Topographic anatomy of the middle nerve. Malnal human nerve: description, anatomy and structure

In the human body - a large number of nerves, they are responsible for movement of legs, hands and other functions. So, for example, in the hand of a person three main: radiation, medven, elbow nerves.Squeezing or injury of the median nerve or any other can lead to serious problems with the movements of the hand. It is about him today and talk today, learn about its functions, location, main pathologies.

Anatomy

Marred nerve is one of the largest nerves of the shoulder plexus. It originates from the beams of the shoulder plexus, or rather, from lateral and medial. In the area of \u200b\u200bthe shoulder, it is conveniently located in Barrotda double-headed muscles among all other nerves. Next, lowers on the front through the hole in the area of \u200b\u200bthe elbow to the forearm, where it is very conveniently located between the fingertips - deep and superficial. Further, it goes to the lower division on the median furrow and already through the crank canal falls into the palm. In the field of the palm aponeurosis, it is divided into three final branches, which further create seven separate finger nerves.

The middle nerve in the field of forearm innervates not only two of the Propators, but all the bends. The exception is half a deep flexor responsible for the motor function of the fingers. As for the brush, it is responsible for the muscles of the thumb and both worm-shaped, the middle of the palm and the palm side I-III and half the IV fingers.

Nerva function

Each of the nerves in the human body is responsible for certain functions. So, the middle nerve provides bending and extension of three fingers on hand: large, index and medium. In addition, he is responsible for opposition to the thumb and forearm.

The nerve fabric is very poorly regenerated, also with this kind of damage in the distal part of the nerve, Valerova degeneration can develop - this is a process during which the nervous tissue is dissolved, and its scar connecting tissue replaces it. That is why it is advantageous to ensure that the outcome of treatment is favorable, no one can, ultimately the patient gets disability.

Nerve damage: classes

Medized nerve brushes, depending on how damaged, can provoke several pathologies:

• Shake. In this case, morphological and anatomical disorders are not observed. The sensitivity and function of movement come back already 15 minutes after injury.
• Injury. This state is due to the fact that the anatomical continuity of the nervous trunk is preserved, but the epineural shells are torn, and blood falls into the nerve. With this damage, the motor function is restored only a month later.
• Compression. With this pathology, the severity of disorders is observed, and it depends on the severity and duration of squeezing, minor violations may be observed, but there are also serious cases requiring only surgeon intervention.

• Partial damage is manifested in the form of individual functions. In this case, the functions are not restored independently, only the operation is needed.
• A complete break - at this state, the nerve is smelled into two separate end - peripheral and central. If you do not take serious measures, then in this case the middle fragment is replaced by a small part of the scar tissue. Independently, the functions will not restore, muscle atrophy every day will grow, then there are trophic disorders. In this case, only the operation can help, but it also does not always give the desired results.

Neuropathy or neuritis of the middle nerve can be diagnosed in the initial stage, and if you take appropriate measures, you can cure this pathology without any consequences.

Causes of neuropathy

Many people in the world are faced with such a problem as neuropathy hands. Very often they are associated with fatigue, lack of sleep, and if you have a good rest, sleep, everything will pass, but in fact everything is not at all.

Usually mononeiropathy - damage to one of the nerve fibers is most often evolving due to the fact that it is shifting the nerve in the place where it passes superficially under the skin itself or in narrow bone canals. The causes of neuropathy can be several:

• transferred surgical intervention, in the place where the operation was carried out, with time the blood ceases to circulate correctly, which ultimately leads to edema and muscle atrophy, as well as to the fact that the nerves are squeezed;
• hand injury, during which the swelling developed, leading to the sacrifice of the nerve;
• frequent supercooling;
• irradiation;
• strong loads on the muscles of the hands;

• endocrine pathology, it concerns diabetics;
• intoxication of the body;
• lack of group vitamins in;
• tumors;
• transferred infections: herpes, malaria, diphtheria, tuberculosis and even HIV;
• long-term reception of drugs, which contains phenytoin and chlorookhin.

Symptoms of neuropathy

Few patients drawn to the hospital at the first symptoms of pathology, most often try to use folk remedies. Used ointments, make compresses, but it is not always possible to cure the middle nerve in this way, the symptoms can appear again and be even more acute. Pathology appears in the form of burning pain, which accompany the patient throughout the day, also appears numbness of fingers, brushes and even completely hands. In addition, other symptoms may appear:

• edema;
• spasms and convulsions;
• feeling of goosebumps on the skin;
• decrease in temperature sensitivity;
• coordination violation;
• difficult movement with hands.

When visiting a doctor or independently, at home, you can determine by motor disorders, is there a patient neuritis, the neuropathy of the median nerve, or not.

Determination of the median nerve motor disorder

To determine the motor disorders in squeezing or any other defeat of the median nerve, the doctor may recommend to carry out such samples:

• if you squeeze a fist, then at this point the index, and also partially large and the middle fingers remain dispelled, and the two remaining fingers on the hand are so strongly pressed, which is difficult to disobey them even then;
• if the middle nerve is struck, then the patient with the crossing of the fingers is not able to quickly rotate with a thumb of the affected brush around the thumb with a healthy, this sample is called "mill";
• the patient will not be able to scratch the index finger on the table, he can only get the friction of the distal phalanx of the finger, or he just knocks them, at that moment the brush lies on the table;
• if you fold two palms together, the index finger of a damaged hand will not be able to scratch a healthy;
• the patient fails to take the thumb so much so that it can form a straight angle with the index finger.

If after the visual inspection there are such failures in the movement of the fingers, then it is recommended to undergo a comprehensive examination.

Diagnosis of the disease

Before you choose the right method of treatment, you need to go through a full survey at the neurologist, which will appreciate the reflexes, muscle strength, will hold special samples and tests.

Of the instrumental diagnostic methods, it is best:

• electroneuromyography;
• x-ray study;
• magnetic tomography.

These studies will be detected where the nerve was damaged, find out what the cause of pathology and identify the degree of failures in conductivity. If necessary, the patient will advise both laboratory studies, only after that it is possible to diagnose and select the most effective therapy.

Treatment of the disease

Treatment of the median nerve is selected individually to each patient, because the causes of the disease can be different and the degree of defeat for each one. During treatment, the doctor can resort to etiotropic therapy. This treatment includes the reception of antibiotics, antiviral and vascular funds.

In addition, the doctor prescribes the reception of anti-inflammatory and anti-eased drugs, also good results gives physiotherapy, massage and leaf.

In cases where it was found that the nerve is composed, it is necessary to eliminate the cause. In this case, you need a powerful absorption therapy, but to carry out it, you need to start with various enzymes, as well as take absorbing and softening scar tissue facilities. There are such cases that manual therapy and massage help to quickly cure all the symptoms.

In order for the treatment to be effective, it is necessary to carry out restorative procedures, which will be in a specific case, solves the resuscator.

If the middle nerve is injured, then in this case you need to determine exactly which methods of treatment will be effective - conservative or operational. To do this, it is recommended to spend a needle myography, it is with its help you can accurately determine the degree of defeat.

Prevention

The defeat of the median nerve is a serious state, if you do not take any measures, then it will be impossible to restore the motor function of the fingers. As preventive measures, techniques that help to normalize metabolic processes are also very important in time to treat infectious pathologies. In addition, it is necessary to regularly make gymnastics for hands, especially if the patient has a permanent operation of the hands (seamstations, programmers and others).

Conclusion

Summing up the above, it is possible to say exactly that any even adverse damage to the median nerve can lead to irreparable consequences. Therefore, if suddenly noticed that the fingers are poorly bend, they often reduce them with a convulsion or a fist cannot be squeezed, it is better to consult with the doctor. When injured hands, the doctor's advice and inspection is very important. It is better to cure minor changes than then to make an operation, which also does not give the desired results in severe cases.

17.1. Borders and region of the upper limb

The upper limb is delivered from the body in front of a deltoid-thoracic furrow (sulcus deltoopectoralis), behind - the rear edge of the deltoid muscle, from the bottom and inside - the conditioned line connecting the lower edges of the large thoracic and the widest muscles of the back.

On the upper limb allocate: deltoid, axillary region, shoulder areas, elbow, forearm, wrists, brushes. In addition, for the upper limb and breasts are reserved (connectible) and the ass (blade) chest area, described above.

17.2. Migratic area

The axillary area (REDIO AXILLARIS) (Fig. 17.1) is limited in front with the lower edge of the big breast muscle, behind the lower edges of the widest muscle of the back and a large round muscle; From the inside and outside the lines connecting the edges of these muscles on the chest and shoulder.

The skin of the area is thin, movable, covered in adult rigid bristly hair, contains a lot of rigorous and sweat glands; Innervated intercore-shoulder nerve (N. Intercostobrachialis). The subcutaneous fiber is expressed moderately, contains 5-6 surface lymph nodes. Surface fascia is poorly expressed, its own is more dense along the edges and thin, loose in the center, where it is projected by numerous lymphatic and blood vessels. After removing its own fascia, the muscles restricting the axillary hole, having the shape of a truncated tetrahedral pyramid, the base turned down and the duck, the vertex - up and inside. The base of the pyramid corresponds to the outer boundaries of the region. The front wall of the axillary

the depressions are a big and small breast muscles, the back - the sublock, small round and widest muscles of the back, the inner - the breast wall with the front gear muscle, the outer - shoulder bone with a short head of the two-headed and the bevum-shoulder shoulder shoulder.

Fig. 17.1.Topography of blood vessels and the nerves of the axillary depression:

I - front gear muscle; 2 - the widest muscle of the back; 3 - big breast muscle; 4 - small breast muscle; 5 - axillary artery; 6 - lateral chest artery; 7 - subcupatic artery; 8 - artery, envelope shovel; 9 - threshing artery; 10 - Mortar Vienna;

II - outdoor subcutaneous vein hands; 12 - rear bunch of shoulder plexus; 13 - internal beam of shoulder plexus; 14 - the outer beam of the shoulder plexus; 15 - elbow nerve; 16 - muscular skin nerve; 17 - middle nerve; 18 - the inner skin nerve of the forearm; 19 - the inner skin nerve; 20 - threshing nerve; 21 - long breast nerve; 22 - intercore-shoulder nerve

The axillary fossa is filled with a deep loose fatty tissue, in which the axillary lymph nodes and the main vascular-nervous beam, including the axillary vessels (a. Et. V. Axillaris) and shoulder plexus. The projection of the artery corresponds to the front border of hair growth (by N.I. Pogogo). For the convenience of studying in the armpit, three departments are distinguished: Trigonum CLALIPECTORALE - from the clavicle to the top edge of the small breast muscle, Trigonum Pectoral - corresponds to the width of a small breast muscle, Trigonum SUBPECTORALE - located between the lower edges of small and large pectoral muscles.

In the keyful-thoracic triangle of Vienna lies the highest downward book and knutrice, the shoulder plexus is deeper than the duck and the stop, the artery is located between them. In this department, the top breast (a. Thoracica Superior) and breastacomial (a. Thoracoachromialis) arteries are departed from the axillary artery.

In the thoracic triangle, the artery and vein are located as well as surrounded with three sides by secondary beams (Fasciculi Lateralis, Medialis et Posterior) shoulder plexus. From the axillary artery, outdoor chest artery (a. Thoracica Lateralis).

In the subepoploral triangle, the artery is also surrounded from all sides with long nerves of the shoulder plexus: the muscular-skin and outer root of the middle nerve outside, the inner root of the middle nerve in front, the elbow, the inner skin nerves of the shoulder and forearm from the inside; Beam and axillary nerves from behind. The axillary vein occupies the most inner position. In this department, the axillary artery gives its largest branch - the sublock (a. Subscapularis) and the front and rear arteries surrounding the shoulder (a. Circumflexa Humeri Anterior et. Rosterior) participating in the formation of the arterial network of the shoulder joint. In addition to the nerves that are part of the main vascular beam, the nerves of the test (cervical) part of the shoulder plexus (short branches) pass along the walls of the axillary depression: n. THORACICUS LONGUS, N. Subclavius, n. THORACODORSALIS, N. Subscapularis, NN. Pectorals, n. Suprascapularis, n. Dorsalis Scapulae and lower leg n. phrenicus.

In the armpit depression there are 15-20 lymph nodes, which are divided into 5 groups: NODI Lymphatici Centralis; Nodi Lymphatici pectoralis; NODI Lymphatici Subsscapularis; Nodi Lymphatici Lateralis; NODI Lymphatici apicalis (Fig. 17.2). The fatty tissue of the axillary depression goes back to the front gap of the predain

the cellulum, and through a triparter and four-sided hole - into the sirent bed of the blades and the adhesive cellular space, forward - into the surface and deep subcompener cellular spaces, up to the fiber of the outer triangle of the neck and down - into the bone-fascial shoulder case.

Fig. 17.2.Group of lymph nodes of the axillary depression:

1 - the top nodes; 2 - lateral nodes; 3 - central nodes,

4 - medial nodes; 5 - bottom nodes

17.3. Shoulder joint

In the formation of a shoulder joint (Articulatio Humeri) (Fig. 17.3), the head of the shoulder bone and the articular blade blades, enlarged due to the cartilage of the articular lip (Labrum Glenoi- Dale) take part. The articular capsule is attached to the shovel around the cartilage ring and to the anatomical neck of the shoulder. Sustav Capsule Strengthen

top, Middle and Lower Art-Shoulder Bundles (Lig. Glenohumerales Superior, Internum et. Inferior) and a bevoid-shoulder bunch (Lig. CoracoHumerale), representing the thickening of the fibrous layer of the articular bag. The synovial shell of the joint capsule form three worships, at the expense of which the joint cavity increases:

Fig. 17.3.Shoulder joint (from: Kishchez-Sentagota, 1959): 1 - transverse bundle of the blade; 2 - clavicle; 3 - conical bunch; 4 - a trapezoid bunch; 5 - a beak-cleaned bunch; 6 - the bevis-shaped process; 7 - acromial-crooking bunch; 8 - a bezvoid-acromial bunch; 9 - acromial process; 10 - tendon of the subband muscle; 11 - the root surface of the blade; 12 - the armpits; 13 - articular capsule; 14 - a tendon of the long head of the double muscle; 15 - Shoulder bone

recessus Subscapularis, Recessus Intertubercularisand Recessus Subcoracoideus. Sinovial wobbies are weak places of the joint capsule, and with purulent omputs, their melting and the propagation of purulent chapels are possible in a predaginal bone-fibrous bed, an axillary region and a fake-shaped space.

The blood supply to the joint occurs due to the front and rear arteries surrounding the shoulder bone, and the boreacomial artery. Innervates the joint with sublock and axillary nerves.

17.4. Shoulder area

The upper boundary of the front and rear regions of the shoulder (Regiones Brachii Anterior et Posterior) is the conditional line connecting the lower edges of the big breast and widest muscles on the shoulder, the bottom line, passing on 2 transverse fingers above the brachial bone supermarkets. On the front surface of the shoulder, the contours of the two-headed muscles are clearly visible, on the sides of which two furrows are determined: internal and outer (Sulci Bicipitales Medialis et Lateralis), dividing shoulder on the front and rear surfaces.

The shoulder skin is thinner on the inside of the shoulder, is innervated by the outer, inner and rear skin nerves of the shoulder. Subcutaneous fiber is developed moderately, and in addition to these nerves, it contains v. Cephalica (outside) and v. Basilica (from within). Surface fascia in the lower arm of the shoulder forms cases for subcutaneous veins and skin nerves.

The own fascia is well expressed, the shoulder covers the shoulder from all sides give two intermuscular partitions to the bone and divides the shoulder into two bone-fascial beds: the front and rear. The inner intensured partition, splitting, forms the fascial vagina of the main vascular-nerve beam. In the front beds are located in two layers, the bending of the shoulder and forearm, in the back - the extension. The most superficially in the front bed lies the double-headed muscle, the jacket and Knutrice from it, the carriage muscle passes from it, and the kice and duck - the shoulder muscle. Between the first and second muscle layer there is a muscular-skin-skinned nerve (N. Musculocutaneus), which in the lower shoulder will perform its own fascia and goes into subcutaneous tissue called n. Cutaneus Antebrachii Lateralis. The main content of the rear bed is the three-lying muscle, and in the lower third - and the shoulder (Fig. 17.4).

Fig. 17.4. Cross sections of the shoulder in the middle third.

a - Fascial Lodge and Film Scrolls: 1 - own shoulder fascia; 2 - double-headed shoulder muscle; 3 - shoulder muscle; 4 - Klude muscle;

5 - the box of the medial vascular beam; 6 - medial intermushny partition; 7 - Miscellaneous Canal; 8 - three-headed muscle;

9 - rear bone-fibrous bed; 10 - lateral intermissile septum; 11 - Front bone fibrous bed.

6 - blood vessels and shoulder nerves: 1 - medial subcutaneous vein hands; 2 - medial skin nerve forearm; 3 - medial leak nerve; 4 - elbow nerve; 5 - radiation nerve; 6 - deep artery and shoulder vein; 7 - shoulder artery; 8 - median nerve; 9 - leather nerve;

10 - lateral subcutaneous vein hands

In the inner groove, the main vascular-nerving beam of the shoulder is held, which includes a. Brachialis with two accompanying veins and long branches of shoulder plexus. From the shoulder artery departs a. PROFUNDA BRACHII, who, together with the radial nerve, heads into the outer furrow and goes to the rear surface in Canalis Humeromuscularis; a. Colladeralis Ulnaris Superior Together with an elbow nerve, the inner intermushny partition will be performed and goes on the back surface; a. Colladeralis ulnaris Inferior. N. MEDIANUS In the upper third of the shoulder, the front of the artery is located, in the middle it is crossing it and in the bottom lies in the artery.

17.5. Front area elbow

The front area of \u200b\u200bthe elbow (REGIO. Cubiti Anterior) is limited to two conventional lines carried out on 2 transverse fingers above and below the shoulder supermarkets, and two vertical lines that are passing through the supermarket, it is separated from the rear area of \u200b\u200bthe elbow (Fig. 17.5).

Fig. 17.5.Topography of deep layers of the front elbow region: 1 - double-headed arm muscle; 2 - shoulder muscle; 3 - shoulder-ray muscle; 4 - supinator; 5 - Round Pronator; 6 - medial intermushny partition; 7 - shoulder artery; 8 - upper collateral elbow artery; 9 - lower collateral elbow artery; 10 - radiation artery; 11 - elbow artery; 12 - Returnability of the Local Artery; 13 - Return radiation artery; 14 - general inter-site artery; 15 - radiation nerve; 16 - the surface branch of the radial nerve; 17 - deep branch of radial nerve; 18 - middle nerve; 19 - Lucky Nerve

The skin is thin, movable, with well-developed saline and sweat glands. In the subcutaneous tissue pass surface veins and nerves: outside - v. CEPHALICA and N. Cutaneus Antebrachii Lateralis, from within - v. Basilia and N. Cutaneus Antebrachii Medialis. Both veins are interconnected, forming an anastomosis in the form of the letter M or N. Own fascia of the elbow area from the lower part is thickened due to the tendral stretching of the double-headed muscle (APNUROSIS Bicipitalis). Under its own fascia, the muscles forming the elbow hole, limited outside the shredelichell muscle and the supinator, from the inside - a round pronator and the wrist flexors, from above - the border muscles of the shoulder, the tendon of which is introduced between the two first groups and divides the elbow hole into two front elbow furrows : Medial and lateral. The lateral furrow passes the radial nerve along with the collateral radial artery and is divided into superficial and deep branches. In the medial furrow, the main vascular-nerve beam is located, consisting of a shoulder artery with the accompanying two veins and middle nerve. Behind APNUROSIS Bicipitalis, the shoulder artery is divided into elbow and radiation, from which the return radiation and elbow artery depart.

The elbow joint (ARTICULATIO CUBITI), is a complex joint consisting of a shoulder-flow - between the brachial bone block and the block-shaped elbow bone; there is a shoulder - between the head of the brachial bone and the hole of the radial bone head; The proximal brass - between the articular semicircle of the radial bone and the radial cutting of the elbow bone surrounded by the overall articular capsule. Shoulder bone supermarkets remain outside the hollow of the joint. The articulated capsule is strengthened by a ring bundle of radii (Lig. Annulare RADII), an elbow collateral bunch (Lig. Collaterale Ulnare) and a radiation collateral bunch (Lig. Collaterale Radii). The blood supply to the joint is carried out at the expense of the elbow articular network. Innervate the joint branch of the beam, median and elbow nerves.

17.7. Areas of forearm

The front and rear area of \u200b\u200bthe forearm et posterior) are limited to two horizontal lines passing on top of 2 transverse fingers below the shoulder supermarkets and from the bottom - 1 cm above the breadcrumbs of the elbow and radiation bones. Two vertical lines connecting the shoulder supermarkets with cylost-shaped processes, the forearm is divided into the front and rear areas (Fig. 17.6).

The forearm is covered with fine and moving skin, innervated by the outer, inner and rear skin nerves of the forearm. Subcutaneous fiber is poorly developed, and in it, in addition to the named

Fig. 17.6.Cross cuts of forearm in the middle third: A - Fascial Lodge and Muscles of the forearm: 1 - Radiant wrist flexor; 2 - long palm muscle; 3 - elbow wrist flayer; 4 - deep wrist flayer; 5 - Misinent Extension; 6 - elbow wrist extension; 7 - the extensor V of the finger; 8 is a long extensor I finger; 9 - short finger extension; 10 - the extensor of the fingers; 11 - long muscle, reducing i finger; 12 - short ray wast extension; 13 - long flexor I finger; 14 - a tendon of a long ray wast extension; 15 - surface flexor fingers; 16 - the shoulder muscle; 17 - Round Pronator.

6 - vessels and nerves of the forearm: 1 - middle vein forearm; 2, 3 - medial skin nerve and medial subcutaneous vein forearm; 4 - elbow artery and veins; 5 - elbow nerve; 6 - front intercelter artery and veins;

7 - rear intercepted artery and veins; 8 - Rear skin nerve forearm; 9 - rear intercellate nerve; 10 - front intercellate nerve; 11 - radiation nerve; 12 - the surface branch of the radiot nerve; 13 - radiation artery and veins; 14, 15 - lateral skin nerve and lateral subcutaneous vein forearm

skin nerves pass v. Cephalica (outside) and v. Basilica (from the inside), and sometimes the third vein - v. Antebrachi intermedia. Surface fascia is poorly developed. The own fascia is thicker and durable in the proximal department, and it gradually thinning the book. It covers the forearm from all sides and sends an intermushny partition to the bones of the forearm: one to the elbow dice (media) and two to the radial (front and rear) and, thus, together with the intercellate partition, three bone-fascial beds are formed: the front, rear and outdoor.

In the front bone-fascial beds are located in four layers of wrist fiftese and fingers, as well as pronators and basic vascular beams of forearm. In the first layer outside the inside are the following muscles: m. PRONATOR TERES, M. Flexor Carpi Radialis, m. Palmaris Longus and M. Flexor Carpi Ulnaris. In the second lies m. Flexor Digitorum superficialis. In the third layer, located under a deep leaflet of its own fascia, are m. Flexor Policis Longus and M. Flexor Digitorum PROFUNDUS. In the fourth lies m. PRONATOR QUADRATUS. Between the third and fourth layers in the lower third of the forearm is the intermuscular cellular space of the Paron Pirogov, which accommodates with the development of phlegmon to 0.25 pm.

In the outer bone-fascial beds are the radial extensors of the wrist and the supinator, located in 4 layers: m. Brachio- Radialis, m. Extensor Carpi Radialis Longus, m. Extensor Carpi Radialis Brevis and M. supinator. In the rear bone-fascial bed, the extensors of the wrist and fingers are located in two layers: m. Extensor Digitorum, m. Extensor Digiti Minimi and M. Extensor Carpi Ulnaris is the first layer; m. Abductor Policis Longus, m. Extensor Policis Brevis, m. Extensor Policis Longus and M. Extensor Indicis - second layer.

At the forearm, 5 vascular-nerve beams are isolated, of which 4 are located on the front surface: radiation artery with veins and the surface branch of the radiot nerve; elbow artery with veins and elbow nerve; median nerve with an arterial nerve; front intercellate vascular nerve beam and one on the back; Rear intercepted vascular-nervous beam with a deep branch of radial nerve.

The radiation artery with two veins and the surface branch of the radiation nerve is located in the radial furrow between M. Brachioradialis (outside) and m. Flexor Carpi Radialis (from within). The surface branch of the radiot nerve is located all over the dust from the artery,

and in the lower third goes under the tendon of the shoulder muscles on the rear of forearm, brushes and fingers.

The elbow vascular-nerving beam, which includes the elbow artery, two veins and the elbow nerve located in them, passes between M. Flexor Digitorum superficialis and m. Flexor Carpi Ulnaris in the elbow furrow.

The middle nerve along with its accompanying artery (a. Comitans N. Medianus) from the anterior interceptional artery is located in the median furrow between the surface and deep fingertips, and in the lower third of the forearm goes to the surface under its own fascia.

The front intercellate beam is formed by the front intercepted nerve (branch N. Medianus) and anterior interceptional artery (from the elbow artery system) with the accompanying veins, located on the front surface of the inter-emergency membrane. In the lower third of the forearm of the upper edge of the square Pronator, giving the branch to the ray-male joint, the artery goes to the back surface of the forearm, where he takes part in the formation of the back of the wrist.

Rear intercepted vascular beam formed by the deep branch of radial nerve and a. Interossea Posterior (from the system a. Ulnaris), with the accompanied veins is located between the surface and deep layers of the muscles of the back surface of the forearm.

17.8. BRUSH

Brush (Manus) is proximally limited by a line passing over a pea bone. There are palm areas (REG. Palmae Manus) and rear (REG. Dorsi Manus) brushes. Two elevations formed by muscles I and V fingers are clearly visible on the palm, - Thenar and Hypothenar. The middle palm department has the type of depression, derived from the tone of the skin fold, the proximal third of which is called the forbidden zone of the groove. In this section, the middle nerve gives a motor branch to the muscles of the thumb, so there are dangerous cuts here.

The skin of the palm surface brushes is thick and low-lifted, as it is tightly connected by fibrous jumpers with deep palm aponeurosis. The skin is deprived of hair and sebaceous glands, but rich in sweating glands, innervated by the skin branches.

elbow and median nerves. The subcutaneous fiber is well developed, permeated with fibrous jumpers and has a cellular structure. Own fascia is well pronounced, especially in the middle departments, where tendon fibers are woven with long and short palm muscles. This thickened part of the fascia in the form of a triangle, the base of the fingers facing, is the name of the palm aponeurosis. In the distal departments of the palm aponeurosis there are three commissioned holes through which the vessels and nerves go to the fingers. Through these holes, the subcutaneous fiber of the proximal departments of the fingers and palms is reported to the median suppression of the palm of the palm.

The palm's own fascia is divided into superficial and deep leaflets. Deep fascia sheet covers palm and rear intercepted muscles. The surface sheet surrounds the brush from all sides and moves to the fingers, attaching to the side surfaces of the phalange of the fingers. Two intermuncular partitions are departed from it: media - to v metropolitan bone and lateral - to the III of Metal bone. Thus, 5 bone-fibrous spaces are formed on the brush: the rear, deep, tenor bed, the hypotenor's bed and the median palm bed. The contents of the medial and lateral spaces are the muscles V and I of the fingers, the contents of the middle bed are surrounded by the synovial sheath of the tendon of surface and deep finger flexors, as well as the main vessels and the nerves of the palm.

Immediately under the palm aponeurosis there is a surface palm arterial arc, which is formed mainly due to the elbow artery and the surface branch of the radial artery (Fig. 17.7). Three common palpal palm arteries are departed from the surface palm arc, which at the level of the heads of the Metatar bones take into themselves the palm films from the deep palm arc and through the comer holes go to the fingers, where they are divided into their own palm finger arteries to two adjacent fingers. The total palm finger arterys to I and V fingers depart directly from radiation and elbow arteries.

Under the surface palm arc there are branches of the median and elbow nerves, which, by analogy with the arteries, are divided into common and their own finger nerves. The middle nerve supplies I, II, III and the radiation side of the IV fingers, the elbow - V finger and the elbow side IV.

Fig. 17.7.The arteries of the palm surface of the brush (from: Sinelnikov RD 1952): 1 - elbow artery; 2 - Lokatevorev; 3 - Lockeequency wrist; 4-hood bone; 5 - deep palm branch of the elbow artery; 6 - Retinaculum Flexorum; 7 - surface palm arc; 8 - deep palm arc; 9 - common palm finger arteries; 10 - tendon of the surface flexor of the fingers; 11 - the tendon of the radiation flayer of the wrist; 12 - middle nerve; 13 - radiation artery; 14 is the palm branch of the median nerve; 15 - Surface Ladon Branch of the Rade Artery; 16 - short muscle discharge I finger; 17 - Finger I Fig; 18 - muscle leading to finger; 19 - artery branches I finger; 20 - own palm finger arteries; 21 - fibrous vagina tendons; 22 - tasking branches; 23 - palm millpaths; 24 - m. pronator quadrates; 25 - tendon of the shoulder muscle; 26 - Clay piping branches of the elbow and radial arteries; 27 - artery I finger; 28 - Front inter-site artery; 29 - Rady Arteri II Finger

Under a deep leaflet of its own fascia on intercepted muscles, a deep palm arc is located, which is formed by compounding the deep branch of the radial artery (translates from the rear of the brush through the I interpital interval) and the deep branch of the elbow artery. Three groups of branches are departed from deep arcs: palm mill-arteries, anathematizing with common finger arteries, tasking branches, anatomosing with rear milling arteries and return arteries involved in the formation of the arterial network of ray-taking joint.

The back surface of the brush is covered with fine, very movable skin with moderately pronounced saline and sweat glands. Subjecting fiber is poorly developed, very loose, with a well-pronounced network of lymphatic vessels, therefore, with inflammatory processes, swelling from the palm side applies to the rear. In the fiber there are branches of the surface branch of the radial nerve and the rear branch of the elbow nerve, as well as the venous network, giving rise to V. CEPHALICA and V. Basilica. Under the surface leaflet of its own fascia, the tendons of the wrist and fingers are located. On the back surface, directly under the tenders of the extensors, on the ligament apparatus of the wrist bones, there is a back arterial network (Rete Carpi Dorsalis), formed by the reary branches of radiation and elbow arteries. Three rear milling arterys are departed from it, which at the level of the faded bones heads are divided into two rear finger arteries, walking along the side surfaces of adjacent fingers.

Under the deep leaflet of its own fascia are in closed interpoint intervals of 4 pairs of rear and palm interceptional muscles.

Fingers.The skin and subcutaneous finger cells have a similar brush structure. Longitudinal beams of the palm aponeurosis (own fascia) are moving to the fingers and are attached along the edges of the palm surface of the phalange, forming bone-fibrous channels, in which the tendons of the finger bends are located. Fibrous channels at the level of interphalating joints are strengthened by transverse and cross-shaped ligaments. For the convenience of slipping tendons within these fibrous channels, both the channels and tendons are coated with a synovial shell consisting of parietal (Epitenon Seu Epitendinum) and mesenter (mesotenon) sheets (Fig. 17.9). Between the parietal and visceral leaves of the synovial vagina there is a slightlike

the space filled with synovial fluid and called the cavity of the synovial vagina. The length of the synovial vagina of the fingertips of the fingers is not the same (Fig. 17.8). The synovial vagina I finger in the proximal departments is communicated with the synovial bag of a radiot flexor wrist and is called a radial synovial vagina. The synovial vagina V of the finger in the proximal department, covering all 4 pairs of tendons of surface and deep finger flexors, communicates with the synovial bag of the elbow wrist flexor and is called elbow

Fig. 17.8.Sinovial vagina Palm:

1 - the vagina of the tendon of the long thumb; 2 - vagina tendons V finger; 3 - the vagina of tendons II finger; 4 - the vagina tendons III finger; 5 - Vagina of the tendon IV finger

Fig. 17.9.The topographic-anatomical structure of the finger at the level of the middle phalanx. Transverse section:

1 - leather; 2 - subcutaneous fatty fiber; 3 - tendon of surface and deep finger bent; 4 - own fascia (fibrous vagina); 5 - peritenon; 6 - epitiates; 7 - Mesotenon; 8 - the cavity of the synovial vagina; 9 - own palm finger nerve; 10 - own finger palm artery; 11 - phalanx of the finger; 12 - rear finger nerve; 13 - rear finger artery; 14 - finger extensor tendon

synovial vagina. Sinovial vagina II, III and IV fingers begin at the level of head-bones heads. Sinovial vagina ends with all 5 fingers at the bases of the nail phalange.

The tendons of the surface flexor fingers are split into two legs and are attached to the side surfaces of the base of the middle phalanx. The tendons of the deep flexor fingers pass between the legs of the surface flexor and are attached to the base of the nail phalanx.

On the rear, the phalange of the fingers of the tendon of the fingers are connected to each other jumpers (Connexus intertendineus), are flattened and split into three parts. The average is attached to the bases of the average phalange, and the side - to the bases of the nail.

17.9. Borders and lower limb area

The lower limb is separated from the body in front and on top of the groin fold (PLICA inguinalis), behind and on top - the ridge of the iliac bone (crista iliaca) and the conditional line connecting the bone-toaded resistant to the iliac bone with an accelerated lens vertebra.

On the lower limb, it is isolated: a berium region, a hip area, knee, legs, ankle joint and foot.

17.10. White area

The jagodic region (REGIO Glutea) is limited from above the ridge of the iliac bone, from the bottom - with a bean fold, from the inside - inter-fodder fold (median line), outside the line connecting the reserved residue of the ileal bone with a large slicer of the femoral bone (Fig. 17.10).

The leather of the berium area is thick, low-live, as fibrous jumpers are fought with deep-livet with their own fascia, contains flush hair, saline and sweat glands. Innervated by the upper, medium and lower skin nerves of the buttocks (NN. Clunii Superiores, Medii Et Inferiors). The subcutaneous fiber is well developed and has a valued structure. Surface fascia is poorly pronounced, and in the external departments of the region, it splits into two sheets and divides the fiber into two layers - the surface and deep, which, turning into the tissue of the lumbar region, forms a lumbly-berged fatty pillow (Massa Adiposa Lumboglutealis).

The own fascia at the top edge of a large jagged muscle is split into two sheets. The surface sheet forms the fasal vagina of the latter. The deep leaf cover the muscles of the second layer: the middle buttock, pear-shaped, inner locking with the twins and the square muscle of the thigh.

Fig. 17.10.Topography of muscles, vessels and nerves of the berry region: 1 - a large bodied muscle; 2 - the average jagged muscle; 3 - small jagged muscle; 4 - pear muscle; 5, 7 - upper and lower twin muscles; 6 - internal locking muscle; 8 - the square muscle of the thigh; 9, 10 - over- and progressive holes; 11 - a sacroy-bug bunch; 12 - small sedlication hole; 13, 14 - Upper berry nerve and artery; 15, 16 - lower berry nerve and artery; 17 - internal interground; 18 - Sex nerve; 19 - rear skin thigh; 20 - Sedal Nerve

Between the muscles of the first and second layer is a significant layer of loose fatty fiber, in which the main vessels and nerves emerging from the cavity of the pelvis through the above and the diaphorenoid hole (Fig. 17.10).

Through the prugure-shaped hole, the upper berium artery, vein and nerve, branches are located deeper - between the middle (second layer) and the small (third layer) with the buttock muscles. Through a stroke -ide hole pass from the inside of the duct internal genital artery and veins (a. Et v. Pudendae internae), sex nerve (N. Pudeudus), lower buttock artery and veins (a.et v. Gluteae inferiors), sedellastic nerve (N. Ischiadicus ), rear skin thigh (n. Cutaneus Femoris Posterior), and the most outdoor position occupies the lower berry nerve (N. Gluteus Inferior). The deep (third) layer of muscles form a small berry (above) and the outer locking (below).

There are two deep melting spaces in the jagbon area: between the large jagged muscle and the second layer of muscles and between the middle and small buttock muscles. The first (lifting) cellular space in the course of the seeded nerve is reported to the deep fiber of the back surface of the thigh, through a subguing hole - with a small pelvic of a small pelvic, through a small sedlication hole along the germ vessel - with a fiber of a sedlicate-straight hole and along the branches of the lower berical artery. - With the lies of the thrust muscles. The second cellulum is closed, since the average and small jagged muscles are concluded in one fascial vagina.

17.11. Hip joint

The hip joint (ARTICULATIO COXAE) is formed by a grateful depression of the pelvic bone (Acetabulum) and a femoral head (Caput Ossis Femoris). Due to the incomplete correspondence of the artic surfaces of the thigh head and the godpadin, the latter is complemented by the cartilage lip (Fig. 17.11).

The joint capsule is attached along the edge of the godflower in the duck from the cartilage lip. On the hip, the articular capsule covers the front cover the entire neck to the interstate line, and the back does not reach the first 1/3 of the hip before the interstate jar.

Fig. 17.11.Hip joint (opened) (from: Sinelnikov R.D., 1952) 1 - semi-lunar surface; 2 - vertical depression yam; 3 - straight thigh muscle; 4 - cartilage lip; 5 - bunch of the hip head; 6 - femoral head; 7 - articular capsule (rotate); 8 - transverse bundle of the godded depression; 9 - locking membrane; 10 - articular lip

Circular tendon fibers are passing around the hip neck in the capsule, forming a circular zone (Zona Orbicularis). The bunch of the femoral bone head stretches from the hip head to the hole of the master's depression (Lig. Capitis Femoris), which passes the branch of the locking artery, the blood supply to the hip head.

The articular capsule is strengthened by three ligaments: iliac-femoral (Lig. Bertinii), sedalence and femoral and pubic-femoral. Between these ligaments, the joint capsule is thin, and in these weak places there may be dislocations of the hip joint.

The blood supply to the joint is carried out by the branches of the deep artery of the hip, the locking artery and the buttock arteries. Innervates the joint branches of the femoral, sedlication and locking nerves.

17.12. Fear areas

The front and rear hips (Regiones Femori Anterior et Posterior) are limited from above and in front of the groin fold, on top and rear - a berry fold, from the bottom - the conditioned horizontal line, spent on 2 transverse fingers above the base of the patella. They are separated by two vertical lines connecting the thigh supermarkets with the reserved uluch of the ilium outside and the symphysome from the inside.

The thigh leather is thin, mobile, with well-developed sweat (in the upper parts) and sall glands. Innervates the skin of the femoral branch of the femoral-sex, the front skin branches of the femoral nerve, the lateral skin nerve of the thigh and the skin branch of the locking nerve (from the lumbays) in front and the rear skin nerve of the thigh (from the sacrilatory plexus) from the back.

The subcutaneous fiber on the thigh is well expressed and the surface fascia consisting of two sheets is divided into several layers. In subcutaneous tissue, in addition to these skin nerves, there are two groups of surface lymph nodes (inguinal and subpaffy) and surface branches of the femoral artery with accompanied veins: superficial arteries (a. Epigastrica Superficialis), surface artery, iliac envelope (a. Circumflexa Ilium SuperFicilis), and external genital arteries ^ a. Pudendae EXTERNAE). In addition, V artifically passes on the front of the thigh. SAPHENA MAGNA (Fig. 17.12).

Fig. 17.12.Superficial formations of the front area of \u200b\u200bthe thigh in the upper third: 1 - wide fascia of the thigh; 2 - sick-shaped edge; 3 - lattice fascia; 4 - surface (subpass) lymph nodes; 5 - front skin branches of the femoral nerve; 6 - skin branches of the outer skin nerve of the thigh; 7 - superficial surfing artery and vein; 8 - surface artery and vein envelope iliac bone; 9 - external genital artery and vein; 10 - big subcutaneous vein

Hip's own fascia (wide fascia; F. LATA) is a rather thick fibrous plate, especially from the outside, where tendon fibers of the muscle muscles of wide fascia are woven into it. This thickened portion of its own fascia is called the iliac-tibial tract and in surgery is used for plastic operations. Surrounding the thigh from all sides, the fascia sends three intermushkin partitions to the femoral bone: the medial, forming, in addition, the faschic vagina of the femoral vascular beam, lateral and rear.

Thus, the thigh is divided into three bone-fascial beds: front, inner and rear. In addition, in the upper thigh departments (kntuta from the tailoring muscle), its own fascia is split into the surface and deep leaflets. The surface leaf is located ahead of the femur vessels and is woven into the inguinal bunch. The inner part of this leaf has a lot of holes through which the surface vessels and nerves go into subcutaneous tissue, and v. Saphena Magna flows into a femoral vein and is called the lattice fascia (f. Ctibrosa). If you delete the lattice fascia, then a small deepening of oval shape (FOSSA OVALE) is found, where the mouth V is located. Saphena Magna, called Hiatus Saphenus. This site of its own fascia is a weak point where femoral hernias go into subcutaneous tissue, and is called an outdoor, or superficial, thigh hole. The boundary between the dense outer and lattice inside of the fascia has a thickened sickle form (Margo Falciformis), ending the upper, woven into the inguinal ligament, and the lower vein fluid from the femoral vein with a deep leaflet, horns.

Deep leaflet of own fascia (f. RECTINEA) King from m. IliopSoas reaches Eminentia iliopectinea and is called the iliac-swing arc, Arcus Iliopeectineus, moving to the Lobo Dice Support (Lig. Pectineale, Seu Cooperi), lowers down behind the thigh vessels, covering the massive muscle, and knutrice from the femoral vein merges with the surface sheet. Thus, the space located behind the groove bundle is divided into two departments: muscle and vascular lacuna (Fig. 17.13, 17.14). Muscular lacuna contains m. iliopsoas, n. Femoralis and N. Cutaneus Femoris Laterlis, vascular (smaller in volume) - femoral artery, vein and 2-3 deep inguinal lymph nose Rosenmulller-Pirogov.

Fig. 17.13.Muscular and vascular lacuna:

1 - a groin bunch; 2 - iliac bone; 3 - iliac-swing bund; 4 - deep sheet of wide fascia; 5 - lacunar bunch; 6 - outdoor skin thigh; 7 - m. iliopsoas; 8 - femoral nerve; 9, 10 - femoral artery and vein; 11, 12 - inner femur ring with deep lymphatic nodes located in it

These lymph nodes located in the interior sections of vascular lacuna in loose fatty tissue, with an increase in intra-abdominal pressure, are easily extruded, and a femoral channel is formed. The channel itself is an interfascial triangular shape, knutrice from the femoral vein limited in front of a superficial sheet of wide fascia, from the back - a deep leaflet, outside the fasal vagina of the femur vein. The inner hole (or a femoral ring) of the femoral canal, located in the abdominal cavity (Fossa Femoralis) and the coated intra-abdominal fascia, is the medial part of the vascular lacuna. Femoral

the ring is limited in front of a groin bond, behind - a combed bunch, outside the femoral vein and from the inside - a lacunar bundle.

The contents of the front bone-fascial lodge are the muscles - thigh bends or extensors of the lower leg - and the main vascular-nerve beam of the lower limb (a., V., N. Femoreles). The front muscle group is formed by m. Tensor f. May, m. Sartorius, m. IliopSoas and m. Quadriceps Famoris consisting of m. Vastus Lateralis, m. Rectus Femoris, m. Vastus Medialis and M. Vastus Intermedius.

The femoral vascular-nerving bundle in the upper third of the thigh is located between two sheets of its own fascia in Sulcus Iliopeectineus, where the artery occupies a central position, Vienna is located Knutrice from it, and the nerve - duck and separated from the artery of the deep plate of its own fascia. 5-6 cm below the groove bunch of the femoral nerve disintegrates into motor and skin branches, stopping their existence, and only one long

Fig. 17.14.Cross sections of the hips in the middle third.

a - fascial beds and fiberglass slots: 1 - medial wide muscle thigh; 2 - tailoring muscle; 3 - short muscle leading; 4 - Long muscle leading 5 - thin muscle; 6 - large muscle leading; 7 - semi-stepped muscle; 8 - semi-dry muscle; 9 - two-headed thigh muscle; 10 - lateral wide muscle thigh; 11 - Intermediate wide thigh muscle; 12 - straight muscle;

b - blood vessels and shoulder nerves: 1 - femoral vein, 2 - femoral artery; 3 - subcutaneous nerve; 4 - large subcutaneous vein legs; 5 - skin branch of the locking nerve; 6 - rear skin thigh; 7 - Sedal Nerve; 8, 9 - deep artery and vein hips

the branch (n. Saphenus) reaches the foot. At the same level of the femoral artery, in addition to the surface branches, the largest branch is departed - deep artery of the hip, which gives two artery surrounding the thigh, and in the form of the trifling branches go on the back surface. In the middle third of the hip, the bundle is located between m. Vastus Medialis and M. Adductor Longus in Sulcus Femoralis Anterior and coated in front of the tailoring muscle. In the lower third of the thigh a. ET V. Femoralis and N. Saphemus is included in the femoral-ponaching channels channel formed by m. Vastus Medialis Outside, m. Adductor Magnus from the inside and Lamina Vastoadductoria in front. Within this channel, the femoral artery gives a downward branch of the knee, which is with n. Saphenus through the front opening, located in the tendon plate, goes to the surface of the hip.

The contents of the medial bone-fascial bed are leading muscles of the hip: m. Pectineus, m. Adductor Brevis, m. Adductor Lougus, m. Adductor Magnus and m. Gracilis. Here under the comb muscle (m. Pectiineus) there is a second vascular-nervous (lockable) beam of the hip, penetrating on the hip from the cavity of the small pelvis through the locking hole.

The contents of the rear bone-fascial lodge are the muscles-extensors of the thigh or the shin bends: semi-dry, semi-seamless, double-headed thigh muscles and a sedal nerve with accompanying vessels. The seeded nerve in the upper third of the thigh is located under its own fascia between the bond muscle from the inside and the lower edge of the large butterous muscle outside, in the middle and lower third, the nerve is between the double-headed muscle outside, semi-dry and semi-peculiar muscles from the inside.

17.13. Knee Region

The knee (genu) is limited to two horizontal lines carried out on 2 transverse fingers above and below the patella, and two vertical lines passing through the thigh supermarket is divided into the front and rear areas.

Moderate thickness leather, low-lining on bone protrusions and more movable between them. The subcutaneous fiber is loose, weakly developed in front and better - rear. According to the medial knee surface, V passes. Saphena Magna with N. Saphenus, and back - v. Saphena Parva, which, within the region, proceeds its own fascia

Fig. 17.15.Topography of popliteal pits:

I - double-headed muscle thigh; 2, 3 - semi-dry and semi-seamless thigh muscles; 4 - popling muscle; 5 - icy muscle; 6 - Sedal Nerve; 7 - Tolebly nerve; 8 - Common Maloberes Nerve; 9 - outer skin nerve caviar; 10 - internal skin nerve caviar;

II - Poned Vienna; 12 - popliteal artery; 13 - deep popliteal lymph nodes; 14 - Small subcutaneous vein

and flows into a poploval vein. Own fascia is a continuation of the wide fascia of the thigh, in front and from the sides, it merges with the tendons and bundles of the joint, and in the back passes into the shiven aponeurosis. Under its own fascia in front, the tendon of the four-headed muscles of the thigh is located, covering the patella and attaching already as the own bunch of the patelnik in the field of tibia bones. When removing its own fascia, the Fossa Poplitea (Fossa Poplitea) is naked (Fossa Poplitea), having a rhombus shape and limited to the following muscles: from above and outside - the tendon of the blood muscles of the thigh, on top and inside - semi-dry and semi-peculiar muscles, from the bottom - two heads of the oscracule muscle. The bottom of the patellied pits are the popling surface of the femoral bone, the knee joint capsule and the popliteal muscle (m. Popliteus) located on them. The contents of the popliteal fossa are fatty fiber, in which the popliteal lymphatic nodes are located, and a vascular-nervous beam consisting of a patellied artery, veins and the final sedation nerve department (Fig. 17.15). The stripped nerve is the most superficially, which in the upper part of the patellied fossa is divided into the common small-terrace (N. Perneus Communis) and the tibial (N. Tibalis) nerves. The total small -com nerve deviates the dudder under the tendon of the double muscle towards the head of the small bone, where it is included in the upper muscular-small-terber canal. The tibial nerve is directed to the bottom corner of the patellied pits in the main beam. From each of these nerves at the level of the middle of the patellied fifth, the caviar of the caviar (NN. Cutaneus Surae Lateralis et Medialis) is departed. Kepened and from the inside from the tibial nerve there is a popliteal vein, and the deepest position occupies a. Poplitea. 5 branches for knee joints are departed from the popliteal artery: AA. Genus Superior Lateralis Et Medialis, AA. Genus Inferior Lateralis et nadialis and a. Genus Media, which, together with the returnable tibial arteries and branches of the femoral artery form the arterial network of the joint.

17.14. KNEE-JOINT

The knee joint (Articulatio Genus) is formed by the articular surfaces of the mysteries of the femoral and tibial bones and the rear surface of the patella (Fig. 17.16). The articular surfaces of the summers are uncongenant, so they are aligned with intra-articular cartilage -

a B.

Fig. 17.16.The knee joint (from: Sinelnikov RD, 1952): A - unborn; b - opened;

1 - permanent surface; 2 - Rear Conducting Bundle; 3 - anterior condo bunch; 4 - front menisco-femur bunch; 5 - Medial Menisk; 6 - tibial collateral bunch; 7 - Own bunch of the patella; 8 - the articular surface of the patella; 9 - a small -com collateral bunch; 10 - lateral meniscus; 11 - tendon of the blood muscles of the thigh; 12 - a bunch of the head of the Mulobers bone; 13 - the head of the small bone; 14 - inter-emergency leg membrane; 15 - the articular muscle of the knee; 16, 17, 2 1 - tendons of the four-headed muscles of the thigh; 18 - patella; 19, 22 - medial and lateral supporting bundles of the patella; 20 - tibia jergis; 23 - Cross-bunch of knee

menisky. The lateral meniscus has the form of the letter O, the medial - the letters of C. in front of them with their adjacent edges are connected with a leaning ligament (Lig. TrauusVersum), and their outer edges are intertwined in the joints capsule. The feature of the joint is the presence of intra-articular ligaments (Lig. Cruciatum Anterior et Posterior), beginning in the intermacex pit of the hips and attaching to the interlimine elevation of the tibia. The second feature of the joint is the presence of a large number of stars formed by virtue of a different level of attachment of fibrous and synovial

Fig. 17.17.Sinovial Bags Knee Sustain

parts of the joint capsule and providing greater flexions (Fig. 17.17). There are 9 main revolts: one unpack (Recessus Superior; often communicated with a pumping bag), 4 paired front (2 top and 2 lower) and 4 rear (2 top and 2 lower).

Sustav Capsule Strengthen in front of tendon tensile tensions of a four-headed muscle and her own bunch of a patella, back - oblique and arcuate patellied ligaments (Lig. Popliteum Obliquum et Arcuatum), outside - a small -com collateral bunch (Lig. Collaterale Fibulare), from the inside - TBLATERALE Tibile).

Innegrated by the joint branches of the total small -com, tibial and subcutaneous (N. Saphenus) of the nerves. Breakfasts the knee joint due to numerous arteries forming Rete Articulare Genus described in the previous section.

17.15. Scole area

The root areas are limited to two horizontal lines conducted through the middle of the tibia and the base of the ankles below. Two conventional lines connecting the ankles with the tibia mysteries, the shin is divided into the front and rear areas. (Fig. 17.18).

The skin of the shin is quite thin and movable, with the exception of the front surface, where it almost arrives at the tibia perched. Innervates skin n. Saphenus Front and inside, n. Cutaneus Surae Lateralis and N. Peroneus superficialis in front and outside, n. Cutaneus surae medialis from behind and inside and n. SURALIS is downstairs. The subcutaneous fiber is loose, moderately developed, except for the forefall side, where it is very small. In subcutaneous tissue, except for the names of the nerves, medial tributaries V are located. Saphena Magna, lateral - v. Saphena Parva. Surface fascia thin. The own fascia of the leg (f. Cturis) is characterized by sufficient strength and acquires the type of aponeurosis. In the upper heads of the shin, it is fascinated with muscles, and throughout the medial attitude, the tibia is growing. Surrounding the shin practically from all sides, it sends two intermushny partitions to a small -com bone - the front and rear and with the interceptional partition divides the shin on three bone-fascial beds: outdoor, front and rear.

The front bone-fascial box contains three muscles, extending the stop and fingers located in one layer: m. Tibalis Anterior - from the inside, m. Extensor Digitorum Longus is outside, and in the lower half of the leg between them is m. Extensor Hallucis Longus. In the front fascial bed on the inter-emergency membrane lies a. Tibalis Anterior with two accompanying veins and a duck from them a deep small-terrace nerve (N. Perneus profundus) - a branch of a common little-worn nerve.

In the outer bone-fascial bed, the long and short mining muscles are located (M. Peroneus Longus et Brevis). In the bed of the lateral muscles from the patent fifth between the legs of the long Maloberstor muscle and the cervix of the mulberry bone penetrates the total mining nerve (N. Perneus Communis), which is divided into superficial and deep small nerves. Deep Maloberes Nerve goes to the front bed, and the surface descends down into the top muscular-small-terber canal, then passes between

the long and short small muscle and in the lower third of the leg goes into the subcutaneous fiber.

In the rear bone-fascial case, the flexors of the foot and fingers are located, which are divided into two layers in a deep leaflet of their own fascia: superficial and deep. The surface layer is represented by ionic (m. Gastrocnemius), plantar (m. Plantaris) and Cambalo-shaped (m. Soleus) with muscles, which are merged into the lower heads of the shin, forming one powerful heel tendon (Tendo Calcaneus Achillis). The deep layer of muscles make up the rear tibial outside, a long flexor of the fingers - from the inside, and in the lower half of the tibia there is a long thumbnail flayer, adjacent to a small bone and forming the lower muscular-mulberry channel with the bone (contains a. Et v. Perosea).

Fig. 17.18.Crossheads of the lower legs in the middle third:

a - fascial beds and fiberglass slots: front tibial muscle; 2 - long finger bent; 3 - rear tibial muscle; 4 - tendon of the plantar muscle; 5 - icy muscle; 6 - Cambalo-shaped muscle; 7 - long flexor I finger; 8 - Long Malobert Muscle; 9 - short inlerts muscle; 10 - a long extensor I finger; 11 - long depleting of fingers.

b - blood vessels and nerves of the legs: 1 - front of the tibial artery and veins; 2, 3 - large subcutaneous vein legs, subcutaneous nerve; 4 - rear tibial artery and veins; 6, 7 - small subcutaneous vein legs and medial skin nerve caviar; 8 - Maloberes artery and veins; 9 - Surface branch of a minor nerve; 10 - Deep branch of a minor nerve

Between the surface and deep layers of the muscles of the back surface of the lower leg is located, which passes the main vascular beam, consisting of the rear tibial artery (a. Tibalis Posterior) with two veins and a tibial nerve (N. Tibalis). The nerve throughout the entire artery duct.

17.16. FOOT

The upper boundary of the foot area (Regio Pedis) are conditional lines connecting the tops of the ankles on the rear and the sole of the foot.

The skin of the back surface is thin, movable, innervated by Nn. Ratanei Dorsalis Medialis and Intermediate (from the surface small-terber nerve), n. Cutaneus Dorsalis Lateralis (from N. Suralis) and N. Saphenus.

The skin of the plantar surface of the foot is thick, fixed, is deprived of hair cover, but there is a large amount of sweat glands, innervated by outer and inner sole nerves (from n. Tibalis) and N. SURALIS.

The subcutaneous fiber on the rear is poorly expressed, contains numerous veins that form a network of finger bases from which the back venous arc is formed (Arcus Venosus Dorsalis Pedis), giving rise to large and low subcutaneous veins. The subcutaneous fiber of the sole is well expressed, has a cellular structure, as foaming with fibrous jumpers connecting the skin with aponeurosis. Surface fascia is poorly expressed. Own fascia by analogy with a brush is dense, durable, especially on the plantar side, where it has the form of the aponeurosis, in the distal departments of which the comer holes passing to the fingers of the vessels and nerves. The surface sheet of its own fascia, surrounding the foot, sends two intertensive partitions to the III and V tie bones. A deep leaf covering inter-emergency muscles forms a deep bone-fascial space, and on the back surface between deep and surface leaflets there is a rear interfacial space.

In the rear interfasal space, the following muscles are located in two layers: m. Tibalis Anterior, m. Extensor Hallucis Longus and M. Extensor Digitorum Longus is the first layer; m. Extensor Hallucis Brevis and Extensor Digitorum Brevis - second layer.

Fig. 17.19.Arteries of the foot (from: Sinelnikov RD, 1952): a - back surface; b - plantar surface; 1 - front tibial artery; 2 - the trimming branch of the Malobersovo artery; 3 - back artery feet; 4 - arcuate artery; 5 - deep plantar branch; 6 - tasking branches; 7 - rear ventilation arteries 8 - rear tibial artery; 9 - medial plantar artery 10 - lateral plantar artery; 11, 12 - superficial and deep branch of the medial plantar artery; 13 - plantar arc; 14 - Tweet arteries; 15 - Own plantar finger arteries

The main vascular-nerve beam of the rear of the foot is a. Dorsalis Pedis with two veins and a deep small-terror nerve (Fig. 17.19). The bundle is projected from the middle of the distance between the ankles to the I interpalic gap where the pulse can be patched. At the base of the fingertips, the back artery of the foot forms a. Arcuata, from which AA departs to the fingers. MetaTarseae Dorsales, separated on the rear finger arteries.

The medial bed of the sole of the foot contains the muscles forming the rise of the thumb (MM. Abductor Hallucis, Flexor Hallucis Brevis, Adductor Hallucis). The lateral fascial box contains the muscles of the mother's (MM. Abductor Digiti Minimi, Flexor Digiti Minimi, Opponens Digiti Minimi).

In the middle bed, immediately behind the aponeurosis, there are a short finger flexor, the square muscle soles, the tendon of the long finger flexor with the heart-shaped muscles, the muscle, leading to the movement of the I finger, and the tendon of the long mulberry muscle.

On the plantar side of the foot there are two grooves in which the vessels and nerves are lying. The medial furrow contains medial plantar vessels and nerve (from a. Tibalis Pasterior and N. Tibalis). The lateral plantar vessels and nerve, as well as the previous ones, reach the foot, passing through the ankle, heel and plantar channels, and then occupy a lateral furrow. A. Plantais Lateralis, larger, at the level of V ventilation bone turns inside, forming Arcus Plantaris, from which 4 a is departed. MetaTarse Plantares, and from them soles appear finger arteries.

17.17. Operations on blood vessels limbs

Dressing a blood vessel in the wound they are carried out when bleeding from the artery or veins as a result of injury or during the dissection of the vessel during the operation. At the same time, after draining the wound, the tampon is imposed on the end of a bleeding vessel, the hemostatic clamp is carried out under the clamp of the ligature and the first node is tied. The clip is slowly removed and at the same time tighten the knot. Tie the second knot so that it turns out the naval node.

Dressing a blood vessel throughout it is usually performed during damage to the main vessels. Indications for surgery:

bleeding or firearms, bleeding due to the destruction of the vessel by a purulent process or a tumor, traumatic aneurysm, the amputation of the limb, when the imposition of the harness is impossible (anaerobic infection, high amputation, etc.).

Most often, the operation is performed under local infiltration anesthesia by A.V. Vishnevsky. There are direct and rally access to the vascular-nerve beam depending on the cutting attitude to the projection line of the vessels and nerves. Occolt access is performed in cases where the vascular-nerve bundle is superficially or surface veins and skin nerves are located in its projection. After the introduction of novels in the vascular bundle vagina, the artery is distinguished by the artery. The ligational needle of the deschan on the side of the nerve is carried out under the artery ligature and tie it by a surgical node. Recovering in the distal direction by 2 cm. Similarly impose a second ligature. Between the superimposed ligatures impose a firmware ligature. The artery dissect between the distal and firmware ligature. Two ligatures remain on the central segment of the vessel, which avoids secondary bleeding due to the scaling of ligature. The crossing of the artery is performed for the denervation of the vessel and improve the octal blood circulation in the limb. To improve microcirculation, in some cases, the Vienna of the epitial method is suspended simultaneously.

Binding of the shoulder artery on the shoulder. The patient is placed on the operating table, the hand is placed on the dottal table in the position of supination. The projection line of the shoulder artery takes place from the top of the axillary depression until the middle of the distance between the medial superchair and the tendon of the double-headed muscle. The cut of superficial tissues of 8-10 cm long is carried out by retreating 2 cm dust from the projection line. The shoulder fascia dissect through the grooved prison, the double-headed muscle diverged. Through the rear wall of the fascial muscle case, which is at the same time the front wall of the vascular vascular beam, is exposed with a shoulder artery, a middle nerve and shoulder veins. The shoulder artery impose ligatures between which the vessel crosses. Owl blood circulation after the hurrying artery dressing is carried out according to the branches of the deep artery of the shoulder - the median and radial equal arteries, which are anastomized with returnable radiation and inter-emergency arteries.

Gleaming radiation artery at the forearm. The projection line of the radial artery on the forearm passes from the medial edge of the tendon of the two-headed muscles to the point located 0.5 cm knutrice from the cylinder radial bone outflow (pulse point). Discontinue surface tissue by incision along the projection line 6-8 cm long, between the shoulder muscle and radial bent, the brush is released radiation artery, co-veins and the surface branch of the radiation nerve. Owl blood circulation after dressing of the radial artery is carried out by anastomoses with an elbow artery (superficial and deep palm arcs and the arterial network of the beam-toll joint).

Bearing a femoral artery. The projection line of the femoral artery with a rotated duck, slightly bent in the knee and hip joints of the limb, passes from the middle of the groove bundle to the lipper of the femoral bone (the CAN line). The ligation of the femoral artery is better to produce below the level of extinction of the deep artery of the thigh. The incision of a length of 8-10 cm is performed according to the projection line in the middle third of the thigh. The tailoring muscle is diverted. The femoral artery occupies the most surface position in the vascular-nervous beam. After her dressing, the area circulatory circulation is carried out according to the anastomoses between the branches of the deep artery of the hip and the arterial network of the knee joint.

17.18. Operations for purulent diseases

Soft fabrics of the limbs

Purulent diseases of soft tissues are the most frequent surgical pathology of the limbs. Operational intervention is shown in the stage of purulent melting of tissues, with an extensive focus of soft tissue infiltration with abscess and lymphangitis. The operation should ensure the autopsy of all purulent illuminations, their drainage and liquidation of the purulent focus.

17.18.1. Operations with felm limbs

Surface purulent foci is localized mainly in subcutaneous fatty tissue (surface phlegmon, furunculae, carbuncules, hydraenites, surface adenoflems, ventilated atters). Operation is performed under local anesthesia. At the same time, purulent foci are opened in the region of the most pronounced.

fluctuations or in the center of infiltrate. After emptying the cavity of the purulent focus, it is drained and imposed a bandage with hypertensive solution.

The position and propagation of deep phlegm limbs are determined by the topography of fascial cases, vascular beams and cellulum spaces of specific limbs. Accordingly, operational access is carried out (Fig.17.20). The operation is performed under anesthesia, intra-view anesthesia or case anesthesia. After the dissection of surface tissues and its own fascia in the deeper layers penetrate blunt by using an anatomical tweezers, a hemostatic clamp or Corncang. The purulent cavity is revealed and examined, the stupid disconnection of the tissue eliminate pockets and chapels. If necessary, an additional incision or contraperture is performed. After emptying the purulent cavity, it is drained with gauze or rubber graduates, rubber and polychlorvinyl tubes are introduced for the introduction of antiseptics and antibiotics. Avoid contact with drainage with large vessels for preventing the vessel bedding and subsequent bleeding.

Fig. 17.20.Cuts with felm limbs

17.18.2. Operations under panaria

Patients with purulent diseases of the fingers (panarium) represent the most extensive group of outpatient surgical patients. In the emergence of Panarisians, open microtraums and wound injured of fingers play dominant role. The anatomical features of the structure of the tissue of the brush determine the originality of the flow of purulent processes.

Panaritics of the palm surface of the fingers (Fig. 17.21)

Skin Panarium it is a purulent cavity in the thickness of the epidermis and, as a rule, is a consequence of the suppuration of water corns. With small unbroken foci, purulent liquid removes 96% ethyl alcohol, lubricated with a solution of diamond green. With extensive or shut-off skin tests, it is carefully removed by the removed epidermis, dried wound and lubricated with a solution of diamond green.

Subcutaneous panarium more often is localized on the palm surface of the nail phalanx. Due to the presence of fibrous partitions in the thickness of subcutaneous fatty fiber, inflammation tends to purulent melting tissues and rapidly spreading deep into the tissue.

The operation is performed under the conductor anesthesia in Lukashevich-Obrist. On the base of the finger impose a harness. On the rear of the main phalanx with the lateral and medial sides, a 1-2% solution of novocaine and through the obtained "lemon crusts" the needle is promoted to the palm surface with simultaneous administration of 5-10 ml of novocaine solution. Anesthesia occurs after 3-5 minutes.

Cuts during localization Panarium on the middle and the main phalanges are performed on palm-side surfaces and are not distributed to interphalangeal folds (clap cuts) (Fig. 17.22). It does not damage the working (palm) surface of the finger and vascular-nerve bundles. Through drainage is carried out with rubber ribbon.

When localizing, panarium on the nail phalange on one side surface is performed by a key-shaped incision, the contraperture is applied to the other (zezester section). Carry through a rubber tape drainage. This incision avoids the denergi denergie.

Tendon Panarium - inflammation of the synovial vagina of the tendon (tendovaginitis), is accompanied by the compression of purulent

Fig. 17.21.Views of Panaritsiyev (from: V.K. Hotel, 1996):

1-4 - paronychy; 5 - skin; 6 - subcutaneous; 7 - skin-subcutaneous "in the form of a cufflink"; 8 - tendon; 9 - articular; 10-12 - bone

Fig. 17.22.Cuts under panaria.

Cuts with subcutaneous panarium nail phalanx on the III finger - the key-shaped cuts, on the IV finger - the incision of the zehress. Cuts with tendon panarium fingers in clap, IV finger - vanquel (with tendon necrosis). Cuts with phlegmon brushes. Marked "Forbidden zone of the Tenar"

the containers of the mesenzheki tendon and circulating vessels passing in it. When untimely operation, this leads to necrosis of the tendon.

The operation is performed under the conductor anesthesia according to Brown-Usoltseva: 0.5-1% novocaine solution is administered from the back surface of the brush to the distal deposits of interpoints to the palm surface. Anesthesia occurs after 5-10 minutes.

Cuts on the middle and the main phalanges, through which the synovial finger vagina is revealed. Produce through rubber tape drainage. In order to avoid damage to the mesenzheki tendon, the tape is carried out over the tendon.

With tendovagint of the I finger, the clappa cuts on the main phalange are opened and drained the radial synovial bag with a cut in the rise of the thumb. At the same time, to preserve the branches of the median nerve, retreat from the folds of the tensor of the dudder by 1 cm.

With tendovagint of the V finger, in addition to the cuts of the clap, on the middle and the main phalanges are revealed and drained the elbow synovial bag with a cut along the outer edge of the hypothenera.

Panarias of the rear surface of the fingers

Subcast Panarium open under local anesthesia by full or partial removal of the nail plate.

OcoloneNogte Panarium (Paronichius) operate, using conductive anesthesia in Lukashevich-Obrist. The separation of the lateral nail roller is opened by the longitudinal cut of the side roller. The otolnogte panarium of the rear nail roller is opened with a P-shaped section. Under the cutting flap as a drainage laid a rubber tape.

17.18.3. Operations with phlegmon brushes

Commissioning phlegmon open the longitudinal cut in the gap between the heads of the Metatar bones. Use conduction anesthesia in Brown-Usoltseva.

Flexions of the median beds (suppressor phlegmon), lodge of the Tenar and hypotenaropen the longitudinal single or paired cuts, avoiding damage to the branches of the median and elbow nerves. Effective is through drainage.

17.19. Amputation and examination

Amputation- truncation of the limb throughout the bone. Removal of the peripheral part of the limb at the level of the joint without crossing the bone is called exarttuculation.These operations refer to the category of crilever operations, and the definition of indications is a challenge. Amputations and testing are produced in injuries with a violation of the viability of the peripheral part of the limb, a long-lasting syndrome, the limb gangrene due to various causes (pathology of vessels, burns, frostbite, etc.), progressive gas gangrene, some purulent processes, oncological pathology. When performing an operation, in view

the physical and psychological severity of the operational injury, more often use general anesthesia.

Classify amputations on different features. By the time of the appearance of the testimony, primary, secondary and repeated (reampactation) are isolated. In the form of the dissection of soft tissues distinguish circular (circular), ellipsis and patchwork amputations (Fig. 17.23).

Fig. 17.23.Seasons of soft tissues in amputations (from: Matyushin I.F., 1982):

1 - circular (round); 2 - oval (ellipsoid); 3 - in the form of a racket; 4 - bunk; 5 - monoloscient

The method of shelting the bone culture in amputation determines the repair of the crust of the limb. Depending on the tissues used, skin, fascioplastic, myoflatical and bone-plastic amputation is isolated.

Creating a stock of soft tissues for the shelter of the bone culture is ensured by shifting them in the proximal direction under layer-by-layer dissection (Fig. 17.24). With guillotine amputation, they do not produce their delay and bone culture do not cover. Operation is used for gas gangrene, severe patient condition. Somnation

Figure 17.24.Methods of dissection of soft tissues in amputations (from: Matyushin I.F., 1982):

a - guillotine amputation; 1 - bone; 2 - periosteum; 3 - muscles; 4 - own fascia; 5 - subcutaneous fat layer; 6 - leather; b - single-stage amputation; in - two-one amputation; g - three-one amputation; d - fascioplastic amputation; E - Tendoplastic amputation

amputation allows you to create a stock of surface tissues that are covered with bone culture (skin and fascioplastic amputation). With two- and three-year amputations, a margin of muscle tissues for shelter bone sawing (myoplastic amputation) is created.

Stages of surgery: anesthesia, the imposition of the harness, layer-by-layer dissection of the tissues, rebirth of the vessels, the treatment of the nerves, dissection and displacement of the periosteum, the crossing of the bone, the removal of the harness, the layers of the wound and its drainage, postoperative immobilization of the cult.

17.20. Operations on bones

Along with the conservative treatment of bone pathology, operational methods of treatment are applied in traumatology and orthopedics. The most typical operations on the musculoser (on the bones and joints) are:

Skeletal stretch - Comparison of bone fragments by their dosage and multidirectional stretching with special devices.

Osteotomy- dissection for correcting the shape, axis, removal of altered bone tissue, etc.

Trepanation- overlaying holes in the bone to access other structures, opening the pathological focus.

Sequestand nekratectomy- removal of a purulent or necrotized bone area.

The seamand bonding bone- Connection of bone fragments with suture material (wire, lavasan ribbon, ketgut) or glue.

Extra-and intramedullar osteosynthesis- Connection of bone fragments with metal structures imposed on the surface of the bone or administered in the bone cerebral channel

(Fig. 17.25).

Bone plastic - Connection of bone fragments of the bone graft (Fig. 17.26).

Compression-distraction osteosynthesis - bone connection by apparatuses (Fig. 17.27) or by other devices for fixing spokes of bone fragments outside the fracture.

Fig. 17.25.Intramedullar osteosynthesis of femoral bone with a metal pin (from: Ostroeerhov G.E., Loubotsky D.N., Bomash Yu.M., 1996)

Fig. 17.26.Bone plastic according to Chaklin (from: Ostroeerhov G.E., Loubotsky D.N.,

Bomash Yu.M., 1996)

Fig. 17.27.Apparatus G.A. Ilizarova (from: Ostrovherkh G.E., Loubotsky D.N.,

Bomash Yu.M., 1996)

17.21. Sustav operations

Among the sample operations on the joints, the most famous are:

Puncture of Sustav- Cressing puncture of the joint capsule with therapeutic or diagnostic purpose.

Arthrotomy- Opening the joint cavity for drainage of the joint cavity or in order to access the cavity for subsequent operational intervention.

Arthrodez(Sin.: Arthrizes) - Orthopedic operation of the joint fixation in the specified position.

Susta resection - removal of articular surfaces and joint capsules with subsequent arthrodesis.

Arthoplasty- Restore the joint function by replacing its damaged structures.

Prosthetics Sustav - replacement of the resected joint with artificial endoprosthesis.

17.22. Test tasks

17.1. The surgeon exposes the armpit vascular-nerving bundle by incision along the anterior boundary of the axillary region. At the same time, the first anatomical formation with which he will meet is:

1. Middle artery.

2. More Vienna.

3. Shoulder plexus.

17.2. In the armpit, at the level of a curady-breast triangle, the trunks of the shoulder plexus relative to the axillary artery are located:

3. From above and front.

4. From above and rear.

5. From all sides.

17.3. In the armpit, at the level of the orphanage, the nerves of the shoulder plexus relative to the axillary artery are located:

1. Medial, lateral and front.

2. Medial, lateral and rear.

3. From above and front.

4. From above and rear.

5. From all sides.

17.4. At the phlegmon, the axillary depression purulent chapels in the rear fascial bed shoulder develops along the way:

1. The long head of the three-headed muscles shoulder.

2. Kryvoid-shoulder muscle.

3. Rauchery nerve.

17.5. In the shoulder area there are two fascial beds from those listed:

1. Rear.

2. Lateral.

3. Front.

17.6. In the front fascial bed shoulder, there are three muscles from those listed:

1. Twitting shoulder muscle.

2. Three-headed shoulder muscles.

3. Kryvoid-shoulder muscle.

4. Round Pronator.

5. Shoulder muscle.

17.7. The surgeon exposed the shoulder artery in the upper third of the shoulder with the goal

its dressing and solves the issue of dressing levels: before or after the removal of the deep artery of the shoulder. Determinate the preferred level from the position of the reduction of blood supply to the distal limb:

1. It is preferable to the removal of the deep artery of the shoulder.

2. Preferably a bandage after the removal of the deep artery of the shoulder.

3. Both levels of dressings are equally possible.

17.8. The patient with a fracture of the shoulder bone at the surgical neck level was formed an extensive hematoma in the field of fracture, most likely due to damage:

1. Artery that feeds the shoulder bone.

2. Deep artery shoulder.

3. Rear artery envelope with shoulder bone.

4. Shoulder artery.

17.9. During the formation of the bone corn after a closed bracket fracture in the middle third, the patient developed a difficult extension of the brush, I, II and III fingers, the brush and fingers are in a bent position, the sensitivity of the rear surface of the specified fingers and the corresponding brush rear section was broken, which was resulting Communication:

2. Rauchery nerve.

3. Muscular and skin nerve.

4. Middle nerve.

17.10. Verpeccation in the elbow jam may be accompanied by a sharp pain when some injected substances enter the surrounding tissues, which is due to:

1. irritation of skin receptors.

2. Irritation located near the skin nerves.

3. irritation of the podium nervous plexus.

4. irritation of the middle nerve.

17.11. In the patient, the silent rhenium in the lower third of the forearm of the forearm. During the examination, the absence of flexion I, II, III fingers, skin sensitivity disorders on the palm surface of the first three fingers and the corresponding part of the palm, which indicates damage to:

2. The surface branch of the radiot nerve.

3. Middle nerve.

17.12. Set the correspondence of the name of the connective tissue nerve shells to determine them:

1. Epishery external.

2. Epideus internal.

3. Perinoveuria.

4. Endoneurry.

A. Connectant for a nervous beam shell.

B. Connecting tissue in a nervous beam between nerve fibers.

B. Connecting tissue between nerve beams.

The connective tissue shell around the nervous barrel.

17.13. The inflammatory processes on the palm surface of the fingers and the brush are accompanied by a pronounced edema of the rear of the brush, which is due to:

1. The spread of edema on interfascial cellulum slots.

2. Prediable location on the rear of the surface veins.

3. Transition to the rear brushes of the main mass of lymphatic vessels.

17.14. One of the complications of acute purulent tendovaginite is necrosis of the finger flexor tendons, which is due to:

1. With the squeezing of the tendon in the GNOM, accumulating in the synovial vagina.

2. Purulent melting of tendon in the synovial vagina.

3. Squeezing the mesenter of the tendon in the gear accumulating in the synovial vagina.

17.15. In a patient with diabetes mellitus, the post-adjusting phlegmon of summits has spread in the form of a purulent chapek in the rear fascial bed of the thigh in the way:

1. Two thigh muscles.

2. Semi-peculiar muscle.

3. Semi-dry muscle.

4. Sedal nerve.

17.16. Vascular lacuna is limited:

1. Front.

2. Rear.

3. Outside.

4. From the inside.

A. Grebbed bond. B. Lacooner Bunch.

B. Pakhovoy Bunda.

G. iliac-comb-bias.

17.17. The inner ring of the femoral kana la is limited:

1. Front.

2. Rear.

3. lateral.

4. Medial.

A. Bear Vienna.

B. combed bond.

B. Lacooner bundle. G. Pakhovoy Bunda.

17.18. The contents of the femoral canal is:

1. Hip artery.

2. High Vienna.

3. Hip hernia.

4. Poor nerve.

17.19. From the blood vessels of the thigh for the operation of the Aorticoronary shunting as a free vascular transplant are used:

1. Hip artery.

2. High Vienna.

3. Large subcutaneous vein.

4. Deep hip artery.

5. Cleaning artery.

17.20. The following artery, veins and nerves are located in the ankle channel:

1. Front Tired Artery and Vienna.

2. Rear Trulybly Artery and Vienna.

3. Maloberstar artery and veins.

4. Target nerve.

5. Deep any-terror nerve.

6. Surface small-terror nerve.

17.21. A boy has entered the surgical department with a stupid trauma of the lateral surface of the tibia in the upper third of the hockey stick). There are no bone changes on the radiograph. Clinically: the lateral edge edge is omitted, the sensitivity of the skin of the lateral part of the stop of the foot, except for the I interpalic interval. Such a clinical picture corresponds to damage:

1. Target nerve.

2. Deep minor nerve.

3. Total small nerve.

4. Surface small-terrestrial nerve.

17.22. Sustain fixation operation in a given position is called:

1. Arthrodez.

2. Arthrollis.

3. Arthoplasty.

4. Arthrotomy.

5. Sustain resection.

17.23. The operation of restoration of mobility in the joint by exchanging fibrous battles between the joint surfaces is called:

1. Arthrodez.

2. Arthrollis.

3. Arthoplasty.

4. Arthrotomy.

5. Sustain resection.

17.24. The surveillance operation of the joint function by replacing the damaged or functionally unsuitable elements is called:

1. Arthrodez.

2. Arthrollis.

3. Arthoplasty.

4. Arthrotomy.

5. Sustain resection.

17.25. The aperipital method of treating bone in amputation of the limb is the dissection of the periosteum, shifting it distally and the cut of the bone:

1. On the edge of the dissected periosteum.

2. Immediately recovering the edge of the dissected periosteum.

3. Recovering the edge of the periosteum by 3-5 mm.

4. Recovering the edge of the periosteum by 5-10 mm.

Applications

Answers to test tasks

Chapter 6. Preparation for surgery and pain relief in surgical dentistry

6.1 - 1.

6.2 - 1.

6.3 - 4.

6.4 - 4.

6.5 - 4.

6.6 - 2.

6.7 - 4.

6.8 - 3.

6.9 - 3.

6.10 - 2.

6.11 - 1.

6.12 - 5.

6.13 - 5.

Chapter 8. Topographic Anatomy of the Head Brain Department

8.1 - 1, 5, 2, 4, 3, 6.

8.2 - 1b, 2V, 3A

8.3 - 5, 8, 7, 3, 4, 2, 9, 1, 6.

8.4 - 2.

8.5 - 3.

8.6 - 2.

8.7 - 2.

8.8 - 3.

8.9 - 3, 4.

8.10 - 2, 4, 5, 6.

8.11 - 1, 6, 4, 2, 5, 3, 7.

8.12 - 5.

8.13 - 1, 3, 4, 7.

8.14 - 2.

8.15 - 3.

8.16 - 5.

8.17 - 3.

8.18 - 2.

8.19 - 3.

8.20 - 2.

8.21 - 5, 6, 4, 2, 1, 3.

8.22 - 3, 5.

8.23 - 1.

8.24 - 5.

8.25 - 6, 1, 4, 2, 3, 5.

8.26 - 1, 5.

8.27 - 2, 3, 4.

8.28 - 1, 2, 3, 5, 6.

8.29 - 1, 5.

8.30 - 2, 4, 5.

8.31 - 1.

8.32 - 1B, 2a, 3B.

Chapter 9. Operational Head Brain Department Surgery

9.1 - 2.

9.2 - 2.

9.3 - 2.

9.4 - 2, 5.

9.5 - 1, 3.

9.6 - 3, 4, 5.

9.7 - 3.

9.8 - 3.

9.9 - 2.

9.10 - 4.

9.11 - 3.

9.12 - 2.

9.13 - 2.

9.14 - 3.

9.15 - 2.

9.16 - 5.

9.17 - 2.

9.18 - 1.

9.19 - 2.

9.20 - 3, 5.

Chapter 10. Topographic Anatomy of the Facial Head Department

10.1 - 1. 10.19 - 2. 10.37 - 2.

10.2 - 3. 10.20 - 2. 10.38 - 4.

10.3 - 4. 10.21 - 3. 10.39 - 1.

10.4 - 4. 10.22 - 2. 10.40 - 2.

10.5 - 2. 10.23 - 4. 10.41 - 4.

10.6 - 3. 10.24 - 3. 10.42 - 2, 3, 4.

10.7 - 5. 10.25 - 1, 2. 10.43 - 4.

10.8 - 3. 10.26 - 1. 10.44 - 2, 3, 4, 5.

10.9 - 3, 5. 10.27 - 3. 10.45 - 3.

10.10 - 1. 10.28 - 1, 2, 6. 10.46 - 1, 2, 3.

10.11 - 5. 10.29 - 1, 2, 3, 6. 10.47 - 1, 4, 5.

10.12 - 1b, 2a, 3B. 10.30 - 3. 10.48 - 1, 3, 4, 5.

10.13 - 4. 10.31 - 2. 10.49 - 1.

10.14 - 2, 6, 4, 3, 1, 5. 10.32 - 2. 10.50 - 2.

10.15 - 1. 10.33 - 3, 4, 5. 10.51 - 1.

10.16 - 3. 10.34 - 4. 10.52 - 2.

10.17 - 2. 10.35 - 2, 3. 10.53 - 1, 2, 3, 4.

10.18 - 4. 10.36 - 1, 2.

Chapter 11. Operational Surgery of the Facial Head Department

11.1 - 4. 11.21 - 3. 11.41 - 1. 11.61 - 4.

11.2 - 4. 11.22 - 4. 11.42 - 5. 11.62 - 1.

11.3 - 3. 11.23 - 3. 11.43 - 3. 11.63 - 5.

11.4 - 5. 11.24. - 5. 11.44 - 4. 11.64 - 3.

11.5 - 5. 11.25. - 3. 11.45 - 1. 11.65 - 2.

11.6 - 3. 11.26. - 4. 11.46 - 2. 11.66 - 5.

11.7 - 4. 11.27 - 5. 11.47 - 1. 11.67 - 4.

11.8 - 5. 11.28 - 5. 11.48 - 2. 11.68 - 1.

11.9 - 2. 11.29 - 3. 11.49 - 5. 11.69 - 3.

11.10 - 5. 11.30 - 5. 11.50. - 3. 11.70 - 5.

11.11 - 1. 11.31 - 2. 11.51. - 4. 11.71 - 2.

11.12 - 1. 11.32 - 2. 11.52. - 5. 11.72 - 2.

11.13 - 2. 11.33 - 3. 11.53 - 3. 11.73 - 4.

11.14 - 1. 11.34 - 4. 11.54 - 3. 11.74 - 5.

11.15 - 2. 11.35 - 3. 11.55 - 5. 11.75 - 1.

11.16 - 4. 11.36 - 3. 11.56 - 1. 11.76. - 5.

11.17 - 5. 11.37 - 5. 11.57 - 1. 11.77. - 3.

11.18 - 2. 11.38 - 2. 11.58 - 1. 11.78. - 2.

11.19 - 2. 11.39 - 3. 11.59 - 2.

11.20 - 3. 11.40 - 5. 11.60 - 1.

Chapter 12. Topographic Neck Anatomy

12.1 - 2, 4, 5. 12.24 - 3, 5.

12.2 - 1, 3. 12.25 - 1.

12.3 - 2. 12.26 - 3, 4.

12.4 - 1B, 2V, 3A. 12.27 - 2, 3, 7.

12.5 - 1B, 2a, 3b. 12.28 - 3.

12.6 - 1B, 2B, 3A. 12.29 - 3.

12.7 - 3, 5, 2, 1, 4. 12.30 - 4.

12.8 - 1, 2. 12.31 - 2, 3.

12.9 - 1, 2, 4, 6. 12.32 - 4.

12.10 - 1, 2, 3, 4, 5. 12.33 - 2.

12.11 - 1, 2, 5. 12.34 - 2.

12.12 - 1, 2, 3, 5. 12.35 - 2.

12.13 - 2. 12.36 - 3.

12.14 - 4. 12.37 - 1.

12.15 - 2. 12.38 - 3.

12.16 - 2. 12.39 - 1.

12.17 - 4. 12.40 - 2.

12.18 - 2. 12.41 - 2.

12.19 - 3. 12.42 - 1.

12.20 - 2. 12.43 - 4.

12.21 - 4. 12.44 - 2.

12.22 - 3. 12.45 - 3.

12.23 - 4.

Chapter 13. Operational Neck Surgery

13.1 - 2, 3. 13.12 - 2.

13.2 - 2, 4, 5. 13.13 - 5.

13.3 - 3. 13.14 - 3.

13.4 - 4. 13.15 - 4.

13.5 - 2. 13.16 - 3.

13.6 - 2, 4. 13.17 - 3.

13.7 - 1. 13.18 - 1B, 2G, 3A, 4B.

13.8 - 1, 5. 13.19 - 3.

13.9 - 3, 2, 4, 1, 6, 5. 13.20 - 3.

13.10 - 5, 1, 3, 2, 4, 6. 13.21 - 1, 3, 5.

13.11 - 2.

Chapter 14. Topographic Anatomy and Operational Breast Surgery

14.2 - 2. 14.28 - 1ABVDE, 2AW.

14.3 - 2. 14.29 - 3, 4, 1, 2.

14.4 - 2. 14.30 - 2.

14.5 - 2. 14.31 - 2.

14.6 - 1. 14.32 - 1B, 2A, 3G, 4B.

14.7 - 1. 14.33 - 1B, 2G, 3B, 4A.

14.8 - 3b. 14.34 - 2.

14.9 - 3. 14.35 - 4.

14.10 - 3. 14.36 - 3.

14.11 - 2. 14.37 - 3.

14.12 - 1. 14.38 - 2.

14.13 - 2. 14.39 - 3.

14.14 - 2. 14.40 - 4.

14.15 - 3. 14.41 - 4.

14.16 - 2. 14.42 - 3.

14.17 - 3. 14.43 - 2.

14.18 - 2. 14.44 - 6, 5, 1, 4, 3.2

14.19 -1V, 2D, 3G, 4A, 5B. 14.45 - 2.

14.20 - 2. 14.46 - 5.

14.21 - 2. 14.47 - 3.

14.22 - 3. 14.48 - 3.

14.23 - 1B, 2D, 3A, 4G, 5B. 14.49 - 1.

14.24 - 1, 2. 14.50 - 2.

14.25 - 4. 14.51 - 2.

14.26 - 3. 14.52 - 1, 2, 3, 7.

Chapter 15. Topographic Anatomy and Operational Belly Surgery

15.1 - 2 15.26 - 2

15.2 - 2, 4, 7, 1, 5, 6, 3 15.27 - 2, 4

15.3 - 3 15.28 - 2, 4, 3, 1

15.4 - 1, 3, 5 15.29 - 2

15.5 - 2 15.30 - 1, 4, 5

15.6 - 3 15.31 - 1, 3, 5, 7, 8

15.7 - 2 15.32 - 2, 4, 6

15.8 - 2 15.33 - 3

15.9 - 3 15.34 - 1

15.10 - 1 15.35 - 4

15.11 - 4 15.36 - 2, 4, 5

15.12 - 3 15.37 - 1

15.13 - 3 15.38 - 2

15.14 - 2, 4, 5, 6 15.39 - 2

15.15 - 1, 3, 7, 8, 9 15.40 - 2

15.16 - 1d, 2V, e, 3b, 4g, 5a, 6zh 15.41 - 3, 1, 2

15.17 - 1B, 2e, 3D, 4V, g, 5zh, 6a 15.42 - 1

15.18 - 1, 4, 5 15.43 - 3

15.19 - 1Z, 2A, E, 3B, B, G, 4D 15.44 - 2, 3, 5, 7

15.20 - 4 15.45 - 1, 4, 6

15.21 - 1 15.46 - 2

15.22 - 2 15.47 - 1

15.23 - 4 15.48 - 3

15.24 - 2, 3 15.49 - 1, 2

15.25 - 1

Chapter 16. Topographic Anatomy and Operational Surgery Tas

16.1 -

16.2 -

16.3 -

16.4 -

16.5 -

16.6 -

16.7 -

16.8 -

16.9 - 16.10

Chapter 17. Topographic Anatomy and Operational Limit Surgery

17.1 - 2.

Transcript.

1 1 The diagnostic anatomy of the median nerve of the middle nerve is formed by the fibers of the four roots of the spinal nerves participating in the formation of the shoulder plexus (from C6 to Th1), and occupies a median anatomical position throughout its course of the book along the upper limb, wherever it passes: along the intermushkin The partitions between the two-headed and three-headed muscles of the shoulder, in the opposite pit, or distally in the wrist area, the middle nerve is always in the middle. From a functional point of view, this nerve innervates the main muscles of the brush, including muscles responsible for flexing the wrist and the movement of the first three fingers. The compression of the median nerve in the wrist area leads to the development of a custody tunnel syndrome, which is the most frequent peripheral damage to the nerve found in clinical practice. Topographic anatomy of the median nerve topographic anatomy of the median nerve shoulder median nerve is formed by the lateral and medial beams of the shoulder plexus; The lateral beam contains predominantly sensitive fibers from the spinal nerves C6 and C7, and the medial bundle motor fibers from C8 and TH1. Therefore, for the motor function, mostly meets the medial beam. Bundles of the shoulder plexus get their names (medial, lateral and rear) on the basis of their location in relation to the axillary artery in the depth of the axillary pit under the small thoracic muscle. In accordance with this nomenclature, when considering the upper limb from the medial (internal) surface 13

2 Chapter 1. The diagnostic anatomy of the median nerve towards the axillary region the medial beam is media from the axillary artery, and the lateral beam is laterally from the artery. The terminal departments of the medial and lateral beams, connecting under an acute angle, form the middle nerve, forming a loop located on the front surface of the shoulder artery. Formed, further among the middle nerve follows in the distal direction accompanied by this artery in the shoulder area. In the shoulder area, the middle nerve is somewhat lateral and superficial shoulder artery. He lies the Kechada and passes in parallel with the intensured partition, which separates the three-headed muscle of the shoulder from the shoulder flexors (double-headed and shoulder muscles) (Fig. 1-1). If you look at the area of \u200b\u200bthe shoulder from the inside (for this, your hand needs to be left and turning the duck), it will be seen that the nerve occupies the middle position, following the direction towards the front elbow yam. Approximately half of his turn in the shoulder area, the middle nerve crosses the shoulder artery of the Kepened 14 rice medial nerve in the rather part of the shoulder. The middle nerve is a slightly duck and a superficial shoulder artery and passes down the shoulder. Around the middle of the shoulder, the middle nerve crosses the top of the shoulder artery and then it follows the medial, passing under the aponeurosis of the biceps

3 from it and then is medially in relation to her, following the place where it takes place under the aponeurosis of the Lacertus Fibrosis shoulder two-headed muscles) in the proximal area of \u200b\u200bthe forearm. In the area of \u200b\u200bthe shoulder, the median nerve does not inner any muscles and, in general, does not give any branches. In the shoulder area there are several anatomical options for the course of the middle nerve. First, the medial and lateral bundles can be merged not in the axillary region, but at different points along the forearm, sometimes reaching the area of \u200b\u200bthe elbow joint. Secondly, these bundles can form a loop under the axillary / shoulder artery (in contrast to the more common embodiment of their fusion on the front surface of the artery), forming, among the middle nerve. Finally, in some individuals, the lateral portion of the middle nerve from the lateral beam is very small due to the fact that most of the fibers of the cylinder nerves C6 and C7 are involved in the formation of a muscular nerve instead of the middle nerve and returns to the middle nerve through the connecting branches in about the middle of the shoulder. Such innervation options are not an unusual phenomenon; It looks like the fact that the fibers turned not in the other direction during their development, then "asked" the direction and corrected its route. The front elbow yam / elbow area in the elbow area of \u200b\u200bthe anatomy of the median nerve becomes more complex. The nerve is included in the region of the front of the pump medially from the shoulder biceps, passing along the shoulder muscle, which separates the nerve from the distal end of the shoulder bone. In the frontal fossa, the middle nerve (one after another) passes three vessels or tunnels that guide the nerve of the forearm to appear on the surface of the distal scope of the forearm before reaching the brush (Fig. 1-2). The first alternation under which the nerve passes is the aponeurosis of the leak muscle (fibrous fascia lacertus fibrosis) thick fascia, binding the shoulder biceps with the proximal part of the forearm flexors. It should be noted that the middle nerve can be placed before it is immersed under this aponeurosis, at a distance of two transverse fingers above and two fingers laterally media supermarket. Under this aponeurosis, the tendon of the two-headed shoulder muscles and shoulder artery are located laterally, while the brass head of the round pronator median nerve (Fig. 1-3). Topographic anatomy of the median nerve 15

4 Chapter 1. Diagnostic anatomy of the middle nerve rice is the middle nerve in the forearm. In front of the middle, the middle nerve passes under three consistently located arches or tunnels (biceps aponeurosis, a round pronator, a surface flexor of the fingers), guides its deployment directly to the level of the distal forearm near the brush 16 passing the short distance from the proximal edge of the shoulder biceps, the middle nerve is immersed Under the second arch shoulder head of the circular pronator. Round Pronator is a Y-shaped muscle having a narrow long base and two distal heads and lateral heads. If you look at the front of the front of the front yam in front, when the forearm is in a dispere and supinated position, then the round Pronator is turned in such a way that its upper part (head) occupies a proximal and medial position, located above other forearm muscles. This top of the muscle includes two heads of a large surface, which is attached to the shoulder bone (shoulder head), and a deeper, smaller, which is attached to

5 rice transverse section of the median nerve in the front of the pump. The biceps aponeurosis is superficially, shoulder deeper, lancerly there are a biceps tendon and shoulder artery, the medial shoulder head of the circular pronator more distally to the elbow dice (elbow head). The middle nerve penetrates right between the two heads of the circular pronator, while the radiation head turns out behind the nerve, and the shoulder head over it. Further, as soon as the round Pronator remains behind, the middle nerve almost immediately penetrates the third tunnel, formed by two heads of the surface flexor fingers. The shoulder head of this muscle is medial, its radiation head laterally. The surface flexor of the fingers, in essence, forms the second "y", through which the middle nerve passes again. However, unlike the round Pronator, if you look at the suspensed forearm, the "Y" of the surface flexor fingers does not turn after the forearm. A fibrous crest is formed between the two heads of this muscle, which penetrates the middle nerve. Topographic anatomy of the median nerve. The buildings of this area predominantly relate to the muscles and tendons. Either a round pronator, or a surface flexor of the fingers can have only one head instead of two, and their proximal department as a result may be different. Such versions of the muscle structure create anatomical prerequisites for the compression of the median nerve in the opposite pit. The forearm of the middle nerve should be further down the middle line of the forearm under the surface flexor of the fingers, but above the lying 17

6 Chapter 1. Diagnostic anatomy of the middle nerve 18 deeper with a deep finger bent. More precisely, the middle nerve goes towards the lateral edge of the deep flexor of the fingers, not far from the long thumbnail flayser, located laterally from the nerve. Approximately the third or half of the path in the area of \u200b\u200bthe forearm, the middle nerve gives an important branch of the front intercellate nerve, which is separated from its dorsolateral surface. From the place of his extinction, the front interkostal nerve is sent deeper by the forearm, penetrating between the radial and elbow bones, it lies on the inter-emergency membrane, between and behind the muscular peasants of the deep finger flexor and the long thumb. This branch ends in the distal list of forearm, reaching a square pronator. Not far from the place of his extinction, the front inter-emergency nerve passes under one or more fibrous ridges formed by a round pronator or a surface flexor of the fingers. Actually, the middle nerve should be further down the hand and again takes the surface position, approximately 5 cm is proximal than custodial fold, immediately the most medal than the tendon of the radiant brush flayer. This tendon will be most noticeable of all tensioning in the proximal wrist (immediately laterally average line), if bending the brush in the rays-up joint, overcoming resistance. The tendon of the long palm muscle, with its presence, is medial from the middle nerve in the proximal wrist department. Located superficially, before the entrance to the brush region, the middle nerve gives the sensitive branch of the palm skin branch, which goes in the treasury area surface and branches over the proximal part of the radial half of the palm, especially in the field of the Tenar. Sometimes this sensitive branch passes through its own channel in the transverse casal bundle. The shoulder artery takes place under the aponeurosis of the two-headed muscles of the shoulder, where it is divided into radiation and elbow artery. The radiation artery should be distally, near the surface sensitive radiation nerve. The elbow artery, on the contrary, penetrates deep into the mass of the muscles of the pronator flexors, where it passes under the middle nerve. In the distal area of \u200b\u200bthe forearm, the elbow artery is adjacent to the elbow nerve, together they follow towards the wrist. Before passing under the middle nerve in the frontal fossa, the elbow artery gives a connecting intercotic artery, which is soon divided into the front and rear interceptional arteries. Front inter-site artery should be distally with

7 Dimin intercepted nerve, passing between and behind the long thumb and deep thumbnail flexor. The wrist / brush is the middle nerve runs along the middle line in the area of \u200b\u200bthe brush in the cutting channel. Chatting canal it is customary to compare with an inverted upside table. The "table" cover is formed by the wrist bones, the "table" feet are the hook hook and pea bone from the medial side, and the hooks of a large trapezoidal and laden bone with a lateral side. Through these legs stretched a thick transverse cupta bunch, similar to the carpet on the imaginary floor. From the palm surface, the middle nerve is the most superficial of nine formations passing through the cranky channel. Other structures passing here include a tendon of a long thumbnail flexor, four surface flexor tendons and four deep-flexor tendons (Fig. 1-4). The tendon of the long palm muscle is not included in the cutting canal, and goes into superficially located palm aponeurosis. The radial bending brush also does not pass through the cranky channel, and it follows in his own small channel, located the lateral of the cranky canal, attaching to the second metal bone. Topographic anatomy of the middle nerve rice transverse section of the median nerve in the deckal channel. View from the palm surface, the middle nerve of the most superficially located structure from the presented nine. The rest located near the formation of the tendon of the long thumbnail flayer, four tendons surface flexors and four tendons of deep bends 19

8 Chapter 1. The diagnostic anatomy of the median nerve after passing the cuptum channel is the middle nerve gives a branch from its radial side the motor branch of the rise of the thumb (return motor branch of the Tenar). Next, in the depths of the palm, the middle nerve is divided into two trunks of radiation and elbow. The radiation part is divided into the total finger finger's finger nerve and its own finger nerve ray half of the second finger. The total finger's finger's finger is sequentially divided into two-finger's finger finger. The elbow part of the middle nerve is divided into common finger nerves of the second and third interfallated gaps, which, in turn, are separated on their own finger nerves. The elbow and radiation trunks of the median nerve are followed behind (or dorsally) surface palm arc, but the superficial tendons of flexors. Numerous deposition and location options relate to the motor branch of the rise of the thumb. For example, this branch can be formed inside a cpalar channel, it can arise a cross-ligament of the wrist, reaching the shortest path of the muscles of the Tenar, and even to move from the elbow side of the middle nerve, after that passing over or under it, heading towards the muscles of the Tenar. Other embodiments of the median nerve include: 1) the high separation of it on the radium and elbow trunks of the proximal cassette channel (which often occurs in the presence of a "constant median artery"), and 2) the connection between the tensor's motor branch and the deep palm branch of the elbow nerve (discussed below ). Motor innervation and its study 20 median nerve does not inger the muscles of the top of the shoulder. However, in the area of \u200b\u200bthe forearm and brush, this nerve innerves numerous muscles providing the predication of the forearm, flexing the wrist, flexing the fingers (especially the first three) and opposition and the first finger disharden (Fig. 1-5). To facilitate memorization, these muscles can be divided into the following four groups: muscles of the proximal region of the forearm; muscles innervated by the front inter-emergency nerve; Tenar muscles and ultimate muscle group.

9 Muscles of the proximal area of \u200b\u200bthe forearm This group includes four muscles: a round pronator, a radial brush bending, a surface flexor fingers and a long palm muscle. Round Pronator (C6, C7) is the main forearm forearm and the first muscle, motor innervation and its study rice motor innervation of the median nerve. Medicinal nerve does not innequate any of the muscles of the top of the shoulder. Provides sound innerware of numerous muscles of forearm and brushes, carrying out the forearm, bending brushes, fingers (in particular, the first three), contrasting and discharge of thumb 21

10 Chapter 1. Diagnostic anatomy of the middle nerve is innervated by the middle nerve. The branches of this muscle are departed from the middle nerve at the bottom of the shoulder, until the nerve passes between the two heads of the circular pronator. Given the peculiarities of attaching the muscles, providing its function, in order to see the effect of the muscle, the forearm must be in the dispere position. Therefore, when studying the muscle of the patient's forearm, firstly, it is inflicted and then entered as much as possible. Next, the patient is asked to prevent the supination produced by the researcher (Fig. 1-6). The radius brush flayer (C6, C7) is one of the two masterpieces of the wrist. The second muscle is the ulnash brush flexor, which is innervated by the elbow nerve. The radial bending brush performs an important function, with a violation of which the brush bending is significantly limited, except for bending at the elbow direction. To explore the radial brush flayer, the patient must bend the wrist towards the forearm (Fig. 1-7). With the pronounced weakness of this muscle, it is necessary to estimate the bending of the wrist at the forearm located on the table surface, the elbow edge of the reversed book; This position of the patient's hand helps to eliminate the effect of gravity. The tendon of the radiation flayer of the brush can be seen and put on the proximal wrist. Long palm muscle (C7, C8) goes into palm aponeurosis and shrinks the skin of the palm. This muscle cannot be explored for it. We are 22 rice research of the round Pronator (C6, C7): the forearm of the examined is dispersed and fully permeated. The survey must resist the suspension of the forearm conducted by a doctor

11 Rice Study of the radios brush benthatel (C6, C7): The surveyed bends the brush located on the same line and the examination with the pronounced weakness, the examined brush with the estark, located the ulnar surface on the table, which allows to eliminate the effect of gravity. The tendon of the muscles can be seen and put on the proximal wrist of the wedding force; In fact, it is missing about 15% of the population. The surface flexor of the fingers (C8, TH1) is also innervated by the middle nerve, and ensures the bending of the fingers from the second to the fifth (everything, with the exception of the first) in the proximal interphalating joints. To estimate the bending in the proximal interphalangeal joint, each finger is examined separately. At the same time, the investigator places his fingers between the patient's tested and the rest of his fingers, thereby ensuring their immobility (Fig. 1-8). Thus, it seeks that the test finger is somewhat bent in the Metal-Falangie joint, at the same time the remaining fingers are fixed in the dispere position. This position allows you to isolate the surface flexor fingers. To determine the location of individual muscles in the entire mass of the flexors, it is necessary to place the brush of one hand at the forearm of the other, aligning the protruding part of the Tenar with the medial superiority, the ring finger put along the medial boundary of the forearm, while the remaining fingers will naturally fall on the forearm in the direction of the other brush. In this position, the thumb will turn out to be over a round pronator, indexing over the radiant brush bent, the middle finger will indicate the location of the long palm muscle, and the unnamed elbow brush bentor innervated by the elbow nerve. Motor innervation and its study 23

12 Chapter 1. Diagnostic anatomy of the median nerve Rice Research of a long finger bent (C8, TH1): For the study of bending in proximal phalangeing joints, the brush and forearms are in a dispere and supinated position. The study of each finger is carried out separately. The doctor's finger is placed in front of the finger of the examined, while the remaining fingers are fixed. When conducting a study, the finger should be in the position of light bending in the Metal-Falangie joint, the remaining fingers in the position of extension. This position makes it possible to eliminate the effect of the surface flexor of the fingers in patients with the weakness of the circular pronator (as well as the square pronator, see below) with a combined allocation and internal rotation of the hand, the pronation can be carried out due to gravity. Moreover, in the study of the Pronation, the fingers and the patient's brush should be relaxed to eliminate participation in the movement of the radios of the brush and long finger bent. When the finger bends are investigated, the wrist should be in the middle position, and it is impossible to allow extension in the wrist, since in this case the phenomenon of tendhen may occur (movement in the distal joint due to the tension of the tendon when the position of the more proximal joint) in which passive occurs Fingering fingers. The muscle group innervated by the front intercepted nerve 24 front intercelter nerve innervates three deeply located muscles of the forearm of the forearm: a deep finger bent (second and third fingers), a long thumbnail flayer and a square pronator. Deep flexor

13 fingers (C8, TH1), overall, innervated by two nerves: front intercellate nerve (the branch of the middle nerve) and the elbow nerve. The front intercellate nerve controls the bending in the distal interphalating joint of the second and, partly, third fingers; The elbow nerve innerves the flexible muscles of the third (partially), fourth and fifth fingers. The degree of participation of the front intercourse and elbow nerves in ensuring flexion in the distal interphalating joint of the third finger will separately vary. Additionally, even with complete denervation of one of these nerves, a certain movement of the middle finger is maintained, since both parts of a deep finger bent innervated by various nerves act through a common tendon attached in the area of \u200b\u200bthis finger. Therefore, in order to isolated the innervation of a deep thumbnail flexor only to the front inter-emergency nerve, an index finger should be explored. To do this, it is necessary to fix the psyche-phalange and proximal interfalangive joints and ask the patient to bend a finger in the distal phalange, overcoming the resistance provided by you (Fig. 1-9). The long thumbnail flayer (C8, TH1) performs a function similar to a deep bent, only in relation to the first finger; It ensures the bending of the distal phalanx of the thumb in the interphalating joint. To estimate the function of the long thumbnail flexor, it is necessary to fix the finger, excluding interfa-motor innervation and its study rice study of a deep finger flexor (C7, C8): To estimate the function of the median innervation of the deep flexor fingers, it is necessary to investigate the index finger. To do this, it is necessary to immobilize the metallic-phalange and proximal interphalating joints, while the examined should bend a finger in the distal phalanx against the resistance provided to it 25

14 Chapter 1. Diagnostic anatomy of the median nerve Rice study of a long thumb refiner (C8, TH1): the thumb should be immobilized, with the exception of the interphalating joint, then the examiner must bend a finger in the distal phalange joint, overcoming the Langing joint impedance, and ask the patient Flexing distal phalanx, overcoming resistance (Fig. 1-10). An easy way to check the innervation of the front inter-emergency nerve of both muscles of a deep thumb and long thumb twin is asked to show the patient to show the sign "O K", while creating the tips of the big and index fingers together. With the weakness of these muscles, distal phalanxes cannot bend, and instead of contacting the fingertips, the palm surfaces are closed with the palm surfaces of each of the phalange (Fig. 1-11). The third muscle innervating front inter-26 rice is detected by the weakness of the anterior intermetain muscle when performing the sign "O K" (folding the fingers of the ring). A quick way to distinguish the lesion of a deep thumb and a long thumb twin from the lesion of the front intercellate nerve to ask the examined to show the sign "o k" to reduce the tips of the big and index fingers. In the case of weakness of these muscles, bending in distal phalanges is impossible, instead of contacting the tips of the fingers, the patient closes the ring with distal phalanxes

The 15 bone nerve is a square pronator (C7, C8). This is a significantly weaker forearm pronator compared to a round pronator. In fact, the weakness of this muscle is usually not noticeable in the normal functioning of the circular pronator. However, with full bending of the forearm, when the possibility of manifestation of the function of the circular pronator is eliminated, when compared with a healthy hand, the weakness of the square pronator can be revealed. For the study of the square pronator, it is necessary that the patient resisted the supinal of a completely bent and entered forearm (Fig. 1-12). Motor innervation and its study Rice Study of the Square Pronator (C7, C8): The survey should make a nation in the forearm, overcoming the resistance provided to him. At the same time, the forearm is in the position of maximum flexion and pronation. Such a position eliminates the effect of round pronator 27

16 Chapter 1. Diagnostic anatomy of the median nerve 28 Investigating the functions of a deep thumb or long thumb refiner, do not allow the patient to blend fingers in distal interfalage joints before their bending, as this can lead to passive involuntary bending that imitating active flexion in the joints. The muscle group of the rise of the thumb (Tenar) The muscle group of the Tenar consists of three muscles, innervated by the motor branch of the Tenar, departing from the middle nerve. The first short muscle discharges the thumb (C8, TH1), which, as can be seen from the name, assigns the first finger of the brush. A thumb response can be carried out in two directions: palm lead in the palm plane (mediated by the short muscle, reducing the thumb) and radiation lead from the forearm line (mediated by the long muscle, reducing the thumb). Therefore, even with the full paralysis of the short muscle, reducing the thumb, the ray fingerhead is preserved. To explore the function of the short muscle, reducing the thumb, have resistance to the definition by the patient of the thumb from the palm plane (palm assignment), while eliminating any movement in the remaining fingers (Fig. 1-13). The short first finger bent (C8, TH1) is innervated by two nerves of the median (surface branch) and elbow (deep branch). This muscle flexs the thumb in the Mispan Falangie Susta. For the study of a short thumb twin, the first finger in the interfalance joint of the first finger is provided and asked the patient to bend a finger in the Metal-Falangie joint (Fig. 1-14). Conducting a sample, it is necessary to exclude the movement in the distal interphalating joint, otherwise flexion in the Metal-Falangie joint will occur due to the long thumbnail flexor. Also, with the help of the second hand of the surveyed, it is necessary to eliminate the movements of the first metatar bone to reduce the effect of the muscle, which is opposing the thumb. Due to the participation in the innervation of the muscles of two nerves, a certain possibility of flexing the first finger remains even with the full paralysis of the tensor's motor branch. However, nevertheless, when compared with a healthy hand, a small weakness of bending will be noticeable. To estimate the function of the muscle, which is opposing the thumb (C8, TH1), the patient is necessary with the power to hold the contact between the pads

17 Rice Study of the short muscle, reducing the thumb (C8, TH1): The surveyed, counteracting the resulting resistance, removes the thumb from the plane of the brush (creep), while the remaining fingers are fixed in the field of the Motor Bones Motor Innervation and its study Rice Study of the short bent First finger (C8, TH1): The surveyed should be blown up the thumb in the Metal-Falangie joint, counteracting the rendered resistance to the proximal and distal phalanx. It is necessary to exclude bending in the distal interphalating joint to avoid participation in the movement of long thumbs. Another researcher's hand immobilizes the first custodial bone to eliminate the possible impact of the muscle opposing the thumb. Due to double innervation, even with full damage to the motor branches of the Tenar, it is possible for some of the thumb 29

18 Chapter 1. Diagnostic anatomy of the median nerve Rice is a muscle study that is opposing the thumb (C8, TH1): The surveyed must be forced to wash the large and fifth fingers, while the researcher must delay the first fetal bone in the distal direction. Although the contrastration of thumbs is provided only by the middle nerve, the combined pulling of a thumb (muscle, leading a thumb, an elbow nerve) and its bending (short flexor, deep head, elbow nerve) can simulate opposition even with full damage to the middle nerve of the distal first and fifth nerve Fingers, while the investigator tries to break this compound, pulling away the first finger from the fifth, holding the distal department of the first metatar bone (Fig. 1-15). Although the oppression of thumbs is controlled only by the median nerve, the combined movement of the thumb reduction (muscle, leading the thumb, the elbow nerve) and its flexion (short muscle, flexing the first finger, deep head, elbow nerve) can imitate opposition even if there is a full paralysis of the median nerve. 30 Study of the motor function of the thumb is not always indicative. The key point is to compare the results with a healthy hand, while it should be borne in mind that even with the full loss of the function of the median nerve, some possibility of the thumb movement will be maintained either due to the actions of the muscles innervated by radiation or elbow nerves, or due to the functioning of the neighboring muscles .

19 Complete Muscles Group The final muscle group includes the first and second drawing muscles (C8, TH1), which are innervated by the final radiation and elbow sprigs of the median nerve, respectively. To study the first drawing muscle, it is necessary to fix the index finger in the position of the reinforcement in the millpoplating joint and then to oppose the patient, an extensive finger in the proximal interphalating joint (Fig. 1-16). The location and attachment of the heart-shaped muscles are pretty variable. In fact, one or more of these muscles may be absent. Such a variability and / or lack of drawing muscles are functionally permissible, since in flexion in the plug--phalangeal joints, as well as in extension in proximal interphalating joints in the re-installing of bulk-phalangeless joints (both movements are provided with the cut-shaped muscles) and palm and rear participation. Inter-care muscles. Therefore, in the study of the forces of the heart-shaped muscles, the function of inter-emergency muscles is also taken into account. Motor innervation and its study Rice Study of the black-shaped muscles of the second finger (C8, TH1): The index finger is fixed in the position of hyperextension in the Metal-Falangie joint and then the survey must be blown in the last phalange joint, counteracting the resistance rendered 31

20 Sensitive Innervation Chapter 1. The diagnostic anatomy of the median nerve Although the middle nerve is sensitivity from a relatively small area of \u200b\u200bthe upper limb, perhaps this zone of sensitive innervation is one of the most significant. Through the three branches of the palm nerve and radiation and elbow sprigs of the median nerve (through the finger nerves), the middle nerve performs sensitive pulses from two thirds of the radiy surface of the palm and from the palm surface of the first, second, third and radial half of the fourth fingers (Fig. 1-17) . The middle nerve also provides sensitivity on the back surface of the fingertips, including the rear surface of the elbow half of the distal phalanx of the first finger, the back surface of the distal phalanx of the second, third and radial half of the fourth fingers. The palm skin branch innervates the largest field innervation of the median nerve, while the sensitive innervation of the fingers is carried out by small nerves of radial and elbow sprigs of the median nerve. 32 rice Sensitive innervation of the median nerve. Malnal nerve conducts sensitive information from two-thirds of the palm from the radiation side and from the palm surface of the first, second, third and radial half of the fourth fingers

21 Therefore, it is advisable to investigate the field of the Tenar to estimate the function of the palm skin branch, and the distal departments of the second and third fingers to evaluate the function of sensitive fibers passing through the cutting channel. In addition to the fibers of surface skin sensitivity, the median nerve contains the fibers of proprioceptive sensitivity, which comes from the joints, in particular, from the elbow and ray-taking joint, as well as from the muscles. Although many consider the front intercellate nerve of a purely motor nerve that does not take part in the skin innervation, in reality, this nerve contains sensitive fibers conductive pulses from the ray-taking joint and muscles. The boundary of the zone of sensitive innervation of the median nerve from the elbow side of the brush can vary, which depends on the relationship between this nerve with the adjacent elbow nerve or from the predominance in the sensitive innervation of one or another nerve. For example, the elbow or median nerve can provide sensitivity on the entire fourth finger palm surface. In addition, there can also be different aspect ratio on the palm surface innervated by the palm skin branch and radiation and the elbow branches of the median nerve. Anastomoza Martin Rruzer and Rice Canya in the field of forearm can exist anastomoses between the elbow nerve and the median nerve, or its front inter-branch. Perhaps a huge variety of options for such anastomoses, but several most common is essential clinical significance. Anastomosis Martin Rruzer is found in 15% of patients and includes muscles of the rise of the thumb, innervated by the middle nerve (muscle, opposing the first finger; short muscle, reducing the first finger; short finger bent). This anastomosis is formed as follows: the nerve fibers, the innervating muscles of the rise of the thumb, are not as usual as usual, the book from the middle nerve through the motor branch of the Tenar, and from the front interception branch, passing through the deep flexor of the fingers to the elbow nerve, and then enter the palm area Through a deep elbow branch. In the depths of the palm, these fibers are returned back to the motor branch of the Tenar, where the corresponding muscles innervate. This is a distal connection to sensitive innervation 33

22 Chapter 1. The diagnostic anatomy of the median nerve between the deep elbow branch and the motor branch of the Tenar in the field of the palm is referred to as anastomaosis of Rice Canya and anatomically (not functionally) is detected at least in 50% of cases. That is why, in the existence of this anastomosis, when motor axons, ensuring the innervation of the tensar muscles, pass through the elbow nerve, at low damage to the median nerve in the wrist area or forearm, the motor function of the tenar remains saved. As a result, damage to the elbow nerve in the wrist area in such cases leads to a much more serious functional shortage of the brush than it could be expected. With a different embodiment, their own muscles of the brush are involved in the anastomosis of Martin Harter, usually innervating inner-core branch, including the heart-shaped muscles, the first rear interception muscle, the muscle, a latter finger, and a deep (elbow) part of the short muscle flexing the thumb. In this embodiment, motor fibers innervating the indicated muscles are lowered in the composition of the middle nerve and then return to the elbow nerve in the middle of the forearm through the connecting branches from the front intercellate nerve, proof of the deep finger bent or turning it. Another option occurs when the Tenar's motor branch innervates the third black-shaped or even all the black-like muscles, through the anastomosis of Riche Canya. Clinical signs of nerve lesions and shoulder syndromes 34 full paralysis Damage to the median nerve in the shoulder area usually arises due to injury: with ripped wounds, gunshot wounds or stupid injury. Due to the proximity of the middle nerve to the shoulder artery, concomitant damage to this vessel may occur. Moreover, in the proximal area of \u200b\u200bthe shoulder, both nerves of the elbow and radiation are close to the middle nerve, so all three of these nerves may be damaged at the same time (triple neuropathy). The paralysis of the middle nerve may occur in the following situations: when hanging

23 Hands with the back of the chair (inxicated) so-called, paralysis of Saturday night; Or with the paralysis of the newlyweds, when on the shoulder of one sleeping person for a long time is the head of another. Damage to the median nerve may occur when it squeezes it in the axillary region of the crutch head, although this mechanism of injury is classic for lesion of radiation nerve. The complete defeat of the median nerve leads to disablement. At the same time, the forearm cannot be perpetrated against the strength of gravity or the resistance rendered. The brush can only be tightly bended in the elbow direction in the ray-tank joint. The thumb can not be opposed or removed in the palm plane. The weakness of the drawing muscles in the index and middle fingers is revealed. There is a numbness of the palm surface of the first three and half of the fourth fingers, as well as the radial two-thirds of the palm. In addition, if you ask a patient with a full paralysis of the median nerve to squeeze your hand in the fist, then the first finger will barely bend, the second will be seized in part (partial bending will be possible due to muscles innervated by other nerves), the third finger will bend, but weakly, Time as the fourth and the fifth fingers will be reached normally, which is called the Symptom of Benedict (speaker brush) (Fig. 1-18). This symptom of the paralysis of the middle nerve received its name due to the similarity with the position of the fingers of the brush during a blessing and is presented on many images of Jesus. When studying a patient with full paralysis of the median nerve, it is necessary to remember the following possible diagnostic errors. The shoulder muscle (innervated radial nerve) may be due to the action of gravity, clinical signs of nerve lesion and syndromes Rice by Sipmt Benedict. If you ask a patient with a full paralysis of the median nerve to squeeze your hand in a fist, then the first finger will barely bend, the second will be seized in part (partial bending will be possible due to muscles innervated by other nerves), the third finger will bend, but weakly, while the fourth And the fifth fingers will be bent normally symptom of Benedict 35

24 Chapter 1. The diagnostic anatomy of the median nerve 36 turn the forearm of Knutrice from the position of complete supination. You can also incorrectly appreciate the opposition of a thumb, which may be performed due to the indirect effect of the short thumb (its deep head) and the muscles leading the thumb (both are innervated by the elbow nerve). And the last, the palm alignment of the thumb can be mimicated by the action of a short thumb twin (deep head), or a true radial lead can be carried out due to the action of a long muscle, reducing the thumb (innervated by a radial nerve). Supported spur / bunch of the Structure of about 1% of people have a supermarket spur on the medial side of the shoulder bone at a distance of about 5 cm proximal than the medial screwdriver. It is believed that in most cases the existence of such an additional screwdriver in between it and the medial nickname, a bunch of a stick is stretched, called so in honor of the anatom describing the supermarket spur. In the presence of a bundle, the middle nerve usually passes under it either with the shoulder artery or with its elbow branch. This anatomically limited space may be the reason for the compression here of the middle nerve in some patients (Fig. 1-19). Clinically, such a compression of the median nerve manifests itself unnoticed by the weakness of the muscles of the forearm and the brush, with the occurrence of various options for the distribution of sensitive disorders in the zone of sensitive nerve innervation. It is characteristic of the presence of deep-labeled pain in the proximal area of \u200b\u200bthe forearm, which is sometimes enhanced with repeated movements of the pronation / supination or when evaluating the function of the round Pronator or a radios of the brush. In the study, the muscular weakness or even hypotrophy muscles innervated by the median nerve can be detected. Sometimes a branch, innervating round pronator, departs from the middle nerve until it penetrates the ligament, as a result of which the function of this muscle remains preserved. It is also necessary to investigate the flexors of the proximal department of the forearm, especially the muscles innervated by the front inter-care nerve (to ask the patient to show the sign "o k"), whose function can often be disrupted with such a compression of the median nerve. In the distal department of the medial surface of the shoulder, a symptom of tinel may occur. Of course, the diagnosis requires palpator

25 Rice Bunch of Structure. Approximately 1% of people on the medial side of the shoulder bone at a distance of 5 cm proximal than the medial screwdriver there is a supermarket spur. With the existence of such an additional screwdriver, in most cases, a bunch of a clinical signs of nerve lesion and syndromic examination or radiation diagnosis confirming the presence of supermarket spurs take place between it. Supported fractures The supermarket fractures usually occur in children and can lead to damage to the median nerve, which is especially characteristic of fracture stamps. Late paralysis of the median nerve may occur due to the formation of bone corn. As already mentioned in squeezing the middle nerve of the ligament of the string, the fibers included in the anterior intercellate nerve often suffer from supermarket damage. This happens for two reasons. First, a relatively fixed front intercellate nerve under- 37

26 Chapter 1. The diagnostic anatomy of the median nerve 38 is tagged with the mixing of the bone fragment of the stop. Secondly, nerve fibers for the front intercept nerve, together with sensitive fibers for the first two fingers of the brush, are located in the rear sections of the median nerve, and are most damaged by passing through the supermarket area. If the patient has an isolated impaired of the front intercept nerve function due to partial damage to the middle nerve in the supermarket area (but not the most front intercelter branch), then this is indicated as a false neuropathy of the front intercellate nerve. Such more proximal damage also causes numbness in the field of large and index fingers, which helps in the differential diagnosis of this damage from the true neuropathy of the anterior intercept nerve. The forearm of the muscular-tendon neuropathy of the median nerve of the aponeurosis of the two-headed muscles of the shoulder, which is stretched from the lateral to the medial edge over the front-factor fossa, and by which the tendon of the double muscle is attached to the elbow bone, can cause irritation of the median nerve. The pathogenesis is finally uncalled, but thickened aponeurosis, hypertrophied shoulder muscle (which lies under the middle nerve and, theoretically, can push it to the aponeurosis) or an unusual attachment of the round Pronator (which changes the normal anatomical ratios in this area) All these factors may be predispose to such a type of compression. At the same time, clinical manifestations are similar to those that occur during the squeezing of the middle nerve of the ligament. Patients often complain of pain in the elbow area, irradiating in both proximal and distal directions. Sometimes a voltage when flexing the forearm located in the suspension position for 30 C may cause amplification of symptoms. It should be noted that such compression is extremely rare. The middle nerve can be composed or stirred at the place of its passage between the two heads of the circular pronator (Fig. 1-20). Such damage to the median nerve is most often arising in people who produce a repeated pronation in the forearm committed with effort; And the name of the circular pronator syndrome is called. Round Pronator itself is the only muscle whose function may not suffer

27 At the same time, the syndrome, since the branches of the median nerve, innervating it, move proximal to the location of the middle nerve under the indicated muscle. The Round Pronator syndrome is characterized by a gradual beginning with a stupid-having pain in the proximal branch of the forearm, amplifying during repeated or produced with an effort of the forearm of the forearm. In fact, the most common sign of the syndrome is the voltage of the round pronator detected during palpation. The sensitivity in the area of \u200b\u200bthe brush in the innervation zone of the median nerve often does not suffer, and the violation of the motor function is difficult to establish because of pain. Nevertheless, weakness is sometimes noticeable when flexing the second and third fingers. Often, the symptom of tinell is often detected in the front-mek. In contrast to the cake tunnel syndrome, patients usually do not complaints about night pain and / or numbness. The true prevalence of this syndrome is unknown, some authors propose to allocate those cases of this disease that accompanied the clinical signs of nerve lesion and syndromes rice Round Pronator syndrome and the first arc syndrome. The middle nerve can be compressed or disadvantaged when it passes between two heads of the circular pronator. Also, the compression of the middle nerve can cause a fibrous arc in the place where it passes under the two heads of the surface flexor of the fingers 39

28 Chapter 1. The diagnostic anatomy of the median nerve 40 is given by objective features and those that are not accompanied by. The fibrous arc between the two heads of the surface flexor fingers can also cause damage to the median nerve (Fig. 1-20). This fibrous arc, called the most first arc, can cause the compression of the middle nerve at its passage under the heads of the specified muscle. The clinical manifestations of such a compression are quite similar to the manifestations of the circular pronator syndrome, except that the forced bending of the second fifth fingers in the proximal interphalating joints, which is carried out due to the action of the surface flexor of the fingers, can enhance the symptoms. It should be noted that in the surgical treatment of the compression of the middle nerve in the elbow area, all three possible places of its gradation of the aponeurosis, the two-headed muscles of the shoulder, the round pronator and the first arc must be subjected to careful revisions and decompression. The front intercellate nerve is an isolated paralysis of the front intercellate nerve may occur due to injuries, fractures, under the PARSERGA SURNER syndrome, muscle and / or tendon anomalies, or in the absence of known causes. Patients usually complain of weakness or awkwardness in the first two fingers of the brush when squeezing the item (for example, when holding a coffee cup in the hand). Usually they do not impose complaints of pain, and due to the fact that the specified nerve does not have branches of skin sensitivity, also does not arise complaints about the feeling of numbness. The weakness of the deep flexor of the fingers (second and third fingers), the long thumb and square pronator bent. Patients have a positive symptom of "O`k" (Fig. 1-11). The isolation of the paralysis of the front intercellate nerve is confirmed by the saved motor and sensitive functions of all other muscles innervated by the median nerve. With partial damage to the median nerve, a clinical picture may occur, imitating the paralysis of the front intercellate nerve (false neuropathy of the front intercellate nerve). Although the diagnosis of the paralysis of the front intercellate nerve can be put by clinically, magnetic resonance imaging (MRI) can help reveal the denervation of all three muscles innervated by this nerve.

29 In patients with rheumatoid arthritis, spontaneous and painless tenders of the tendons of a deep thicker of fingers and a long thumb twin, imitating the paralysis of the front intercept nerve, can occur. To exclude such pathology, ask the patient to relax your hand. If the muscle tendons are intact, then the pressure of your thumb on the front surface of the forearm at a distance of 2 3 inches (4 6 cm) proximalous brushes should cause passive finger bending. Crowded tunnel syndrome Symptoms of clarified tunnel syndrome are well known. These are a mischievous pain and paresthesia in the radial half of the palm and the first three fingers of the brushes, forcing patients at night and decreasing with a shaking brush. Of course, the clinical picture of each patient may have some differences, which, as a rule, are only options for the main symptoms; At the same time, the patient may have pain and paresthesias only in the fingers, or only the paresthesia and the feeling of cold are worried about them, etc. When studying, hyptestesia, hyperesthesia and / or reduction of vibration sensitivity can be detected in the first three fingers. It should be remembered that most of the palm innervated by the median nerve receives sensitivity through the palm skin branch of this nerve that does not pass through the cranky canal. Therefore, objective sensitive disorders in the field of the Tenar are not detected; However, in most cases, patients still impose complaints of pain and paresthesia in this zone. In severe cases, the hypotrophy of the muscles of the Tenar can be detected, as well as the weakness of opposition, flexion and palm finger dischairs. In rare cases, only the motor branch of the Tenar can selectively squeeze. Other diagnostic signs of this syndrome are a symptom of tinel on the brush, the TEST FALENA and / or the feed test of Falen. The Positive Test Falen is considered in the event that the bending of the affected wrist is about for a minute reinforces the symptoms. Reverse Test Falen: The extension of the wrist causes the same thing. I note that Dr. Falen was a pioneer in the field of diagnosis and surgical treatment of a custody tunnel syndrome. The etiology of the custod canal syndrome is unknown. Obviously, volumetric education and damage in this space may be factors that predispose to clinical signs of nerve and syndromes 41

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