Standard of treatment for femoral fractures order. Fractures of the femur. Damage to the thoracic and lumbar vertebrae

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2013

Fracture of unspecified part of femur (S72.9)

Traumatology and orthopedics

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development Issues
No. 18 of the Ministry of Health of the Republic of Kazakhstan dated September 19, 2013

Hip fracture- damage to the femur with disruption of its integrity as a result of injury or pathological process.

I. INTRODUCTORY PART

Protocol name:"Fractures of the femur"
Protocol code:

ICD-10 codes:
S72 Fracture of the femur

The following subcategories are provided for optional use to further characterize a condition where multiple coding to identify fracture and open wound is not possible or practical; If a fracture is not designated as closed or open, it should be classified as closed:

0 - closed
1 - open
S72.0 Fracture of the femoral neck
S72.1 Pertrochanteric fracture
S72.2 Subtrochanteric fracture
S72.3 Fracture of the body (shaft) of the femur
S72.4 Fracture of the lower end of the femur
S72.7 Multiple fractures of the femur
S72.8 Fractures of other parts of the femur
S72.9 Fracture of unspecified part of the femur

Abbreviations used in the protocol:
HIV - human immunodeficiency virus
Ultrasound - ultrasonography
ECG - electrocardiogram

Date of development of the protocol: year 2013.
Patient category: patients with femur fractures.
Protocol users: traumatologists, orthopedists, surgeons in hospitals and clinics.

Classification

Clinical classification

According to the nature of soft tissue damage:
- closed;
- open.

According to the location of the fracture site:
- epiphyseal;
- metaphyseal;
- diaphyseal.

By displacement of fragments:
- without displacement;
- with offset.

International classification of JSC (Association of Osteosynthesis)

Based on location, femur fractures are divided into three segments:

1. Proximal segment

2. Middle (diaphyseal) segment

3. Distal segment

1. Injuries to the proximal femur
A1- periarticular fracture of the trochanteric zone, pertrochanteric simple:
1 - along the intertrochanteric line;
2 - through the greater trochanter + detailing;
3- below the lesser trochanter + detailing.
A2- periarticular fracture of the trochanteric zone, pertrochanteric comminuted:
1 - with one intermediate fragment;
2 - with several intermediate fragments;
3 - extending more than 1 cm below the lesser trochanter.
A3- periarticular fracture of the trochanteric zone, intertrochanteric:
1 - simple oblique;
2 - simple transverse;
3 - splintered + detailing.
IN 1- periarticular neck fracture, subcapital, with slight displacement:
1 - impacted with valgus more than 15° + detailing;
2 - impacted with valgus less than 15° + detailing;
3 - not hammered in.
AT 2 - periarticular neck fracture, transcervical:
1 - basiccervical;
2 - through the middle of the neck, adduction;
3 - transcervical from shear.
AT 3- periarticular neck fracture, subcapital, displaced, non-impacted:
1 - moderate displacement with external rotation;
2 - moderate displacement along the length with external rotation;
3 - significant displacement + detail.
C1- intra-articular head fracture, splitting (Pipkina):
1 - separation from the place of attachment of the round ligament;
2 - with a rupture of the round ligament;
3 - large fragment.
C2- intra-articular fracture of the head, with depression:
1 - postero-superior part of the head;
2 - anterosuperior part of the head;
3 - splitting with indentation.
NW- intra-articular fracture of the head with a fracture of the neck:
1 - splitting and transcervical fracture;
2 - splitting and subcapital fracture;
3 - depression and fracture of the neck.

2. Damage to the diaphyseal segment of the femur
A1- simple fracture, spiral:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
A2- simple fracture, oblique (>30°):
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
A3- simple fracture, transverse (<30°):
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
IN 1 - wedge fracture, spiral wedge:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
AT 2- wedge-shaped fracture, wedge from flexion:
1 - subtrochanteric region;
2 - middle section;
3 - distal section.
AT 3- wedge-shaped fracture, fragmented wedge + detailing for all subgroups:
- subtrochanteric region;
- middle section;
- distal section.
C1- complex fracture, spiral + detailing for all subgroups:
- with two intermediate fragments;
- with three intermediate fragments;
- more than three intermediate fragments.
C2- complex fracture, segmental:
- with one intermediate segmental fragment + detailing;
- with one intermediate segmental and additional wedge-shaped
fragments + detailing;
- with two intermediate segmental fragments + detailing.
NW- complex fracture, irregular:
1 - with two or three intermediate fragments + detailing;
2 - with fragmentation in a limited area (<5 см) + детализация;
3 - with widespread fragmentation (>5 cm) + detailing.

3. Damage to the distal femur
A1- periarticular fracture, simple:
1 - apophysis detachment + detailing;
2 - metaphyseal oblique or spiral;
3 - metaphyseal transverse.
A2- periarticular fracture, metaphyseal wedge:
1 - intact + detailing;
2 - fragmented, lateral;
3 - fragmented, medial.
A3- periarticular fracture, complex metaphyseal:
1 - with a split intermediate fragment;
2 - irregular shape, limited to the metaphysis zone;
3 - irregularly shaped, extending to the diaphysis.
IN 1- incomplete intra-articular fracture of the lateral condyle, sagittal:
1 - simple, through the tenderloin;

3 - splintered.
AT 2- incomplete intra-articular fracture of the medial condyle, sagittal:
1 - simple, through the tenderloin;
2 - simple, through the loaded surface;
3 - splintered.
AT 3- incomplete intra-articular fracture, frontal:
1 - fracture of the anterior and outer and lateral parts of the condyle;
2 - fracture of the posterior part of one condyle + detailing;
3 - fracture of the posterior part of both condyles.
C1- complete intra-articular fracture, articular simple, metaphyseal simple:
1 - T- or Y-shaped with slight offset;
2 - T- or Y-shaped with pronounced displacement;
3 - T-shaped epiphyseal.
C2- complete intra-articular fracture, articular simple, metaphyseal
splintered:
1 - intact wedge + detailing;
2 - fragmented wedge + detailing;
3 - difficult.
NW- complete intra-articular fracture, articular comminuted:
1 - metaphyseal simple;
2 - metaphyseal comminuted;
3 - metaphyseal-diaphyseal splintered.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic diagnostic measures before/after surgery:
1. General analysis blood
2. General urine test
3. X-ray of the thigh
4. Examination of stool for helminth eggs
5. Microreaction
6. Determination of glucose
7. Determination of clotting time, duration of bleeding
8. ECG
9. Biochemical blood test
10. Determination of blood group and Rh factor

Additional diagnostic measures before/after surgical interventions:
1. Troponins, BNP, D-dimer, homocysteine (according to indications)
2. HIV testing
3. Radiography of organs chest, spine, skull and limbs
4. CT scan
5. Ultrasound of the abdominal and pelvic organs, kidneys,
6. Immunogram (according to indications)
7. Cytokine profile (interleukin-6.8, TNF-α) (according to indications)
8. Markers of bone metabolism (osteocalcin, deoxypyridinoline) (according to indications)

Diagnostic criteria.

Complaints: for pain, impaired support ability of the limb, the presence of wounds due to open fractures.

Anamnesis: presence of injury. Trauma genesis is taken into account. Direct impacts during car and motorcycle injuries, “bumper” fractures in pedestrians, falls from heights, landslides and various accidents. The magnitude of the acting force (mass), the direction of influence, and the area of application of the force are assessed.
The mechanism of injury can be either direct (a strong blow, heavy objects falling on the leg) or indirect (sharp rotation of the lower leg with a fixed foot). In the first case, transverse fractures occur, in the second - oblique and helical ones. Comminuted fractures are common.

Physical examination

Absolute (direct) signs of fractures:
- hip deformation;
- bone crepitus;
- pathological mobility;
- protrusion of bone fragments from the wound;
- shortening of the limb.

Relative (indirect) signs of fractures:
- pain (coincidence of localized pain and localized tenderness on palpation);
- symptom of axial load - increased localized pain when the limb is loaded along the axis;
- presence of swelling (hematoma);
- impairment (absence) of limb function.
The presence of even one absolute sign gives grounds to diagnose a fracture.

Symptoms of bone crepitus and pathological mobility should be checked carefully; if there are obvious signs of a fracture, do not check!

Laboratory research: not informative.

Instrumental studies: To establish a diagnosis, radiography must be performed in two projections. Sometimes with fractures of the proximal segment, computed tomography is required for clarification.

Indications for specialist consultation is a combination of hip fractures with other organs and systems, as well as concomitant diseases. In this connection, if necessary, consultations with a neurosurgeon, surgeon, vascular surgeon, urologist, therapist, and other specialists according to indications can be scheduled.

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Treatment

Goal of treatment: elimination of displacement and fixation of bone fragments, restoration of limb function.

Treatment tactics

On prehospital stage:
- for open fractures - stop bleeding (pressure bandage, pressing the vessel, applying a tourniquet), applying a sterile bandage. Do not reduce bone fragments protruding from the wound!
- transport immobilization: use pneumatic, vacuum tires, Dieterichs, Kramer tires. The hip, knee and ankle joints should be fixed. You can also bandage the injured limb to the healthy leg (so-called autoimmobilization); a board with soft material should be laid between the limbs at the level of the knee joints and ankles;
- cold on the damaged area.

Mode depending on the severity of the condition - 1, 2, 3. Diet - 15; other types of diets are prescribed depending on the concomitant pathology.

Drug treatment

Basic medications:
- pain relief non-narcotic analgesics - (for example: ketorolac 1 ml/30 mg IM);
- at severe pain narcotic analgesics - (for example: tramadol 50 - 100 mg IV, or morphine 1% - 1.0 ml IV, or trimeperidine 2% - 1.0 ml IV, you can add diazepam 5-10 mg IV ).

Additional medications:
- during phenomena traumatic shock: infusion therapy - crystalloid (for example: sodium solution chloride 0.9% - 500.0-1000.0, dextrose 5% - 500.0) and colloid solutions (for example: dextran - 200-400 ml., prednisolone 30-90 mg);
- immunocorrectors.

Conservative treatment: application of a plaster splint or coxite plaster cast or circular bandage, application of skeletal traction.

Surgical intervention:
78.15 - Application of an external fixation device on the femur;
78.45 - Other restorative and plastic manipulations on the femur;
78.55 - Internal fixation of the femur without reduction of the fracture;
79.15 - Closed reduction of bone fragments of the femur with internal fixation;
79.151 - Closed reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.152 - Closed reduction of bone fragments of the femur with internal fixation with a locking extramedullary implant;
79.25 - Open reduction of bone fragments of the femur without internal fixation;
79.35 - Open reduction of bone fragments of the femur with internal fixation;
79.351 - Open reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.45 - Closed reduction of fragments of the epiphyses of the femur;
79.45 - Open reduction of fragments of the epiphyses of the femur;
79.65 - Surgical treatment of an open fracture of the femur.
81.51 - Total hip replacement;
81.52 - Partial hip replacement.

Depending on the level of fracture, the following is used in clinical practice:
- For fractures of the proximal femur (femoral neck, trochanteric region), depending on the age and duration of the injury, osteosynthesis or unipolar or total hip arthroplasty is used.
- For fractures of the diaphyseal region and distal metaepiphysis of the femur, osteosynthesis is used with various fixators (extrafocal, extramedullary, intramedullary, combined).

Preventive measures (prevention of concomitant diseases) :

Drugs for the prevention and treatment of fat embolism and thromboembolic complications (nadroparin calcium 0.3 ml * 1-2 times a day s.c., enoxaparin 0.4 ml * 1-2 times a day s.c., fondaparinux sodium 2.5 mg * 1 once a day, rivaroxaban 1 tablet * 1 time a day);
- vasocompression lower limbs using elastic bandages or stockings.
To prevent pneumonia, early activation of the patient, exercise therapy, breathing exercises and massage are necessary.

Further management: in the postoperative period to prevent suppuration postoperative wound assigned:
- antibiotic therapy (ciprofloxacin 500 mg IV 2 times a day, cefuroxime 750 mg * 2 times a day IM, cefazolin 1.0 mg * 4 times a day IM, ceftriaxone - 1.0 mg * 2 times a day IM, lincomycin 2.0 2 times a day IM);
- metronidazole 100*2 times a day;
- infusion therapy according to indications.

Sick in early dates is activated, learns to move on crutches without load or with load (depending on the type of fracture and operation) on the operated limb, is discharged to ambulatory treatment after mastering the technique of walking on crutches.
Control radiographs are taken at 6, 12 and 36 weeks after surgery.
After surgical treatment fractures, external immobilization is used according to indications.

Rehabilitation: the time of onset of movements in the operated joint is determined by the location of the fracture, its nature, the position of the fragments, the severity of reactive phenomena and the characteristics of the course of reparative processes. It is necessary to strive for the earliest possible start physical exercise, since with prolonged immobilization of the joint, changes develop that limit its mobility.

Exercise therapy. From the first days after surgery, active management of patients is indicated:
- turning in bed;
- breathing exercises(static and dynamic nature);
- active movements in large and small joints of the shoulder girdle and upper limbs;
- isometric muscle tension of the limbs;
- lifting the body with support from a Balkan frame or trapeze suspended above the bed.

Specialexercisesfor the operated limb is prescribed for to prevent muscle atrophy and improve regional hemodynamics of the injured limb, use:

Isometric tension muscles of the thigh, lower leg and gluteal muscles, the intensity of the tension is increased gradually, duration 5-7 seconds, number of repetitions 8-10 per session;

Active repeated flexion and extension of the toes, flexion and extension in the ankle joints, performed until slight fatigue appears in the calf muscles, which activate the so-called muscle pump and help prevent thrombophlebitis, as well asexercises that train peripheral blood circulation (lowering and then giving an elevated position to the injured limb);

Ideomotor exercises are given Special attention, as a method of maintaining a dynamic motor stereotype, which serves to prevent stiffness in the joints. Imaginary movements are especially effective when a specific motor act with a long-developed dynamic stereotype is mentally reproduced. The effect turns out to be much greater if, in parallel with the imaginary ones, this movement is actually reproduced by a symmetrical healthy limb. During one lesson, 12-14 ideomotor movements are performed;

U exercises aimed at restoring the supporting function of the uninjured limb (dorsal and plantar flexion of the foot, grasping various small objects with the toes, axial pressure with the foot on the headboard or footrest);

Postural exercises or positional treatment - placing the limb in a corrective position. It is carried out using splints, fixing bandages, splints, etc. Treatment by position is aimed at preventing pathological positions of the limb.For decreasing pain manifestations in the zone of fracture and relaxation of the muscles of the pelvic girdle, muscles of the thigh and lower leg, under the knee joint should belive cotton-gauze roller, the size of which must be changed during the day. The procedure time is gradually increased from 2-3 to 7-10 minutes. Alternation passive flexion followed by extensionniya (when removing the roller) in knee joint improves movements in it;

Relaxation exercises involve consciously reducing the tone of various muscle groups. To better relax the muscles of the limb, the patient is given a position in which the attachment points of tense muscles are brought closer together. To teach the patient active relaxation, swing movements, shaking techniques, and a combination of exercises with prolonged exhalation are used;

Exercises for joints of the operated limb that are free from immobilization, which help improve blood circulation and activate reparative processes in the damaged area;

Exercises for a healthy symmetrical limb, to improve the trophism of the operated limb;

Lighter movements in the joints of the operated limb are performed with self-help, with the help of a physical therapy instructor.

Mechanotherapy
Prescribed for limited range of motion in the knee and hip joints. Its goal is to increase mobility in an isolated joint, which is achieved by dosed stretching of the periarticular tissues under the condition of muscle relaxation. The effectiveness of the effect is due to the fact that passive movement in the joint is carried out according to an individually selected program (amplitude, speed), for example, on the “Artromot” devices. The number of classes is gradually increased from 3-5 to 7-10 per day.

The question of the duration of bed rest after surgical treatment of fractures is decided in each case individually. With the early onset of dosed functional load under conditions of stable osteosynthesis, there is an increase in blood supply to the damaged area of the injured limb. First, the patient sits independently on the bed, then he is transferred to a vertical position. First, you should stand by the bed, holding onto its back.

Patients learn to move with the help of crutches - first within the ward, then in the department (without putting any weight on the operated leg!). When learning to move with the help of crutches, you should remember that both crutches must be carried forward at the same time, standing on your healthy leg. Then they put the operated leg forward and, leaning on crutches and partly on the operated leg, take a step forward with the non-operated leg; standing on the healthy leg, the crutches are brought forward again. It must be remembered that the weight of the body when leaning on crutches should be on the hands, and not on the armpit. Otherwise, compression of the neurovascular formations may occur, which leads to the development of so-called crutch paresis.

Recovery correct posture and walking skills are included in the classes general strengthening exercises, covering all muscle groups, performed in the initial position lying, sitting and standing (with support on the back of the bed).

Massage
Massage of the muscles of the back, lower back and symmetrical healthy limb is prescribed. The course of treatment is 7-10 procedures.

Physical treatments are aimed at reducing pain and swelling, relieving inflammation, improving trophism and metabolism of soft tissues in the surgical area. Apply:
- local cryotherapy;
- ultraviolet irradiation;
- magnetic therapy;
- laser therapy.
The course of treatment is 5-10 procedures.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
- satisfactory position of bone fragments on control radiographs;
- restoration of function of the damaged limb.

Drugs ( active ingredients), used in the treatment

Hospitalization

Indications for hospitalization : indications for emergency hospitalization are patients with femoral fractures of all types.

Information

Sources and literature

Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
1. 1. Müller M.E., Allgover M., Schneider R. et al. Guide to internal osteosynthesis. Methodology recommended by the AO group (Switzerland). - trans. from English Ad Marginem. - M. - 2012. 2. Michael Wagner, Robert Frigg AO Manual of Fracture Management: . Thieme, 2006. 3. Neubauer Th., WagnerM., Hammerbauer Ch. System of plates with angular stability (LCP) - a new AO standard for external osteosynthesis // Vestn. traumatol. orthopedist. - 2003. - No. 3. - P. 27-35. 4. Advanced trauma life support, eighth edition, 2008 5. N.V. Lebedev. Assessment of the severity of the condition of patients in emergency surgery and traumatology. M. Medicine, 2008.-144 p.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification information:
Dosmailov B.S. - Head of the Department of Traumatology No. 2, Scientific Research Institute of Traumatology and Orthopedics, Ph.D.
Dyriv O.V. - manager Department of Rehabilitation of Scientific Research Institute of Traumatology and Orthopedics
Baimagambetov Sh.A. - deputy Director of Scientific Research Institute for Clinical Work, Doctor of Medical Sciences
Rustemova A.Sh. - manager department innovative technologies, Doctor of Medical Sciences

Reviewers:
Orlovsky N.B. - head Department of Traumatology and Orthopedics JSC " Medical University Astana", Doctor of Medical Sciences, Professor

Conflict of interest: absent

Indication of the conditions for reviewing the protocol:
Review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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Transcript

1 “APPROVED” 3 im.r.r. harmful 1ravs/>tsrazvitiya”) :] d R.M.Tikhilov 2010 STANDARD OF MEDICAL CARE FOR PATIENTS WITH INJURIES OF THE FIRST GROUP Nosological form and code according to ICD-10: Open wound of the forearm S51, Open wound of the elbow (not penetrating the joint) S51.0, Injury of the vein at the level of the forearm, S56.5, Open wound of other parts of the wrist and hands S61.8, Multiple superficial injuries of the lower leg S80.7, Open wound of the lower leg S81, Open wound of the knee joint (not penetrating the joint) S81.0, Multiple open wounds of the lower leg S81.7, Open wound of the lower leg of unspecified localization S81.9, Open wound of the toe(s) without damage to the nail plate S91.1, Open wound of the toe(s) with damage to the nail plate S91.2, Characteristics of the group. The injuries are of mild severity. They require a one-time minor surgery, (minor PSO with skin suturing and subcutaneous tissue), but requiring observation in a hospital to prevent complications with a hospital stay of 3 days.

2 Directs -5S3CsRStoK “APPROVED” MD, PhD STANDARD OF MEDICAL CARE PATIENTS WITH JOINT DISLOCATIONS Nosological form and code according to ICD-10: S43,...Subluxation of the acromioclaidal joint S43.1,...Subluxation of the sternoclavicular joint , S43.2, Dislocation shoulder joint S43.0, Dislocation, sprain and overstrain of the capsular ligament apparatus of the elbow joint S53, Dislocation of the head radius S53.0, Dislocation in elbow joint unspecified S53.1, Dislocation of the wrist (hand) S63.0, Dislocation of the fingers S63.1 Dislocation, sprain and strain of the capsular-ligamentous apparatus of the knee joint S83, Dislocation of the toes S93.1, Sprain and strain of the ankle ligaments S93.4, Characteristics of the group. The injuries are of mild severity. They require a single reduction and observation in the hospital to exclude hidden pathology and prevent complications with a hospital stay of 3 days.

3 Director Doctor of Medical Sciences "Social Development" MU1.Tikhilov STANDARD OF MEDICAL CARE FOR PATIENTS WITH KNEE DISLOCATION (CONSERVATIVE TREATMENT) Nosological form and ICD-10 code: Knee dislocation S83.1 Characteristics of the group. The damage is of moderate severity. An operation to restore the ligamentous apparatus is indicated. Conservative treatment is permissible only if the patient refuses surgery or absolute contraindications to him. When forced conservative treatment reduction of the dislocation and plaster immobilization are required), which allows further limitation in the hospital to only observation to exclude hidden pathology, preventive treatment with a hospital stay of up to 8 days. Upon discharge, the patient receives a recommendation for surgical restoration of the ligamentous apparatus as planned. Quality control criteria at discharge: 1. General satisfactory condition.

4 STANDARD OF MEDICAL CARE FOR PATIENTS WITH CLOSED FRACTURES OF THE FOREARM WITHOUT DISPLACEMENT OF Fragments Nosological form and code according to ICD-10: Fracture of the upper end of the radius, closed S52.10, Fracture of the body [diaphysis] of the ulna, closed S52.20, Fracture of the body [diaphysis] of the radius closed S52.30, Combined fracture of the diaphysis of the ulna and radius, closed S52.40, Combined fracture of the lower ends of the ulna and radius, closed S52.60, Fracture of other parts of the bones of the forearm, closed S Characteristics of the group. The injuries are relatively mild in severity. They require a one-time effective medical manipulation (fracture reduction, minor PSO with skin suturing, closed fixation with knitting needles or analogues), which allows further in-hospital observation to be limited to only observation to exclude hidden pathology, preventive treatment and (or) dressings and (or) inexpensive plaster work with a hospital stay of up to 5 days. Pathology. Fractures of the bones of the forearm without displacement of fragments or with displacement of fragments after successful simultaneous reduction. After the provision of qualified benefits, the likelihood of secondary displacement or other

5 STANDARD OF MEDICAL CARE FOR PATIENTS WITH NON-COMMULGATED FRACTURES OF THE FEMOR DHAPHYSAL WITH DISPLACEMENT OF FRAGMENTS Nosological form and code according to ICD-10: Fracture of the body [diaphysis] of the femur, closed S72.30, Fracture of the body [diaphysis] of the femur, open (I degree - by puncture type from the inside) S72.31 (according to ASIF Muller from 32 A1-3). Stage: I Characteristics of the group. Damage above average severity with a specific probability of usually local and, less often, general complications. They require a one-step surgical treatment, the use of generally accepted standard average-cost techniques and implants, with low risk(with pure technology) surgical error and postoperative complications, duration inpatient treatment with a total period of 19 days. Quality control criteria at discharge: 1. General satisfactory condition. 2. On control radiographs, the position of the fragments is satisfactory, the axial relationships and in adjacent joints are correct, the location of the fixators is within the limits prescribed by the technology.

6 Direk d.m ^APPROVE" "im.r.r.harmful to social development" R.M.Tikhilov 2010 STANDARD OF MEDICAL CARE FOR PATIENTS WITH ANKLE FRACTURES (CONSERVATIVE TREATMENT) Nosological form and code according to ICD-10: S82.50 and S82 .60 Fracture of the internal [medial] ankle, closed and Fracture of the external [lateral] ankle, closed. Characteristics of the group. The injuries are characterized by a relatively mild degree of severity. They require a single effective medical manipulation (reposition of the fracture and reduction of the subluxation, and plaster immobilization), which allows further limitation in the hospital only by observation to exclude hidden pathology, preventive treatment and (or) dressings and (or) inexpensive plaster work with a hospital stay of up to 8 days. Pathology. Fracture of both ankles with displacement of fragments after successful closed manual reduction. There is no need for inpatient observation less than a week is determined by the inevitability of edema and the threat of compression in the plaster cast, the prevention of which requires bed rest and dynamic medical supervision. Quality control criteria at discharge: 1. General satisfactory condition.

7 “APPROVED” About im.r.r.harmful to the development of the Russian Federation” R.M.Tikhilov 2010 STANDARD OF MEDICAL CARE FOR PATIENTS WITH A FRACTURE OF THE FEMOR OR TIBIAL BONE WITH DISPLACEMENT OF Fragments Nosological form and code according to ICD-10: Fracture of the proximal tibia, closed S82.10, Fracture of the lower end of the femur, closed S72.40, Fracture of the proximal tibia, open (I degree - by type of puncture from the inside) S82.11, Open fracture of the lower end of the femur (I degree -type puncture from the inside) S (according to ASIF Muller 33-B1-3, 41-B 1-3). Stage: I Characteristics of the group. Damage above average severity with a specific probability of usually local and, less often, general complications. They require one-stage surgical treatment, the use of generally accepted standard, medium-cost techniques and implants, with a low risk (if the technology is used purely) of surgical error and postoperative complications, and the duration of hospital treatment with a total period of 15 days. Quality control criteria at discharge: 1. General satisfactory condition.

8 I ENJOY "> ish, R.R. Harmful and eav^otsrazvitiya" /7/TR.M.Tikhilov 010 STANDARD OF MEDICAL CARE FOR PATIENTS WITH PERIOD (CONSERVATIVE TREATMENT) Nosological form and code according to ICD-10: Closed clavicle fracture S42.00, Pathology: Fractures of the clavicle without displacement or with displacement of fragments after successful simultaneous reposition. Characteristics of the group. The injuries are relatively mild in severity. They require a one-time effective medical manipulation (fracture reduction and plaster immobilization), which makes it possible to further limit the hospital stay to only observation to exclude hidden pathology, preventive treatment and (or) dressings and (or) inexpensive plaster work with a hospital stay of up to 5 days. After the provision of qualified assistance, secondary displacement is not excluded, and its detection will serve as an indication for surgery with transfer to the VI-8 standard. The absence of secondary displacement or the patient’s refusal to undergo intervention serves as the basis for discharge for ambulatory treatment. Quality control criteria at discharge: 1. General satisfactory condition.

9 Dire “APPROVED” to them. R, R. Vreden avsotsrdzvitiya "/) /1shU1.Tikhilov STANDARD OF MEDICAL CARE FOR PATIENTS WITH COOTAGE FRACTURE (CONSERVATIVE TREATMENT) Nosological form and code according to ICD-10:. Closed fracture of the calcaneus S92.00, Closed fracture of the talus S92.10, Closed fracture of other tarsal bones S92.20, Closed fracture of the metatarsal bones S92.30, Fracture thumb foot closed S92.40, Fracture of the other toe closed S92.50, Multiple fractures of the foot closed S92.70, Dislocation of the talus and subtalar dislocation S93.0 Characteristics of the group. The injuries are relatively mild in severity. They require a one-time effective medical manipulation (reposition of the fracture and reduction of the subluxation, and plaster immobilization), which makes it possible to further limit the hospital stay to only observation to exclude hidden pathology, preventive treatment and (or) dressings and (or) inexpensive plaster work with a hospital stay up to 8 days. Pathology. Fracture of the foot bones without displacement or after successful closed manual reduction. The need for inpatient monitoring for this period is determined by the inevitability of edema and the threat of compression in the plaster cast, the prevention of which requires bed rest and dynamic medical supervision.

10 I LOVE" 4ITO im.r.r.vredena [Izdr^v otsrazvitiya" "chash R.M.Tikhilov ^20 South. STANDARD OF MEDICAL CARE FOR PATIENTS WITH SUPERFICIAL TRAUMA Nosological form and code according to ICD-10: Contusion of the shoulder girdle and shoulder S40 .0, Multiple superficial injuries of the shoulder girdle and shoulder S40.7, Other superficial injuries of the shoulder girdle and shoulder S40.8, Contusion of the knee joint S80.0, Multiple superficial injuries of the lower leg S80.7, Multiple superficial injuries of the ankle and foot S90.7 , Rupture of ligaments at the level of the ankle joint and foot S93.2, Sprain and strain of the ankle joint ligaments S93.4, Superficial injuries of several areas of the upper limb(s) TOO.2, Multiple superficial injuries of the abdomen, lower back and pelvis S30.7, Other superficial injuries of the abdomen, lower back and pelvis S30.8, Superficial injury of the abdomen, lower back and pelvis of unspecified localization S30.9, Multiple superficial injuries of the chest S20.7, Superficial injuries of another and unspecified part of the chest S20.8

11 Direk D.m. “I APPROVED.” R.R. Harmful to social development” R.M. Tikhilov 2010 STANDARD OF MEDICAL CARE FOR PATIENTS WITH BRAIN CONCUSSION Nosological form and code according to ICD-10: Concussion S 060.0, Contusion of the eyelid and periocular region S00.1, Other superficial injuries of the eyelid and periorbital region S00.2, Superficial injury of the nose S00.3, Superficial injury to the ear S00.4, Superficial injury to the lip and oral cavity S00.5, Multiple superficial injuries to the head S00.7, Superficial injury to other parts of the head S00.8, Open wound of the scalp S01.0, Open wound of the eyelid and periorbital region S01 .1, Open wound of the nose, S01.2, Open wound of the ear S01.3, Open wound of the cheek and temporomandibular region S01.4, Open wound of the lip and oral cavity S01.5, Multiple open wounds of the head S01.7 Characteristics of the group. The injuries are relatively mild in severity. They require a one-time specialized examination (ultrasound-ECHO, and if severe TBI is suspected, a CT scan or

12 “APPROVED” About im.r.r.harmful to the development of all countries.” M.Tikhilov 2010 STANDARD OF MEDICAL CARE B< С УШИБОМ ГЕМАРТРОЗОМ КОЛЕННОГО СУСТАВА Нозологическая форма и код по МКБ-10: Ушиб коленного сустава S80.0 Характеристика группы. Повреждения отличаются лёгкой степенью тяжести. Они требуют однократной эффективной врачебной манипуляции (пункция коленного сустава, эвакуация крови, иммобилизация), но требующей наблюдения в стационаре для профилактики осложнений со сроком пребывания в стационаре 3 суток. После оказания emergency assistance the likelihood of secondary displacement or other indications for surgery is unlikely. The need for inpatient observation is determined by the threat of compression due to increasing edema, recurrence of effusion in the joint, inflammation and conduction early prevention complications. Indicated: 1. dynamic monitoring of the blood circulation of the immobilized limb, correction of splint fixation if there is a threat of compression in the bandage, strengthening (correction) of immobilization before discharge; repeated puncture is possible; 2. The patient is not recommended to walk in the first 2 days.

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Urgent Care:

Anesthesia;

Immobilization with Kramer splints, a scarf bandage from the lower third of the shoulder to the base of the fingers: the arm is bent at the elbow joint at a right angle;

Transportation to the trauma department,

Fracture of the radius in a typical location

Traumogenesis

Falling with emphasis on the hand, direct blows, etc.

Diagnostics

Severe pain at the fracture site, when fragments are mixed, bayonet-shaped deformation of the joint, swelling, hematoma (may be absent). Movement in the joint is severely limited and painful. A combination with a fracture of the styloid process of the ulna is often found.

Urgent Care:

Pain relief - 2 ml of 50% analgin solution (metamizole sodium);

Immobilization with a splint applied from the base of the fingers to the upper third of the forearm;

Transportation to a trauma center.

INJURIES TO THE LOWER LIMB

Hip dislocation

Traumogenesis

More often they occur in car injuries, when traumatic forces act along the axis of a leg bent at the knee joint with a fixed torso: when falling from a height.

Diagnostics

There are posterior dislocations (more than 90% of cases), suprapubic and obturator. At posterior dislocation the leg is bent at the hip and knee joints, adducted and internally rotated. When suprapubic, it is straightened, slightly abducted and rotated outward, and the head is palpated under the Pupart ligament. With an obturator dislocation, the leg is bent at the hip joint, abducted and rotated outward.

Since hip dislocation is very often combined with fractures of the acetabulum, when it is very difficult to differentiate a dislocation from a fracture, at the prehospital stage it is advisable to formulate a diagnosis: fracture, dislocation in the hip joint.

Differential diagnosis- from hip fractures.

Unlike hip fractures, deformities in hip dislocations are fixed. When trying to change position, springy resistance is felt. There is a flattening of the contours of the hip joint on the side of the injury.

Urgent Care:

Pain relief (see “Shoulder Fracture”);

Immobilization - the patient is placed on a stretcher on his back, cushions from available soft material are placed under the knee joints, without changing the position in which the limb is fixed;

Hip fractures

Traumogenesis

Direct impacts during auto and motorcycle injuries, “bumper” fractures in pedestrians, falls from heights, landslides and various accidents. It is necessary to evaluate the magnitude of the acting force (mass), the direction of influence, and the area of application of the force.

There are epiphyseal, metaphyseal and diaphyseal fractures.

Diagnostics

Epiphyseal (femoral neck fractures). More often observed in people over 60 years of age. The most characteristic position is the extreme external rotation of the foot on the affected side, the “stuck heel symptom.” Localized pain in the hip joint.

Metaphyseal. They are often driven in. Localized pain and localized tenderness, increased pain in the area of the fracture when the limb is loaded along the axis. Shortening of the limb can be noted.

Diaphyseal. Most common. Large displacements of fragments are characteristic. Localized pain and tenderness in the area of the fracture. Significant swelling - hematoma. All direct and indirect signs of fractures are expressed, the symptom of a “stuck heel”.

Shock may develop.

Urgent Care:

Immobilization (Diterichs, Kramer splints, with fixation of 3 joints of the limb, inflatable splints, improvised means (foot to foot, there may be a board with soft material between the limbs at the level of the knee joints and ankles);

In the presence of shock - anti-shock therapy, pain relief with the use of narcotic analgesics;

Transport to the trauma department.

Closed knee injuries

Traumogenesis

Most often they occur during falls on the knee joints, during transport accidents and during falls from a height.

Diagnostics

Pain, swelling, limitation of movement, symptom of patellar tendon. A clicking sensation during an injury indicates a torn cruciate ligament; a violation of its integrity confirms the pathological mobility of the joint in the anteroposterior direction. Damage to the meniscus is characterized by a sudden onset of movement block. When dislocations in the knee joint are often damaged, the meniscus and joint capsule are damaged; with posterior dislocations, damage to the popliteal vessels and peroneal nerve is possible.

When the patella is fractured, a rupture of the lateral tendon stretch often occurs, due to which the superior fragment of the patella is displaced upward. The knee joint is enlarged in volume, there is pain in the anterior part of the joint, and abrasions and hematoma are often detected there. Palpation can reveal a defect between the fragments of the patella.

Urgent Care:

Pain relief (see “Shoulder Fracture”);

The patient is placed on his back, a bolster is placed under the knee joint;

Transport to the trauma department.

Fracture of the shin bones

Traumogenesis is the same.

Diagnostics

The occurrence of pain and swelling localized below the knee joint. As a rule, most often there are 3–4 absolute signs of a fracture and all relative signs. When the tibial condyles are fractured, valgus deformity of the knee joint, hemarthrosis, and limited joint function occur. Fractures without displacement are characterized by pain in the knee joint, especially when loading along the axis of the limb, and excessive lateral mobility of the leg.

Tibial shaft fracture

They are often open. The most unstable are oblique and spiral fractures of both tibia bones.

Urgent Care:

Pain relief (see “Shoulder Fracture”);

Immobilization transport bus;

In the presence of shock - antishock therapy;

Transport to the trauma department.

Ankle injuries

The most common are ankle sprains, then fractures of the base of the fifth metatarsal, etc.

Traumogenesis

Domestic injuries (sudden twisting of the foot inward or outward, falling from a height, heavy objects falling on the foot).

Diagnostics

When the ligaments of the ankle joint are sprained, swelling quickly develops due to hemorrhage from the inside or outside of the joint, and sharp pain during supination. On palpation under the ankles there is sharp pain. If a fracture of the fifth metatarsal bone occurs simultaneously with stretching, then sharp pain is detected upon palpation of the base of the bone. When both ankles are fractured with a subluxation of the foot, the joint is sharply increased in volume, and attempting to move causes significant pain. The foot is displaced outward, inward, or posteriorly, depending on the type of subluxation. Crepitation of the fragments is felt. Palpation of the outer and inner ankles reveals pain, and a defect between bone fragments is often determined.

Urgent Care:

Pain relief (see “Shoulder Fracture”);

Immobilization with Kramer or inflatable splints from the knee joint to the ends of the toes;

Transportation to the trauma department; Only victims with an isolated fracture of the lateral malleolus are sent to the trauma center.

SPINE INJURY

Damage to the cervical vertebrae

Traumogenesis

Occurs when the neck is sharply flexed or hyperextended. They are observed during a fall from a height, among divers, during car injuries, and during a strong direct blow from behind.

Diagnostics

Characterized by sharp pain in the neck area. Fractures and dislocations of the cervical vertebrae can damage the spinal cord. With a complete break, paralysis of the upper and lower extremities occurs with the absence of reflexes, all types of sensitivity, and acute urinary retention. In case of partial damage spinal cord The victim may experience numbness, tingling, and weakness in one or both arms.

The presence of tetraparesis or tetraplegia makes the diagnosis indisputable. In all cases, it is necessary to conduct a minimal neurological examination: check the strength of the muscles of the upper extremities by asking the victim to shake your hand, check for movement in the legs, tactile and pain sensitivity in the hands and feet, and find out the possibility of independent urination. Differential diagnosis is carried out with acute myositis of the cervical muscles, acute cervical radiculitis. In this case, the injury is insignificant or absent altogether, diffuse soreness is noted in the neck muscles, the load on the head is usually painful; in the anamnesis - a cold factor.

Urgent Care:

Pain relief (see “Shoulder Fracture”);

Mandatory fixation of the head and neck using a bent Kramer splint or a “necklace” splint; the patient should not be placed in a sitting or semi-sitting state, or try to tilt or turn his head;

Having secured the head and neck with splinting, carefully transfer the victim onto a stretcher (board);

If injury and drowning are combined, see “Drowning”;

Transportation to traumatology or neurosurgical departments.

Damage to the thoracic and lumbar vertebrae

Traumogenesis

It is more often observed during a fall on the back, auto and motorcycle injuries, a fall from a height, or sudden flexion and extension of the body.

Diagnostics

The coincidence of localized pain with localized tenderness upon palpation along the line of the spinous processes, reflected here is tenderness with axial load of the spine (soft pressure on the head).

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Fracture of unspecified part of the tibia (S82.9)

Traumatology and orthopedics

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development Issues
No. 18 of the Ministry of Health of the Republic of Kazakhstan dated September 19, 2013

Tibia fracture — pathological condition, which occurs as a result of a violation of the anatomical integrity of the bones of the lower leg.

I. INTRODUCTORY PART

Protocol name:"Fractures of the shin bones"
Protocol code:

ICD-10 codes:
S82.1 Fracture of the proximal tibia
S82.2 Fracture of the body [diaphysis] of the tibia
S82.3 Fracture of the distal tibia
S82.4 Fracture of fibula only
S82.5 Fracture of the medial malleolus
S82.6 Fracture of the external [lateral] malleolus
S82.7 Multiple fractures of the tibia
S82.8 Fractures of other parts of the leg
S82.9 Fracture of unspecified part of the tibia

Abbreviations used in the protocol:
HIV - human immunodeficiency virus
Ultrasound - ultrasound examination
ECG - electrocardiogram

Date of development of the protocol: year 2013
Patient category: patients with leg bone fractures
Protocol users: traumatologists, orthopedists, surgeons in hospitals and clinics

Classification

INTERNATIONAL CLASSIFICATION OF JSC(Association of Osteosynthesis)

By localization Tibia fractures are divided into three segments with one exception:
1. Proximal segment
2. Middle (diaphyseal) segment
3. Distal segment
Exception for distal tibia:
4. Ankle segment

1. Fractures of the proximal segment are divided into 3 types:
1A. Periarticular, with this type of fracture, the articular surface of the bones is not damaged, although the fracture line passes inside the capsule.
1B. Incomplete intra-articular, only part of the articular surface is damaged, while the rest remains connected to the diaphysis.
1C. Complete intra-articular, the articular surface is split and completely separated from the diaphysis.

2. Diaphyseal fractures are divided into 3 types based on the presence of contact between the fragments after reduction:
2A. There is only one fracture line; it can be helical, oblique or transverse.
2B. With one or more fragments that retain some contact after reduction.
2C. A complex fracture, with one or more fragments, fragments, in which after reposition there is no contact between the fragments.

3. Fractures of the distal segment are divided into 3 types based on the degree of extension of the fracture to the articular surface:
3A. Periarticular, the fracture line can be helical, oblique, transverse with fragments.
3B. Incomplete intra-articular, only part of the articular surface is damaged, the other part remains connected to the diaphysis.
3C. Complete intra-articular, the articular surface is split and completely separated from the diaphysis.

4. Ankle fractures are divided into 3 types based on the level of damage to the lateral malleolus in relation to the level of the syndesmosis:
4A. Subsyndesmotic fractures (can be isolated, combined with a fracture of the medial malleolus and with a fracture of the posterior edge of the tibia).
4B. Transsyndesmotic (isolated, can be combined with medial damage and a fracture of the posterior edge of the tibia).
4C. Suprasyndesmotic (simple fracture of the lower third of the fibular diaphysis, comminuted fracture of the lower third of the fibular diaphysis in combination with damage to the medial structures and fracture of the fibula in the upper third in combination with damage to the medial structures).

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic diagnostic measures before/after surgical interventions:
1. General blood test
2. General urine test
3. Radiography
4. Examination of stool for helminth eggs
5. Microreaction
6. Determination of glucose
7. Determination of clotting time and bleeding duration
8. ECG
9. Biochemical blood test
10. Determination of blood group and Rh factor

Additional diagnostic measures before/after surgical interventions:
1. Computed tomography
2. Troponins
3. BNP (according to indications)
4. D-dimer
5. Homocysteine (according to indications)

Diagnostic criteria.

Complaints: for pain in the lower leg, impaired ability to support the limb, the presence of wounds due to open fractures.

Anamnesis: presence of injury. The mechanism of injury can be either direct (a strong blow to the shin, heavy objects falling on the leg) or indirect (sharp rotation of the shin with a fixed foot). In the first case, transverse fractures occur, in the second - oblique and helical ones. Comminuted fractures are common.

Physical examination: upon examination, a forced position of the patient’s limb, swelling at the fracture site, deformation, hemorrhage into the surrounding tissue, shortening of the limb are noted; on palpation, pain that increases with axial load, gross pathological mobility, pain, crepitus of fragments. The victim cannot lift his leg independently.

Laboratory research- uninformative.

Instrumental studies: To establish a diagnosis, radiography must be performed in two projections. For fractures of the proximal segment of the tibia type 1A, 1B, 1C (S82.1), computed tomography is required to clarify the degree of compression fracture.

Indications for specialist consultation is a combination of tibia fractures with other organs and systems, as well as concomitant diseases. In this connection, if necessary, consultations with a neurosurgeon, surgeon, vascular surgeon, urologist, or therapist can be scheduled.

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Treatment

Goal of treatment: elimination of displacement of bone fragments, restoration of limb support.

Treatment tactics

Non-drug treatment: Regimen depending on the severity of the condition - 1, 2, 3. Diet - 15; other types of diets are prescribed depending on the concomitant pathology.

Drug treatment
Basic medications:
- pain relief non-narcotic analgesics - (for example: ketorolac 1 ml/30 mg IM);
- for severe pain, narcotic analgesics - (for example: tramadol 50 - 100 mg IV, or morphine 1% - 1.0 ml IV, or trimeperidine 2% - 1.0 ml IV, you can add diazepam 5- 10 mg IV).

Additional medications:
- for symptoms of traumatic shock: infusion therapy - crystalloid (for example: sodium chloride solution 0.9% - 500.0-1000.0, dextrose 5% - 500.0) and colloid solutions (for example: dextran - 200 -400 ml., prednisolone 30-90 mg).

Conservative treatment: application of a plaster splint or circular bandage, application of skeletal traction.

Surgical intervention:
79.16 - Closed reduction of bone fragments of the tibia and fibula with internal fixation;
79.36 - Open reduction of bone fragments of the tibia and fibula with internal fixation;
79.06 - Closed reduction of bone fragments of the tibia and fibula without internal fixation;
78.17 - Application of an external fixation device to the tibial and fibula;
78.47 - Other restorative and plastic manipulations on the tibia and fibula.

The main treatment method is various ways osteosynthesis:
- extrafocal;
- extramedullary;
- intramedullary;
- combined.

Preventive actions:
Drugs for the prevention and treatment of fat embolism and thromboembolic complications (anticoagulants, antiplatelet agents), vasocompression of the lower extremities using elastic bandages or stockings.
To prevent pneumonia, early activation of the patient, exercise therapy, breathing exercises and massage are necessary.

Further management
In the postoperative period, to prevent suppuration of the postoperative wound, antibiotic therapy is prescribed (ciprofloxacin 500 mg IV 2 times a day, cefuroxime 750 mg * 2 times a day IM, cefazolin 1.0 mg * 4 times a day IM, ceftriaxone - 1 .0 mg * 2 times a day IM, lincomycin 2.0 2 times a day IM), metronidazole 100 * 2 times a day IM and infusion therapy as indicated.
The patient is activated early, learns to move on crutches without weight-bearing or with weight-bearing (depending on the type of fracture and operation) on the operated limb, and is discharged for outpatient treatment after mastering the technique of walking on crutches.
Control radiographs are taken at 6, 12 and 36 weeks after surgery.
After surgical treatment of fractures, external immobilization is used as indicated.

Rehabilitation
The time for the onset of movements in the operated joint is determined by the location of the fracture, its nature, the position of the fragments, the severity of reactive phenomena and the characteristics of the course of reparative processes. It is necessary to strive for the earliest possible start of physical exercise, since with prolonged immobilization of the joint, changes develop that limit its mobility.

Exercise therapy
From the first days after surgery, active management of patients is indicated:
- turning in bed;
- breathing exercises (static and dynamic nature);
- active movements in large and small joints of the shoulder girdle and upper limbs;
- isometric tension of the muscles of the shoulder girdle and upper limbs;
- lifting the body with support from a Balkan frame or trapeze suspended above the bed.

Specialexercises for the operated limb, it is prescribed to prevent muscle atrophy and improve the regional hemodynamics of the damaged limb, the following is used:
- isometric tension of the muscles of the thigh and lower leg, the intensity of the tension is increased gradually, duration 5-7 seconds, number of repetitions 8-10 per session;
- active repeated flexion and extension of the toes, as well as exercises that train peripheral blood circulation (lowering and then giving an elevated position to the injured limb);
- Ideomotor exercises are given special attention as a method of maintaining a dynamic motor stereotype, which serves to prevent stiffness in the joints. Imaginary movements are especially effective when a specific motor act with a long-developed dynamic stereotype is mentally reproduced. The effect turns out to be much greater if, in parallel with the imaginary ones, this movement is actually reproduced by a symmetrical healthy limb. During one lesson, 12-14 ideomotor movements are performed;
- exercises aimed at restoring the support function of an intact limb (dorsal and plantar flexion of the foot, grasping various small objects with the toes, axial pressure with the foot on the headboard or footrest);
- postural exercises or positional treatment - placing the limb in a corrective position. It is carried out using splints, fixing bandages, splints, etc. Treatment by position is aimed at preventing pathological positions of the limb. To reduce pain in the fracture area and relax the muscles of the thigh and lower leg, a cotton-gauze roll should be placed under the knee joint, the size of which must be changed throughout the day. The procedure time is gradually increased from 2-3 to 7-10 minutes. Alternating passive flexion with subsequent extension (when the roller is removed) in the knee joint improves movement in it.
- relaxation exercises involve a conscious decrease in the tone of various muscle groups. To better relax the muscles of the limb, the patient is given a position in which the attachment points of tense muscles are brought closer together. To teach the patient active relaxation, swing movements, shaking techniques, and a combination of exercises with prolonged exhalation are used;
- exercises for joints of the operated limb that are free from immobilization, which help improve blood circulation and activate reparative processes in the damaged area;
- exercises for a healthy symmetrical limb, to improve the trophism of the operated limb;
- facilitated movements in the joints of the operated limb are performed with self-help, with the help of a physical therapy instructor.

Mechanotherapy
Prescribed for limited range of motion in the knee or ankle joints. Its goal is to increase mobility in an isolated joint, which is achieved by dosed stretching of the periarticular tissues under the condition of muscle relaxation. The effectiveness of the effect is due to the fact that passive movement in the joint is carried out according to an individually selected program (amplitude, speed), for example, on the “Artromot” devices.
The number of classes is gradually increased from 3-5 to 7-10 per day.
Patients learn to move with the help of crutches - first within the ward, then in the department (without putting any weight on the operated leg!). When learning to move with the help of crutches, you should remember that both crutches must be carried forward at the same time, standing on your healthy leg. Then they put the operated leg forward and, leaning on crutches and partly on the operated leg, take a step forward with the non-operated leg; standing on the healthy leg, the crutches are brought forward again. It must be remembered that the weight of the body when leaning on crutches should be on the hands, and not on the armpit. Otherwise, compression of the neurovascular formations may occur, which leads to the development of so-called crutch paresis.
To restore correct posture and walking skills, classes include general strengthening exercises covering all muscle groups, performed in the initial position lying, sitting and standing (with support on the headboard).

Massage
Prescribe muscle massage of a symmetrical healthy limb. The course of treatment is 7-10 procedures.

Drugs (active ingredients) used in treatment

Hospitalization

Indications for hospitalization: indications for emergency hospitalization are fractures of the tibia type 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B, 3C, 4A, 4B, 4C (according to International classification AO).

Information

Sources and literature

Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
1. 1. Müller M.E., Allgover M., Schneider R. et al. Guide to internal osteosynthesis. Methodology recommended by the AO group (Switzerland). - trans. from English Ad Marginem. - M. - 2012. 2. Michael Wagner, Robert Frigg AO Manual of Fracture Management: . Thieme, 2006. 3. Neubauer Th., WagnerM., Hammerbauer Ch. System of plates with angular stability (LCP) - a new AO standard for external osteosynthesis // Vestn. traumatol. orthopedist. - 2003. - No. 3. - P. 27-35. 4. Advanced trauma life support, eighth edition, 2008 5. N.V. Lebedev. Assessment of the severity of the condition of patients in emergency surgery and traumatology. M. Medicine, 2008.-144 p. 6. Advanced trauma life support, eighth edition, 2008

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification information:
Mursalov N.K. - manager Department of Traumatology No. 5 NIITO, Ph.D.
Dyriv O.V. - manager Department of Rehabilitation of Scientific Research Institute of Traumatology and Orthopedics
Baimagambetov Sh.A. - deputy Director of Scientific Research Institute for Clinical Work, Doctor of Medical Sciences
Rustemova A.Sh. - manager Department of Innovative Technologies, Doctor of Medical Sciences

Reviewers:
Orlovsky N.B. - head Department of Traumatology and Orthopedics JSC "Astana Medical University", Doctor of Medical Sciences, Professor

Conflict of interest: absent

Attached files

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Standards for the treatment of shin bone fractures
Protocols for the treatment of shin bone fractures

Fracture of the diaphysis of both leg bones

Profile: surgical.
Stage: hospital (treatment with surgery).

Purpose of the stage: timely diagnosis of shin bone fractures, determination of therapeutic tactics (conservative, surgical), prevention possible complications, carrying out rehabilitation measures, restoring limb function.
Duration of treatment (days): 16.

ICD codes: S82.2 Fracture of the body [diaphysis] of the tibia
S82.3 Fracture of the distal tibia
Excludes: medial malleolus (S82.5)

Definition: Fracture of the diaphysis of both bones of the leg - violation of integrity bone tissue body small and tibia as a result of injury or pathological process.

Classification:(according to JSC classification)
1. Open (infected fracture);
2. Closed fracture.
Along the fracture plane:
1. transverse;
2. oblique;
3. helical;
4. longitudinal;
5. splintered (segmental).

Risk factors: detraining, careless sudden movements, old age.

Admission: emergency.

Diagnostic criteria:
1. Pain syndrome in the injured limb;
2. Changes in soft tissue over the fracture site (swelling, hematoma, deformation, etc.);
3. Crepitation of bone fragments upon palpation of the suspected injured
area of the lower leg;
4. Pathological mobility of bone fragments;
5. X-ray signs of a fracture of the diaphysis of the tibia bones.

List of main diagnostic measures:
1. X-ray examination of the injured lower leg in 2 projections
2. ECG
3. General blood test (6 parameters)
4. General urine test
5. Coagulogram
6. Biochemistry
7. Serological examination for syphilis
8. HIV
9. HbsAg, Anti-HCV.

Treatment tactics:
Reduction of most associated tibial fractures is performed using spinal anesthesia. Indications for surgical treatment of a fracture:
1. Displaced fracture of both tibia bones (in cases where the desired reduction is not achieved);
2. In the presence of large, deep injuries to soft tissues or a vascular bundle;
3. Complicated fracture of the leg bones;
4. Segmental fracture of the leg bones.

Surgical treatment:
1. Application of an external fixation device on the tibia and fibula.
2. Intramedullary closed blocking osteosynthesis;
3. Intramedullary osteosynthesis;
4. Osteosynthesis with a plate and screws.
Immediately after surgical treatment, it is necessary to begin mobilization of the injured limb.

After osteosynthesis, the fixator is removed no earlier than 6 months later. In patients over 60 years of age, the fixative can be left in place for life. For 1 month after removal of the metal structure, the patient should avoid excessive physical activity on a limb.

Management after reduction of a tibia fracture:
Within 3 days after reposition, an elevated position of the injured leg is indicated; after the swelling disappears, the patient should begin movements, the scope of which gradually expands until discharge from the hospital. Exercises to develop your toes and
muscles should begin immediately.

Weight bearing on the injured leg should begin as soon as possible after repositioning, with a gradual increase by 6-8 weeks. With a clinically stable fracture, walking is allowed with a gradual increase in weight bearing. The process of bone tissue restoration is slowed down with severe bone displacement or deep soft tissue damage. The results of multicenter studies have established that the use of antibiotic prophylaxis in patients with open fractures significantly reduces the risk of developing purulent-inflammatory complications.

Patients can be divided into 3 risk groups:
1. Open fracture with damage to the skin and soft tissue less than 1 cm in length, the wound is clean.
2. Open fracture with skin damage more than 1 cm in length in the absence of significant damage to the underlying tissues or significant displacements.
3. Any segmental fractures, open fractures with severe damage to underlying tissues or traumatic amputation.
Patients in risk groups 1-2 require a preoperative dose of antibiotics (as early as possible after injury), mainly with an effect on gram-positive microorganisms.
For patients at risk group 3, antibiotics that act on gram-negative microorganisms are additionally prescribed.

Antibiotic prophylaxis regimens:
1. For patients in risk groups 1-2 – 3-4 generation cephalosporins i/m 1.0-2.0;
2. Patients of the 3rd risk group - 3-4 generation cephalosporins IM 1.0-2.0 every 12 hours (2 times a day) 7 days + metronidazole 100 ml. IV every 8 hours (3 times a day) for 3-5 days.

List of essential medications:
1. Metronidazole tablet 250 mg solution for infusion 0.5 in a 100 ml bottle.
2. Ceftriaxone powder for the preparation of injection solution 250 mg, 500 mg, 1,000 mg in a bottle.
3. Cefazolin powder for the preparation of injection solution 1000 mg.

Criteria for transfer to the next stage:
1. Correct reposition of the fracture according to X-ray examination 1-3, 6-8, 10-12 weeks after reposition;
2. Stability of the fracture for 5 months;
3. Possibility of passive abduction immediately after reposition;
4. Opportunity active movements after reposition;
5. Restoration of limb function;
6. No complications after treatment.