Body build can also be judged by the Pinier index. The index is equal to the difference between height in centimeters, body weight in kilograms and the length of the chest circumference at nipple level during exhalation in centimeters. A difference of less than 10 indicates a strong physique, from 10 to 20 - good, from 20 to 25 - average, and from 25 to 35 - weak.

By the general appearance, skin color, activity and position of the patient, you can get a first impression of his condition. Changes in proportions and the presence of deformations suggest their possible cause or localize the area of ​​pathological changes. (Uh-huh, skin color is especially relevant in a country with 50% Mongoloid population - H.B.)

Appearance can be changed due to impaired development (growth) of the body or its individual parts, congenital diseases, systemic skeletal diseases, endocrine diseases, or due to injury and its consequences. The characteristic features of some deformities may determine the diagnosis: torticollis, scoliosis, kyphosis, clubfoot, dislocations and some fracture locations.

Congenital diseases caused by genetic (often inherited factors) or endogenous and exogenous influences during intrauterine development can manifest themselves as various deformities, deformations and functional disorders (Fig. 35).

35. Examples of skeletal malformations.
a - b - multiple skeletal malformation (diaphyseal dysplasia in an 8-year-old girl - a - front view; b - side view); c - isolated skeletal malformation (right-sided clubfoot)

Bone development abnormalities may be
- quantitative (numerical),
— structural (anatomical and morphological),
- single and multiple,
- one-sided and two-sided.

A quantitative anomaly can be manifested by the absence of one or more bones (for example, the collarbone, scapula, vertebrae, ribs) or the presence of additional ones (ribs, vertebrae, foot bones).

Underdevelopment, hypoplasia or dysplasia of bones leads to structural changes and disruption of the shape of the bones, varus deformation of the necks of the femurs, disruption of the relationships in the joints (usually in the hip and knee), wedge-shaped and semi-wedge-shaped deformation of the vertebrae, synostosis (impaired differentiation) of the ribs and vertebrae. With local underdevelopment of not only bones, but also surrounding tissues, changes are formed that acquire nosological significance. These primarily include congenital scoliosis, myelodysplasia (a combination of spinal dysplasia with dysplasia of the spinal cord and its membranes), congenital clubhand, Madelung's disease, congenital subluxation or dislocation of the hip, dislocation of the patella, congenital flatfoot and clubfoot. Underdevelopment can extend to the weight of the limb tissue and be manifested by its complete absence or the presence of only a rudiment (peromelia).

Shortening or absence of a limb segment is called ectromelia. If one of the bones of the two-bone segment is absent or shortened, it is called longitudinal, and if both are abnormal, it is called transverse. The preservation of the hand in the absence of the shoulder and forearm makes the rudiment look like a seal flipper and is called “phocomelia.”

Violation of proportions and deformations can be caused by a violation of the development and topographic location of muscles. With congenital lateroposition of the quadriceps femoris muscle, valgus deviation of the tibia develops. Shortening of the sternocleidomastoid muscle leads to torticollis. There is a congenital absence of one or both pectoral muscles.

Severe growth disturbances occur in systemic and endocrine diseases. Dwarfism (nanism), which occurs when the function of the anterior lobe of the pituitary gland is insufficient, is characterized by the preservation of the correct proportions of the body. With a decrease or loss of thyroid function, dwarf growth is accompanied by a violation of body proportions - an enlargement of the skull, deformation of the facial skeleton and varus deformation of the hips.

At hyperthyroidism (Graves disease), which occurs before the end of growth, early synostosis of the growth zones occurs and in adults shortening and deformation of the bones are noted.

Most pronounced disturbances of proportions and deformations in dwarfs with chondrodystrophy. Unusually high growth - gigantism - occurs with hyperfunction of the pituitary gland, most often caused by eosinophilic adenoma. With early-onset hyperfunction, gigantic growth is observed. If changes in the pituitary gland occur after the closure of the growth zones, then a disproportionate increase in the facial skull, torso and limbs (especially the lower jaw, hands and feet) occurs.

In other systemic osteopathies, changes in body proportions are caused by disturbances in bone growth, changes in their structure and resulting deformations (hyperparathyroid osteodystrophy, Itsenko-Kushnang disease, Braitsev disease) and pathological fractures. Most often, pathological fractures occur due to imperfect bone formation.

Vitamin deficiencies have a specific effect on the skeleton. With vitamin A deficiency, excessive growth of tubular bones occurs due to epiphyseal cartilage, and a lack of B vitamins causes growth arrest. Vitamin C deficiency leads to disruption of metabolic processes in bone tissue, bone hypotrophy and a tendency to fractures.

Combinations of congenital and systemic pathological deformations and functional changes are identified as symptom complexes - syndromes, knowledge of which facilitates diagnosis. The most typical ones are:

Ahner's syndrome - tower skull, moon-shaped face, flattened nose, bulging eyes, high cleft palate, poly- or syndactyly, radioulnar synostosis with stiffness in the elbow joint;

Generalized ossifying periostosis or periostitis - Bamberger-Marie syndrome;

A combination of curvature of the spine with a funnel-shaped deformity of the chest, disproportion of the humerus, deformities of the feet and fingers and skin manifestations (scar changes, funnel-shaped retractions, hairiness);

Bremer's syndrome is a clinical manifestation of dysraphic status;

The combination of dolichocephaly with various types of deformation of the chest and spine, disproportionately long and thin limbs and fingers and toes (arachnodactyly) - Marfan syndrome - is caused by congenital mesenchymal deficiency.

Other types of congenital underdevelopment of collagen structures are, along with kyphoscoliotic deformity of the spine, hyperelasticity of the skin, hypotonia of muscles, loose joints, cardiovascular disorders, fragility of blood vessels and a tendency to bleeding, as well as damage to the organ of vision - Ehlers-Danlos syndrome.

To assess static-dynamic function based on clinical data, it is necessary and sufficient to determine and analyze a number of clinically determined indicators:
- mobility in joints,
- pelvic distortion,
- pelvic tilt,
- the magnitude of valgus or varus deformation of the thigh, leg and foot,
— reference and calculated shortening,
- limb support ability,
- muscle strength of flexors and extensors,
- length and width of step,
- walking speed.

Joint mobility is measured in degrees. Hip mobility, if possible, is measured in the supine position with the opposite leg maximally flexed at the hip and knee joints (Thomas position).

Mobility in the sagittal plane is counted from 180°, and abduction-adduction and rotational mobility - from 0° (For more fans, obviously - H.B.) .

Limitation of mobility is assessed in points. Decreased range of motion (contracture)
- 15-25% compared to the norm corresponds to 1 point,
- by 26-35% - 2, and
- by 36% and more - 3 points.

Contracture is assessed as mild if the sum of points determined when measuring mobility in each of the planes possible for movement does not exceed 8. With a score of 9 to 14, contracture is assessed as moderate, and from 15 n above - as severe.

(Where is the assessment of hypermobility? - H.B.)

Limb shortening consists of
- anatomical (if any),
- dislocation,
- projection and
- shortening caused by adductor contracture (abduction contracture will give functional lengthening).

Every 10° of contracture results in a change in functional length of 1 cm. To determine shortening, measure the relative shortening from the anterior superior iliac spine to the medial malleolus and add to it the shortening due to adductor contracture. (I repeat: all these measurements with a centimeter on the knee are unreliable - this is scientifically proven - H.B.)

Support shortening does not take into account compensatory pelvic distortion, since it is measured when aligning the anterior superior iliac spines. Pelvic tilt and skew occur to compensate for shortening caused by flexion and abduction or adduction contractures.

In the presence of abductor or adduction contracture, the relative length of the limb should be measured from the xiphoid process of the sternum to the inner malleolus with the legs parallel. In order for the legs to be parallel, during abduction contracture the pelvis will tilt towards the abducted leg and the relative length of this leg will increase. In other words, pelvic tilt will either increase the length of the limb on the side of abduction contracture, or compensate for shortening (or part of it) if flexion contracture and/or anatomical shortening have occurred. An adductor contracture will reduce the relative length of the limb, measured from the xiphoid process, by elevating the pelvis on the side of the contracture. These details are very important when assessing compensation for static-dynamic disturbances. (It is very clearly written how and what to measure. And, most importantly, these tests are statistically, scientifically verified, yeah - H.B.)

Support shortening- the distance from the plantar surface of the foot to the plane of support in a standing position and when the bispinal line is parallel to the plane of support. The easiest way to measure is by placing measuring boards under the foot until the pelvic distortion is eliminated.

In the supine position, the patient is placed so that the axis of the body is perpendicular to the bispinal line, and the feet rest against the supports. Measure the distance from the xiphoid process to the inner malleolus.

Calculated shortening- shortening that would occur in the absence of compensation. It consists of relative shortening, measured from the anterior superior iliac spine to the medial malleolus and including (if any) anatomical and dislocational, and changes in length that occur with abduction or adduction contracture.

An estimated shortening of 2-4 cm is regarded as mild, by 4-6 cm as moderate, and by
7 cm or more - as expressed.

Pelvic distortion. A change in the position of the pelvis in the frontal plane occurs when compensating for functional shortening (Illiteracy. There can be a lot of reasons for pelvic distortion - H.B.) .

Throttle tilt is determined by measuring the angle between the vertical axis of the torso and the bispinal line. Normally this angle is 90°.

If the limb is fixed in the abduction position, then to restore supportability the pelvis tilts towards the abducted leg and functional lengthening occurs. With adduction contracture, the pelvis rises, increasing the existing shortening.

The desired angle of inclination for abductor contracture will be equal to the value obtained during measurement, minus 90°, and for adductor contracture, it will be equal to 90° minus the angle obtained during measurement. (In addition to contractures, there is actually muscle weakness - H.B.)

Tilt of the pelvis towards the shortened leg for every 3° compensates for shortening by 1 cm. (The numbers are taken out of thin air, as usual, one must think? - H.B.)

Muscle wasting. Muscle wasting is determined in relation to the symmetrical “healthy” segment of the limb. The perimeter is measured at symmetrical levels, and its relative decrease in percentage is determined. Hypotrophy up to 5% is considered mild. From 5 to 10% as moderate, and more than 10% as severe. (Why did anyone think that a large limb is healthy and not hypertrophied, I wonder? - H.B.)

Muscle strength. Muscle strength is determined with a backbone dynamometer, measuring the forces developed by the subject at maximum flexion and extension. A decrease in muscle strength in relation to symmetrical healthy ones by no more than 40% is regarded as mild, from 40 to 70% as moderate, and more than 70% as pronounced.

Supportability determined by the results of “separate” weighing. The subject is placed on two floor scales and their readings are determined as a percentage of body weight, the ratio and the difference in absolute values. The data obtained allow us to judge the distribution of the load on the limbs and the support coefficient (ratio of absolute values), which is normally equal to 1.

Standing and walking. Using the data obtained from the analysis of prints of 3-5 double steps, it is possible to obtain biomechanical characteristics of standing and walking, allowing one to assess the state of static-dynamic function.

Step length- the distance between the prints of the rear edge of the heel with two successive supports of the same leg. The length of an adult's step is equal to three times the length of his foot. On average, without taking into account gender, height and age, it is 780 mm. (The most meaningless indicator imaginable is one that is calculated without taking into account gender, height and age - H.B.)

Step width measured by the distance between the heel and the center line of movement; the value of the indicator varies depending on the speed of movement, height and type of gait and averages 5-7 cm.

The angle of rotation of the foot varies depending on the reasons mentioned above and at an average speed of movement it is 8-15°.

Walking speed averages 4.5 km/h, or 75 m/min.

The duration of a double step is on average 1.38 s. (three steps - 4.14 s.)

Rhythm factor- the ratio of the time of a double step with the right and left foot. Normally the coefficient is equal to I.

Marching test. Using a pedometer and a stopwatch, determine the time and number of steps when walking a distance of 100 m. An increase in the number of steps and time of passage indicates an increase in double-foot and single-foot time, an increase in the duration of a double step and a slower pace of walking. These changes are caused by limited mobility in the affected joints and the severity of pain.

Since the walking speed is 75 m/min, it will take a healthy person 1 minute to walk 100 m. 18 s.. With an average step length of 78 cm, to walk 100 m you will need to take 128 steps. The walking pace will be 98-99 steps/min.

A very important way to obtain additional information about the state of the support and movement system. The study should be carried out comparing the diseased and healthy limbs on

Rice. 1.30. Example of measuring the length of the lower limb: A - the first stage of establishing a symmetrical position of the pelvis by determining the distance between the xiphoid process and the anterosuperior iliac spine B - if the position of the pelvis is symmetrical, then the length of the lower limb is measured from the anterosuperior iliac spine to the inner malleolus

based on the measurement results with a centimeter tape (Fig. 1.30, 1.31). When examining a patient, the length of the limb and its circumference are measured. Measurements are performed on both the affected and healthy limbs. The results obtained are compared, which gives an idea of ​​the degree of anatomical and functional disorders. The length and circumference of the limb are measured with a regular measuring tape. Identification points for comparative measurement of limb length are bony protrusions. When measuring, the patient must be positioned correctly: pay attention to the fact that the patient’s pelvis is not skewed, but a line

Rice. 1.31. An example of measuring the length of the femur and tibia: a) measuring the length of the femur from the apex of the greater trochanter to the joint space of the knee joint b) measuring the length of the tibia from the joint space of the knee joint to the lateral malleolus

connects both anterosuperior spines, was perpendicular to the midline of the body. When determining the length of the lower limb, measure the distance from the anterosuperior iliac spine to the lower edge of the inner malleolus. When measuring the length of the femur, the distance between the greater trochanter and the joint space of the knee joint is determined. The length of the tibia is determined by measuring the distance from the joint space of the knee joint to the lower edge of the outer malleolus (Fig. 1.31).

Limb circumference is measured at equal distances from certain bony landmarks.

The length of the upper limb is measured from the suprahumeral process of the scapula to the styloid process of the radius or to the end of the third finger. The length of the shoulder is from the edge of the girdle to the top of the olecranon process. Length of the forearm - from the top of the ulna to the styloid process of the ulna (Fig. 1.32)

Rice. 1.32. Upper limb length measurement:

a) measuring the length of the upper limb from the supra-humeral process to the end of the third finger 6) measuring the length of the shoulder from the supra-humeral process to the top of the olecranon or to the external epicondyle of the humerus: c) measuring the length of the forearm from the external process of the humerus to the styloid process of the radius

When recording measurement results, it is necessary to indicate the points from which the length of the limb or its segment was measured.

The following types of limb shortening are distinguished:

Absolute or anatomical shortening (true)- is caused by an anatomical change in the limb and is determined by comparing the total measurement data of the length of the thigh and lower leg (shoulder and forearm) on the damaged and healthy limbs. Determined by measuring the anatomical length by segment (thigh, lower leg, etc.). Such shortening is observed when bone growth is delayed, fragments are displaced, etc.

Projective (imaginary) shortening- caused by a defective position of the limb due to contracture or ankylosis in the joint.

Relative (dislocation) shortening- occurs with dislocations, when one cyst

Rice. 1.33. Determination of functional shortening of the left lower limb by placing compensating pads under the foot to align the symmetry of the bony landmarks of the pelvis

The articulating one is displaced relative to the other (for example, when the hip is dislocated and displaced upward from the acetabulum, a shortening of the limb is determined, despite the same anatomical length of the lower limbs).

Total (functional) shortening can be measured using planks (boards) of a certain thickness. These planks are placed under the shortened leg until the pelvis takes the correct position (the line connecting the anterosuperior spine should take a horizontal position). The height of the substrates determines the total shortening of the lower limb (Fig. 1.33).

The circumference of the limbs (sick and healthy) is measured in symmetrical places at a certain distance from the lower limb of bone identification points: for the lower limb - from the anterosuperior iliac spine, greater trochanter of the femur, articular space of the knee joint, head of the fibula, etc.; for the upper limb - from the supra-humeral process, internal epicondyle of the shoulder, etc.

Determination of muscle strength. The functional capabilities of the musculoskeletal system largely depend on the condition of the muscles. The study of muscle strength in case of uneven muscle damage (poliomyelitis, spastic infantile paralysis, paresis, etc.) is especially important for developing the correct treatment plan. In the clinic, when studying muscle strength, the method of active movements with overcoming resistance created by the researcher’s hand is widely used. The patient is asked to bend, straighten, adduct or abduct a limb, and what is being examined seeks to create resistance, opposition to these movements. By comparing the data obtained on the diseased and healthy limbs, one can imagine the state of muscle strength. Muscle strength is assessed using a five-point system: 5 - normal muscle strength, 4 - reduced muscle strength, 3 - pronounced decrease, 2 - significant decrease, 1 - complete paralysis.

When conducting special studies to objectively determine muscle strength, a dynamometer is used, which is fixed motionless on one side and fixed on the other.

Rice. 1.34. Testing thigh muscle strength using a dynamometer

m - to the cuff attached to the segment of the limb under study (Fig. 1.34).

Study of injuries and diseases of the spine. In the diagnosis of injuries and diseases of the spine, clinical, radiological, electrophysiological, instrumental and laboratory research methods are used. The main method is clinical, which involves a certain system of sequential actions by the doctor. It is recommended to adhere to the following order: clarification of complaints, collection of anamnesis (mechanism of injury), examination of the patient, establishment of a preliminary diagnosis.

Complaints. When clarifying complaints, the main ones should be identified. Most trauma patients complain of pain in the damaged area, which intensifies with movement, limitation of movements, and visible deformation of the segment.

Anamnesis. It is necessary to determine the mechanism of injury in the patient. Based on its typical mechanism, one or another type of damage can be suspected. A survey of the patient or his relatives about the onset and first manifestations of the disease, its dynamics, and previous treatment should be carried out in detail. There are diseases and injuries in which a well-collected history of the disease or injury allows not only to suspect, but also to make a correct diagnosis. In some patients, over time, many objective symptoms may disappear and cannot be detected during examination.

As with other diseases, it is necessary to collect an anamnesis of the patient’s life: state of health at birth, living conditions in childhood, adolescence and adulthood, working conditions and occupational hazards, past illnesses, allergy history.

Objective review. The spine is examined with the patient standing, sitting and lying down, both at rest and in motion (head, torso, limbs). The level of spinal damage is determined by counting the number of vertebrae from certain anatomical landmarks or according to a special scheme. To examine a patient while standing, he should turn his back to the light. The person being examined should stand straight, with relaxed muscles, barefoot, with his arms hanging freely along the body. In a normally built adult, the spine has physiological curvatures in the form of two lordoses in the cervical and lumbar regions and one kyphosis in the thoracic region. The final shape of the spine is established until adulthood and remains until 45-50 years of age, after which the thoracic region again begins to gradually round, approaching senile kyphosis. In adult women, lumbar lordosis is more pronounced than in men. With a special marker or glance (with sufficient research experience) the line of the spinous processes (median groove of the back), the lower angles of the shoulder blades, the crests of the iliac bones, the lateral contours of the waist and neck, the position of the shoulder girdle, and the deviation of the intergluteal groove from the vertical are noted. When examining the spinous processes, their protrusion is revealed; A sharp protrusion of one process relative to others does not normally occur. When examining your back, pay attention to the contours of the muscles located next to the spine.

In practice, in addition to the normal structure of the spine, it is customary to distinguish the following types of appearance: flat, round and stooped back. In the thoracic region, even due to slight deformation, kyphosis becomes very noticeable. The appearance of kyphosis in the cervical or lumbar regions indicates the presence of serious pathological changes: the protrusion of one or more spinous processes with cutopodibous kyphosis forms a hump }