What is the name of the distal phalanx of the fingers. The structure of the hand and wrist

The phalanges of human fingers have three parts: proximal, main (middle) and terminal (distal)... There is a clearly visible nail tuberosity on the distal part of the nail phalanx. All fingers are formed by three phalanges, called the main, middle and nail. The only exception is thumbs - they consist of two phalanges. The thickest phalanges of the fingers form the thumbs, and the longest form the middle fingers.

Structure

The phalanges of the fingers are short tubular bones and look like a small elongated bone, in the form of a half-cylinder, with the convex part facing the back of the palm. At the ends of the phalanges, there are articular surfaces that take part in the formation of interphalangeal joints. These joints are block-shaped. It is possible to perform extensions and flexions in them. The joints are well strengthened with collateral ligaments.

The appearance of the phalanges of the fingers and the diagnosis of diseases

In some chronic diseases of the internal organs, the phalanges of the fingers are modified and take the form of "drumsticks" (spherical thickening of the terminal phalanges), and the nails begin to resemble "watch glasses". Such modifications are observed in chronic lung diseases, cystic fibrosis, heart defects, infective endocarditis, myeloid leukemia, lymphoma, esophagitis, Crohn's disease, liver cirrhosis, diffuse goiter.

Fracture of the phalanx of the finger

Fractures of the phalanges of the fingers are most often caused by a direct blow... A fracture of the nail plate of the phalanges is usually always fragmented.

Clinical picture: the phalanx of the fingers hurts, swells, the function of the injured finger becomes limited. If the fracture is displaced, then the deformation of the phalanx becomes clearly visible. With fractures of the phalanges of the fingers without displacement, sprains or displacements are sometimes mistakenly diagnosed. Therefore, if the phalanx of the finger hurts and the victim associates this pain with injury, then an X-ray examination (fluoroscopy or X-ray in two projections) should be mandatory, which allows a correct diagnosis to be made.

Treatment of a fracture of the phalanx of the fingers without displacement is conservative. An aluminum splint or plaster cast is applied for three weeks. After that, physiotherapy, massage and physiotherapy exercises are prescribed. Full mobility of the injured toe is usually restored within a month.

In case of fracture of the phalanges of the fingers with displacement, the bone fragments are compared (reposition) under local anesthesia. Then a metal splint or plaster cast is applied for a month.

In case of a fracture of the nail phalanx, it is immobilized with a circular plaster cast or adhesive plaster.

The phalanges of the fingers hurt: causes

Even the smallest joints in the human body, the interphalangeal joints, can be affected by diseases that impair their mobility and are accompanied by excruciating pain. Such diseases include arthritis (rheumatoid, gouty, psoriatic) and osteoarthritis deformans. If these diseases are not treated, then over time they lead to the development of severe deformation of the damaged joints, a complete disruption of their motor function and atrophy of the muscles of the fingers and hands. Despite the fact that the clinical picture of these diseases is similar, their treatment is different. Therefore, if you have pain in the phalanges of the fingers, then you should not self-medicate.... Only a doctor, having carried out the necessary examination, can make the correct diagnosis and, accordingly, prescribe the necessary therapy.

Dislocations of the phalanges of the fingers of the hand make up from 0.5 to 2% of all injuries of the hand. The most common dislocations occur in the proximal interphalangeal joint - about 60%. Dislocations in the metacarpophalangeal and distal interphalangeal joints occur with approximately the same frequency. Dislocations in the joints of the fingers of the hand are more often observed on the right hand in people of working age due to household injury.

Dislocations in the proximal interphalangeal joints. The proximal interphalangeal joint is characterized by two types of damage:

1) dislocation posterior, anterior, lateral;

2) fracture dislocation.

Posterior dislocations occur during overextension of the proximal interphalangeal joint. This injury is characterized by rupture of the palmar plate or collateral ligaments.

Lateral dislocations are a consequence of the impact on the finger of abductive or adductive forces when the finger is extended. The radial collateral ligament is damaged much more often by the ulnar ligament. As a rule, spontaneous reduction occurs with this damage. Reduction of fresh lateral and posterior dislocations is often not difficult and is performed in a closed manner.

Anterior dislocation occurs as a result of combined forces - leading or abducting - and a force directed anteriorly and displacing the base of the middle phalanx forward. In this case, the central bundle of the extensor tendon is detached from the attachment point to the middle phalanx. Palmar dislocations occur much less frequently than others, since a dense fibrous plate exists in the anterior wall of the capsule, which prevents the occurrence of this damage.

Clinically, with this type of injury in the acute period, edema and pain can mask the existing deformity or dislocation. On examination, patients with lateral dislocations show pain during the rocking test and tenderness on palpation on the lateral side of the joint. Lateral instability indicating complete rupture.

Radiographically, with a rupture of the collateral ligament or with severe swelling, a small fragment of bone is revealed at the base of the middle phalanx.

With fracture dislocations, there is a dorsal subluxation of the middle phalanx with a fracture of the palmar lip of the middle phalanx, which can cover up to 1/3 of the articular surface.

Dislocations in the distal interphalangeal joints.

The distal interphalangeal joints are stable in all positions, since the supporting apparatus consists of dense collateral accessory ligaments connected to the fibrous plate from the outer palmar side. Here, dislocations are also possible, both in the back and in the palmar side. Reduction of fresh dislocations is not difficult. The only inconvenience is the short reduction lever represented by the nail phalanx. Reduction of chronic dislocations in the interphalangeal joints is much more difficult, since contracture rapidly develops with cicatricial changes in the surrounding tissues and the organization of hemorrhage in the joint. Therefore, you have to resort to various methods of surgical treatment.

Dislocations in the metacarpophalangeal joints.

The metacarpophalangeal joints are condylar joints, which, in addition to flexion and extension, are characterized by lateral movement of at least 30 ° with the joint extended. Because of its shape, this joint is more stable in flexion when the collateral ligaments are taut than in extension, which allows lateral movement in the joint. The first finger suffers more often.

With old dislocations of the phalanges of the fingers of the hand, the main method of treatment is the imposition of compression-distraction devices. This method is often combined with open reduction. In other cases, if reduction is impossible and the articular surfaces are destroyed, arthrodesis of the joint is performed in a functionally advantageous position. Arthroplasty using biological and synthetic pads is also used.

Metacarpal fracture treatment

The main methods of restoring the function of the finger joints are open and closed repositions of fragments as soon as possible after trauma, arthroplasty using various auto-, homo- and alloplastic materials, treatment with external fixation devices of various designs. Recently, with the development of microsurgical techniques, many authors have proposed the use of vascularized grafts for total and subtotal destruction of articular surfaces, such as transplantation of a blood-supplied joint. However, these operations are lengthy, which is unfavorable for the patient, they have a high percentage of vascular complications, and subsequent rehabilitation treatment is difficult due to prolonged immobilization.

For non-operative treatment of fractures and dislocation fractures, the most common method is the use of plaster casts, twists and splint-sleeve devices. In clinical practice, immobilization with splints and circular plaster casts is used. Recently, various types of plastic dressings have been increasingly used.

The terms of immobilization with plaster casts for fractures and dislocations of the phalanges of the fingers and metacarpal bones of the hand is 4-5 weeks.

When carrying out open reduction or reposition of fragments of the phalanges and metacarpal bones of the hand for osteosynthesis, various extraosseous and intraosseous fixators of various sizes are widely used - rods, pins, pins, screws made of various materials.

Especially great difficulties arise in the treatment of complex intra-articular fractures - at the same time the head and base of the bones in the same joint, with multiple comminuted fractures, accompanied by ruptures of the capsule and ligamentous apparatus of the joint and as a result of dislocation or subluxation. Often, these injuries are accompanied by the interposition of bone fragments with joint blockade. The authors also propose various methods of treatment: the imposition of external fixation devices, primary arthrodesis of the damaged joint. The most effective surgical treatment consists in open reduction and connection of fragments with various fixators.

There is an opinion that in case of severe damage to the joints of the fingers of the hand, one should not restore the integrity of the articular surfaces, but close the joint by primary arthrodesis, since the creation of a supporting finger when fixing the injured joint in a functionally advantageous position contributes to a faster and more complete rehabilitation of a patient whose profession is not associated with fine differentiated hand movements. Arthrodesis is widely used for injuries of the distal interphalangeal joints. Priority is given to this operation for chronic joint injuries with significant damage to the articular surfaces.

In the last decade, many technical solutions have been described related to the modernization of existing and the creation of new models of compression-distraction and hinge-distraction devices.

M.A. Boyarshinov developed a method for fixing the fragments of the phalanx of the finger with a structure of knitting needles, which is mounted like this. Through the proximal fragment of the phalanx, closer to the base, a Kirschner's wire is passed transversely, a thin wire is passed through the same fragment, but closer to the fracture line, and a pair of thin wires is also passed through the distal fragment. The protruding ends of the Kirschner wire, passed through the proximal fragment at the base of the phalanx, at a distance of 3-5 mm from the skin, are bent in the distal direction at an angle of 90 ° and placed along the finger. At a distance of 1 cm from the distal end of the damaged phalanx, the ends of the spoke are again bent counter to each other at an angle of 90 ° and twisted together. As a result, a one-plane rigid frame is formed. For it, thin wires are fixed with the effect of compression or distraction of the repressed phalanx fragments. Depending on the location and nature of the fracture, the technique for introducing the needles may be different. For transverse and close to them fractures, we use the fixation of fragments at the junction in the form of a lock using L-shaped curved needles according to E.G. Gryaznukhin.

To eliminate the contracture of the fingers in both interphalangeal joints, an external I.G. device can be used. Korshunov, equipped with an additional trapezoidal frame made of Kirschner spoke, and a screw pair from the top of the frame. The external apparatus consists of two arcs with a diameter of 3-3.5 cm, in the area of ​​the ends of the arc there are holes: 0.7-0.8 mm in diameter - for carrying the needles and 2.5 mm in diameter - for threaded rods connecting the arcs to each other. One arch is fixed with a wire to the proximal phalanx, the other to the middle phalanx. A needle is passed through the distal phalanx at the level of the base of the nail, the ends of the needle are bent towards the end of the phalanx and fastened together. The resulting frame is attached to the screw pair of the outer trapezoidal frame. In this case, a spring can be placed between the screw pair and the frame fixing the end phalanx for a more gentle and efficient thrust.

With the help of screw pairs, distraction-extension of the phalanges is performed at a rate of 1 mm / day in the first 4-5 days, then up to 2 mm / day until full extension and creation of diastasis in the interphalangeal joints up to 5 mm. Straightening of the finger is achieved within 1-1 / 2 weeks. Distraction of the interphalangeal joints is maintained for 2-4 weeks. and longer depending on the severity and duration of the contractures. First, the distal phalanx is released and the distal interphalangeal joint is developed. After the restoration of active movements of the distal phalanx, the proximal interphalangeal joint is released. Final rehabilitation measures are carried out.

When using surgical treatment and osteosynthesis according to the AO method, it is recommended to start early movements in the operated hand. But in the future, it is necessary to carry out repeated surgery to remove the metal structures. At the same time, when fixing the fragments with wires, their removal does not present any technical difficulties.

In otropedo-traumatological practice, only some of the devices with originality and fundamentally significant differences are widely used: Ilizarov and Gudushauri devices, Volkov-Oganesyan articulated and repositioning devices, Kalnberz “stress” and “rigid” devices, Tkachenko's “frame” apparatus. Many constructions were used only by the authors and did not find wide application in hand surgery.

The main advantage of the Ilizarov apparatus is the variety of layout options, as well as the simple technology of manufacturing the apparatus elements. The disadvantages of this device include the multi-subject set; labor intensity and duration of assembly processes, imposition and replacement of elements on the patient; the possibility of fixed displacements in the apparatus; difficulties in eliminating rotational displacements; limited possibilities of precisely controlled and strictly dosed hardware reduction.

When using distraction devices, one should take into account the rather long duration of treatment, the impossibility of complete restoration of the articular surfaces. As a result, the range of their application for various types of injuries to the joints of the fingers of the hand is limited.

To restore joint mobility, since the 40s of the last century, metal and plastic structures began to be widely used, which replaced various parts of the joints, articular ends and whole joints. The solution to the problem of endoprosthetics of the joints of the fingers of the hand went in two main directions:

development of hinged endoprostheses;

creation of endoprostheses from elastic materials.

An obligatory component in the complex of reconstructive and restorative treatment of patients with injuries of the bones of the hand is postoperative rehabilitation, which includes exercise therapy and a complex of physiotherapeutic measures. A set of measures is used in rehabilitation treatment, phototherapy has been actively used recently. These procedures help to improve trophism, reduce swelling and pain.

The loss of the first finger leads to a decrease in hand function by 40-50%. The problem of its recovery continues to be relevant today, despite the fact that surgeons have been doing this for more than a hundred years.

The first steps in this direction belong to French surgeons. In 1852, P. Huguier first performed plastic surgery on the hand, later called phalangization. The meaning of this operation is to deepen the first board-to-board gap without increasing the length of 1 beam. In this way, only the key grip was restored. In 1886, Ouernionprez developed and performed an operation based on a completely new principle - the transformation of finger II into I. This operation was called pollicization. In 1898, the Austrian surgeon S. Nicoladom performed for the first time a two-stage transplant of the second toe. In 1906 F. Krause used the first toe for transplantation, considering it more suitable in shape and size, and in 1918 I. Joyce replanted the finger of the opposite hand to replace the lost toe. Methods based on the principle of two-stage transplantation on a temporary feeding pedicle have not become widespread due to technical complexity, low functional results and prolonged immobilization in a forced position.

The method of skin and bone reconstruction of the first finger of the hand is also due to the emergence of C. Nicoladoni, who developed and described the operation technique in detail, but for the first time in 1909 the Nikoladoni method was applied by K. Noesske. In our country V.G. Shchipachev in 1922 performed phalangization of the metacarpal bones.

B.V. Parii, in his monograph, published in 1944, systematized all reconstruction methods known at that time and proposed a classification based on the source of the plastic material. In 1980 V.V. Azolov supplemented this classification with new, more modern methods of reconstruction of the first finger: distraction lengthening of the first ray using external fixation devices and microsurgical methods for free transplantation of tissue complexes.

With the development of microsurgery, it became possible to replant completely detached fingers of the hand. Obviously, replantation provides the most complete restoration of function, compared with any reconstruction operation, even with shortening and possible loss of motion in the finger joints.

All modern methods of restoration of the first finger of the hand can be divided as follows.

plastic with local tissues:

plastic with displaced flaps;

cross plastic;

plastic with flaps on the vascular pedicle:

plastic according to Holevich;

Littler plastic;

radial rotated flap;

2) distant plastic:

on a temporary supply leg:

sharp Filatov stem;

plastic according to Blokhin-Conyers;

free transplantation of tissue complexes with microsurgical techniques:

flap of the first interdigital space of the foot;

other blood-supplied tissue complexes.

Methods for restoring segment length:

heterotopic replantation;

pollicization;

transplant of II toe:

transplant of segment I of toe.

Methods that do not increase the segment length:

phalangization.

Methods for increasing segment length:

1) methods using tissues of the injured hand:

distraction lengthening of the segment;

pollicization;

bone and skin reconstruction with a rotated radial bone and skin graft;

2) distant plastic surgery using free transplantation of tissue complexes using microsurgical techniques:

opposite hand finger transplant;

second toe transplant;

transplant of segment III of the toe;

simultaneous skin and bone reconstruction using a free skin and bone graft.

The criteria for primary and secondary recovery is the time elapsed after the injury. Permissible terms in this case are the deadlines during which replantation is possible, i.e. 24 hours.

The main requirements for a reconstructed finger I are as follows:

sufficient length;

stable skin;

sensitivity;

mobility;

acceptable appearance;

the ability to grow in children.

The choice of method for its restoration depends on the level of loss, in addition, gender, age, profession, the presence of injuries to other fingers of the hand, the patient's health status, as well as his desire and the capabilities of the surgeon are taken into account. Traditionally, it is believed that the absence of the nail phalanx of the 5th toe is compensated damage and surgical treatment is not indicated. However, the loss of the nail phalanx of the first finger is the loss of 3 cm of its length, and, consequently, a decrease in the functional ability of the finger and the hand as a whole, namely, the inability to grasp small objects with the fingertips. In addition, nowadays more and more patients want to have a complete brush in aesthetic terms. The only acceptable reconstruction method in this case is the grafting of a part of the first toe.

The length of the stump of the 1st ray is a decisive factor in the choice of the method of surgical treatment.

In 1966, in the USA, N. Buncke performed the first successful one-step transplant of the first toe to the hand in a monkey with microvascular anastomoses, and Cobben in 1967 was the first to perform such an operation in the clinic. Over the next two decades, the technique of performing this operation, indications, contraindications, functional results and consequences of borrowing the first toe from the foot were studied in detail by many authors, including in our country. Studies have shown that, in functional and cosmetic terms, the 1st toe almost completely corresponds to the 1st toe. As for the function of the donor foot, here the opinions of the surgeons differ. N. Buncke et al. and T. Mau, performing biomechanical studies of the feet, came to the conclusion that the loss of the first toe does not lead to significant gait restrictions. However, they noted that long-term healing of the donor wound is possible due to poor engraftment of a free skin graft, as well as the formation of gross hypertrophic scars on the dorsum of the foot. These problems, according to the authors, can be minimized by observing the rules of precision technique when extracting a toe and closing a donor defect, as well as with proper postoperative management.

Special studies carried out by other authors have shown that in the final stage of the step I toe drops to 45% of body weight. After its amputation, lateral instability of the medial part of the foot may occur due to dysfunction of the plantar aponeurosis. So, when the main phalanx of the 1st finger is displaced to the dorsiflexion position, the body weight moves to the head of the 1st metatarsal bone. In this case, the plantar aponeurosis is stretched, and the interosseous muscles through the sesamoid bones stabilize the metatarsophalangeal joint and raise the longitudinal arch of the foot. After the loss of the first toe, and especially the base of its proximal phalanx, the effectiveness of this mechanism decreases. The load axis is shifted laterally to the heads of the II and III metatarsal bones, which in many patients leads to the development of metatarsalgia. Therefore, when taking the first finger, it is advisable to either leave the base of its proximal phalanx, or firmly suture the tendons of the short muscles and the aponeurosis to the head of the first metatarsal bone.

Transplant I toe moans by Buncke

Preoperative planning.

The preoperative examination should include a clinical assessment of the blood supply to the foot: determination of pulsation of the arteries, Doppler sonography and arteriography in two projections. Angiography helps document the adequacy of the blood supply to the foot through the posterior tibial artery. In addition, hand arteriography should be performed if there is any doubt about the condition of potential recipient vessels.

The dorsal artery of the foot is an extension of the anterior tibial artery, which runs deep under the supporting ligament at the level of the ankle joint. The dorsal artery of the foot is located between the tendons of m. extensor hallucis longus medially, etc. extensor digitorum longus laterally. The artery is accompanied by commitant veins. The deep peroneal nerve is located lateral to the artery. Passing over the bones of the tarsus, the dorsal artery of the foot gives off the medial and lateral tarsal arteries and in the region of the base of the metatarsal bones forms an arterial arch that runs in the lateral direction. The second, third and fourth dorsal metatarsal arteries are branches of the arterial arch and run along the dorsum of the corresponding dorsal interosseous muscles.

The first dorsal metatarsal artery is an extension of the dorsal artery of the foot. It is usually located on the dorsum of the first dorsal interosseous muscle and supplies blood to the skin of the dorsum of the foot, I and II metatarsal bones and interosseous muscles. In the area of ​​the first interdigital space, the first dorsal metatarsal artery is divided into at least two branches, one of which runs deep to the extensor longus tendon of the 1st toe, supplying blood to the medial surface of the 1st toe, and the other branch supplies the adjacent sides of the 1st and 2nd toes.

The deep plantar branch departs from the dorsal artery of the foot at the level of the base of the first metatarsal bone and goes to the plantar surface of the foot between the heads of the first dorsal interosseous muscle. It connects to the medial plantar artery and forms the plantar arterial arch. The deep plantar artery also gives off branches to the medial side of the first toe. The first plantar metatarsal artery is a continuation of the deep plantar artery, which is located in the first intermetatarsal space and supplies blood to the adjacent sides of the I and II toes from the plantar side.

According to the group of studies, the dorsal artery of the foot is absent in 18.5% of cases. Nutrition from the anterior tibial artery system is carried out in 81.5% of cases. Of these, 29.6% have a predominantly dorsal type of blood supply, 22.2% have predominantly plantar blood supply, and 29.6% have a mixed blood supply. Thus, in 40.7% of cases, there was a plantar type of blood supply to the I and II toes.

Venous outflow is carried out through the veins of the dorsum of the foot, which flow into the dorsal venous arch, which forms the large and small saphenous systems. Additional outflow occurs through the veins that accompany the dorsal artery of the foot.

The dorsum of the toes is innervated by the superficial branches of the peroneal nerve, and the first interdigital space is innervated by the branch of the deep peroneal nerve and the plantar surface of the I-II toes - by the digital branches of the medial plantar nerve. All of these nerves can be used to reinnervate the transplanted complexes.

Usually, a toe on the side of the same name is used, especially if additional skin grafting is needed to cover the toe on the hand, which can be taken from the foot along with the toe being transplanted. The problem of soft tissue deficiency in the recipient area can be solved by traditional plastic methods, such as free skin grafting, grafting with a pedicle flap, and free tissue transplantation before or during toe reconstruction.

Highlight on the foot

Before the operation, the course of the great saphenous vein and the dorsal artery on the foot are marked. A tourniquet is applied to the lower leg. On the back of the foot, a straight, curved or zigzag incision is made along the dorsal artery of the foot, preserving the saphenous veins, the dorsal artery of the foot and its continuation - the first dorsal metatarsal artery. If the first dorsal metatarsal artery is present and superficial, then it is traced distally and all lateral branches are ligated. If the plantar metatarsal artery is the dominant artery, dissection begins at the first interdigital space in the proximal direction, making a longitudinal incision in the sole for a wider view of the metatarsal head. Allocation in the proximal direction is continued until an artery of sufficient length is obtained. Sometimes it is necessary to transect the transverse intermetatarsal ligament to mobilize the plantar metatarsal artery. If it is impossible to determine which of the vessels is dominant, then the selection begins in the first intermetatarsal space and is performed in the proximal direction. In the first interdigital space, the artery is ligated to the second finger and the first intermetatarsal artery is traced until it becomes clear how to select it - from the dorsal or plantar approach. The vascular bundle is not transected until the finger is convinced of the possibility of blood supply through it and the preparation of the hand for transplantation is completed.

Trace the dorsal artery of the foot to the short extensor of the first toe, cross it, raise and open the deep peroneal nerve located lateral to the dorsal artery of the foot. The deep peroneal nerve is isolated to restore it with the recipient nerve on the hand. The first metatarsal artery is traced to the interdigital space, keeping all branches going to the first toe, and tying up the rest. The superficial veins are isolated and mobilized so as to obtain a long venous pedicle. In the first interdigital space, the plantar digital nerve is isolated along the lateral surface of the finger and separated from the digital nerve leading to the second finger by carefully separating the common digital nerve. In the same way, the plantar nerve is isolated on the medial surface of the 1st toe and mobilized as much as possible. The length of the secreted nerves depends on the requirements of the recipient area. Sometimes nerve plastic surgery may be required. Determine the approximate required length of the tendons on the hand. The extensor longus tendon of the 1st finger is transected at the level of the supporting ligament or more proximally, if necessary. To expose the long flexor tendon of sufficient length, an additional incision is made on the sole. At the level of the sole, between the long flexor tendon of the first toe and the flexor tendons of the other fingers, there are bridges that prevent it from being separated from the incision behind the ankle. The finger is isolated from the metatarsophalangeal joint. If it is necessary to restore the metacarpophalangeal joint on the hand, then you can take the joint capsule with your finger.

The plantar surface of the head I of the metatarsal bone must be preserved, but the dorsum of it can be taken with a finger if an oblique osteotomy of the head is done. After removing the tourniquet, hemostasis is carefully performed on the foot. After ligation of the graft vessels and their intersection, their finger is transferred to the hand. The wound on the foot is drained and sutured.

Brush preparation.

The operation begins with the application of a tourniquet on the forearm. Two incisions are usually required to prepare the recipient site. A curved incision is made from the dorsal-radial surface of the stump of the 1st finger through the palm along the thenar fold, and, if necessary, it is extended to the distal part of the forearm, opening the canal of the wrist. An incision is made along the back of the hand in the projection of the anatomical snuffbox, continuing it to the end of the finger stump. The tendons of the long and short extensors of the 1st finger, the long abductor muscle of the 1st finger, the head vein and its branches, the radial artery and its terminal branch, the superficial radial nerve and its branches are isolated and mobilized.

Allocate the stump of the first finger. From the palmar incision, the digital nerves are mobilized to the 1st finger, the tendon of the long flexor, the adductor muscle of the 1st finger, and the abductor short muscle, if possible, as well as the palmar digital arteries, if they are suitable for anastomosis. Now the tourniquet is removed and thorough hemostasis is performed.

The actual transplantation of a toe onto a hand.

The base of the main phalanx of the toe and the stump of the main phalanx of the toe are adapted, and osteosynthesis is performed with Kirschner wires.

The flexor and extensor tendons are repaired in such a way as to balance the forces on the transplanted toe as much as possible. T. Mau et al. proposed a scheme for the reconstruction of the tendons.

Check the inflow through the recipient radial artery, and impose an anastomosis between the dorsal artery of the foot and the radial artery.

Anastomosis is applied to the head vein and the great saphenous vein of the foot. Usually one arterial and one venous anastomosis is sufficient. The lateral plantar nerve of the toe and the ulnar digital nerve of the toe, as well as the medial plantar nerve of the toe with the radial nerve of the toe are sutured epineurally. If possible, the superficial branches of the radial nerve can be sutured to a branch of the deep peroneal nerve. The wound is sutured without tension and drained with rubber graduates. If necessary, use free skin graft plastic. Immobilization is performed with a plaster cast bandage so as to avoid compression of the transplanted finger in the bandage and to ensure control over the state of its blood supply.

Transplant of a fragment of the first toe

In 1980 W. Morrison described a free vascularized complex tissue complex from the first toe, “wrapping” a traditional non-blood-supplied bone graft from the iliac crest for reconstruction of the lost I toe.

This flap includes the nail plate, dorsum, lateral and plantar skin of the first toe and is considered indicated for the reconstruction of the first toe in case of loss at or distal to the metacarpophalangeal joint.

The advantages of this method are:

restoration of the length, full size, sensitivity, movement and appearance of the lost toe;

only one operation is required;

preservation of the skeleton of the toe;

minimal gait disturbance and minor damage to the donor foot.

The disadvantages are:

the need for the participation of two teams;

potential loss of the entire flap due to thrombosis;

bone resorption capabilities;

the absence of the interphalangeal joint of the reconstructed finger;

the possibility of long-term healing of the donor wound due to the rejection of a free skin graft;

the inability to use it in children due to the lack of the ability to grow.

As with all microvascular foot surgeries, the adequacy of the first dorsal metatarsal artery must be assessed prior to surgery. On feet where it is absent, a plantar approach may be required to isolate the first plantar metatarsal artery. Before the operation, it is necessary to measure the length and circumference of the 1st finger of a healthy hand. Use the toe on the side of the same name to suture the lateral plantar nerve to the ulnar digital nerve of the hand. Two surgical teams are involved to expedite the operation. One team isolates the complex on the foot, while the other prepares the hand, takes a bone graft from the iliac crest and fixes it.

Operation technique

A skin-fat flap is isolated so that the entire I toe of the foot is skeletonized, with the exception of a strip of skin on the medial side and distal tip of the toe. The distal end of this strip should extend almost to the lateral edge of the nail plate. The width of this band is determined by the amount of skin required to fit the size of a normal I toe. Usually a 1 cm wide strip is left. The flap should not extend too proximally to the base of the first toe. Enough skin is left in the interdigital space so that the wound can be sutured. The direction of the first dorsal metatarsal artery is noted. With the foot down and using a venous tourniquet, the appropriate dorsal veins of the foot are marked.

A longitudinal incision is made between the I and II metatarsal bones. The dorsal artery of the foot is identified. Then it is isolated distally to the first dorsal metatarsal artery. If the first dorsal metatarsal artery is deep in the intermetatarsal space, or if the plantar digital artery is dominant for the first toe, a plantar incision is made in the first interdigital space. The lateral digital artery is isolated in the first interdigital space, and its isolation is continued proximally through a linear incision. The vascular branches are tied to the II toe, keeping all branches to the flap. The branch of the deep peroneal nerve is traced, running next to the lateral digital artery to the 1st toe, and the nerve is divided proximally so that its length meets the requirements of the recipient zone.

The dorsal veins leading to the flap are isolated. The lateral branches are coagulated to obtain a vascular pedicle of the required length. If the plantar metatarsal artery is used, it may require plastic surgery with a venous graft to obtain a vascular pedicle of the required length.

Once the neurovascular pedicle is exposed, a transverse incision is made at the base of the toe, avoiding damage to the vein draining the flap. The toe flap is raised, unfolded, and the lateral plantar neurovascular bundle is identified. The medial neurovascular bundle is isolated and mobilized, keeping its connection with the medial skin flap.

The toe flap is removed under the nail plate by careful subperiosteal discharge, avoiding damage to the matrix of the nail plate. Remove with a flap approximately 1 cm of tuberosity of the nail phalanx under the nail plate. The paratenon is retained on the extensor longus tendon of the first toe to provide an opportunity to perform plastic surgery with a free split skin graft. The plantar part of the flap is raised, leaving the subcutaneous tissue along the plantar surface of the toe. The lateral plantar digital nerve is cut off from the common digital nerve at the appropriate level. If the lateral plantar digital artery is not the main feeding artery of the flap, then it is coagulated and transected.

At this stage, the flap retains its connection with the foot only due to the vascular bundle, consisting of the dorsal digital artery, which is a branch of the first dorsal metatarsal artery and veins flowing into the system of the great saphenous vein of the leg. The tourniquet is removed and the blood supply to the flap is made sure. It may take 30 to 60 minutes to restore blood flow in the flap. Wrapping with a napkin dipped in warm isotonic sodium chloride solution or lidocaine solution can help stop persistent vasospasm. When the flap turns pink and the preparation of the hand is complete, microclips are applied to the vessels, tied and transected. Thoroughly perform plastic surgery of the first toe with a split skin graft. Removing 1 cm of the distal phalanx allows a medial skin flap to be wrapped around the top of the toe. A free split skin graft is used to cover the plantar, dorsum and lateral surface of the toe. W. Morrison suggested using crossplasty to cover a donor defect on the first toe, but usually it is not required.

Brush preparation.

The hand preparation team should also take a cancellous cortical graft from the iliac crest and process it to the size of a healthy finger. Normally, the tip of the first finger of the hand, in adduction to the second finger, is 1 cm proximal to the proximal interphalangeal joint of the second finger. On the hand, two areas require preparation. This is the dorsal-ray surface slightly distal to the anatomical snuffbox and the amputation stump itself. A longitudinal incision is made under the tourniquet in the first interdigital space. Two or more dorsal veins of the hand are isolated and mobilized. Between the first dorsal interosseous muscle and the adductor I finger muscle, mobilize a. radialis. The superficial radial nerve is identified. The arterial pedicle is mobilized, highlighting it proximally to the level of the proposed anastomosis at the level of the metacarpal-carpal or metacarpophalangeal joint.

The skin on the stump of the first finger is dissected with a straight cut across its tip from the mid-medial to the mid-lateral line, highlighting the dorsal and palmar subperiosteal flap about 1 cm in size. The neuroma of the ulnar digital nerve is isolated and excised. The end of the stump is refreshed for osteosynthesis with a graft. A depression is created in the stump of the main phalanx of the first finger or in the metacarpal bone in order to place a bone graft in it and then fix it with Kirschner wires, a screw or a miniplate with screws. The flap is wrapped around the bone so that its lateral side lies on the ulnar side of the bone graft. If the bone graft is too large, then it must be reduced to the required size. The flap is fixed with interrupted sutures in place so as to position the nail plate on the rear and the neurovascular bundle in the first intercarpal space. Using optical magnification, an epineural suture is applied to the ulnar digital nerve of the 1st toe and the lateral plantar nerve of the toe with a 9/0 or 10/0 thread. The own digital artery of the finger is sutured to the first dorsal metatarsal artery of the flap. Arterial inflow is restored, and dorsal veins are sutured. The deep peroneal nerve is sutured with a branch of the superficial radial nerve. The wound is sutured without tension, and the space under the flap is drained, avoiding placing the drain near the anastomoses. Then apply a loose bandage and plaster cast so as not to squeeze the finger, and leave the end of it to monitor the blood supply.

Postoperative management is carried out according to the usual technique developed for all microsurgical operations. Active finger movements begin after 3 weeks. As soon as the wound on the foot heals, the patient is allowed to walk with support on the foot. No special footwear required.

Finger osteoplastic reconstruction

Composite insular radial flap of the forearm.

This operation has the following advantages: good blood supply to the skin and bone graft; the working surface of the finger is innervated by transplanting an insular flap on a neurovascular pedicle; one-stage method; there is no resorption of the bone part of the graft.

The disadvantages of the operation include a significant cosmetic defect after the removal of the forearm flap and the possibility of a fracture of the radius in the distal third.

Before the operation, angiography is performed to determine the consistency of the ulnar artery and the superficial palmar arch, which provides blood supply to all fingers of the injured hand. Revealing the predominant blood supply due to the radial artery or the absence of the ulnar artery excludes the possibility of performing this operation in the author's version, but free transplantation of a complex of tissues from a healthy limb is possible.

The operation is performed under the tourniquet. The flap is lifted from the palmar and dorsal-radial surfaces of the forearm, its base is positioned several centimeters proximal to the styloid process of the radial bone. The flap should be 7-8 cm long and 6-7 cm wide. After preparation of the distal part of the stump of the first toe, the flap based on the radial artery and its comitant veins is lifted. Special care must be taken not to damage the cutaneous branches of the radial nerve or disrupt the blood supply to the radius just proximal to the styloid process. Small branches of the radial artery are identified, going to the muscle of the square pronator and further to the periosteum of the radial bone. These vessels are carefully mobilized and protected, after which an osteotomy of the radius is performed and a fragment of the radius is raised using bone instruments. The length of the graft can vary depending on the length of the stump of the 1st toe and the planned lengthening. The bone graft should include a cortico-cancellous fragment of the lateral surface of the radius at least 1.5 cm wide and should be lifted so that vascular connections to the flap are preserved. The radial vessels are ligated proximally, and the entire flap is mobilized as a complex complex to the level of the anatomical snuffbox. The tendon of the long abductor I finger muscle and the short extensor of the I finger is released proximally by dissecting the distal part of the first dorsal supportive ligament. A complex skin-bone graft is then carried out under these tendons to the rear to the distal wound of the stump of the first toe. The bone graft is fixed with the I metacarpal bone with the spongy part in the position of opposing the II finger. Fixation is carried out longitudinally or obliquely with knitting needles, or using a mini-plate. The distal end of the graft is processed to give it a smooth shape. The skin portion of the flap is then wrapped around the graft and the remainder of the metacarpal bone or base phalanx.

At this stage, an insular flap on a vascular pedicle is raised from the ulnar side of the III or IV finger and placed on the palmar surface of the bone graft to provide sensitivity. A full-thickness skin graft is used to cover the donor defect. A split or full-thickness skin graft is taken from the front of the thigh to cover the donor forearm after covering the radius defect with the muscles. After removing the tourniquet, it is necessary to check the blood supply to both flaps and, if there are any problems, to revise the vascular pedicle.

A plaster cast is applied, and sufficient portions of the flaps are left open to ensure constant monitoring of their blood supply. Immobilization is maintained for 6 weeks or more until signs of consolidation appear.

Second toe transplant.

The first successful transplantation of the second toe into the position of the second toe was performed by Chinese surgeons Yang Dong-Yue and Chen Zhang-Wei in 1966.The second toe is supplied with blood by both the first and second dorsal metatarsal arteries extending from the dorsal artery of the foot, and the first and the second plantar metatarsal arteries extending from the deep plantar arch. The first dorsal metatarsal artery runs in the first intermetatarsal space. Here it is divided into the dorsal digital arteries going to fingers I and II. The deep branch of the dorsal artery of the foot goes between the I and II metatarsal bones, connecting with the lateral plantar artery, and forms a deep plantar arch. The first and second plantar metatarsal arteries extend from the deep plantar arch. On the plantar surface of each interdigital space, the plantar artery bifurcates and forms the plantar digital arteries to the adjacent toes. In the first interdigital space, the digital vessels of the I and II fingers are located. The second toe is transplanted either on the first dorsal metatarsal artery extending from the dorsal artery of the foot as a feeding artery, or on the first plantar metatarsal artery extending from the deep plantar arch. There are variants of the anatomy of the vessels of the toes, in which the second toe is supplied with blood mainly from the system of the dorsal artery of the foot and the plantar arch. Toe identification can be simple or difficult, depending on the anatomical features. Based on the technique proposed by S. Poncber in 1988, a method was developed for isolating the second toe on the foot, which allows one to isolate all vessels supplying the second toe from the dorsal approach.

Isolation of the graft on the foot. For transplantation, a finger from the side of the same name is preferable, since normally the fingers on the foot have a deviation to the lateral side, and therefore the transplanted finger is easier to orient to long fingers. Before the operation, the pulsation of the dorsal artery of the foot is determined and the course of the artery and great saphenous vein is marked. Then a tourniquet is applied to the limb.

On the back of the foot, a curved incision is made in the projection of the dorsal artery of the foot and the first intermetatarsal space. At the base of the second toe, a bordering incision is made with cutting out triangular flaps along the back and plantar surface of the foot. The size of the cut out flaps can be different. After separating the skin and providing wide access to the dorsal structures of the foot, veins are carefully isolated - from the great saphenous vein at the level of the ankle joint to the base of the triangular flap at the second toe. The tendon of the short extensor of the 1st toe is transected and retracted, after which the dorsal artery of the foot is isolated at the required length proximally and distally to the base of the 1st metatarsal bone. At this level I define! the presence of the first dorsal metatarsal artery and its diameter. If the first dorsal metatarsal artery is more than 1 mm in diameter, then it must be traced to the base of the second toe. After the isolation and intersection of the extensor tendons of the second finger, a subperiosteal osteotomy of the second metatarsal bone is performed in the region of its base, the interosseous muscles are exfoliated, and the second metatarsal bone is raised by flexion at the metatarsophalangeal joint. This allows you to open wide access to the plantar vessels and to trace the deep branch connecting the dorsal artery of the foot with the plantar arch. From the plantar arch, the plantar metatarsal arteries leading to the second toe are traced and evaluated. Usually, the medial plantar digital artery of the second toe is large in diameter and departs from the first plantar metatarsal artery in the first interdigital space perpendicular to the axis of the toe. With this variant of the anatomy, the first plantar metatarsal artery, departing from the plantar arch, goes in the first intermetatarsal space and goes under the head of the I metatarsal bone, where, giving away the lateral branches, goes to the plantar surface of the I toe. It can be isolated only after the intersection of the intermetatarsal ligament and the muscles attached to the lateral side of the head of the first metatarsal bone. Excretion is facilitated by pulling the container onto the rubber grip. After mobilization of the artery, the branches going to the 1st finger are coagulated and crossed. If necessary, a second plantar metatarsal artery can be isolated, running in the second intermetatarsal space. Then, the common finger plantar nerves are isolated, the bundles going to the adjacent fingers are separated, and the digital nerves of the second finger are cut. The flexor tendons of the II finger are isolated and crossed. After crossing the vessels leading to the third finger, the second finger remains connected to the foot only by the artery and vein. Remove the tourniquet. It is necessary to wait until the full restoration of blood flow in the finger.

Selection on brushes. A tourniquet is applied to the forearm. An incision is made through the end of the stump of the 1st ray with a continuation to the rear and the palmar surface of the hand. All structures to be restored are highlighted:

dorsal saphenous veins;

extensors of the first finger;

the tendon of the long flexor of the first finger;

palmar digital nerves;

recipient artery;

remove the scars and the endplate of the stump of the 1st ray.

After removing the tourniquet, the presence of inflow through the recipient artery is checked.

Hand graft transplant... The graft is prepared for osteosynthesis. This moment of the operation depends on the level of the defect in the first finger of the hand. If the 1st metacarpophalangeal joint is intact, the 2nd metatarsal bone is removed and the cartilage and cortical plate of the base of the main phalanx of the 2nd finger are removed. In the presence of a stump at the level of the metacarpophalangeal joint, 2 options are possible - joint restoration and arthrodesis. When performing arthrodesis, the graft is prepared as described above. When restoring the joint, oblique osteotomy of the metatarsal bone is performed under the head at the level of attachment of the metatarsophalangeal joint capsule at an angle of 130 °, open to the plantar side. This eliminates the tendency to hyperextension in the joint after finger transplantation to the hand, since the metatarsophalangeal joint is anatomically an extensor joint. In addition, such an osteotomy can increase the amount of flexion in the joint.

In the presence of a stump of the first finger at the level of the metacarpal bone, the required length of the metatarsal bone is left as part of the graft. After preparation of the graft, osteosynthesis is performed with Kirschner wires. In addition, we fix the distal interphalangeal joint of the second finger in a state of extension with a wire in order to exclude the possibility of developing flexion contracture of the finger. When performing osteosynthesis, it is necessary to orient the transplanted finger on the existing long fingers of the hand to be able to perform a pinch grip. Next, the extensor tendons are sutured, while the necessary condition is the position of full extension of the finger. The flexor tendons are then sutured. The suture is applied with slight tension on the central end of the long flexor tendon to avoid the development of flexion contracture of the finger. Then the arteries and veins are anastomosed and the nerves are sutured epineurally. When suturing a wound, it is necessary to avoid skin tension to exclude the possibility of vascular compression. When transplanting a toe with a metatarsophalangeal joint, most often it is not possible to cover the lateral surfaces in the area of ​​the joint. In such a situation, plastic with a free full-thickness skin graft is most often used. The rollers are not fixed to these grafts.

If there is a cicatricial deformity in the area of ​​the stump of the 1st ray on the hand or a finger transplant with a metatarsal bone is planned, then additional skin grafting may be required, which can be performed either before the finger transplant or at the time of the operation. Immobilization is carried out with a plaster cast longuette.

Suturing the donor wound on the foot. After careful hemostasis, the intertarsal ligament is restored and the intersected muscles are sutured to the 1st finger. The metatarsal bones are brought together and fixed with Kirschner wires. After that, the wound is easily sutured without tension. The space between the I and II metatarsal bones is drained. Immobilization is carried out with a plaster cast longitudinal bandage on the back surface of the leg and foot.

Postoperative management is carried out as in any microsurgical operation.

Hand immobilization is maintained until consolidation occurs, on average 6 weeks. From the 5-7th day after the operation, you can begin to gently active movements of the transplanted finger in the bandage under the supervision of a doctor. After 3 weeks, the wire is removed to fix the distal interphalangeal joint. The immobilization of the foot is carried out for 3 weeks, after which the needles are removed, the plaster cast is removed. Within 3 months. after the operation, the patient is not recommended to fully load the leg. Within 6 months. after the operation, bandaging of the foot is recommended to prevent flattening of the forefoot.

Pollicization

The operation of tissue transposition, which turns one of the fingers of the injured hand into the first finger, has more than a century of history.

The first report on true pollicization of the second toe with the isolation of the neurovascular bundle and the description of the transplant technique belongs to Gosset. A necessary condition for successful pollicization is the separation of the corresponding common palmar digital arteries from the superficial arterial arch.

Anatomical studies have found that in 4.5% of cases, some or all of the common digital arteries depart from the deep arterial arch. In this case, the surgeon must select a donor finger to which the common palmar digital arteries extend from the superficial arterial arch. If all common palmar digital arteries depart from the deep arterial arch, then the surgeon can transpose the second finger, which, unlike other fingers, can be moved in this case.

Pollicisation of II finger... Under the tourniquet, flaps are planned around the base of the second toe and over the second metacarpal bone. A racquet-shaped incision is made around the base of the II finger, starting with the palm at the level of the proximal finger fold and continuing around the finger, connecting with a V-shaped incision over the middle part of the metacarpal bone with a bend extending to the base of the metacarpal bone, where it deviates laterally to the stump area I metacarpal bone.

The skin flaps are carefully isolated, and the remnants of the second metacarpal bone are removed. In the palm of the hand, neurovascular bundles are isolated to the second finger and flexor tendons. The digital artery to the radial side of the third finger is identified and transected behind the bifurcation of the common digital artery. A careful division of the bundles of the common digital nerve to the II and III fingers is performed.

On the back, several dorsal veins are isolated to the II finger, mobilized by bandaging all the lateral branches that interfere with its movement. The transverse metacarpal ligament is transected, and the interosseous muscles are divided. The extensor tendons of the second finger are mobilized. Further, the course of the operation changes depending on the length of the stump of the 1st ray. If the saddle joint is preserved, then the second finger is isolated in the metacarpophalangeal joint and the base of the main phalanx is resected, thus, the main phalanx of the second finger will perform the function of the I metacarpal bone. If the saddle joint is absent, only the polygonal bone is preserved, then the metacarpal bone is resected under the head, thus the II metacarpophalangeal joint will perform the function of the saddle joint. The second finger now remains on the vascular bundles and tendons and is ready for transplantation.

Prepare the first metacarpal bone or, if it is small or absent, a polygonal bone for osteosynthesis. The bone marrow canal of the stump of the first metacarpal or trapezoidal bone is expanded, and a small bone nail taken from the removed part of the second metacarpal bone is inserted into the base of the proximal phalanx of the second finger, as soon as it is transferred to a new position, and fixed with Kirschner wires. It is important to position the finger to be moved in a position of sufficient abduction, opposition and pronation. If possible, the extensor tendons of the second finger are sutured with the mobilized stump of the long extensor of the first finger. Since the second finger is noticeably shortened, it may sometimes be necessary to shorten the flexor tendons to the second finger. The tourniquet is removed, the viability of the displaced finger is assessed. The skin wound is sutured after moving the lateral flap of the interdigital space into a new cleft between the moved finger and the third finger.

Immobilization of the first ray is maintained for 6-8 weeks, until fusion occurs. Additional surgical interventions are possible, including shortening of the flexor tendons, extensor tenolysis, opponoplasty, if the function of the thenar muscles is lost and satisfactory rotational movements in the saddle joint are preserved.

Pollicisation of the IV finger.

Under the tourniquet, a palmar incision begins at the level of the distal palmar fold, continues on each side of the IV finger through the interdigital spaces and connects distally over the IV metacarpal bone approximately at the level of its middle. Then the incision is continued to the base of the IV metacarpal bone.

The flaps are separated and lifted and identified through the palmar incision, the neurovascular bundles are mobilized. The ligation of the ulnar digital arterial branch to the third finger and the radial finger arterial branch to the fifth finger is performed slightly distal to the bifurcation of the common digital artery in the third and fourth interdigital spaces, respectively. Under a microscope, the common digital nerves are carefully split to the III and IV fingers and to the IV and V fingers, which is required to move the finger through the palm without tension of the digital nerves or damage to the nerves to the III and V fingers.

The transverse intermetacarpal ligaments are dissected on each side, leaving sufficient length to allow the two ligaments to be connected after the IV toe transplant. The extensor tendon of the IV finger is transected at the level of the base of the IV metacarpal bone and mobilized distally to the base of the proximal phalanx. The metacarpal bone is freed from the interosseous muscles attached to it, and the tendons of the short muscles to the 4th finger are cut distally. Then, osteotomy of the IV metacarpal bone is performed at the base level and removed. The flexor tendons are mobilized to the middle of the palm, and any remaining soft tissue attached to the fourth finger is transected in preparation for passing it through the subcutaneous tunnel in the palm.

The I metacarpal bone is prepared for the IV toe transplant, and if it is short or absent, then the articular surface of the polygonal bone is removed to a cancellous substance. It is possible to make a canal in the I metacarpal or in the trapezius bone for the introduction of the bone nail when fixing the transplanted finger. Along the rear of the I metacarpal bone, an incision is made in the proximal direction to identify and mobilize the stump of the extensor longus tendon of the I finger. Scars in the area of ​​the stump of the 1st toe are removed, leaving well-supplied skin to cover the brine after the toe transplant.

A tunnel is formed under the skin of the palmar surface of the hand for holding the 4th finger to the stump of the 1st ray. The finger is carefully passed through the tunnel. In its new position, the finger is rotated by 100 ° along the longitudinal axis to achieve a satisfactory position with minimal tension of the neurovascular bundles. The articular surface of the proximal phalanx of the IV finger is removed, and the bone is modeled to obtain the required length of the toe. Fixation is carried out with Kirschner needles. The use of a bone intramedullary nail through the bone contact is optional.

The operation is completed by suturing the extensor tendon of the 4th finger with the distal stump of the long extensor of the 1st finger. The tendon suture is performed with sufficient tension until full extension of the IV finger is obtained in the proximal and distal interphalangeal joints. The remainder of the tendon of the short abductor I finger muscle is connected to the remainder of the tendons of the interosseous muscles of the IV finger from the radial side. Sometimes it is possible to suture the remainder of the adductor tendon to the stumps of the short muscle tendon along the ulnar side of the transplanted toe. Since the outflow of blood is carried out mainly through the dorsal veins, and when the finger is removed and passed through the tunnel, they have to be crossed, it is often necessary to restore the venous outflow by suturing the veins of the transplanted finger with the veins of the dorsum of the hand in a new position. The tourniquet is then removed to control blood flow and hemostasis.

The donor wound is sutured after the restoration of the transverse intercarpal ligament of the III and V fingers.

In the first interdigital space, the wound is sutured so that there is no splitting of the hand. When suturing the wound at the base of the transplanted toe, it may be necessary to perform multiple Z-plastics to prevent the formation of a circular compression scar that interferes with the blood supply to the transplanted toe.

Immobilization is maintained until bone fusion, approximately 6-8 weeks. Movements of the fourth finger begin in 3-4 weeks, although when fixing with a plate, movements can be started earlier.

Two-stage pollicization method.

It is based on the "prefabrication" method, which consists in a staged microsurgical transplantation of a blood-supplied tissue complex, including a vascular bundle with its surrounding fascia, into the proposed donor area to create new vascular connections between this vascular bundle and the future tissue complex. The fascia surrounding the vascular bundle contains a large number of small vessels, which already by 5-6 days after transplantation grow into the surrounding tissues and form connections with the vasculature of the recipient region. The "prefabrication" method allows you to create a new vascular bundle of the required diameter and length.

A two-stage pollicization can be indicated in the presence of hand injuries that exclude the possibility of classical pollicization due to damage to the superficial arterial arch or common digital arteries.

Operation technique... The first stage is the formation of the vascular pedicle of the selected donor finger. Preparing the brush... Scars on the palm are excised. An incision is made along the palmar surface of the main phalanx of the donor finger, which is connected to the incision in the palm. Then a small longitudinal incision is made along the rear of the main phalanx of the donor finger. Carefully peel off the skin along the lateral surfaces of the main phalanx of the toe to form a bed for the fascia of the flap. Next, an incision is made in the projection of the future recipient vessels in the area of ​​the "anatomical snuffbox". The recipient vessels are mobilized and prepared for anastomosis.

Fascial flap formation... A radial fascial skin flap is used from the other extremity in order to, in addition to forming the vascular pedicle of the donor finger, in order to replace the defect on the palmar surface of the hand. Any fascial flap with an axial type of blood supply can be used. The details of the operation are known. The length of the vascular pedicle of the flap is determined in each case by measuring from the edge of the defect or the base of the donor finger, if there is no defect, then to the recipient vessels.

Formation of the vascular pedicle of the donor finger... The flap is placed on the palm of the injured hand so that the distal fascial part of the flap is held under the skin of the main phalanx of the donor finger in a previously formed tunnel, wrapped around the main phalanx and sutured to itself in a palmar incision. If there is a skin defect on the hand, then the skin part of the flap replaces it. The vascular pedicle of the flap is brought out to the site of recipient vessels through an additional incision connecting the anastomosis area and the palmar wound. Then, anastomoses are applied to the artery and veins of the flap and recipient vessels. The wound is sutured and drained. Immobilization is carried out with a plaster cast cast for 3 weeks.

Second phase... Actually pollicization of the donor finger to the position of the 1st finger. Preparing the stump. Scars at the end of the stump are excised, they are refreshed to prepare for osteosynthesis, and the skin is mobilized. The extensor tendons of the 1st finger and the dorsal veins are distinguished.

On the palmar surface, the digital nerves and the tendon of the long flexor of the first finger are mobilized.

Isolation of a donor finger on a pedicle... Initially, on the palmar surface, before the tourniquet is applied, the course of the vascular pedicle is marked by pulsation. A skin incision is made at the base of the donor finger, with triangular flaps cut out on the dorsum and palmar surface. On the dorsum of the finger, saphenous veins are isolated, and after marking, they are crossed. The finger extensor tendon is transected. An incision is made along the palmar surface from the apex of the triangular flap along the marked vascular pedicle. The digital nerves themselves are carefully isolated. Disarticulation of the finger in the metacarpophalangeal joint is performed by dissecting the joint capsule and cutting the tendons of the short muscles. The finger is lifted on the new vascular pedicle by carefully extracting it in the direction of the stump of the first toe.

Isolation of the vascular pedicle is continued until sufficient length is allocated for rotation without tension. At this stage, the tourniquet is removed and the blood supply to the finger is monitored. The incision along the palmar surface of the stump of the 1st ray is connected to the incision in the palm in the area of ​​the selected vascular pedicle.

The vascular pedicle is unrolled and placed in the incision.

Fixation of the donor finger in positionIfinger... Resection of the articular surface of the base of the main phalanx of the donor finger is performed. The finger is rotated 100-110 ° in the palmar direction in order to position the palmar surface of the donor finger in a position of opposition to the remaining long fingers.

Osteosynthesis is performed with Kirschner wires, trying not to restrict movement in the interphalangeal joints of the transplanted finger. The extensor and flexor tendons are restored and the digital nerves themselves are sutured epineurally. In the presence of signs of venous insufficiency under a microscope, anastomoses are applied to 1-2 veins of the donor finger and the veins of the dorsal surface of the stump of the 1st finger.

On the dorsum of the stump, a skin incision is made to place a triangular flap in order to avoid a circular compression scar.

The wound is sutured and drained. Immobilization is carried out with a plaster cast longuette before the onset of consolidation.

| Hand | Hand fingers | Bumps in the palm of your hand | Hand lines | Dictionary | Articles

This section looks at each finger in turn, analyzing factors such as length, width, marks and phalanges of each finger individually. Each finger is associated with a specific planet, each of which, in turn, is associated with classical mythology. Each finger is seen as an expression of a different facet of the human character. The phalanges are the length of the toes between the joints. Each finger has three phalanges: the main, middle and initial. Each phalanx is associated with a special astrological symbol and reveals certain personality traits.

The first, or forefinger, finger. In the ancient Roman pantheon, Jupiter was the supreme deity and ruler of the world - the equivalent of the ancient Greek god Zeus. In full accordance with this, the finger bearing the name of this god is associated with the ego, the ability to lead, ambition and status in the world.

Second, or middle, finger. Saturn is considered the father of Jupiter and corresponds to the ancient Greek god Kronos, the god of time. The Saturn finger is associated with wisdom, a sense of responsibility and a general attitude in life, for example, whether a person is happy or not.

Third, or ring finger. Apollo, god of the Sun and youth in ancient Roman mythology; in ancient Greece, it was associated with a deity with the same name. Since the god Apollo is associated with music and poetry, Apollo's finger reflects a person's creativity and sense of well-being.

The fourth finger, or little finger. Mercury, among the Greeks, the god Hermes, the messenger of the gods, and this finger is the finger of sexual intercourse; it expresses how clear a person is, that is, whether he is really as honest as he says about it.

Definition of phalanges

Length. In order to determine the phalanges, the palmist considers factors such as its length in comparison with other phalanges and overall length. In general, the length of the phalanx reflects how expressive a person is in a particular area. Insufficient length indicates a lack of intelligence.

Width. Width is also important. The width of the phalanx indicates how experienced and practical a person is in this area. The wider the finger, the more actively the person uses the special features guided by this phalanx.

Marks

These are vertical lines. These are generally good signs as they channel energy from the phalanx, but too many grooves can indicate stress.

Stripes are horizontal lines across the phalanx that have the opposite effect of grooves: they are believed to block the energy released by the phalanx.

Since a person moves in a straight position, the lion's share of the load falls on the fate of the lower limbs. Therefore, it is important to monitor your body weight, making it easier for the bones of the foot.

The structure of the ankle joint in humans is represented in the form of the articulation of the bones of the foot with the lower bones among themselves, ensuring the implementation of the complex functions produced.

• Human ankle
• The circulatory and nervous systems of the foot
• Diagnostic measures
• Ankle and foot pathologies

Human ankle

The bones are clearly shown in the diagram and are classified into groups.

These include:

1. The articulation of the bones of the lower leg with the bones of the foot.
2. Internal articulation of the tarsal bones.
3. The joints between the bones of the metatarsus and tarsus.
4. Articulation of the proximal phalanges with the bones of the metatarsus.
5. Articulation of the phalanges of the fingers with each other.

The anatomical abilities of the foot suggest a high level of physical activity. For this reason, a person is able to perform large physical activities.

Both the foot and the entire leg are designed to help a person move freely in the environment.

The foot structure is divided into 3 working parts:

1. Bones.
2. Ligaments.
3. Muscles.

The skeletal base of the foot includes 3 sections: toes, metatarsus and tarsus.

The design of the toes includes phalanges. Just like the hand, the big toe consists of 2 phalanges, and the remaining 4 fingers consist of 3.

Often there are cases when 2 components of 5 fingers grow together, forming a finger structure of 2 phalanges.

The structure has a proximal, distal and middle phalanges. They differ from the phalanges of the hand in that their length is shorter. A clear expression of this is manifested in the distal phalanges.

The bones of the tarsus of the posterior region are composed of the talus and calcaneal components, and the posterior region is subdivided into cuboid, scaphoid and sphenoid bones.

The talus is located at a distance from the distal end of the tibia, becoming a bony meniscus between the bones of the foot and knees.

It consists of a head, neck, and body, and is designed to connect to the calf bones, ankles, and heel bone.

The calcaneus is part of the posterior lower lobe of the tarsus. It is the largest part of the foot and has an elongated appearance flattened from the sides. Together with this, the calcaneus is the link between the cuboid and talus.

The scaphoid is located on the inner side of the foot. It has a forward-convex appearance with articular components connecting to closely spaced bones.

The cuboid part is located on the outer side of the foot, articulating with the calcaneus, scaphoid, sphenoid and metatarsal bones. A groove passes at the bottom of the cuboid bone, into which the tendon of the elongated peroneal muscle is laid.

The sphenoid bones include:

• Medial.
• Intermediate.
• Lateral.

They run in front of the scaphoid, inward from the cuboid, behind the first 3 metatarsal fragments and represent the anterior inner part of the tarsus.

The skeleton of the metatarsus is represented in segments of a tubular shape, consisting of a head, body and base, where the body is similar to a triangular prism. In this case, the longest bone is the second, and the thickened and short is the first.

The bases of the metatarsal bones are equipped with articular surfaces that serve as a connection with the bony components of the tarsus. In addition, by articulating with the adjacent metatarsal bones. At the same time, the heads provided with articular surfaces are connected to the proximal phalanges.

The metatarsal bones are easy to palpate, due to the rather thin coverage of soft tissues. They are placed in different-angled planes, creating a vault in the transverse line.

The circulatory and nervous systems of the foot

Nerve endings and blood arteries are considered an important component of the foot.

There are 2 main arteries of the foot:

• Back.
• Posterior tibial.

Also, the circulatory system includes small arteries that distribute to all areas of tissue.

Due to the remoteness of the arteries of the feet from the heart, circulatory disorders are often recorded, due to oxygen deficiency. The results are manifested in the form of atherosclerosis.

The longest vein that carries blood to the region of the heart is located at a segment from the point of the big toe, extending inside the leg. It is called the great saphenous vein. In this case, a small saphenous vein runs along the outer side of the leg.

The tibial anterior and posterior veins are located deep in the leg, and the small ones drive blood into the large veins. Moreover, small arteries supply the tissues with blood, and the smallest capillaries join the veins and arteries.

A person suffering from circulatory disorders notes the presence of edema in the afternoon. In addition, varicose veins may appear.

As in other parts of the body, nerve roots in the foot read all sensations and transmit them to the brain, controlling movement

The nervous system of the foot includes:

1. Superficial fibular.
2. Deep fibular.
3. Posterior tibial.
4. Calf.

Close shoes are capable of pinching any nerve, causing swelling, which will lead to discomfort, numbness and pain.

Diagnostic measures

At the moment when alarming symptoms arise in the area of ​​the foot, a person comes to an orthopedist and a traumatologist, who, knowing the complete structure of the ankle joint, can determine a lot by external signs. But at the same time, specialists prescribe an examination necessary for a 100% correct diagnosis.

Survey methods include:

• X-ray examination.
• Ultrasound procedure.
• Computed and magnetic resonance imaging.
• Atroscopy.

Identification of pathologies by means of X-ray is the most budgetary option. Pictures are taken from several sides, recording a possible dislocation, swelling, fracture and other processes.

Ultrasound helps to detect blood concentration, find foreign bodies, a possible edematous process in the joint capsule, and also check the condition of the ligaments.

Computed tomography provides a complete examination of bone tissue, with neoplasms, fractures and arthrosis. Magnetic resonance imaging is an expensive research technique that brings the maximum of reliable information about the Achilles tendon, ligaments and articular cartilage.

Atroscopy is a small invasive intervention, which implies the introduction of a special camera into the joint capsule, due to which the doctor can see all the pathologies of the ankle joint.

After collecting all the information with instrumental and hardware tools, examining doctors and obtaining the results of laboratory tests, an accurate diagnosis is made with the definition of a treatment method.

Ankle and foot pathologies

Frequent painful sensations, external changes, swelling and impaired motor functions can serve as signs of foot ailments.

As a rule, a person can develop the following diseases:

• Arthrosis in the ankle joint.
• Arthrosis of the toes.
• Hallux valgus.

Ankle arthrosis is characterized by crunching, pain, swelling, fatigue while running and walking. This is due to the course of the inflammatory process, which spoils the cartilaginous tissue, leading to a typical deformation of the tissues of the joints.

The causes of the disease can be constant increased stress and trauma, provoking the development of dysplasia, osteodystrophy and negative changes in statics.

Treatment is carried out based on the degree of arthrosis with drugs that reduce pain, restore blood circulation and block the spread of the disease. In difficult cases, surgical intervention is carried out, relieving the patient of the damaged segments of the joint, recreating mobility and eliminating painful sensations.

Arthrosis of the toes is observed in the course of metabolic disorders and typical blood circulation in the metatarsophalangeal joints. This is facilitated by the lack of moderation in stress, uncomfortable tight shoes, injuries, excess weight and frequent hypothermia.

Symptoms of the disease include swelling, deformation of the structure of the fingers, pain during movement and crunching.

At the initial stage of arthrosis of the fingers, measures are taken to avoid deformation, with the removal of pain. When an advanced stage is detected, in most cases, the doctor prescribes arthrodesis, endoprosthetics or arthroplasty by surgery, which should completely solve the problem of the disease.

A hallux valgus, more commonly known as a "bump" at the base of the thumb. This disease is characterized by the displacement of the head of one phalangeal bone, the inclination of the big toe to the other four, muscle weakening and the resulting deformity of the foot.

Treatment that inhibits the development of the disease is due to the prescription of baths, physiotherapy, and physiotherapy exercises. When the form of changes becomes pronounced, an operation is performed, the method of which is determined by the attending physician orthopedist, taking into account the stage of the disease and the general well-being of the patient.

Why fingers hurt: causes of pain in the joints of the fingers of the right and left hand

To learn more…

Pain in the small joints of the fingers and toes is quite common and seems safe at first glance.

Most often, this condition is observed in people after forty years, however, there are many diseases in which pain in the fingers of the right or left hand occurs in the younger generation.

The human musculoskeletal system includes more than 300 small and large joints. The most mobile are found in the fingers and toes. These joints have a thin connective membrane and a small articular surface.

That is why they are so often exposed to damage and disease.

A joint is the junction of the end bones covered with hyaline cartilage. The joint is covered with the synovium, which contains the articular exudate.

Each finger of the hand (middle, little, index, ring, except for the thumb) consists of three phalanges:

1. Proximal.
2. Average.
3. Distal.

In addition, they have three joints:

• Proximal - connects the bones that form the palm to the proximal phalanx of the finger.
• Middle phalanx - connects the proximal and middle phalanx.
• Distal - with the help of it, the middle phalanx is articulated with the distal one.

Why do finger pains appear? The reason for this condition is inflammatory diseases of the joints and traumatic injuries.

Diseases damaging the joint

Pain in fingers and toes can occur due to the following conditions:

1. Arthritis (psoriatic, stenosing, infectious, reactive, rheumatoid).
2. Arthrosis.
3. Gout.
4. Bursitis.
5. Osteoarthritis.
6. Osteomyelitis.
7. Tenosynovitis.
8. De Quervain's disease.
9. Raynaud's Syndrome.
10. Angiospastic peripheral crisis

That is why pains may appear in the fingers, both in the right and in the left extremity. And now more about each disease.

Arthritis

Arthritis is a whole group of pathologies for which acute inflammation of the elements of the joint and adjacent tissues is typical.

With any type of arthritis, pain in the fingers and toes appears not only when the limb performs any actions, but also in a state of complete rest.

Moreover, the pains are intense, in the morning there is stiffness in the joints. During loads, crepitus (crunching), an increase in local temperature and deformation of the joint are possible.

Rheumatoid arthritis is a combined type of connective tissue pathology. Rheumatoid arthritis typically affects the small joints (the little fingers and other fingers of the left or right hand).

Rheumatoid arthritis symptoms:

• inflammation of the metacarpophalangeal joints of the fingers;
• symmetry - if inflammation develops on the right hand, it will certainly affect the other limb.

This disease is insidious in that when it appears, there is a high risk of involvement of large joints in the inflammatory process: knee elbow, ankle, hip.

Rheumatoid arthritis pain usually occurs at night and in the morning.

Gout

Gout, or gouty arthritis, is another type of arthritis group. The cause of the disease is an excessive accumulation of uric acid in the body, the crystals of which settle on soft and hard tissues and destroy the joint.

Previously, only rich people suffered from gout, who could afford excess in food: fatty meat and fish, alcoholic beverages.

Meat is the main source of purines, which lead to the development of gouty arthritis. Gout usually affects the big toes.

Symptoms:

• pain in the big toes;
• if the disease covers the joints of the right or left hand, we can talk about the development of polyarthritis;
• the joint becomes red and swollen.

With gouty attack:

1. the joints of the toes are very swollen;
2. burning pain, mainly at night;
3. there is a local increase in temperature.

On average, a gout attack lasts from three days to several weeks. A characteristic feature of gouty arthritis is the formation of tofuses - pathological compacted nodules that do not cause pain to the patient and are only a cosmetic defect.

Psoriatic arthritis is a form of psoriasis. In addition to the fact that the skin is affected, inflammation occurs in the joints of the legs and arms (right or left). This type of arthritis affects all joints of one finger at once. The inflamed toe becomes red and swollen. The joints are affected asymmetrically.

Septic infectious arthritis occurs due to the penetration of the joint tissue into the joint tissue through damaged areas of the skin or through the blood. Only one joint may hurt, or several at once. The intensity of the symptoms of the disease depends on the stage of its development.

For purulent or advanced inflammation, the following symptoms are characteristic:

• fever;
• severe intoxication;
• body temperature rises to a critical level.

In childhood, the symptoms of the disease are more pronounced, which cannot be said about the pathology that develops in an adult.

Other joint diseases

Stenosing ligamentitis is characterized by inflammation of the annular ligament of the fingers of the right or left hand.

Symptoms of the disease

1. numbness;
2. severe burning sensation;
3. cyanosis and swelling of the finger;
4. pain affects all fingers, but does not affect the little finger.
5. the joint cannot be extended without the application of external forces.

Discomfort and pain are worse at night and in the morning. During the day, painful sensations disappear altogether.

With osteoarthritis, the destruction of cartilage tissue occurs in the joint. This disease is more susceptible to women during menopause.

Causes of osteoarthritis:

• hereditary factors;
• hormonal disorders;
• metabolic disease;
• loads associated with the profession.

Osteoarthritis symptoms:

1. stiffness of the right or left hand in the morning;
2. limitation of joint mobility;
3. crepitus when working with hands;
4. with a load on the joint, pain appears, which subside at night;
5. dull pains at night are possible with venous stasis.

At first, the disease affects only one joint, after which the remaining joints are also involved in the inflammatory process. Those diarthrosis that, during the first inflammation, took over all the work, are subject to secondary damage.

If only the thumb joint on the right hand hurts, the doctor may suspect rhizarthrosis, a type of osteoarthritis. Typical for this disease is the base of the joint, which connects the metacarpal and wrist bones.

Rhizarthrosis can be triggered by constant stress on the muscles and joints of the thumb. Signs of pathology include pain and deformation of the bones of the thumb.

Osteomyelitis is a purulent-necrotic process that can occur in the bones of the arms and legs, bone marrow, soft tissues and joints. The reasons for the development of osteomyelitis are bacteria that produce pus.

The main symptoms of the onset of the disease:

• severe intoxication;
• significant increase in temperature;
• nausea and vomiting;
• joint pain;
• chills;
• deterioration of the general condition;
• headache.

If osteomyelitis has lasted for several days, additional symptoms appear:

1. limitation of active and passive movement of the hands;
2. swelling of the muscles of the hand;
3. the appearance of a venous pattern on the skin is possible;
4. increased painful sensations.

Even if the pain in the joints, intoxication and temperature have eased somewhat, this is not at all an indication that the disease is receding. On the contrary, these signs may indicate the transition of the disease to the chronic stage.

Fistulas often appear on the affected areas, from which pus is released in small quantities. The fistula fusion forms the subcutaneous canals, leading to the curvature of the fingers and their immobility.

Bursitis is a disease in which the joint bags become inflamed, and fluid accumulates in the joint cavity.

Bursitis symptoms:

• sharp pain on palpation;
• dark red skin tone;
• increase in local temperature;
• the formation of a mobile and soft swelling.

If the cause of bursitis is an injury to the hand or finger, there is a likelihood of developing a purulent form of bursitis, which is accompanied by:

1. weakness in the whole body;
2. pain in the limb;
3. constant nausea;
4. headache.

Angiospastic peripheral crisis is another cause of pain in the fingers. The disease is accompanied by a cold snap of the fingers, their cyanosis, and after a strong reddening of the skin. The cause of the pathology is hypothermia.

If the wrist is injured or squeezed, ulnar neuropathy can occur, in which the fingers hurt. The more advanced the disease, the more limited the functionality of the fingers at the time of abduction and adduction of the hand.

If the pain in the fingers is paroxysmal and accompanied by pallor of the tips - this pathology is called "Raynaud's syndrome". The disease can occur on its own or be a symptom of another disease.

The main signs of Raynaud's syndrome:

• white color of the fingertips;
• severe burning pains that occur after stress or hypothermia.

The disease is dangerous because its presence in the body disrupts the process of oxygen delivery to cells and tissues, as a result of which the fingertips can become dead. All symptoms of the disease are directly related to impaired peripheral blood circulation in the vessels.

De Quervain's disease is an inflammation of the thumb ligament. For pathology, the appearance of pain in the wrist joint is typical, which increases with hand movements. Pain can radiate to the forearm, shoulder and neck area. On palpation, there is swelling and severe pain in the affected area.

Tenosynovitis is a pathology characterized by an acute or chronic inflammatory process in the connective tissue sheaths of the tendons.

Symptoms:

1. pain when flexing and extending the finger;
2. crepitus with any movement;
3. swelling in the tendon sheath area.

• Relieves pain and swelling in joints with arthritis and arthrosis
• Restores joints and tissues, is effective in osteochondrosis

To learn more…

Among all bone fractures, the data is 5%.

Fractures of the second finger are more common, followed by the fifth finger.

In almost 20% of cases, multiple fractures of the phalanges of various fingers are observed.

Damage to the main phalanges occurs more often, then to the nail and, rarely, to the middle phalanges.

Four of the five fingers of the hand consist of three phalanges - the proximal (upper) phalanx, the middle and distal (lower).

The thumb is formed by the proximal and distal phalanx.

The distal phalanges are the shortest, the proximal ones are the longest.

Each phalanx has a body as well as a proximal and distal end. For articulation with adjacent bones, the phalanges have articular surfaces (cartilage).

Causes

Fractures occur at the level of the diaphysis, metaphysis and pineal gland.

They come in non-offset or offset, open and closed.

Observations show that almost half of phalangeal fractures are intra-articular.

They cause functional disorders of the hand. Therefore, phalangeal fractures should be considered as severe in the functional sense of the injury, which must be treated with the utmost seriousness.

The fracture mechanism is predominantly straight. They occur more often in adults. The blows fall on the back of the fingers.

Symptoms

Pulsating pain, deformation of the phalanges, and with fractures without displacement, deflection due to edema, which spreads to the entire finger and even the back of the hand.

Displacements of fragments are often angular, with lateral deviation from the axis of the finger.

A typical phalangeal fracture is the inability to fully extend the finger.

If you put both hands on the table with your palms, then only the broken finger does not adhere to the plane of the table. With displacements along the length, shortening of the finger and phalanx is noted.

For fractures of the nail phalanges

Subungual hematomas appear. Active and passive finger movements are significantly limited due to exacerbation of pain, which radiates to the tip of the finger and is often pulsating in nature.

The severity of the pain corresponds to the site of the phalanx fracture.

Not only the function of the fingers is impaired, but also the grasping function of the hand.

When the dorsal edge of the nail phalanx is torn off

When the dorsal edge of the nail phalanx is torn off (Bush's fracture) with the extensor tendon, the nail phalanx is bent, and the victim cannot actively straighten it.

Intra-articular fractures cause deformation of the interphalangeal joints with axial deviations of the phalanges.

Axial pressure on the finger exacerbates the pain at the site of the phalanx fracture. Fractures with displacement of fragments are always a positive symptom of pathological mobility.

Diagnostics

X-ray examination clarifies the level and nature of the fracture.

First aid

Any fracture requires temporary fixation prior to medical intervention in order not to aggravate the injury.

In case of a fracture of the phalanges of the hand, two or three ordinary sticks can be used for fixation.

They need to be put around the finger and wrapped with a bandage or any other cloth.

In extreme cases, you can bandage the injured finger to the healthy one. If an analgesic tablet is available, give it to the victim to relieve pain.

The ring on the damaged finger provokes an increase in edema and tissue necrosis, so it must be removed in the first seconds after the injury.

In the event of an open fracture, it is forbidden to set the bones on their own. If disinfectants are available, the wound should be cleaned and a splint should be carefully applied.

Treatment

No offset

Fractures without displacement are subject to conservative treatment with plaster immobilization.

Fractures with displacement with a transverse plane or a plane close to it are subject to closed one-step comparison of the fragments (after anesthesia) with plaster immobilization for a period of 2-3 weeks.

The ability to work is restored after 1.5-2 months.

With an oblique fracture plane

Treatment with skeletal traction or special compression-distraction devices for fingers is indicated.

With intra-articular fractures

Intra-articular fractures, in which it is not possible not only to eliminate the displacement, but also to restore the congruence of the articular surfaces, are subject to surgical treatment, which is carried out with open reduction with osteosynthesis of fragments, and early rehabilitation.

It must be remembered that the treatment of all fractures of the phalanges should be carried out in the physiological position of the fingers (bent at the joints).

Rehabilitation

Rehabilitation for finger fractures is one of the components of comprehensive treatment, and it has an important place in restoring finger function.

On the second day after the injury, the patient begins to move with the healthy fingers of the injured hand. The exercise can be performed in sync with a healthy hand.

An injured finger, accustomed to being in a motionless state, will not be able to freely bend and unbend immediately after removing the immobilization. To develop it, the doctor prescribes physiotherapy, electrophoresis, UHF, magnetotherapy, and physiotherapy exercises.

Each toe consists of three phalanges - proximal (upper), middle and distal (lower), except for the big toe, which lacks the middle phalanx. The bones are short, tubular.

The proximal and middle phalanges have a head, which is the pineal gland, a body and a base with an articular surface.

Distal phalanges have flattened distal ends with tuberosity.

Causes and mechanisms

They arise as a result of the direct action of traumatic factors: the fall of weights on the toes, the squeezing of the fingers between hard objects, falling on the toes from a height, while jumping, etc.

Classification

Fractures can be:

• isolated(fracture of one phalanx of one finger);
• multiple(on one or more fingers) with localization in the area of ​​the distal end of the diaphysis, the proximal end of the phalanx.

By nature, fractures are:

• transverse;
• oblique;
• longitudinal;
• fragmentation;
• intra-articular;
• combined;
• tears of the tuberosity of the nail phalanx with and without displacement.

In addition, there are closed and open fractures of the fingers.

Isolated fractures account for about 82%, and multiple fractures - about 18%. In terms of frequency, the first place is occupied by fractures of the distal phalanges, the second - the proximal and the third - the fractures of the middle phalanges.

With fractures of the phalanges, the displacement of fragments is most often in width and at an angle.

Symptoms

No offset

Clinical manifestations of fractures without displacement: pain, finger deflection depending on the amount of edema, loss of active finger movements through pain.

Palpation and pressing along the axis of the finger in an extended state exacerbates pain at the fracture site, which never happens with bruises.

Offset

In the presence of displacement of fragments, there is a pronounced shortening of the finger, deformation of the phalanx.

When the fragments are displaced outward in width, the angle of deformation is open outward. Angular displacements of fragments (in the sagittal plane) lead to deformation with an angle open to the rear, less often to the plantar side.

X-ray examination clarifies the nature of the fracture.

First aid

First of all, you should start by examining the injured area. If all joints are functioning normally (bending and unbending), then this is a severe injury.

If a violation of mobility is found, it is necessary to contact the emergency room.

First aid measures include applying a cold compress to relieve pain and reduce hematoma.

Ice cannot be applied directly to the skin; it must first be wrapped in a cloth, such as a towel.

Keep the ice for 10 minutes, then a 20-minute break, repeat 3-4 times.

If there is damage to the skin, it must be disinfected. It is not recommended to use iodine for this, as it has a warming effect.

Treatment

Fractures of the phalanges of the toes in most cases are treated conservatively.

No offset

Fractures without displacement or with slight displacement, which do not lead to dysfunction, are treated by immobilization with a plaster plantar splint overlapping the injured toe and the adjacent one on the dorsal surface in the form of a visor.

Such a plaster cast provides immobilization during the entire period of adhesion (3 weeks). The ability to work is restored in 4-5 weeks.

Offset

Fractures of the phalanges with displacement of fragments with the transverse plane after anesthesia with 1% novocaine solution are simultaneously closed and matched.

With an oblique plane - after the closed juxtaposition of the fragments under X-ray control, they are fixed with wires, which are passed through the phalanx, the joint into the intact phalanx, preventing secondary displacement.

Additionally, a plantar plaster splint with a visor along the dorsum of the toe is applied to the foot.

In cases where the comparison fails (interposition, significant edema, stale fracture), an open comparison of the fragments with the osteosynthesis of their nails is shown, which is carried out through the phalanges into the head of the metatarsal bone into the medullary canal, or osteosynthesis with special plates.

With beveled and helical planes

Skeletal traction or surgery is used.

Surgical treatment consists in open juxtaposition of the fragments with subsequent osteosynthesis with wires, plates or corresponding screws.

Special attention it is necessary to pay attention to the elimination of angular deformations that cause the occurrence of hammer-shaped deformities of the fingers.

Left angular deformity causes subluxation in the metatarsophalangeal joint with contraction of the flexors of the fingers and the development of hammer-shaped deformities of the fingers.

Taking into account the static load of the foot, it is necessary to pay particular attention to the anatomical restoration of the I and V axis of the fingers.

The duration of disability for phalanx fractures is 4-6 weeks.

Rehabilitation

After a fracture within 6-7 weeks, it is contraindicated to overextend the injured finger.

Long walks and of course sports should be excluded.

During the recovery period, the doctor prescribes therapeutic massage, physiotherapy, and special gymnastics.

The diet should include foods rich in protein and calcium.

Proximal phalanx (phalanx proximalis) Foot bones(ossa pcdis). View from above. 1-distal (nail) phalanges; 2-proximal phalanges; 3-middle phalanges; 4-metatarsal bones; 5-tuberosity of the V metatarsal bone; 6-cuboid bone; 7-talus; 8-lateral malleolus surface; 9-heel bone; 10-lateral process of the calcaneus puff; 11-tubercle of the calcaneus; 12-posterior process of the talus; 13-block of the talus; 14-support of the talus, 15-neck of the talus; 16-navicular bone; 17-lateral sphenoid bone; 18-intermediate sphenoid bone; 19-medial sphenoid bone; 20-sesamoid bone.

Foot bones(ossa pedis). Plantar side (bottom view). A-bones of the tarsus, G-bones of the metatarsus, B-bones of the fingers feet (phalanges). 1 phalanges; 2-sesamoid bones; 3-metatarsal bones; 4-tuberosity of the I metatarsal bone; 5-lateral sphenoid bone; 6-intermediate sphenoid bone; 7-medial sphenoid bone; 8-tuberosity of the V metatarsal bone; 9-groove of the tendon of the peroneus longus muscle; 10-navicular bone; 11 cuboid bone; 12-head of the talus; 13-support of the talus; 14-heel bone; 15-tubercle of the calcaneus.

• - a tightly closed line formation of heavy infantry in Ancient Greece, Macedonia and Ancient Rome. It had 8-16 ranks. She had great striking power, but was inactive ...

  Historical Dictionary

• - the battle formation of the Greek army in the form of a tightly closed formation of hoplites of 8-16, sometimes even 25 rows ...

  The ancient world. Reference dictionary

• - I will closely close a linear military formation, consisting of several. a line of heavy infantry in dr. Greece ...

  Dictionary of antiquity

• - order of battle in ancient Greek. troops in the form of a closely-knit linear formation of hoplites with a formation depth of 8-16 rows. Along the front, the F. occupied up to 500 m ...

  Soviet Historical Encyclopedia

• - Phalanx,. The battle in the heroic era was, apparently, a battle of the leaders alone ...

  The Real Dictionary of Classical Antiquities

• - see Kugelberg-Welander disease ...

  Comprehensive Medical Dictionary

• - V. of page, at which branches of the vagus nerve are crossed only to the upper parts of the stomach ...

  Comprehensive Medical Dictionary

• -, tightly closed linear construction of the Greek. infantry) for battle. F. had 8-16 rows, along the front it occupied up to 500 m ...

  Great Soviet Encyclopedia

• - a lot - a hint of a phalanx among the ancients - an army, a detachment. Wed He is not here alone, but a whole phalanx of them ... Pisemskiy. People of the forties. 5, 12. Cf. servants, powdered, in livery caftans ... gives her a place ...

  Michelson's Explanatory Phraseological Dictionary (original orph.)

• -; pl. fala / ngi, R ....

  Spelling dictionary of the Russian language

• - Greek. row, line; | poisonous insect, centipede ...

  Dahl's Explanatory Dictionary

• - PHALANGA, -and, wives. 1. The ancient Greeks: a close formation of the infantry. 2. In Utopian socialism S. Fourier: a large community, a commune. 3. In Spain: the name of the fascist party ...

  Ozhegov's Explanatory Dictionary

• - PHALANGA, phalanxes, wives. ... 1. The tightly closed formation of the infantry among the ancient Greeks. || transfer In general, a slender, closed row of something. A phalanx of white pawns moved to attack the black king. 2 ...

  Ushakov's Explanatory Dictionary

• Efremova's Explanatory Dictionary

• - phalanx I 1. Each of the three short tubular bones that form the skeleton of the fingers of the extremities in humans and vertebrates. 2. see also. phalanges II 1...

  Efremova's Explanatory Dictionary

• - phalanx I 1. Each of the three short tubular bones that form the skeleton of the fingers of the extremities in humans and vertebrates. 2. see also. phalanges II 1...

  Efremova's Explanatory Dictionary

"Proximal phalanx" in books

PHALANX

From Fourier's book the author Vasilkova Yulia Valerievna

PHALANGA Unlike the Theory of Four Movements, the Treatise is full of practical advice: how to create an association ... how best to arrange the life of harmonians ... Fourier groups humanity into phalanges, borrowing this name from the ancient Greeks, from whom it meant

§ 5. Greek phalanx

From the book The Ancient City the author Elizarov Evgeny Dmitrievich

§ 5. The Greek phalanx Of course, it is impossible to see in all this the formation of a really very special breed of heroes, intermarried with the immortal inhabitants of Olympus, victorious supermen, "blond beasts", for whom there are no barriers or

Macedonian phalanx

From the book Daily Life of the Army of Alexander the Great by For Paul

Macedonian phalanx From the infantry formations of the Greeks, whether they were allies in the Greek federation or mercenaries, the Macedonian phalanx (literally meaning "log", "grinding roller") differed not only and, perhaps, not so much in weapons or equipment, but before

Phalanx

From the book Greece and Rome [The Evolution of Military Art Throughout 12 Centuries] author Connolly Peter

Phalanx During the VIII century. BC. in the military affairs of the ancient Greeks, revolutionary changes took place. Instead of the previous principle of battle, when everyone fought the enemy "on his own", now a system was introduced that required much more discipline. Such a system was

"African phalanx"

From the book Foreign Volunteers in the Wehrmacht. 1941-1945 the author Jurado Carlos Caballero

"African Phalanx" After the Allied landings in Northern France (Operation Torch), of all the North African territories of France, only Tunisia remained under Vichy sovereignty and the occupation of the Axis forces. After the landing, the Vichy regime attempted to create volunteer

Phalanx

From the book Greece and Rome, Encyclopedia of Military History author Connolly Peter

Phalanx During the VIII century. BC. in the military affairs of the ancient Greeks, revolutionary changes took place. Instead of the previous principle of battle, when everyone fought the enemy "on his own", now a system was introduced that required much more discipline. Such a system was

Chapter 2 Phalanx

From the book The Art of War: The Ancient World and the Middle Ages [SI] the author

Chapter 2 Phalanx But the role of the infantry phalanx in Alexander's victories should not be underestimated either. Let's look at all the advantages and disadvantages of the Macedonian phalanx. I already said above in the section on the Greco-Persian wars that the main advantage of the phalanx is

Chapter 2 Phalanx

From the book The Art of War: The Ancient World and the Middle Ages the author Andrienko Vladimir Alexandrovich

Chapter 2 Phalanx But the role of the infantry phalanx in Alexander's victories should not be underestimated either. Let's look at all the advantages and disadvantages of the Macedonian phalanx. I already said above in the section on the Greco-Persian wars that the main advantage of the phalanx is

Spanish phalanx

From the book Great Soviet Encyclopedia (IS) of the author TSB

Phalanx

From the book Great Soviet Encyclopedia (FA) of the author TSB

Solpuga or phalanx

From the book I get to know the world. Insects author Lyakhov Petr

Solpuga or Solpuga's phalanx, or as they are also called phalanges, constitute a separate detachment among arachnids. The appearance of the phalanx is frightening and clearly does not dispose to close acquaintance. Her body, 5-7 centimeters long, is usually brown-yellow in color and is completely covered

Zhdanovskaya phalanx

From the book Air battle for the city on the Neva [Defenders of Leningrad against the aces of the Luftwaffe, 1941-1944] the author Degtev Dmitry Mikhailovich

Zhdanovskaya phalanx In Leningrad, meanwhile, they were preparing for defense. The situation that reigned in the city now made everyone understand that the enemy was already at the gates. Not regular units were already sent to the front, but improvised units assembled from the world on a string. 10 july

Phalanx of Heroes

From the book Literary Newspaper 6305 (No. 4 2011) the author Literary Newspaper

"Phalanx of Heroes" Legacy "Phalanx of Heroes" On the moral and aesthetic experience of Decembrism Nikolai SKATOV, Corresponding Member of the Russian Academy of Sciences Decembrism is not only a social and political movement, not only a phenomenon of national culture. Even apart from

Phalanx of Christ

From the book Volume V. Book 1. Moral and ascetic creations author Studite Theodore

Phalanx of Christ My brethren, fathers and children. Do not be offended by the words with which I, humble one, address you, for I do this constantly out of love for you and as a result of the most zealous concern for you. Since I am unworthy of your shepherd, I must carry out my ministry and, as

"Phalanx"

From the book Domestic anti-tank complexes the author Angelsky Rostislav Dmitrievich

"Phalanx" The resolution of 1957, along with work on the future complex "Bumblebee", prescribed the implementation of theme number 8, which also provided for the development of an infantry reactive guided anti-tank projectile with a light launcher with similar moderate characteristics.